Small bowel perforation consecutive to feeding jejunostomy: A case report

Jejunostomy is a surgical procedure by which a tube is placed in the lumen of the proximal jejunum to administer nutrition when the oral route is impossible or insufficient. It is a rather safe procedure. Major complications are rare, but they can be lethal, nevertheless.

We report a case of a 57-year-old male patient, with a history of smoking and chronic obstructive pulmonary disease, who initially presented with dysphonia, and was diagnosed with a moderately differentiated epidermoid carcinoma of the larynx (T4N0M0) on CT scan, confirmed on direct laryngoscopy with biopsies and pathology work-up. Following a curative approach decision, the patient received 3 cures of induction chemotherapy with TPF (Docetaxel, Cisplatin, and Fluorouracil) before being lost to follow-up.

One year later, the patient re-engaged, presenting with significant dysphagia to both liquids and solids in addition to aphonia. He was subsequently hospitalized and benefited from a palliative feeding jejunostomy utilizing the Witzel technique.

Postoperative course was marked, on day 1, by mild fever and basal crepitations at chest auscultation. A chest X-ray was performed showing bilateral lower lobe consolidation. The evolution was marked by an aggravation on day 3, despite antibiotics take, with an abdominal tenderness associated with a persisting fever, tachycardia (145 bpm), a blood pressure of 105/62 mmHg, an oxygen saturation of 85% (on high concentration oxygen mask at 20 L/min). Lab tests showed a C-reactive protein reaching up to 214 mg/L, and an elevated white blood cell count to 14350 cells/μL.

A thoracoabdominal CT scan was performed subsequently, which revealed on the thoracic floor, a bilateral lower lobe consolidation, associated with a bilateral pleural effusion (Figure 1). On the abdominal floor, however, we noticed an extradigestive distal end of the jejunostomy tube, associated with a voluminous pneumoperitoneum, which was abundant and predominant around the tube end (Figure 2), keeping with a small bowel perforation.

The evolution was marked by respiratory fatigue, and hemodynamic instability. The patient unfortunately died soon after CT was performed, due to multiorgan failure, despite maximal supportive measures, including intubation and norepinephrine initiation.

Jejunostomy is indicated for enteral nutrition when oral route is impossible or insufficient, and when nasoenteral tube is not possible (due to obstruction or motility disorders or due to high risk of gastric content aspiration), and when enteral nutrition is expected for a time exceeding four weeks [1], [2], [3]. It is generally performed in case of impaired swallowing caused by neurologic conditions or head trauma, luminal obstruction from malignancy or other causes, motility disorders such as gastroparesis, Crohn’s disease, and during upper digestive tract surgeries such as esophagectomy, gastrectomy, and pancreatic interventions especially on patients for whom postoperative complications are expected [2], [3].

It is, however, contra-indicated in case of: Absence of intestinal function, severe inflammation, complete intestinal obstruction or complete ileus, severe burns or multiple traumas making the access to the gut not possible, high loss intestinal fistulae, severe diarrhea, severe malabsorption (e.g., small bowel syndrome), or active gastrointestinal bleeding [1].

Major complications related to feeding jejunostomy (Bowel necrosis, obstruction, or perforation) have an incidence ranging between 1.7% and 5% in many studies. Nevertheless, other authors have reported much higher rates [4]. Feeding jejunostomy utilizing the Witzel technique is a rather safe procedure. The incidence of related major complications is about 1.5–2.1% [5], [6].

Small bowel perforation as a complication of this surgical procedure is rare. And it is probably due to localized pressure necrosis of the bowel wall caused by constant pressure exerted by the tip of the feeding tube. Using soft tipped tubes and fixing the bowel wall to the anterior abdominal wall to prevent rotation can help avoid this complication [6].

Perforation should be suspected on physical examination in case of abdominal tenderness and could be diagnosed on CT scan if it reveals the tip of the tube localized outside of the bowel wall, surrounded by a voluminous pneumoperitoneum, or if it shows leakage of feeding solution into the peritoneal cavity.

When an intra-abdominal complication is suspected, the feeding should immediately be stopped [4]. Computed tomography scan can have a fundamental role in helping with the diagnosis of potential complications, particularly with opacification, looking for extravasation of contrast.

A relaparotomy should be performed, based on persisting clinical signs, to explore the abdomen and to treat a potential complication, even if imaging is without anomalies.

In case of jejunal ischemia, the affected segment should be resected. Immediate anastomosis is often not possible due to the risk of leak [7].

In case of a perforation associated with a collection, or a feeding leak, an exhaustive washing of the abdominal cavity should be performed, with bowel resection of ischemic loops. However, if there is no feeding leak nor ischemia, then the perforation and the feeding jejunostomy site should be closed; and the tube replaced by a new one positioned distally [6], [8].

In case of inspissated feed within the jejunum without ischemia nor necrosis, the feeding tube should be removed and the inspissated feed evacuated with suction [7].

This case reminds us of the importance of limiting feeding jejunostomy to narrow indications, and the importance of being attentive to surgical details including the use of a more blunt and soft tipped tube, a proper positioning of the bowel loop distal to the tube, and a proper fixation of the bowel wall to the anterior abdominal wall which help prevent this complication. It also spotlights the importance of recalling the diagnosis of perforation in front of abdominal tenderness with increasing biological infectious markers. And it highlights the fundamental role of CT scan (with opacification eventually) in establishing the diagnosis. We also weight the value of emphasizing the importance of continuous care to both the patient and his family members, and the importance of reaching for the patient through phone calls and other correspondence means to encourage him to re-engage in treatment after missing appointment. As these measures can help prevent the patient from being lost to follow up and hence avoid the progression of the tumor.