Case history

A 50-year-old man with esophageal cancer M/3, T1N0M0, underwent esophagectomy with lymphadenectomy and reconstruction using a gastric tube on 19 February 2003. After 2 years, left laryngeal cancer, T2N0M0, was observed and treated by total pharyngolaryngectomy with left neck dissection on 17 March 2005. Three years later, tongue base cancer, T4aN2aM0, was diagnosed, and the patient underwent total glossectomy with right neck dissection, reconstruction of the intra-oral defect with microvascular free radial forearm flap transfer, and feeding jejunostomy using a 14F nasogastric tube on 4 June 2008. Subsequently, he received adjuvant chemotherapy with 5-fluorouracil (800 mg/m ² ) combined with bleomycin (15 mg/m ² ) and postoperative radiotherapy with 6000 cGy/30 fractions. The feeding jejunostomy tube was changed at various intervals from 16 September 2008 until 12 January 2009 when the feeding jejunostomy nasogastric tube could not be replaced with a new one. Tubography using water-soluble contrast media showed knotting and kinking of the feeding jejunostomy tube ( Fig. 1 ). Kelly clamp-assisted removal without invasive procedures was considered initially.

Tubography using water-soluble contrast media showed knotting (arrow) and kinking (arrowhead) of the feeding tube.

The jejunostomy tube was drawn until resistance was encountered, and a constant pulling force was maintained to tighten the knot and lessen its size. This was followed by manipulation of the Kelly clamp to slide the tip of the clamp along the feeding tube into the superficial portion of the jejunostomy stoma and to dilate the stoma gently by opening the tip of the Kelly clamp, enabling the holding of both the feeding tube and the open tip. The tip of the Kelly clamp was closed to flatten the clamped part of the tube and make its size smaller than the circumference of the dilated stoma. The Kelly tip holding the tube was carefully pulled out to create enough space for placing the tip of the second Kelly clamp, which was manipulated in the same way. The two clamps were alternately moved inch by inch until the knot was removed. Finally, the self-knotted feeding tube was directly removed without additional invasive surgery ( Fig. 2 ). The patient tolerated the procedure well. The patient was followed-up at the outpatient department, and the tube was replaced once a month; no further complications associated with the feeding jejunostomy tube have been encountered to date.

Self-knotted feeding jejunostomy tube was directly removed using Kelly clamps without additional invasive surgery.

Discussion

The first surgical jejunostomy was performed by Surmay in 1878. Feeding jejunostomy is a common and safe procedure performed in patients who require: enteral nutrition when the oral route is obstructed; gastric bypassing such as tracheal aspiration, gastroparesis, or postoperative feeding during major operative procedures; and in patients with unresectable oral, esophageal, gastric, or pancreatic cancers . The percentage of mechanical, infectious, gastrointestinal, and metabolic complications has been estimated to be between 0.6% and 21%, depending on the different types of jejunostomy . Cases of self-knotted feeding jejunostomy tubes have rarely been reported. On the basis of a literature review, the author thinks that this is the third report of a case of tube knotting in jejunostomy .

Most previous reports were related to intragastric knotted tubes. The methods used to resolve this problem cannot be applied for the removal of knotted feeding jejunostomy tubes, which do not have a natural orifice as large as the mouth to facilitate the introduction of instruments to correct the complication or to remove the knotted tube . M yers et al. severed the knotted tube, and left it in the bowel for spontaneous passage through the gastrointestinal tract . It is better to remove the foreign body from the gastrointestinal tract, rather than to leave it to pass through the bowel, to prevent the risk of intestinal obstruction, ulceration, or perforation. The author did not consider leaving the severed portion of the knotted segment in the bowel and attempted to remove it with the help of Kelly clamps. This manipulation, assisted by Kelly clamps, facilitated the dilation of the stoma and tightening and flattening of the knot, allowing the successful removal of the tube through the stoma.

The mechanism underlying feeding jejunostomy tube knotting is presumed to be similar to that of an intragastric tube; the excessively advanced tube loops back on itself when resistance is encountered. This unnecessary advancement of the nasogastric tube may result in knot formation . Knotting of the feeding jejunostomy tube may be prevented by modifying the placement procedure, by advancing the tube forward with saline flushing under gravity, avoiding forward advancement of the tube when resistance is encountered, reducing the insertion length of the tube if possible. Although knotting of large-caliber (14F) nasogastric tubes, such as the one used in this case, is rare , it can lead to serious complications, including soft tissue injury, bowel perforation, stoma rupture, or bleeding, if it is not detected or is removed forcefully. The possibility of feeding jejunostomy tube knotting should be considered if stiff resistance is encountered during removal of the tube.