Download Jejunostomy Feeding Tube - Meridian Surgery Center

Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Jejunostomy Feeding Tube
Placement
We have determined that you would benefit from a feeding jejunostomy tube. You may not be able to take
adequate nutrition or liquid by mouth, and this will permit your doctors to supply your nutritional needs.
Description of the Procedure
A small incision is made in the mid-abdomen to expose the small bowel (jejunum). A tube is placed in the
jejunum, with a small tunnel created where the tube exits the bowel. The tube is then brought out through
the abdominal wall, the jejunum is sutured to the abdominal wall, and the abdomen is closed.
Alternatives for Treatment
1. No tube – the jejunostomy tube is placed for supportive nutritional care. Without the tube, we expect
that your nutrition and condition may deteriorate.
2. Nasogastric tube – this is a tube that goes through the nose into the stomach. It is uncomfortable, and
awkward to maintain in public. There are multiple problems that may arise with prolonged use of a
nasogastric tube.
Risks/Complications of Treatment
Treatment risks fall into two categories; those that could happen during any operation under anesthesia, and
those that are specific for a gastrostomy placement. In any medical treatment, it is impossible to predict all
the things that could go wrong. Fortunately, complications are the exception rather than the rule. Every
reasonable effort is made to avoid complications. The most common possible complications are as follows:
Possible complications of major surgery
1. Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
transfusion is rare.
2. Infection – we take special care to prevent an infection, but it is always a possibility.
3. Reactions to medications – this could be many things, from a minor rash to possible death.
4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia,
sore throat, or potential death, in rare cases.
5. Injury to bowel or other internal organs – an injury to a portion of the bowel or other intraabdominal to repair the injury. This may require opening your abdomen to determine the problem.
6. Leakage/obstruction at jejunostomy tube insertion site – this is uncommon. Reoperation may be
required to correct this if it occurs.
7. Poor overall condition of patients undergoing this procedure brings increased risk of wound healing,
respiratory difficulties, infection, etc.
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. Most people can resume previous activities the day
after surgery, if this procedure is done as an outpatient. Inpatients tend to be quite ill, and a gastrostomy will
not effect that initially; it will facilitate care and hasten recovery. The gastrostomy may usually be use within
four hours of placement.
(see other side)
Consent for Treatment
I understand my need for a gastrostomy. I have read and understand the above explanation of the
operation required to create a gastrostomy. My surgeon has answered my questions, and I choose to
proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act
on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding
that complications may arise from that action.
I understand that while most people receiving a gastrostomy will benefit from the operation, I may
not. My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you
invite to attend the surgery will be informed of the surgical finding, your surgical status, and
anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or
may not remember these important details.
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
____ I waive the right to read this form, and do not want to be educated and informed of treatment
risks; nonetheless, I understand the need for this surgery and grant permission to the surgeon to
proceed on my behalf.
SIGNATURE _____________________________________________________ DATE _________________
6/04pjd