Enteral nutrition (EN) is an important component of advanced life support in the critically ill patient, and has demonstrated to be more physiologic, cheaper and with better results than parenteral nutrition (PN) in terms of immune response, preserving the gut microbiome and with fewer complications than those associated with vascular accesses. Jejunostomy for enteral nutrition is indicated when the oral route is impossible and the use of a nasogastric or nasojejunal feeding tube is contraindicated; it is a feeding route with low rate of complications¹.

Many techniques are used for jejunostomy: Witzel open jejunostomy, needle catheter jejunostomy using the Seldinger technique, percutaneous endoscopy, and laparoscopy. We perform needle catheter jejunostomy using the Seldinger technique. A 5-cm long subserosal tunnel is created with saline injection using a fine needle, and a 7.6 Fr multi-fenestrated plastic catheter is inserted through the submucosa into the intestinal lumen (Fig. 1). We routinely indicate jejunostomy for enteral nutrition in patients undergoing total gastrectomy and esophagectomy, and in cases of suture failure of subtotal gastrectomy; in this case, jejunostomy is performed during reoperation, with a low rate of complications which are rarely serious, except for this case. The patient leaves the operating room with intrajejunal infusion of 5% glucose solution, and after 24 hours we start using a commercially available enteral nutrition formula, gradually increasing the dose according to the patient’s tolerance and requirements.

Figure 1 A: Needle catheter jejunostomy using the Seldinger technique with a 7 Fr multi-fenestrated catheter. B: Subserosal saline injection. Catheter tunneled towards the submucosa C: Catheter fixation D: Catheter exteriorized through the abdominal wall 

The complications of enteral nutrition by jejunostomy are rare and usually mild, but occasionally they can be serious and even fatal. Bowel necrosis due to non-occlusive mesenteric ischemia (NOMI) has been described as an exceptional complication, with a mortality of about 70%².

The diagnosis of this complication is difficult, especially in the critically ill patient under sedation and orotracheal intubation. Most cases present with abdominal pain and progressive bloating. Other manifestations include ileus and absence of bowel sounds. The laboratory tests show metabolic acidosis typical of mesenteric ischemia. A computed tomography (CT) scan may show lack of perfusion of the bowel mucosa or intramural bowel gas.

Treatment consists of discontinuing the use of jejunostomy and, in case of suspected irreversible ischemia, surgical resection of the affected segments. The restoration of intestinal continuity or creation of an ostomy will depend on each case.

We report a case of bowel necrosis associated with a jejunostomy performed for enteral nutrition in a patient who underwent oncologic gastrectomy.

The patient was a 62-year-old man current smoker without a history of cardiovascular disease with an adenocarcinoma of the gastric antrum with elements of stenosis, dietary vomiting, and mild anemia (Hb 9.1 mg/dL). He had poor clinical status with weight loss of about 5 kg and albumin levels of 3.9 g/dL.

A subtotal gastrectomy with Roux-en-Y gastrojejunostomy was performed, with unfavorable postoperative outcome and biliary peritonitis on postoperative day 5 requiring reoperation. Diffuse biliary and suppurative peritonitis was observed due to inadequate duodenal stump closure, with no evidence of mesenteric ischemia. The duodenal stump was repaired, the peritoneum was washed and a jejunostomy was created for enteral nutrition with a needle catheter using the Seldinger technique on the healthy bowel. The abdomen was left open with temporary closure using Bogota bag vacuum-assisted closure. Scheduled laparotomies were performed every 48 hours for peritoneal lavage. The abdomen was closed on the fourth day and enteral nutrition through the jejunostomy was started on the following day (500 mL in 24 hours on the first day which increased to 1000 mL/day from the second day onwards).

The patient had an unfavorable course with hemodynamic impairment, requiring a higher dose of vasopressor agents and presented persistent metabolic acidosis. Therefore, three days after enteral nutrition was initiated, the patient was reoperated. Diffuse peritonitis with bowel necrosis was observed, together with extensive patchy perforation of the jejunum in an area of about 40 cm around the jejunostomy. The sediment of the enteral nutrition formula was visualized inside the bowel in a near-solid state (Fig. 2). The involved segment of the jejunum was resected and anastomosed, the abdomen was left open with temporary closure using Bogota bag, but the patient developed refractory shock and died a few days later.

Figure 2 Non-occlusive mesenteric necrosis associated with feeding jejunos tomy. Extensive ulcerated necrotic plaque and the solidified enteral nutrition formula in the bowel lumen. 

On gross examination, the pathology examination reported a surgical specimen of small bowel 42 cm long with pseudo-membranes on its external surface, areas of necrosis with perforation and other areas with hemorrhage. On microscopic examination, there was an acute inflammatory process of the bowel with necrosis and areas of deep ulceration extending through all the bowel layers.

Although the rate of complications associated with enteral nutrition through jejunostomy is low, they may occur and can be serious. The most common complications are intolerance (expressed by different degrees of abdominal bloating, diarrhea, colicky pain or vomiting), bleeding, wall infection, biliary leakage and peritonitis³. The incidence of NOMI ranges from 0.14% to 1.7% according to the different series and the mortality rate is about 70%^4,5.

The pathogenesis of bowel necrosis associated with feeding jejunostomy remains uncertain. High-osmolarity formula, sepsis, previous malnutrition, ileus and hypovolemic shock with use of vasopressor agents have been related with the development of NOMI⁶. In this patient, postoperative ileus and hemodynamic impairment may have contributed to disease progression.

The percentage of complications associated with feeding jejunostomy is low. In a series of 100 cases treated in our department, we reported 10% of temporary intolerance, which improved by reducing the volume of the commercially available formula, and 2% of jejunostomy obstruction that required other feeding methods (parenteral), without serious complications⁷. At present, we have performed jejunostomies in more than 200 patients, and the one here described is the first case of non-occlusive mesenteric necrosis.

Although the benefit of enteral nutrition is widely known, it is important to acknowledge the existence of its complications, which, although they are usually mild, they can sometimes be serious and even fatal. Shock and ileus are contraindications for enteral nutrition and other routes of feeding should be used. This complication should be suspected in case of abdominal bloating, abdominal pain, and metabolic acidosis. In such cases, EN should be discontinued and replaced by parenteral nutrition, and the need for emergency surgery should be evaluated.