The common purpose of an ostomy is to let a patient's intestinal contents get out past an obstruction in his large gut. Occasionally, you may need to make an ostomy in his small gut to let food and drink get in past an obstruction in his oesophagus. Alternatively, you can make an ostomy in his stomach (gastrostomy, 11.8), unless his problem happens to be there.
If he cannot feed himself by mouth, and needs building up, an alternative to total parenteral nutrition (which will probably be impossibly expensive) is to put a tube into his jejunum and feed him through that. Feeding jejunostomies are seldom needed, but they can be life-saving: for example, when a suture line in an injured duodenum needs protecting. To reduce the danger of a leak, introduce the tube into his gut through a long oblique track.
FEEDING JEJUNOSTOMY INDICATIONS. (1) An oesophageal obstruction which is correctable. (2) To protect a suture line in the duodenum following an injury. (3) To protect a suture line in the stomach which has leaked. (4) A pancreatic abscess.
METHOD. Make a small laparotomy in the patient's upper abdomen under local or general anaesthesia.
Find his upper jejunum by following it downwards from his duodenojejunal flexure. Confirm that it is his duodenojejunal junction by finding his inferior mesenteric vein along its left border and feeling it emerge from its fixed position behind his peritoneum. Take a loop about 25 cm from his duodenojejunal junction, and make an incision on its antemesenteric border through the longitudinal muscle layer for about 8 cm. At the distal end of this make a hole through into the lumen. Insert a feeeding catheter (18 Ch for an adult), or a long Ryle's tube, through this hole for about 10 cm. Close his gut around it with continuous catgut, as if you were doing the Lembert suture of a bowel closure (9-6).
Make a second incision in his abdominal wall above where this loop of jejunum will comfortably lie. Draw the end of the tube back through his abdominal wall, as you would with a caecostomy (66-18). Draw his jejunum and the interior of his abdominal wall together with a purse string suture, as for a caecostomy. Close his abdomen and anchor the tube to his abdominal wall with a ''Saxon stocking' type of anchoring stitch, or with tape (D, to G, Fig. 65-8).
To remove the tube, snip the ligature anchoring it to the skin, and pull. The long oblique tunnel through the mucosa and submucosa will seal rapidly. The purse string anchoring it to his peritoneal wall will prevent his jejunal contents soiling his peritoneal cavity.
Fig. 9-20 MAKING A FEEDING JEJUNOSTOMY. A, making the incision. B, inserting the tube. C, closing the jejunum over the tube with continuous catgut. D, the tube fixed in the gut. E, leading the tube out through the abdominal wall. The inner suture between the jejunum and the parietal peritoneum is not shown.