Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Tube Placement: A Single Institution Experience and Outcomes to 30 Days and Beyond

Safety and efficacy of direct percutaneous endoscopic jejunostomy tube placement compared with surgical jejunostomy: a tertiary care analysis

BACKGROUND AND AIMS

Jejunostomy tube placements provides enteral access for feeding in eligible patients who cannot meet their nutritional needs by mouth. They can be surgically placed laparoscopically (lap-J) or with the use of a conventional open laparotomy approach (open-J). Recently, direct percutaneous endoscopic jejunostomy (DPEJ) has emerged as an alternative owing to its low cost and shorter recovery times. We sought to retrospectively compare the procedural success rates and adverse events of these methods.

METHODS

Patients were identified by querying our health system patient database and the departmental database of patients who underwent DPEJ. The patients were divided into 3 cohorts based on the procedure: DPEJ, lap-J, or open-J. Patient age and body mass index, procedural success rate, and adverse event rate were compared among the 3 groups.

RESULTS

A total of 201 patients met inclusion criteria (65 DPEJ, 111 lap-J, and 25 open-J). Procedural success rates were similar among the 3 groups (DPEJ 96.9%, lap-J 99.1%, open-J 100%; P = .702). Rates of infection and bleeding were also similar among the 3 groups. There were no cases of GI perforation. Tube dysfunction for any reason that required complete removal or replacement within 90 days occurred more often in the surgical groups than in the DPEJ group (DPEJ 0%, lap-J 35.1%, open-J 40.0%; P < .001). This was driven largely by increased rates of tube clogging and tube dislodgement in the surgical groups.

CONCLUSIONS

DPEJ is a safe and effective alternative to surgical jejunostomy in eligible patients and may be associated with decreased adverse event rates at 90 days.

Safety of Percutaneous Endoscopic Jejunostomy Placement Compared With Surgical and Radiologic Jejunostomy Placement: A Nationwide Inpatient Assessment

BACKGROUND AND AIMS

We compared the safety and outcomes of percutaneous jejunostomy tubes placed endoscopically (PEJ), fluoroscopically by interventional radiology (IR-jejunostomy), and open jejunostomy placed surgically (surgical jejunostomy).

METHODS

Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a jejunostomy from 2016 to 2019. Selected patients were divided into 3 cohorts: PEJ, IR-jejunostomy, and surgical jejunostomy. Adjusted odds ratios (OR) for adverse events were calculated using multivariable logistic regression analysis.

RESULTS

A total of 6022 (65.2±9.8 y) surgical jejunostomy patients, 3715 (63.6±11.0 y) endoscopic jejunostomy patients, and 14,912 (64.8±11.6 y) IR-jejunostomy patients were identified. Compared with surgery, PEJ patients were 32% less likely to experience postprocedure complications (OR: 0.68; 95% CI: 0.58-0.79, P<0.001) while IR-jejunostomy patients were 17% less likely to experience complications (OR: 0.83; 95% CI: 0.73-0.94, P<0.001); test of proportion showed that endoscopy had significantly fewer total adverse events compared with IR (P<0.001). For individual complications, compared with surgery, the odds of intestinal perforation using PEJ and IR, respectively, were 0.26 (95% CI: 0.14-0.49, P<0.001) and 0.31 (95% CI: 0.21-0.47, P<0.001), for postprocedure infection 0.32 (95% CI: 0.20-0.50; P<0.001) and 0.61 (95% CI: 0.45-0.83; P=0.001); and for hemorrhage requiring blood transfusion 0.71 (95% CI: 0.56-0.91; P=0.005) and 0.75 (95% CI: 0.61-0.91; P=0.003).

CONCLUSIONS

Endoscopic placement of percutaneous jejunostomy tubes (PEJ) in inpatients is associated with significantly lower risks of adverse events and mortality compared with IR and surgical jejunostomy.

Direct percutaneous endoscopic jejunostomy tube placement in patients post Roux-en-Y gastric bypass, a single tertiary care center experience

Background and study aims Obesity prevalence continues to rise in the United States with Roux-en-Y gastric bypass (RYGB) surgery being one of the most common bariatric procedures. With this trend, more patients with altered upper gastrointestinal (UGI) anatomy have required endoscopic intervention including direct percutaneous endoscopic jejunostomy (DPEJ) placement. We aimed to assess the safety and success rates of DPEJ in RYGB patients. Patients and methods All patients at a tertiary care referral center who underwent DPEJ during an 8-year period were queried from a prospectively maintained registry of all enteroscopy procedures. Duplicate cases and altered upper UGI anatomy subtypes other than RYGB were excluded. The final cohort consisted of two groups: RYGB vs native anatomy (NA). Demographic, procedural, readmission, follow-up, and complication data were recorded. Comparative analysis was performed. Results Seventy-two patients were included where 28 had RYGB and 44 had NA. Both groups had similar baseline and pre-procedure data. Procedure success rate was 89 % in RYGB patients and 98 % in NA patients ( P  = 0.13). There were no intraprocedural complications. Early and late postprocedural complication rates were similar between the groups (both 4 % vs 7 %). Average follow-up times in the RYGB and NA groups were 12.97 ± 9.35 and 13.44 ± 9.21 months, respectively. Although readmission rates at 1 and 6 months were higher in the NA versus the RYGB group (21 % vs 7 % and 25 % vs 15 %), these differences were not significant. Conclusions DPEJ can be successful and safely placed in RYGB patients with no significant difference in procedure success, complication, or readmission rates when compared to control.

Percutaneous endoscopic jejunostomy: when, how, and when to avoid it

PURPOSE OF REVIEW

The current review summarizes current evidence regarding the indications, contraindications, and technical aspects of placing a direct percutaneous endoscopic jejunostomy (DPEJ), as well as procedure-related and patient-related outcomes.

RECENT FINDINGS

DPEJ is indicated for patients who require long-term (>4 weeks) jejunal nutrition due to existing altered foregut anatomy (e.g., previous gastrectomy) or because the gastric route is not an option (e.g., due to high risk of aspiration, intolerance, gastroparesis). DPEJ may also offer decompression of the gastrointestinal tract in cases of small bowel obstruction (e.g., peritoneal carcinomatosis). Absolute contraindications include active peritonitis, uncorrectable coagulopathy, and ongoing bowel ischemia. Technically, the 'pull' technique using a paediatric colonoscope will be sufficient for most cases. Recent publications demonstrate high rates of technical success (>85%), while patient outcomes do not differ among patients undergoing percutaneous endoscopic gastrostomy (PEG) and those undergoing DPEJ. Obesity is a risk factor for technical failure, while age more than 80 years, diabetes mellitus, and ongoing inflammatory status may be considered risk factors for DPEJ-associated mortality.

SUMMARY

DPEJ is a safe and efficacious modality for long-term jejunal nutrition with an acceptable risk of mild complications. Careful patient selection and respect of preprocedural, periprocedural, and postprocedural precautions are of the utmost importance to ensuring a favourable outcome.

Direct percutaneous endoscopic jejunostomy (DPEJ) and percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) technical success and outcomes: Systematic review and meta-analysis

Background and study aims  Endoscopic methods of delivering uninterrupted feeding to the jejunum include direct percutaneous endoscopic jejunostomy (DPEJ) or PEG with jejunal extension (PEG-J), validated from small individual studies. We aim to perform a meta-analysis to assess their effectiveness and safety in a variety of clinical scenarios. Methods  Major databases were searched until June 2021. Efficacy outcomes included technical and clinical success, while safety outcomes included adverse events (AEs) and malfunction rates. We assessed heterogeneity using I ² and classic fail-safe to assess bias. Results  29 studies included 1874 patients (983 males and 809 females); mean age of 60 ± 19 years. Pooled technical and clinical success rates with DPEJ were 86.6 % (CI, 82.1-90.1, I ² 73.1) and 96.9 % (CI, 95.0-98.0, I ² 12.7). The pooled incidence of malfunction, major and minor AEs with DPEJ were 11 %, 5 %, and 15 %. Pooled technical and clinical success for PEG-J were 94.4 % (CI, 85.5-97.9, I ² 33) and 98.7 % (CI, 95.5-99.6, I ²  < 0.001). The pooled incidence of malfunction, major and minor AEs with DPEJ were 24 %, 1 %, and 25 %. Device-assisted DPEJ performed better in altered gastrointestinal anatomy. First and second attempts were 87.6 % and 90.2 %. Conclusions  DPEJ and PEG-J are safe and effective procedures placed with high fidelity with comparable outcomes. DPEJ was associated with fewer tube malfunction and failure rates; however, it is technically more complex and not standardized, while PEG-J had higher placement rates. The use of balloon enteroscopy was found to enhance DPEJ performance.

Prognostic outcomes after direct percutaneous endoscopic jejunostomy in elderly patients: comparison with percutaneous endoscopic gastrostomy

BACKGROUND AND AIMS

Direct percutaneous endoscopic jejunostomy (DPEJ) is an alternative method of enteral feeding to percutaneous endoscopic gastrostomy (PEG). Although long-term outcomes of PEG have been reported, little is known regarding the outcomes of DPEJ.

METHODS

A retrospective cohort study was conducted including 115 and 651 consecutive attempts of DPEJ and PEG, respectively, in a total of 766 elderly patients between April 2004 and March 2019. Patients' clinical background, procedural and long-term outcomes, survival analysis, and cause of death were analyzed.

RESULTS

Successful placement rates were 93.9% and 97.1% for DPEJ and PEG, respectively. There was no significant difference in procedure-related adverse events (AEs) between the DPEJ and PEG groups. Rates of pneumonia, vomiting, and upper GI bleeding were significantly lower, whereas those of fistula enlargement and ileus were significantly higher in the DPEJ group as long-term AEs. The median survival periods were 694 and 734 days for DPEJ and PEG, respectively, with no significant differences between the 2 groups. Multivariate analysis revealed that age 80 years old or older, C-reactive protein level of 1.0 mg/dL or higher, and the presence of diabetes were independent risk factors for mortality after DPEJ. Respiratory tract infection was the primary cause of death in both groups.

CONCLUSIONS

DPEJ is considered a safe and feasible method of access for enteral feeding as well as PEG. Although the survival period after DPEJ may be expected to be as long as that with PEG, DPEJ-specific AEs should be kept in mind on long-term feeding.

Endoscopic Enteral Access

Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed.

Jejunostomy with Enteroenterostomy for Enteral Nutrition in Critically Ill Trauma Patients. A Novel Technique

Purpose The aim of the current study was to report the surgical outcome and complications of jejunostomy with enteroenterostomy for enteral nutrition (EN) in critically ill trauma patients with prolonged nasogastric (NG) nutrition. Methods This cross-sectional study was carried out in a level I trauma center in Shiraz, southern Iran during a one-year period from 2016 to 2017. We included a total number of 30 patients with severe trauma admitted to the intensive care unit (ICU) with more than three months NG nutrition and bowel atrophy. We performed a novel jejunostomy with an enteroenterostomy procedure for providing a route for enteral nutrition in all 30 patients. The rate of complications, such as dislodgement, clogging, obstruction, leakage, mucosal bleeding, and infection, were recorded and reported. We also recorded the hospital and ICU length of stay (LOS). Results We included a total number of 30 patients with a mean age of 35.64 ± 8.91 years, and there were 23 (76.6%) men and seven (23.4%) women among the patients. Overall, 14 (46.6%) patients experienced complications related to the jejunostomy with enteroenterostomy. The most common complication was nausea and vomiting (33.3%) and distention (33.3%), followed by surgical site infection (30.0%). The mean ICU LOS and hospital LOS was found to be 16.8 ± 3.7 and 24.3 ± 4.1 days, respectively. The overall mortality rate was 17 (56.6%), which was secondary to the primary injury and was not related to the procedure. Conclusion Jejunostomy with enteroenterostomy is a safe and feasible method for providing a route for EN in critically ill trauma patients with prolonged NG nutrition and bowel atrophy.

Transnasal Snare Technique for Retrograde Primary Jejunostomy Placement After Surgical Gastrojejunostomy

PURPOSE

To report a transnasal snare technique for retrograde primary jejunostomy placement after surgical gastrojejunostomy.

MATERIALS AND METHODS

Two patients underwent the transnasal snare technique for retrograde primary jejunostomy placement. Patients included two females, age 58 and 62. In both patients, a gooseneck snare was inserted in a transnasal fashion. After insertion of the snare into the jejunum, the location was confirmed with ultrasound. The snare was then targeted using a Chiba needle through which a 0.018-inch wire was advanced and snared through the nose. The wire was exchanged for a 0.035-inch Amplatz wire over which the tract was serially dilated followed by insertion of the jejunostomy catheter through a peel-away sheath. Technical success, complications, and follow-up were recorded.

RESULTS

Primary jejunostomy placement was technically successful in both patients. No minor or major complications occurred. Both patients received enteral nutrition the day following placement. Follow-up was at 54 and 38 days for patients 1 and 2, respectively.

CONCLUSION

The transnasal snare technique provides a novel alternative for primary jejunostomy insertion allowing for targeting of the jejunum with improved procedural success and no complications.