The incidence of BOFJ after esophagectomy was 8.5% in our study cohort, with all cases arising in the HALS group. Patients with BOFJ showed a significantly longer VD than patients without BOFJ. Our study demonstrated that longer VD between the jejunostomy and navel might represent a risk factor for BOFJ.
Recent clinical guidelines have recommended early postoperative enteral nutrition as a method of reducing major complications, such as infection and anastomotic leakage, postoperative ileus and albumin requirements compared to parenteral nutrition [16, 17]. PFJ is commonly performed during esophagectomy to subsequently maintain adequate enteral nutrition [6,7,8,9].
The following are the objectives of PFJ: (1) to prevent villous atrophy and maintain gastrointestinal integrity by promoting peristalsis, blood flow and secretion of digestive juices; (2) to maintain or enhance immune function and reduce operative complications by administration of immunonutrients; (3) to avoid complications of parenteral nutrition such as catheter-associated hematological infection and venous thrombosis, which are related to long-term indwelling central venous catheters; and (4) to avoid physical loss of the mucosal barrier due to long-term disuse of the gut, by promoting bacterial translocation [18].
In a large cohort study of 2495 patients, Lorimer et al. demonstrated that enteral feeding access is associated with improved short-term survival at 90 days and does not prolong the hospital stay [19].
However, PFJ during esophagectomy is associated with a 2–15% incidence of serious complications such as bowel obstruction, intractable jejuno-cutaneous fistula, PFJ-site infection, tube occlusion, and leakage [9,10,11,12]. Among these complications, BOFJ is a particularly serious problem because of repeated occurrence and the need for surgical intervention. The incidence of BOFJ has been reported as 0–11.5% in recent reports [10, 12, 18, 20,21,22,23,24]. However, few reports have described risk factors for BOFJ.
Kitagawa [25] mentioned lower adhesion formation after laparoscopic surgery as a potential risk factor for postoperative BOFJ and internal hernia. With gastric mobilization, a large intra-abdominal space is formed on the left side of the jejunostomy, into which the jejunum might invaginate and twist around the feeding jejunostomy. This might explain the higher rate of BOFJ among patients who underwent a treatment with a laparoscopic approach, and shorter distance between the jejunostomy and midline or xiphoid process line in their study group.
Furthermore, Shiraishi et al. [24] suggested that in cases of laparoscopic surgery, the main mechanism of BOFJ is torsion of the mesentery accompanied by migration of the anal-side intestine across the site of stoma fixation to the abdominal wall toward the opposite side, similar to an internal hernia. In their study, closing the space within the triangle formed by the ligament of Treitz, the site of stoma fixation, and the lower pole of the spleen with omentum stuck to the transverse colon (as the so-called curtain method) could prevent BOFJ. Other studies have also reported that prolonged duration of tube feeding or internal hernia space created after the surgery might be risk factors for BOFJ or internal hernia [26, 27].
We consider that BOFJ involves several mechanisms. One is the torsion + internal hernia pattern (TI pattern) (Fig. 3a, b) as reported by Shiraishi et al. [24]. The other is the adhesion + bending pattern (AB pattern) (Fig. 3c).
In the TI pattern, the curtain method [24] and fixation at several points or longitudinal fixation to the abdominal wall [28] are feasible procedures to reduce the rate of BOFJ.
However, in our experience, of the 6 patients with BOFJ, only 2 patients showed a TI pattern. Four cases displayed an AB pattern and the main cause of BOFJ was the bending angle between the abdominal wall and jejunostomy. An acute bending angle would cause repeated BOFJ and thus requires reconstruction of jejunostomy. This is why our result for VD from the navel appears very important. No consensus has yet been reached regarding the optimal site of jejunostomy. We consider that when the VD is > 9 cm from the navel, the angle from the ligament of Treitz and jejunostomy becomes steeper. A longer VD might thus be associated with a higher rate of BOFJ.
Furthermore, our button jejunostomy might be associated with a higher rate of BOFJ with the AB pattern. We applied a simple and efficient button jejunostomy that is not prone to dislodgement and employs an easily replaceable feeding button. Button jejunostomy is also relatively comfortable for patients because of the esthetic outcomes and short length [15, 29]. Recent reports [10, 12, 18, 20,21,22,23,24] have applied the conventional Witzel tube jejunostomy. In the Witzel technique, longitudinal sutures are placed on both sides of the feeding tube to imbricate the bowel wall over the feeding tube, creating a serosal tunnel. In button jejunostomy, the fixation area is shorter than that with the Witzel technique, so the AB pattern might result. We consider that PFJ within 9 cm from the navel might be able to prevent BOFJ with the AB pattern.
Recently, some researchers have recommended insertion of the feeding catheter into the duodenum [18] or gastric tube [20, 22], through the round ligament of the liver, rather than through the jejunum to prevent BOFJ.
However, in patients with posterior mediastinal route reconstruction, constructing a feeding gastrostomy with round ligament is sometimes difficult because the location of gastric antrum is separate from the round ligament [22]. Another concern about duodenostomy has been inflammation around the duodenal bulb or pylorus following leakage and/or catheter-related abscess, leading to gastric tube stasis due to edema of the duodenum and/or pylorus [18].
This study showed several limitations, including the fact that it was a retrospective study of data obtained from a single institution with a small number of patients and clear selection bias. Our study included only patients who had undergone button jejunostomy, and whether the same results would be true for conventional Witzel tube jejunostomy remains unclear.
Furthermore, in our study, all BOFJ occurred in the HALS group. Confirmation of whether VD from the navel is truly associated with BOFJ warrants further investigation. We consider HALS as a confounding factor among risk factors for BOFJ. However, our procedure for PFJ was consistent among all patients, so the finding of a significant difference in VD from the navel as a risk factor for BOFJ is crucial.
Studies using data from a large-scale, multicenter registry are necessary to determine risk factors for BOFJ in the future.
