• Informed consent regarding the procedure, type of anesthesia, and potential complications must be obtained. 
• The patient should be nil per os (NPO) for at least 6 hours before the procedure.
• Antibiotic pre-surgical prophylaxis should be given as per institutional guidelines.
• Reliable bedside suction should be present.
• Intravenous sedation should be provided and administered at the bedside.

There are four techniques for jejunostomy placement: open surgical technique (longitudinal or transverse Witzel), laparoscopic technique, needle catheter technique, and percutaneous technique. Although the preferred technique depends on the type of patient and expertise of the surgeon, the minimally invasive techniques are standard of care.

Open Surgical Technique

The patient is prepped and draped with sterility. An exit site is chosen in the LUQ, preferable a few centimeters away from the midline. A stab incision is made and dissected with tonsil forceps. A loop of proximal jejunum is delivered into the wound. A diamond-shaped purse-string suture is tied to the antimesenteric border of the jejunal loop, and a small incision is given in the center of the suture, large enough to accommodate the jejunostomy tube. The tube is inserted into the jejunum with care to ensure enough length of tube into the jejunum to prevent the backflow of tube feeds. The purse-string suture is secured tightly without kinking the tube.

The Witzel technique is used to prevent extravasation of enteric contents at the exit site of the jejunostomy tube. This involves placing the tube along the length of the bowel for about 5 cm proximally and creating a serosal tunnel to imbricate the tube into position. The serosal tunnel is created by taking perpendicular Lambert sutures with 3-0 silk on either side of the tube. Once the tube is delivered through the abdominal wall, the jejunal loop is attached to the abdominal wall with seromuscular sutures. This is done to prevent bowel obstruction or volvulus.[10]

Laparoscopic Technique 

It is a minimally invasive approach and preferred modality with the current advancement of technology. The patient is placed in a supine position initially, and after the creation of pneumoperitoneum and visual entry into the abdomen, the ligament of Treitz is visualized by upward retraction of the bowel and removal of omentum. The patient is kept in a reverse Trendelenburg position to allow the bowel to be traced. The jejunum is traced from the ligament of Treitz for 1-2 ft, and a site is chosen, which may be adhered to the abdominal wall. Four seromuscular sutures in the shape of a diamond are placed on the antimesenteric border of the jejunum. The loose ends of the sutures are used to pull the jejunum to the corresponding site over the abdominal wall. A percutaneous needle is used to enter the jejunum, and a guidewire is passed into the jejunum. The opposite side of the abdominal wall is inspected to make sure the guidewire has not passed through. Using serial dilators, the skin and subcutaneous tissue are dilated to make a track for the passage of the jejunostomy tube with a stent. Once the tube is in position, the stent is removed, and the balloon is inflated. The tube is secured in position, and laparoscopic incisions are closed with sutures and glue.[11][12]

Needle Catheter Technique

This technique is often used as part of laparotomy with major gastrointestinal resection. A submucosal tunnel is created through the anti-mesenteric well of the jejunum with a needle catheter after its introduction into the abdominal cavity. The tunnel should be about 4-5 cm. This prevents the development of fistula after the placement of the tube. The catheter is introduced through the needle and sutured to the jejunal wall with a purse-string suture. Finally, the jejunum is attached to the peritoneal lining with sutures. Tube feeds can be started soon after surgery, within 6-12 hours.

Percutaneous Technique (Direct Percutaneous Endoscopic Jejunostomy) 

Percutaneous insertion is done with the help of endoscopy. An enteroscope or colonoscope is passed into the jejunum. Transillumination of the tip of the scope is used to identify the position of the endoscope over the abdominal wall. A trocar is inserted through the abdominal wall into the jejunum, and a guidewire is passed distally into the jejunum. The tips of an awaiting snare or forceps are used to grasp the wire. A dilator is subsequently passed to create the track for the tube, and the tube is secured similarly to a ‘pull-PEG’ technique.[13][14]

There is no evidence suggesting the type of jejunostomy tube with the lowest rate of complications; however, all techniques are associated with complications. Complications may be classified into mechanical, infectious, gastrointestinal, and metabolic complications. 

Mechanical 

Intestinal obstruction is a frequent complication and can be caused by over-inflation of the balloon; deflation of the balloon is both diagnostic and therapeutic. Transverse Witzel technique has been associated with the reflux of intestinal contents from intestinal ischemia and erosion of mucosa by the tube. Needle catheterization has been associated with withdrawal or blockage of the catheter, enterocutaneous fistulas, intestinal pneumatosis, and intestinal abscesses within the tunneled tube site. A laparoscopic jejunostomy is associated with inherent complications of laparoscopic surgery, such as problems arising from increased intra-abdominal pressure and anesthetics. 

Infectious 

Pneumonia from aspiration and contamination of feeds are the two common infectious complications. Aspiration may result from improper placement of the jejunostomy tube. A tube placed proximally may be associated with reflux. Some studies have shown that continuous enteral nutrition is associated with aspiration pneumonia in critically ill patients.[15]

Gastrointestinal 

Nausea, vomiting, diarrhea, abdominal distension, and colic are some of the frequently observed complications. The type of feed being used plays an essential role in the severity of complications.

Metabolic 

Hypokalemia, hyperglycemia, and acid-base balance disturbances are frequently observed. Some causes are the improper placement of the jejunostomy tube, the use of incorrect feeds, and failure to correct resulting biochemical abnormalities.[9] As the stomach and duodenum are bypassed, there is the possibility of deficiencies of vitamin B12 and iron, absorbed through these two organs, respectively. Initiation of tube feeding after a period of starvation may lead to the development of refeeding syndrome characterized by hypokalemia, hypophosphatemia, and hypomagnesemia. The pathophysiology is believed to be related to the release of insulin from the pancreas when feeding is initiated. It often manifests in ICU patients as hemodynamic instability, respiratory failure, and other non-specific features.[16]

A feeding jejunostomy is a vital technique to achieve enteral access when a contraindication to the placement of a gastrostomy tube is present. It is sometimes also a part of a more extensive surgical procedure such as esophageal or gastric resection. Multiple techniques exist to place a feeding jejunostomy; however, minimally invasive methods are preferred. Complications are related to the type of feed used or mechanical causes. The feeding jejunostomy is a relatively simple procedure that can be performed by general surgeons.

When the decision is made to initiate enteral feeding in a patient, the involvement of a multidisciplinary team is vital in improving cost-effectiveness and patient satisfaction.[17][18] The interprofessional team comprises of the provider, surgeon, dietician, speech-language therapist, and nurse. Home enteral nutrition team is a new concept that has been shown to increase the effectiveness of enteral feeding through reduction of hospital admissions, reduction of waste of feeds, and optimization of nutritional status.[17] The surgeon is an integral part of the team in determining the best possible long-term enteral access for patients and managing complications.