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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 65-67

Nasojejunal tube in the treatment of enterocutaneous fistula: A blessing in disguise


1 Department of General Surgery, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Gastroenterology, Zulekha Hospital, Sharjah, United Arab Emirates

Date of Submission28-Aug-2017
Date of Acceptance24-Oct-2017
Date of Web Publication25-May-2018

Correspondence Address:
Jacob Jayakar Raju Mandapati
Department of General Surgery, Pondicherry Institute of Medical Sciences, Kanakachettykulam, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_45_17

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  Abstract 


We present a patient who developed a jejunocutaneous fistula following jejunal resection, in whom a nasojejunal tube was placed with the tip distal to the fistula. Although the primary purpose of placing the tube was for feeding, the output from the fistula that was averaging 600 ml/day, stopped completely on the day after the tube was placed and the wound healed within 10 days. In this report, the role of a nasojejunal tube in functioning as an internal scaffold to facilitate closure of an enterocutaneous fistula is highlighted.

Keywords: Enterocutaneous fistula, high-output jejunocutaneous fistula, nasojejunal tube


How to cite this article:
Raju Mandapati JJ, Alexander T. Nasojejunal tube in the treatment of enterocutaneous fistula: A blessing in disguise. J Curr Res Sci Med 2018;4:65-7

How to cite this URL:
Raju Mandapati JJ, Alexander T. Nasojejunal tube in the treatment of enterocutaneous fistula: A blessing in disguise. J Curr Res Sci Med [serial online] 2018 [cited 2018 Nov 15];4:65-7. Available from: http://www.jcrsmed.org/text.asp?2018/4/1/65/233194




  Introduction Top


Nasojejunal tubes have been used for postpyloric feeding in patients with acute pancreatitis, those at risk of regurgitation and also to give enteric feeds distal to a duodenal fistula. Management of an enterocutaneous fistula is a challenging, laborious, and time-consuming task. Healing of jejunal fistulas which are known to take the longest time to heal, may be expedited by the use of a nasojejunal tube placed beyond the fistula. We report the use of a nasojejunal feeding tube, which facilitated the healing of a jejuno-cutaneous fistula.


  Case Report Top


A 50-year-old gentleman presented to the accident and emergency department with features suggestive of intestinal obstruction. The patient was evaluated preoperatively with requisite investigations and taken up for an exploratory laparotomy. Intraoperatively, he was found to have a gangrenous segment of the jejunum, measuring 100 cm in length, beginning about 30 cm distal to the duodenojejunal junction. The cause for the intestinal obstruction and the subsequent the gangrene was an adhesion band. A standard resection and primary anastomosis were performed. The patient was kept nil by mouth and appropriate antibiotics were given. On the 9th postoperative day, he developed an anastomotic leak, which became a high-output enterocutaneous fistula draining about 600 ml/day. He was managed conservatively for 20 days with IV fluids, TPN, and somatostatin. However, the output did not reduce and the patient developed features of sepsis. On the 30th postoperative day, it was decided to start him on enteric feeds through a nasojejunal tube sited beyond the fistula. A particularly long nasojejunal tube (16Fr, 240 cm manufactured by Blue Neem medical devices private limited. [Figure 1]) was introduced through a therapeutic upper gastrointestinal endoscope (Olympus TJF 160) under fluoroscopic guidance and placed with the distal few centimeters beyond the fistula [Figure 2]. The very next day it was observed that the drainage from the fistula had stopped completely and the wound slowly started granulating. The patient tolerated the feeds given through the nasojejunal tube and made a rapid clinical improvement. The tube was removed on the 8th day following insertion since it got blocked, but by then, the abdominal wound had healed and he was started on oral feeds.
Figure 1: Long nasojejunal tube used for the procedure

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Figure 2: Fluoroscopic image of the tube being inserted beyond the fistula (dye leak) which is indicated by the black arrow and the tip of tube is indicated by the white arrow

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  Discussion Top


Enterocutaneous fistulas, defined as abnormal communications between the bowel and skin, are among the most challenging conditions managed by the general surgeon. In an era when the mortality from pancreaticoduodenectomy has dropped to <3%, the mortality of enterocutaneous fistulas remains 10%–30% due to the accompanying complications of sepsis, malnutrition, and electrolyte disturbances.[1]

It is well known that the early institution of enteric nutritional support significantly reduces the incidence of septic complications, decreases mortality, and shortens the duration of hospital stay in patients with enterocutaneous fistulas.[2]

A structured approach to the management of enterocutaneous fistulas results in improved outcomes. Physiologic stabilization of the postoperative patient focused on hemodynamic and fluid support along with aggressive sepsis control are the important initial maneuvers. Subsequent optimization of nutrition and wound care allows the patient to regain a positive nitrogen balance and facilitates healing. Advanced wound care techniques help to maximize healing as well as the quality of life.[3]

Nasojejunal tube placement for enteric feeding is indicated for short-term feeding lasting <4 weeks. Although gastric feeding is considered the best mode of feeding, jejunal feeding is done when gastric feeding is contraindicated. Nasoenteric feeding has its own set of complications such as nasopharyngeal ulcers, necrosis of the nasal septum, and hoarseness of the voice. The advantage of nasoenteric tubes over gastric tube is the reduced risk of aspiration. The major disadvantages include difficulty in tube placement, clogging of the tube, and failure to maintain its position. Nasojejunal tubes are often inserted into the stomach at the bedside with migration into the jejunum occurring by peristalsis. This can be facilitated by the administration of prokinetic drugs such as erythromycin or metoclopramide.[4]

In this patient, an extra-long (240 cm) nasojejunal tube was sited over a guide wire through a therapeutic upper gastrointestinal endoscope having an extra-large instrument channel (6 mm) and fluoroscopic guidance. Final nasojejunal tube position confirming that the distal few centimeters were beyond the jejunal aspect of the enterocutaneous fistula was confirmed by injection of water-soluble contrast through the tube.[5]

The routine use of somatostatin infusion and somatostatin analogs remains controversial; although there are data suggesting reduced time to fistula closure, there is little evidence of the increased probability of spontaneous closure.[6]

Although there are numerous references in literature to the usage of nasojejunal feeding, there are none which highlight its usefulness in patients with high-output enterocutaneous fistulas. Feeding beyond the fistula with a long nasojejunal tube could help not only in giving adequate enteral nutrition to the patient but also by acting as a stent in providing an internal scaffold and stemming the flow of contents through the fistula and thus hastening healing. This simple modality appears to be another valuable tool in the management of such patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Evenson AR, Fischer JE. Current management of enterocutaneous fistula. J Gastrointest Surg 2006;10:455-64.  Back to cited text no. 1
    
2.
Silk DB. The evolving role of post-ligament of Trietz nasojejunal feeding in enteral nutrition and the need for improved feeding tube design and placement methods. JPEN J Parenter Enteral Nutr 2011;35:303-7.  Back to cited text no. 2
    
3.
Bleier JI, Hedrick T. Metabolic support of the enterocutaneous fistula patient. Clin Colon Rectal Surg 2010;23:142-8.  Back to cited text no. 3
    
4.
Stone SJ, Pickett JD, Jesurum JT. Bedside placement of postpyloric feeding tubes. AACN Clin Issues 2000;11:517-30.  Back to cited text no. 4
    
5.
Lalitha K, George LB. Enteral nutrition support. In: Fischer JE, editor. Mastery of Surgery. Vol. 1. 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2007.  Back to cited text no. 5
    
6.
Lloyd DA, Gabe SM, Windsor AC. Nutrition and management of enterocutaneous fistula. Br J Surg 2006;93:1045-55.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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