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Anthony - 4. page

Anthony Bissell

J-tube Time

Anthony is scheduled to go to the OR at 10:30 this morning to have a surgical J-tube inserted. They plan to do an “open” procedure as opposed to laparoscopic procedure (minimally invasive surgery). I think this is a good idea considering Anthony’s history. With an open procedure the surgeon will be able to get a better look and hopefully a good placement of the new tube. This tube will be placed beyond the anastomosis from the vulvulus. He will also keep his G-tube, so that we will be able to keep his stomach empty (and reduce the risk of aspiration), while feeding via the J-tube. Anthony will go to the PICU after surgery.

Right now, Anthony has two student nurses caring for him. It is interesting to watch the interactions between the students and thier instructor. I know exactly what these girls are dealing with, and I still get a sort of sick feeling from my own days as a student nurse. I sure would not want to go through that again! These girls are so green, but I can tell that at least one of them is going to be an excellent nurse. The instructor is very good and sure knows her stuff. One of the students is going to do her first sterile procedure, changing Anthony’s PICC line dressing. Should be interesting.

I’m just sitting in the corner typing. They have no idea that I’m an RN and I don’t volunteer that information. I’m sure they are nervous enough.

10:30 Update: Anthony just went into the OR, right on time.

1:30 Update: The surgery went well. It took a little over 2 hours. The surgeon said that Anthony had a bit of scar tissue at the anastomosis area, but nothing he was concerned about. The j-tube was placed “down stream” from that area. The GJ-tube was replaced with a G-tube. He is in recovery now and we are waiting to see him. After recovery he will go to the PICU. Will update again when we get to the PICU.


Plan B

It seems that Anthony is unable to tolerate anything in his stomach without reflux causing stomach contents up to the back of his throat. Anthony has a very strong cough, which is good for clearing his lungs, however when he coughs, this also pushes his stomach contents up to his airway, which causes more coughing – it’s a vicious cycle. Even on an empty stomach, the stomach still has acids and any saliva that Anthony swallows, so his stomach is never really empty. We tried attaching a bag to the G-tube port (stomach port) to allow his stomach to empty. With this drainage bag, when he coughs, the acids go into the bag rather than up to his airway. We were feeding him via the J-tube and not seeing any formula in his stomach drainage. This approach was working great and we were up to 40cc/hour (with a goal of 50cc/hour).

Unfortunately, Anthony vomited about a week ago and the vomiting seems to have displaced the tube. We are now getting formula in his G-tube drainage. Basically, some of the formula is going in and then out again. This will not do. It seems the shorter GD-tube will not stay in place, plus considering the difficulty placing this type of tube, we have decided to go with a surgical J-tube.

So, Anthony will have two separate tubes, a G-tube to keep his stomach empty and a J-tube for feeding. The J-tube will be place beyond the site of his vulvulas surgery. Another advantage to this type of tube is that once Anthony is completely healed from this surgery, I’ll be able to change or replace both tubes myself, without having to go to the hospital. This is a big plus to me.

Anthony is scheduled to be admitted to the hospital on January 31st for pre-op testing and bowel prep. Surgery will be on Tuesday Feb. 1st and if all goes well he will be discharged on Wednesday or Thursday. He will continue on TPN via the PICC line until we are able to get enough calories into him via the new J-tube. We are optimistic that this procedure will work for Anthony and we can get him off the TPN and back to school.


Update on Anthony

Brief recap

On December 7th Anthony had emergency surgery for a jejunal volvulus and had 135cm of his small intestine removed. Details here

He spent 11 days in the hospital and came home with a g-tube and a PICC line. Because of the surgery, they had to discontinue his GJ-tube and place a G-tube. Prior to the volvulus, Anthony had to be fed via J-tube (Jejunal tube) because he is unable to tolerate G-tube (gastostomy tube) feedings due to severe gastric reflux.

We were unable to feed him sufficient calories via the new g-tube because of his reflux and we could not place a new GJ-tube because of the surgery. So, he came home with a PICC line for TPN (Total Parenteral Nutrition via an intravenous).

The Plan: to replace his GJ-tube once his small intestine heals. If they are unable to replace the GJ-tube, then they would do a surgical J-tube.


On January 5, 2011, Anthony returned to the hospital for a GJ-tube. Anthony had had a G-tube for many years. However, after his spinal fusion about 4 years ago, his reflux kept getting worse until we finally decided to place a GJ-tube. A GJ-tube is basically a tube that is threaded through his present G-tube stoma and then guided via x-ray into his Jejunum (second part of the small intestine).

Because of Anthony’s past abdominal surgeries (Nissen fundoplication and the more recent bowel resection) threading the tube from stomach into the small intestine is a challenge. Plus, they have to be very careful with the placement of the tube to avoid the surgical site (where they sutured the small intestine together). They had to order a custom JG-tube, which is a short tube and could actually be called a GD-tube, because it goes into the duodenum, (first portion of the small intestine). If they were unable to place this tube, the back-up plan was to do a surgical J-tube.

It took them about 3 hours under general anesthesia to get proper placement of the tube. He was admitted overnight for observation. He was discharge the next day with the new tube at 20cc/per hour. We need to gradually increase this amount with a goal of 50cc/hr 24/7. This is enough calories to be able to discontinue the TPN and remove the PICC line.

We are really in no hurry to stop the TPN, because Anthony has lost a lot of weight and we would like him to gain some weight before removing the PICC line. We have a follow up appointment with the surgeon on Wednesday.


He’s Home!

Anthony came home Friday afternoon after an 11 day hospitalization. We’ve been busy the past couple of days trying to catch up on life and get use to Anthony’s care. He came home with a g-tube and a PICC line. He is getting about 80% of his nourishment via TPN and about 20% via his g-tube. He is tolerating only around 20cc an hour via the g-tube.

The surgeon would like to try inserting a post-pyloric tube or GD-tube on January 5th. He will try placing the tube in the duodendum at a point before the anastomosis (where the two ends of his small intestine were sutured together). Anthony obviously can not tolerate gastric feedings, but hopefully if they can place the tube beyond the pyloric sphincter he will be able to tolerate tube feedings and we can ween him off the TPN. He will be in the hospital again for a couple of days after the new tube is placed to be sure he can tolerate the feedings via the new tube. We will also continue the TPN until he is able to take in enough calories via the tube. We are not in a hurry to get him off the TPN, because he has lost a lot of weight. We’d like to beef him up a bit while he has the PICC line.

Shortly after Anthony got home all the feeding supplies were delivered and a visiting nurse came to show us how to manage the PICC line, feedings and pump. She was very nice and helpful. She came back on Saturday to watch me hang the TPN. I felt like I was back in nursing school, but didn’t mind a bit, since it’s been a long time since I’ve done any kind of IV. I guess I passed, since I was on my own today. The nurse will come in once a week on Mondays to assess him and change his PICC line dressing.

We are running the TPN 16 hours a day from 6pm – 10am and the G-tube feedings during the day. Of course, keeping his bowels moving is another important part of his care.

That’s about it for now. We are so happy to have Anthony home for Christmas. We will deal with the next procedure after the holidays.



Anthony had a bit of a set back last night. They bumped his feeding up from 30 to 40cc per hour and he vomited. This is disappointing, but not surprising. The reason we switched Anthony from a G-tube to a GJ-tube is because he was not tolerating feedings in his stomach, due to severe reflux.

Problem is that we can’t replace the GJ-tube until he heals from the surgery and we can’t get enough nourishment into him via the G-tube, without risking aspiration. So, the plan is to insert a PICC line in order to feed him intravenously.

A PICC line is a type of catheter used for prolonged intravenous access. He will receive TPN (total parenteral nutrition) via the PICC line. We will continue to feed him as tolerated via the G-tube, because it is important to keep his GI system moving. But the PICC line will be used to supplement is feedings.

Once his GI tract is completely healed, we will decide whether or not to go back to the GJ-tube. There are other surgical options that we may explore in the future, but no one wants to do more surgery on Anthony at this time, especially us!

The PICC line was inserted at 2pm. They will be removing the central line, which is leaking. Plus, they don’t like to send patients home with a central line, they prefer PICC lines in the home setting. Apparently they are safer with less chance of infection.

His G-tube feedings have been restarted at 20cc per hour.