Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy

Safety of Percutaneous Endoscopic Jejunostomy Placement Compared With Surgical and Radiologic Jejunostomy Placement: A Nationwide Inpatient Assessment

BACKGROUND AND AIMS

We compared the safety and outcomes of percutaneous jejunostomy tubes placed endoscopically (PEJ), fluoroscopically by interventional radiology (IR-jejunostomy), and open jejunostomy placed surgically (surgical jejunostomy).

METHODS

Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a jejunostomy from 2016 to 2019. Selected patients were divided into 3 cohorts: PEJ, IR-jejunostomy, and surgical jejunostomy. Adjusted odds ratios (OR) for adverse events were calculated using multivariable logistic regression analysis.

RESULTS

A total of 6022 (65.2±9.8 y) surgical jejunostomy patients, 3715 (63.6±11.0 y) endoscopic jejunostomy patients, and 14,912 (64.8±11.6 y) IR-jejunostomy patients were identified. Compared with surgery, PEJ patients were 32% less likely to experience postprocedure complications (OR: 0.68; 95% CI: 0.58-0.79, P <0.001) while IR-jejunostomy patients were 17% less likely to experience complications (OR: 0.83; 95% CI: 0.73-0.94, P <0.001); test of proportion showed that endoscopy had significantly fewer total adverse events compared with IR ( P <0.001). For individual complications, compared with surgery, the odds of intestinal perforation using PEJ and IR, respectively, were 0.26 (95% CI: 0.14-0.49, P <0.001) and 0.31 (95% CI: 0.21-0.47, P <0.001), for postprocedure infection 0.32 (95% CI: 0.20-0.50; P <0.001) and 0.61 (95% CI: 0.45-0.83; P =0.001); and for hemorrhage requiring blood transfusion 0.71 (95% CI: 0.56-0.91; P =0.005) and 0.75 (95% CI: 0.61-0.91; P =0.003).

CONCLUSIONS

Endoscopic placement of percutaneous jejunostomy tubes (PEJ) in inpatients is associated with significantly lower risks of adverse events and mortality compared with IR and surgical jejunostomy.

Direct percutaneous endoscopic jejunostomy tube placement in patients post Roux-en-Y gastric bypass, a single tertiary care center experience

Background and study aims Obesity prevalence continues to rise in the United States with Roux-en-Y gastric bypass (RYGB) surgery being one of the most common bariatric procedures. With this trend, more patients with altered upper gastrointestinal (UGI) anatomy have required endoscopic intervention including direct percutaneous endoscopic jejunostomy (DPEJ) placement. We aimed to assess the safety and success rates of DPEJ in RYGB patients. Patients and methods All patients at a tertiary care referral center who underwent DPEJ during an 8-year period were queried from a prospectively maintained registry of all enteroscopy procedures. Duplicate cases and altered upper UGI anatomy subtypes other than RYGB were excluded. The final cohort consisted of two groups: RYGB vs native anatomy (NA). Demographic, procedural, readmission, follow-up, and complication data were recorded. Comparative analysis was performed. Results Seventy-two patients were included where 28 had RYGB and 44 had NA. Both groups had similar baseline and pre-procedure data. Procedure success rate was 89 % in RYGB patients and 98 % in NA patients ( P  = 0.13). There were no intraprocedural complications. Early and late postprocedural complication rates were similar between the groups (both 4 % vs 7 %). Average follow-up times in the RYGB and NA groups were 12.97 ± 9.35 and 13.44 ± 9.21 months, respectively. Although readmission rates at 1 and 6 months were higher in the NA versus the RYGB group (21 % vs 7 % and 25 % vs 15 %), these differences were not significant. Conclusions DPEJ can be successful and safely placed in RYGB patients with no significant difference in procedure success, complication, or readmission rates when compared to control.

Direct percutaneous endoscopic jejunostomy (DPEJ) and percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) technical success and outcomes: Systematic review and meta-analysis

Background and study aims  Endoscopic methods of delivering uninterrupted feeding to the jejunum include direct percutaneous endoscopic jejunostomy (DPEJ) or PEG with jejunal extension (PEG-J), validated from small individual studies. We aim to perform a meta-analysis to assess their effectiveness and safety in a variety of clinical scenarios. Methods  Major databases were searched until June 2021. Efficacy outcomes included technical and clinical success, while safety outcomes included adverse events (AEs) and malfunction rates. We assessed heterogeneity using I ² and classic fail-safe to assess bias. Results  29 studies included 1874 patients (983 males and 809 females); mean age of 60 ± 19 years. Pooled technical and clinical success rates with DPEJ were 86.6 % (CI, 82.1-90.1, I ² 73.1) and 96.9 % (CI, 95.0-98.0, I ² 12.7). The pooled incidence of malfunction, major and minor AEs with DPEJ were 11 %, 5 %, and 15 %. Pooled technical and clinical success for PEG-J were 94.4 % (CI, 85.5-97.9, I ² 33) and 98.7 % (CI, 95.5-99.6, I ²  < 0.001). The pooled incidence of malfunction, major and minor AEs with DPEJ were 24 %, 1 %, and 25 %. Device-assisted DPEJ performed better in altered gastrointestinal anatomy. First and second attempts were 87.6 % and 90.2 %. Conclusions  DPEJ and PEG-J are safe and effective procedures placed with high fidelity with comparable outcomes. DPEJ was associated with fewer tube malfunction and failure rates; however, it is technically more complex and not standardized, while PEG-J had higher placement rates. The use of balloon enteroscopy was found to enhance DPEJ performance.

Prognostic outcomes after direct percutaneous endoscopic jejunostomy in elderly patients: comparison with percutaneous endoscopic gastrostomy

BACKGROUND AND AIMS

Direct percutaneous endoscopic jejunostomy (DPEJ) is an alternative method of enteral feeding to percutaneous endoscopic gastrostomy (PEG). Although long-term outcomes of PEG have been reported, little is known regarding the outcomes of DPEJ.

METHODS

A retrospective cohort study was conducted including 115 and 651 consecutive attempts of DPEJ and PEG, respectively, in a total of 766 elderly patients between April 2004 and March 2019. Patients' clinical background, procedural and long-term outcomes, survival analysis, and cause of death were analyzed.

RESULTS

Successful placement rates were 93.9% and 97.1% for DPEJ and PEG, respectively. There was no significant difference in procedure-related adverse events (AEs) between the DPEJ and PEG groups. Rates of pneumonia, vomiting, and upper GI bleeding were significantly lower, whereas those of fistula enlargement and ileus were significantly higher in the DPEJ group as long-term AEs. The median survival periods were 694 and 734 days for DPEJ and PEG, respectively, with no significant differences between the 2 groups. Multivariate analysis revealed that age 80 years old or older, C-reactive protein level of 1.0 mg/dL or higher, and the presence of diabetes were independent risk factors for mortality after DPEJ. Respiratory tract infection was the primary cause of death in both groups.

CONCLUSIONS

DPEJ is considered a safe and feasible method of access for enteral feeding as well as PEG. Although the survival period after DPEJ may be expected to be as long as that with PEG, DPEJ-specific AEs should be kept in mind on long-term feeding.

Device-assisted enteroscopy: An update on techniques, clinical indications and safety

After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.

Direct percutaneous endoscopic jejunostomy using single-balloon enteroscopy without fluoroscopy: a case series

BACKGROUND

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method to provide enteral nutrition to individuals when gastric feeding is not possible or contraindicated. The aim of this study was to analyze the efficacy and safety of DPEJ tube placement with the Gauderer-Ponsky technique by the pull method, using single-balloon enteroscopy (SBE) without fluoroscopy.

METHODS

This is a retrospective analysis of patients undergoing SBE for DPEJ placement in a referral hospital between January 2010 and March 2016. Technical success, clinical success and procedure related complications were recorded.

RESULTS

Twenty-three patients were included (17 males, median age 71 years, range 37-93 years). The most frequent indications for DPEJ were gastroesophageal cancer (n = 10) and neurological disease (n = 8). Eighty-seven percent of the patients had a contraindication to percutaneous endoscopic gastrostomy (PEG) and PEG was unsuccessful in the remaining patients. The technical success rate was 83% (19/23), transillumination was not possible in three patients and an accidental exteriorization of the bumper resulting in a jejunal perforation occurred in one patient. The clinical success was 100% (19/19). The median follow-up was five months (range 1-35 months). Apart from the case of jejunal perforation and the two cases of accidental exteriorization, there were no other complications during follow-up. The 6-month survival was 65.8% and the 1-year survival was 49.3%.

CONCLUSION

DPEJ can be carried out successfully via SBE without fluoroscopy with a low rate of significant adverse events. Although, leaving the overtube in place during the bumper pulling can be useful for distal jejunal loops, it can be safely removed in proximal loops to minimize complications.

Enteral Access in Mechanically Ventilated Patients

The early institution of enteral nutrition is now accepted as the preferred route of feeding in critically ill patients with a functioning gastrointestinal tract. It is particularly important to establish early enteral nutrition in mechanically ventilated patients because of the metabolic demands associated with mechanical ventilation. The options for enteral access in mechanically ventilated patients are reviewed, with an emphasis on those techniques that may be performed at the bedside. The advantages, disadvantages, and complications of the different techniques will be considered.

Enteroscopy

Noninvasive imaging with CT and magnetic resonance enterography or direct visualization with wireless capsule endoscopy can provide valuable diagnostic information and direct therapy. Enteroscopy technology and techniques have evolved significantly and allow diagnosis and therapy deep within the small bowel, previously attainable only with intraoperative enteroscopy. Push enteroscopy, readily available in most endoscopy units, plays an important role in the evaluation and management of lesions located up to the proximal jejunum. Currently available device-assisted enteroscopy systems, DBE, SBE, and spiral enteroscopy each have their technical nuances, clinical advantages, and limitations. Newer, on-demand enteroscopy systems appear promising, but further studies are needed. Despite slight differences in parameters such as procedural times, depths of insertion, and rates of complete enteroscopy, the overall clinical outcomes with all overtube-assisted systems appear to be similar. Endoscopists should therefore master the enteroscopy technology based on institutional availability and their level of technical expertise.

Current considerations of direct percutaneous endoscopic jejunostomy

BACKGROUOND: Direct percutaneous endoscopic jejunostomy (DPEJ) is a well-known approach to deliver postpyloric enteral nutritional support to individuals who cannot tolerate gastric feeding. However, it is technically difficult, and some case series have reported significant procedural failure rates. The present article describes current indications, successes and complications of DPEJ placement.

METHODS

A MEDLINE database search was performed to identify relevant articles using the key words "direct percutaneous endoscopic jejunostomy", "percutaneous endoscopic gastrostomy", and "percutaneous endoscopic gastrostomy with a jejunal extension tube". Additional articles were identified by a manual search of the references cited in the key articles obtained in the primary search.

RESULTS

DPEJ is gradually becoming more common in the treatment of patients who cannot tolerate gastric feeding. Differences in patient selection and technique modifications may contribute to the various success rates reported. Failure is most often due to inadequate transillumination or gastroduodenal obstruction. Currently, there are limited data to evaluate the safety and effectiveness of DPEJ.

CONCLUSION

The clinical use of DPEJ is increasing. With appropriate care and expertise, DPEJ may prove to be reliable and safe.

Enteral nutrition access devices

The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, performing a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such situations, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the ASGE Governing Board. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to endoscopy in patients requiring enteral feeding access by using the keywords "endoscopy," "percutaneous," "gastrostomy," "jejunostomy," "nasogastric," "nasoenteric," "nasojejunal," "transnasal," "feeding tube," "enteric," and "button." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Direct Percutaneous Endoscopic Jejunostomy: High Completion Rates with Selective Use of a Long Drainage Access Needle

Background. Direct percutaneous endoscopic jejunostomy (DPEJ) insertion is a useful technique for artificial nutritional support in selected patients. However, it is technically difficult and most case series report significant procedural failure rates. Methods. We reviewed our case series of DPEJ insertions, done in a tertiary care referral centre from 2002 to 2008. Patients were selected for DPEJ if they required artificial enteric nutritional support but were unsuitable for endoscopic gastrostomy. Our technique includes selective usage of a long drainage access needle for gut luminal puncture, selective fluoroscopic guidance and selective usage of general anaesthesia. Results. Of 40 consecutive patients undergoing attempted DPEJ insertion, 39/40 (97.5%) had a successful procedure. Sixteen cases (40%) required the drainage access needle for completion, nineteen cases (47.5%) were done with fluoroscopy, and five cases (12.5%) were done under general anaesthesia. There were no procedural complications. Conclusions. This technique led to a high completion rate and low complication rate. With appropriate care and expertise, DPEJ insertion is reliable and safe.

Colojejunal Fistula Resulting from a D-PEJ Feeding Tube

Numerous procedures have been developed to provide adequate enteral nutrition to patients with gastrointestinal disorders. Previously, operative placement of a feeding gastrostomy or jejunostomy tube was the accepted means of gaining chronic enteral access. However, improved technology and experience with endoscopic techniques have quickly replaced primary operative placement of enteral access. Direct percutaneous endoscopic jejunostomy (D-PEJ) is a procedure that was designed to deliver enteral feeding solutions for patients with proximal disease after unsatisfactory results from percutaneous endoscopic gastrostomy tubes with jejunal extensions (PEG-J). As with any procedure, it is associated with complications. We present the first reported case of a colojejunal fistula resulting from a D-PEJ placement. While D-PEJ has been shown to be relatively safe, complications related to the inherent limitations of the procedure need to be considered when the patient experiences unusual post-procedure symptoms and worked up appropriately.

Small bowel endoscopic enteral access

The use of small bowel access for small intestinal delivery of enteral nutrition is becoming more common. Patients at risk for gastric regurgitation and aspiration, gastric intolerance, and pancreatitis are some of the classic patient groups for which small bowel feedings may be necessary. The endoscopist should have command of all forms of endoscopic small bowel enteral access, including nasojejunal tube placement, percutaneous gastro/jejunostomy, and direct percutaneous jejunostomy. Knowledge of not only the procedure techniques, but also the potential complications, is imperative to achieving good clinical outcomes.

Minimizing endoscopic complications in enteral access

Percutaneous enteral access techniques are important tools in the armamentarium of the skilled endoscopist. Endoscopic and post-procedural complications of enteral access are not uncommon, and the increasing population of patients requiring long-term feeding tubes places even more emphasis on minimizing them. Most enteral feeding tube complications are minor, but several have the potential to cause significant morbidity and even mortality if not recognized and managed correctly. When complications do arise, early recognition and aggressive management are essential to optimize outcomes. Expertise with the proper patient selection, choice of feeding tube and insertion techniques are critical to minimizing endoscopic complications of percutaneous enteral feeding tubes.

Direct Percutaneous Endoscopic Jejunostomy Placement in a Patient with Intracorporeal Left Ventricular Assist Device

We present a case involving a patient who required enteral feeding after implantation of an abdominally positioned left ventricular assist device. The position of the device occupied most of the abdomen, precluding percutaneous endoscopic gastrostomy tube placement. However, in the case presented, direct percutaneous endoscopic jejunostomy (DPEJ) tube placement was achieved without interfering with the intracorporeal device. To our knowledge, there are no previous reports in the literature of successful DPEJ placement in a patient with an abdominally positioned heart assist device. DPEJ should be considered as a long-term enteral feeding route when structural barriers prevent percutaneous gastric access.

Endoscopic approaches to enteral nutritional support

Enteral is preferred to parenteral nutritional support for acute and chronic diseases because it is more physiological and associated with fewer infection complications. Nasal tube feedings are generally used for 30 days or less and percutaneous access for the longer-term. Feeding by naso-gastric tubes is appropriate for most critically ill patients. However, trans-pyloric feeding is indicated for those with regurgitation and aspiration of gastric feeds. Deep naso-jejunal tube feeding is appropriate for patients with severe acute pancreatitis. There are several methods for endoscopic placement of naso-enteric tubes. Percutaneous endoscopic gastrostomy is used for most persons requiring long-term support. Long-term jejunal feeding is most often used for persons with chronic aspiration of gastric feeds, chronic pancreatitis intolerant to eating, or persons in need of concomitant gastric decompression. Percutaneous endoscopic gastrostomy with a jejunal tube extension is fraught with tube dysfunction and dislocation. Direct percutaneous endoscopic jejunostomy tubes may be more robust, but are less commonly performed.

Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts

BACKGROUND

Clinical utilization of direct percutaneous endoscopic jejunostomy (DPEJ) is increasing. However, little data exist regarding important clinical outcomes with DPEJ.

OBJECTIVE

To describe the indications, success, and complications of DPEJ in a large cohort of >300 consecutive attempted DPEJ cases at our institution.

METHODS

Institutional databases identified 316 consecutive attempted DPEJ placements between January 1996 and August 2004. The medical records of consenting patients were abstracted for demographics, indication, success, complications, and follow-up. A scheme for classifying complication severity was designed.

RESULTS

Three hundred and seven attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%). The most common indications for DPEJ included resectable distal esophageal cancer, other malignancies causing obstruction, gastroparesis, prior esophageal or gastric resection, and high aspiration risk. Overall, 81 adverse events (AEs) were associated with DPEJ placement or removal in 69 (22.5%) cases. There were 14 serious AEs, 20 moderate AEs, and 47 mild AEs. Serious AEs included 7 bowel perforations, 3 jejunal volvuli, 3 major bleeds, and 1 aspiration. The only death was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 9 chronic enterocutaneous fistulae. Many of the 47 mild AEs were site infections requiring oral antibiotics (23) or persistent site pain (14).

CONCLUSIONS

DPEJ was associated with a moderate or severe complication in approximately 10% of cases. While DPEJ is a useful technique to gain enteral access that obviates the need for surgery and is more reliable than percutaneous gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved.

Percutaneous endoscopic gastro-duodenostomy: modified technique

OBJECTIVES

Percutaneous endoscopic gastro-jejunostomy is appropriate for patients with severe neurologic deficit to avoid repeated tube feeding-related aspiration. We describe a modified technique of endoscopic gastro-duodenostomy.

PATIENTS AND METHODS

This technique was performed in 9 patients with severe neurologic deficit. No fluoroscopy was necessary. The gastrostomy button was pushed across the pylorus into the bulb; a nasogastric tube was then placed in the duodenum under endoscopic control and the button was drawn to the gastric wall. When the gastroduodenal tube migrated or was occluded, the button was placed in the bulb through the pylorus and maintained in this position for alimentation.

RESULTS

Placement of the gastro-duodenostomy tube was successful without any complication in 100% of patients. The mean duration of the procedure was 15 min. The tube had to be removed for migration (N = 4) and occlusion (N = 5) after a mean period of 5.8 weeks (range: 2-10). During the follow-up period, no tube feeding-related aspiration was observed.

CONCLUSION

This modified low-cost technique of endoscopic gastro-duodenostomy is simple and efficient.

Placement of jejunal feeding tubes for post-gastric feeding

In veterinary patients, postgastric feeding is indicated for uncontrollable gastric vomiting, gastroparesis, biliary tract disease, pancreatitis, and for patients at increased risk for aspirating secondary to decreased mentation, prolonged recumbency, or an unprotected airway. Postgastric feeding may be implemented via the placement of a jejunal feeding tube. These tubes can be placed surgically (jejunostomy tubes) or with fluoroscopic or endoscopic guidance. This article will focus on methods of jejunal feeding-tube placement, advantages and disadvantages of the methods described, and complications associated with jejunal feeding.

Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension

BACKGROUND

Jejunostomy tubes can be placed endoscopically by means of percutaneous gastrostomy with jejunal extension (PEG-J) or by direct percutaneous jejunostomy. These 2 techniques were retrospectively compared in patients requiring long-term jejunal feeding.

METHOD

An endoscopy database was used to identify all patients who underwent endoscopic jejunal feeding tube placement from January 1996 to May 2001. Patients with a history of upper GI surgery were excluded. There were 56 patients with a direct percutaneous jejunostomy and 49 with a percutaneous gastrostomy with jejunal extension. Patients in the direct percutaneous jejunostomy group received a 20F direct jejunostomy tube; a 20F PEG tube with a 9F jejunal extension was used in the percutaneous gastrostomy with jejunal extension group. Medical records for the period of 6 months after establishment of jejunal access were reviewed. Complications and need for further endoscopic intervention within this time frame were recorded. The duration of feeding tube patency (number of days from established jejunal access to first endoscopic reintervention) was compared for both groups.

RESULTS

Feeding tube patency was significantly longer in patients who had a direct percutaneous jejunostomy compared with those with a percutaneous gastrostomy with jejunal extension. Within the 6-month period, 5 patients with a direct percutaneous jejunostomy required endoscopic reintervention for tube dysfunction compared with 19 patients who had a percutaneous gastrostomy with jejunal extension (p < 0.0001).

CONCLUSIONS

For patients who require long-term jejunal feeding, a direct percutaneous jejunostomy with a 20F tube provides more stable jejunal access compared with a percutaneous gastrostomy with jejunal extension with a 9F extension and has a lower associated rate of endoscopic reintervention.