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Deliwala SS, Chandan S, Kumar A, Mohan B, Ponnapalli A, Hussain MS, Kaushal S, Novak J, Chawla S. Direct percutaneous endoscopic jejunostomy (DPEJ) and percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) technical success and outcomes: Systematic review and meta-analysis. Endosc Int Open 2022; 10:E488-E520. [PMID: 35433212 PMCID: PMC9010104 DOI: 10.1055/a-1774-4736] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Smit S. Deliwala
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, United States
| | - Saurabh Chandan
- Gastroenterology and Hepatology, CHI Health Creighton University Medical Center, Omaha, Nebraska, United States
| | - Anand Kumar
- Gastroenterology & Hepatology, Lenox Hill Hospital, New York, New York, United States
| | - Babu Mohan
- Gastroenterology & Hepatology, University of Utah, Salt Lake City, Utah, United States
| | - Anoosha Ponnapalli
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, United States
| | - Murtaza S. Hussain
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, United States
| | - Sunil Kaushal
- Gastroenterology, Mclaren Health Corporation, Flint, Michigan, United States
| | - Joshua Novak
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Saurabh Chawla
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
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Paydar S, Moein-Vaziri N, Dehghankhalili M, Abdolrahimzaeh H, Bolandparvaz S, Abbasi HR. Jejunostomy with Enteroenterostomy for Enteral Nutrition in Critically Ill Trauma Patients. A Novel Technique. Cureus 2018; 10:e3431. [PMID: 30546978 PMCID: PMC6289558 DOI: 10.7759/cureus.3431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Shahram Paydar
- General Surgery, Shiraz University of Medical Sciences, Shiraz, IRN
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3
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Ripamonti C, Gemlo BT, Bozzetti F, De Conno F. Role of Enteral Nutrition in Advanced Cancer Patients: Indications and Contraindications of the Different Techniques Employed. TUMORI JOURNAL 2018; 82:302-8. [PMID: 8890960 DOI: 10.1177/030089169608200402] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the last 20 years there has been great progress regarding total parenteral nutrition and enteral nutrition for patients who cannot take food by mouth or cannot swallow, or so that controlled feeding can be established in anorexic and malnourished patients. The use and the role of artificial nutrition is still controversial in advanced cancer patients. Such controversies often are due to the fact that these patients have a survival expectancy that varies from one to several months. The present review describes the most frequent techniques used for enteral nutrition (nasoenteral tubes, gastrostomy and jejunostomy), their indications, contraindications and complications, and gives an indication regarding which patients may really benefit from enteral nutrition taking into consideration not only the potential advantages but also the discomfort and distress related to enteral nutrition and the different techniques that are employed.
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Affiliation(s)
- C Ripamonti
- Pain Therapy and Palliative Care Division, National Cancer Institute, Milan, Italy
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Comparison of laparoscopic jejunostomy tube to percutaneous endoscopic gastrostomy tube with jejunal extension: long-term durability and nutritional outcomes. Surg Endosc 2017; 32:2496-2504. [DOI: 10.1007/s00464-017-5954-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 10/21/2017] [Indexed: 01/03/2023]
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5
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Strong AT, Sharma G, Davis M, Mulcahy M, Punchai S, O'Rourke CP, Brethauer SA, Rodriguez J, Ponsky JL, Kroh MD. Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Tube Placement: A Single Institution Experience and Outcomes to 30 Days and Beyond. J Gastrointest Surg 2017; 21:446-452. [PMID: 27995433 DOI: 10.1007/s11605-016-3337-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/23/2016] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Andrew T Strong
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA.
| | - Gautam Sharma
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Davis
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Michael Mulcahy
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
- US Army Tripler Army Medical Center, Honolulu, HI, USA
| | - Suriya Punchai
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Colin P O'Rourke
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
- Statistical Center for HIV/AIDS Research and Prevention, Seattle, WA, USA
| | - Stacy A Brethauer
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - John Rodriguez
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey L Ponsky
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew D Kroh
- Digestive Disease and Surgery Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
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El-Matary W. Review: Percutaneous Endoscopic Gastrojejunostomy Tube Feeding in Children. Nutr Clin Pract 2017; 26:78-83. [DOI: 10.1177/0884533610392236] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Wael El-Matary
- Division of Pediatric Gastroenterology, Hepatology and
Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom,
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Heyland DK, Konopad E, Alberda C, Keefe L, Cooper C, Cantwell B. How Well Do Critically Ill Patients Tolerate Early, Intragastric Enteral Feeding? Results of a Prospective, Multicenter Trial. Nutr Clin Pract 2016. [DOI: 10.1177/088453369901400105] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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9
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Ye P, Zeng L, Sun F, An Z, Li Z, Hu J. A new modified technique of laparoscopic needle catheter jejunostomy: a 2-year follow-up study. Ther Clin Risk Manag 2016; 12:103-8. [PMID: 26869794 PMCID: PMC4734724 DOI: 10.2147/tcrm.s87071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The aim of this study was to establish a modified technique for performing laparoscopic needle catheter jejunostomy. Methods From May 2011 to October 2013, laparoscopic needle catheter jejunostomy was performed in 21 patients with esophageal cancer. During the procedure, jejunal inflation was performed via a percutaneous 20-gauge intravenous catheter to facilitate the subsequent puncture of the jejunal wall by the catheter needle. The success rate, procedure time, complications, and short-term outcomes were evaluated. Results All laparoscopic needle catheter jejunostomies were technically successful, with no perioperative mortality or conversion to a laparotomy. The operation required a mean time of 51.4±14.2 (range 27–80) minutes, and operative bleeding range was 5–20 mL. There was one reoperation required for one patient on postoperative day 5, because the feeding tube was accidentally pulled out during sleep, by patient himself, and the second laparoscopic jejunostomy for this patient was performed successfully. One patient had puncture site pain and was successfully treated with oral analgesics. Other complications, such as gastrointestinal bleeding, intestinal perforation, intestinal obstruction, tube dysfunction, pericatheter leakage, and infection at the skin insertion site, were not observed. The 30-day mortality rate was 4.8% (one out of 21), which was not attributed to the procedure. Enteral nutrition was gradually administered 24–48 hours after operation. Conclusion The novel modified technique of laparoscopic needle catheter jejunostomy is a technically feasible, with a high technical success rate and low complication rate. Its specific advantage is simplicity and safety, and this modified approach can be considered for routine clinical use after long-term outcome evaluation.
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Affiliation(s)
- Peng Ye
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Liping Zeng
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Fenghao Sun
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Zhou An
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Zhoubin Li
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Jian Hu
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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Capriati T, Cardile S, Chiusolo F, Torroni F, Schingo P, Elia D, Diamanti A. Clinical management of post-pyloric enteral feeding in children. Expert Rev Gastroenterol Hepatol 2015; 9:929-41. [PMID: 25926033 DOI: 10.1586/17474124.2015.1041506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Post-pyloric feeding (PF) allows the administration of enteral nutrition beyond the pylorus, either into the duodenum or, ideally, into the jejunum. The main indications of PF are: upper gastrointestinal tract obstructions, pancreatic rest (e.g., acute pancreatitis), gastric dysmotility (e.g., critically ill patients and chronic intestinal pseudo-obstruction) or severe gastroesophageal reflux with risk of aspiration (e.g., neurological disability). Physiological and clinical evidence derives from adults, but can also be pertinent to children. This review will discuss the practical management and potential clinical applications of PF in pediatric patients. Some key studies pertaining to the physiological changes during PF will also be considered because they support the strategy of PF management.
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Affiliation(s)
- Teresa Capriati
- Hepatology, Gastroenterology and Nutrition Unit, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165 Rome, Italy
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11
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Gong L, Yan B, Chen Y, Wang M, Zhang Q, Hui C, Wang C. Alternative method for jejunostomy in Ivor-Lewis esophagectomy. Thorac Cancer 2015; 6:296-302. [PMID: 26273375 PMCID: PMC4448396 DOI: 10.1111/1759-7714.12182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 09/15/2014] [Indexed: 12/18/2022] Open
Abstract
Background To supplement nutrition, jejunostomy has been widely adopted as an adjunct surgical procedure for Ivor-Lewis esophagectomy. Most Chinese surgeons have a preference for parenteral nutrition even though it has some disadvantages compared with jejunostomy. In this report, we describe a new approach that allows the quick insertion of a feeding tube in Ivor-Lewis esophagectomy. We retrospectively analyze cases that have applied this approach and compare the advantages and disadvantages of jejunostomy. Methods Between January 2010 and December 2012, 131 patients underwent Ivor-Lewis esophagectomy in our hospital. These patients were divided into three groups: the total parenteral nutrition (PN) group, the jejunostomy (JT) group and the feeding tube (FT) group. The effect and safety of the procedure were compared. Results It took approximately 20 minutes longer to perform jejunostomy compared to placing a feeding tube (P < 0.05). The nutrition cost of the JT group was higher than the FT group (P < 0.05). There was no significant difference between the FT and JT groups (P > 0.05) in the ratio of body weight loss seven days post-surgery. The anal exsufflation time of the FT group was similar to the JT group (P > 0.05). The incidence of intestinal adhesion and obstruction in the JT group was 26.3%, which is much higher than in the FT and PN groups (P < 0.05). Conclusion Placing the feeding tube after Ivor-Lewis esophagectomy can decrease operative damage and bring sufficient nutrition. We believe it can be an alternative to jejunostomy in Ivor-Lewis esophagectomy.
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Affiliation(s)
- Liqun Gong
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer Tianjin, China ; Key Laboratory of Cancer Prevention and Therapy Tianjin, China
| | - Bo Yan
- Department of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer Tianjin, China
| | - Yulong Chen
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer Tianjin, China ; Key Laboratory of Cancer Prevention and Therapy Tianjin, China
| | - Meng Wang
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer Tianjin, China ; Key Laboratory of Cancer Prevention and Therapy Tianjin, China
| | - Qiang Zhang
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer Tianjin, China ; Key Laboratory of Cancer Prevention and Therapy Tianjin, China
| | - Chen Hui
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer Tianjin, China ; Key Laboratory of Cancer Prevention and Therapy Tianjin, China
| | - Changli Wang
- Department of Lung Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer Tianjin, China ; Key Laboratory of Cancer Prevention and Therapy Tianjin, China
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Ao P, Sebastianski M, Selvarajah V, Gramlich L. Comparison of Complication Rates, Types, and Average Tube Patency Between Jejunostomy Tubes and Percutaneous Gastrostomy Tubes in a Regional Home Enteral Nutrition Support Program. Nutr Clin Pract 2014; 30:393-7. [DOI: 10.1177/0884533614554263] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Peter Ao
- Department of Medicine, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Meghan Sebastianski
- Epidemiology Coordinating and Research (EPICORE) Centre, University of Alberta, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Vijeyakumar Selvarajah
- Division of Gastroenterology, Grey Nuns Hospital, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Leah Gramlich
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
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13
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Outcomes after through-the-PEG tube placement of jejunal extensions: a case series from a single center. Gastrointest Endosc 2014; 80:349-53. [PMID: 24785126 DOI: 10.1016/j.gie.2014.02.1035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 02/27/2014] [Indexed: 12/11/2022]
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Lewis S, Jackson S, Latchford A. Randomized Study of Radiologic vs Endoscopic Placement of Gastrojejunostomies in Patients at Risk of Aspiration Pneumonia. Nutr Clin Pract 2014; 29:498-503. [PMID: 24759762 DOI: 10.1177/0884533614529999] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Objective: In patients at risk of aspiration pneumonia due to gastroesophageal reflux who require gastrojejunostomy feeding tubes, the tubes are placed either radiologically (RIGJ) or endoscopically (PEGJ). There is little published evidence of the superiority of one technique over the other. Methods: Patients referred for long-term jejunal feeding were randomly allocated to have a 14F RIGJ or 15F with 9F jejunal extension PEGJ inserted. A technetium-99m (99mTc) colloid study was done to determine the presence of gastroesophageal reflux and jejunogastric reflux after feeding tube placement. We recorded enteral feed and tube-related complications, in addition to tube-related morbidity and mortality to 90 days following placement. Results: Baseline characteristics were similar between groups, with gastroesophageal reflux demonstrated in 52%. Following enteral tube placement, gastroesophageal reflux was not observed by 99mTc studies or any difference in clinical outcome to 90 days after placement. No jejunal tubes were displaced in any of the 31 RIGJ tubes, while 9 tubes were displaced in the 34 PEGJ patients (P = .008). Reversible jejunal tube blockages occurred: 19 RIGJ (5 patients) and 61 PEGJ (11 patients) (P = .003, χ2 = 9.1). Conclusion: There was little difference between the 2 tubes for clinical outcomes. RIGJ tubes were less prone than PEGJ tubes to reversible blockage and displacement. It is likely that the better outcome for RIGJ tubes relates to their larger tube diameter and stiffness.
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Affiliation(s)
- Stephen Lewis
- Department of Gastroenterology, Derriford Hospital, Plymouth, UK
| | - Simon Jackson
- Department of Radiology, Derriford Hospital, Plymouth UK
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Kimber TE, Schoeman M. Direct endoscopic jejunosotomy for the administration of levodopa-carbidopa intestinal gel in Parkinson's disease. Parkinsonism Relat Disord 2014; 20:786-8. [PMID: 24721490 DOI: 10.1016/j.parkreldis.2014.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/12/2014] [Accepted: 03/16/2014] [Indexed: 01/24/2023]
Affiliation(s)
- Thomas E Kimber
- Neurology Unit, Royal Adelaide Hospital and Department of Medicine, Adelaide University, North Terrace, Adelaide, SA 5000, Australia.
| | - Mark Schoeman
- Gastrointestinal Endoscopic Services, Royal Adelaide Hospital and Department of Medicine, Adelaide University, North Terrace, Adelaide, SA 5000, Australia.
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Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, Fisher DA, Fisher L, Fukami N, Hwang JH, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Dominitz JA, Cash BD. Adverse events of upper GI endoscopy. Gastrointest Endosc 2012; 76:707-18. [PMID: 22985638 DOI: 10.1016/j.gie.2012.03.252] [Citation(s) in RCA: 214] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 12/13/2022]
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17
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Mistry RC, Mehta SS, Karimundackal G, Pramesh CS. Novel cost-effective method of laparoscopic feeding-jejunostomy. J Minim Access Surg 2011; 5:43-6. [PMID: 19727379 PMCID: PMC2734900 DOI: 10.4103/0972-9941.55108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Accepted: 07/13/2009] [Indexed: 01/24/2023] Open
Abstract
A feeding jejunostomy tube placement is required for entral feeding in a variety of clinical scenarios. It offers an advantage over gastrostomies by eliminating the risk of aspiration. Standard described laparoscopic methods require special instrumentation and expensive custom-made tubes. We describe a simple cost-effective method of feeding jejunostomy using regular laparoscopic instruments and an inexpensive readily available tube. The average operating time was 35 min. We had no intra-operative complications and only one post-operative complication in the form of extra-peritoneal leakage of feeds due to a damaged tube. No complications were encountered while pulling out the tubes after an average period of 5–6 weeks.
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Affiliation(s)
- Rajesh C Mistry
- Department of Thoracic Surgery, Tata Memorial Hospital, Mumbai, India
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18
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Despott EJ, Gabe S, Tripoli E, Konieczko K, Fraser C. Enteral access by double-balloon enteroscopy: an alternative method of direct percutaneous endoscopic jejunostomy placement. Dig Dis Sci 2011; 56:494-8. [PMID: 20585980 DOI: 10.1007/s10620-010-1306-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 06/14/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND 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. AIMS AND METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- E J Despott
- St. Mark's Hospital and Academic Institute, Imperial College, London, UK
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Mohiuddin SS, Anderson CE. A novel application for single-incision laparoscopic surgery (SILS): SIL jejunostomy feeding tube placement. Surg Endosc 2010; 25:323-7. [DOI: 10.1007/s00464-010-1168-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 05/23/2010] [Indexed: 10/19/2022]
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Percutaneous laparoscopic assisted gastrostomy (PLAG)—a new technique for cases of pharyngoesophageal obstruction. Langenbecks Arch Surg 2010; 395:1107-13. [DOI: 10.1007/s00423-010-0612-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 02/08/2010] [Indexed: 12/13/2022]
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21
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Economou G, Lee SH. Radiologically-guided percutaneous gastrostomy: Three-year follow up and literature review. MINIM INVASIV THER 2009. [DOI: 10.3109/13645709609153059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Endoscopic identification of the jejunum facilitates minimally invasive jejunostomy tube insertion in selected cases. Surg Endosc 2009; 23:2587-90. [PMID: 19357919 DOI: 10.1007/s00464-009-0469-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Revised: 01/23/2009] [Accepted: 02/11/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG), direct percutaneous endoscopic jejunostomy, and laparoscopic feeding tube insertion are established techniques for placing a feeding tube. However, these techniques may be difficult or contraindicated after previous gastric or upper abdominal surgery. METHODS A total of 10 patients underwent minimally invasive jejunostomy tube insertion via endoscopic identification of the jejunum. The indications for the procedure were dysphagia, poor nutritional status, prolonged intensive care unit (ICU) admission, and gastroparesis. Eight of the patients had undergone previous upper abdominal surgeries and were rejected for either PEG or direct percutaneous jejunostomy. With the patients under general anesthesia, esophagogastroduodenoscopy was performed. The jejunum was identified and intubated. A small abdominal incision (1 in.) was made. The proximal jejunum was identified easily by the light and digital palpation of the endoscope. The jejunum was delivered in the wound, and the jejunostomy tube was inserted using Witzel's technique. The wound was closed. RESULTS All the patients tolerated the procedure well. The mean time for the procedure was 29 +/- 13 min. There was no mortality related to the procedure and no complications. Jejunal feeding started on the first postoperative day. CONCLUSION The use of intraoperative endoscopy facilitated identification of the jejunum. Easy, safe, and quick, the procedure saved the patient a formal laparotomy and extensive manipulation.
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Abstract
Postpyloric feeding is an important and promising alternative to parenteral nutrition. The indications for this kind of feeding are increasing and include a variety of clinical conditions, such as gastroparesis, acute pancreatitis, gastric outlet stenosis, hyperemesis (including gravida), recurrent aspiration, tracheoesophageal fistula and stenosis in gastroenterostomy. This review discusses the differences between pre- and postpyloric feeding, indications and contraindications, advantages and disadvantages, and provides an overview of the techniques of placement of various postpyloric devices.
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Panagiotakis PH, DiSario JA, Hilden K, Ogara M, Fang JC. DPEJ tube placement prevents aspiration pneumonia in high-risk patients. Nutr Clin Pract 2008; 23:172-5. [PMID: 18390785 DOI: 10.1177/0884533608314537] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Percutaneous endoscopic gastrostomy (PEG) or PEG tube with transgastric jejunostomy tube (PEG-J) feeding has not been shown to decrease aspiration pneumonia. The aim of this study was to determine if direct percutaneous endoscopic jejunostomy (DPEJ) tube placement results in a decreased incidence of aspiration pneumonia in high-risk patients. The design was a retrospective review of all patients receiving DPEJ tube for aspiration pneumonia from 1999 to 2005. Demographics, incidence of aspiration pneumonia, and outcomes were collected and compared before and after the DPEJ placement. Eleven patients (4 women, 7 men) were identified; their mean age was 44.9 years (range, 18-94 years). The etiologies for recurrent aspiration pneumonia were neurologic disease (9), esophageal surgery (1), and severe debilitation (1). The mean follow-up was 20.9 months (range, 6-48 months). The patients' mean weight increased from 43.8 kg (range, 19-55 kg) to 48.3 kg (range, 30-65 kg) after placement (P < .001). The total number of documented aspiration pneumonia episodes for all patients decreased from 29 (mean, 3.64; range, 1-6) before DPEJ placement to 3 (mean, 0.27; range, 0-2) after DPEJ placement (P < .001). The mean number of aspiration pneumonia events per month prior to the DPEJ placement was 3.39 and postplacement was 0.42 (P < .001). DPEJ placement appears to decrease recurrent aspiration pneumonia in patients with history of aspiration pneumonia.
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Affiliation(s)
- Panagiotis H Panagiotakis
- Division of Gastroenterology and Hepatology, University of Utah, 4R118 School of Medicine, Salt Lake City, UT 84132, USA
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25
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Abstract
Numerous procedures have been developed to provide adequate enteral nutrition to patients with gastrointestinal disorders. Previously, operative placement of a feeding gastrostomy or jejunostomy tube was the accepted means of gaining chronic enteral access. However, improved technology and experience with endoscopic techniques have quickly replaced primary operative placement of enteral access. Direct percutaneous endoscopic jejunostomy (D-PEJ) is a procedure that was designed to deliver enteral feeding solutions for patients with proximal disease after unsatisfactory results from percutaneous endoscopic gastrostomy tubes with jejunal extensions (PEG-J). As with any procedure, it is associated with complications. We present the first reported case of a colojejunal fistula resulting from a D-PEJ placement. While D-PEJ has been shown to be relatively safe, complications related to the inherent limitations of the procedure need to be considered when the patient experiences unusual post-procedure symptoms and worked up appropriately.
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Affiliation(s)
- Martin D Zielinski
- Department of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, Minn., USA
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26
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Ishii M, Yakabe M, Teramoto S, Oike Y, Ogawa S, Iijima K, Eto M, Yamamoto H, Hanaoka Y, Yamaguchi Y, Akishita M, Ouchi Y. [A 94-year-old woman with nontuberculous mycobacterium who developed small intestinal intussusception associated with a percutaneous endoscopic jejunostomy tube]. Nihon Ronen Igakkai Zasshi 2007; 44:648-52. [PMID: 18049013 DOI: 10.3143/geriatrics.44.648] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We report a 94-year-old woman, who underwent percutaneous endoscopic Jejunostomy (PEJ) tube feeding for enteral nutrition, developed the intussusception of the small intestine. She suffered from nontuberculous mycobacterium (NTM), and her lung inflammation deteriorated due to aspiration pneumonia and malnutrition. Because of old age, dysphagia, esophageal hiatus hernia, gastro-esophageal reflux and her bedridden condition due to severe osteoporosis, oral nutritional supplementation is nearly impossible. To reduce the aspiration risk, we chose PEJ instead of percutaneous endoscopic gastrostomy (PEG) as the route of tube feeding. Six months after the placement of a PEJ tube, aspiration pneumonia was diagnosed and she was readmitted to our hospital. During hospitalization, she had sudden diarrhea, vomiting, and lower abdominal pain. Abdominal CT scan and radiographs using contrast medium showed small intestinal intussusception related to the PEJ tube. We observed the clinical course without performing surgery, pulling it back towards the stomach and placing an ileus tube, because the small intestine was not completely obstructed. Two months later, although she suffered from aspiration pneumonia once more, she remained in a stable condition without further intervention so that she could move to aother hospital. Recently PEJ has been expected to prevent aspiration pneumonia, but we believe that it can be a risk factor for intussusception. Although the PEJ can be a good parenteral nutrition route for frail elderly with dysphagia, we need to consider possible complications including intussusception.
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Affiliation(s)
- Masaki Ishii
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo
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27
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Jenkinson AD, Lim J, Agrawal N, Menzies D. Laparoscopic feeding jejunostomy in esophagogastric cancer. Surg Endosc 2006; 21:299-302. [PMID: 17122985 DOI: 10.1007/s00464-005-0727-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Accepted: 05/24/2006] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patients with esophagogastric malignancies often require nutritional supplementation in the perioperative period, especially in the setting where neoadjuvant therapy may delay tumor resection. A simple technique is described here that can be performed at the time of staging laparoscopy and that has not been described before. RESULTS Forty-three patients treated over a 4-year period who had a laparoscopic feeding jejunostomy placed at the time of staging laparoscopy were reviewed. Of these, 35 had preoperative chemotherapy according to a modified MRC OEO2 protocol. In the period between staging and eventual resection, 32% required immediate feeding, and in 14% of those who were thought not to need feeding it later became necessary. More patients gained weight or had a rise in albumin in the group that had jejunal feeding (p < 0.05). The mean time to surgery was 10 weeks. There were no conversions to an open procedure, nor were there any laparotomies for tube-related complications. Dislodgement was recorded in 6 patients; blockage, in 4. In most of these cases a simple bedside replacement of the tube was all that was required. Mean time in the operating room for each procedure was 44 minutes. CONCLUSIONS Laparoscopic percutaneous feeding jejunostomy is a safe and simple technique that adds little to the morbidity and cost of managing patients with esophagogastric cancers. It facilitates optimization of nutrition in the perioperative period for these patients, especially in those receiving preoperative chemotherapy.
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Affiliation(s)
- A D Jenkinson
- Department of Surgery, Colchester General Hospital, Turner Road, Colchester, Essex, CO4 5JL, United Kingdom.
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Abstract
Enteral nutrition is the delivery of nutrients through the gastrointestinal tract. For those patients who cannot or will not swallow, an enteral access device (EAD) is required. Some of these devices can be passed through the oral or nasal cavity into the stomach or small bowel. Alternatively, the devices can be percutaneously placed by an endoscopist or a radiologist into the stomach or small bowel. Knowledge of the appropriate use of these devices, the appropriate maintenance management of these devices, and the appropriate treatment of EAD-related complications is essential for the clinician to understand in order to provide effective nutrition therapy.
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Affiliation(s)
- Mark H DeLegge
- Coram Healthcare, Section of Nutrition, Digestive Disease Center, Medical University of South Carolina, South Carolina, USA.
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McClave SA, Ritchie CS. The role of endoscopically placed feeding or decompression tubes. Gastroenterol Clin North Am 2006; 35:83-100. [PMID: 16530112 DOI: 10.1016/j.gtc.2005.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The minimally invasive nature of endoscopically placed gastrostomy tubes makes them a viable consideration in palliative care. Complications related to the procedure appear to correlate with age and underlying comorbidities.However, in many instances, the scientific basis for establishing benefit or harm from tube placement is methodologically inadequate. Decisions must be preceded by a discussion of the value and potential risk of artificial nutrition in a particular setting, respecting the wishes and beliefs of each patient and his or her family. The decision to use PEG placement for any reason should be consistent with legal and ethical principles, reflect patient autonomy over any other consideration (including beneficence), and arise from a clear determination of the goals of care (and whether the PEG placement will truly help meet those goals). Whenever possible, further studies with better design are needed to evaluate whether the use of PEG truly affects quality of life and patient outcome in palliative care. PEG tubes for decompression are placed successfully most of the time. Symptom relief occurs usually within 7 days of the procedure. Overall, the morbidity related to the PEG procedure for decompression is only slightly higher than when the same technique is used for nutritional purposes. The appropriate timing for PEG tube placement for nutritional support and for decompression throughout the course of disease progression may be difficult to determine and yet may be a factor in its overall efficiency. Only minor modifications of the basic technique used for PEG placement for nutritional purposes are required to adapt the technique to a variety of other applications in palliative care.
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Affiliation(s)
- Stephen A McClave
- Division of Gastroenterology/Hepatology, University of Louisville School of Medicine, 550 South Jackson Street, KY 40202, USA.
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30
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Abstract
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.
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Affiliation(s)
- James A DiSario
- University of Utah Health Sciences Center, 30 North 1900 East, 4R 118, Salt Lake City, UT 84132, USA.
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DeLegge MH, McClave SA, DiSario JA, Baskin WN, Brown RD, Fang JC, Ginsberg GG. Ethical and medicolegal aspects of PEG-tube placement and provision of artificial nutritional therapy. Gastrointest Endosc 2005; 62:952-9. [PMID: 16301043 DOI: 10.1016/j.gie.2005.08.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2005] [Accepted: 08/27/2005] [Indexed: 01/15/2023]
Affiliation(s)
- Mark H DeLegge
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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32
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McMahon MM, Hurley DL, Kamath PS, Mueller PS. Medical and ethical aspects of long-term enteral tube feeding. Mayo Clin Proc 2005; 80:1461-76. [PMID: 16295026 DOI: 10.4065/80.11.1461] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Clinicians frequently care for patients in whom long-term enteral tube feeding is being considered. The substantial increase in the use of endoscopically placed tubes for long-term feeding reflects the aging population, advances in medicine and technology, and inadequate advance care planning. Physicians should address advance care planning with all patients at the earliest opportunity. Prospective randomized trials measuring clinical outcomes for patients receiving long-term tube feeding are understandably limited. In addition, confusion regarding medical and ethical guidelines for long-term tube feeding often exists among clinicians, patients, and surrogate decision makers. Therefore, we discuss the physiology and clinical tolerance of limited oral nutritional intake, the prevalence of and Indications for long-term tube feeding, the endoscopic procedures and their complications, the reported medical and quality-of-life outcomes, and the critical importance of advance care planning. We present our multidisciplinary approach that combines medical, nutritional, and ethical principles for the care of these patients.
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Affiliation(s)
- M Molly McMahon
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA.
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Erdil A, Saka M, Ates Y, Tuzun A, Bagci S, Uygun A, Yesilova Z, Gulsen M, Karaeren N, Dagalp K. Enteral nutrition via percutaneous endoscopic gastrostomy and nutritional status of patients: five-year prospective study. J Gastroenterol Hepatol 2005; 20:1002-7. [PMID: 15955206 DOI: 10.1111/j.1440-1746.2005.03892.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Since it was described in 1980, percutaneous endoscopic gastrostomy (PEG) has been a widely used method for insertion of a gastrostomy tube in patients who are unable to swallow or maintain adequate nutrition. The aim of the present paper was to determine the complications of PEG insertion and to study pre- and post-procedural nutritional status. METHODS During the period of March 1999-September 2004, placement of PEG tube was performed in 85 patients (22 women and 63 men). Patient nutritional status was assessed before and after PEG insertion via anthropometric measurements. RESULTS The most frequent indication for PEG insertion was neurological disorders (65.9%). Thirty patients died due to primary disease and two patients due to PEG-related complications within 5 years. There were 14 early complications in 10 patients (15.2%; <30 days), and 18 late complications in 12 patients (19.6%). Total mortality was 37.6%. All complications other than four were minor. Before PEG insertion, patients were assessed with subjective global assessment and it was determined that 43.2% of them had severe, and 41.9% of them had mild malnutrition. After PEG insertion, significant improvements on patient nutrition levels was observed. CONCLUSION Percutaneous endoscopic gastrostomy is a minimally invasive gastrostomy method with low morbidity and mortality rates, is easy to follow up and easy to replace when clogged.
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Affiliation(s)
- Ahmet Erdil
- Department of Gastroenterology, Gulhane Military Medical Academy, Ankara, Turkey.
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Carnes ML, Sabol DA, DeLegge M. Does the presence of esophagitis prior to PEG placement increase the risk for aspiration pneumonia? Dig Dis Sci 2004; 49:1798-802. [PMID: 15628706 DOI: 10.1007/s10620-004-9573-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
The aim of this study is to determine if the endoscopic presence of esophagitis predicts aspiration pneumonia after the initiation of enteral feedings in a newly placed PEG tube. A retrospective analysis of 278 patients who received a PEG tube from November 1999 to June 2002 was performed. All PEG procedures performed by a single endoscopist were reviewed from the GI Trac database at the Medical University of South Carolina. Eleven of the procedures were aborted due to technical difficulties. Nine patients received the PEG for gastric decompression only. Seven patients died within 14 days of PEG placement from non-PEG-related complications and were excluded. The resulting 251 patients included for our analysis successfully had PEG tube placement and had at least 14 days of enteral feeding. Esophagitis was defined macroscopically by the endoscopic presence of mucosal edema, friability, or obscurity of the normal vascular pattern in the distal esophagus. Aspiration was defined as the witnessed regurgitation of or tracheal suctioning of PEG feedings. Pneumonia as a consequence of aspiration was defined by development of fever and new infiltrate on chest radiograph within 14 days of PEG placement. Two hundred fifty-one patients had PEG placement (M, 127; F, 124; average age, 62.4 year; age range, 18-95 years) performed by a single endoscopist over a 32-month period. Fourteen (5.6%) of these patients had clinically evident pulmonary aspiration, with seven of them developing pneumonia. Thirteen (93%) of these patients had normal esophageal mucosa. One of the 24 patients (4%) with esophagitis or esophageal ulceration present endoscopically had an aspiration event with subsequent pneumonia. None of the 20 patients found to have some other form of esophageal pathology had an aspiration event. The overall incidence of aspiration pneumonia after the initiation of PEG feedings was 2.7% (7/251). The odds ratio that the presence of esophagitis would predict the development of aspiration pneumonia was 1.60, with a 95% confidence interval of 0.18 to 13.89. This study argues that the presence of esophagitis alone does not increase the risk of aspiration pneumonia from PEG feedings. Other factors apart from esophagitis play an important role in the incidence of aspiration pneumonia with PEG feeding
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Affiliation(s)
- Matthew L Carnes
- Medical University of South Carolina, Department of Medicine, Division of Gastroenterology and Hepatology, Digestive Disease Center, Charleston, South Carolina 29425, USA
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35
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KIKUI SHOJI, YOKOSE YOSHIHIKO, SUGIMOTO YASUSHI, INOUE HIROYA, KIN TESSEKI, SAKURAI RITSURO. Application of percutaneous endoscopic gastrostojejunostomy in a case of amyotrophic lateral sclerosis associated with the superior mesenteric artery syndrome. Dig Endosc 2003. [DOI: 10.1046/j.1443-1661.2003.00233.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
| | - YOSHIHIKO YOKOSE
- Internal Medicine, Medical Corporation, Takuseikai, Nara Central Park Hospital, Nara, Japan
| | | | | | | | - RITSURO SAKURAI
- Internal Medicine, Medical Corporation, Takuseikai, Nara Central Park Hospital, Nara, Japan
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36
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Abstract
BACKGROUND Jejunostomy tubes can be placed endoscopically by means of percutaneous gastrostomy with jejunal extension (PEG-J) or by direct percutaneous jejunostomy. These 2 techniques were retrospectively compared in patients requiring long-term jejunal feeding. METHOD An endoscopy database was used to identify all patients who underwent endoscopic jejunal feeding tube placement from January 1996 to May 2001. Patients with a history of upper GI surgery were excluded. There were 56 patients with a direct percutaneous jejunostomy and 49 with a percutaneous gastrostomy with jejunal extension. Patients in the direct percutaneous jejunostomy group received a 20F direct jejunostomy tube; a 20F PEG tube with a 9F jejunal extension was used in the percutaneous gastrostomy with jejunal extension group. Medical records for the period of 6 months after establishment of jejunal access were reviewed. Complications and need for further endoscopic intervention within this time frame were recorded. The duration of feeding tube patency (number of days from established jejunal access to first endoscopic reintervention) was compared for both groups. RESULTS Feeding tube patency was significantly longer in patients who had a direct percutaneous jejunostomy compared with those with a percutaneous gastrostomy with jejunal extension. Within the 6-month period, 5 patients with a direct percutaneous jejunostomy required endoscopic reintervention for tube dysfunction compared with 19 patients who had a percutaneous gastrostomy with jejunal extension (p < 0.0001). CONCLUSIONS For patients who require long-term jejunal feeding, a direct percutaneous jejunostomy with a 20F tube provides more stable jejunal access compared with a percutaneous gastrostomy with jejunal extension with a 9F extension and has a lower associated rate of endoscopic reintervention.
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37
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Abstract
Improvements in delivery systems for enteral feeding, in formulas, and in the understanding of complications have made the technology for enteral feeding easy to apply. Adequate nutrients can be delivered, and individual tolerance for feeding is acceptable. The remaining question is when to apply the technology. Formula selection should be as simple as possible. Aspiration and other early complications are a serious risk and are not diminished by route of feeding. Long-term enteral feeding is associated with a high complication rate, with high mortality, and may not be effective.
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Affiliation(s)
- Rami Y Haddad
- Division of Geriatric Medicine, Saint Louis University Health Sciences Center, 1402 South Grand Boulevard M238, Saint Louis, MO 63104, USA.
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38
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Abstract
Gastrostomy is a preferred method of nutrition in patients with impaired ability to eat. Although surgical gastrostomy is a well-established method and has been widely performed in the last century, beginning with early 1980s, percutaneous gastrostomy techniques, either endoscopic or radiologic, has widely gained acceptance. As percutaneous methods have been shown to be an effective, safe, easy to perform and low-cost techniques with low morbidity and mortality rates, nowadays percutaneous gastrostomy is the first method of choice in need of nutrition in patients with functioning gut. In this article authors review the technique of percutaneous radiologic gastrostomy, as well as indications, contraindications, variations of technique, ethical considerations, controversies and comparison with surgical and endoscopic methods.
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Affiliation(s)
- Mustafa N Ozmen
- Department of Radiology, School of Medicine, Hacettepe University, 06100, Ankara, Turkey.
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39
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Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, Mallery JS, Raddawi HM, Vargo JJ, Waring JP, Fanelli RD, Wheeler-Harbough J. Complications of upper GI endoscopy. Gastrointest Endosc 2002; 55:784-93. [PMID: 12024128 DOI: 10.1016/s0016-5107(02)70404-5] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.
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40
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Carucci LR, Levine MS, Rubesin SE, Laufer I, Assad S, Herlinger H. Evaluation of patients with jejunostomy tubes: imaging findings. Radiology 2002; 223:241-7. [PMID: 11930073 DOI: 10.1148/radiol.2231010961] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To determine the frequency and nature of abnormalities observed on radiographs after placement of jejunostomy (J) tubes for enteral nutrition. MATERIALS AND METHODS Radiology database review revealed that 280 studies of the J tube or of the small bowel with water-soluble contrast material and/or barium sulfate were performed in patients during 10 years. Review of the radiologic reports revealed abnormalities related to the placement of tubes in 105 (38%) cases. Images were reviewed to determine abnormalities in these 105 cases. Radiologic, medical, and surgical records were also reviewed to determine the clinical course and any subsequent interventions. RESULTS One or more complications were detected in 40 (14%) of 280 cases: small-bowel obstruction in 17 (6%) cases, nonobstructive small-bowel narrowing in six (2%), extraluminal tracks or collections in seven (2%), extravasation of contrast material to the skin in 11 (4%), jejunal hematomas in five (2%), and intussusceptions in four (1%). Mechanical problems related to the tube were detected in 52 (19%) cases, including coiling, kinking, or knotting of the tube in 38 (14%), malpositioning in five (2%), retrograde flow in four (1%), occlusion in four (1%), and a hole in one (<1%). Focal thickening of small-bowel folds was detected in 24 (9%) cases. CONCLUSION Radiographs in 280 patients with J tubes revealed one or more complications that resulted from tube placement (40 [14%] cases), mechanical problems related to location or function of the tube (52 [19%] cases), and development of focally thickened small-bowel folds (24 [9%] cases).
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Affiliation(s)
- Laura R Carucci
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
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41
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Teoh DL. Tricks of the trade: Assessment of high-tech gear in special needs children. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2002. [DOI: 10.1016/s1522-8401(02)90018-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Godbole P, Margabanthu G, Crabbe DC, Thomas A, Puntis JWL, Abel G, Arthur RJ, Stringer MD. Limitations and uses of gastrojejunal feeding tubes. Arch Dis Child 2002; 86:134-7. [PMID: 11827911 PMCID: PMC1761076 DOI: 10.1136/adc.86.2.134] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Gastrostomy feeding is a well established alternative method to long term nasogastric tube feeding. Many such patients have gastro-oesophageal reflux (GOR) and require a fundoplication. A transgastric jejunal tube is an alternative when antireflux surgery fails, or is hazardous or inappropriate. AIMS To review experience of gastrojejunal (G-J) feeding over six years in two regional centres in the UK. METHODS Retrospective review of all children who underwent insertion of a G-J feeding tube. RESULTS There were 18 children, 12 of whom were neurologically impaired. G-J tubes were inserted at a median age of 3.1 years (range 0.6-14.7) because of persistent symptoms after Nissen fundoplication (n = 8) or symptomatic GOR where fundoplication was inappropriate. Four underwent primary endoscopic insertion of the G-J tube; the remainder had the tube inserted via a previous gastrostomy track. Seventeen showed good weight gain. There was one insertion related complication. During a median follow up of 10 months (range 1-60), four experienced recurrent aspiration, bilious aspirates, and/or diarrhoea. There were 65 tube related complications in 14 patients, necessitating change of the tube at a median of 74 days. Jejunal tube migration was the commonest problem. Five died from complications of their underlying disease. CONCLUSIONS Although G-J feeding tubes were inserted safely and improved nutritional status, their use was associated with a high rate of morbidity. Surgical alternatives such as an Roux-en-Y jejunostomy may be preferable.
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Affiliation(s)
- P Godbole
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med 2001; 29:1495-501. [PMID: 11505114 DOI: 10.1097/00003246-200108000-00001] [Citation(s) in RCA: 255] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine the extent to which postpyloric feeding reduces gastroesophageal regurgitation and pulmonary microaspiration in critically ill patients. DESIGN Randomized trial. SETTING A medical/surgical intensive care unit at a tertiary care hospital. PARTICIPANTS Intensive care unit patients were expected to remain ventilated >72 hrs. We excluded patients with esophageal, gastric, or small bowel surgery in the last week and patients with overt or clinically significant gastrointestinal bleeding. We studied 33 patients; 42.4% were female, mean age (sd) was 59.2 (+/- 16.8) yrs, and mean Acute Physiology and Chronic Health Evaluation II score was 22.5 (7.8). INTERVENTIONS Patients were randomized to gastric or postpyloric enteral feeds. Technetium 99-sulphur colloid was added to the feeds for 6 hrs of each of the first 3 days on study. MEASUREMENTS AND RESULTS We sampled the oropharynx and trachea hourly for the 6 hrs per day that patients received radioisotope-labeled enteral feeds, and the level of radioactivity in these specimens was measured. We defined an episode of gastroesophageal regurgitation and microaspiration as an increase in radioactivity >100 counts per minute/g. Patients fed into the stomach had more episodes of gastroesophageal regurgitation (39.8% vs. 24.9%, p =.04) and trended toward more microaspiration (7.5% vs. 3.9%, p =.22) compared with patients fed beyond the pylorus. When the logarithmic mean of the radioactivity count was compared across groups, there was a trend toward an increase in gastroesophageal regurgitation (3.7 vs. 2.9 counts/g, p =.22) and a trend toward increased microaspiration (1.9 vs. 1.4 counts/g, p =.09) in patients fed into the stomach. Patients who had gastroesophageal regurgitation were much more likely to aspirate than patients who did not have gastroesophageal regurgitation (odds ratio: 3.2; 95% confidence interval: 1.36, 7.77). CONCLUSIONS Feeding beyond the pylorus is associated with a significant reduction in gastroesophageal regurgitation and a trend toward less microaspiration.
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Affiliation(s)
- D K Heyland
- Department of Medicine, Kingston General Hospital, Queen's University, 76 Stuart Street, Kingston, Ontario, KVL 2V7, Canada.
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Shetzline MA, Suhocki PV, Workman MJ. Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy. Gastrointest Endosc 2001; 53:633-8. [PMID: 11323594 DOI: 10.1067/mge.2001.114420] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Approaches to the creation of a percutaneous jejunostomy (PEJ) include enteroscopy with jejunal transillumination, fluoroscopy with small bowel distension and tract dilation, and jejunal enteral tube placement through a percutaneous endoscopic gastrostomy. Although all have been successful, the combination of enteroscopy and fluoroscopy may improve visualization and the success of PEJ placement. This is a description of such a technique and its successful use in 7 patients. METHODS The procedure was performed with the patient under conscious sedation in a manner similar to standard PEG placement. The proximal jejunum was visualized and a standard snare was passed though the enteroscope and was opened. A needle and guidewire were directed percutaneously though the snare by using fluoroscopic guidance. Under direct endoscopic visualization the snare was closed around the guidewire. A standard 20F push-type "gastrostomy" tube was passed over the guidewire and through the mouth and the dome seated in the jejunum. A bumper was passed externally over the tube and tightened at the skin. RESULTS PEJ placement was successful in all 7 patients. The average length of the procedure was 40 minutes (range 22-64 minutes). There were no major complications. Mean follow-up was 124 days (range 28-308 days). Feeding tubes remained functional until removal (2), death (1), or surgical removal for an unrelated reason (1). Three tubes are still in use. CONCLUSIONS Percutaneous endoscopic jejunostomy tube placement can be performed successfully with enteroscopy and fluoroscopy. This technique is safe and efficient and provides distal enteral nutritional support for patients in whom PEG cannot be used.
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Affiliation(s)
- M A Shetzline
- Department of Medicine, Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Ginsberg GG. Direct percutaneous endoscopic jejunostomy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2001. [DOI: 10.1053/tgie.2001.19911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lien HC, Chang CS, Chen GH. Can percutaneous endoscopic jejunostomy prevent gastroesophageal reflux in patients with preexisting esophagitis? Am J Gastroenterol 2000; 95:3439-43. [PMID: 11151874 DOI: 10.1111/j.1572-0241.2000.03281.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Percutaneous endoscopic jejunostomy has been used for preventing pulmonary aspiration arising from gastric contents by concomitant jejunal feeding and gastric decompression in susceptible patients. Our objective was to evaluate gastroesophageal reflux in patients with percutaneous endoscopic jejunostomy tube feeding. METHODS Eight cerebrovascular accident patients with percutaneous endoscopic jejunostomy tube placement caused by reflux esophagitis with hematemesis, food regurgitation or vomiting, and/or recurrent aspiration pneumonia were tested for gastroesophageal reflux using 24-h esophageal pH monitoring during continuous jejunal liquid meal or saline infusion with concomitant gastric decompression. Twenty-four hour pH monitoring was also performed during intragastric feeding on a different day. RESULTS During the liquid meal feeding period, percutaneous endoscopic jejunostomy feeding reduced esophageal acid exposure 46% [12.9% (4.9-28.2%) versus 24.0% (19.0-40.6%), p = 0.01], compared to intragastric feeding. However, in the period of the jejunal tube infusion, esophageal acid exposure was significantly lower during saline infusion than during meal infusion [3.2 (0.0%-10.8%) versus 12.9% (4.9-28.2%), p = 0.008]. CONCLUSION Percutaneous endoscopic jejunostomy feeding reduced but did not eliminate gastroesophageal reflux, compared to intragastric feeding in patients with severe gastroesophageal reflux. However, gastroesophageal reflux during percutaneous jejunal feeding was associated with meal infusion. This might, in part, explain the failure of percutaneous endoscopic jejunostomy tube placement to prevent pulmonary aspiration.
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Affiliation(s)
- H C Lien
- Department of Internal Medicine, Taichung Veterans General Hospital, Taiwan
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Unintentional Ileostomy: A Complication of the Videolaparoscopic Method? Report of the First Case. Surg Laparosc Endosc Percutan Tech 2000. [DOI: 10.1097/00129689-200008000-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gama-rodrigues J, Seid V, Santos V, de Martino R, Volpe P, Bresciani C. Surg Laparosc Endosc Percutan Tech 2000; 10:253-257. [DOI: 10.1097/00019509-200008000-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Rumalla A, Baron TH. Results of direct percutaneous endoscopic jejunostomy, an alternative method for providing jejunal feeding. Mayo Clin Proc 2000; 75:807-10. [PMID: 10943234 DOI: 10.4065/75.8.807] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the results of direct percutaneous endoscopic jejunostomy (DPEJ) as a method for jejunal feeding. PATIENTS AND METHODS We conducted a retrospective study of all patients who were referred for DPEJ between October 1998, when the procedure was implemented at our institution, and January 2000. Medical records were reviewed to assess technical success, complications, and the need for repeat procedures. Patient satisfaction with DPEJ was also evaluated by means of standardized telephone interviews. RESULTS In 26 (72%) of 36 patients, DPEJ placement was successful. During the mean follow-up of 107 days, none of the patients with DPEJ required reintervention for tube malfunction or displacement. Two patients developed a persistent enterocutaneous fistula following the removal of the DPEJ tube. No other procedure-related complications were noted. Fifteen (78%) of 19 patients who responded to follow-up questions reported an overall satisfaction rating of 8 or higher on a 10-point scale (1, completely dissatisfied, to 10, completely satisfied). CONCLUSIONS We conclude that DPEJ is an effective and safe method for providing jejunal tube feeding. A low reintervention rate along with high patient satisfaction makes DPEJ an attractive alternative to the more commonly placed jejunostomy feeding tubes.
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Affiliation(s)
- A Rumalla
- Division of Gastroenterology and Hepatology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
More than a century after its initial clinicopathologic description, amyotrophic lateral sclerosis (ALS) remains a largely fatal, progressive neurodegenerative disorder for which few efficacious pharmacotherapies with an impact directly on the natural course of the illness exist. The only currently approved therapy, the antiglutamatergic agent riluzole, has been shown to have only a marginal survival benefit in the absence of changes in functional assessments during the disease course. The efficacy of recombinant human insulin-like growth factor (rhIGF-1) remains controversial. In light of this, the primary focus of treatment for individuals with ALS remains symptomatic, through a multidisciplinary team approach including physicians, nurses, speech/language pathologists, physical therapists, occupational therapists, dietitians, social workers, and respiratory therapists.
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Affiliation(s)
- BM Demaerschalk
- Room 7OF10, University Campus, London Health Sciences Centre, 339 Windermere Road, London, Ontario N6A 5A5, Canada
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