Laparoscopic versus open feeding jejunostomy insertion in oesophagogastric cancer

Laparoscopic versus open feeding jejunostomy insertion in oesophagogastric cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Laparoscopic versus open feeding jejunostomy insertion in oesophagogastric cancer Sotiris Mastoridis, Giada Bracalente, Chistine-Bianca Hanganu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-45981/v3 This work is licensed under a CC BY 4.0 License Status: Under Review Version 3 posted 9 You are reading this latest preprint version Show more versions Abstract Background: Jejunal feeding is an invaluable method by which to improve the nutritional status of patients undergoing neoadjuvant and surgical treatment of oesophageal malignancies. However, the insertion of a feeding jejunostomy can cause significant postoperative morbidity. The aim of this study is to compare the outcomes of patients undergoing placement of feeding jejunostomy by conventional laparotomy with an alternative laparoscopic approach. Methods: A retrospective review of data prospectively collected at the Oxford Oesophagogastric Centre between August 2017 and July 2019 was performed including consecutive patients undergoing feeding jejunostomy insertion. Results: In the study period, 157 patients underwent jejunostomy insertion in the context of oesophageal cancer therapy, 126 (80%) by open technique and 31 (20%) laparoscopic. Pre-operative demographic and nutritional characteristics were broadly similar between groups. In the early postoperative period jejunostomy-associated complications were noted in 54 cases (34.4%) and were significantly more common among those undergoing open as compared with laparoscopic insertion (38.1% vs 19.3%, P = 0.049). Furthermore, major complications were more common among those undergoing open insertion, whether as a stand-alone or at the time of staging laparoscopy (n = 11/71), as compared with insertion at the time of oesophagectomy (n = 3/86, P = 0.011). Conclusions: This report represents the largest to our knowledge single-centre comparison of open versus laparoscopic jejunostomy insertion in patients undergoing oesophagectomy in the treatment of gastroesophageal malignancy. We conclude that the laparoscopic jejunostomy insertion technique described represents a safe and effective approach to enteral access which may offer superior outcomes to conventional open procedures. Surgery General Surgery Laparoscopic Feeding Jejunostomy Oesophagogastric Cancer Figures Figure 1 Background Oesophageal cancer is the eighth most common cancer worldwide [1]. It is a highly lethal condition, leading to over 400,000 deaths annually [2]. The incidence of weight loss in patients with oesophageal cancer is among the highest of all cancer types. The majority of patients with oesophageal cancer will have experienced a significant degree of weight loss by the time of diagnosis and will have complex nutritional needs [3]. The effect of such weight loss on patient performance status can be detrimental to the delivery of gold-standard multimodal treatment strategies and, consequently, can adversely impact survival outcomes. The likelihood of encountering severe dose-limiting toxicity is substantially greater among individuals with nutritional deficiency who undergo chemotherapy [4]. It is evident, therefore, that the nutritional status of patients with oesophageal cancer should be carefully considered during the diagnostic and staging phases; and routine nutritional assessment should form a central component of the multimodal treatment of patients [5]. In their systematic review and meta-analysis of randomized controlled trials, Mazaki and colleagues demonstrated that, when compared to parenteral nutrition, enteral nutrition was associated with fewer infectious complications, anastomotic leaks, intra-abdominal abscesses, overall complications, and decreased length of hospital stay [6]. Feeding jejunostomy is the most commonly employed approach to enteral nutrition in patients undergoing treatment for oesophageal malignancy, given that sparing of the stomach is necessary for its potential use as a conduit to replace the resected oesophagus. Jejunostomy insertion can be performed open via laparotomy, laparoscopically, or by percutaneous techniques assisted either endoscopically or using other imaging modalities. In patients with severe dysphagia or with significant weight loss (≥10%) at presentation, a jejunostomy is usually placed at the time of the staging laparoscopy or as a stand-alone procedure. The goal is to support the patient’s nutritional status and hydration during neo-adjuvant treatment. When a jejunostomy is not indicated before neo-adjuvant treatment it is usually placed at the time of oesophagectomy to provide fluids and nutrition if the oral route is compromised, for instance in the case of anastomotic leak. Given the variation in timing and technique of jejunostomy insertion, the aim of this study is to compare outcomes of subjects undergoing open and laparoscopic jejunostomy insertion in the management of oesophageal malignancy. Methods Retrospective review was performed of databases prospectively compiled between August 2017 and July 2019 at the Churchill Hospital, Oxford, UK. The indication for jejunostomy was decided by multidisciplinary team discussion involving surgeons, oncologists, gastroenterologists, and dietitians according to the severity of dysphagia, weight loss, and nutritional status. Demographic data and baseline patient characteristics including age, gender, body mass, preoperative serum albumin, performance status (Eastern Cooperative Oncology Group, ECOG), American Society of Anaesthesiologists physical status classification (ASA grade), TNM staging, relevant comoborbidities, and oesophagogastric tumour histology were reviewed. All jejunostomy procedure-related complications were collated and classified in accordance with Clavien-Dindo (CD) scoring, whereby minor complications are those scoring 2 or less and major complications constitute those scoring 3 or more [7]. Surgical Techniques For both the open and laparoscopic techniques described, a 9 Fr feeding jejunostomy tube kit was used (Freka® Surgical Jejunostomy Set ENFit®, Fresenius Kabi). In instances where feeding jejunostomy placement was performed at the time of oesophagogastrectomy, laparoscopic insertion was performed where the abdominal phase of the resectional procedure was performed minimally invasively. The decision as to whether jejunostomy was performed laparoscopically or open at SP was determined primarily by surgeon preference. Open insertion was performed via a midline laparotomy employing the Witzel technique - the most common method of jejunostomy creation [8]. The duodenojejunal (DJ) flexure was identified and a loop of jejunum selected and confirmed to reach the abdominal without excess tension. The jejunostomy tube was introduced into the jejunum using the dedicated kit through a purse string suture made with absorbable monofilament on the small bowel. A 2 cm submucosal tunnel was created with the introducer and subsequently a short Witzel tunnel made with 3/0 absorbable monofilament to prevent leak of enteric content. The small bowel was secured to the abdominal wall with parachuting sutures, and the jejunostomy secured to the skin with the flange provided using non absorbable braided or monofilament sutures. Where open jejunostomy was performed concurrently with open oesophagectomy, the jejunostomy was introduced via the established abdominal incision. Laparoscopic jejunostomy insertion was performed using a three-port technique modified from Senkal and colleagues (Fig. 1. An additional movie file demonstrates the technique in further detail, see Additional file 1) [9]. Briefly, a 12mm laparoscopic port was placed in the right flank to accommodate the laparoscope, and a further two 5mm working ports were inserted under vision. The DJ-flexure was identified, and a loop of proximal jejunum confirmed to reach the abdominal wall with ease was selected. Placement of two absorbable braided sutures in a ‘W’ configuration was performed to define a square area that would become the jejunostomy insertion point (Fig. 1B). The four ends of the two sutures were retrieved outside the abdominal cavity through a 2-3mm skin incision using Endo Close TM Trocar Site Closure Device (Covidien, USA), and ensuring that the points of retrieval or exit from the peritoneum are adequately spaced to mirror the square area created by the sutures placed at the jejunum (Fig. 1D). The jejunostomy kit’s introducer is inserted through the abdominal wall into the jejunum, thereby permitting direct passing of the tube distally. Positioning is visually verified and tested by saline infusion, with vigorous flushing alongside gentle laparoscopic manipulation employed to promote uncoiling where possible. The intra-abdominal pressure is lowered to 5mmHg to enable parachuting of the small bowel up to the abdominal wall upon tying of the extracorporeal sutures. The procedure is completed by securing the jejunostomy tube using the flange supplied as per the open approach aforementioned. Statistical Analyses Statistical analyses were performed using GraphPad Prism v7.0 Software. Group comparisons of continuous variables were performed by t test, where normality was confirmed using the D’Agostino-Pearson, or by Mann-Whitney U test where not normally distributed. Chi-square or Fisher’s-exact test, when appropriate, were used to compare categorical variables. A P value of less than 0.05 was considered significant. Results After performing a database search, 175 consecutive jejunostomy procedures were identified during the study period, 157 of which were associated with the management of oesophageal malignancy and therefore eligible for inclusion. Of this cohort, 126 subjects underwent open jejunostomy insertion while 31 underwent laparoscopic insertion. Comparisons of subject characteristics between both groups are shown in Table 1, and operative approaches to resectional procedures are outlined in Table 2. While groups were comparable for gender, body mass index (BMI), serum albumin, pre-procedural performance status, tumour histology, and tumour stage, the laparoscopic group were marginally younger than those undergoing open surgery (P = 0.014). Comparisons of operative outcomes are shown in Table 3. Jejunostomy insertion was performed as a stand-alone procedure or in conjunction with a laparoscopic staging procedure (SP), which is to say prior to definitive oesophagectomy, in 71 (45.2%) of 157 cases. The remaining 86 (54.8%) cases underwent insertion at the time of tumour resection procedure (RP). A trend towards a higher incidence of complications was noted among those in the ‘staging’ (SP) group (29/71, 40.8%) as compared with the RP group (25/86, 29.1%), though this did not reach statistical significance (P = 0.12). The rate of major complications (CD≥3) however, was noted to be significantly higher at SP (P = 0.011), a finding predominantly attributable to the particularly high rates of complications seen in cases of open insertion in this setting (11/63, 17.5%, P = 0.016). Across all procedures performed, significantly fewer complications were encountered following laparoscopic insertion as compared with open (P = 0.049). Among the subset of cases undergoing jejunostomy insertion at SP, a substantially greater proportion of those performed open encountered major complications (11, 17.5%), than did those performed laparoscopically (0, 0%), though not reaching statistical significance (P = 0.34). Similarly, in the RP group, 21 major or minor complications were encountered among the 63 patients undergoing open jejunostomy placement (33.3%), whilst 4 (17.3%) were noted among the laparoscopic group (P = 0.19). In this setting however, although only jejunostomy-associated complications were analysed, the impact of the resectional approach itself is not controlled for. Median length of stay was longer amongst those undergoing open procedures in both the SP (1.5 vs. 3 days, P = 0.17) and the RP (9 vs. 10, P = 0.09). With regards to the small but significant difference of approximately 4 years in mean age among groups, increasing age was not noted to be associated with higher rates of complications (P = 0.10). One death occurred in the cohort of 157 cases (0.6%), and this was following open jejunostomy insertion at the time of staging. The death was associated with the perforation of a closed bowel loop involving a segment between the obstructive oesophageal tumour and the jejunostomy site. Discussion The integration of appropriate nutritional support into the overall management of patients undergoing curative treatment for cancer of the oesophagus is of utmost importance to the successful completion of neoadjuvant therapy and of surgery, as well as to survival outcomes [10,11]. Feeding jejunostomy is the preferred approach to long-term enteral feeding and, since minimally invasive techniques have many advantages, total laparoscopic or laparoscopically assisted methods of feeding jejunostomy insertion have garnered increasing attention [12]. This study, which represents the largest to our knowledge comparison of total laparoscopic and open jejunostomy insertion in the setting of oesophageal cancer, shows that laparoscopic feeding jejunostomy can be performed safely and has the potential to confer the benefits of minimally invasive surgery including lower rates of morbidity and shorter hospitalisations. Furthermore, the study highlights the risk of major complications among subjects undergoing jejunostomy insertion as an open stand-alone procedure. This finding is in keeping with the literature, wherein reported complication rates for this approach range widely but can reach 37% and beyond in some series [12,13]. One explanation for the higher rates of complication encountered in stand-alone open insertions is that such procedures are generally performed as ‘mini-laparotomies’ to avoid the morbidity of larger incisions. As a consequence, they may not afford sufficient exposure and access to ensure adequate visualisation of the DJ-flexure, jejunum, and abdominal wall. Suboptimal exposure can lead to inadvertent injury, kinking or narrowing of the lumen, and difficulties with fixation to the abdominal wall. The laparoscopic technique described here enabled excellent visualisation of the DJ-flexure and of the abdominal wall, and the use of the Endo Close TM device makes parachuting the jejunum to the abdominal wall uncomplicated. The direct puncture of the jejunum, without tunnelling, was a source of concern at the beginning of our experience, but leakage of enteric content was encountered in only one case and was successfully managed with antibiotics and temporary suspension of enteral feeding. A second consideration is that open procedures may be performed by less experienced junior surgeons as compared with laparoscopic approaches. In our series, the number of laparoscopic jejunostomy insertions was relatively lower (31 vs 126 open) due to the fact that only one senior surgeon in our unit employs the laparoscopic technique and, as a consequence, all such procedures were either performed by this senior surgeon or by a junior surgeon under direct supervision. In addition to this latter point, this study is limited by the small number, specifically in the subgroup of procedures performed laparoscopically as a staging or stand-alone procedure. The postoperative mortality in our series of 157 patients was 0.6%, again mirroring published reports. The single death involved a subject with an obstructing tumour at the gastro-oesophageal junction, a closed-loop obstruction which was diagnosed late, and multiple comorbidities. While mortality rates are low, the significant risks of minor or major complications highlight the value of careful patient selection pre-operatively, emphasise the importance of patient counselling and informed consent, and focus attention on the development of improved surgical approaches. The cost-effectiveness of laparoscopic surgery is often questioned. Though not formally assessed in our study, in broad terms the cost of the equipment and length of operation time should be balanced against potential benefits regarding the length of stay, cosmesis, reduced analgesic requirements, and improved outcomes. It is important to note, that laparoscopic jejunostomy insertion was predominantly performed in conjunction with either staging laparoscopy or with minimally invasive oesophagectomy, and thereby incurred no significant additional equipment costs. This study is limited by its retrospective nature and in that data is derived from a single centre. Though this represents the largest comparative study of total laparoscopic and open jejunostomy insertion in the setting of oesophageal cancer, the nevertheless is limited by its relatively small patient population. Future prospective studies comparing laparoscopic versus open feeding jejunostomy insertion are required to determine the superiority of either approach. Our report focuses on patients undergoing treatment for oesophageal malignancy and, however likely, it remains to be confirmed whether the findings hold true in patients undergoing jejunostomy insertion in the contexts of gastric, pancreatic, or hepatic malignancies for instance. Conclusions Feeding jejunostomy represents a key adjunct in the treatment of oesophageal malignancy. Though considered by some to be a routine, innocuous procedure, open insertion of feeding jejunostomy is a procedure which should not be underestimated. Keeping in mind the aims of successful neoadjuvant treatment and the reduction of early postoperative morbidity, any complications arising from such a procedure could jeopardise potential benefits and incur significant costs. The total laparoscopic approach outlined here can serve as a safe, effective alternative with the associated advantages of minimally invasive surgery. Abbreviations BMI: Body mass index CD: Clavien-Dindo Score DJ: duodenojejunal SP: Staging/Stand-alone Procedure RP: Resection Procedure Declarations Ethics approval and consent to participate The present study conforms to the Declaration of Helsinki. Ethical approval is waived per Oxford Central University Research Ethics Committee guidelines (CUREC). Written informed consent was provided for the use of intraoperative images. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to patient data confidentiality but are available from corresponding author upon reasonable request. Competing interest The authors declare they have no competing interests. Funding No source of funding. Author contributions BS, GB, BH, MN, AG were involved in conception and design; RG, RM, NM performed operations and were involved in manuscript reviews; SM, BS, BH, GB, MN, AG were involved in data interpretation, and manuscript preparation. All authors have read an approved the manuscript. Acknowledgements None to declare. References Ferlay J, Shin H-R, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. John Wiley & Sons, Ltd; 2010 Dec 15;127(12):2893–917. Parkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000. The global picture. Eur J Cancer. 2001 Oct;34:503–9. Martin L, Senesse P, Gioulbasanis I, Antoun S, Bozzetti F, Deans C, et al. Diagnostic criteria for the classification of cancer-associated weight loss. J Clin Oncol. 2015 Jan 1;33(1):90–9. Andreyev H, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies. Eur J Cancer. 1998 Dec;34(13):2132–3. Steenhagen E, van Vulpen JK, van Hillegersberg R, May AM, Siersema PD. Nutrition in peri-operative esophageal cancer management. Expert Rev Gastroenterol Hepatol. Taylor & Francis; 2017 Jul;11(7):663–72. Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg. 2nd ed. Springer-Verlag; 2008 Apr;12(4):739–55. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205–13. Tapia J, Murguia R, Garcia G, de los Monteros PE, Oñate E. Jejunostomy: techniques, indications, and complications. World Journal of Surgery. Springer-Verlag; 1999 Jun;23(6):596–602. Senkal M, Koch J, Hummel T, Zumtobel V. Laparoscopic needle catheter jejunostomy: modification of the technique and outcome results. Surgical Endoscopy. Springer-Verlag; 2004 Feb;18(2):307–9. Steenhagen E. Preoperative nutritional optimization of esophageal cancer patients. J Thorac Dis. 2019 Apr;11(S5):S645–53. Cox S, Powell C, Carter B, Hurt C, Mukherjee S, Crosby TDL. Role of nutritional status and intervention in oesophageal cancer treated with definitive chemoradiotherapy: outcomes from SCOPE1. Nature Publishing Group; 2019 Apr 6;:1–6. Han-Geurts IJM, Lim A, Stijnen T, Bonjer HJ. Laparoscopic feeding jejunostomy: A systematic review. Surgical Endoscopy. Springer-Verlag; 2005 May 12;19(7):951–7. Siow SL, Mahendran HA, Wong CM, Milaksh NK, Nyunt M. Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: the technique and review of outcomes. BMC Surgery; 2017 Mar 17;:1–10.14. Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg. 2008 Apr;12(4):739–55. Supplementary Files AdditionalFile1.mp4 Supplementary File: Intraoperative video demonstration of laparoscopic feeding jejunostomy placement and positioning. Cite Share Download PDF Status: Under Review Version 3 posted Editorial decision: Minor revision 06 Apr, 2021 Review # 2 received at journal 02 Apr, 2021 Reviewer # 2 agreed at journal 28 Mar, 2021 Reviewer # 1 agreed at journal 28 Mar, 2021 Review # 1 received at journal 28 Mar, 2021 Reviewers invited by journal 27 Mar, 2021 Editor assigned by journal 10 Feb, 2021 Editor invited by journal 10 Feb, 2021 Submission checks completed at journal 11 Jan, 2021 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-45981","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":7980081,"identity":"262012b4-e623-493d-8a5a-a46465b83028","order_by":0,"name":"Sotiris Mastoridis","email":"","orcid":"https://orcid.org/0000-0001-7689-2330","institution":"Oxford University Hospitals NHS Foundation Trust","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sotiris","middleName":"","lastName":"Mastoridis","suffix":""},{"id":7980082,"identity":"4bfaa2e4-5597-44e6-9403-fa862fb4bc5d","order_by":1,"name":"Giada Bracalente","email":"","orcid":"","institution":"University of L'Aquila","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Giada","middleName":"","lastName":"Bracalente","suffix":""},{"id":7980083,"identity":"9364a768-8749-422e-b40d-c87b5a58a384","order_by":2,"name":"Chistine-Bianca Hanganu","email":"","orcid":"","institution":"University of Cambridge Medical School","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chistine-Bianca","middleName":"","lastName":"Hanganu","suffix":""},{"id":7980084,"identity":"6264f240-8651-4c03-a03b-6f219f9cd8e7","order_by":3,"name":"Michela Neccia","email":"","orcid":"","institution":"University of L'Aquila Medical School","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Michela","middleName":"","lastName":"Neccia","suffix":""},{"id":7980085,"identity":"0df0f372-027a-4b9a-8d18-68a62af74f9d","order_by":4,"name":"Antonio Giuliani","email":"","orcid":"","institution":"University of L'Aquila Medical School","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Giuliani","suffix":""},{"id":7980086,"identity":"03d1c68f-a5a5-48dd-ae73-1c14e38d068b","order_by":5,"name":"Richard Gillies","email":"","orcid":"","institution":"Oxford Oesophagogastric Centre, Churchill Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Gillies","suffix":""},{"id":7980087,"identity":"5b33ce1a-6079-4865-bf4e-1c749e380b01","order_by":6,"name":"Robert Marshall","email":"","orcid":"","institution":"Oxford Oesophagogastric Centre, Churchill Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Marshall","suffix":""},{"id":7980088,"identity":"38f65fd9-ee63-4a1a-a8b6-3b26333e24f6","order_by":7,"name":"Nicholas Maynard","email":"","orcid":"","institution":"Oxford Oesophagogastric Centre, Churchill Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nicholas","middleName":"","lastName":"Maynard","suffix":""},{"id":7980089,"identity":"470f6d12-4145-4ab8-9966-ae054fd4657d","order_by":8,"name":"Bruno Sgromo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYBACAxTeBwaGBAYGHhAzgTgtjDNI1sLMQ4wWc+kzZg8+MNTZbW/vTnxsU3E4j0G69/AHxrY0nFos+3LMDWcwHE6ec+bsZuOcM4eLGWTOpUkwtuXgdtgZHjNpHoYDyRISudukc9sOJzZI5JgxMLZVENJSB9FiCdFi/IEILcx2YC2MEC0GeB1m2cNWJjnD4HCCBM/ZzYY9Z9IT24AOk0g4h9v75jzM2yQ+VNTZS7D3bnzwo8I6sR/ksA9lyTi1QJ3HkNgAY7OBiAQCGkDAngg1o2AUjIJRMFIBAL5VS0LhGzNdAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-1010-9301","institution":"","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Bruno","middleName":"","lastName":"Sgromo","suffix":""}],"badges":[],"createdAt":"2020-07-20 11:04:57","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.3.rs-45981/v3","doiUrl":"https://doi.org/10.21203/rs.3.rs-45981/v3","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":5059113,"identity":"add1abb7-03e0-4d75-8797-5293f5d10162","added_by":"auto","created_at":"2021-01-18 19:22:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":100681,"visible":true,"origin":"","legend":"Laparoscopic Jejunostomy technique. (A) Two jejunal sutures inserted in ‘W’ configuration leaving an approximately 1cm2 box target as shown in red in schematic representation (B). (C) Endo CloseTM device introduced via a 2-3mm skin incision for retrieval of suture ends. (D) peritoneal entry must be judged to ensure creation of a 1cm2 box configuration which mirrors that at the jejunum. (E) Jejunostomy insertion trocar targeted at centre of jejunal box target. (F) Jejunostomy tube delivered via trocar, with visual confirmation of placement towards distal limb, and saline flush of tube for confirmation of patency and positioning. (G) Antirotation suture placed at nearby distal jejunal limb.","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-45981/v3/42074256ce72571c88016c00.jpg"},{"id":13648361,"identity":"f8697288-4b81-4123-82c0-3f0f95b27b1a","added_by":"auto","created_at":"2021-09-17 09:32:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":513062,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-45981/v3/4018aa11-3758-44be-ab1d-88db7e67f4b2.pdf"},{"id":5059281,"identity":"689b6257-7e5f-4abd-8660-b23a53c44be7","added_by":"auto","created_at":"2021-01-18 19:25:20","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":141390840,"visible":true,"origin":"","legend":"Supplementary File: Intraoperative video demonstration of laparoscopic feeding jejunostomy placement and positioning. ","description":"","filename":"AdditionalFile1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-45981/v3/4895d24643aa1ef1b12b0db4.mp4"}],"financialInterests":"","formattedTitle":"Laparoscopic versus open feeding jejunostomy insertion in oesophagogastric cancer","fulltext":[{"header":"Background","content":"\u003cp\u003eOesophageal cancer is the eighth most common cancer worldwide [1]. It is a highly lethal condition, leading to over 400,000 deaths annually [2]. The incidence of weight loss in patients with oesophageal cancer is among the highest of all cancer types. The majority of patients with oesophageal cancer will have experienced a significant degree of weight loss by the time of diagnosis and will have complex nutritional needs [3]. The effect of such weight loss on patient performance status can be detrimental to the delivery of gold-standard multimodal treatment strategies and, consequently, can adversely impact survival outcomes. \u0026nbsp;The likelihood of encountering severe dose-limiting toxicity is substantially greater among individuals with nutritional deficiency who undergo chemotherapy [4]. It is evident, therefore, that the nutritional status of patients with oesophageal cancer should be carefully considered during the diagnostic and staging phases; and routine nutritional assessment should form a central component of the multimodal treatment of patients [5].\u003c/p\u003e\n\u003cp\u003eIn their systematic review and meta-analysis of randomized controlled trials, Mazaki and colleagues demonstrated that, when compared to parenteral nutrition, enteral nutrition was associated with fewer infectious complications, anastomotic leaks, intra-abdominal abscesses, overall complications, and decreased length of hospital stay [6]. Feeding jejunostomy is the most commonly employed approach to enteral nutrition in patients undergoing treatment for oesophageal malignancy, given that sparing of the stomach is necessary for its potential use as a conduit to replace the resected oesophagus.\u003c/p\u003e\n\u003cp\u003eJejunostomy insertion can be performed open via laparotomy, laparoscopically, or by percutaneous techniques assisted either endoscopically or using other imaging modalities. In patients with severe dysphagia or with significant weight loss (\u0026ge;10%) at presentation, a jejunostomy is usually placed at the time of the staging laparoscopy or as a stand-alone procedure. The goal is to support the patient\u0026rsquo;s nutritional status and hydration during neo-adjuvant treatment. When a jejunostomy is not indicated before neo-adjuvant treatment it is usually placed at the time of oesophagectomy to provide fluids and nutrition if the oral route is compromised, for instance in the case of anastomotic leak. Given the variation in timing and technique of jejunostomy insertion, the aim of this study is to compare outcomes of subjects undergoing open and laparoscopic jejunostomy insertion in the management of oesophageal malignancy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eRetrospective review was performed of databases prospectively compiled between August 2017 and July 2019 at the Churchill Hospital, Oxford, UK. The indication for jejunostomy was decided by multidisciplinary team discussion involving surgeons, oncologists, gastroenterologists, and dietitians according to the severity of dysphagia, weight loss, and nutritional status. Demographic data and baseline patient characteristics including age, gender, body mass, preoperative serum albumin, performance status (Eastern Cooperative Oncology Group, ECOG), American Society of Anaesthesiologists physical status classification (ASA grade), TNM staging, relevant comoborbidities, and oesophagogastric tumour histology were reviewed. All jejunostomy procedure-related complications were collated and classified in accordance with Clavien-Dindo (CD) scoring, whereby minor complications are those scoring 2 or less and major complications constitute those scoring 3 or more [7].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSurgical Techniques\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor both the open and laparoscopic techniques described, a 9 Fr feeding jejunostomy tube kit was used (Freka\u0026reg; Surgical Jejunostomy Set ENFit\u0026reg;, Fresenius Kabi). In instances where feeding jejunostomy placement was performed at the time of oesophagogastrectomy, laparoscopic insertion was performed where the abdominal phase of the resectional procedure was performed minimally invasively. The decision as to whether jejunostomy was performed laparoscopically or open at SP was determined primarily by surgeon preference. Open insertion was performed via a midline laparotomy employing the Witzel technique - the most common method of jejunostomy creation [8]. The duodenojejunal (DJ) flexure was identified and a loop of jejunum selected and confirmed to reach the abdominal without excess tension. The jejunostomy tube was introduced into the jejunum using the dedicated kit through a purse string suture made with absorbable monofilament on the small bowel. A 2 cm submucosal tunnel was created with the introducer and subsequently a short Witzel tunnel made with 3/0 absorbable monofilament to prevent leak of enteric content. The small bowel was secured to the abdominal wall with parachuting sutures, and the jejunostomy secured to the skin with the flange provided using non absorbable braided or monofilament sutures. Where open jejunostomy was performed concurrently with open oesophagectomy, the jejunostomy was introduced via the established abdominal incision.\u003c/p\u003e\n\u003cp\u003eLaparoscopic jejunostomy insertion was performed using a three-port technique modified from Senkal and colleagues (Fig. 1. An additional movie file demonstrates the technique in further detail, see Additional file 1) [9]. Briefly, a 12mm laparoscopic port was placed in the right flank to accommodate the laparoscope, and a further two 5mm working ports were inserted under vision. The DJ-flexure was identified, and a loop of proximal jejunum confirmed to reach the abdominal wall with ease was selected. Placement of two absorbable braided sutures in a \u0026lsquo;W\u0026rsquo; configuration was performed to define a square area that would become the jejunostomy insertion point (Fig. 1B). The four ends of the two sutures were retrieved outside the abdominal cavity through a 2-3mm skin incision using Endo Close\u003csup\u003eTM\u003c/sup\u003e Trocar Site Closure Device (Covidien, USA), and ensuring that the points of retrieval or exit from the peritoneum are adequately spaced to mirror the square area created by the sutures placed at the jejunum (Fig. 1D). The jejunostomy kit\u0026rsquo;s introducer is inserted through the abdominal wall into the jejunum, thereby permitting direct passing of the tube distally. Positioning is visually verified and tested by saline infusion, with vigorous flushing alongside gentle laparoscopic manipulation employed to promote uncoiling where possible. The intra-abdominal pressure is lowered to 5mmHg to enable parachuting of the small bowel up to the abdominal wall upon tying of the extracorporeal sutures. The procedure is completed by securing the jejunostomy tube using the flange supplied as per the open approach aforementioned.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analyses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using GraphPad Prism v7.0 Software. Group comparisons of continuous variables were performed by t test, where normality was confirmed using the D\u0026rsquo;Agostino-Pearson, or by Mann-Whitney U test where not normally distributed. Chi-square or Fisher\u0026rsquo;s-exact test, when appropriate, were used to compare categorical variables. A P value of less than 0.05 was considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAfter performing a database search, 175 consecutive jejunostomy procedures were identified during the study period, 157 of which were associated with the management of oesophageal malignancy and therefore eligible for inclusion. Of this cohort, 126 subjects underwent open jejunostomy insertion while 31 underwent laparoscopic insertion. Comparisons of subject characteristics between both groups are shown in Table 1, and operative approaches to resectional procedures are outlined in Table 2. While groups were comparable for gender, body mass index (BMI), serum albumin, pre-procedural performance status, tumour histology, and tumour stage, the laparoscopic group were marginally younger than those undergoing open surgery (P = 0.014).\u003c/p\u003e\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58653_1b1c6aeb34a62c68/58653_custom_files/img1610997585.jpg\"\u003e\u003c/p\u003e\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58653_1b1c6aeb34a62c68/58653_custom_files/img1610997596.jpg\"\u003e\u003c/p\u003e\u003cp\u003eComparisons of operative outcomes are shown in Table 3. Jejunostomy insertion was performed as a stand-alone procedure or in conjunction with a laparoscopic staging procedure (SP), which is to say prior to definitive oesophagectomy, in 71 (45.2%) of 157 cases. The remaining 86 (54.8%) cases underwent insertion at the time of tumour resection procedure (RP). A trend towards a higher incidence of complications was noted among those in the \u0026lsquo;staging\u0026rsquo; (SP) group (29/71, 40.8%) as compared with the RP group (25/86, 29.1%), though this did not reach statistical significance (P = 0.12). The rate of \u003cem\u003emajor\u003c/em\u003e complications (CD\u0026ge;3) however, was noted to be significantly higher at SP (P = 0.011), a finding predominantly attributable to the particularly high rates of complications seen in cases of open insertion in this setting (11/63, 17.5%, P = 0.016).\u003cu\u003e \u003c/u\u003e\u003c/p\u003e\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58653_1b1c6aeb34a62c68/58653_custom_files/img1610997618.jpg\"\u003e\u003c/p\u003e\u003cp\u003eAcross all procedures performed, significantly fewer complications were encountered following laparoscopic insertion as compared with open (P = 0.049). Among the subset of cases undergoing jejunostomy insertion at SP, a substantially greater proportion of those performed open encountered major complications (11, 17.5%), than did those performed laparoscopically (0, 0%), though not reaching statistical significance (P = 0.34). Similarly, in the RP group, 21 major or minor complications were encountered among the 63 patients undergoing open jejunostomy placement (33.3%), whilst 4 (17.3%) were noted among the laparoscopic group (P = 0.19). In this setting however, although only jejunostomy-associated complications were analysed, the impact of the resectional approach itself is not controlled for. Median length of stay was longer amongst those undergoing open procedures in both the SP (1.5 vs. 3 days, P = 0.17) and the RP (9 vs. 10, P = 0.09).\u003c/p\u003e\n\u003cp\u003eWith regards to the small but significant difference of approximately 4 years in mean age among groups, increasing age was not noted to be associated with higher rates of complications (P = 0.10). One death occurred in the cohort of 157 cases (0.6%), and this was following open jejunostomy insertion at the time of staging. The death was associated with the perforation of a closed bowel loop involving a segment between the obstructive oesophageal tumour and the jejunostomy site.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe integration of appropriate nutritional support into the overall management of patients undergoing curative treatment for cancer of the oesophagus is of utmost importance to the successful completion of neoadjuvant therapy and of surgery, as well as to survival outcomes [10,11]. Feeding jejunostomy is the preferred approach to long-term enteral feeding and, since minimally invasive techniques have many advantages, total laparoscopic or laparoscopically assisted methods of feeding jejunostomy insertion have garnered increasing attention [12].\u003c/p\u003e\n\u003cp\u003eThis study, which represents the largest to our knowledge comparison of total laparoscopic and open jejunostomy insertion in the setting of oesophageal cancer, shows that laparoscopic feeding jejunostomy can be performed safely and has the potential to confer the benefits of minimally invasive surgery including lower rates of morbidity and shorter hospitalisations. Furthermore, the study highlights the risk of major complications among subjects undergoing jejunostomy insertion as an open stand-alone procedure. This finding is in keeping with the literature, wherein reported complication rates for this approach range widely but can reach 37% and beyond in some series [12,13]. One explanation for the higher rates of complication encountered in stand-alone open insertions is that such procedures are generally performed as \u0026lsquo;mini-laparotomies\u0026rsquo; to avoid the morbidity of larger incisions. As a consequence, they may not afford sufficient exposure and access to ensure adequate visualisation of the DJ-flexure, jejunum, and abdominal wall. Suboptimal exposure can lead to inadvertent injury, kinking or narrowing of the lumen, and difficulties with fixation to the abdominal wall. The laparoscopic technique described here enabled excellent visualisation of the DJ-flexure and of the abdominal wall, and the use of the Endo Close\u003csup\u003eTM\u003c/sup\u003e device makes parachuting the jejunum to the abdominal wall uncomplicated. The direct puncture of the jejunum, without tunnelling, was a source of concern at the beginning of our experience, but leakage of enteric content was encountered in only one case and was successfully managed with antibiotics and temporary suspension of enteral feeding. A second consideration is that open procedures may be performed by less experienced junior surgeons as compared with laparoscopic approaches. In our series, the number of laparoscopic jejunostomy insertions was relatively lower (31 vs 126 open) due to the fact that only one senior surgeon in our unit employs the laparoscopic technique and, as a consequence, all such procedures were either performed by this senior surgeon or by a junior surgeon under direct supervision. In addition to this latter point, this study is limited by the small number, specifically in the subgroup of procedures performed laparoscopically as a staging or stand-alone procedure.\u003c/p\u003e\n\u003cp\u003eThe postoperative mortality in our series of 157 patients was 0.6%, again mirroring published reports. The single death involved a subject with an obstructing tumour at the gastro-oesophageal junction, a closed-loop obstruction which was diagnosed late, and multiple comorbidities. While mortality rates are low, the significant risks of minor or major complications highlight the value of careful patient selection pre-operatively, emphasise the importance of patient counselling and informed consent, and focus attention on the development of improved surgical approaches.\u003c/p\u003e\n\u003cp\u003eThe cost-effectiveness of laparoscopic surgery is often questioned. Though not formally assessed in our study, in broad terms the cost of the equipment and length of operation time should be balanced against potential benefits regarding the length of stay, cosmesis, reduced analgesic requirements, and improved outcomes. It is important to note, that laparoscopic jejunostomy insertion was predominantly performed in conjunction with either staging laparoscopy or with minimally invasive oesophagectomy, and thereby incurred no significant additional equipment costs. This study is limited by its retrospective nature and in that data is derived from a single centre. Though this represents the largest comparative study of total laparoscopic and open jejunostomy insertion in the setting of oesophageal cancer, the nevertheless is limited by its relatively small patient population. Future prospective studies comparing laparoscopic versus open feeding jejunostomy insertion are required to determine the superiority of either approach. Our report focuses on patients undergoing treatment for oesophageal malignancy and, however likely, it remains to be confirmed whether the findings hold true in patients undergoing jejunostomy insertion in the contexts of gastric, pancreatic, or hepatic malignancies for instance.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFeeding jejunostomy represents a key adjunct in the treatment of oesophageal malignancy. Though considered by some to be a routine, innocuous procedure, open insertion of feeding jejunostomy is a procedure which should not be underestimated. Keeping in mind the aims of successful neoadjuvant treatment and the reduction of early postoperative morbidity, any complications arising from such a procedure could jeopardise potential benefits and incur significant costs. The total laparoscopic approach outlined here can serve as a safe, effective alternative with the associated advantages of minimally invasive surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI: Body mass index\u003c/p\u003e\n\u003cp\u003eCD: Clavien-Dindo Score\u003c/p\u003e\n\u003cp\u003eDJ: duodenojejunal\u003c/p\u003e\n\u003cp\u003eSP: Staging/Stand-alone Procedure\u003c/p\u003e\n\u003cp\u003eRP: Resection Procedure\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study conforms to the Declaration of Helsinki. Ethical approval is waived per Oxford Central University Research Ethics Committee guidelines (CUREC). Written informed consent was provided for the use of intraoperative images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to patient data confidentiality but are available from corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo source of funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBS, GB, BH, MN, AG were involved in conception and design; RG, RM, NM performed operations and were involved in manuscript reviews; SM, BS, BH, GB, MN, AG were involved in data interpretation, and manuscript preparation. All authors have read an approved the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFerlay J, Shin H-R, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. John Wiley \u0026amp; Sons, Ltd; 2010 Dec 15;127(12):2893\u0026ndash;917.\u003c/li\u003e\n\u003cli\u003eParkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000. The global picture. Eur J Cancer. 2001 Oct;34:503\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eMartin L, Senesse P, Gioulbasanis I, Antoun S, Bozzetti F, Deans C, et al. Diagnostic criteria for the classification of cancer-associated weight loss. J Clin Oncol. 2015 Jan 1;33(1):90\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eAndreyev H, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies. Eur J Cancer. 1998 Dec;34(13):2132\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eSteenhagen E, van Vulpen JK, van Hillegersberg R, May AM, Siersema PD. Nutrition in peri-operative esophageal cancer management. Expert Rev Gastroenterol Hepatol. Taylor \u0026amp; Francis; 2017 Jul;11(7):663\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eMazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg. 2nd ed. Springer-Verlag; 2008 Apr;12(4):739\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eDindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eTapia J, Murguia R, Garcia G, de los Monteros PE, O\u0026ntilde;ate E. Jejunostomy: techniques, indications, and complications. World Journal of Surgery. Springer-Verlag; 1999 Jun;23(6):596\u0026ndash;602.\u003c/li\u003e\n\u003cli\u003eSenkal M, Koch J, Hummel T, Zumtobel V. Laparoscopic needle catheter jejunostomy: modification of the technique and outcome results. Surgical Endoscopy. Springer-Verlag; 2004 Feb;18(2):307\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSteenhagen E. Preoperative nutritional optimization of esophageal cancer patients. J Thorac Dis. 2019 Apr;11(S5):S645\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003eCox S, Powell C, Carter B, Hurt C, Mukherjee S, Crosby TDL. Role of nutritional status and intervention in oesophageal cancer treated with definitive chemoradiotherapy: outcomes from SCOPE1. Nature Publishing Group; 2019 Apr 6;:1\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eHan-Geurts IJM, Lim A, Stijnen T, Bonjer HJ. Laparoscopic feeding jejunostomy: A systematic review. Surgical Endoscopy. Springer-Verlag; 2005 May 12;19(7):951\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eSiow SL, Mahendran HA, Wong CM, Milaksh NK, Nyunt M. Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: the technique and review of outcomes. BMC Surgery; 2017 Mar 17;:1\u0026ndash;10.14. Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg. 2008 Apr;12(4):739\u0026ndash;55.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic, Feeding, Jejunostomy, Oesophagogastric, Cancer","lastPublishedDoi":"10.21203/rs.3.rs-45981/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-45981/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Jejunal feeding is an invaluable method by which to improve the nutritional status of patients undergoing neoadjuvant and surgical treatment of oesophageal malignancies. However, the insertion of a feeding jejunostomy can cause significant postoperative morbidity. The aim of this study is to compare the outcomes of patients undergoing placement of feeding jejunostomy by conventional laparotomy with an alternative laparoscopic approach. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective review of data prospectively collected at the Oxford Oesophagogastric Centre between August 2017 and July 2019 was performed including consecutive patients undergoing feeding jejunostomy insertion. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In the study period, 157 patients underwent jejunostomy insertion in the context of oesophageal cancer therapy, 126 (80%) by open technique and 31 (20%) laparoscopic. Pre-operative demographic and nutritional characteristics were broadly similar between groups. In the early postoperative period jejunostomy-associated complications were noted in 54 cases (34.4%) and were significantly more common among those undergoing open as compared with laparoscopic insertion (38.1% vs 19.3%, P = 0.049). Furthermore, major complications were more common among those undergoing open insertion, whether as a stand-alone or at the time of staging laparoscopy (n = 11/71), as compared with insertion at the time of oesophagectomy (n = 3/86, P = 0.011). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis report represents the largest to our knowledge single-centre comparison of open versus laparoscopic jejunostomy insertion in patients undergoing oesophagectomy in the treatment of gastroesophageal malignancy. We conclude that the laparoscopic jejunostomy insertion technique described represents a safe and effective approach to enteral access which may offer superior outcomes to conventional open procedures.\u003c/p\u003e","manuscriptTitle":"Laparoscopic versus open feeding jejunostomy insertion in oesophagogastric cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2021-01-18 19:22:16","doi":"10.21203/rs.3.rs-45981/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2021-04-07T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-04-03T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe manuscript has been substantially improved. I just have a few comments not addressed previously.\n\nIt appears in the reference list that maybe 2 references have been combined under #13.\nCan the authors explain why the left thoracoabdominal approach is being used--this is a fairly morbid approach in this patient population.\nrevised table 3 is quite complicated. I wonder whether you could percentages after the numbers of patients (although this may make it even more difficult to follow); also the p-values should have a leading zero 0.65 for example.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **none**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2021-03-29T01:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-03-29T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-03-29T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nThe authors have made the suggested amendments to the manuscript* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewersInvited","content":"","date":"2021-03-28T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-02-11T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-02-10T23:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-01-11T17:20:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-09-23 10:15:12","doi":"10.21203/rs.3.rs-45981/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-12-14T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-12-07T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-07T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThis is an interesting topic area. I would like the authors to address the following areas:\n\n1) Tables 2 and 3 could be combined into one. It would be helpful to see a breakdown of all complications split into four columns according to whether the feeding tube was placed at the time of staging laparoscopy or oesophagectomy - ie. open surgery (staging), open surgery (resection), laparoscopic surgery (staging) and laparoscopic surgery (resection)\n2) My conclusion from reading the data was that feeding tubes should not be placed at the time of diagnostic laparoscopy? Can the authors comment/reflect on this and amend their recommendations\n3) The Clavien-Dindo (grade 3-5) complications should be split into their constituent parts. Did the patients with small bowel obstruction need laparotomy? Non-enthusiasts of jejunostomies always point out the mortality, relaparotomy rates - what were these. The grade 3, 4 and 5 complications need to be spelled out more clearly\n4) Were any patients fed at home after discharge from hospital? To get patients through pre- and/or post-operative chemotherapy. This should be made clear\n5) How do the authors guarantee that the tube migrates into the distal limb when placed laparoscopically. It looks asthough it would be possible for the tube to curl up into a coil or figure of 8. What tips do the authors have?\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-11-03T00:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThe authors present a retrospective review of laparoscopic versus open feeding jejunostomy tube placement for patients with esophageal cancer. These placements occur either open or laparoscopically at a staging procedure or open or laparscopically at the time of definitive surgery. They conclude that laparoscopic placement is associated with less complications. I have the following comments/questions:\n1.) There are methodology problems inherent in this comparison, as we are comparing neoadjuvant to resection operations, and in the latter, essentially open esophagectomy to lap esophagectomy outcomes. A reasonable design would be to separately compare neoadjuvant open and lap patients, and primary resection open and lap patient outcomes, controlling for esophagectomy, as the prior reviewer mentioned. I'm not sure statistically that this point was addressed in the revision.\n2.) The classification of Clavien Dindo III or greater should be clarified for the following variables:\nSmall bowel obstruction, blockage or obstruction- if class III or above, this implies reoperation or an invasive intervention was required. Is this correct? \nWhat was the difference between the replacement/dislodgement groups in the minor and major complications?\nIntraabdominal sepsis and leak- similarly, did these patients require re-operation? It would be helpful to include \"re-operation\" as an additional variable to compare between open and lap, OR endoscopic/radiologic intervention needed\n3.) Table 1 should be expanded to include more patient demographic and tumor variables. TNM stage of disease, histopathology (adeno vs. squamous), receipt of neoadjuvant chemo/radiation, history of smoking, ASA class or cumulative score such as Charleson Comorbidity Score. If propensity score matching is not possible secondary to small sample size, these variables should at least be gathered and compared to assure similarity between groups. Intra-operative and esophagectomy-specific data should be included here or in another table, including esophagectomy type (THE, Ivor-Lewis, 3-hole), EBL, operative time (this is an important variable looking at MIS techniques), anastomotic leak, hospital length of stay.\n4.) Line 17—open insertion in conjunction with laparoscopic staging is confusing to me.\n5.) I think authors need to address more the significant selection bias for open vs. laparoscopic FJ placement since it appears to me that the only rationale for one or the other is surgeon experience. Additionally, with only 8 patients in the laparoscopic, staging FJ group, it is very difficult to make meaningful comparisons.\n6.) Can the authors comment on whether the exit site for FJ is different based on open vs. laparoscopic technique as this can correlate with increased incidence of bowel obstruction.\n7.) Can the authors also please discuss the lack of a gastroenterologist as part of the multidisciplinary group. Is there ever consideration of placement of a stent across the tumor which could obviate the need for a j-tube?\n8.) In Table 2, it would be helpful to have p-values for all of the specific complications to help determine what may be driving the differences in all complications.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **none**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewersInvited","content":"","date":"2020-10-21T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-10-21T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-16T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-15T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-15T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-07-30 14:54:06","doi":"10.21203/rs.3.rs-45981/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-09-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-10T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nHereby I would like to comment on the article entitled: \"Laparoscopic versus open feeding jejunostomy insertion in oesophagogastric cancer\" by the authors Sotiris Mastoridis et al.\nIn this study a retrospective analysis was made on the outcomes of patients receiving a laparoscopic or open jejunostomy placement. The article is well written and touches on an important topic.\nIn the open group, the jejunostomy was placed in 50% of cases during the staging process. In the laparoscopic group, jejunostomy placement was performed in 75% of cases at the esophagectomy. So, indirectly, also the difference between open and laparoscopic esophagectomy is taken as well. Although it is mentioned, this may be put forward better.\nAdditional statistical analysis may also be helpful to ascertain the contribution of esophagectomy to the effect on complications. A limitation of the study is the relatively small patient population (in relation with the incidence of jejunostomy-related complications). This should be added in the discussion\nNext, it is unclear to me what complications are exactly included in these analysis, I would specify this in the methods section. Also the definition of major and minor complications need to be included in the method section; now it is only mentioned in Table 2.\n\n\nOther points\n* The introduction and discussion may be compacted\n* Table 1 can be mentioned in the results section.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **no competing interest**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-03T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-08-01T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-07-20T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-07-19T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-07-19T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-07-18T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c8f9213d-61c8-4670-9592-019e512f6028","owner":[],"postedDate":"January 18th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":589134,"name":"Surgery"},{"id":589135,"name":"General Surgery"}],"tags":[],"updatedAt":"2021-01-11T17:20:26+00:00","versionOfRecord":[],"versionCreatedAt":"2021-01-18 19:22:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v3","identity":"rs-45981","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-45981","identity":"rs-45981","version":["v3"]},"buildId":"ApUGefWb6u5IBVtyqm6d5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}