Jejunal Extension Research Articles

Sa1638 Risk Factors for Local Recurrence After En Bloc Resection of Endoscopic Submucosal Dissection for the Early Gastric Cancer Treatment

Clinical data concerning patients in whom a PEJ was scheduled between 1/2006 and 1/2010 were retrospectively collected and analyzed. Results: Twenty-two patients were included. In 4 patients, the procedure was unsuccessful, due to lack of translumination; therefore the success rate was 81%. In 3 of these patients, a percutaneous endoscopic gastrostomy with a jejunal extension was placed and one patient underwent surgery. The remaining 18 patients (10 men, 8 women) who underwent successful PEJ placement had a median age of 57 years (22-79) and a body mass index of 18,5 (13-33). Regarding underlying disease, 5 patients (27.8%) had previous lung transplantation and 7 (38.9%) had gastrectomy. Indications for jejunal access were as follows: gastroparesis (n 5, 27.8%), gastrectomy (n 7, 38.9%) and severe reflux (n 6, 33.3%). Eight patients had previous nasogastric (n 2) or nasojejunal (n 6) tube. An enteroscope was used in 11 patients, whereas a gastroscope was used in 6 and a pediatric colonoscope in 1 patient. Eighteen french tubes with an internal bumper were used in all patients. No patient presented with short-term complications. Six patients had long-term complications (tube migration and local infection). Seven patients required a second procedure during follow-up. Enteral feeding was well tolerated in 13 patients (72.2%) and weight gain was observed in 6 (33.3%). Total median length of jejunal feeding was 6 months (1-36). Conclusions: PEJ is a useful endoscopic alternative for providing enteral nutrition when gastrostomy is not possible. Frequent indications in our series include previous gastrectomy and gastroparesis following lung transplantation. Sa1638 Risk Factors for Local Recurrence After En Bloc Resection of Endoscopic Submucosal Dissection for the Early Gastric Cancer Treatment Eunsoo Kim, Kwangbum Cho, Kyung Sik Park Internal medicine, Keimyung University School of Medicine, Daegu, Republic of Korea Backgrounds/Aim: Endoscopic submucosal dissection (ESD) has been accepted as an alternative method to surgery for the treatment of early gastric cancer (EGC). Piecemeal resection has been reported to be associated with the local recurrence after ESD. However, there is no study evaluating local recurrence after en bloc resection of ESD. The aim of this study was to assess risk factors for local recurrence after en bloc resection of ESD for the treatment of EGC. Methods: From April 2003 to May 2010, patients with EGC treated by ESD and followed up for at least 6 months were eligible for this study and their medical records were evaluated retrospectively. We excluded the lesions removed by the way of a piecemeal resection and involved in the deep margin pathologically. The lesions with lateral safety margin less than 1 mm was considered as the inadequate group. Results: Among 1,215 gastric epithelial lesions in 1,121 patients, 415 EGC lesions in 401 patients were included (median age 66 (32-87), male 291, median follow-up month 14.8). The overall recurrence rate was 8.7% (36/415) and EGC with ill defined margin was identified as a significant independent risk factor for local recurrence in the multivariate analysis (OR 2.369, 95% CI 1.101-5.098, p 0.027). The cumulative recurrence was more observed in the inadequate group (lateral safety margin 1 mm) through Kaplan-Meier analysis (p 0.019). Multivariate predictive factor for inadequate lateral safety margin was the tumor location (upper third vs. lower third, p 0.001). Conclusion: Aside from achievement of en bloc resection during ESD, efforts should be made to identify the clear lateral margin of tumor for avoiding local recurrence. Endoscopists should pay attention to obtain an adequate tumor safety margin especially in upper-located gastric tumor lesions.

Tu1593 Placement of Percutaneous Endoscopic Jejunostomy With Single-Balloon Enteroscopy

Direct percutaneous endoscopic jejunostomy (DPEJ) has emerged as a viable alternative for percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) in patients not tolerating gastric feedings. Reportedly, DPEJ placement with regular endoscopes fails in up to one third of cases, mainly due to inadequate transillumination or failure to pass the scope into the jejunum. Single-balloon enteroscopy (SBE), with its ability to provide controlled small-bowel intubation, may facilitate direct percutaneous jejunal feeding tube placement.

Novel Endoscopic Triangulation Approach to Percutaneous Transgastric Placement of Jejunal Extension Feeding Tube

In patients who have surgically-altered upper gastrointestinal anatomy, postoperative endoscopic enteral nutrition options can be limited by issues such as bowel stenosis and/or acute angulation. This report details the use of an endoscopic triangulation method combining per-oral and percutaneous transgastric approaches to overcome an efferent gastrojejunostomy limb stenosis, to successfully place a jejunal extension feeding tube through a newly placed PEG site. This description provides an alternative endoscopically feasible option for successful enteral nutrition access, thus obviating the need for additional operations to place surgical feeding tubes or to commit patients to long-term total parenteral nutrition.

Two Cases of Failed Jejunostomy Tube Changes Using the AMT Capsule Monarch Feeding Tube

Purpose: 1st case: 56-year-old man with gastroparesis secondary to chronic pancreatitis became malnourished, necessitating a direct PEJ tube. At the time of tube change, the original tube was replaced with a MIC feeding tube with a balloon. However, he subsequently had problems with leakage as well as a severe infection at the tube site requiring hospitalization. Therefore, the tube was changed to an AMT Capsule Monarch 18 Fr tube. At the time of the next tube change, due to some patient discomfort and difficulty, a 14 Fr tube was used. Soon afterwards the patient complained of severe abdominal pain. Tube check showed the tube within a jejuna loop with intraperitoneal leakage of contrast. He was taken to surgery where the tract was found to be very weak intraoperatively. He later had a gastric tube with a jejunal extension placed. He has done well with that tube since then. 2nd case: 20-year-old woman with a history of cerebral palsy and gastroparesis had a PEJ tube placed for nutrition. Three months later, the PEJ tube was pulled out and replaced with an AMT Capsule Monarch 18 Fr tube. She later experienced severe rectal bleeding secondary to a rod from a previous back surgery eroding into her colon. She underwent surgery with removal of the hardware. She also underwent a second surgery that admission for lysis of adhesions. Following recovery from these surgeries, she did not tolerate any jejunal feedings. Around that time, it was noted that the existing tube was worn out and it was therefore replaced. Within a few hours, the patient complained of severe abdominal pain. Tube check showed contrast going into the peritoneal cavity. She was treated conservatively with IV antibiotics and no surgical intervention. Her abdominal pain eventually improved and she was discharged. Discussion: We present two cases of perforation happening after a tube change with a jejunal AMT Capsule Monarch tube. Both cases were thought to be due to a weak fibrous tract. In the first case, the tract was likely weakened by the patient's persistent malnutrition. In the second case, the tract was weakened by the patient's recent two major abdominal surgeries. Ideally, jejunal exchange should be done under direct endoscopic visualization. If the replacement tube cannot be seen, then a tube check should be done before discharge from the GI lab. Patients who are malnourished or those who have undergone recent abdominal surgery may have a weakened fibrous tract necessitating great caution when changing a jejunal tube.

Percutaneous Endoscopic Jejunostomy and Jejunal Extension Tube through Percutaneous Endoscopic Gastrostomy: A Retrospective Analysis of Success, Complications and Outcome

Background: Percutaneous access to the jejunum is an important approach if gastrostomy feeding is not possible. Objective: To analyze success, short- and long-term complications (STCs, LTCs) in patients with percutaneous endoscopic jejunostomy (PEJ) and jejunal access through percutaneous endoscopic gastrostomy (Jet-PEG). Methods: A retrospective analysis of endoscopically placed PEJs and Jet-PEGs. Success rates, mortality, STCs and LTCs were investigated for risk factors comprising demographic data, underlying disease, previous surgery and experience of the endoscopist. Results: 205 PEJ and 58 Jet-PEG placements were included in the study. PEJs and Jet-PEGs were successfully placed in 65.4 and 89.7%, respectively. Billroth II surgery predisposed in favor of a significantly higher success rate for PEJ placement (p = 0.014, OR = 2.27). Inexperienced examiners have a significantly (p = 0.040) lower success rate for tube insertion than examiners with a medium level of experience. STCs and LTCs occurred evenly in PEJ and Jet-PEG patients. Dislocation of the tube occurred significantly more frequently in Jet-PEG patients (33.3%, p = 0.005). Aspiration was most common for bedridden patients. Conclusion: PEJ has a significantly lower success rate for insertions, but fewer LTCs. The experience of the endoscopist correlates with the success rate of tube insertion.

Diagnostic and Therapeutic Approach to Pancreatic Cancer-Associated Gastroparesis

Patients with unresectable pancreatic carcinoma often present with early satiety, nausea, and vomiting without evidence of mechanical obstruction, mucosal disease, or metabolic abnormality. This condition is well described in the literature and is thought to result from pancreatic cancer-associated gastroparesis (PCAG). No clinical guideline is available for diagnosing and managing this rare disease. To propose an algorithm for diagnosing and managing patients with PCAG based on a literature review and our clinical experience. A comprehensive review was conducted of literature on the subject from 1966 to 2005, and retrospective analysis was performed for patients with PCAG who presented to the University of Iowa Hospitals and Clinics (Iowa City, IA, USA) during the period 1998-2005. Literature on an optimal diagnostic and therapeutic approach to PCAG is lacking. There are only two small case series and one case report regarding management of PCAG. Extensive chart review only identified two patients who met the diagnostic criteria of PCAG. We propose performing routine upper GI series and esophagogastroduodenoscopy on all patients with pancreatic cancer who present with nausea and vomiting, to rule out obstruction and mucosal disease. If there is no obstruction or mucosal disease, we do not recommend further workup. Prokinetic agents are the first line therapy for PCAG. In refractory cases, percutaneous endoscopic gastrostomy with jejunal extension may be considered in selected patients who respond to nasojejunal decompression. We propose a time-effective and useful strategy for diagnosing and managing patients with PCAG. We also define the diagnostic end-point for this difficult to manage condition.

Buried Bumper Syndrome: Cut and Leave It Alone!

Buried bumper syndrome (BBS) occurs due to the overgrowth of gastric mucosa over the inner bumper of a gastrostomy tube. Various therapeutic approaches have been described for the management of BBS. However, no standardized clinical protocol deals with this complication. The authors describe their experience of dealing with BBS. Case notes of the patients undergoing percutaneous endoscopic gastrostomy (PEG) between February 2002 and December 2007 at their institute were reviewed retrospectively, and cases of BBS were analyzed. During this 71-month period, 356 PEG procedures were preformed. Seven patients with BBS were identified from the case note review (incidence of 1.97%). Attempts at endoscopic removal of the buried bumper were made but unfortunately failed. In view of the patients' associated comorbidity, the buried bumpers in these patients were left in situ, and a new PEG was inserted adjacent to the first site in 6 individuals. In 1 patient, a jejunal extension tube was inserted through the original PEG tube for feeding. No complications from the buried bumper arose in these patients during a median follow-up of 18 months (range, 1-46 months). Some patients being fed by a PEG tube are in poor general health and have significant comorbidities. They are therefore poor candidates for surgical or endoscopic removal of a buried bumper. In such patients, leaving the internal bumper in situ should be considered as a relatively safe treatment option.

Indications and complications of percutaneous endoscopic gastrostomy with jejunal extension tube

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Indications and complications of percutaneous endoscopic gastrostomy with jejunal extension tube

Indications and complications of percutaneous endoscopic gastrostomy with jejunal extension tube

Endoscopic retrograde cholangiography in post–orthotopic liver transplant population with Roux-en-Y biliary reconstruction

Endoscopic retrograde cholangiography (ERC) is a well-established modality for diagnostic and therapeutic maneuvers in pancreaticobiliary disorders. However, it is technically more challenging in patients with postsurgical anatomy like Roux-en-Y anastomoses. Its effectiveness in post-orthotopic liver transplantation (OLT) patients with Roux-en-Y biliary reconstruction has not been reported. We sought to assess the efficacy and safety of ERC in this patient population. A total of 132 OLTs with Roux-en-Y biliary reconstruction were performed at our institution from June 1998 to August 2005. Data from consenting patients who underwent ERC were reviewed once they were identified through computerized medical index system. Of 132 OLT patients with Roux-en-Y biliary reconstruction, 31 patients (9 female and 22 male subjects ranging in age from 11 months to 70 years) underwent ERC. The indication for liver transplant was end-stage liver disease or occurrence of cholangiocarcinoma from primary sclerosing cholangitis in 28 patients and a case each of chronic hepatitis C, alcoholic liver disease, and metastatic islet cell carcinoma. A variable-stiffness pediatric colonoscope was used in most cases. ERC indications were both diagnostic and therapeutic and included the following: evaluation of increased liver biochemistries and fever in 12 patients, dilation of anastomotic biliary strictures in 10 patients, removal of fractured biliary tube or retained biliary stent in 6 patients, and in 1 patient each, biliary stone removal, management of bile leak, and jejunal tube extension placement for nutritional purpose. ERC was successful in 22 patients (71%). There were no postprocedural complications. Although ERC is technically more difficult and time-consuming in OLT patients with Roux-en-Y anastomoses, these data suggest that ERC is an effective and safe diagnostic and therapeutic modality with few or no complications when performed by experienced endoscopists. ERC was successful in most patients and allowed therapeutic interventions that obviated the need for percutaneous radiological intervention or surgery.

Jejunostomy Tube Placement with Transgastric Endoscopic Guidance

Purpose: To evaluate the feasibility of jejunostomy tube placement with transgastric endoscopic guidance. Methods: After a 48 hour fast, each pig was intubated and sedated with general anesthesia. A pediatric colonoscope was passed to the proximal jejunum, and a location for the jejunostomy tube placement was determined based on transillumination and digital pressure. An opening in the jejunal wall was made using a gold probe. A Jag wire was then passed into the peritoneal space, and the pediatric colonoscope was removed. An upper endoscope was then passed into the stomach and a needle knife was used to create a gastrotomy. The endoscope was then passed into the peritoneal space and the wire was found. A small incision was made in the abdominal wall, and a Kelley clamp was passed into the peritoneal space. Under direct vision, the tip of the wire was grasped by the Kelley clamp and pulled through the abdominal wall. The jejunal tube was passed into place and secured tightly under direct vision. Each pig was euthanized after the procedure. Results: Jejunostomy tube placement was successful in both of the 35 kg pigs that underwent the procedure. In the first pig, the jejunostomy tube was placed at 65 cm from the mouth and the procedure was completed in 90 minutes. In the second pig, the jejunostomy tube was placed at 60 cm from the mouth, and the procedure was completed in 85 minutes. After the jejunostomy tube was placed, the position was confirmed with contrast injection under fluoroscopy. There was no evidence of extraintestinal leakage of contrast. Conclusions: Direct percutaneous endoscopic jejunostomy may be problematic because of the mobility of the jejunum and difficulty in obtaining tranillumination, while percutaneous gastrostomy with jejunal extension often requires endoscopic reintervention, and surgical placement of a jejunostomy tube is more invasive. Our preliminary results indicate that jejunostomy tube placement is feasible under transgastric endoscopic guidance. This is a novel technique which allows one to directly observe a procedure from within the peritoneal cavity. Further studies could focus on closure of the gastrotomy and monitoring for leakage after survival surgery. Creating an opening in the jejunum was surprisingly straightforward, and a variant of this procedure could be to pass a narrow lumen endoscope through the jejunal opening into the peritoneal space so the wire can be directly guided into the Kelley clamp without the need for a gastrotomy.

Endoscopic placement of jejunal feeding tubes by using the Resolution clip: report of 2 cases

The utility of jejunal feeding in critically ill patients is well accepted.1-4 There are multiple techniques for placing jejunal feeding tubes, including surgical jejunostomy, direct percutaneous enterojejunostomy, passing a jejunal extension through a PEG (PEG-J), and nasojejunal (NJ) placement. Inadvertent withdrawal of the tube during scope removal and other complications during the placement of a jejunal feeding tube can lead to a frustrating experience for the endoscopist. We describe our experience with a technique that may ease the endoscopic placement of either NJ or PEG-J tubes.

Randomized Prospective Comparison of Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Feeding Tube Placement Versus Percutaneous Endoscopic Gastrostomy Feeding Tube Placement with Jejunal Extension (PEG-J), for Enteral Feeding

Randomized Prospective Comparison of Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Feeding Tube Placement Versus Percutaneous Endoscopic Gastrostomy Feeding Tube Placement with Jejunal Extension (PEG-J), for Enteral Feeding Mark Delegge, Greg Buck, John Fang, James Disario, Glen Lehman, Gregory Ginsberg, Steve Mcclave PEG-J and DPEJ are accepted procedures for enteral feeding into the jejunum. The prospective comparison of DPEJ to PEG-J methods of percutaneous, endoscopic, jejunal access has not been previously examined. This study aimed to compare the clinician re-intervention rates related to complications of DPEJ versus PEG-J placement with regard to retrograde jejunal (J)-tube migration and J-tube failure within three to six months. The primary endpoint was re-intervention rate within three to six months related to J-tube migration and J-tube failure. Re-intervention rate was defined as the percentage of subjects with successful J-tube placement requiring any intervention at a hospital/clinic by the investigator and/or medical Staff, related to tube repositioning, tube repair, tube trade-out, or tube removal. Clinical assessment, physical exam, procedure data, device performance, patient satisfaction, and adverse events were tracked at baseline and at 1, 2, 3, 4, 5, and 6 months post placement. Eligible patients were randomized to receive either a DPEJ or a PEG-J tube. A total of 40 patients were treated. Nineteen (19) patients were treated with DPEJ, 20 patients with PEG-J, and 1 patient with both devices. The demographics of both groups were comparable. The primary reasons for receiving jejunal feeding included gastroparesis (8, 20.5%), chronic pancreatitis (23, 59%), and increased risk of reflux and aspiration (8, 20.5%). Sixteen (16) (84.2%) patients in the DPEJ group had a successful device placement as compared to 18 (90%) patients in the PEG-J group (p Z 0.59). The device was retained in place for 57.5 days for the DPEJ group and 51.5 days for the PEG-J group (p Z 0.77). Reintervention rate difference between the two groups was statistically significant with 31% of the DPEJ patients receiving a re-intervention and 75% of PEG-J patients (p Z .007). Both groups were satisfied with the feeding tube. A total of 31 patients experienced an adverse event, with 14 (73.7%) patients in the DPEJ group and 17 (85%) in the PEG-J group (p Z 0.38). Eight (8) events were serious and device related (1 DPEJ, 7 PEG-J). None were unanticipated. One patient in the PEG-J group experienced pneumonia.Re-intervention rates and serious device related events were statistically significantly lower in the DPEJ group than in the PEG-J group. No serious complications were unanticipated.

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.

Gastric Dilatation Secondary to Diabetic Autonomic Neuropathy

A 75-year-old woman was admitted to the hospital due to severe nausea and vomiting. she had a 12-year history of type 2 diabetes with erratic glucose control complicated by severe bilateral retinopathy and peripheral neuropathy. Symptoms of bloating had developed during the previous several months. A plain abdominal radiograph showed a very dilated stomach (arrows) occupying most of the abdomen. A nasogastric tube was inserted, which decompressed her stomach and relieved her acute symptoms. She underwent placement of a percutaneous endoscopic gastrostomy tube with jejunal extension for the management of symptoms. Two weeks later, she died of complications from aspiration . . .

Direct Percutaneous Endoscopic Jejunostomy: Outcomes in 307 Consecutive Attempts

Clinical utilization of direct percutaneous endoscopic jejunostomy (DPEJ) is increasing. However, little data exist regarding important clinical outcomes with DPEJ. To describe the indications, success, and complications of DPEJ in a large cohort of >300 consecutive attempted DPEJ cases at our institution. 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. 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). 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.

Superior Mesenteric Artery (Wilkie's) Syndrome as a Result of Cardiac Cachexia

Superior mesenteric artery (SMA) syndrome is a rare acquired disorder in which acute angulation of SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction. Loss of fatty tissue as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the acute angulation. We report a case of an 86-year-old man with prolonged congestive heart failure and aortic stenosis in which SMA syndrome developed as a result of cardiac cachexia. Because of poor functional status and comorbidities, he was not a suitable candidate for decompressive surgery. Conservative treatment using a gastrostomy tube with jejunal extension led to improvement in nutritional status and resolution of symptoms.

Superior mesenteric artery (Wilkie’s) syndrome as a result of cardiac cachexia

Superior mesenteric artery (SMA) syndrome is a rare acquired disorder in which acute angulation of SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction. Loss of fatty tissue as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the acute angulation. We report a case of an 86-year-old man with prolonged congestive heart failure and aortic stenosis in which SMA syndrome developed as a result of cardiac cachexia. Because of poor functional status and comorbidities, he was not a suitable candidate for decompressive surgery. Conservative treatment using a gastrostomy tube with jejunal extension led to improvement in nutritional status and resolution of symptoms.

Necrotizing fasciitis after direct percutaneous endoscopic jejunostomy

Enteral jejunal feeding is indicated in patients who require enteral feeds but who are unable to tolerate intragastric feeding. These include patients with acute pancreatitis, patients with altered gastric anatomy after surgery, patients at high risk of aspiration pneumonia from gastric contents, and patients with gastroparesis. Enteral nutrition via a nasojejunal tube is suitable as a temporizing measure in these patients but not as a long-term option, because of patient discomfort and a propensity for accidental dislodgement. The 3 options for mediumto long-term jejunal feeding include a surgically placed jejunal tube, a percutaneous gastrostomy with jejunal extension (PEG/J), and a direct percutaneous endoscopic jejunostomy (DPEJ) tube. We describe a patient who underwent a DPEJ insertion complicated by necrotizing fasciitis.

The Frequency, Severity, and Spectrum of Adverse Events Associated with Direct Percutaneous Endoscopic Jejunostomy (DPEJ)

Background: DPEJ is increasingly utilized as a method for obtaining enteral access. Though it has been described for more than 15 years, scant data exists regarding the safety profile of DPEJ. Aims: To describe the frequency and type of complications associated with DPEJ. Methods: Institutional databases identified 316 attempted DPEJ placements at Mayo Clinic Rochester from 1996 to August 2004. All but 9 patients had consented to have their records used for research. These records were abstracted with attention to adverse events (AEs). Severe AEs were defined as those requiring urgent surgery or endoscopy or seriously threatening a patient's health. Moderate AEs were defined as those requiring non-urgent surgery or endoscopy, or any hospitalization (not meeting criteria for severe). All other AEs were categorized as mild. Mean follow-up (f/u) time was 251 days, median f/u time was 88 days, and 91% of patients had at least 48 hours of f/u. Results: 307 attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%) and 98 failed (32%). Overall, 89 AEs were associated with DPEJ placement or removal in 73 (23.7%) of the cases, with a clear causal relationship in 65 cases. In 16 cases more than one AE occurred. There were 13 serious AEs (4.2% of all cases), 18 moderate AEs, and 58 mild AEs. Serious AEs included 7 bowel perforations, 3 cases of jejunal volvulus, and 3 major bleeding events. The only death in this group was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 8 chronic enterocutaneous fistulae that required surgical or endoscopic closure and 2 significant site infections requiring hospitalization for IV antibiotics and/or abscess drainage. Many of the mild AEs were site infections requiring oral antibiotics (22/58) or persistent site pain (14/58). Conclusions: DPEJ was associated with a moderate or severe complication in 29/307 (9.4%) of cases. While DPEJ is a useful technique to gain enteral access that often obviates the need for surgery and is more reliable than percutaneous endoscopic gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved. Given incomplete follow-up in many patients, these complication rates may be an underestimate.