Laparoscopic jejunostomy for obstructing upper gastrointestinal malignancies

Abstract

The aim of this study was to describe a minimally invasive laparoscopic jejunostomy (Lap-J) technique for obstruction due to upper gastrointestinal malignancies and evaluate the nutritional benefit of Lap-J during neoadjuvant chemotherapy (NAC) in cases with obstructing esophageal cancer. Under general anesthesia, the jejunum 20-30 cm distant from the Treitz ligament was pulled out through an extended umbilical laparoscopic incision and a jejunal tube was inserted to 30 cm. The loop of bowel was gently returned to the abdomen and the feeding tube was drawn through the abdominal wall via the left lower incision. The jejunum was then laparoscopically sutured to the anterior abdominal wall. Lap-J was performed in 26 cases. The median operative time was 82 min. The postoperative course was uneventful. Lap-J prior to NAC was not associated with a decrease in body weight or serum total protein during NAC, compared with patients who received NAC without Lap-J. This minimally invasive jejunostomy technique may be particularly useful in patients in whom endoscopic therapy is not feasible due to obstruction from upper gastrointestinal malignancies.

Keywords: enteral nutrition; esophageal cancer; laparoscopic jejunostomy; minimally invasive surgery.

Figure 1.

Port positioning. A camera port was inserted through a median umbilical incision and 3 additional ports (1 port with a diameter of 12 mm and 2 ports with a diameter of 5 mm) were inserted into the right lower (12 mm), right upper (5 mm) and left lower (5 mm) quadrants under laparoscopic imaging. The left lower quadrant port was the intended jejunostomy site.

Figure 2.

Surgical procedures in laparoscopic jejunostomy. (A) Following exploration of the peritoneal cavity, the jejunum 20–30 cm distant from the Treitz ligament was pulled out through the umbilical trocar incision. (B) After a serosal suture was placed, a trocar with a peel-away sheath was used to penetrate the subserosa for ~8 cm prior to penetrating the jejunal lumen. (C) The peel-away sheath was removed and a jejunal tube was inserted to 30 cm. The tube was held by a laparoscopic grasper inserted through the left lower trocar. The loop of bowel was gently returned to the abdomen and the feeding tube was drawn through the abdominal wall via the left lower incision. (D) The jejunum was laparoscopically sutured to the anterior abdominal wall with 5 or 6 sutures.

Figure 3.

Laparoscopic view during esophagectomy following laparoscopic jejunostomy (Lap-J). §, jejunum sutured to the anterior abdominal wall for Lap-J; *, trocar in the left lower quadrant during esophagectomy.