Optimizing nutritional support in upper gastrointestinal surgery: A comprehensive review of feeding jejunostomy techniques and outcomes

Abstract

This minireview synthesizes literature on the use of feeding jejunostomy tubes (FJTs) in the postoperative management of gastroesophageal cancer patients. Gastrectomy and esophagectomy remain the primary curative treatments for gastric and esophageal cancers, respectively, but are frequently accompanied by significant postoperative malnutrition, which adversely impacts surgical and oncological outcomes as well as patients’ quality of life. To address this, the European Society for Clinical Nutrition and Surgery and the National Comprehensive Cancer Network recommend early enteral feeding through FJT placement following major surgery. While previous studies have demonstrated that FJT is an effective and reliable route for nutritional support, its placement is invasive and carries associated risks. Consequently, many clinicians opt for less invasive alternatives such as total parenteral nutrition or nasogastric tube feeding, although these approaches yield variable results. This review explores the benefits and potential complications of FJT placement, identifies variability in clinical adoption and the absence of standardized protocols, and highlights areas for future research to optimize patient care in this challenging context.

Key Words: Nutrition; Nutritional support; Cancer; Feeding jejunostomy; Feeding jejunostomy tube

Core Tip: Nutritional support is of utmost importance for the postoperative management of patients with gastroesophageal malignancy, with National Comprehensive Cancer Network recommending early enteral feeding to enhance patients’ surgical and oncological outcomes. Feeding jejunostomy tube (FJT) placement can offer a secure route for rapidly improving patients’ nutritional status; however, its placement is not a risk-free procedure and hence, is not preferred in daily clinical practice. In this review, by weighing up the benefits and complications of FJT placement, we discuss its utility in the postoperative management of patients with gastroesophageal cancer, promoting its use and disclosing areas that need further investigation.

INTRODUCTION

This review synthesizes literature on the use of feeding jejunostomy (FJ) tubes (FJTs) following gastroesophageal cancer surgery. Gastric and esophageal cancer are two of the main upper gastrointestinal (GI) malignancies. Gastric cancer is the 5^th most common malignancy, with around 1.1 million new cases per year, and the 4^th deadliest[1-3]. Nowadays, due to early diagnosis, surgery is considered the only definite treatment, with partial and total gastrectomy being the most commonly performed procedures. Likewise, esophageal cancer accounts for 600000 new cases and about 550000 deaths per year, being the 6th deadliest cancer, with total esophagectomy being the only procedure performed with curative intent[4]. Esophagectomy at early stages increases the survival of patients but is a complex procedure associated with high morbidity. Studies show that adjuvant therapy offers additional survival benefit for both cancers, but its application largely depends on patients’ nutritional status[1,2,5].

The importance of preserving the nutritional status of patients with gastroesophageal malignancies is well established, yet difficult to achieve. Gastroesophageal cancer often leads to body mass depletion in a significant proportion of patients (32%-87%)[6], with malnutrition, sarcopenia, and reduced muscle tone adversely affecting survival[1,7-10]. Although curative resection may improve nutritional status long term, in the immediate postoperative period patients often experience a reduction in BMI exceeding 10%. This decline is linked to multiple factors including anorexia, nausea, altered intestinal anatomy, gastroesophageal reflux, and dumping syndrome, as well as the common “nil by mouth” strategy[2,3,11-15].

Timely nutritional recovery is critical to support patients through adjuvant therapy and to mitigate the side effects of chemotherapy[1-3,8,12,16]. Various nutritional methods have been explored including oral feeding, enteral feeding (via jejunostomy or nasojejunal tubes), and total parenteral nutrition (PN)—the latter being increasingly outdated[2,13,14]. Both European Society for Clinical Nutrition and Metabolism and National Comprehensive Cancer Network guidelines recommend early enteral nutrition (EN) and support the use of FJT, contributing to its growing adoption[7,16-20]. Enhanced Recovery After Surgery (ERAS) for gastrectomy prioritizes early oral intake, which a meta-analysis of 9 randomized controlled trials (RCTs; n = 1087) shows reduces length of stay (LOS) by approximately 1.5 days (MD = -1.50, 95%CI: -1.91 to -1.10) and lowers costs, without increasing overall complications (RR = 0.96, 95%CI: 0.72-1.26) or feeding intolerance (RR = 0.95, 95%CI: 0.79-1.15)[21]. When early per-oral nutrition isn’t feasible (e.g., intolerance, anastomotic concerns), ERAS remains consistent with early enteral rather than PN to support the gut barrier and microbiota: In a randomized study after hematopoietic transplant, predominantly enteral feeding preserved beneficial taxa (greater Faecalibacterium, P < 0.001) and patients with minimal oral intake had lower microbial diversity (P = 0.004), whereas antibiotic exposure and longer LOS also reduced diversity—supporting the ERAS emphasis on keeping the gut fed when safe[22]. Gastrectomy itself remodels the microbiome—studies report post-surgical shifts toward oral/aerotolerant/bile-transforming bacteria and structural changes in community composition—so maintaining enteral flow is biologically plausible to mitigate dysbiosis[23,24]. In this context, a selective FJ at gastrectomy can operationalize ERAS goals by guaranteeing early enteral calories when oral intake will be inadequate; however, it carries non-trivial device morbidity: Jejunostomy-related complications occur in 17% with 3% reoperation after total gastrectomy, and other series report 19%-21% early and approximately 21% late events, with some cohorts noting ≥ 1 complication in approximately 36%[1,7]. Taken together, ERAS for gastric cancer favors early oral feeding first; when that’s not possible, EN via a selectively placed FJ aligns with ERAS by sustaining the gut-microbiota axis while accepting a quantified, patient-specific risk of tube-related complications[21,22].

However, despite these advantages, FJT is not uniformly adopted in clinical practice. There is considerable variability in FJT placement strategies across centers, and no standardized protocols exist to guide its implementation. Moreover, concerns about high-risk complications—ranging from mechanical failure to infectious and metabolic issues—continue to challenge its routine use[1,2,7,8,12,13]. This lack of consensus on timing, technique, and patient selection represents a clear gap in the literature and limits the development of evidence-based guidelines. Future studies addressing these uncertainties and incorporating standardized protocols could enhance the generalizability and safety of FJT use. In this review, we summarize current evidence on the use of jejunostomy feeding in gastroesophageal cancer surgery, analyze its benefits and drawbacks, and highlight areas requiring further research to support evidence-based, patient-specific decision-making.

SEARCH STRATEGY

PubMed, Cochrane Library, MEDLINE Scopus-clinical trial register, and Web of Science databases were initially searched by two of the authors (Prisacariu IA and Koumarelas KE) to retrieve studies reporting data on FJT placement from inception up to April 2025. The following medical subject heading terms alone or matched by the logical operators “OR” or “AND” were used: ‘Gastrectomy’, ‘feeding jejunostomy’, ‘esophagectomy’, ‘jejunostomy’, ‘gastroesophageal cancer’. Old, repetitive, and non-English studies were excluded. After an initial title screen, each relevant article was subsequently reviewed, and 64 representative scientific papers were finally quoted. All included studies were reviewed to ensure that they adhered to accepted ethical standards for human research; RCTs followed CONSORT recommendations, and observational studies were consistent with STROBE guidelines as reported by their respective authors.

INDICATIONS-CONTRAINDICATIONS

In general, surgeons utilize jejunostomy feeding in patients either malnourished (> 10% weight loss in the last 6 months) due to their comorbidities or in the postoperative period after major upper GI surgeries involving the esophagus, stomach, pancreas, and duodenum resection. The indications of FJT include patients who cannot be fed orally, patients with severe trauma, patients in need of nutrition for more than 6 weeks, patients with gastroparesis or gastric outlet obstruction caused by malignancies or Bouveret syndrome, and for delivering drugs in specific patient groups such as patients with Parkinson disease. FJTs are a great asset for surgeons and patients in order to maintain a good nutritional income. However, some patients are excluded from this operation. The contraindications of FJT are categorized as local and systemic. The local contraindications are associated with abdominal wall infection, severe ascites, peritonitis, and history of bowel necrosis due to a previously installed FJT whereas the systemic complications include severe coagulopathy with international normalized ratio > 1.5, activated partial thromboplastin time > 50 seconds and platelet < 50000/mm³, hemodynamic instability, and ventilatory dependence.

The choice between open and laparoscopic FJT placement depends on patient-specific anatomical and pathological conditions, the duration of anticipated enteral feeding, and institutional or surgeon-specific expertise. While jejunostomy is generally well-tolerated, there are several contraindications that can influence the chosen surgical approach. The only absolute contraindication for any form of jejunostomy is mechanical intestinal obstruction. Relative contraindications, which may impact both open and laparoscopic routes, include significant edema of the intestinal wall, active enteritis (particularly post-radiation), Crohn’s disease, and uncorrected coagulopathies due to increased risk of hemorrhage or enterocutaneous fistula. Conditions such as massive ascites, severe immunodeficiency, or post-radiation changes increase the risk of intra-abdominal infections and wound complications[25].

When considering laparoscopy specifically, its minimally invasive nature is advantageous but may be limited by certain intra-abdominal pathologies. Extensive intra-abdominal adhesions and peritoneal carcinomatosis represent key relative contraindications for laparoscopic FJT, as they compromise visualization, safe dissection, and tube placement. In such cases, open surgery may be preferred despite its more invasive profile, as adhesiolysis or direct bowel mobilization can be performed under direct vision. On the other hand, open jejunostomy is relatively contraindicated in patients with severe cardiopulmonary compromise, where prolonged general anesthesia and larger abdominal incisions increase morbidity; in such situations, a laparoscopic or minimally invasive approach may be safer. Conversely, laparoscopic jejunostomy (Lap-J) is favored when percutaneous endoscopic access is not feasible or contraindicated (e.g., due to gastric surgery, altered anatomy, or severe gastroesophageal reflux with high aspiration risk), and when a less traumatic approach is desirable to reduce postoperative pain and recovery time. The final decision is guided by a structured algorithm that weighs the duration of nutritional support, risk of aspiration, the technical feasibility of each method, and most importantly, the surgeon’s experience and available resources[25-27].

TECHNIQUES

As mentioned above FJT improves patients’ postoperative nutritional status. The latest data indicates that the FJ is mainly performed as an additional procedure to the main surgery, for patients undergoing total gastrectomy and esophagectomy[7,28]. There is a wide variety of techniques for jejunostomy placement, including open surgical technique with longitudinal Witzel or transverse Witzel or Stamm, laparoscopic technique, needle catheter technique, and percutaneous technique mostly Seldinger[5,8,29,30]. The insertion of the jejunostomy nowadays tends to be carried out by minimally invasive methods, with the preferred one being Witzel performed in 44.6% of the patients, followed by Seldiger and Stamm techniques with percentages of 30.4% and 16.1% respectively[7]. There is a great similarity between the stages of performing open or Lap-J placement, with the laparoscopic placement being conducted much more often, offering the patient shorter hospitalization time and less pain (Figure 1)[13,31]. Komek et al[31] studied 74 patients receiving a FJT, dividing them into 2 groups: Laparoscopic and open. Then, by measuring the mean morphine dosage came to the conclusion, that patients belonging to the Laparoscopic group had less pain compared to the open surgery group with the difference in the dosage being 3.3 vs 7.19 (P < 0.001)[31]. A recent propensity score-matched study comparing Lap-J with nasoenteral tube feeding in patients undergoing minimally invasive esophagectomy for esophageal cancer demonstrated that Lap-J is associated with shorter postoperative hospital stays, lower perioperative albumin loss, and fewer respiratory complications, such as pneumonia and pleural effusion. While the rate of anastomotic leakage (AL) was similar between groups, patients in the Lap-J group experienced fewer admissions and better nutritional stability in the presence of leakage. These findings support the use of Lap-J as a safe and effective strategy for perioperative nutritional support in selected high-risk patients[32]. With regards to open-access surgery, the commonest method of jejunostomy's placement is through the creation of Witzel's tunnel[13]. Ryle's tube number 14 French is the most widely used since it reduces site infections. For inserting the tube, a small opening is created into the second loop of the jejunum, about 20 to 50 cm distal to the Treitz ligament. The tube is then passed throughout the jejunum and secured in place by tunneling. A suture is then placed between the peritoneal layer and the jejunum to prevent intussusception as well as peritoneal contamination[13]. In the absence of immediate tube-related complications, the tube is finally secured with a suture to the skin of the abdominal wall[28]. As for high-risk patients, needle catheter jejunostomy is considered as the most suitable option[14,15]. In recent years, research has focused on developing new techniques concerning the placement of jejunostomy tube in order to minimize the frequency of side effects after the procedure. A study published by Lin et al[33] in the year 2023 concluded that by using the ultra-proximal jejunostomy- a technique in which the jejunostomy tube is no longer sawn to the abdominal wall, after McKeown-Type Esophagectomy, the risk of developing enterocutaneous fistula was close to zero, and there were no complications related to tube removal, suggesting that this improved method was effective and safe. To contextualize these findings, contemporary series using traditional, anchored Witzel/purse-string jejunostomies (with abdominal-wall fixation) still report non-trivial jejunostomy-site leakage. In a 2015-2018 esophagectomy cohort, Kim et al[34] documented 41 jejunostomy-related complications among 72 insertions, including 8 cases of jejunostomy leakage (approximately 11.1%), despite purse-stringing and fixation to the abdominal wall. By contrast, the ultra-proximal approach reported by Lin et al[33] (puncture approximately 5 cm distal to the ligament of Treitz, no abdominal-wall fixation, transmesocolic exit) observed no postoperative intestinal fistulas in 43 patients and no tube-removal complications, suggesting a potential reduction in fistula/Leak risk with this configuration. Technique choice also matters for late fistula after tube removal: Button-type jejunostomies are associated with a substantially higher risk of refractory enterocutaneous fistula after removal—31.9% in a recent cohort—particularly when dwell time exceeds 12 months, underscoring the value of minimizing abdominal-wall fixation and limiting long-term indwelling time when feasible[35]; Finally, modern laparoscopic Witzel series report overall complication profiles comparable or favorable to open placement but still employ abdominal-wall fixation, and explicit fistula events remain uncommon in small cohorts[36]. The main reasons for the fixation of the jejunum to the abdominal wall during the common jejunostomy procedure are: Prevention of the slipping of the jejunal nutrient tube from the lumen due to the peristaltic movement of the intestine, which could lead to the occurrence of enterocutaneous fistula and nutrient fluid entering the abdominal cavity and moreover to close the gap between the intestinal tube and peritoneum to reduce the occurrence of enterocutaneous fistula when the jejunal nutrient tube is removed. Lin et al[33] improved the jejunostomy technique by choosing the jejunal puncture spot at 5 cm from the distal end of the ligament of Treitz instead of the classical approach. The jejunum was fixed at this point and the jejunal nutrient tube was less likely to slip out of the intestinal canal because of the small change in position of the space produce by peristalsis. With this approach the jejunum did not need to be fixed. Furthermore, the lateral wall of the jejunum was used for the tunelisation of the nutrient tube over the span of 2 cm and the tube was posed through the root of the transvers mesocolon to the outside of the abdomen through the peritoneum. Because of the formation of a sinus tract, this resulted in the less likelihood of enterocutaneous fistula. Although the study provides valuable insight into the safety and feasibility of ultra-proximal jejunostomy following McKeown-type esophagectomy, it is important to acknowledge that the relatively small sample size of patients may introduce a selection bias and limit the generalizability of the findings, therefore larger, multicenter studies are needed to validate these outcomes and confirm the advantages of this modified technique in broader clinical practice[33]. During the postoperative period, feeding through the tube starts either immediately or within the 12 first hours[14]. Especially, during the first three postoperative days, when patients receive no oral intake (nil-by-mouth), jejunostomy's nutritional benefit is crucial[1]. Only in cases of adequate oral intake, improvement in the postoperative course, presence of tube-related complications, or need for post-operative vasopressor support of the patient is the feeding tube suspended[1,28]. For all gastrectomy patients, a standardized feeding protocol, the Harris-Benedict Formula, is applied[1,28]. According to that protocol, patients are only hydrated with 20 mL/ hour of water during the first postoperative day. Then, during the second one, they receive high protein concentration feeding 10 mL/hour increased by 10 mL/hour for each day following until the 5^th one[28]. To this point, the feeding rates become personalized, based on whether the minimum of half of the nutritional requirements is provided or not[14,28]. FJT support continues until the 6^th postoperative week when the GI tract has finally recovered and the tube can be safely removed[2].

Figure 1 Feeding jejunostomy tube placement technique[39]. A: First layer of purse-string suture of the tube (polyglactin 910 3/0); B: Enterotomy performed by hook; C: Enterotomy extension with the aid of a Maryland dissector; D: T-tube insertion; E: Securing the knot of the first layer suture; F: Second layer of suture (polyglactin 910 3/0); G: Transfascial suturing with thread grasper; H: T-tube test for patency and leak. Citation: Siow SL, Mahendran HA, Wong CM, Milaksh NK, Nyunt M. Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: The technique and review of outcomes. BMC Surg 2017; 17: 25. Copyright ©The Author(s) 2019. Published by BioMed Central Ltd (Supplementary material).

Regarding new jejunostomy placement techniques, the results of a study published in 2023 by Colletier et al[37] highlighted that in the case of patients with a history of partial gastrectomy reconstruction (PGR), direct percutaneous endoscopic jejunostomy (DPEJ) has proven to be a more effective and safer option for long-term jejunal access compared to PEGJ. Due to altered anatomy, PEGJ is often less feasible, while DPEJ allows better jejunal fixation and fewer complications within 30 days. Although the sample size was limited, the results support DPEJ as the preferred method in PGR cases. Recent evidence supports the use of DPEJ as a safe and effective alternative to surgical jejunostomy. A retrospective cohort study published in 2024 reported a 96.9% procedural success rate for DPEJ, along with significantly lower rates of tube-related dysfunction within the first 90 days postoperatively (0% for DPEJ vs 35.1% and 40% for laparoscopic and open surgical jejunostomy, respectively). These findings suggest that DPEJ may reduce complication rates and improve short-term outcomes compared to traditional methods, highlighting the value of innovation in postoperative nutritional strategies[38].

BENEFITS OF FJT

Esophagectomy and gastrectomy are associated with increased operative stress that strongly affect patients’ overall status. They can lead to metabolic disorders and malabsorption of nutrients for a long period of time, and to a disturbed innate immune response with a higher incidence of infections caused by damage in the intestinal barrier and by the variated gut flora[15,39-46]. Enteral and parenteral feeding are the two main modalities for supporting patients' recovery and treating postoperative malnutrition. One aspect of enteral feeding is FJ. FJT placement is accomplished by inserting a feeding tube in the proximal jejunum. As we mentioned above, PN is the most conventional but with little to no place in these procedures, since it is associated with a higher rate of infections[47]. On the other hand, EN is widely preferred, causing much fewer complications as well as minimizing hospitalization and septic incidences[8,14,28,48-55]. Han et al[56] reported in their prospective cohort study comparing 300 patients with colorectal cancer, that at the 3^rd and 5^th postoperative day, the C-reacting protein (CRP)-value of patients after EN was 49.39% and 25.65%respectively compared to the non-EN (69.35% and 49.89%, P < 0.001). IL-6 and IL-10 were significantly lower at the EN-group at the 3^rd postoperative day (18.94% vs 83.97% and 17.08% vs 25.46% P < 0.001). These findings are supported by recent clinical evidence from upper GI surgery. In a RCT, Na et al[57] (2025) demonstrated that jejunostomy-assisted feeding after esophagectomy significantly mitigated postoperative weight loss at 4-5 weeks (5.6% vs 8.3%; P = 0.002) and 4 months (10.5% vs 15.0%; P = 0.003), while ensuring higher caloric and protein intake and without increasing complications. Furthermore, a prospective cohort study from Malaysia comparing EN and PN after esophagectomy reported higher protein intake with PN (1.4 g/kg vs 1.2 g/kg; P = 0.036), but found no significant differences in 30-day mortality, intensive care unit stay, ventilation days, or overall postoperative complications, confirming the safety of enteral feeding via jejunostomy in this setting[58]. Collectively, these data provide clinical evidence that beyond mechanistic advantages, FJT-based EN supports improved nutritional recovery and modulates systemic inflammatory responses without increasing postoperative risk. FJT placement remarkably enhances the nutrition, protein, and albumin serum levels postoperatively. The same capability is seen in preserving the adequacy of micronutrition. Baker et al[11], in their RCT, indicated that after total gastrectomy or esophagectomy, 94% of the patients with FJTs had an adequate intake of nutrients, micronutrients, and energy compared to the 77% of the control group at 6 months postoperatively. Even though feeding via FJTs seems to reach an adequate level of nutritional and energy intake, it leaves oral intake totally intact. As a result, early oral feeding is feasible at the same time, and “sip feeds” contribute to reaching the preferred daily energy intake. Patients undergoing major upper GI surgeries, or other surgeries, tend to present severe weight loss following the operation. FJT’s nutritional boost can improve surgery outcomes. Multiple studies emphasize on the FJT's short-term beneficial effects on increasing cell mass and weight gain. Along with weight increase, patients slowly regain physical activity and strength[11,14]. Froghi et al[12] point out the vast improvement in quality of life during the first 3 postoperative months. While afterward, it reaches a plateau[12,59,60].

This has been confirmed in a large retrospective service evaluation involving 165 patients who underwent esophagectomy, where those receiving jejunostomy feeding (n = 24) experienced significantly less weight loss at both 6 and 12 months postoperatively, even after adjusting for age, gender, tumor staging, and adjuvant treatment (P ≤ 0.001 and P = 0.03, respectively). Additionally, 43.2% of early readmissions in the non-jejunostomy group were due to nutritional failure, while 8.5% of these patients required “rescue” tube feeding within the first year after surgery. These findings highlight the protective effect of FJTs in preventing nutritional deterioration and readmission, supporting the integration into postoperative care[61]. Moreover, a recent study conducted by Kato et al[62] evaluated the impact of long-term EN through jejunostomy on skeletal muscle preservation after minimally invasive esophagectomy. The researchers found that extended tube feeding significantly reduced the loss of skeletal muscle mass, which is a common and serious complication in post-esophagectomy patients. This benefit was particularly evident in the long-term follow-up, where patients receiving prolonged nutritional support demonstrated improved muscle retention and overall better recovery profiles. These findings highlight the critical role of sustained enteral feeding in the postoperative care of esophageal cancer patients, supporting the integration of jejunostomy as a key strategy for preventing sarcopenia and improving clinical outcomes[62].

Therefore, inserting an FJT is nowadays considered a safe and feasible procedure improving clinical outcomes, despite its high rate of minor complications. FJTs placement can be successfully practiced by trainee surgeons and does not affect postoperative mortality and morbidity. Morbidity and major complications after the procedure are far less common, leading to reduced hospitalization and lowering the hospital readmission rate. Anastomotic leaks are a common complication of esophagectomy, affecting 5% to 40% of the patients and they require reoperation[47]. Holmén et al[63], in their retrospective cohort study, observed that patients with FJTs didn’t require reoperation after the occurrence of an anastomotic leak, as there was a secure enteral route[61,63]. Although the presence of a jejunostomy tube did not significantly influence overall survival in patients with AL, its use has been associated with faster recovery and the ability to continue EN at home. This finding supports the prolonged use of jejunostomy tubes in selected patients, particularly those recovering from complications such as AL, where maintaining adequate nutrition is essential for healing and functional recovery[64]. All these are in favor of conserving hospital funds and simultaneously increasing patients’ quality of life[5,13,14]. FJT's placement, as with any other invasive procedure, has its complications, but these are easily manageable and most of them are classified as grade IIIa in the Clavien-Dindo scale, meaning “moderate”, and can be overcome with treatment methods that do not affect neither the mortality nor the morbidity[64-67]. Compared with PN, FJT is associated with a lower rate of intraoperative and postoperative morbidity, but with longer operation time[3,7,13,14]. Jaquet et al[66], on their retrospective study observed that FJT after major upper GI surgery, including gastrectomy and esophagectomy, significantly improves postoperative nutritional status—reducing weight loss (5.7 kg vs 9.9 kg) and albumin drop (7.2 g/L vs 14.7 g/L)—and lowers the risk of infectious complications (1.2% vs 9.3%) and grade 3 morbidity (0% vs 4.7%). Additionally, it helps maintain weight at 6 months and 12 months post-esophagectomy (P ≤ 0.001 and P = 0.03), reduces early hospital readmissions due to nutritional failure (43.2%), and minimizes the need for rescue tube feeding (8.5%), supporting its routine use in perioperative care[66].

Furthermore, compared to other methods of enteral feeding, like nasojejunal tubes (NJT) or gastric tube, several studies showed that patients who are Fed through a jejunostomy showed improved values of global health status and functioning (physical, role and social) and a reduction in intensity of side effects like fatigue, nausea/vomiting, pain and appetite loss. Compared to the group that received enteral feeding through NJT patients who have received jejunostomies have reported significantly reduced pain in the first 3 days after operation. All these results support the use of jejunostomy as the Methods of preferred enteral feeding in the case of patients who require perioperative nutritional support, contributing to a better and quicker recovery and an improved quality of life[68].

Moreover, FJTs can be preserved for a long period of time, after hospital discharge with little to no burden on the community[12]. Other than that, we should not forget to mention the beneficial outcomes of jejunostomy feeding on preserving the gut microbiota and the GI and epithelial structure while it allows the gut motility to slowly return to the preoperative levels. Maintaining the normal gut flora and boosting the innate gut immune system leads to less infectious complications[5,8,14]. Last but not least, a malnourished patient can be excluded from receiving adjuvant chemotherapy. FJT, by increasing the nutritional status of the patients, plays a significant role in the continuation of the adjuvant therapy, overcoming its systemic complications and thus prolonging the patients’ survival. National Comprehensive Cancer Network currently suggests the use of FJTs for cancer patients, aiming at their increased survival rates[1,3]. Furthermore, among the patients who suffer from esophageal and gastroesophageal junction cancer, the insertion of a jejunostomy tube can be done at various stages, including at diagnosis or during curative surgery. When started before neoadjuvant therapy in patients with poor oral intake, a FJ has been show to safety support nutritional status. Retrospective data suggests that early implementation helps maintain body weight and composition, aiding treatment completion and surgical recovery[69]. All these findings contribute to the fact that FJ is an essential procedure, especially in specific patient groups. The importance of EN is emphasized by the American Society for Parenteral and Enteral Nutrition guidelines regarding the early beginning of EN within 24 to 48 hours following the surgery[70].

COMPLICATIONS OF FJT

While FJT placement is widely used due to its nutritional benefits, it is not without risks. A range of postoperative complications have been reported in the literature, varying in severity and clinical relevance.

Apart from its benefits, the use of FJT in gastroesophageal cancer surgery is associated with a variety of complications. Although most are moderate in severity (Clavien-Dindo Grade IIIa or lower), they can still impact patient outcomes. Importantly, these complications do not seem to increase mortality[67,71].

Mechanical complications

Mechanical issues are the most frequently reported, with an overall incidence of up to 44.4% (Table 1)[7,61,72].

Table 1 Frequency of complications in the included studies (%).

Ref.	Tube specific complications	Early complications	Late complications	More than 1 complications	Severe complications	Complications requiring re-operation	Tube mortality
Al-Taan et al[28], 2017
Baker et al[11], 2017							0
Blakely et al[8], 2017	12.8 (6/47 only in TG)					12.8 (6/47)
Brenkman et al[1], 2017	17					3
Choi et al[7], 2017	44.4 (52/117)
Deepjyoti et al[2], 2020
Froghi et al[12], 2017
Okida et al[13], 2021	39.6	19.1 (14)	20.5 (15)	5.5 (4)		4.1	0
Dutta et al[5]	40-50
Wobith et al[6], 2020	44.1				10.8 (11/102)		0

Tube dislodgement (luxation): Occurs in 18.8% of patients (Table 2)[7,61,72].

Table 2 Frequency of common complications of feeding jejunostomy tube placement in the included studies.

Ref.	Dislocation	Clogging	Gastrointestinal symptoms	Feeding tube leak	Bile leak	Infection	Anchor suture loss	Skin irritation	Torsion	Closed loop obstruction	Small bowel obstruction	Small bowel perforation/necrosis	Hemorrhage	Intraperitoneal displacement	Multi-organ failure after tube feeds	Weight loss
Al-Taan et al[28], 2017												8 (TG); 1.66 (in OE)
Blakely et al[8], 2017				4.25 (2/47)						2/47 (4.25)		2.12 (1/47)			2.12 (1/47)
Baker et al[11], 2017	2	16	9 (in hospital); 35 (out of hospital)	13
Bowrey et al[82], 2015		18	9	23
Brenkman et al[1], 2017	5	3		5	3	1.65			1.54 (1/65)
Choi et al[7], 2017	18.8 (22/117)	11.17 (13/11)		5.12 (6/117)			11.11 (13/117)	11.11 (13/117)			2.56 (3/117)		0.85 (1/117)
Deepjyoti et al[2], 2020	1/42	6/42			3/42	3/42		4/42					1/42			63
Okida et al[13], 2021	12.3	18.8		4		5.4					2.7			1.3
Wobith et al[6], 2020	9.8 (10/102)	3.9 (4/102)		5.9 (6/102)							3.9		1.96 (2/102)		3.9 (4/102)

TG: Total gastrectomy; EO: Esophagectomy.

Occlusion, leakage, and skin irritation: Often due to sutures or anchor dysfunction[2,5,61].

Tube torsion: Rare complication[1,72].

Small bowel obstruction: (1) Acute obstruction: Observed in 2.56% of patients[7,8]; (2) Closed-loop obstruction: Observed in 4.25%[7,8]; (3) Insertion site bleeding: Reported in 0.85% of cases[7]; and (4) Need for reoperation: The overall rate is 3.4%[7,8].

Infectious complications

FJT, being a foreign body, increases the risk of infection, especially when operative time is prolonged[1,2,73]. (1) Cutaneous or intra-abdominal infections: May lead to abscesses and require prolonged treatment[1,5]; and (2) Urinary tract infections: Higher in FJT patients (6.4%) compared to non-FJT patients (3.4%, P = 0.01)[3].

GI symptoms and metabolic disorders

Jejunal administration of nutrition post-gastrectomy/esophagectomy can lead to: (1) GI symptoms: Bloating, nausea, vomiting, constipation, and diarrhea[5,29]; (2) Electrolyte disturbances: Hypokalemia, hypophosphatemia, hypomagnesemia; and (3) Acid-base imbalances: Further complicating the postoperative status[5,29].

Severe complications requiring emergency intervention

Intussusception[74]: (1) May require urgent evaluation[5]; (2) Incidence: 0.1%-3.4% after gastroesophageal surgery, up to 8% after total gastrectomy; (3) Mortality: 40%-100%[28]; (4) Symptoms: Non-specific (abdominal pain, bloating, nausea, vomiting, delayed bowel movement); (5) Diagnosis: Urgent computed tomography to detect pneumatosis intestinalis[30,75,76]; and (6) Risk factors: High osmolarity feeds, poor intestinal perfusion, use of inotropes[28].

Perforation and ischemia/necrosis: High-risk, potentially fatal[8,30,77,78].

Bile content leakage: Can vary in severity. From mild, conservatively managed cases to severe requiring reoperation[1,2,8,65].

Minor complications

These occur in 40%-50% of patients[5,71] and are usually: (1) Localized to the insertion site; (2) Related to the feeding solution; and (3) Managed conservatively without need for par EN[2].

Complications from other jejunostomy techniques (e.g., needle catheter jejunostomy)

(1) Dislodgement: 9.8%[6,79]; (2) Occlusion: 3.9%[6,79]; (3) GI symptoms: Occur in 30% of patients[6,79] and (4) Major complications (Clavien-Dindo): Seen in 10.8%[6,78,80-82].

In summary, although FJT provides effective enteral access in patients undergoing gastroesophageal cancer surgery, clinicians must remain vigilant about its potential complications. Mechanical problems are the most frequent, affecting up to 44% of patients, with tube dislodgement reported in 18.8%, small bowel obstruction in 2.6%-4.3%, and reoperation required in 3.4%. Infectious events, including cutaneous or intra-abdominal infections, are common, and urinary tract infections occur more often in FJT patients (6.4% vs 3.4%). GI symptoms such as bloating, nausea, diarrhea, and electrolyte disturbances are also frequent. Severe complications, though rare, can be life-threatening: Intussusception occurs in 0.1%-3.4% (up to 8% after total gastrectomy) with a mortality of 40%-100%, while perforation, ischemia, or bile leakage may also require urgent intervention. Minor complications occur in 40%-50% of patients but are usually managed conservatively. Proper patient selection, with consideration of approach-specific contraindications, meticulous surgical technique, and close postoperative monitoring are essential to minimize adverse outcomes.

DISCUSSION

Patients undergoing total gastrectomy oresophagectomy for upper GI malignancies are at great risk of malnourishment. Post-operative nutritional levels are directly related to the hospitalization and recovery time. As a result, the establishment of enteral feeding is vital in improving the patient's postoperative prognosis. Installation of a FJT seems the best available alternative with zero mortality rates and mostly intermediate- conservatively managed-complications. However, it is also associated with some severe complications. Therefore, special attention must be given to their prevention, early detection and treatment.

Since FJT's role for patients undergoing upper GI surgeries is crucial, its placement comes with a variety of inserting techniques. The laparoscopic insertion seems to outperform the rest in terms of reduced postoperative pain and shortened hospitalization time[5,8,13]. Only for high-risk patients needle catheter jejunostomy is considered a more suitable technique[14,15]. Based on the Harris benedict formula, a standardized feeding protocol, all total gastrectomy and esophagectomy patients receive immediately after surgery until the sixth postoperative week high protein concentration feeding, through FJ, covering each one’s personalized nutritional requirements[14,28]. The FJT can then, after the sixth postoperative week, safely be removed[2].

It is well known that patients undergoing major GI surgeries are at great risk of malnutrition. That’s why maintaining a high nutritional profile enhances the patient’s recovery and prognosis. FJTs has shown a greater clinical impact than parenteral feeding in terms of energy and protein intake as well as in minimizing infectious complications[8,30] Barlow et al[14] in their prospective multicenter RCT shed evidence that 69% of patients who underwent upper GI surgeries achieved, by the use of feeding jejunostomies, the daily nutritional target during the first postoperative week. Baker et al[11] furtherly indicate that the percentage of patients reaching adequate protein and energy intake after surgery ranges in 55% and 61% in the first 3 months and increases to 77% and 94% respectively in a 6-month period. This nutritional boost contributes to the maintenance of the patient’s weight, while at the same time albumin and prealbumin serum levels are increased, and so does functionality indicated by the strength of hand grip[2,15]. The enhanced nutritional status has also critical significance for those in need of adjuvant therapy, as pointed out by the National Comprehensive Cancer Network[1,3]. According to Barlow et al[14], FJT significantly reduces the hospitalization time to a 16-day period. Zheng et al[48], support that feeding at the first 48 hours post-surgery decreases the volume of thoracic drainage after esophagectomy, accelerates the first fecal passage and decreases the hospitalization time. As mentioned by Okida et al[13], FJ comes with multiple early or late complications. However, the majority of them, can be managed conservatively being mostly grade IIIa in Clavien-Dindo classification. Only a small percentage requires further surgical treatment. Especially long-term complications do not require any reoperation[13]. FJTs beneficial effects in maintaining gut's anatomy and function cannot be overlooked. Neither can the boost in guts immunity, since it significantly minimizes infection rate and bacterial translocation[5,8,14]. Taking all these into account, Barlow et al[14] and Okida et al[13] came to the conclusion that FJ is considered both safe and feasible, leaving the postoperative mortality rates totally intact[3,7,13]. A further FJT alternative available nowadays is, according to Froghi et al[12], jejunal feeding in community, encouragingly resulting in no complications at all.

Beside FJTs beneficial effects, a variety of studies highlights its potential risks. Initially the tube-related complication rate ranges from 12.8% according to Blakely et al[8] (P = 0.0003) to 44.4% based on Choi et al[7]. A total 39.6% complication rate calculated by Okida et al[13], consists of 19.1% early and 20.5% late complications, while more than one complication affects only 5.5% of the patient sample. As the percent of severe complications reaches 10.8% about 3% of them are in urgent need of operative re-exploration[1]. Based on the tube's characteristics and its installation method occlusion may present with a maximum frequency of 4.25%[8]. So does the feeding tube's leak with a frequency of 5.12%[7]. Most commonly, an early dislocation is observed in a percentage up to 18.8%[13]. A tube's clogging may affect up to 11.1% of the patients[7]. About 11.11% of them suffer from skin irritation or anchor suture loss[7]. The previously mentioned severe complications include small bowel ischemia or necrosis in 8% of the patients (P = 0.05), small bowel obstruction with a percentage of 2.7%, small bowel perforation and multi-organ failure both with the same 2.12% frequency of occurrence and last but not least hemorrhage affecting only 0.85% of the patient sample[7,8,13,28]. Small bowel necrosis and perforation have been observed only in patients who underwent total gastrectomy. However, Baker et al[11] in their prospective RCT noticed no tube associated mortality. Great importance should be given to the statistically significant incidence of infection of the tube insertion site affecting 5.4% of the patients[13]. Taking all this into consideration Froghi et al[12] marked the fact that FJT does not offer better life quality neither to the patients nor to the family and health economics. Actually 30% of the patients suffer from diarrhea[6]. Common are also fluid and electrolyte imbalances leading to a significant weight loss affecting 63%of the ailing’s[2]. Therefore, the fact that, around the 25.6% of patients receiving jejunal tube feeding required PN as a bridge to achieve another great enteral intake, is not surprising at all[8]. Last but not least, Holmen et al[63] observed a rare complication on 4.3% of their patients with FJTs, paralysis of the recurrent laryngeal nerve, and it could lead to an increased percentage of aspiration pneumonia (11.8% instead of 7.2% on the control group)[61]. However, this complication was correlated with the locally advanced stage of the tumor in these patients who had an FJT.

Surgeons tend to utilize nasojejunal tubes instead of FJTs. Nasojejunal tubes are a great alternative of Enteral Feeding, in order to achieve an adequate nutritional intake[8]. They have been associated with no major complications, in contrast with PN and FJTs and they do not affect the operative and postoperative morbidity[8]. However, when it comes to patients with prolonged hospital stay or in need of long-term additional nutrition, after hospital discharge, nasojejunal tubes serve no role as they can be easily dislocated in about 20%-35% of the patients and cannot be tolerated making the use of JFTs inevitable[1,6].

Nowadays, the management of the patients undergoing major upper GI surgeries is based on the ERAS protocol. According to this protocol, surgeons initiate early oral feeding directly after surgery and at the same time they aim to minimize pain via epidural anesthesia, fast mobilization and other pre-operative, intraoperative and postoperative interventions[1]. This protocol appears to be even more beneficial as it activates the GI tract in a more natural way, it is associated with no complications, it reduces the postoperative weight-loss and the hospitalization time[1,6].

Early oral feeding, and in general early enteral feeding consist of protein and glucose-based solutions. In the last couple of years the benefits of enteral immunonutrition (IMN) and also the mechanism through which this type of nutrition can improve the outcome of patients suffering from GI cancer-surgery has been studied. Evidence suggest that adding nutrients such as probiotics, ω-3 fatty acids, glutamine, and arginine (Arg) enhances patients’ postoperative course. Enteral IMN (EIN) has been showed to aid the regulation of inflammation and enhance immunity by strongly reducing tumor necrosis factor-α,interleukin-6, and C-reactive protein concentrations and increasing CD4+ and Ig-A level. Eicosapentaenoic acid and docosahexaenoic acid are included in the group of omega 3 acids. They represent primary fish oil components that have the ability to modulate the immune inflammatory responses. This modulation occurs through the activation of T and B-lymphocytes, through alteration of the fluidity of the membrane, lipide peroxide formation, eicosanoid generation, gene expression regulation and the inhibition of subsequent inflammatory processes which consist of leukocyte chemotaxis, leukocyte-endothelial adhesive interactions, adhesion molecule expression, eicosanoid production (prostaglandins and leukotrienes) from n-6fatty acid arachidonic acid, and stimulation of proinflammatory cytokines. Glutamine, as one of the main sources of energy for enterocytes, is observed to suspend the apoptosis of the mucosal cells and promotes their proliferation. Arg, a semi-essential amino acid, is known to stimulate the multiplication of T-lymphocytes in response to mitogens or cytokines. Furthermore, it is proven that probiotics hold a significant role on reconstructing the GI barrier while concurrently behaving as immunomodulators. Recent evidence has further clarified these effects: Perioperative glutamine supplementation significantly increases humoral immunity (IgA SMD = 1.15; IgM SMD = 0.68; IgG SMD = 1.10), enhances T-cell parameters (CD4+ SMD = 0.76; CD4+/CD8+ ratio SMD = 0.92; CD8+ SMD = -0.50), and reduces surgical site infection (SSI; RR = 0.48), anastomotic leak (RR = 0.23), and hospital stay (SMD = -1.13) in colorectal cancer surgery patients[83]. A meta-analysis of upper GI cancer surgery trials found that IMN containing glutamine, Arg, and ω-3 fatty acids significantly lowered infectious complications by about 30% (RR = approximately 0.72; 95%CI: 0.57-0.92; moderate certainty)[84]. Although probiotic evidence in GI cancer surgery is still emerging, randomized trials suggest they may enhance IgA secretion, strengthen tight-junction integrity, and reduce pro-inflammatory cytokine release; however, recent small-scale RCTs, such as Kaźmierczak-Siedlecka et al[85], showed no significant shifts in gut microbiota composition after 7-day preoperative EIN, likely due to sample size limitations. As a result, IMN can enhance patients’ immune response, recovery and intestinal epithelial functionality. Xu et al[15], on their RCT of 60 patients observed that the concentration of CRP was lower in patients treated with immunonutrients and CD4+ lymphocytes were increased indicating greater activation of the immune system, in contrast to the control group (P = 0.01)[15,86]. Wobith et al[16] noticed that IMN decreases the hospitalization time by about 1.58 days as it reduces the postoperative complications. Furthermore, the results of e recent metananlysis comparing thirty-seven studies, supported these results and identified that the main outcome of post-operative infectious complications was reduced with IMN OR = 0.58, 95%CI: 0.47-0.72]. This association was significant in subgroup analysis only with pre-operative and peri-operative administration and in trials including upper GI cancers, colorectal cancer and 'mixed GI' cancer populations, and significance was independent of nutritional status. IMN in pooled analysis reduced SSI (OR = 0.65, 95%CI: 0.52-0.81), anastomotic leak (OR = 0.67, 95%CI: 0.47-0.93) and LOS by 1.94 days (95%CI: -3 to -0.87)[16,87]. However, some studies have also indicated that the administration of EIN is not always effective in reducing the occurrence of complications. It should be acknowledged that the inconsistency in results has been attributed to factors such as the preoperative nutritional status of the study population, variations in the immunonutritional components used, as well as differences in administration timing and routes. The combination formula containing Arg, ω-3 fatty acids, glutamine, and RNA was considered the optimal regimen in several studies, whereas others reported that administering only Arg and RNA resulted in limited clinical benefits. Regarding the duration of therapy, a perioperative immunonutritional intervention lasting seven to fourteen days is recommended for moderately to severely malnourished patients undergoing gastric surgery. Furthermore, administering EIN both pre- and postoperatively was not found to provide additive benefits, while several studies suggested that the perioperative period represents the most effective window for this intervention[86]. Even though IMN indicates encouraging results for patient’s early recovery, the need for multicentre RCTs still remains in order to support these findings.

Patients exacerbating nutritional status may require the continuance of feeding via a jejunostomy tube at home for a prolonged time period. This is known as Home Enteral Feeding, and this method is proven to be safe and tolerable for the patients and their families, while it does not affect their working capabilities. Patients with Home Enteral Feeding reported no major complications after hospital discharge (Clavien-Dindo > IIIb). As a result the readmission rate ranges to 6% and 9% for the intervention and the control group respectively at the last 3 months of the study. However, these rates were 30% and 24% respectively at the first 6postoperative weeks[79]. Consequently, this method is considered feasible, safe, cost-effective, leads to weight gain and does not suppress oral feeding[11].

We acknowledge that many of the studies included in this review are retrospective in nature and therefore subject to inherent limitations, including selection bias, recall bias, and language bias. In particular, the restriction of our search to English-language publications may have introduced language bias, a well-recognized limitation in systematic reviews that can result in the omission of relevant data from non-English studies. This may lead to an overrepresentation of findings from certain regions or research settings and potentially limit the global applicability of our conclusions. Inclusion of studies published in other languages could broaden the evidence base, capture regional variations in practice and outcomes, and thereby enhance the generalizability of future analyses. Additionally, the small sample sizes in many included studies, coupled with variability in reported complication rates, underscore the need for future large-scale, prospective, and multicentre investigations. A future meta-analysis incorporating both English and non-English literature would be valuable to minimize potential biases and provide more definitive conclusions.

CONCLUSION

Patients who undergo major upper GI surgeries, for the treatment of gastric and esophageal malignancies experience increased postoperative stress, leading to a great nutritional deficiency in the postoperative period. These nutritional levels are closely related to the patient's recovery and healing process. Therefore, nutritional support is urgently needed with the insertion of a FJT being the most widespread enteral feeding technique. It provides the patients with adequate caloric support, having mostly manageable complications, with minimal reoperation rates and no mortality. However, it is neither an easy nor a risk-free procedure due to the presence of some major complications too. Taking all these into consideration, there is a need to redefine the selection and placement processes, as well as the use of FJT based on the patient's characteristics, creating a personalized approach to each patient's postoperative status. Furthermore, given the variability in patient profiles undergoing gastroesophageal cancer surgery, there is a clear need to move toward personalized, evidence-based protocols for FJT placement and management. Decisions should be informed by a comprehensive assessment of tumor stage, preoperative nutritional status, body composition, and comorbidities, as well as anticipated postoperative recovery trajectory. Integrating precision medicine principles—already gaining traction in GI surgical oncology—can facilitate the development of tailored EN strategies that align with each patient’s unique risk profile and treatment plan. Such an approach may enhance tolerance to adjuvant therapies, reduce complication rates, and improve both short- and long-term outcomes. Future guidelines should incorporate precision-based algorithms for FJT use, ensuring that individualized EN plans become a standard component of patient-centered perioperative care in GI surgery.