Purely laparoscopic feeding jejunostomy: a procedure which deserves more attention.

BACKGROUND: Laparoscopic procedure has inherent merits of smaller incisions, better cosmesis, less postoperative pain, and earlier recovery. In the current study, we presented our method of purely laparoscopic feeding jejunostomy and compared its results with that of conventional open approach. METHODS: We retrospectively reviewed our patients from 2012 to 2019 who had received either laparoscopic jejunostomy (LJ, n = 29) or open ones (OJ, n = 94) in Chang Gung Memorial Hospital, Linkou. Peri-operative data and postoperative outcomes were analyzed. RESULTS: In the current study, we employed 3-0 Vicryl, instead of V-loc barbed sutures, for laparoscopic jejunostomy. The mean operative duration of LJ group was about 30 min longer than the OJ group (159 ± 57.2 mins vs 128 ± 34.6 mins; P = 0.001). There were no intraoperative complications reported in both groups. The patients in the LJ group suffered significantly less postoperative pain than in the OJ group (mean NRS 2.03 ± 0.9 vs. 2.79 ± 1.2; P = 0.002). The majority of patients in both groups received early enteral nutrition (< 48 h) after the operation (86.2% vs. 74.5%; P = 0.143). CONCLUSIONS: Our study demonstrated that purely laparoscopic feeding jejunostomy is a safe and feasible procedure with less postoperative pain and excellent postoperative outcome. It also provides surgeons opportunities to enhance intracorporeal suture techniques.

Is the placement of jejunostomy tubes in patients with esophageal cancer undergoing esophagectomy associated with increased inpatient healthcare utilization? An analysis of the National Readmissions Database.

BACKGROUND: Patients undergoing esophagectomy often receive jejunostomy tubes (j-tubes) for nutritional supplementation. We hypothesized that j-tubes are associated with increased post-esophagectomy readmissions. STUDY DESIGN: We identified esophagectomies for malignancy with (EWJ) or without (EWOJ) j-tubes using the 2010-2015 Nationwide Readmissions Database. Outcomes include readmission, inpatient mortality, and complications. Outcomes were compared before and after propensity score matching (PSM). RESULTS: Of 22,429 patients undergoing esophagectomy, 16,829 (75.0%) received j-tubes. Patients were similar in age and gender but EWJ were more likely to receive chemotherapy (24.2% vs. 15.1%, p < 0.01). EWJ was associated with decreased 180-day inpatient mortality (HR 0.72 [0.52-0.99]) but not with higher readmissions at 30- (15.2% vs. 14.0%, p = 0.16; HR 0.9 [0.77-1.05]) or 180 days (25.2% vs. 24.3%, p = 0.37; HR 0.94 [0.79-1.10]) or increased complications (p = 0.37). These results were confirmed in the PSM cohort. CONCLUSION: J-tubes placed in the setting of esophagectomy do not increase inpatient readmissions or mortality.

Jejunostomy Tube Insertion for Enteral Nutrition: Comparison of Outcomes after Laparoscopic versus Radiologic Insertion.

PURPOSE: To retrospectively compare technical success and major complication rates of laparoscopically versus radiologically inserted jejunostomy tubes. MATERIALS AND METHODS: In this single-institution retrospective study, 115 patients (60 men; mean age, 59.7 y) underwent attempted laparoscopic jejunostomy tube insertion as a standalone procedure during a 10-year period and 106 patients (64 men; mean age, 61.0 y) underwent attempted direct percutaneous radiologic jejunostomy tube insertion during an overlapping 6-year period. Clinical outcomes were retrospectively reviewed with primary focus on predictors of procedure-related major complications within 30 days. RESULTS: Patients undergoing laparoscopic jejunostomy tube insertion were less likely to have previous major abdominal surgery (P < .001) or to be critically ill (P < .001) and had a higher body mass index (P = .001) than patients undergoing radiologic insertion. Technical success rates were 95% (110 of 115) for laparoscopic and 97% (103 of 106) for radiologic jejunostomy tube insertion (P = .72). Major procedural complications occurred in 7 patients (6%) in the laparoscopic group and in 5 (5%) in the radiologic group (P = 1.0). For laparoscopic jejunostomy tubes, only previous major abdominal surgery was significantly associated with a higher major procedure complication rate (14% [5 of 37] vs 3% [2 of 78] in those without; P = .039). In the radiologic jejunostomy group, only obesity was significantly associated with a higher major complication rate: 20% (2 of 10) vs 3% (3 of 96) in nonobese patients (P = .038). CONCLUSIONS: Laparoscopic and radiologic jejunostomy tube insertion both showed high success and low complication rates. Previous major abdominal surgery and obesity may be pertinent discriminators for patient selection.

Further Development of Magnetic Compression for Gastrojejunostomy in Rabbits.

BACKGROUND: Technical improvement of gastrojejunostomy is critical in bariatric and metabolic surgery. In this study, a novel magnetic compression approach for gastrojejunostomy was evaluated. MATERIALS AND METHODS: Both cylindrical and rectangular magnets were used in rabbits, and the magnets were named according to their location. All the magnets were perorally introduced into the stomach. The position of the jejunal magnet was controlled by a connecting line. When the jejunal magnet spontaneously entered the jejunum, the gastric magnet was introduced into the stomach. An extracorporeal magnet was used to guide these two magnets together, and the magnet pair was left to create a side-to-side anastomosis. The state of the animals and extrusion time of the magnets were observed. The anastomoses were evaluated by burst pressure and histology. RESULTS: Gastrojejunostomy was successfully established in all animals. Cylindrical and rectangular magnets spontaneously entered the jejunum through the pylorus within 2.4 ± 0.5 and 6.0 ± 0.8 d, respectively (P < 0.01). The cylindrical and rectangular magnet pairs fell off within 15.3 ± 0.8 and 11.9 ± 1.1 d, respectively (P < 0.01). The burst pressures were statistically similar between the two types of magnets (P > 0.05). Histological examination showed sealed anastomoses with mild inflammation of the mucosa and fibrosis within the submucosa. CONCLUSIONS: The feasibility and efficacy of establishing gastrojejunostomy by guidewire introduction of magnets, which were guided together with an extracorporeal magnet, were confirmed in rabbits. In humans, with the clinical use of this procedure, surgery would be greatly simplified.

Timing of Direct Enteral Tube Placement and Outcomes after Acute Stroke.

BACKGROUND: Direct enteral feeding tube (DET) placement for dysphagia after stroke is associated with poor outcomes. However, the relationship between timing of DET placement and poststroke mortality and disability is unknown. We sought to determine the risk of mortality and severe disability in patients who receive DET at different times after stroke. METHODS: We used the Ontario Stroke Registry and linked administrative databases to identify patients with acute ischemic stroke or intracerebral hemorrhage between 2003 and 2013 who received DET (gastrostomy or jejunostomy) during their hospital admission. We grouped patients by week of DET placement and evaluated mortality at 30 days and 6 months after DET insertion, and disability at discharge. We used Cox proportional hazard models and multiple logistic regression to determine the association between time from admission to DET placement and outcomes, adjusting for patient and hospital factors. RESULTS: In the study sample of 1367 patients, the median time from admission to DET placement was 17 days. After adjustment, each week of delay to DET placement was associated with lower mortality at 30 days (adjusted hazard ratio [aHR] .88, 95% confidence interval [CI] .79-.98), but not at 6 months (aHR .98, 95% CI .91- 1.05), and a higher likelihood of severe disability at discharge (adjusted odds ratio 1.35, 95% CI 1.13- 1.60). CONCLUSIONS: Later DET placement after stroke was associated with lower 30-day mortality but higher severe disability at discharge. Further research is needed to understand the reasons for these observations and to optimize patient selection and timing of DET.

ROUTINE USE OF V-LOCK® SUTURE FOR BARIATRIC ANASTOMOSIS IS SAFE: COMPARATIVE RESULTS FROM CONSECUTIVE CASE SERIES.

BACKGROUND: In high-income countries, morbid obesity is a growing health problem that has already reached epidemic proportions. When performing a laparoscopic gastric bypass several operative methods exist. AIM: To describe the institutional experience using a knotless unidirectional barbed suture (V-Loc 180/Covidien, Mansfield, MA) to create a hand-sewn gastrojejunostomy (GJ) and jejunojejunostomy (JJ) during bariatric surgery. METHODS: Evaluation of a case series of 87 morbidly obese patients who underwent laparoscopic gastric bypass with a hand-sewn gastrojejunostomy (GJA) and jejunojejunostomy (JJA) between 01/2015 and 06/2017. The patients were divided into two groups: in group I, GJA und JJA sutures were performed using the knotless unidirectional barbed suture; in group II, GJA and JJA were sutured with resorbable multifilament thread (Vicryl® 3/0 Ethicon, Livingstone, UK). The recorded data on gender, age, BMI, ASA score, operative time, postoperative morbidity, length of hospital stay, and reoperation, were analyzed and compared. RESULTS: All procedures were completed laparoscopically with no mortality. The mean operative time was 123.23 (±30.631) in group I and 127.57 (±42.772) in group II (p<0.05). The postoperative complications did not differ significantly between the two groups. Early complications were observed for two patients (0.9%) in the barbed suture group and for one patient (0.42%) in the multifilament suture group (p<0.05). In group I two patients (0.9%) required reoperation: on the basis of jejunojejunal stenosis in one patient, and local abscess near the gastrojejunostomy, without a leakage, in the other. In group II one patient (0.42%) required reoperation due to stenosis of the GJA. The duration of hospital admission was similar for both groups: 3.36 (±0.743) days in group I vs. 3.38 (±1.058) days in group II (p<0.05). CONCLUSION: The novel anastomotic technique is a safe and effective method and can be applied to gastrojejunal anastomosis and jejunojejunal anastomosis in laparoscopic gastric bypass.

Comparison of the safety and efficacy between linear stapler and circular stapler in totally laparoscopic total gastrectomy: protocol for a systematic review and meta-analysis.

INTRODUCTION: Total gastrectomy is often recommended for upper body gastric cancer, and totally laparoscopic total gastrectomy (TLTG) is deemed to be a promising surgical method with the well-known advantages such as less invasion and fast recovery. However, the anastomosis between oesophagus and jejunum is the difficulty of TLTG. Although staplers have promoted the development of TLTG, the choice of suitable staplers to complete oesophagojejunostomy is controversial and unclear. Therefore, a higher level of research evidence is needed to compare the two types of staplers in terms of safety and efficacy for oesophagojejunostomy in TLTG among patients with gastric cancer. METHODS AND ANALYSIS: PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI) and Wanfang Databases will be comprehensively searched from January 1990 to July 2019. All eligible randomised controlled trials (RCTs), non-RCTs or observational studies comparing the two types of staplers will be included. A meta-analysis will be performed using Review Manager V.5.3 software to compare the safety and efficacy of linear and circular staplers for oesophagojejunostomy in TLTG. The primary outcomes are anastomotic leakage, anastomotic stricture, anastomotic haemorrhage. The secondary outcomes include time to first instance of passing gas after surgery, first feeding time, total operation time, reconstruction time, estimated blood loss. The heterogeneity of this study will be assessed by p values and I2 statistic. Subgroup analyses and sensitivity analyses will be used to explore and explain the heterogeneity. The risk of bias will be assessed using the Cochrane tool or the Newcastle-Ottawa Quality Assessment Scale. ETHICS AND DISSEMINATION: Ethical approval will not be required because this proposed systematic review and meta-analysis is based on previously published data, which does not include intervention data on patients. The findings of this study will be submitted to a peer-reviewed journal and will be presented at a relevant congress. PROSPERO REGISTRATION NUMBER: CRD42018111680.

[Analysis of PEG-J associated complications in 14 adult patients treated with levodopa-carbidopa intestinal gel].

We analyzed 14 patients in our hospital, who underwent levodopa-carbidopa intestinal gel (LCIG) treatment through a percutaneous endoscopic gastrojejunostomy (PEG-J). The PEG-J related complications were observed in 10 patients (71.4%). Detailed complications are as followings: J-tube related complications such as kinking (3 cases, 21.4%), pump malfunctions (3 cases, 21.4%), skin troubles in the gastrostoma (7 cases, 50.0%), duodenal perforation, peritonitis, and ulcers (2 cases, 14.3%). These results indicated that the sufficient care for PEG-J associated complications are important in LCIG treatment.

Routine use of v-lock® suture for bariatric anastomosis is safe: comparative results from consecutive case series / Uso rotineiro da sutura v-lock® para anastomoses em obesidade é seguro: resultados de estudo clínico comparativo

ABSTRACT Background: In high-income countries, morbid obesity is a growing health problem that has already reached epidemic proportions. When performing a laparoscopic gastric bypass several operative methods exist. Aim: To describe the institutional experience using a knotless unidirectional barbed suture (V-Loc 180/Covidien, Mansfield, MA) to create a hand-sewn gastrojejunostomy (GJ) and jejunojejunostomy (JJ) during bariatric surgery. Methods: Evaluation of a case series of 87 morbidly obese patients who underwent laparoscopic gastric bypass with a hand-sewn gastrojejunostomy (GJA) and jejunojejunostomy (JJA) between 01/2015 and 06/2017. The patients were divided into two groups: in group I, GJA und JJA sutures were performed using the knotless unidirectional barbed suture; in group II, GJA and JJA were sutured with resorbable multifilament thread (Vicryl® 3/0 Ethicon, Livingstone, UK). The recorded data on gender, age, BMI, ASA score, operative time, postoperative morbidity, length of hospital stay, and reoperation, were analyzed and compared. Results: All procedures were completed laparoscopically with no mortality. The mean operative time was 123.23 (±30.631) in group I and 127.57 (±42.772) in group II (p<0.05). The postoperative complications did not differ significantly between the two groups. Early complications were observed for two patients (0.9%) in the barbed suture group and for one patient (0.42%) in the multifilament suture group (p<0.05). In group I two patients (0.9%) required reoperation: on the basis of jejunojejunal stenosis in one patient, and local abscess near the gastrojejunostomy, without a leakage, in the other. In group II one patient (0.42%) required reoperation due to stenosis of the GJA. The duration of hospital admission was similar for both groups: 3.36 (±0.743) days in group I vs. 3.38 (±1.058) days in group II (p<0.05). Conclusion: The novel anastomotic technique is a safe and effective method and can be applied to gastrojejunal anastomosis and jejunojejunal anastomosis in laparoscopic gastric bypass.

RESUMO Racional : Em países de alta renda, a obesidade mórbida é um problema crescente de saúde que já atingiu proporções epidêmicas. Ao realizar um bypass gástrico laparoscópico, existem vários métodos operatórios. Objetivo: Descrever a experiência institucional utilizando uma sutura farpada unidirecional sem nós (V-Loc 180/Covidien, Mansfield, MA) para criar gastrojejunostomia (JJ) e jejunojejunostomia (JJ) costuradas à mão durante a cirurgia bariátrica. Métodos: Avaliação de uma série de casos com 87 pacientes obesos mórbidos submetidos ao bypass gástrico por videolaparoscopia com gastrojejunostomia (JJA) e jejunojejunostomia (JJA) suturados à mão entre 01/2015 e 06/2017. Os pacientes foram divididos em dois grupos; no grupo I, GJA e JJA as suturas foram realizadas com a sutura farpada unidirecional sem nós e, no grupo II, com sutura multifilamentar reabsorvível (Vicryl® 3/0 Ethicon, Livingstone, UK). Foram analisados ​​e comparados os dados registrados sobre gênero, idade, IMC, escore ASA, tempo operatório, morbidade pós-operatória, tempo de internação hospitalar e reoperação. Resultados: Todos os procedimentos foram concluídos por laparoscopia sem mortalidade. O tempo cirúrgico médio foi 123,23 (±30,631) no grupo I e 127,57 (±42,772) no grupo II (p<0,05). As complicações pós-operatórias não diferiram significativamente entre os dois grupos. Complicações precoces foram observadas em dois pacientes (0,9%) no grupo de sutura farpada e um (0,42%) no de sutura multifilamentar (p<0,05). No grupo I, dois pacientes (0,9%) necessitaram de reoperação; um devido à estenose jejunojejunal e abscesso local próximo à gastrojejunostomia, sem vazamento, no outro. No grupo II, um paciente (0,42%) necessitou de reoperação por estenose da GJA. O tempo de internação hospitalar foi semelhante nos dois grupos: 3,36 (±0,743) dias no grupo I vs. 3,38 (±1,058) dias no grupo II (p<0,05). Conclusão: A nova técnica de anastomose é método seguro e eficaz e pode ser aplicado nas anastomoses gastrojejunal e jejunojejunal no bypass gástrico laparoscópico.

Evaluation of various gastrojejunostomy tube constructs for enteral support of small animal patients.

OBJECTIVE To evaluate the feasibility of manufacturing gastrojejunostomy tubes from jejunostomy and gastrostomy tubes that would allow for gastric and enteral feeding of and aspiration of gastric contents from small animal patients. DESIGN In vitro study. SAMPLE 9 gastrojejunostomy constructs. PROCEDURES Commercially available gastrostomy and jejunostomy tubes were combined to create 9 constructs. Three investigators tested each construct with 4 solutions (tap water, a commercial enteral diet, and 2 canned food-water mixtures) and 3 syringe sizes for ease of injection through the gastrostomy and jejunostomy tubes and aspiration through the gastrostomy tube. Flow rates were calculated and analyzed to evaluate effects of tube diameter and syringe size for each solution. RESULTS The 20F/8F, 24F/8F, 28F/8F, and 28F/10F (gastrostomy tube/jejunostomy tube) constructs allowed for injection and aspiration of all solutions. The 5F jejunostomy tubes allowed only water to be injected, whereas the 8F jejunostomy tubes did not allow injection of the canned food-water mixtures. The 20F/10F construct did not allow injection or aspiration through the gastrostomy tube, whereas the 18F/8F construct allowed injection but not aspiration through the gastrostomy tube. Faster flow rates through the gastrostomy tube were associated with larger gastrostomy tube diameter, smaller jejunostomy tube diameter, and smaller syringe size. Faster flow rates through the jejunostomy tube were associated with smaller jejunostomy tube diameter. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that homemade gastrojejunostomy constructs would allow for administration of a variety of enteral diets. Limitations to the administration and aspiration of various enteral diets as well as patient needs should be considered before a gastrojejunostomy tube combination is chosen.

Animal Model: Reflux Models in Esophageal Adenocarcinoma.

Many mouse models have been developed to mimic the inflammation-metaplasia-dysplasia-carcinoma sequence seen in the gastroesophageal reflux disease (GERD)-Barrett's esophagus-esophageal adenocarcinoma progression. Surgical reflux models in mice are technically challenging due to the small size and intolerance to surgical stress of mice. Herein, we detail three representative surgical procedures that allow for creation of an esophageal adenocarcinoma model in mice, either with or without the use of carcinogens. Additionally, we describe a genetic model that shows spontaneous development of esophageal adenocarcinoma.

Endoscopic suturing for the management of recurrent dislodgment of percutaneous endoscopic gastrostomy-jejunostomy tube.

OBJECTIVE: To describe a novel technique for the prevention of recurrent percutaneous endoscopic gastrostomy-jejunostomy (PEG-J) tube dislodgements and assess its feasibility and efficacy. This technique utilizes endoscopic suturing to secure the PEG-J tube to the gastric wall. METHODS: This was a retrospective analysis of consecutive cases of recurrent PEG-J tube dislodgements referred to a single endoscopist between June 2016 and June 2017, using an endoscopic suturing system to secure the PEG-J tube directly to the gastric wall. Technical success rates, the procedure time and related adverse events were analyzed. RESULTS: There were five patients in total (three females). The procedure was technically successful in all patients. There were no procedure-related adverse events. The mean duration of follow-up was 7.8 ± 5.1 months. Two patients had accidental dislodgement at 8.5 and 12 months, respectively. There were no other unintended dislodgements. CONCLUSION: Endoscopic suturing with internal fixation of PEG-J tube is a safe and feasible approach to manage recurrent unintended dislodgements.

Central Line-Associated Mucor velutinosus Bloodstream Infection in an Immunocompetent Pediatric Patient.

We report here the isolation of Mucor velutinosus from multiple blood cultures performed on samples from Broviac catheters and culture of a Broviac insertion-site wound sample from a 6-year-old boy with a history of intestinal failure secondary to chronic intestinal pseudo-obstruction, parenteral nutrition, and jejunostomy tube dependence. Examination of a slide from the culture revealed the presence of wide nonseptate hyphae with sporangiophores, columella, and chlamydospores. The fungal isolate was sent to the National Institutes of Health for further evaluation and was identified as Mucor velutinosus by matrix-assisted laser desorption ionization-time-of-flight mass spectrometry and genomic sequencing. The patient was treated successfully with intravenous amphotericin B and prompt removal of his central line. To the best of our knowledge, this is the first case of M velutinosus bloodstream infection in a child without cancer.

Usefulness of the Transoral Anvil Delivery System for Esophagojejunostomy After Laparoscopic Total Gastrectomy: A Single-institution Comparative Study of Transoral Anvil Delivery System and the Overlap Method.

PURPOSE: Many reconstruction techniques have been reported after laparoscopic total gastrectomy (LTG), but it is not clear which anastomosis technique is most useful, and no standard methods have been established. This study examined whether LTG using the transoral anvil delivery system (TOADS) is a feasible and safe procedure for gastric cancer. MATERIALS AND METHODS: A series of 47 patients underwent the overlap method and 36 underwent the hemi-double-stapling technique with TOADS. Intraoperative and postoperative outcomes were compared between the 2 groups. RESULTS: In the TOADS group, operation time for reconstruction was shorter (16±3 vs. 45±10 min, P=0.003), and blood loss was reduced (45±15 vs. 126±13 mL, P=0.0002). There were no significant differences in intraoperative complications, conversion to open surgery, and intraoperative anastomosis-related complications between the 2 groups. Furthermore, there were no significant differences in the incidence of complications, reoperation, mortality, and postoperative hospital stay. CONCLUSION: LTG using TOADS for gastric cancer may be a technically feasible surgical procedure with acceptable morbidity.

Intra-corporeal hand-sewn esophagojejunostomy is a safe and feasible procedure for totally laparoscopic total gastrectomy: short-term outcomes in 100 consecutive patients.

BACKGROUND: An optimal method for intracorporeal esophagojejunostomy has not yet been standardized. This study sought to introduce intracorporeal hand-sewn end-to-side esophagojejunostomy after totally laparoscopic total gastrectomy. METHODS: The author conducted a consecutive series of 100 intracorporeal hand-sewn esophagojejunostomies after totally laparoscopic total gastrectomy for upper third gastric cancer from September 2012 to December 2016. RESULTS: All patients were successfully operated on without conversion to open- or laparoscope-assisted surgery. The mean reconstruction time was 45 min, and the time until first flatus was 4 days. The time to start a soft diet was 7 days. The length of postoperative hospital stay was 8 days. The overall postoperative morbidity was 8%, including one anastomotic leak, and the mortality was zero. The median follow-up duration was 13 months; no anastomotic strictures were encountered. CONCLUSIONS: Intracorporeal hand-sewn end-to-side esophagojejunostomy after totally laparoscopic total gastrectomy is a safe and feasible procedure. This method can identify negative margins with intraoperative frozen sections before reconstruction and could be a good option for performing intracorporeal esophagojejunostomy with an advanced endoscopic suture technique.