Clinically Significant Pneumatosis Intestinalis with Postoperative Enteral Feedings by Needle Catheter Jejunostomy: An Unusual Complication* C. DANIEL From the
SMITH,
M.D.
AND
MICHAEL G.
SARR, M.D.
Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT. We evaluated the incidence of clinically significant pneumatosis intestinalis and intestinal necrosis with the use of needle catheter jejunostomy in 217 consecutive patients who had undergone complicated abdominal operations or selected bariatric procedures. The needle catheter jejunostomy was used to deliver immediate postoperative nutrition, maintenance, and replacement fluids, and selected medications. In this group, no serious complications requiring surgical intervention were related to the use of needle catheter jejunostomies. Clinically significant pneumatosis intestinalis was encountered in two of 217 patients (1%). With the needle catheter jejunostomy in place, both patients improved rapidly when enteral
were discontinued and parenteral antibiotics were administered. None of the 217 patients developed ischemic intestinal necrosis. We conclude that 1) clinically significant pneumatosis is a rare complication of enteric feeding via needle catheter jejunostomy when the intrajejunal feeding is begun with a diluted, hypoosmolar solution with stepwise increases in osmolality, and 2) patients who do develop clinically significant
The benefits of early postoperative nutrition in selected patients is clearly recognized.1-3 The needle cath-
resections; complicated
feedings
pneumatosis (n=2)
seem to respond rapidly to a temporary stoppage of enteral feedings and administration of parenteral antibiotics. ( Journal of Parenteral and Enteral Nutrition
:328-331, 1991) 15
eter jejunostomy, as described by Delaney et al,4-6 Page et al,7,8 and others,9-11 has proven to be an effective, safe, and inexpensive way to deliver enteral nutrition in the
modification of the technique described by Delaney and associates4,6 using the Vivonex needle jejunostomy kit (Norwich Eaton Pharmaceuticals, Inc, Norwich, NY).lo,l1 A 14-gauge, 7-cm-long needle is inserted obliquely into the jejunal wall, advanced intramurally for 6 cm and then plunged into the lumen. The 16-gauge catheter with guidewire is then passed through the needle and into the lumen of the bowel. The needle is carefully removed, and the catheter advanced 25 cm distally. The guidewire is removed and a purse-string suture of 3-0 We
On an ongoing basis, we have been evaluating the use of needle catheter jejunostomy, assessing the clinical setting when it is used and determining the number of complications encountered. Needle catheter jejunostomy has been used in 217 consecutive patients over the last 4 years, primarily in elective or semiemergency operations involving major esophageal, gastric, and pancreatobiliary
to:
Michael G.
Sarr, M.D., Gastroenterology Unit,
Rm. 2-
Rochester, MN 55905. ’This work was supported in part by United States Public Health Service, National Institutes of Health Grant DK 39337, the Mayo Foundation, and the Ethicon Corporation
use our
polyglycolic acid placed around the catheter at the bowel
METHODS
Reprints
procedures in;
procedures.lo
Technique of Insertion
immediate postoperative period. Complications are unusual, and most of these are minor, including diarrhea and bloating.ll However, others have cautioned against the routine use of immediate postoperative intrajejunal feedings via the needle catheter jejunostomy because of the complication of pneumatosis intestinalis12,13 and intestinal necrosis.14 Because of these reports, we reviewed our experience with the use of needle catheter jejunostomy in 217 consecutive patients to determine the incidence of these complications.
424, Alfred Bldg, Saint Marys Hospital, 1216 Second Street SW,
upper abdominal
and after selected bariatric
insertion site. Next, a separate, sterile 14-gauge needle is passed from the skin through the abdominal wall in an oblique fashion entering the peritoneum at a location where the catheter will exit the abdomen without tension; the oblique path within the abdominal wall prevents kinking of the catheter as it leaves the bowel. The catheter is then passed through this needle and the needle removed. At this point, the bowel is carefully tacked to the anterior abdominal wall with 3-0 silk. sutures at the exit site both in four-point fashion around the entrance in the jejunum and with two proximal sutures to ensure a smooth loop of bowel fixed to the. abdominal wall. Finally, the catheter is fixed to the skin with a nonreactive 3-0 polypropylene suture, and a blunt tip butterfly needle adapter attached to the catheter with the union secured with 0-silk suture. The wings of the butterfly are fixed to the skin with the nonreactive suture. The entire catheter complex is fixed to the skin
328 Downloaded from pen.sagepub.com at UNIV NEBRASKA LIBRARIES on April 9, 2015
329
with Tagaderm adhesive dressing (3M Corporation, St.
Paul, MN). Nutritional Supplementation Routine immediate postoperative feedings have using either Isocal (Mead Johnson Nutritionals, Evansville, IN) or Osmolite (Ross Laboratories, Columbia, OH), or, if the pancreatobiliary secretions were diverted, an elemental supplement Vital HN (Ross Laboratories, Columbia, OH) or Vivonex HN (Norwich-Eaton, Norwich,
NY). Feedings
were
begun
1
day postoperatively
on a
strict regimen with one-fourth strength solutions at 25 ml h and increased by 25 ml h every 12 hours until the target volume was reached; thereafter, the strength (osmolarity) was increased every 12 hours from a one-fourth to one-third to one-half to two-thirds to three-fourths strength solution. With operations necessitating biliary diversion, the bile was reinfused in parallel with the
jejunal feedings. RESULTS
With this postoperative regimen, the incidence of significant diarrhea requiring treatment (addition of opiates to slow transit) has been 19%; there have been no major early or late complications such as intraabdominal sepsis, inadvertent intraperitoneal feeding, intestinal obstruction related to the needle catheter jejunostomy, necrotizing fascitis of the abdominal wall, or intestinal necrosis or ischemia. However, we have had two patients (2/217 or 1 %) develop clinically significant pneumatosis intestinalis. Patient 1 A previously healthy 49-year-old male underwent gastrojejunostomy, cholecystojejunostomy, and intraoperative celiac plexus block for unresectable pancreatic cancer. A needle catheter jejunostomy was placed concomitantly should resumption of oral intake be delayed. The patient did well until the 3rd postoperative day when he complained of abdominal distention and cramping abdominal pain. At this time, the enteral feedings, which consisted of one-half strength Isocal at 100 ml/h, were then decreased to 50 ml/h. He became febrile (temperature 39°C) and developed abdominal distention with generalized tenderness. An abdominal radiograph showed pneumatosis intestinalis (Fig. lA ). The enteral feedings were stopped, but the needle catheter jejunostomy was not removed. Broad spectrum parenteral antibiotics were given, his fever disappeared, and he rapidly improved within 45 hours. Blood cultures were negative. Abdominal radiographs showed resolution of the pneu=
FIG. 1. Pneumatosis intestinalis in two patients. A, abdominal radiograph showing gas within bowel wall near tip of intrajejunal catheter (narrow). B, computerized axial tomography showing extensive pneumatosis intestinalis (arrotc).
matosis intestinalis.
catheter jejunostomy was placed to permit enteral feeding. On postoperative day 36, he became febrile (temper-
Patient 2
ature
39.2°C), relatively hypotensive (blood pressure 90/60), and developed abdominal distension with diffuse tenderness. Abdominal computerized tomography showed extensive pneumatosis intestinalis (Fig. 1B). At this time, the enteral feedings consisted of three-quarter strength Osmolite at 100 ml/h; he had been given enteral feedings continuously for 30 days previously. The feed=
=
-
A 64-year-old was transferred with infected pancreatic necrosis 2 weeks following pancreatic cystojejunostomy and gastrojejunostomy for a presumed pancreatic pseudocyst with gastric outlet obstruction. He was managed by necrosectomy and open marsupialization. A needle
Downloaded from pen.sagepub.com at UNIV NEBRASKA LIBRARIES on April 9, 2015
330
ings were stopped immediately, broad-spectrum antibiotics were begun, his gastrostomy tube was unclamped, and the needle catheter jejunostomy was not removed. Within 24 hours, the patient became afebrile, and his abdominal pain disappeared. Blood cultures were negative. One week later, enteral feedings through the needle catheter jejunostomy were resumed without further problems. Repeat radiographs showed resolution of the pneumatosis intestinalis. DISCUSSION
Enteral nutrition has proven to be beneficial in the early postoperative period in selected patients, and needle catheter jejunostomy is an effective, safe, and inexpensive method of delivery, not only of nutrition, but also of fluid and electrolytes, and various medications,.&dquo; Most complications of needle catheter jejunostomy have been minor, including diarrhea, abdominal cramping and distension, and catheter malfunction. Rare but more serious complications have been reported, including the intraperitoneal infusion of nutrient solutions with subsequent death, 15,16 small-bowel ischemia and necrosis17, small-bowel variceal hemorrhage,18 and pneumatosis intestinalis. 12,13 Our experience has shown that these
complications, in particular, are clinically significant pneumatosis intestinalis during unusual early postoperative enteral feeding via needle catheter jejunostomy in patients undergoing major elective or semiemergency upper abdominal operations. Only two of 217 patients developed clinically significant pneumatosis intestinalis; both of them recovered rapidly when the enteral feedings were discontinued with the needle catheter jejunostomy in place and parenteral antibiotics were administered. Nevertheless, although it is unusual, one must be aware that pneumatosis intestinalis is a potential complication. In this series, no patient developed intestinal necrosis. Others have reported individual patients with pneumatosis intestinalis that developed during intrajejunal feedings by needle catheter jejunostomy. 12,13 Yet how this mode of postoperative nutrition is associated with gas within the bowel wall remains unexplained. One theory
Whatever its cause, it appears that this form of clini-
cally significant pneumatosis intestinalis can be treated conservatively by temporary discontinuation of enteral feedings, nasogastric decompression, and parenteral antibiotics. While others&dquo; have suggested removal of the needle catheter jejunostomy, we believe that this is not necessary, although our experience is anecdotal (two patients). In both of our patients, the needle catheter jejunostomy was left in place, treatment was instituted, and both recovered rapidly without sequelae. In one patient, intrajejunal feedings were later restarted without adverse sequelae. Smith-Choban and Max14 have described intestinal ischemia and necrosis during postoperative enteral feedings in 5 of 143 patients; whether this complication is related to the osmolality of the feedings is unknown, since these investigators did not mention the osmolality of the jejunal feedings. By initiating intrajejunal feedings with a diluted, hypoosmolar solution with a stepwise increase in osmolality, none of the 217 patients studied developed intestinal ischemia while being fed enterally via a needle catheter jejunostomy. Thus, our experience does not support reports 14 relating a high incidence of associated bowel ischemia with post-
operative intrajejunal feedings. In conclusion, early postoperative enteral feedings by needle catheter jejunostomy is safe, inexpensive, and effective, but it is not without potential complications, Most associated complications are minor and are easily managed by manipulating the rate and concentration of’ the feedings. In this study, clinically significant pneumatosis intestinalis was a rare complication. In both instances in which clinically significant pneumatosis intestinalis developed, the patients responded rapidly to parenteral antibiotics, nasogastric decompression, and discontinued jejunal feedings. We feel that the needle catheter jejunostomy can be left in place and used later if nutritional support is necessary. Pneumatosis intestinalis may occur occultly in some patients who never develop clinical symptomatology. Intestinal necrosis did not occur in our experience. REFERENCES
suggests that gas accumulates within the lumen secondary to postoperative ileus, air swallowing, or intraluminal bacterial overgrowth with fermentation of the feedings; in conjunction with the mucosal and intramural defect created by the needle catheter jejunostomy, extravasation of this intraluminal gas into the wall of the bowel may occur. Another possibility is that the gas is formed within the wall of the bowel by transmucosal invasion of gas-forming organisms. Review of the clinical presentation of our patients does not allow differentiation of the above possibilities; although both responded rapidly to antibiotics, we cannot be certain that this represents a true bacterial infection because the feedings were also discontinued simultaneously. Also, Cogbill and colleagues12 retrospectively identified several patients who had radiographic evidence of pneumatosis intestinalis during a course of intrajejunal feedings but never developed any clinical symptoms suggestive of an infective etiology.
GL, Pickford I, Young GA, et al: Malnutrition in surgical patients: an unrecognized problem. Lancet 1:689-692, 1977 Dunn EL, Moore EE, Jones TN: Nutritional support of the critically ill patient. Surg Gynecol Obstet 153:45-48, 1981 Bower RH, Talamini MA, Sax HC, et al: Postoperative enteral us parenteral nutrition: A randomized controlled trial. Arch Surg 121:1040-1045, 1986 Delaney HM, Carnevale NJ, Garvey JW: Jejunostomy by a needle catheter technique. Surgery 73:786-790, 1973 Carnevale NJ, Garvey JW, Moss CM: Postoperative nutritional support using catheter feeding jejunostomy. Ann Surg 186:165-
1. Hill
2. 3.
4.
5.
170, 1977 HM: An improved technique for needle catheter jejunostomy. Arch Surg 115:1235-1237, 1980 7. Page CP, Ryan JA, Haff RC: Catheter administration of an elemental diet. Surg Gynecol Obstet 142:184-188, 1976 8. Page CF, Andrassy RJ, Moore EE, et al: Needle catheter jejunos-
6.
Delaney
tomy feeding. Contemp Surg 27:107, 1985 9. Hoover HC Jr, Ryan JA, Anderson EJ, et al: Nutritional benefits of immediate postoperative jejunal feeding of an elemental diet. Am J Surg 139:153-159, 1980 10. Sarr MG: Needle catheter jejunostomy: An aid to postoperative
Downloaded from pen.sagepub.com at UNIV NEBRASKA LIBRARIES on April 9, 2015
331 morbidly obese patient. Am Surg 54:510-512, 1988 Sarr MG, Mayo S: Needle catheter jejunostomy: An unappreciated and misunderstood advance in the care of patients after major abdominal operations. Mayo Clin Proc 63:565-572, 1988 Cogbill TH, Wolfson RH, Moore EE, et al: Massive pneumatosis intestinalis and subcutaneous emphysema: Complication of needle catheter jejunostomy. JPEN 7:171-175, 1981 Zern RT, Clarke-Pearson DC: Pneumatosis intestinalis associated with enteral feeding by catheter jejunostomy. Obstet Gynecol 65:81, 1985 Smith-Choban P, Max MN: Feeding jejunostomy: A small bowel care
11.
12.
13.
14.
of the
test? Am J Surg 155:112-117.1988 Brenner DW, Schellhammer PF: Mortality associated with feeding catheter jejunostomy after radical cystectomy. Urology 10:117-140, 1987 Blebea J, King TA: Intraperitoneal infusion as a complication of needle catheter feeding jejunostomy. JPEN 9:758-759 1985 Gaddy MC, Max MN, Schwab CW, et al: Small bowel ischemia: A consequence of feeding jejunostomy? South Med J 79:180-182, 1986 Edington N, Zajko A, Reilly JJ: Jejunal variceal hemorrhage: An unusual complication of needle catheter jejunostomy. JPEN 7:489stress
15.
16. 17.
18.
491, 1984
Downloaded from pen.sagepub.com at UNIV NEBRASKA LIBRARIES on April 9, 2015
SMITH,
M.D.
AND
MICHAEL G.
SARR, M.D.
Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT. We evaluated the incidence of clinically significant pneumatosis intestinalis and intestinal necrosis with the use of needle catheter jejunostomy in 217 consecutive patients who had undergone complicated abdominal operations or selected bariatric procedures. The needle catheter jejunostomy was used to deliver immediate postoperative nutrition, maintenance, and replacement fluids, and selected medications. In this group, no serious complications requiring surgical intervention were related to the use of needle catheter jejunostomies. Clinically significant pneumatosis intestinalis was encountered in two of 217 patients (1%). With the needle catheter jejunostomy in place, both patients improved rapidly when enteral
were discontinued and parenteral antibiotics were administered. None of the 217 patients developed ischemic intestinal necrosis. We conclude that 1) clinically significant pneumatosis is a rare complication of enteric feeding via needle catheter jejunostomy when the intrajejunal feeding is begun with a diluted, hypoosmolar solution with stepwise increases in osmolality, and 2) patients who do develop clinically significant
The benefits of early postoperative nutrition in selected patients is clearly recognized.1-3 The needle cath-
resections; complicated
feedings
pneumatosis (n=2)
seem to respond rapidly to a temporary stoppage of enteral feedings and administration of parenteral antibiotics. ( Journal of Parenteral and Enteral Nutrition
:328-331, 1991) 15
eter jejunostomy, as described by Delaney et al,4-6 Page et al,7,8 and others,9-11 has proven to be an effective, safe, and inexpensive way to deliver enteral nutrition in the
modification of the technique described by Delaney and associates4,6 using the Vivonex needle jejunostomy kit (Norwich Eaton Pharmaceuticals, Inc, Norwich, NY).lo,l1 A 14-gauge, 7-cm-long needle is inserted obliquely into the jejunal wall, advanced intramurally for 6 cm and then plunged into the lumen. The 16-gauge catheter with guidewire is then passed through the needle and into the lumen of the bowel. The needle is carefully removed, and the catheter advanced 25 cm distally. The guidewire is removed and a purse-string suture of 3-0 We
On an ongoing basis, we have been evaluating the use of needle catheter jejunostomy, assessing the clinical setting when it is used and determining the number of complications encountered. Needle catheter jejunostomy has been used in 217 consecutive patients over the last 4 years, primarily in elective or semiemergency operations involving major esophageal, gastric, and pancreatobiliary
to:
Michael G.
Sarr, M.D., Gastroenterology Unit,
Rm. 2-
Rochester, MN 55905. ’This work was supported in part by United States Public Health Service, National Institutes of Health Grant DK 39337, the Mayo Foundation, and the Ethicon Corporation
use our
polyglycolic acid placed around the catheter at the bowel
METHODS
Reprints
procedures in;
procedures.lo
Technique of Insertion
immediate postoperative period. Complications are unusual, and most of these are minor, including diarrhea and bloating.ll However, others have cautioned against the routine use of immediate postoperative intrajejunal feedings via the needle catheter jejunostomy because of the complication of pneumatosis intestinalis12,13 and intestinal necrosis.14 Because of these reports, we reviewed our experience with the use of needle catheter jejunostomy in 217 consecutive patients to determine the incidence of these complications.
424, Alfred Bldg, Saint Marys Hospital, 1216 Second Street SW,
upper abdominal
and after selected bariatric
insertion site. Next, a separate, sterile 14-gauge needle is passed from the skin through the abdominal wall in an oblique fashion entering the peritoneum at a location where the catheter will exit the abdomen without tension; the oblique path within the abdominal wall prevents kinking of the catheter as it leaves the bowel. The catheter is then passed through this needle and the needle removed. At this point, the bowel is carefully tacked to the anterior abdominal wall with 3-0 silk. sutures at the exit site both in four-point fashion around the entrance in the jejunum and with two proximal sutures to ensure a smooth loop of bowel fixed to the. abdominal wall. Finally, the catheter is fixed to the skin with a nonreactive 3-0 polypropylene suture, and a blunt tip butterfly needle adapter attached to the catheter with the union secured with 0-silk suture. The wings of the butterfly are fixed to the skin with the nonreactive suture. The entire catheter complex is fixed to the skin
328 Downloaded from pen.sagepub.com at UNIV NEBRASKA LIBRARIES on April 9, 2015
329
with Tagaderm adhesive dressing (3M Corporation, St.
Paul, MN). Nutritional Supplementation Routine immediate postoperative feedings have using either Isocal (Mead Johnson Nutritionals, Evansville, IN) or Osmolite (Ross Laboratories, Columbia, OH), or, if the pancreatobiliary secretions were diverted, an elemental supplement Vital HN (Ross Laboratories, Columbia, OH) or Vivonex HN (Norwich-Eaton, Norwich,
NY). Feedings
were
begun
1
day postoperatively
on a
strict regimen with one-fourth strength solutions at 25 ml h and increased by 25 ml h every 12 hours until the target volume was reached; thereafter, the strength (osmolarity) was increased every 12 hours from a one-fourth to one-third to one-half to two-thirds to three-fourths strength solution. With operations necessitating biliary diversion, the bile was reinfused in parallel with the
jejunal feedings. RESULTS
With this postoperative regimen, the incidence of significant diarrhea requiring treatment (addition of opiates to slow transit) has been 19%; there have been no major early or late complications such as intraabdominal sepsis, inadvertent intraperitoneal feeding, intestinal obstruction related to the needle catheter jejunostomy, necrotizing fascitis of the abdominal wall, or intestinal necrosis or ischemia. However, we have had two patients (2/217 or 1 %) develop clinically significant pneumatosis intestinalis. Patient 1 A previously healthy 49-year-old male underwent gastrojejunostomy, cholecystojejunostomy, and intraoperative celiac plexus block for unresectable pancreatic cancer. A needle catheter jejunostomy was placed concomitantly should resumption of oral intake be delayed. The patient did well until the 3rd postoperative day when he complained of abdominal distention and cramping abdominal pain. At this time, the enteral feedings, which consisted of one-half strength Isocal at 100 ml/h, were then decreased to 50 ml/h. He became febrile (temperature 39°C) and developed abdominal distention with generalized tenderness. An abdominal radiograph showed pneumatosis intestinalis (Fig. lA ). The enteral feedings were stopped, but the needle catheter jejunostomy was not removed. Broad spectrum parenteral antibiotics were given, his fever disappeared, and he rapidly improved within 45 hours. Blood cultures were negative. Abdominal radiographs showed resolution of the pneu=
FIG. 1. Pneumatosis intestinalis in two patients. A, abdominal radiograph showing gas within bowel wall near tip of intrajejunal catheter (narrow). B, computerized axial tomography showing extensive pneumatosis intestinalis (arrotc).
matosis intestinalis.
catheter jejunostomy was placed to permit enteral feeding. On postoperative day 36, he became febrile (temper-
Patient 2
ature
39.2°C), relatively hypotensive (blood pressure 90/60), and developed abdominal distension with diffuse tenderness. Abdominal computerized tomography showed extensive pneumatosis intestinalis (Fig. 1B). At this time, the enteral feedings consisted of three-quarter strength Osmolite at 100 ml/h; he had been given enteral feedings continuously for 30 days previously. The feed=
=
-
A 64-year-old was transferred with infected pancreatic necrosis 2 weeks following pancreatic cystojejunostomy and gastrojejunostomy for a presumed pancreatic pseudocyst with gastric outlet obstruction. He was managed by necrosectomy and open marsupialization. A needle
Downloaded from pen.sagepub.com at UNIV NEBRASKA LIBRARIES on April 9, 2015
330
ings were stopped immediately, broad-spectrum antibiotics were begun, his gastrostomy tube was unclamped, and the needle catheter jejunostomy was not removed. Within 24 hours, the patient became afebrile, and his abdominal pain disappeared. Blood cultures were negative. One week later, enteral feedings through the needle catheter jejunostomy were resumed without further problems. Repeat radiographs showed resolution of the pneumatosis intestinalis. DISCUSSION
Enteral nutrition has proven to be beneficial in the early postoperative period in selected patients, and needle catheter jejunostomy is an effective, safe, and inexpensive method of delivery, not only of nutrition, but also of fluid and electrolytes, and various medications,.&dquo; Most complications of needle catheter jejunostomy have been minor, including diarrhea, abdominal cramping and distension, and catheter malfunction. Rare but more serious complications have been reported, including the intraperitoneal infusion of nutrient solutions with subsequent death, 15,16 small-bowel ischemia and necrosis17, small-bowel variceal hemorrhage,18 and pneumatosis intestinalis. 12,13 Our experience has shown that these
complications, in particular, are clinically significant pneumatosis intestinalis during unusual early postoperative enteral feeding via needle catheter jejunostomy in patients undergoing major elective or semiemergency upper abdominal operations. Only two of 217 patients developed clinically significant pneumatosis intestinalis; both of them recovered rapidly when the enteral feedings were discontinued with the needle catheter jejunostomy in place and parenteral antibiotics were administered. Nevertheless, although it is unusual, one must be aware that pneumatosis intestinalis is a potential complication. In this series, no patient developed intestinal necrosis. Others have reported individual patients with pneumatosis intestinalis that developed during intrajejunal feedings by needle catheter jejunostomy. 12,13 Yet how this mode of postoperative nutrition is associated with gas within the bowel wall remains unexplained. One theory
Whatever its cause, it appears that this form of clini-
cally significant pneumatosis intestinalis can be treated conservatively by temporary discontinuation of enteral feedings, nasogastric decompression, and parenteral antibiotics. While others&dquo; have suggested removal of the needle catheter jejunostomy, we believe that this is not necessary, although our experience is anecdotal (two patients). In both of our patients, the needle catheter jejunostomy was left in place, treatment was instituted, and both recovered rapidly without sequelae. In one patient, intrajejunal feedings were later restarted without adverse sequelae. Smith-Choban and Max14 have described intestinal ischemia and necrosis during postoperative enteral feedings in 5 of 143 patients; whether this complication is related to the osmolality of the feedings is unknown, since these investigators did not mention the osmolality of the jejunal feedings. By initiating intrajejunal feedings with a diluted, hypoosmolar solution with a stepwise increase in osmolality, none of the 217 patients studied developed intestinal ischemia while being fed enterally via a needle catheter jejunostomy. Thus, our experience does not support reports 14 relating a high incidence of associated bowel ischemia with post-
operative intrajejunal feedings. In conclusion, early postoperative enteral feedings by needle catheter jejunostomy is safe, inexpensive, and effective, but it is not without potential complications, Most associated complications are minor and are easily managed by manipulating the rate and concentration of’ the feedings. In this study, clinically significant pneumatosis intestinalis was a rare complication. In both instances in which clinically significant pneumatosis intestinalis developed, the patients responded rapidly to parenteral antibiotics, nasogastric decompression, and discontinued jejunal feedings. We feel that the needle catheter jejunostomy can be left in place and used later if nutritional support is necessary. Pneumatosis intestinalis may occur occultly in some patients who never develop clinical symptomatology. Intestinal necrosis did not occur in our experience. REFERENCES
suggests that gas accumulates within the lumen secondary to postoperative ileus, air swallowing, or intraluminal bacterial overgrowth with fermentation of the feedings; in conjunction with the mucosal and intramural defect created by the needle catheter jejunostomy, extravasation of this intraluminal gas into the wall of the bowel may occur. Another possibility is that the gas is formed within the wall of the bowel by transmucosal invasion of gas-forming organisms. Review of the clinical presentation of our patients does not allow differentiation of the above possibilities; although both responded rapidly to antibiotics, we cannot be certain that this represents a true bacterial infection because the feedings were also discontinued simultaneously. Also, Cogbill and colleagues12 retrospectively identified several patients who had radiographic evidence of pneumatosis intestinalis during a course of intrajejunal feedings but never developed any clinical symptoms suggestive of an infective etiology.
GL, Pickford I, Young GA, et al: Malnutrition in surgical patients: an unrecognized problem. Lancet 1:689-692, 1977 Dunn EL, Moore EE, Jones TN: Nutritional support of the critically ill patient. Surg Gynecol Obstet 153:45-48, 1981 Bower RH, Talamini MA, Sax HC, et al: Postoperative enteral us parenteral nutrition: A randomized controlled trial. Arch Surg 121:1040-1045, 1986 Delaney HM, Carnevale NJ, Garvey JW: Jejunostomy by a needle catheter technique. Surgery 73:786-790, 1973 Carnevale NJ, Garvey JW, Moss CM: Postoperative nutritional support using catheter feeding jejunostomy. Ann Surg 186:165-
1. Hill
2. 3.
4.
5.
170, 1977 HM: An improved technique for needle catheter jejunostomy. Arch Surg 115:1235-1237, 1980 7. Page CP, Ryan JA, Haff RC: Catheter administration of an elemental diet. Surg Gynecol Obstet 142:184-188, 1976 8. Page CF, Andrassy RJ, Moore EE, et al: Needle catheter jejunos-
6.
Delaney
tomy feeding. Contemp Surg 27:107, 1985 9. Hoover HC Jr, Ryan JA, Anderson EJ, et al: Nutritional benefits of immediate postoperative jejunal feeding of an elemental diet. Am J Surg 139:153-159, 1980 10. Sarr MG: Needle catheter jejunostomy: An aid to postoperative
Downloaded from pen.sagepub.com at UNIV NEBRASKA LIBRARIES on April 9, 2015
331 morbidly obese patient. Am Surg 54:510-512, 1988 Sarr MG, Mayo S: Needle catheter jejunostomy: An unappreciated and misunderstood advance in the care of patients after major abdominal operations. Mayo Clin Proc 63:565-572, 1988 Cogbill TH, Wolfson RH, Moore EE, et al: Massive pneumatosis intestinalis and subcutaneous emphysema: Complication of needle catheter jejunostomy. JPEN 7:171-175, 1981 Zern RT, Clarke-Pearson DC: Pneumatosis intestinalis associated with enteral feeding by catheter jejunostomy. Obstet Gynecol 65:81, 1985 Smith-Choban P, Max MN: Feeding jejunostomy: A small bowel care
11.
12.
13.
14.
of the
test? Am J Surg 155:112-117.1988 Brenner DW, Schellhammer PF: Mortality associated with feeding catheter jejunostomy after radical cystectomy. Urology 10:117-140, 1987 Blebea J, King TA: Intraperitoneal infusion as a complication of needle catheter feeding jejunostomy. JPEN 9:758-759 1985 Gaddy MC, Max MN, Schwab CW, et al: Small bowel ischemia: A consequence of feeding jejunostomy? South Med J 79:180-182, 1986 Edington N, Zajko A, Reilly JJ: Jejunal variceal hemorrhage: An unusual complication of needle catheter jejunostomy. JPEN 7:489stress
15.
16. 17.
18.
491, 1984
Downloaded from pen.sagepub.com at UNIV NEBRASKA LIBRARIES on April 9, 2015
