Laparoscopic Witzel feeding jejunostomy: a procedure overlooked!

**Background:** Feeding jejunostomy (FJ) is essential for enteral nutrition in upper gastrointestinal disorders, especially when performed as a standalone procedure. The Witzel technique, which involves creating a serosal tunnel to secure the feeding tube, is widely practiced due to lower leak rates. Minimally invasive laparoscopic FJ (LFJ) offers potential benefits such as less pain, fewer complications, and shorter hospital stay, but reports on the laparoscopic Witzel technique as a standalone procedure are limited. This study aimed to describe the total laparoscopic Witzel FJ technique and compare its outcomes with open FJ.

**Methods:** A retrospective database analysis was conducted on patients who underwent laparoscopic (n=20) or open (n=21) Witzel FJ as a standalone procedure from July 2018 to July 2022 at a single institution. Indications included dysphagia from esophageal carcinoma, acute corrosive injury, or delayed corrosive stricture. The laparoscopic technique used a 14-Fr Ryles tube (nasogastric tube) and routine laparoscopic instruments. Key steps included: patient positioning in reverse Trendelenburg with left side up, four port placements (one 10-mm camera port, two 5-mm working ports, one 5-mm port at the future FJ site), identification of the duodenojejunal flexure, selection of a jejunal loop 20–30 cm distal, anchoring the loop to the abdominal wall, enterotomy with harmonic scalpel, insertion of the Ryles tube, purse-string suture, creation of a serosal tunnel with interrupted Lembert sutures, and three-point fixation of the jejunum to the abdominal wall. The open technique followed similar steps via a supraumbilical midline incision. Postoperatively, patients started normal saline at 50 mL/hr on day 1, half-strength feed on day 2, and full-strength feed on day 3, with most tolerating 1.5–2 L by day 4. Perioperative data and outcomes were compared.

**Key Results:** Baseline characteristics were comparable between groups, though the laparoscopic group had a higher median BMI (18.5 vs. 16.5 kg/m², p=0.05) and better ECOG performance status (95% ECOG 0–1 vs. 66.7%, p=0.05). Median operative duration was significantly longer in the laparoscopic group (180 minutes, range 90–240 vs. 60 minutes, range 40–90; p=0.01). Median postoperative hospital stay was shorter in the laparoscopic group (3 days vs. 4 days, p=0.08). No immediate postoperative complications occurred in the laparoscopic group, while 4 patients (19%) in the open group had complications: two surgical-site infections, one intussusception requiring reoperation, and one pelvic collection requiring percutaneous drainage. There was no 30-day mortality. Early complications (<30 days) were fewer in the laparoscopic group: tube dislodgement (4 vs. 8), tube clogging (13 vs. 15), and surgical-site infection (0 vs. 1). At a median follow-up of 10 months (range 4–32), small bowel obstruction occurred in 1 laparoscopic patient (5%) and 2 open patients (9.5%).

**Clinical Implications:** Laparoscopic Witzel FJ is a safe and feasible alternative to open FJ, with no immediate postoperative complications and a trend toward shorter hospital stay. The technique uses readily available, cost-effective materials (Ryles tube, polyglactin sutures) and avoids expensive introducer kits. The longer operative time (180 minutes) reflects the learning curve and advanced suturing skills required, but is expected to decrease with experience. Patient selection is crucial, favoring those with good performance status and tolerability of pneumoperitoneum. Limitations include the retrospective design, small sample size, and selection bias (fitter patients tended to choose laparoscopy). Future prospective randomized studies are needed to validate these findings and assess cost-effectiveness.