Abstract
Feeding jejunostomy is a simple and common procedure done for providing enteral nutrition. Though generally safe, complications like dislodgement, clogging and leaking are commonly reported with an incidence as high as 44%. Intussusception is however a much rarer complication which may have catastrophic results and often needs urgent surgical intervention. We describe a case of a patient who underwent robot-assisted minimal invasive oesophagectomy but developed an intestinal obstruction in the follow-up period.
Case report
A 25-year-old woman, diagnosed with carcinoma of the middle third of the oesophagus, underwent minimal invasive oesophagectomy with two-field lymphadenectomy and a gastric pull-up after neo-adjuvant chemoradiotherapy. A feeding jejunostomy (FJ) was established for immediate postoperative enteral nutrition. She was discharged on the tenth post-operative day (POD) with oral intake and supplementary FJ feeds.
She presented on the 31st POD with vomiting and bilious discharge from the anastomotic site in the neck. Contrast-enhanced CT scan done showed dilated proximal bowel loops with no passage of contrast beyond the FJ site. A classical ‘target’ sign was seen suggesting a jejuno-jejunal intussusception (Figure 1).
A CECT scan showing the intussuscepted bowel with mesentery inside the intussusception.
At operation, an anterograde intussusception in the mid-jejunum with the feeding jejunostomy tube inside the intussuscepted segments was found. The tip had migrated distally, but was not lost and was 12 cm distal to the intussusception in the intussuscipiens. Gangrenous irreducible bowel was resected and an end-to-end anastomosis performed. The post-operative recovery was uneventful.
Discussion
Feeding jejunostomy is commonly used in patients undergoing curative or palliative surgery for gastrointestinal malignancy to overcome the effects of malnutrition. Despite its establishment being popular and simple, it nonetheless brings with it a complication rate as high as 44%. 1 Apart from problems with the stoma itself, complications associated with tube itself may be by knotting, coiling, kinking or just becoming occluded (most commonly caused by giving crushed medications through the tube). 2 Obstruction due to FJ tube can occur due to narrowing of the lumen due to overzealous ‘burying’ of the tube or hematomas.
The incidence of FJ-induced intussusception is <1%. 3 Since, if the end of the feeding tube remains distal to the intussuseptum, passage through it will not be obstructed; thus, classical signs of intestinal obstruction will not be present. Consequently, signs will be delayed till bowel infarction ensues. The exact mechanism of FJ tube-induced intussusception is unknown, but it is probable that the tip of the tube acts as the lead point of the intussuscipiens; forceful injection of feed may provoke retrograde peristalsis aiding this process. 4
In our case, the intussusception, however, was neither near the entry nor the tip of the tube. Although the exact reason for its occurrence is not understood, it may be related to the inadvertent creation of an internal hernia between the abdominal wall and the stoma or a redundant proximal loop.
A feeding jejunostomy may prove to be a double-edged sword. Whilst intussusception is a potentially fatal result, it is rare. Other possible consequences, however, must remind the surgeon that no intervention is entirely free of complication.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
