What are the indications for feeding jejunostomy in patients with conditions such as severe dysphagia, esophageal obstruction, or neurological disorders affecting swallowing, including those with head and neck cancers, amyotrophic lateral sclerosis (ALS), or severe stroke?

Indications for Feeding Jejunostomy

Feeding jejunostomy is indicated primarily as an adjunct procedure during major upper gastrointestinal surgery when postpyloric feeding is required, and as a standalone procedure for patients with neurological disorders causing severe dysphagia, gastroparesis, or when gastric feeding poses aspiration risk. 1

Primary Indications

During Major Upper GI Surgery

• Feeding jejunostomy should be placed concomitantly during esophagectomy, total gastrectomy, pancreatic surgery, or other major upper digestive tract operations where prolonged inability to feed orally is anticipated. 1
• Consider placement in patients undergoing operations where complicated postoperative recovery is expected, prolonged fasting periods are anticipated, or subsequent chemotherapy/radiotherapy will be needed. 1
• A multicenter RCT demonstrated that home enteral nutrition by jejunostomy after esophagectomy or total gastrectomy was feasible, safe, and led to substantial improvements in anthropometric parameters (weight, mid-arm muscle circumference, triceps skinfold) and functional outcomes (handgrip strength) at six months. 2

Postpyloric Feeding Requirements

• Jejunal feeding is specifically indicated when gastric feeding is unsafe or impossible due to:
  • History of aspiration or high aspiration risk 3
  • Gastroesophageal reflux disease 2, 3
  • Severe gastroparesis 3, 4
  • Delayed gastric emptying 2
  • Recurrent nausea and vomiting 3
• Unconscious patients who must be nursed flat require jejunal rather than gastric feeding. 2

Neurological Disorders

• Feeding jejunostomy as a sole procedure is indicated for:
  • Severe neurological swallowing disorders including stroke, motor neuron disease (ALS), multiple sclerosis, Parkinson's disease, and cerebral palsy 2, 5, 1, 4
  • Head injury with prolonged dysphagia 2
  • Neurodegenerative diseases where median duration of enteral support exceeds 250 days 2

Mechanical Obstruction

• Oropharyngeal or esophageal cancer causing obstruction 2, 5
• Head and neck cancers requiring prolonged nutritional support 2, 4
• Radiation enteropathy 5

Gastrointestinal Dysfunction

• Short bowel syndrome requiring supplementary nutrition 2, 5
• Enterocutaneous fistulae 2
• Esophageal stenosis 2
• Inflammatory bowel disease (Crohn's disease) when oral intake is inadequate 2
• Severe intestinal motility disorders 2

Other Specific Conditions

• Cystic fibrosis with malabsorption 2, 5
• Anorexia nervosa requiring nutritional support 4
• Huntington's chorea with feeding difficulties 4

Timing Considerations

Feeding jejunostomy should be considered when enteral feeding is anticipated for more than 4-6 weeks in patients at high nutritional risk who are unlikely to recover oral feeding ability in the short term. 5

• Initiate planning if nutritional intake is likely to be insufficient for one week or more. 2
• Consider if energy intake is less than 60% of estimated requirements for 1-2 weeks (usually <10 kcal/kg/day or deficit of 600-800 kcal/day). 2
• Patients with >5% unintentional weight loss over 1-3 months should be evaluated for enteral access. 2

Important Caveats

When NOT to Place Jejunostomy

• Life expectancy less than one month—jejunostomy should not be initiated. 2
• The procedure carries substantial risk (technical complication rates 1.5-6.6% depending on technique, with 0.14% mortality) and should only be performed when there is clear indication and high potential for long-term use. 6, 1
• Seven patients in one series died as direct result of jejunostomy complications, emphasizing this is not an innocuous procedure. 6

Complication Awareness

• Early complications (within 30 days) occur in approximately 19% of patients and include tube clogging (10.9%), dislodgement (4.1%), leakage (2.7%), and small bowel obstruction (2.7%). 7
• Late complications (>30 days) occur in approximately 20.5% of patients, most commonly tube clogging (8.2%) and dislodgement (8.2%). 7
• Metabolic complications include hyperglycemia (29%), hypokalemia (50%), and electrolyte imbalances. 1
• Gastrointestinal complications include diarrhea (2.3-6.8%), abdominal distension, and nausea. 1

Patient Selection Priorities

The decision must prioritize the patient's clinical benefit, carefully weighing risks versus benefits, and should never be performed for administrative convenience or as substitute for skilled nursing care. 5

• Patients must have adequate gastrointestinal function to absorb and tolerate enteral feeding. 2
• Ethical considerations regarding artificial nutrition must be thoroughly discussed with patient and family before placement. 2, 3
• Suitability should be confirmed by experienced gastroenterologist or nutrition support team member. 2
• Prognosis of swallowing difficulty should be assessed by a specialist before proceeding. 2