DPEJ placement in cases of PEG insertion failure

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.

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.

Advanced therapy by device-assisted enteroscopy

Standard therapy using device-assisted enteroscopy includes different hemostatic therapies, polypectomy, dilation and other possibilities. The most frequent indication is small bowel bleeding. However, other specific settings could require dedicated therapies such as desinvagination, percutaneous enteroscopic jejunostomy, stent placement, endoscopic mucosal resection in polypoid vascular lesions and foreign body extraction. The present review aimed to investigate and describe device-assisted advanced therapies in the small bowel, excluding conventional hemostatic therapies of vascular lesions.

Direct percutaneous endoscopic jejunostomy using single-balloon enteroscopy without fluoroscopy: a case series

BACKGROUND

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method to provide enteral nutrition to individuals when gastric feeding is not possible or contraindicated. The aim of this study was to analyze the efficacy and safety of DPEJ tube placement with the Gauderer-Ponsky technique by the pull method, using single-balloon enteroscopy (SBE) without fluoroscopy.

METHODS

This is a retrospective analysis of patients undergoing SBE for DPEJ placement in a referral hospital between January 2010 and March 2016. Technical success, clinical success and procedure related complications were recorded.

RESULTS

Twenty-three patients were included (17 males, median age 71 years, range 37-93 years). The most frequent indications for DPEJ were gastroesophageal cancer (n = 10) and neurological disease (n = 8). Eighty-seven percent of the patients had a contraindication to percutaneous endoscopic gastrostomy (PEG) and PEG was unsuccessful in the remaining patients. The technical success rate was 83% (19/23), transillumination was not possible in three patients and an accidental exteriorization of the bumper resulting in a jejunal perforation occurred in one patient. The clinical success was 100% (19/19). The median follow-up was five months (range 1-35 months). Apart from the case of jejunal perforation and the two cases of accidental exteriorization, there were no other complications during follow-up. The 6-month survival was 65.8% and the 1-year survival was 49.3%.

CONCLUSION

DPEJ can be carried out successfully via SBE without fluoroscopy with a low rate of significant adverse events. Although, leaving the overtube in place during the bumper pulling can be useful for distal jejunal loops, it can be safely removed in proximal loops to minimize complications.

Balloon-assisted ultrasonic localization: a novel technique for direct percutaneous endoscopic jejunostomy

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method for the establishment of enteral nutrition (EN) pathway. However, the identification of stomal puncture points for DPEJ is difficult. Here we present a case treated with an improved technique for DPEJ puncture-point localization, which was named DPEJ with balloon-assisted ultrasonic localization (DPEJ-BAUL). There were four steps after insertion of an endoscope into the jejunum: (1) a balloon dilatation catheter was inserted through the endoscope working channel; (2) the balloon was fully filled with water; (3) the site of puncture was selected with an ultrasonic probe percutaneously locating the water-filled balloon; and (4) a jejunostomy tube was placed by introducer technique. Rapid localization of a puncture site was possible with BAUL and the DPEJ procedure was successful. The patient's nutritional status was improved with EN and no postoperative complications were observed. DPEJ-BAUL is a feasible and effective technique to increase the technical success rate of DPEJ in patients with negative transillumination test results.

Direct percutaneous endoscopic jejunostomy - Should we move on to single- and double-balloon enteroscopy techniques?

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful technique to access the jejunum in order to: a) provide enteral nutrition to individuals when the gastric route is absent or contraindicated; and b) to decompress the jejunum in patients with malignant small bowel obstruction. Traditionally, DPEJ is performed using a colonoscope or enteroscope, which is advanced as deep as possible into the jejunum. The insertion technique of the feeding tube is identical to the one used for a gastrostomy tube (Ponsky-Gauderer method).

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

INTRODUCTION

Patients with prior foregut surgery requiring long-term enteral access typically undergo operative jejunostomy tube placement; however, direct percutaneous endoscopic jejunostomy (DPEJ) is a viable alternative.

METHODS

All de novo DPEJ procedures performed by surgical and advanced endoscopists from May 2003 to June 2015 were retrospectively reviewed following approval by the Institutional Review Board. There were 59 cases identified.

RESULTS

Our cohort had a mean age of 50.3 ± 16.9 years and 35 (59.3%) were female. All but two patients previously had foregut surgery including 19 patients (34.5%) with prior bariatric surgery. The composite of malnutrition and dehydration was the indication for DPEJ in 29 patients (49.1%) and was the initial enteral access placed in 47 patients (79.7%). Moderate sedation was used in 32 cases (54.2%), and 29 procedures (49.2%) were performed in the operating room. Within 30 days, there were six complications in five patients, giving a peri-procedural complication rate of 12.5%. Beyond 30 days, the most common complications were peri-tube leakage and dislodgement (each 16.9%). The median time to complication was 197 days.

CONCLUSIONS

In patients with surgically altered foregut anatomy, DPEJ offers a less invasive alternative to operative jejunostomy tube placement. DPEJ can be placed in the endoscopy suite or operating room with an acceptable risk of perioperative complications.

Endoscopist’s approach to nutrition in the patient with pancreatitis

Nutritional therapy has an important role in the management of patient with severe acute pancreatitis. This article reviews the endoscopist’s approach to manage nutrition in such cases. Enteral feeding has been clearly validated as the preferred route of feeding, and should be started early on admission. Parenteral nutrition should be reserved for patients with contraindications to enteral feeding such as small bowel obstruction. Moreover, nasogastric feeding is safe and as effective as nasojejunal feeding. If a prolonged course of enteral feeding (> 30 d) is required, endoscopic placement of feeding gastrostomy or jejunostomy tubes should be considered.

Small bowel endoscopic enteral access

PURPOSE OF REVIEW

Small bowel endoscopic enteral access is perceived as difficult. However, small bowel access is necessary for patients who are unable to tolerate gastric feedings. This review discusses the successes and challenges involved with endoscopic small bowel tube placement in various populations using a variety of placement techniques.

RECENT FINDINGS

In general, direct percutaneous endoscopic jejunostomy (DPEJ) is becoming a more common procedure performed to obtain small bowel enteral access. BMI may be a useful predictor of DPEJ tube placement success and complication rates. A retrospective review determined that DPEJ tube placement significantly decreased the incidence of aspiration pneumonia in patients with previous recurrent aspiration pneumonia episodes. DPEJ is an effective method of providing enteral nutrition for patients when percutaneous endoscopic gastrostomy is not indicated because of anatomical or gastric function abnormalities. However, there are known complications of DPEJ, including small bowel volvulus. Nasojejunal tubes also can provide enteral access to the small intestine. Endoscopic insertion of nasojejunal tubes promotes decreased length of hospital stay and early initiation of enteral feedings as compared with bedside self-migrating jejunal tubes in patients with severe acute pancreatitis. Endoscopically placed small bowel feeding tubes can safely deliver enteral nutrition to patients when gastric feedings are not indicated.

SUMMARY

Continued evaluation of endoscopic jejunal tube placement methods and associated clinical outcomes in assorted populations is necessary to determine the safest and most effective technique.