Percutaneous Endoscopic Jejunostomy Placement Research Articles

Safety and efficacy of direct percutaneous endoscopic jejunostomy placement in patients with previous upper gastrointestinal resection: A retrospective cohort study.

Percutaneous jejunal enteral access can be obtained with percutaneous endoscopic gastric jejunostomy (PEGJ) and direct percutaneous endoscopic jejunostomy (DPEJ) tubes. PEGJ may not be feasible in patients with previous gastric resection (PGR) and DPEJ may be the only option. Our aim is to determine if DPEJ tubes can be placed successfully in patients with history of gastrointestinal (GI) surgery and if success rates are comparable to DPEJ or PEGJ in those without prior GI surgery. We reviewed all tube placements performed from 2010 to present. Procedures were performed using a pediatric colonoscope. Previous upper GI surgery was defined as PGR or esophagectomy with gastric pull-up. Adverse events (AEs) were graded perAmerican Society for Gastrointestinal Endoscopy criteria. Mild events included unplanned medical consultation or hospitalization <3 days, and moderate events included repeat endoscopy without surgical intervention. Successful placement rates were high regardless of GI surgical history. Patients receiving a DPEJ with a history of GI surgery were significantly less likely to experience an AE compared with those receiving DPEJ with no history and compared with PEGJ patients with or without a history. DPEJ placement in patients with previous upper GI surgery has very high success rate. It is associated with lower AE rates than patients receiving DPEJ without previous gastric surgery, or PEGJ regardless of previous gastric surgery. Patients with a history of upper GI surgery requiring enteral access may benefit from DPEJ over PEGJ placement considering its very high success rate and lower incidence of AEs.

Endoscopic Management of Esophageal Anastomotic Leaks Following Surgery for Malignant Disease

Introduction: Esophageal anastomotic leaks following gastric or esophageal cancer surgery remain a major cause of morbidity and mortality. To limit the risks associated with operative repair, endoscopic interventions, including stenting, clipping, and percutaneous endoscopic jejunostomy (PEJ), have been increasingly used to manage these patients. The study aimed to determine the efficacy of endoscopic management of esophageal anastomotic leaks following cancer surgery. Methods: We performed a retrospective review of prospectively maintained databases of all gastric and esophageal operations at our hospital. Included patients had esophageal or gastric cancer and were operated on between January 2003 and December 2012. Patients with radiographic or endoscopic evidence of an anastomotic leak and who underwent an attempt at endoscopic management were included. Results: Of the 107 patients with esophageal anastomotic leaks, 51 underwent an attempt at endoscopic management. Forty were men, and the mean age was 61. Forty-two patients underwent esophagectomies, 6 had partial or total gastrectomies, and 3 had esophagogastrectomies. Fully covered esophageal stents were placed in 32 patients. On average, stents were in place for 59 days (range 12-170 days). Stent migration was seen in 34% of patients and managed with endoscopic revision. There were no other documented complications from stent placement. Overall, 26 patients (81%) treated with stents healed. Direct PEJs were placed in 41 patients for a mean duration of 106 days (range 18-358 days). Four patients failed PEJ placement and required a second attempt for successful insertion. There were no documented complications from PEJ placement. Overall, 39 patients (95%) treated with PEJs healed. Endoscopic clips were placed in 3 patients, all of whom also received stents. There were no documented complications related to clipping, and all 3 patients healed. Among these groups, 22 patients were treated with stent and PEJ. Healing was seen in 21 out of 22 (95%) of these patients in a mean of 105 days (range 31-337 days). Of the 51 total patients, 44 (86%) achieved documented anastomotic healing. Mean healing time was 92 days (range 3-337 days). Of the remaining 7 patients, 3 required anastomotic revision, 1 required esophageal exclusion, 2 died of multiple surgical complications, and 1 died at another facility with stent in place. Conclusion: Our results suggest that anastomotic leaks can be managed safely and successfully with endoscopic therapy in select patients. A combination of esophageal stenting to control the leak and PEJ placement for nutrition was highly effective in achieving anastomotic healing, without the need for highrisk operative repair.

Sa1467 Outcomes of Double Balloon Endoscopy-Assisted Direct Percutaneous Endoscopic Jejunostomy Placement

Conventional direct percutaneous endoscopic jejunostomy (DPEJ) tube placement using pediatric or adult colonoscopes fails in approximately one third of cases, primarily due to lack of abdominal transillumination or limited instrument insertion into the jejunum. In a small pilot study, double balloon endoscopy (DBE)-assisted DPEJ placement was successful in all patients in whom attempted conventional DPEJ failed.

Severe laceration in a percutaneous endoscopic jejunostomy placement resolved with over-the-scope clips

Severe laceration in a percutaneous endoscopic jejunostomy placement resolved with over-the-scope clips

Percutaneous endoscopic jejunostomy in patients with gastroparesis following lung transplantation: feasibility and clinical outcome

The aim of the present study was to describe success rates, complications, and outcome in patients who underwent percutaneous endoscopic jejunostomy (PEJ) because of gastroparesis due to previous lung transplantation. Between October 2008 and May 2011, 14 attempts at PEJ placement were made in 12 patients in our center. Of the 14 attempts, 11 were successful, giving a technical success rate of 78.6 %. Median duration of followup was8.5 months (2–15 months). No immediate complications were reported. Two severe complications occurred during follow up (one volvulus and one jejunocolic fistula). Jejunal nutrition was well tolerated in most of patients (9 /10). PEJ insertion is a feasible technique, which could help to provide nutritional support for patients with gastroparesis and previous lung transplantation.

Enteral Access by Double-Balloon Enteroscopy: An Alternative Method of Direct Percutaneous Endoscopic Jejunostomy Placement

Although direct percutaneous endoscopic jejunal feeding tube placement is an increasingly accepted method of providing small-bowel access for long-term enteral nutrition, it is reliant on push enteroscopy and remains a technically challenging procedure with significant failure rates. Double-balloon enteroscopy, with its ability to provide controlled small-bowel intubation may facilitate direct percutaneous endoscopic jejunal tube placement. We report a prospective series of ten consecutive cases of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunal placement, accompanied by a step-by-step illustrated overview of the technique. Direct percutaneous endoscopic jejunal tube placement by double-balloon enteroscopy was successful in nine of the ten attempted cases. In the first case, direct percutaneous endoscopic jejunal placement was abandoned due to inadequate transillumination; there were no procedure-related complications in any of our patients. This first reported prospective case series of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunal placement shows a promisingly high success rate; larger comparative studies are required to clearly establish any advantages over the originally described push enteroscopy method.

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.

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 placement of direct percutaneous jejunostomy tubes in patients with complications after esophagectomy

Complications after esophagectomy may prevent oral intake, lead to dependence on total parenteral nutrition, and lengthen hospital stay. Direct percutaneous endoscopic placement of a jejunostomy tube allows enteral feeding in the presence of postoperative complications and eliminates the need for total parenteral nutrition. A total parenteral nutrition database was used to identify patients who received total parenteral nutrition because of complications after esophagectomy. Records of all patients subsequently referred for percutaneous endoscopic jejunostomy placement were reviewed. Twenty-five patients with postesophagectomy complications were referred for percutaneous endoscopic jejunostomy placement. A percutaneous endoscopic jejunostomy was successfully placed in 21 patients (84%), all of whom were weaned off total parenteral nutrition. Six patients (29%) in whom percutaneous endoscopic jejunostomy placement was successful died during hospitalization at a mean of 20 days (range 5-40 days) after the procedure for reasons unrelated to percutaneous endoscopic jejunostomy tube insertion. The remaining 15 patients were discharged while receiving nutrition by means of the percutaneous endoscopic jejunostomy. Ten of them had subsequent removal of the percutaneous endoscopic jejunostomy at a mean of 131 days (range 20-281 days). There were no major percutaneous endoscopic jejunostomy-related complications. Minor complications occurred in 4 patients (19%). Percutaneous endoscopic jejunostomy placement may be considered in patients with complications after esophagectomy. In these patients, percutaneous endoscopic jejunostomy placement avoids the need for total parenteral nutrition.

Outcome of direct percutaneous endoscopic jejunostomy tube placement for nutritional support in critically ill, mechanically ventilated patients

Purpose: Gastrointestinal function is adversely affected in critically ill mechanically ventilated patients. The most common abnormality is delayed gastric emptying. Among the options for postpyloric feeds, direct percutaneous endoscopic jejunostomy (PEJ) provides a permanent, reliable, and direct access to the small bowel and can be used for full enteral feedings, thus eliminating the need for parenteral nutrition. Patients and Methods: All patients who underwent direct PEJ tube placement while mechanically ventilated in the intensive care unit (ICU) were evaluated. For each patient the following factors were identified: age, indication for ICU admission and PEJ placement, nutritional support before and after PEJ placement, calories received, complications, and outcome. Results: Seventeen patients underwent the procedure. All had successful placement of direct PEJ tube. There was a single complication. Within 24 hours of PEJ placement, 16 of 17 patients tolerated jejunal feedings. All patients progressed to their established nutritional goals. There were no cases of aspiration of enteral feedings. In the 16 patients, total parenteral nutrition (TPN) was not required once PEJ tubes were placed. Thirteen patients were discharged home or to a rehabilitation facility with jejunal feedings. Conclusions: Direct PEJ placement is a safe and reliable device that can be successfully placed in critically ill, mechanically ventilated patients. With this procedure, all patients can meet their nutritional requirements and eliminate the need for TPN. Copyright © 2002 by W.B. Saunders Company

7194 Percutaneous endoscopic gastrostomies and percutaneous endoscopic jejunostomies: are they being done in time in developing country?

Background and Aims: Percutaneous endoscopic gastrostomy (PEG) or percutaneousendoscopic jejunostomy (PEJ) is considered in patients whorequire prolonged enteral feeding for more than 30 days, and is done moresafely and less expensively than surgical gastrostomy. Increasing numberof patients are being referred for PEG placement in South Korea, but PEGis still delayed and not considered because of refusing by patients andignoring by the physician and surgeons. The aim of our study is to evaluatethe success rate and complications of PEG, and to measure the intervalfrom the onset of indication for enteral feeding to PEG or PEJ placement. Materials and Methods: On 53 patients, 66 PEGs and 4 PEJs were performed by pull-through method. In PEJ placement, jejunal tube was introduced by graping with forceps inserted in endoscope channel through PEG catheter. A retrospective review of all patients who underwent PEG or PEJ placement was performed. Results: In demographics, mean age was 61 years (4-68 years) and 36 patients (68%) were male. PEGs were performed in patients with neurologic dysphagia (n=43), esophageal cancers (n=5), oropharyngeal cancers (n=2), cancer cachexia (n=1), aerophagia (n=1) and mandibular fracture (n=1). PEJs were performed in patients with pyloric obstructions by gastric cancers (n=3) and mediastinitis by esophageal perforation (n=1). All procedures were done successfully without failure. PEG or PEJ was performed in 183 days (7 days-82 months) after onset of indication for enteral feeding. There were major complications in 4 procedures (5.7%) including arterial bleeding on gastric wall (n=1) and wound infections (n=3), and there were minor complications in 15 procedures (25.7%) including PEG dislodge or self-extraction by patients (n=13), minor GI bleeding (n=2), diarrhea (n=2), pain requiring analgesics (n=2) and fever (n=1). Follow-up was possible in 49 patients and mean follow-up was 113 days (26-331 days). There were 4 deaths during follow-up and there was no procedure-related mortality. Three PEGs and 1 PEJ were removed electively for improved oral intake. Conclusions: PEG or PEJ placement is easy, safe and effective method to provide long-term enteral feeding, but is not been doing in time even though in the indication for enteral feeding. More expension of indication for PEG or PEJ should be considered in developing countries. Background and Aims: Percutaneous endoscopic gastrostomy (PEG) or percutaneousendoscopic jejunostomy (PEJ) is considered in patients whorequire prolonged enteral feeding for more than 30 days, and is done moresafely and less expensively than surgical gastrostomy. Increasing numberof patients are being referred for PEG placement in South Korea, but PEGis still delayed and not considered because of refusing by patients andignoring by the physician and surgeons. The aim of our study is to evaluatethe success rate and complications of PEG, and to measure the intervalfrom the onset of indication for enteral feeding to PEG or PEJ placement. Materials and Methods: On 53 patients, 66 PEGs and 4 PEJs were performed by pull-through method. In PEJ placement, jejunal tube was introduced by graping with forceps inserted in endoscope channel through PEG catheter. A retrospective review of all patients who underwent PEG or PEJ placement was performed. Results: In demographics, mean age was 61 years (4-68 years) and 36 patients (68%) were male. PEGs were performed in patients with neurologic dysphagia (n=43), esophageal cancers (n=5), oropharyngeal cancers (n=2), cancer cachexia (n=1), aerophagia (n=1) and mandibular fracture (n=1). PEJs were performed in patients with pyloric obstructions by gastric cancers (n=3) and mediastinitis by esophageal perforation (n=1). All procedures were done successfully without failure. PEG or PEJ was performed in 183 days (7 days-82 months) after onset of indication for enteral feeding. There were major complications in 4 procedures (5.7%) including arterial bleeding on gastric wall (n=1) and wound infections (n=3), and there were minor complications in 15 procedures (25.7%) including PEG dislodge or self-extraction by patients (n=13), minor GI bleeding (n=2), diarrhea (n=2), pain requiring analgesics (n=2) and fever (n=1). Follow-up was possible in 49 patients and mean follow-up was 113 days (26-331 days). There were 4 deaths during follow-up and there was no procedure-related mortality. Three PEGs and 1 PEJ were removed electively for improved oral intake. Conclusions: PEG or PEJ placement is easy, safe and effective method to provide long-term enteral feeding, but is not been doing in time even though in the indication for enteral feeding. More expension of indication for PEG or PEJ should be considered in developing countries.

PERCUTANEOUS ENDOSCOPIC GASTRO-JEJUNAL (PEJ) PLACEMENT IN CHILDREN WITH COMPLEX MEDICAL CONDITIONS

120 Percutaneous endoscopic jejunostomy (PEJ) has gained wide acceptance in adults. We report our experience with PEJ placement in children. Methods: A 4-year retrospective review of charts found 35 such procedures performed in 10 children. Seven were 1 to 7 years with a mean of 2.1 years, two were between 7 to 10 years, and one was 16 years. Diagnosis included esophageal stricture, severe gastroesophageal reflux disease with high risk of aspiration, gastroesophageal dissociation procedure with gastroparesis, and severe delayed gastric emptying. Some had the procedure performed to allow transition from parenteral nutrition. All were considered high risk for a laparotomy. Under conscious sedation (without endotracheal intubation) or general anesthesia, the tip of a G-J tube was positioned in the distal duodenum under endoscopic guidance while using a guide wire. This tube was introduced through an already existing gastrostomy site (n = 29) or through the PEG performed just before the procedure (n = 6). Results: PEJ placement was successful in all children. Feeding via the PEJ was initiated within 12 hours of placement. Most children were discharged within 2 days of PEJ placement. No complications occurred. The jejunal tube remained patent two weeks to eight months (average 2.4 months). When occluded, the G-J tube was endoscopically replaced on an ambulatory procedure. Conclusion: PEJ can be inserted safely and effectively in infants and children requiring long term post pyloric tube feeding. This procedure is a safe alternative to a combined fundoplication and a surgical jejunostomy in high-risk children. It allows a significant decrease in the length of stay. Proper teaching of the caregiver techniques to prevent occlusion should increase the longevity of the G-J tube.

Limitations of percutaneous endoscopic jejunostomy.

Thirty-six patients at the University of Kentucky Medical Center underwent percutaneous endoscopic jejunostomy placement between January 1 and December 31, 1989. We retrospectively reviewed their charts for indications and complications of the procedure. Experience and outcome with the initial placement of the percutaneous jejunostomy tube was evaluated. Primary diagnoses at the time of insertion included central nervous system disorders (28), ventilator dependence (5), cancer (2), and gastroparesis (1). The follow-up period ranged from 2 to 131 days (median 16 days). Tube dysfunction or dislodgment occurred in 31% of patients. Other complications included pulmonary aspiration (11%) and bleeding at the insertion site (3%). The 30-day mortality rate was 19% with all but one death caused by the severity of the underlying primary illness. It is concluded that problems with the currently performed technique of percutaneous endoscopic jejunostomy, along with tube-related problems, seriously limit the usefulness of this technique. Improvements in technology, along with routine postprocedure radiographs to allow early detection of malpositioned jejunostomy tubes, may improve the outcome of this procedure. Newer techniques that have a higher success of distal small intestinal placement need to be evaluated.