Jejunal Extension Tube Research Articles

Supplemental tube feeding: qualitative study of patient perspectives in advanced pancreatic cancer

ObjectivesMalnutrition is associated with poor quality of life and survival outcomes for patients with cancer, but is challenging to prevent or treat in pancreatic cancer due to the multifactorial drivers...

Buried bumper syndrome in percutaneous endoscopic gastrostomy with a jejunal extension tube in patients undergoing levodopa–carbidopa intestinal gel treatment

BackgroundLevodopa–carbidopa intestinal gel (LCIG) treatment is an effective Parkinson’s disease (PD) treatment that requires percutaneous endoscopic gastrostomy with a jejunal extension tube (PEG-J). Buried bumper syndrome (BBS) is an uncommon but significant complication of PEG-J for LCIG.Case presentationA 71-year-old man had been undergoing LCIG therapy for PD since a PEG-J was implemented at our department two years previously. He presented with appetite loss. Computed tomography showed that the gastrostomy bumper was buried in the gastric wall. The patient was surgically treated with the simultaneous removal and replacement of PEG-J. Postoperative gastrocutaneous fistula occurred, which was conservatively treated.ConclusionsNotably, patients and medical staff should be aware that patients with PD on LCIG treatment have a high risk of BBS in PEG-J and that there might be some patients with latent BBS. When simultaneous removal and replacement surgery is performed, establishing a new route at the stomach and abdominal wall is recommended.

Prandial Diarrhea: A Rare Late Complication After Percutaneous Endoscopic Gastrostomy With Jejunal Extension Tube Placement

Prandial Diarrhea: A Rare Late Complication After Percutaneous Endoscopic Gastrostomy With Jejunal Extension Tube Placement

S2216 A Knot in My Stomach: A Rare Cause of a Malfunctioning PEG-J Tube

Introduction: Gastrostomy and jejunostomy tubes are placed to provide long term nutrition. Tube malfunctioning is not uncommon and usually due to coiling, occlusion, and malpositioning. We report a rare case of percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) tube malfunction due to a knot formation. Case Description/Methods: A 45 year old female with history of traumatic brain injury with resultant tracheostomy and PEG-J tube, presented from a nursing home for PEG-J tube malfunction. The PEG-J tube was noted to be torn externally with an inability to administer feeds or medications. An abdominal CT scan revealed a percutaneous G-J tube with the balloon inflated within the gastric body, a portion of the tube coiled within the duodenum, but the distal end in the proximal jejunum. Bedside removal of the tube was unsuccessful due to significant resistance. She then underwent upper endoscopy which revealed an intact gastrostomy with the internal balloon properly inflated in the gastric body. The jejunal extension was found to have a knot in the tube in the gastric portion with the remainder of the tube extending into the duodenum. The distal end of the PEG-J was grasped with a snare, cut externally, and the knotted portion was withdrawn with the scope. A replacement PEG was then placed via the gastrostomy. The patient was subsequently discharged without further complication. Discussion: Enteral feeding tubes provide nutrition in patients who are unable to tolerate oral diet. This can be achieved with feeds administered into the stomach, or into the small bowel via gastrostomy with a longer tube, or via direct access into the small bowel. Jejunal feeding is preferred in patients with gastric bypass, gastroparesis, gastric outlet obstruction or refractory peptic ulcer disease. Complications of PEG-J tubes include coiling, kinking, malpositioning, and occlusion. There are six previously reported cases of knotted PEG-J tubes causing tube malfunction. A proposed mechanism is that the longer tube inserted distally into the GI tract is prone to coiling during peristalsis, which can lead to knot formation. Knotting of a PEG-J tube is a rare complication that may not be apparent on imaging as in this patient. It is important to consider this complication when deciding on the method of enteral feeding. It should also be considered in the differential diagnosis in a case of a malfunctioning PEG-J tube, especially if the tube cannot be removed bedside due to increased resistance to removal.Figure 1.: Knotted PEG-J.

The University of Alabama at Birmingham (UAB) Raptor method for direct percutaneous endoscopic gastrostomy with jejunal extension tube placement.

The University of Alabama at Birmingham (UAB) Raptor method for direct percutaneous endoscopic gastrostomy with jejunal extension tube placement.

Duodenal Decubitus Ulcer Caused by Percutaneous Endoscopic Transgastric Jejunostomy Tube

Percutaneous endoscopic gastrostomy (PEG) has substituted surgical gastrostomy for long-term enteral nutrition. Percutaneous endoscopic transgastric jejunostomy (PEG-J) entails placing a feeding tube into the jejunum through PEG. Unlike PEG, PEG-J is associated with complications caused by the jejunal extension tube. Herein, we report a rare complication of PEG-J. A 71-year-old woman who underwent PEG-J for the administration of carbidopa-levodopa, complained of epigastric pain, dyspepsia, and weight loss of more than 10% in 2 months. Esophagogastroduodenoscopy revealed a duodenal decubitus ulcer caused by the pressure from the jejunal extension tube. After removal of the PEG-J and a 4-week treatment with a proton pump inhibitor, the ulcer healed and the symptoms resolved.

888 Percutaneous Gastrojejunostomy Tubing Utilization and Safety With Levodopa-Carbidopa Intestinal Gel in Advanced Parkinson’s Disease Patients: Interim Results of the Long-Term DUOGLOBE "Real-World" Observational Study

INTRODUCTION: Levodopa-carbidopa intestinal gel (LCIG, carbidopa-levodopa enteral suspension [CLES] in the US) administered via percutaneous gastrojejunostomy (PEG), a jejunal (J) extension tube and an external pump is a long-term treatment option for patients with advanced Parkinson’s disease (aPD). Limited data exists on PEG-J component utilization and replacements during LCIG treatment in a ‘real-world’ setting. This interim analysis investigated the routine clinical practice of PEG-J insertion and component replacements of the device and associated safety. METHODS: DUOGLOBE is an ongoing multinational observational study with 3-year follow-up. This interim analysis included patients who had the PEG-J insertion procedure from 55 global sites. The type of tubing used, frequency of and reasons for tube replacements, and Serious Adverse Events (SAEs) were assessed. This analysis was not powered for statistical comparisons. RESULTS: This interim dataset had 188 patients with PEG-J tube placement (mean duration of PEG-J exposure: 515.8 days); 178 patients with PEG-J tubing manufacturer data were included in this analysis. At initial PEG-J tube placement, 83% (n = 148) of patients received AbbVie-proprietary tubing and 17% (n = 30) received non-AbbVie tubing. Most patients 79% (n = 141) did not require a PEG-J replacement. Patients needing any PEG-J replacement was similar between AbbVie and non-AbbVie tubing (22% and 17%); 5% of patients (n/N = 7/148) with AbbVie tubing required 2 PEG-J replacements (n/N = 0/30 for non-AbbVie tubing). In the first 12 months, Kaplan-Meier estimates demonstrated that 84% of patients did not require a tube replacement with AbbVie tubing (non-AbbVie tubing, 89%). The most common reasons for the first PEG-J replacement for AbbVie tubing was a routine, preplanned procedure (6%), PEG-J dislocation (4%), occlusion and leaking (each 2%), and other (5%); for non-AbbVie tubing PEG-J dislocation (10%) was the only reported reason. Overall, 38% of patients experienced an SAE who had AbbVie tubing (n = 56) and 47% for non-AbbVie tubing (n = 14). Gastrointestinal (GI)-related SAEs were reported in patients [n(%)] with AbbVie tubing [8(5%)] and non-AbbVie tubing [6(20%)]; 1 (1%) and 2 (7%) patients discontinued due to a GI-related AE, respectively. CONCLUSION: This interim analysis of patients in a multinational observational study with LCIG demonstrated that most patients did not require PEG-J tube replacements in a real-world setting and safety was similar to the known safety profile of LCIG.

Percutaneous Endoscopic Gastrostomy with Jejunal Extension Tube for the Delivery of Levodopa Carbidopa Intestinal Gel: Clinical Practice Guidelines of the Romanian Society of Digestive Endoscopy.

Percutaneous endoscopic gastrostomy with jejunal extension (PEG/J) was first described in 1998 and has become the standard technique for fixing the tube in place for levodopa carbidopa intestinal gel (LCIG) infusion. The Romanian Society of Digestive Endoscopy (RSDE) decided to create a consensus paper to meet the needs in medical training and practice. After reviewing the available published data and existing recommendations, a consensus process was carried out involving the leaders of opinion in this field. The resulting text and recommendations were approved, after reaching expert consensus, and reflects the views of the RSDE for the best practice of PEG/J tube placement. The pull through method ("pull technique") is the prevailing PEG-tube placement procedure in Romania. The procedure can be performed with intravenous sedation combined with local anesthesia. Although minor complications are common, serious complications are infrequent, and the tube insertion procedures have a good safety record. Redo procedures are sometimes necessary and clinicians should be aware of these situations.

Insertion of percutaneous endoscopic gastrostomy tubes with jejunal extensions using the "wedge" technique: a novel method to prevent retrograde tube migration into the stomach.

Background and study aim In percutaneous endoscopic gastrostomy (PEG) with jejunal extension (PEGJ) procedures, retrograde migration of the jejunal extension tube into the stomach during endoscope withdrawal is a frustrating problem. We describe the novel "wedge" technique for inserting the jejunal extension tube, utilizing single-balloon enteroscopy to anchor it in place. Patients and methods Prospective 1-year study of consecutive patients undergoing PEGJ insertion at a single tertiary care center. The primary outcome was number of pyloric intubations required to place the jejunal extension tube. Secondary outcomes included success rate, time, and complications related to jejunal extension tube insertion. Results 17 patients underwent the procedure. The jejunal extension tube was inserted at the first attempt in 15 patients (88.2 %) and 2 required another pyloric intubation. Abdominal X-ray showed that all PEGJ tubes were successfully seated in the proximal jejunum. The mean (SD) time required for jejunal extension insertion was 16.9 (8.6) minutes. Two adverse events occurred due to PEG insertion although none were related to the jejunal extension insertion itself. Conclusions: The "wedge" technique is an effective and easy method for inserting a jejunal extension tube after PEG insertion.

Problems related to levodopa-carbidopa intestinal gel treatment in advanced Parkinson's disease.

BackgroundContinuous levodopa‐carbidopa intestinal gel (LCIG) diminishes daily “off” time and dyskinesia in patients with advanced Parkinson′s disease (PD). Complications are common with percutaneous endoscopic gastrostomy with a jejunal extension tube (PEG‐J).Aim of the StudyTo report the clinical outcome of LCIG in patients with advanced PD in the years 2006–2014 at Helsinki University Hospital.Patients and MethodsLevodopa‐carbidopa intestinal gel treatment started following PEG‐J placement in patients with advanced PD after successful in‐hospital LCIG trial with a nasojejunal tube. Demographics, PEG‐J procedures, discontinuation of LCIG, complications and mortality were retrospectively analyzed.Results [mean (SD)]Sixty patients with advanced PD [age 68(7) years; duration of PD: 11(4) years] had LCIG treatment for 26(23) months. The majority of patients with advanced PD were satisfied with the LCIG treatment. For 51 patients (85%), the pump was on for 16 hr a day, and for nine patients (15%) it was on for 24 hr a day. After 6 months, the levodopa‐equivalent daily dose (LEDD) had increased by 30% compared to pre‐LCIG LEDD. Sixty patients underwent a total of 156 PEG‐J procedures, and 48 patients (80%) had a total of 143 complications. Forty‐six patients (77%) had 119 PEG‐J or peristomal complications, and 22 patients (37%) had a total of 25 other complications. The most common complications were accidental removal of the J‐tube in 23 patients (38%) and ≥5% weight loss in 18 patients (30%). Fifteen patients discontinued the LCIG after 21 (21) months. At the end of the follow‐up period of 33(27) months, 38 patients were still on LCIG and nine (15%) had died.ConclusionMost patients were satisfied with LCIG treatment. A few patients lost weight whereas the majority had complications with PEG‐J. When LCIG treatment is carried out, neurological and endoscopic units must be prepared for multiple endoscopic procedures.

850 A Novel Through the Snare Technique for Percutaneous Endoscopic Gastro-Jejunostomy Tube Placement

Percutaneous endoscopic gastro-jejunostomy (PEG-J) tube placement is an increasingly in demand procedure, but due to technical difficulty and its time consuming nature, is often referred to surgeons and interventional radiologists. The most common procedural complications include loop formation within the stomach which causes retraction of either the guidewire or jejunal extension tubing out of the small bowel as well as displacement of the jejunal extension tubing out of the small bowel during withdrawal of the endoscope. Here we present a through the snare technique for PEG-J placement which decreases procedure length and is easier to perform than the traditional methods. A 52-year-old male presents with his first episode of alcohol induced pancreatitis complicated by symptoms of gastric outlet obstruction. A 24 Fr PEG tube was placed in the traditional fashion. The upper endoscopy revealed a luminal stenosis in the second portion of the duodenum secondary to acute inflammation from acute pancreatitis. Next, a snare was placed through the PEG tube and opened. The endoscope is advanced through the snare and a guidewire is placed into the small bowel. The endoscope is then exchanged and the wire left in place. As the endoscope is withdrawn, through the snare, the snare is closed and the wire brought out through the PEG tube. The end of the wire not within the small bowel is then pulled back in order to straighten the guidewire. The jejunal extension tube is then advanced over the guidewire. The patient tolerated the procedure well. The procedure duration was 18 minutes. The PEG portion was immediately used for decompression and the patient was discharged after his jejunal feeds were advanced to a goal rate. This novel method for PEG-J placement is technically simple and virtually eliminates looping of the guidewire. Furthermore, it obviates the need for the use of a second endoscope as well as fluoroscopy, which may not be readily available at all centers.

The PEG-Pedi-PEG technique: a novel method for percutaneous endoscopic gastrojejunostomy tubeplacement(with video).

When PEG tube feeding is complicated by anatomic obstruction, dysmotility, or aspiration, a need arises for feeding beyond the pylorus. The currently available percutaneous gastrojejunostomy (PEG-J) kits have issues with the jejunal extension portion migrating back into the stomach. The aim of this study was to evaluate the feasibility and safety of a novel technique that creates PEG-J tubes by combining an adult percutaneous gastrostomy (PEG) tube with a pediatric PEG tube, the PEG-Pedi-PEG procedure. This was a retrospective study at a single tertiary care center. The main outcome measures were success of placement, rate of retrograde tube migration, early (<24 h after procedure was performed) and late (>24 h after procedure was performed) adverse events. Seventeen patients underwent PEG-Pedi-PEG procedures during the study period. Technical success was achieved in all patients (100%). The retrograde migration rate of the jejunal extension tube was 0%. Early adverse events included peristomal pain in 1 patient. Late adverse events included inadvertent tube removal (3 patients), diarrhea (1 patient), prolonged ileus/gastroparesis (1 patient), and tube occlusion (1 patient). Mean follow-up was 290 days. The PEG-Pedi-PEG procedure is a novel endoscopic technique to facilitate post-pyloric feeding because the pediatric PEG bumper may act like a sail in the small bowel, with peristalsis pushing the bumper distally and thus decreasing the possibility of migration back into the stomach. This study demonstrated excellent technical success, no retrograde migration, and a low rate of adverse events.

Fluoroscopy-guided jejunal extension tube placement through existing gastrostomy tubes: analysis of 391 procedures.

We aimed to evaluate the safety and efficacy of fluoroscopically placed jejunal extension tubes (J-arm) in patients with existing gastrostomy tubes. We conducted a retrospective review of 391 J-arm placements performed in 174 patients. Indications for jejunal nutrition were aspiration risk (35%), pancreatitis (17%), gastroparesis (13%), gastric outlet obstruction (12%), and other (23%). Technical success, complications, malfunctions, and patency were assessed. Percutaneous gastrostomy (PEG) tube location, J-arm course, and fluoroscopy time were correlated with success/failure. Failure was defined as inability to exit the stomach. Procedure-related complications were defined as adverse events related to tube placement occurring within seven days. Tube malfunctions and aspiration events were recorded and assessed. Technical success was achieved in 91.9% (95% CI, 86.7%-95.2%) of new tubes versus 94.2% (95% CI, 86.7%-95.2%) of replacements (P = 0.373). Periprocedural complications occurred in three patients (0.8%). Malfunctions occurred in 197 patients (50%). Median tube patency was 103 days (95% CI, 71-134 days). No association was found between successful J-arm placement and gastric PEG tube position (P = 0.677), indication for jejunal nutrition (P = 0.349), J-arm trajectory in the stomach and incidence of malfunction (P = 0.365), risk of tube migration and PEG tube position (P = 0.173), or J-arm length (P = 0.987). A fluoroscopy time of 21.3 min was identified as a threshold for failure. Malfunctions occurred more often in tubes replaced after 90 days than in tubes replaced before 90 days (P < 0.001). A total of 42 aspiration events occurred (OR 6.4, P < 0.001, compared with nonmalfunctioning tubes). Fluoroscopy-guided J-arm placement is safe for patients requiring jejunal nutrition. Tubes indwelling for longer than 90 days have higher rates of malfunction and aspiration.

Short- and Long-Term Safety of PEG-J Used for Continuous Infusion of Levodopa-Carbidopa Intestinal Gel

Introduction: Irregular drug plasma levels due to impaired gastric emptying may contribute to motor complications observed in patients with Parkinson's disease (PD) treated with oral medication. One treatment for PD uses percutaneous endoscopic gastrostomy with jejunal extension tube (PEGJ) to continuously deliver levodopa-carbidopa intestinal gel (LCIG, known in the US as carbidopa-levodopa enteral suspension [CLES]) directly to the jejunum for 16 hours, thereby bypassing the stomach and avoiding fluctuating drug plasma levels. We assessed short- and long-term safety of the PEG-J procedure and device used to deliver LCIG in mobile patients with PD from our most recent clinical trial data cut. Methods: All patients received a 15 French Freka PEG tube and a 9 French Freka jejunal extension tube, placed during the same endoscopy. The ideal jejunal tube tip position was distal to the ligament of Treitz. PEG-J procedure- and device-related treatment-emergent adverse events (AEs) reported during 4 phase 3 LCIG studies (including an ongoing open-label extension study into which all others filtered) were integrated and evaluated. AEs and serious AEs (SAEs) in patients treated with LCIG were included in this analysis at the March 2014 data cut-off date. Results: A total of 395 patients were included in this analysis. The median (range) exposure to PEG-J was 986 (1-1972) days; 165 patients were exposed for ≥1095 days, 130 patients were exposed for ≥1260 days, and 70 patients were exposed for ≥1460 days. The incidence of SAEs was highest in the first week and declined rapidly thereafter (Figure 1). Over the long-term, procedure/device-associated AEs occurred in 387 (94%) patients and SAEs occurred in 68 (17%) patients (Table 1), although single events may have been coded to >1 preferred term. Procedure/device-associated AEs led to discontinuation in 19 (4.8%) patients; those that led to discontinuation in >1 patient included complication of device insertion (10 patients; 2.5%), abdominal pain (4 patients, 1.0%), abdominal discomfort (2 patients, 0.5%), and peritonitis (2 patients, 0.5%).Figure 1Table 1: Overall Procedure/Device-associated Adverse EventsConclusion: The overall safety profile of LCIG via PEG-J is comparable to published data in immobile patients (Itkin M et al, Gastroenterology, 2011;141:742-65). Incidence of SAEs declined after the first week post-procedure. The low discontinuation rate of LCIG treatment via PEG-J demonstrates that this treatment can be maintained for long-term use in this mobile patient population with advanced PD.

Best practice in placement of percutaneous endoscopic gastrostomy with jejunal extension tube for continuous infusion of levodopa carbidopa intestinal gel in the treatment of selected patients with Parkinson’s disease in the Nordic region

Objective. Continuous infusion of levodopa carbidopa intestinal gel (LCIG) is associated with a significant improvement in the symptoms and quality of life of selected patients with advanced Parkinson’s disease. Percutaneous endoscopic gastrostomy with jejunal extension (PEG/J) was first described in 1998 and has become the most common and standard technique for fixing the tubing in place for LCIG infusion. Material and methods. A workshop was held in Stockholm, Sweden, to discuss the PEG/J placement for the delivery of LCIG in Parkinson’s disease patients with the primary goal of providing guidance on best practice for the Nordic countries. Results. Suggested procedures for preparation of patients for PEG/J placement, aftercare, troubleshooting and redo-procedures for use in the Nordic region are described and discussed. Conclusions. LCIG treatment administered through PEG/J-tubes gives a significant increase in quality of life for selected patients with advanced Parkinson’s disease. Although minor complications are common, serious complications are infrequent, and the tube insertion procedures have a good safety record. Further development of delivery systems and evaluation of approaches designed to reduce the demand for redo endoscopy are required.

Sa1629 Gastrointestinal Safety & Device Longevity of Long-Term PEG-J Used for Continuous Infusion of Levodopa-Carbidopa Intestinal Gel

Motor complications observed in patients with advanced Parkinson's disease (PD) on oral medications might be due to impaired gastric emptying and fluctuating drug plasma levels. A novel treatment for PD involves the use of a percutaneous endoscopic gastrostomy with jejunal extension tube (PEG-J) to provide continuous delivery of levodopa-carbidopa intestinal gel (LCIG) directly to the jejunum.

Endoscopic approaches to enteral feeding and nutrition core curriculum

Endoscopic approaches to enteral feeding and nutrition core curriculum

Percutaneous Endoscopic Gastrostomy (pull method) and Jejunal Extension Tube Placement

BackgroundEnteral feeding should be considered for patients with an intact and functional gastrointestinal tract. Percutaneous endoscopic gastrostomy (PEG) tube placement is indicated in patients requiring medium to long term enteral feeding (>30 days) and with impaired swallowing. Patients and methodsIn this video manuscript, we demonstrate the complete PEG procedure (pull method) in a 65 year old patient and placement of PEG jejunal extension tube in another patient who needed post-pyloric enteral feeding. ConclusionsPEG-pull method is the most widely used PEG technique. Appropriate patient selection, timing of the procedure, informed consent, antibiotic prophylaxis, adequate endoscopic air insufflation during PEG site selection, and optimal PEG site localization are the keys in this procedure.

PMO-082 Outcomes after “through the peg” placement of jejunal extensions

IntroductionPercutaneous endoscopic gastrojejunostomy (PEG-J) placement by conventional techniques is technically demanding, time consuming and its use is often limited by jejunal tube dysfunction. We aim to describe our outcomes using...

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