Feeding Jejunostomy (J-Tube)
4401544300wRVU: 13.41 — Open jejunostomy, standalone procedure44186wRVU: 10.12 — Laparoscopic jejunostomy
[Esophageal cancer / gastric cancer / head and neck malignancy / aspiration risk / malnutrition] requiring enteral access
Same
[Witzel / needle catheter] jejunostomy, [concurrent with / standalone]
[Attending name], MD
[Resident name]
General endotracheal [/ as part of concurrent procedure]
Patient requires enteral feeding access for [anticipated prolonged NPO / perioperative nutritional support / swallowing dysfunction / gastroparesis]. [Concurrent with [esophagectomy / gastrectomy / Whipple]; enteral access required postoperatively.] PEG not feasible given [prior gastric surgery / anticipated gastric resection / elevated aspiration risk]. Risks including tube dysfunction, jejunal injury, volvulus, and wound infection discussed. Consent obtained.
Proximal jejunum [identified at ligament of Treitz, [X] cm distal to Treitz / healthy and mobile]. Tube placement confirmed with position check and [contrast injection / saline flush without resistance / tube clamped and checked].
[WITZEL JEJUNOSTOMY:] A loop of proximal jejunum was identified [20-30 cm] distal to the ligament of Treitz. A purse-string suture of [3-0 Vicryl] was placed on the antimesenteric border. A small enterotomy was made centrally. A [14-Fr / 16-Fr] [red rubber / silicone] tube was inserted into the jejunal lumen and directed distally [10-15 cm]. The purse-string was tied snugly around the tube. A [Witzel tunnel] was created by imbricating the jejunal wall over the tube for [5-6 cm] with interrupted [3-0 silk] Lembert sutures. The tube was brought out through a separate left abdominal wall stab incision. The jejunum was tacked to the abdominal wall peritoneum around the tube exit with [4] interrupted [3-0 silk] sutures (jejunopexy) to prevent internal herniation and volvulus. Tube flushed; no resistance; position confirmed.
[NEEDLE CATHETER JEJUNOSTOMY:] A loop of proximal jejunum was identified [20 cm] distal to the ligament of Treitz. A submucosal tunnel was created along the antimesenteric border using a [14-gauge] needle. A [5-Fr / 7-Fr] feeding catheter was threaded into the lumen and directed distally [15-20 cm]. The needle was removed. The catheter exit was secured with a purse-string of [3-0 Vicryl]. The catheter was brought out through a separate stab incision and secured to the skin with a [0-silk] suture. Jejunopexy performed with [4] interrupted sutures.
Patient tolerated the procedure well.
None
None
Minimal
Feeding jejunostomy tube in place
Patient to PACU / ICU per primary procedure. Tube feeds to start [postoperative day 1-2] per team protocol.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Esophageal cancer / gastric cancer / malnutrition / aspiration risk] requiring jejunal enteral access
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Witzel / needle catheter] jejunostomy, [concurrent add-on / standalone]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX requiring enteral access for [perioperative nutritional support / prolonged NPO / swallowing dysfunction]. [Concurrent with [esophagectomy / gastrectomy].] PEG not feasible. Risks discussed. Informed consent obtained.
FINDINGS: Proximal jejunum identified *** cm distal to ligament of Treitz; healthy and mobile. Tube position confirmed.
DESCRIPTION OF PROCEDURE:
[WITZEL: Loop of proximal jejunum *** cm from Treitz. Purse-string 3-0 Vicryl on antimesenteric border; enterotomy made; [14-Fr / 16-Fr] tube inserted and directed distally 10-15 cm; purse-string tied; Witzel tunnel created with imbrication over tube *** cm using 3-0 silk Lembert sutures; tube brought out through LLQ stab incision; jejunopexy with 4 interrupted 3-0 silk sutures to peritoneum; tube flushed; no resistance.] [NEEDLE CATHETER: Submucosal tunnel with 14-gauge needle; 5-Fr catheter threaded distally 15-20 cm; purse-string secured; brought out through stab incision; jejunopexy performed.] Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: Feeding jejunostomy in place
DISPOSITION: Per primary procedure. Tube feeds start POD [1-2].
Signed: .ME, .MYDEGREE
.TODAYVariants
Laparoscopic jejunostomy
CPT 44186. Port at umbilicus; jejunum identified; T-fasteners or Seldinger technique for tube placement under laparoscopic visualization. Preferred for standalone access without concurrent open procedure.
Combined PEJ (percutaneous endoscopic jejunostomy)
Extension tube through existing PEG into jejunum. Does not require surgery. Bill endoscopic placement codes. Document tube position confirmed past the ligament of Treitz fluoroscopically or endoscopically.
Charting Tips
- Document distance of jejunostomy from ligament of Treitz (20-30 cm standard)
- State tube type, size (Fr), and depth of intraluminal placement
- Confirm Witzel tunnel length (5-6 cm); shorter tunnels have higher dislodgement rates
- Document jejunopexy sutures placed, which prevent internal herniation and volvulus (a life-threatening complication)
- Confirm tube position by flushing with saline; no resistance confirms luminal position
- Note which abdominal wall quadrant tube exits (left upper or left lower standard)
Billing Tips
- Bill 44015 for tube or needle catheter jejunostomy performed as an intraoperative add-on procedure (4.45 wRVU, add-on code with no global period). This is the most common scenario: jejunostomy placed concurrently with esophagectomy, gastrectomy, or Whipple. Do not use a 90-day or 0-day global modifier. 44015 is an add-on code.
- Standalone jejunostomy (not performed with another major procedure): bill 44300 (enterostomy, open, 7.17 wRVU, 90-day global). Use 44300 when the jejunostomy is the primary procedure, e.g., for a debilitated patient needing long-term enteral access without a concurrent major operation.
- Laparoscopic jejunostomy: bill 44186 (laparoscopic enterostomy, 6.67 wRVU, 90-day global). Document the laparoscopic approach explicitly. The code is distinct from open.
- Tube replacement in the clinic or at the bedside after the 90-day global period: bill 44373 (small intestinal endoscopy with tube placement) if done endoscopically, or as an E/M plus supply charge if done at bedside. Document tube type, size, and balloon inflation.
- 90-day global for 44300 bundles jejunostomy tube care, tube site management, and clinic visits. Tube replacement within 90 days of standalone jejunostomy uses modifier -78 if operative, or may be included in the global if non-operative.