Percutaneous Gastrojejunostomy Tube Research Articles

Two endoscopic suturing techniques for the prevention of percutaneous gastrojejunostomy tube retrograde migration

Video 1Two suturing techniques for the fixation of percutaneous gastrojejunostomy tubes.

A68 DISTAL MIGRATION OF A PERCUTANEOUS GASTROJEJUNAL DUODOPA INFUSION TUBE DUE TO BEZOAR FORMATION AT THE JEJUNAL TUBE TIP

Abstract Background Continuous intestinal infusion of levodopa/carbidopa intestinal gel (LCIG) for the treatment of advanced Parkinson’s Disease (PD) leads to less variability in plasma drug levels and improved symptom control. Percutaneous Gastrojejunostomy (PEG-J) tube placement has a high placement success rate; however, delayed tube malfunctions occur in approximately 58% of cases within two years. A rare complication is bezoar formation at the jejunal tube tip. Aims To present a case of bezoar formation at the jejunal tip of a PEG-J tube that caused distal migration of the tube with gastroduodenal ulceration and required surgical extraction. Methods Full chart review was conducted including clinical notes, laboratory results, radiographic imaging, endoscopy reports, and surgical reports. A relevant literature review was conducted. Results A 57-year-old male with severe PD underwent endoscopic guided PEG-J tube insertion for continuous infusion of LCIG; intestinal administration was effective for symptom control. Two years later, he noted that the gastric tube had retracted approximately 15 cm into the stoma without external manipulation of the apparatus. Attempts to externally pull the tube back into position were unsuccessful. The patient underwent Gastroscopy (EGD) with fluoroscopy. Contrast was used to confirm placement of the jejunal tip within the jejunum, but also showed migration of the gastric tip into the duodenum. A gastroscope was used to reposition the gastric tube in the stomach; the jejunal tube was visualized to be under traction. The bumper on the apparatus was re-positioned and external tape was used to further secure the apparatus and prevent migration. A month later the tube had migrated again; repeat EGD showed the jejunal tube to be under traction with some resultant ulceration of the pyloric channel and duodenal bulb where the tube had been pressing against the mucosa. The jejunal tube could not be pulled back and appeared to be fixed distally. A CT scan was obtained to assess for complications and a coiled tip was seen in the proximal jejunum. Surgical extraction of the malfunctioning tube was required. At laparotomy, the coiled tip of the feeding tube was successfully removed via enterotomy. The tube tip had coiled around itself and was encased with food materials, creating a large bezoar that was being pulled distally by peristalsis. The patient subsequently underwent insertion of a new GJ tube for ongoing administration of LCIG and has been doing well since. Conclusions Bezoar formation at the jejunal tip of LCIG PEG-J tubes is a rare complication and can lead to distal migration and traction related gastroduodenal ulceration. Surgical removal may be required. Funding Agencies None

Percutaneous Gastrojejunostomy Tube Insertion in Patients with Surgical Gastrojejunal Anastomoses: Analysis of Success Rates and Durability

Patients with a gastrojejunal anastomosis pose challenging anatomy for percutaneous gastrojejunostomy (GJ)-tube placement. A retrospective review of 24 patients (mean age 67.8 years, 13 males) with GJ anastomoses who underwent attempted GJ tube placement revealed infeasible placement in 6 patients (25%) due to an inadequate window for puncture. When a gastric puncture was achieved, GJ tube insertion was technically successful in 83% (15/18) of attempts, resulting in an overall technical success rate of 63% (15/24). The most common tube-related complication was the migration of the jejunal limb into the stomach, which occurred in 40% (6/15) of successful cases. No major procedure related complications were encountered.

Percutaneous gastrojejunostomy tubes: Identification of predictors of retrograde jejunal limb migration into the stomach

PurposeTo identify whether technically modifiable factors during gastrojejunostomy (GJ) tube insertion are predictive of retrograde jejunal limb migration into the stomach. Materials and methodsRetrospective review of our procedural database over a 5-year period revealed 988 successful primary GJ tube insertions. Medical records and imaging were reviewed for cases of retrograde jejunal limb migration. Primary analysis was performed on 74 patients with retrograde tip migration within 3 months after placement (37 males, mean age = 57). Comparison was performed on 67 control patients (34 males, mean age = 51) who had radiologically confirmed GJ tube stability for at least 6 months. Procedural fluoroscopic images were analyzed for multiple GJ tube configuration parameters. The stomach was designated into antrum, body, and fundus. Predictors of retrograde tip migration were analyzed with univariate and multivariate logistic regression analysis. ResultsA total of 110 patients (11.1%) had retrograde jejunal limb migration, with 74 (7.5%) occurring within 3 months of placement. On multivariate analysis, the factors associated with a significantly lower risk of tip malposition included gastric puncture site in the antrum (OR: 0.27, 95% CI: 0.13–0.56, p < 0.001) and GJ tract angle less than 30 degrees away from the pylorus (OR: 0.35, 95% CI: 0.16–0.76, p = 0.008). No patient in either cohort had a major complication within 30 days of procedure. ConclusionTo minimize the risk of retrograde tip migration, GJ tubes should be inserted into the gastric antrum with an entry tract oriented as directly towards the pylorus as possible.

S2034 An Uncommon Cause of Chest Pain: Acute Esophageal Necrosis

INTRODUCTION: Acute esophageal necrosis (AEN) is a rare but important cause of hematemesis, melena, dysphagia, and chest pain typically seen in patients with vascular disease in which esophageal necrosis circumferentially embodies the esophagus with GEJ (gastroesophageal junction) sparing. We present the case of chest pain and hematemesis secondary to AEN. CASE DESCRIPTION/METHODS: A 70-year-old male with ESRD, DM, prior CVA on Eliquis, with altered mental status, hypotension, neck, back, and chest pain. In the ED, he was hypotensive 67/51mmHg, and had coffee ground emesis. Hemoglobin decreased from 9.9 to 7.1g/dL requiring blood transfusions, PPI drip, and ICU admission. Upper endoscopy demonstrated diffuse, severe mucosal necrosis with black necrotic tissue in the middle and lower thirds of the esophagus (Figure 1, 2), but with normal tissue and sparing of the GEJ (Figure 3). A percutaneous gastrojejunostomy tube was placed. The patient had clinical improvement, but expired after a prolonged hospital course. DISCUSSION: Acute Esophageal Necrosis is a rare endoscopic finding defined by diffuse, circumferential black mucosa that spares the GEJ. More common in older males, and associated with heart failure, atherosclerosis, diabetes, renal failure, and cancer, its etiology remains uncertain though may be from severe underlying chronic disease, progressive vascular insufficiency, reduced mucosal barriers, and gastric regurgitation. Due to less blood, this pathology starts in the distal third of the esophagus, progressing proximally. The GEJ is spared due to increased vasculature. Though a rare cause of chest pain, it is important to consider AEN due to its significant complications of perforation and stricture and high mortality rate. Currently, there are no guidelines for management, though esophageal rest, intravenous fluids, and improved nutrition via PEG-J tube or parenteral nutrition are generally sought after. Though rare, AEN should be considered in patients with severe chest pain due to its significant complications and a high mortality rate, and further studies are needed to aid in management to improve patient outcomes.Figure 1.: Diffuse, severe necrotic tissue encircling the esophagus.Figure 2.: Necrotic tissue circumferentially encompassing the esophagus.Figure 3.: Necrotic tissue of the distal esophagus with abrupt transition point with sparing of the GE junction.

S2361 Endoscopic Ultrasound-Guided Gastrojejunostomy for the Treatment of Benign Gastric Outlet Obstruction

INTRODUCTION: We present a case of a successful endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) for the treatment of benign gastric outlet obstruction (GOO). CASE DESCRIPTION/METHODS: A 37 year-old obese (BMI 80) female with history of an open cholecystectomy presented with nausea and vomiting. Imaging demonstrated a GOO with an obstructive lesion seen at the site of her prior cholecystectomy. An EUS with fine-needle aspiration demonstrated chronic inflammatory changes without evidence of malignancy, and she was discharged with a percutaneous gastrojejunostomy (PEG-J) tube. The patient required frequent PEG-J revisions complicated by the location of the PEG insertion coupled with a deformed pylorus. In order to overcome the anatomy, an ultra-slim bronchoscope was instead used to serve as a rigid steering catheter to advance the wire into the distal small bowel. Unfortunately, despite a longer J-tube, she returned shortly after with a dislodged PEG-J tube, and EUS-GJ was performed given the extensive attempts of revisions. The upper endoscope was advanced under fluoroscopic guidance, and contrast was injected defining the stricture. Water with methylene blue was infused to distend the small bowel. The upper endoscope was exchanged for a linear echoendoscope after which a 19-gauge needle was used to puncture the small bowel from stomach, and methylene blue was aspirated confirming location. An electrocautery-enhanced lumen apposing metal stent (LAMS) was deployed resulting in successful creation of a gastrojejunostomy. The lumen of the LAMS was then dilated with a balloon dilator under fluoroscopic guidance. The stent was then secured in place with the OverStitch device. The patient’s PEG-J was removed and her gastrocutaneous fistula closed using an over the scope clip. The patient tolerated a regular diet without any complications and was discharged. DISCUSSION: Our case highlights the use of bronchoscope to navigate deformed sites that would otherwise be difficult with a flexible angiocatheter. Secondly, it highlights the emergence of EUS-GJ as an innovative alternative to surgical gastrojejunostomy and enteral stenting in benign or malignant GOO. Studies suggests EUS-GJ to be superior to the conventional therapy as it is less invasive and provides lower GOO recurrence and reintervention rates. The EUS-GJ in our patient was technically successful and allowed for resumption of an oral diet, and it signifies EUS-GJ is an effective and potentially safe alternative to conventional treatments of GOO.Figure 1.: Fluoscopic images of navigating through the site of gastric outlet obstruction.Figure 2.: Needle puncture of jejunum under echosonography.Figure 3.: Post-LAMS deployment in gastric body.

Abstract No. 594 Percutaneous gastrojejunostomy tubes: identification of predictors of retrograde tip migration into the stomach

Abstract No. 594 Percutaneous gastrojejunostomy tubes: identification of predictors of retrograde tip migration into the stomach

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.

Dopamine Pumps for Parkinson Disease: Has the Time Come?

Oral treatments for Parkinson disease (PD) are limited mainly by the association with motor fluctuations and dyskinesia, leading to burgeoning interest in better, more continuous delivery strategies for advanced PD. In the trial, researchers tested the safety and efficacy of an intrajejunal levodopa–carbidopa intestinal gel infusion strategy that is investigational in the U.S. The manufacturer-sponsored, randomized, double-blind, double-dummy, double-titration trial was conducted at 26 centers in Germany, New Zealand, and the U.S. All participants underwent placement of a percutaneous gastrojejunostomy tube and were …

Continuous intrajejunal infusion of levodopa-carbidopa intestinal gel for patients with advanced Parkinson's disease: a randomised, controlled, double-blind, double-dummy study

Levodopa is the most effective therapy for Parkinson's disease, but chronic treatment is associated with the development of potentially disabling motor complications. Experimental studies suggest that motor complications are due to non-physiological, intermittent administration of the drug, and can be reduced with continuous delivery. We aimed to assess efficacy and safety of levodopa-carbidopa intestinal gel delivered continuously through an intrajejunal percutaneous tube. In our 12-week, randomised, double-blind, double-dummy, double-titration trial, we enrolled adults (aged ≥ 30 years) with advanced Parkinson's disease and motor complications at 26 centres in Germany, New Zealand, and the USA. Eligible participants had jejunal placement of a percutaneous gastrojejunostomy tube, and were then randomly allocated (1:1) to treatment with immediate-release oral levodopa-carbidopa plus placebo intestinal gel infusion or levodopa-carbidopa intestinal gel infusion plus oral placebo. Randomisation was stratified by site, with a mixed block size of 2 or 4. The primary endpoint was change from baseline to final visit in motor off-time. We assessed change in motor on-time without troublesome dyskinesia as a prespecified key secondary outcome. We assessed efficacy in a full-analysis set of participants with data for baseline and at least one post-baseline assessment, and imputed missing data with the last observation carried forward approach. We assessed safety in randomly allocated patients who underwent the percutaneous gastrojejunostomy procedure. This study is registered with ClinicalTrials.gov, numbers NCT00660387 and NCT0357994. From baseline to 12 weeks in the full-analysis set, mean off-time decreased by 4.04 h (SE 0.65) for 35 patients allocated to the levodopa-carbidopa intestinal gel group compared with a decrease of 2.14 h (0.66) for 31 patients allocated to immediate-release oral levodopa-carbidopa (difference -1.91 h [95% CI -3.05 to -0.76]; p=0.0015). Mean on-time without troublesome dyskinesia increased by 4.11 h (SE 0.75) in the intestinal gel group and 2.24 h (0.76) in the immediate-release oral group (difference 1.86 [95% CI 0.56 to 3.17]; p=0.0059). In the safety analyses 35 (95%) of 37 patients allocated to the levodopa-carbidopa intestinal gel group had adverse events (five [14%] serious), as did 34 (100%) of 34 patients allocated to the immediate-release oral levodopa-carbidopa group (seven [21%] serious), mainly associated with the percutaneous gastrojejunostomy tube. Continuous delivery of levodopa-carbidopa with an intestinal gel offers a promising option for control of advanced Parkinson's disease with motor complications. Benefits noted with intestinal gel delivery were of a greater magnitude than were those obtained with medical therapies to date, and our study is, to our knowledge, the first demonstration of the benefit of continuous levodopa delivery in a double-blind controlled study. AbbVie.

Abstract No. 108: Percutaneous insertion of primary jejunostomy tubes: comparison to percutaneous gastrojejunostomy tubes

Abstract No. 108: Percutaneous insertion of primary jejunostomy tubes: comparison to percutaneous gastrojejunostomy tubes

Pneumoperitoneum Post-Fluoroscopic Percutaneous Gastrojejunostomy Insertion: Computed Tomography and Clinical Evaluation

IntroductionTo assess the incidence and clinical significance of pneumoperitoneum after radiologic percutaneous gastrojejunostomy (PGJ) tube insertion. MethodsSixteen subjects were prospectively assessed after imaging-guided PGJ tube insertion to discern the incidence of pneumoperitoneum related to specific clinical signs and symptoms. Computed tomography of the abdomen and the pelvis was performed immediately after PGJ insertion. A clinical evaluation, including history, general and abdominal physical examination, temperature, complete blood cell count, abdominal pain, and abdominal tension, was performed on days 1 and 3, and at the discretion of the nutritional support team on day 7 after PGJ insertion. ResultsFifteen of the 16 subjects demonstrated imaging findings of pneumoperitoneum after the PGJ-tube insertion. Only a small amount of pneumoperitoneum was demonstrated in 10 of the subjects, whereas a large volume of gas was detected in 2 of the subjects. The only altered clinical findings encountered were increased white blood cell count and fever. These abnormal clinical data were most frequently seen immediately after feeding-tube placement. DiscussionPneumoperitoneum was a common finding after PGJ-tube placement in our study population. There were no statistically significant abnormal clinical parameters, in the presence or absence of pneumoperitoneum, for any of the subjects after PGJ-tube insertion. Conservative management of pneumoperitoneum after PGJ is warranted.

Pharmacokinetics of Antituberculosis Medications Delivered via Percutaneous Gastrojejunostomy Tube

We treated a 23-year-old aboriginal woman with drug-resistant pulmonary tuberculosis (TB). She experienced intolerance to her oral anti-TB medications, had subtherapeutic drug levels, and failed to respond to treatment. She then was effectively treated with percutaneous gastrojejunostomy tube (PGJT) administration of drugs. We present our data on the serum drug levels of rifampin, para-aminosalicylic acid, and levofloxacin after PGJT administration, and compare these values to published levels for oral administration of these drugs. In our patient, serum drug levels peaked and began to decline earlier than in the published data for oral administration of the same drugs.

Successful placement of percutaneous gastrojejunostomy using steerable glidewire—a modified controlled push technique

Percutaneous gastrojejunostomy (PEG-J) is now increasingly utilized to maintain long-term enteral nutrition in patients with recurrent aspiration pneumonia. 1-3 Despite significant advances in accessories and the technology and various techniques used to place percutaneous jejunostomy tubes, 3-6 precise and consistent placement (defined as placement of the jejunostomy tube beyond the ligament of Treitz) is, as yet, not always possible. Recently, Teflon-coated con: ventional guidewires have been utilized to facilitate placement, but with limited success. 5 Glidewires have been utilized in biliary tract maneuvers for some time, but they have not been exploited in the placement of PEG-J tubes. Glidewire features advantageous for PEG-J placement include resistance to formation of kinks and a hydrophilic coating that, when wet, makes the wire extremely slippery. This combination makes the glidewire easily steerable, thus facilitating negotiation of the angles of the upper intestine. The purpose of our study was to evaluate a new technique for placement of a percutaneous jejunostomy tube utilizing a glidewire. MATERIALS AND METHODS Five patients who required gastrostomy for maintenance of enteral nutrition and prevention of recurrent aspiration were studied. They included two cases of severe neurologic deficit secondary to cerebrovascular accidents, two of trauma, and one of mental retardation.