Jejunal tube extensions via percutaneous endoscopic gastrostomy and delayed small-bowel perforations: a case series

Abstract

In patients who cannot tolerate oral feedings or maintain adequate nutrition, supplemental enteric or intravenous nutrition must be provided. Enteric nutrition is the preferred method over total parenteral nutrition when the gastrointestinal tract is intact with functional motility and absorptive capabilities.1, 2 Enteric feeding maintains the bowel’s mucosal structure and integrity, maintains immune-secretory function, improves wound healing, and lowers infection rates and subsequent morbidity.3, 4 The first operation on the stomach, the gastrotomy, was initially performed to extract “bizarre and sundry objects” swallowed by the mentally deficient and circus performers.5 The concept of the gastrostomy followed soon thereafter as a portal of introduction, rather than extraction, and is credited to Dr. Egeberg, in 1837. A decade later, Sedillot performed the first successful gastrostomy and subsequently numerous surgeons including Stamm, Witzel, Dupage, and Janeway, improved various open operative techniques for gastrostomy creation.5, 6, 7 In 1980, the novel technique of percutaneous endoscopic gastrostomy (PEG), or the “sutureless gastrostomy”, was introduced.8 More than 215,000 PEGs are now placed annually for adult enteral nutrition with minimal associated morbidity and thus has become the preferred method for gastrostomy at our institution.9 Distal feeding, via a jejunostomy or jejunal tube extension, is used for patients with gastroparesis, gastric outlet obstruction, abnormal anatomy after esophagectomy or gastrectomy, and for patients with significant gastroesophageal reflux at high risk for aspiration.4, 10–13 Many techniques are used for minimally invasive distal enteric feeding, predominantly with jejunal tubes maneuvered endoscopically or fluoroscopically, with varying rates of success and complications. Herein, we present our institution’s most common technique for jejunal feeding tube advancement and three cases of associated small-bowel perforations.