Intrajejunal feeding: development and current status

Abstract

Techniques of jejunostomy were established in surgical practice by the turn of the century. They were mainly used to administer normal food for the palliation of advanced gastric cancer. Standard postoperative intravenous fluid therapy did not begin in earnest until the late 1930's and did not become routine until the late 1940's because of pyrogens, fear of fluid overload, and commercial nonavailability. For most gastric procedures performed from 1900 until 1940, postoperative treatment consisted of nutrient and saline enemas and subcutaneous infusion of fluid. Jejunal feedings had their greatest use between 1930 and 1950. Gastrectomy was widely applied for cancer and ulcers in dehydrated, malnourished patients. The importance of hypoproteinemia and malnutrition on postoperative morbidity and mortality was established, and the inability of subcutaneous infusions and nutrient enemas to counteract malnutrition and dehydration was recognized. Jejunostomy or nasojejunal tubes were recommended for routine use after gastric operations. During this period, the major advances in jejunal diets and methods of feeding were accomplished. Attention was paid to assuring adequate amounts of nutrients, minerals, and vitamins, and finding diets that were easily tolerated by the jejunum. Important in these developments was the collaboration of surgeons with physiologists, gastroenterologists, pharmacologists, and members of industry. Several factors combined to reduce the use of jejunostomy after 1950. Intravenous therapy became familiar to the surgical profession, widely available, and safe. The number of gastric resections performed has decreased. Earlier referral for operation has resulted in patients with less preoperative debility and malnutrition. By 1970, total parenteral nutrition was available, and fewer jejunostomies were perceived as necessary. During the same interval, however, the increasing incidence of patients with pancreatic, esophageal, and hepatobiliary disease who faced major operations and catabolic postoperative courses presented a new challenge to the surgical community. A resurgence of concern for nutritional support, in part generated by the availability of total parenteral nutrition, prompted a renewed interest in using the gut for feeding the postoperative patient. This renewed interest, an understanding of the techniques of parenteral nutrition, the rediscovery of the gut as an absorptive surface in the postoperative patient, and the ready availability of a variety of defined formula diets have combined to rekindle the enthusiasm of many surgeons for complementary or adjuvant feeding jejunostomy.(ABSTRACT TRUNCATED AT 400 WORDS)