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 .
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 CloseTM 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.