Choosing wisely: Enteral feeding tube selection, placement, and considerations before and beyond the procedure room.

When an enteral feeding tube (EFT) is placed, it is not always known how long this nutrition support intervention will be needed. As a result, the type of device the patient originally has placed may not match the function it is required to serve or the lifestyle needs of the patient throughout their enteral nutrition journey. Medicare considers an EFT a prosthetic device, as it is replacing a permanently inoperable or nonfunctioning organ. If we think about an EFT the same way we think about a prosthetic limb, one that needs to be customized to meet all of the patient's functional and lifestyle needs, we can also begin to think beyond the procedure room and carefully consider a variety of factors that impact the patient at home receiving enteral nutrition. Proper fit, function, and style is essential in order for the patient to have a positive relationship with their EFT, contributing to their successful home enteral nutrition experience. Clinicians who care for these patients in any setting and in any capacity would benefit from enhancing their understanding of available EFT options, their design components, and available methods of placement. Many home care and outpatient clinicians adopt the role of patient advocate as it relates to a patient's enteral nutrition journey, and this expanded knowledge could be used to benefit the patient by improving their overall enteral nutrition experience and ultimately their relationship with their "prosthetic."

Laparoscopic single-layer running "trapezoid-shaped" suture versus mechanical stapling for esophagojejunostomy after total gastrectomy for gastric cancer: cost-effect analysis of propensity score-matched study cohorts.

OBJECTIVES: Totally laparoscopic total gastrectomy has been developed with difficulty in intracorporeal esophagojejunostomy. Although mechanical stapling has been widely used for intracorporeal esophagojejunostomy, manual suture holds great promise with the emergence of high-resolution 3D vision and robotic surgery. After exploration of how to improve the safety and efficiency of intracorporeal suture for esophagojejunostomy, we recommended the technique of single-layer running "trapezoid-shaped" suture. The cost-effectiveness was analyzed by comparing with conventional mechanical stapling. METHODS: The study retrospectively reviewed the patients undergoing laparoscopic gastrectomy for gastric cancer from January 2010 to December 2021. The patients were divided into two cohorts based on the methods of intracorporeal esophagojejunostomy: manual suture versus stapling suture. Propensity score matching was performed to match patients from the two cohorts at a ratio of 1:1. Then group comparison was made to determine whether manual suture was non-inferior to stapling suture in terms of operation time, anastomotic complications, postoperative hospital stay, and surgical cost. RESULTS: The study included 582 patients with laparoscopic total gastrectomy. The manual and stapling suture for esophagojejunostomy were performed in 50 and 532 patients, respectively. In manual suture cohort, the median time for the whole operation and digestive tract reconstruction were 300 min and 110 min. There was no anastomotic bleeding and stenosis but two cases of anastomotic leak which occurred at 3 days after surgery. The median length of postoperative hospital stay was 11 days. After propensity score matching, group comparison yielded two variables with statistical significance: time for digestive tract reconstruction and surgery cost. The manual suture cohort spent less money but more time for esophagojejunostomy. Intriguingly, the learning curve of manual suture revealed that the time for digestive tract reconstruction was declined with accumulated number of operations. CONCLUSIONS: Laparoscopic single-layer running "trapezoid-shaped" suture appears safe and cost-effective for intracorporeal esophagojejunostomy after total gastrectomy. Although the concern remains about prolonged operation time for beginners of performing the suture method, adequate practice is expected to shorten the operation time based on our learning curve analysis.

Assessment of button-type jejunostomy for nutritional management after esophagectomy in 201 cases.

BACKGROUND: Many surgeons preferably place a trans-nasal feeding tube or a feeding enterostomy for post-operative nutritional management after esophagectomy. Various types of tubes (such as nasogastric, transgastric, transduodenal, or transjejunal tubes) have been used for enteral feeding; however, the appropriate enteral feeding routes have not yet been proposed. Therefore, this study aimed to evaluate the feasibility and safety of button-type jejunostomy. METHODS: We reviewed 201 patients who underwent esophagectomy with placement of a button-type jejunostomy at the Jikei University Hospital (Tokyo, Japan) between 2008 and 2019. The analyzed variables included clinicopathological characteristics, operative data, jejunostomy-related characteristics, and postoperative complications. Postoperative bodyweight loss was examined 6 months and 1 year after the operation. RESULTS: Refractory enterocutaneous fistula and bowel obstruction occurred in 13 (6.5%) and 14 (7.0%) patients, respectively. The body mass index at button-type jejunostomy removal was significantly lower and the duration of button-type jejunostomy placement was significantly longer in patients with a refractory enterocutaneous fistula (p = 0.023 and p < 0.001, respectively). Bowel obstruction was significantly more likely to develop in patients with a non-squamous cell carcinoma (p = 0.021) and in patients who underwent open abdominal procedures (p < 0.001). After 1 year, the median bodyweight losses were 12.1% and 15.6% in patients with short and long jejunostomy placement durations (p = 0.642), respectively. CONCLUSION: A button-type jejunostomy is durable and allows easy self-management for maintaining the bodyweight without any adverse events. However, it is strongly recommended that the button be removed within a year to prevent refractory enterocutaneous fistula formation.

Development and validation of the bile leakage grading criterion in patients following Roux-en-Y hepaticojejunostomy.

OBJECTIVE: The present research aimed to propose a severity grading criterion for bile leakage in pediatric patients after Roux-en-Y hepaticojejunostomy for choledochal cysts. SUMMARY BACKGROUND DATA: Despite a bile leakage classification system from the International Study Group of Liver Surgery (ISGLS) has been developed, a commonly used grading system for pediatric patients after Roux-en-Y hepaticojejunostomy has not yet been established. METHODS: A review of clinical, laboratory, and ultrasonographic parameters were used to develop a grading system for classifying the severity of bile leakage. A total of 267 patients with bile leakage were retrospectively assessed to review the system. RESULTS: We developed a grading system for bile leakage severity for use in pediatric patients following Roux-en-Y hepaticojejunostomy. By applying the criteria to 267 patients, grade I, II, or III bile leakage was determined in 103 patients (8.7%), 115 patients (9.8%), and 49 patients (4.2%) patients, respectively. The most severe bile leakage grade (grade III), was associated with significantly higher γ-glutamyl transpeptidase and amylase levels, greater drain fluid output, more intensive care unit (ICU) admissions, and longer postoperative hospital stay. Interestingly, patients with grade II leakage who underwent reoperation had significantly more ICU admissions, longer postoperative hospital stays (p < 0.05), and higher overall hospitalization cost (p < 0.05) compared with those who underwent conservation management. Of the patients with bile duct stricture and common bile duct (CBD) stones, there were no differences among the different grades of postoperative bile leakage. CONCLUSIONS: The proposed bile leakage criteria may optimize objective diagnosis and therapeutic modalities.

A comprehensive evaluation of the long-term economic impact of major bile duct injury.

BACKGROUND: Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI. METHOD: Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes. RESULTS: Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates. CONCLUSION: Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.

Risk factors for increased resource utilization and critical care complications in patients undergoing hepaticojejunostomy for biliary injuries.

BACKGROUND: This project aimed to study resource utilization and surgical outcomes after hepaticojejunostomy (HJ) for biliary injuries utilizing data from ACS NSQIP. METHODS: Data from the Participant Use Data File containing surgical patients submitted to the ACS NSQIP during the period of 1/1/2005-12/31/2014 were analyzed. RESULTS: During the study period, 320 patients underwent HJ. Mean age was 50 years, and 109 (34%) were male. Forty-four percent of patients met criteria for ASA class III-V. Forty patients (12.5%) developed one or more critical care complications (CCC). Eighty-one patients (25%) experienced morbidity with a perioperative mortality rate of 1.9%. The mean age of these patients was 52 years, and 62% were male. Age and preoperative elevated alkaline phosphatase were independent predictors of CCC (p < 0.001 and 0.042, OR 1.035, OR 4.337, respectively). Patients ASA class III, age, and preoperative hypoalbuminemia were found to increase risk for prolonged LOS (OR 1.87, p = 0.041, OR 1.02, p = 0.049, OR 2.63, p = 0.001). DISCUSSION: The most significant predictors of morbidity and increased resource utilization after HJ include increasing age, ASA class III or above, and preoperative hypoalbuminemia. Age and ASA class are the strongest predictors of CCC in these patients.

Assessment of the safety and efficacy of percutaneous laparoscopic endoscopic jejunostomy (PLEJ).

INTRODUCTION AND AIMS: Gastric feeding may not be possible in the neurologically impaired child with foregut dysmotility. Post-duodenal feeding can be crucial, thereby avoiding the need for parenteral nutrition. The aim of this study is to evaluate the technical success, complication and clinical outcome of our institution's technique in creating a jejunostomy using the percutaneous laparoscopic-endoscopic jejunostomy (PLEJ) technique. METHODS: Retrospective review of all paediatric patients (<18) with PLEJ between January 2008 and April 2015 was conducted. Patients were identified using the electronic procedure code and clinic letters. Data were collected in regard to the procedure technical success, short and long-term complications and clinical outcomes. RESULTS: Sixteen patients (age range, 2-17years) were identified. The procedure was successful in all cases. At a median follow up of 25months, eleven patients (68%) had significant improvement of their symptoms of feeding intolerance/aspirations and are permanently PLEJ fed and two (13%) were regraded to gastric feeds. Two patients moved from total parenteral nutrition to partial parenteral nutrition while on PLEJ feeds. All patients had experienced weight gain and either went up or maintained their weight centile. The only major complication was small bowel volvulus encountered in two patients with abnormal gastrointestinal anatomy requiring surgical intervention. CONCLUSIONS: In our small case series, PLEJ placement was safe as it provides valuable visualization of the bowel loops intraabdominally. It is a technically feasible and successful approach for children requiring long-term jejunal feeding especially those with foregut dysmotility.

A randomised controlled trial of six weeks of home enteral nutrition versus standard care after oesophagectomy or total gastrectomy for cancer: report on a pilot and feasibility study.

BACKGROUND: Poor nutrition in the first months after oesophago-gastric resection is a contributing factor to the reduced quality of life seen in these patients. The aim of this pilot and feasibility study was to ascertain the feasibility of conducting a multi-centre randomised controlled trial to evaluate routine home enteral nutrition in these patients. METHODS: Patients undergoing oesophagectomy or total gastrectomy were randomised to either six weeks of home feeding through a jejunostomy (intervention), or treatment as usual (control). Intervention comprised overnight feeding, providing 50 % of energy and protein requirements, in addition to usual oral intake. Primary outcome measures were recruitment and retention rates at six weeks and six months. Nutritional intake, nutritional parameters, quality of life and healthcare costs were also collected. Interviews were conducted with a sample of participants, to ascertain patient and carer experiences. RESULTS: Fifty-four of 112 (48 %) eligible patients participated in the study over the 20 months. Study retention at six weeks was 41/54 patients (76 %) and at six months was 36/54 (67 %). At six weeks, participants in the control group had lost on average 3.9 kg more than participants in the intervention group (95 % confidence interval [CI] 1.6 to 6.2). These differences remained evident at three months (mean difference 2.5 kg, 95 % CI -0.5 to 5.6) and at six months (mean difference 2.5 kg, 95 % CI -1.2 to 6.1). The mean values observed in the intervention group for mid arm circumference, mid arm muscle circumference, triceps skin fold thickness and right hand grip strength were greater than for the control group at all post hospital discharge time points. The economic evaluation suggested that it was feasible to collect resource use and EQ-5D data for a full cost-effectiveness analysis. Thematic analysis of 15 interviews identified three main themes related to the intervention and the trial: 1) a positive experience, 2) the reasons for taking part, and 3) uncertainty of the study process. CONCLUSIONS: This study demonstrated that home enteral feeding by jejunostomy was feasible, safe and acceptable to patients and their carers. Whether home enteral feeding as 'usual practice' is a cost-effective therapy would require confirmation in an appropriately powered, multi-centre study. TRIAL REGISTRATION: UK Clinical Research Network ID 12447 (main trial, first registered 30 May 2012); UK Clinical Research Network ID 13361 (qualitative substudy, first registered 30 May 2012); ClinicalTrials.gov NCT01870817 (first registered 28 May 2013).

An assessment of feeding jejunostomy tube placement at the time of resection for gastric adenocarcinoma: A seven-institution analysis of 837 patients from the U.S. gastric cancer collaborative.

BACKGROUND: Jejunostomy feeding tubes (J-tubes) are often placed during resection for gastric adenocarcinoma (GAC). Their effect on postoperative complications and receipt of adjuvant therapy is unclear. METHODS: Patients who underwent curative-intent resection of GAC at seven institutions of the U.S. Gastric Cancer Collaborative from 2000 to 2012 were identified. The associations of J-tubes with postoperative complications and receipt of adjuvant therapy were determined. RESULTS: Of 837 patients, 265 (32%) received a J-tube. Patients receiving J-tubes demonstrated greater incidence of preoperative weight loss, lower BMI, greater extent of resection, and more advanced TNM stage. J-tube placement was associated with increased infectious complications (36% vs. 19%; P < 0.001), including surgical-site (14% vs. 6%; P < 0.001) and deep intra-abdominal (11% vs. 4%; P < 0.001) infections. On multivariate analysis, J-tubes remained independently associated with increased risk of infectious complications (all: HR = 1.93; P = 0.001; surgical-site: HR = 2.85; P = 0.001; deep intra-abdominal: HR = 2.13; P = 0.04). J-tubes were not associated with increased receipt of adjuvant therapy (HR = 0.82; P = 0.34). Subset analyses of patients undergoing total and subtotal gastrectomy similarly demonstrated an association of J-tubes with increased risk of infectious outcomes and no association with increased receipt of adjuvant therapy. CONCLUSIONS: J-tube placement after resection of gastric adenocarcinoma is associated with increased postoperative infectious outcomes and is not associated with increased receipt of adjuvant therapy. Selective use of J-tubes is recommended.

Esophagojejunostomy after laparoscopic total gastrectomy by OrVil™ or hemi-double stapling technique.

AIM: To investigate the feasibility, advantages and disadvantages of two types of anvil insertion techniques for esophagojejunostomy after laparoscopic total gastrectomy. METHODS: This was an open-label prospective cohort study. Laparoscopy-assisted radical total gastrectomy with D2 lymph node dissection was performed in 84 patients with primary non-metastatic gastric cancer confirmed by pre-operative histological examination. Overweight patients were excluded, as well as patients with peritoneal dissemination and invasion of adjacent organs. After total gastrectomy, all patients were randomized into two groups. Patients in Group I underwent esophagojejunostomy using a transorally-inserted anvil (OrVil(TM)), while patients in Group II underwent esophagojejunostomy using the hemi-double stapling technique (HDST). Both types of esophagojejunostomy were performed under laparoscopy. Patients' baseline characteristics, preoperative characteristics, perioperative characteristics, short-term postoperative outcomes and operation cost were compared between the two groups. The primary endpoint was evaluation of the surgical outcome (operating time, time of digestive tract reconstruction and time of anvil insertion) and the medical cost of each operation (operation cost and total cost of hospitalization). The secondary endpoints were time to solid diet, post-surgical hospitalization time, time to defecation, time to ambulation and intra-operative blood loss. In addition, complications were assessed and compared. RESULTS: Laparoscopic total gastrectomy and esophagojejunostomy were successfully performed in all 84 patients, without conversion to laparotomy. There were no significant differences in the operative time and time for total gastrectomy between the two groups (287.8 ± 38.4 min vs 271.8 ± 46.1 min, P = 0.09, and 147.7 ± 31.6 min vs 159.8 ± 33.8 min, P = 0.09, respectively). The time for digestive tract reconstruction and for anvil insertion were significantly decreased in Group II compared with Group I (47.8 ± 12.1 min vs 55.4 ± 15.7 min, P = 0.01, and 12.6 ± 4.7 min vs 18.7 ± 7.5 min, P = 0.001, respectively). Intra-operative blood loss (96.4 ± 32.7 mL vs 88.2 ± 36.9 mL, P = 0.28), time to defecation (3.5 ± 0.9 d vs 3.2 ± 1.1 d, P = 0.12), time to ambulation (3.9 ± 0.7 d vs 3.6 ± 1.1 d, P = 0.12), time to solid diet (7.6 ± 1.4 d vs 8.0 ± 2.7 d, P = 0.31) and total hospitalization (10.6 ± 2.6 d vs 10.8 ± 3.5 d, P = 0.80) were similar between the two groups. In addition, the total costs of hospitalization were similar between the two groups (73848.7 ± 11781.0 RMB vs 70870.3 ± 14003.5 RMB, P = 0.296), but operation cost was significantly higher in Group I compared with Group II (32401.9 ± 1981.6 RMB vs 26961.9 ± 2293.8 RMB, P < 0.001). CONCLUSION: Anvil insertion was faster and easier using the HDST technique compared with OrVil(TM), and was more cost-effective. There was no significant difference in safety.

Mesenteric Infarction: Clinical Outcomes After Restoration of Bowel Continuity.

INTRODUCTION: Patients who have a bowel resection for mesenteric infarction may require parenteral nutrition (PN). This study primarily aimed to determine the aetiological factors for a mesenteric infarction and the effects of restoring bowel continuity on the long-term PN requirements. METHODS: A retrospective review of data on patients treated for mesenteric infarction from 2000 to 2010. RESULTS: A total of 113 patients (61 women, median age 54 years) were identified. Seventy-four (65%) had a superior mesenteric artery thromboembolism, 25 (22%) had a superior mesenteric vein thrombosis, and 4 (3%) had superior mesenteric artery stricture or spasm. Patients younger than 60 years most commonly had a clotting abnormality (n = 23/46, 50%), whereas older patients had a cardiological risk factor (n = 11/17, 65%). All patients with a jejunostomy required long-term PN. Fifty-seven (49%) patients had restoration of bowel continuity (colon brought into circuit). After this, PN was stopped within 1 year in 20 (35%), within 2 years in 29 (50%) patients and within 5 years in 44 (77%) patients (P = 0.001). CONCLUSIONS: A thrombotic tendency is the main etiological factor in most patients younger than 60 years. An anastomosis of the remaining jejunum to the colon can allow PN to be stopped.

[Clinical nutrition therapy in patients with short bowel syndrome in line with principles of personalized medicine]. / Klinikai táplálásterápia rövidbél-szindrómában a személyre szabott orvoslás elvei szerint.

Home parenteral nutrition administered in selected care centres has been financed in Hungary since January, 2013. The authors discuss diagnostic issues, treatment and nutrition therapy of short bowel syndrome patients in line with the principles of personalised medicine. The most severe form of short bowel syndrome occurs in patients having jejunostomy, whose treatment is discussed separately. The authors give a detailed overview of home parenteral feeding, its possible complications, outcomes and adaptation of the remaining bowel. They describe how their own care centre operates where they administer home parenteral nutrition to 12 patients with short bowel syndrome (5 females and 7 males aged 51.25±14.4 years). The body mass index was 19.07±5.08 kg/m2 and 20.87±3.3 kg/m2, skeletal muscle mass was 25.7±6.3 kg and 26.45±5.38 kg, and body fat mass was 14.25±8.55 kg and 11.77±2.71 kg at the start of home parenteral nutrition and presently, respectively. The underlying conditions of short bowel syndrome were tumours in 4 patients, bowel ischaemia in four patients, surgical complications in three patients, Crohn's disease in one patient, and Crohn's disease plus tumour in one patient.

Six weeks of home enteral nutrition versus standard care after esophagectomy or total gastrectomy for cancer: study protocol for a randomized controlled trial.

BACKGROUND: Each year approximately 3000 patients in the United Kingdom undergo surgery for esophagogastric cancer. Jejunostomy feeding tubes, placed at the time of surgery for early postoperative nutrition, have been shown to have a positive impact on clinical outcomes in the short term. Whether feeding out of hospital is of benefit is unknown. Local experience has identified that between 15 and 20% of patients required 'rescue' jejunostomy feeding for nutritional problems and weight loss while at home. This weight loss and poor nutrition may contribute to the detrimental effect on the overall quality of life (QoL) reported in these patients. METHODS/DESIGN: This randomized pilot and feasibility study will provide preliminary information on the routine use of jejunostomy feeding after hospital discharge in terms of clinical benefits and QoL. Sixty participants undergoing esophagectomy or total gastrectomy will be randomized to receive either a planned program of six weeks of home jejunostomy feeding after discharge from hospital (intervention) or treatment-as-usual (control). The intention of this study is to inform a multi-centre randomized controlled trial. The primary outcome measures will be recruitment and retention rates at six weeks and six months. Secondary outcome measures will include disease specific and general QoL measures, nutritional parameters, total and oral nutritional intake, hospital readmission rates, and estimates of healthcare costs. Up to 20 participants will also be enrolled in a qualitative sub-study that will explore participants' and carers' experiences of home tube feeding.The results will be disseminated by presentation at surgical, gastroenterological and dietetic meetings and publication in appropriate peer review journals. A patient-friendly lay summary will be made available on the University of Leicester and the University Hospitals of Leicester NHS Trust websites. The study has full ethical and institutional approval and started recruitment in July 2012. TRIAL REGISTRATION: UKClinical Research Network ID #12447 (Main study); UKCRN ID#13361 (Qualitative sub study); ClinicalTrials.gov #NCT01870817 (First registered 28 May 2013).

Esophageal perforation management using a multidisciplinary minimally invasive treatment algorithm.

BACKGROUND: The surgical management of esophageal perforation (EP) often results in mortality and significant morbidity. Recent less invasive approaches to EP management include endoscopic luminal stenting and minimally invasive surgical therapies. We wished to establish therapeutic efficacy of minimally invasive therapies in a consecutive series of patients. STUDY DESIGN: An IRB-approved retrospective review of all acute EPs between 2007 and 2013 at a single institution was performed. Patient demographic, clinical outcomes data, and hospital charges were collected. RESULTS: We reviewed 76 consecutive patients with acute EP presenting to our tertiary care center. Median age was 64 ± 16 years (range 25 to 87 years), with 50 men and 26 women. Ninety percent of EPs were in the distal esophagus, with 67% of iatrogenic perforations occurring within 4 cm of the gastroesophageal junction. All patients were treated within 24 hours of initial presentation with a removable covered esophageal stent. Leak occlusion was confirmed within 48 hours of esophageal stent placement in 68 patients. Median lengths of ICU and hospital stay were 3 and 10 days, respectively (range 1 to 86 days). One-third of the patients were noted to have prolonged intubation (>7 days) and pneumonia that required a tracheostomy. One in-hospital (1.3%) mortality occurred within 30 days. Median total hospital charges for EP were $85,945. CONCLUSIONS: Endoscopically placed removable esophageal stents with minimally invasive repair of the perforation and feeding access is an effective treatment method for patients with EP. This multidisciplinary method enabled us to care for severely ill patients while minimizing morbidity and mortality and avoiding open esophageal surgery.

An assessment of feeding jejunostomy tube placement at the time of resection for gastric adenocarcinoma.

BACKGROUND: Feeding jejunostomy tubes (J-tube) are often placed during gastrectomy for cancer to decrease malnutrition and promote delivery of adjuvant therapy. We hypothesized that J-tubes actually are associated with increased complications and do not improve nutritional status nor increase rates of adjuvant therapy. METHODS: One hundred thirty-two patients were identified from a prospectively maintained database that underwent gastric resection for gastric adenocarcinoma between 1/00 and 3/11 at one institution. Pre- and postoperative nutritional status and relevant intraoperative and postoperative parameters were examined. RESULTS: Median age was 64 years (range 23-85). Forty-six (35%) underwent a total and 86 (65%) a subtotal gastrectomy. J-tubes were placed in 66 (50%) patients, 34 of whom underwent a subtotal and 32 a total gastrectomy. Preoperative nutritional status was similar between J-tube and no J-tube groups as measured by serum albumin (3.5 vs. 3.4 g/dL). Tumor grade, T, N, and overall stage were similar between groups. J-tube placement was associated with increased postop complications (59% vs. 41%, P = 0.04) and infectious complications (36% vs. 17%, P = 0.01), of which majority were surgical site infections. J-tubes were associated with prolonged length of stay (13 vs. 11 days; P = 0.05). There was no difference in postoperative nutritional status as measured by 30, 60, and 90-day albumin levels and the rate of receiving adjuvant therapy was similar between groups (J-tube: 61%, no J-tube: 53%, P = 0.38). Multivariate analyses revealed J-tubes to be associated with increased postop complications (HR: 4.8; 95% CI: 1.3-17.7; P = 0.02), even when accounting for tumor stage and operative difficulty and extent. Subset analysis revealed J-tubes to have less associated morbidity after total gastrectomy. CONCLUSION: J-tube placement after gastrectomy for gastric cancer may be associated with increased postoperative complications with no demonstrable advantage in receiving adjuvant therapy. Routine use of J-tubes after subtotal gastrectomy may not be justified, but may be selectively indicated in patients undergoing total gastrectomy. A prospective trial is needed to validate these results.

A cadaveric porcine model for assessment in laparoscopic bariatric surgery--a validation study.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the most effective surgical therapy for morbid obesity. It is an advanced laparoscopic surgical procedure and has a protracted learning curve. Therefore, it is important to develop innovative ways of training and assessing surgeons. The aim of this study is to determine if a cadaveric porcine jejuno-jejunostomy model is an accurate way of assessing a surgeon's technical skills by determining if a correlation exists with how he performs in the operating room. METHODS: Eight surgeons of varying experience performed a side-to-side stapled jejuno-jejunostomy on a cadaveric bench model before proceeding to perform the procedure on a real patient scheduled for LRYGBP. Performance was assessed using a motion tracking device, the Imperial College Surgical Assessment Device. Each procedure was recorded in video and scored by two blinded expert surgeons using procedure-specific rating scales. RESULTS: The cadaveric bench model demonstrated concurrent validity with significant correlations between performance on the cadaveric model and patient for dexterity measures. Left-hand path length, r = 0.857 (median, 27, 41.3; P = 0.007), right-hand path length, r = 0.810 (median, 31.5, 60; P = 0.015) and total number of movements, r = 0.743 (median, 422, 637; P = 0.035). This correlation in performance was also demonstrated in the video rating scales, r = 0.727 (median, 13.2, 14.8; P = 0.041). No correlation was found in operative time (median, 541, 742; P = 0.071). CONCLUSIONS: This study demonstrates the concurrent validity of the cadaveric porcine model, showing similar performances in surgeons completing a jejuno-jejunostomy on the cadaveric model and the patient.

Severe necrotic and septic pancreatitis. Indications to endoscopic, surgical, and nutritional therapy.

Severe acute pancreatitis (SAP) management has changed over the last fifteen years, and from too aggressive behaviour, we moved to a cautious one. In every case, we can appreciate defect of extremist conceptual position. We reviewed our strategy on disease treatment, and we analyzed treatment of single cases. We collected 4 SAP cases from January 2009 to January 2010. All patients were septic, and we adopted the same approach for all of them, avoiding surgery without peritoneal infection. In all patients we placed jejumostomy and, after cleaning of septic site, we started immediate enteral nutrition (EN). Antibiotic therapy against Gram+, Gram- and antifugal drug had been started. No one died and all patients were back to an active life even if social costs are considerably high especially due to very long hospital stay.

Quality-of-life assessment in the treatment of iatrogenic bile duct injuries: hepaticojejunostomy versus end-to-end biliary reconstructions.

BACKGROUND: Assessment and comparison of quality of life (QOL) in patients treated for iatrogenic bile duct injuries (IBDI) with Roux-en-Y hepaticojejunostomy (HJ) or end-to-end ductal anastomosis (EE). METHODS: The Medical Outcomes Study Short Form 36v2 (SF-36v2) Health Survey and the Karnofsky score were used. Comparative analysis of QOL was performed in 41 patients following reconstructive surgery for IBDI between 1990 and 2005: 22 - HJ and 21 - EE. RESULTS: Seven of eight values were comparable in both analysed groups: role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health index. Physical functioning was significantly better in patients following EE (P = 0.04). Physical component summary (P = 0.11) and mental component summary (P = 0.92) in both groups were comparable. QOL according to the Karnofsky scale was comparable in both groups (P = 0.294). CONCLUSIONS: Physical functioning was significantly better in patients after EE. Other values of QOF according to the SF-36v2 and the Karnofsky score were comparable in both groups.

Intestinal failure and the ward nurses: causes, assessment and management.

In order to manage intestinal failure (IF), a complex regimen of care is required to manage fluid intake and electrolyte balance. In the majority of cases ward nurses will bare the responsibility of managing patients with these specific needs, with the support of the nutritional multidisciplinary team. Therefore, nurses need to ensure they have expert knowledge of each area of IF management. This article defines IF and outlines how it can be managed surgically and medically. The author discusses the role of the ward nurse in monitoring and managing therapy, and states the importance of providing emotional and psychological care.