Intraoperative placement of feeding jejunostomy (FJ) is a well-established method of providing access to enteral feeding for providing long-term nutritional support. However, the procedure has been well documented to have serious complications with definite morbidity and even mortality. We report a case of spontaneous intraluminal migration of a Foleys catheter placed as feeding jejunostomy which represents an extremely rare mechanical complication.

Case Report

A 52 year-old lady, a diagnosed case of advanced carcinoma stomach, presented with features of gastric outlet obstruction. She underwent a palliative distal gastrectomy at our center. Peroperatively a standard Witzel feeding jejunostomy, with serosal tunnel on antemesenteric border was performed using an 18F Foleys’s catheter. The serosal tunnel with the tube was tacked on a broad front to intra abdominal wall and the catheter itself anchored to skin outside. The patient was thereafter put on adjuvant chemotherapy. Patient was able to partake orally but as she had severe anorexia and cachexia related to chemotherapy, her oral intake was not adequate. Hence it was decided to maintain her on FJ supplementation. Two months later, on a routine follow-up, it was noticed that the skin surrounding the FJ tract was macerated and infected. The anchoring sutures had cut through and the FJ tube was missing (Figure 1). The patient was in a poor general condition, dehydrated and tolerated very little oral fluids .However, there was no clinical evidence of obstruction or peritonitis. Plain X ray abdomen revealed the tube in the small bowel (Figure 2). The patient was put on conservative management with intravenous fluids, antibiotics and total parenteral nutrition. During her subsequent stay in hospital she never developed features of intestinal obstruction. Due to extreme cachexia secondary to her advance stage disease, the patient expired on the 18th day post-admission. An ultrasound examination of the abdomen just prior to her demise, revealed the foleys catheter beyond the illeocolic junction and  in the ascending colon.



Figure 1



Figure 2

Discussion

Feeding Jejunostomy has been described to result in complications with incidences ranging from 4-15%. [1 ,2 ,3 ,4]. Majority of the complications may be minor such as dislodgement, blockage of the tube and pericatheter leak. But there can be major complications necessitating re-laparotomy and mortality being reported up to 3.2 %. [2,3,5,6,7 ]. The peristalsis-induced intraluminal antegrade migration of the distal end of a jejunostomy has been described [8 ,9].In these cases the tube remained in place but there was concomitant retrograde movement of the small bowel over the tube which ultimately resulted in the bulb being positioned in  the distal ileum, therefore bypassing most of the small intestine and resulting in malnutrition.  However, complete dislodgement of the catheter and it’s subsequent antegrade migration down the gut is an extremely unusual occurrence. To the best of the author’s knowledge there have been only two previous reports of such incidence. One by Polychronidis A et al[10] where a 28-F silicone catheter with a mushroom tip (Pezzer catheter) was used and another by Bose AC et al [11]where a 18F Levine's tube was utilized .In our institution, we routinely fix the catheter both on intraperitoneal side as well as anchor it to skin outside. In our case, the peri -jejunostomy leak led to maceration of surrounding skin, and tear through of the anchoring sutures, thus allowing the tube to dislodge. Retrospectively, it is conjectured that this complication could have been prevented had there had been a proper care of the jejunostomy tube and site at home. Another option could have been stabilization of the tube by sterile gauze and tapes as described by Tuel et al.[12]

In both the aforementioned two case reports, the tube was expelled spontaneously over the period of time. It took five days in one [10] and twenty days in the other [11].  The significant fact to note in our case is that the catheter did not cause obstruction anytime during the course of her illness and indeed the foleys catheter had negotiated its way beyond the IC junction. In normal course of events we would have expected  this tube to be expelled per annum over period of time. Though the fact that patient expired prior to this possibility, makes the point moot. This report adds to awareness of the possibility of  a rare but vexing complication of spontaneous enteral migration of feeding jejunostomy tube. It reiterates the fact that patients who have had a FJ placed, need to followed up closely ,especially if they have been discharged to home for domiciliary care .Expectant treatment is apparently the correct way of management should such a mishap occur

References