A novel technique for percutaneous endoscopic gastrojejunostomy tube placement

Direct endoscopic placement of percutaneous endoscopic gastrostomies with jejunal extension tubes (PEG-J) using ultra-thin endoscopes - long-term outcomes from a U.S. tertiary referral center

INTRODUCTION

Several techniques for PEG-J tube placement have been described, commonly requiring fluoroscopic guidance and/or fixation of the jejunostomy tube (J-tube) into the small intestine. We describe a modified technique for placing jejunostomy tubes under direct visualization through a PEG with the use of ultra-thin endoscopes and steel guidewire.

METHODS

A retrospective study at a single tertiary academic center evaluating patients who underwent PEG-J placement between 2010 and 2020. All PEG tubes were placed with a pull-through technique. The Olympus GIF-N180 endoscope was advanced through the PEG to the jejunum and a Savary-Gilliard guidewire was used for placement of the J-tube extension.

RESULTS

Fifty-eight patients underwent PEG-J placement (median age 61 years; women 52%). Surgically altered gastric anatomy was observed in 11 patients (19%). Median procedure time was 44 min for new PEG-J tube placement (range 26-103) and 20 min for placement of a J-tube extension through an existing PEG tube (range 9-86) or gastrostomy tract. Technical success rate was in 100%. Sixty-two repeat procedures were performed for J-tube exchange in 27 patients (46%, range 1-9 per patient), of which 51 procedures (82%) were done using the same technique. The most common indication for tube replacement was tube dysfunction (63%, n = 39). The median procedure time for tube exchange was 20 min (range 2-62). No major adverse events were encountered.

CONCLUSION

PEG-J tubes can be placed effectively, rapidly, and safely using an ultra-thin caliber endoscope and a stiff steel wire through the PEG tube or mature gastrostomy site, precluding the need for fluoroscopy or oral access. J-tubes can be easily replaced utilizing the same technique.

Combined laparoscopic-fluoroscopic technique for primary gastrojejunostomy button tube placement

BACKGROUND

Gastrojejunostomy (GJ) tubes are frequently used to provide pediatric enteral nutritional support for pediatric patients. Various placement methods have been described, each with attendant advantages and disadvantages.

DESCRIPTION OF THE OPERATIVE TECHNIQUE

We present a technique for primary laparoscopic/fluoroscopic GJ button tube placement designed to avoid delay in placement of the jejunal limb, and difficulties associated with endoscopic-assisted and primary fluoroscopic placement.

RESULTS

There were 52 gastrojejunostomy button tubes placed via this technique in patients ranging from 3.8 to 90.3 kg in weight. Three postoperative complications were identified; one bowel perforation on postoperative day two, and two tube dislodgements within 30 days.

CONCLUSION

The described technique was uniformly effective and was associated with a low complication rate (5.8%).

Small bowel endoscopic enteral access

The use of small bowel access for small intestinal delivery of enteral nutrition is becoming more common. Patients at risk for gastric regurgitation and aspiration, gastric intolerance, and pancreatitis are some of the classic patient groups for which small bowel feedings may be necessary. The endoscopist should have command of all forms of endoscopic small bowel enteral access, including nasojejunal tube placement, percutaneous gastro/jejunostomy, and direct percutaneous jejunostomy. Knowledge of not only the procedure techniques, but also the potential complications, is imperative to achieving good clinical outcomes.

The role of endoscopically placed feeding or decompression tubes

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.

Percutaneous transgastric placement of jejunal feeding tubes with an ultrathin endoscope

BACKGROUND

Placement of jejunal feeding tubes in patients with PEG tubes by conventional techniques is often difficult. This is a description of a simple method for placement of jejunal tubes by using an ultrathin endoscope. This method does not always require conscious sedation.

METHODS

An ultrathin endoscope is passed through a mature gastrostomy tract to the proximal jejunum. A guidewire passed through the endoscope and placed beyond the ligament of Treitz is then used under fluoroscopy to place a transgastric jejunal feeding tube.

OBSERVATIONS

Sixteen jejunal feeding tube placements were performed in 13 patients over a period of 20 months. Six patients required conscious sedation. Jejunal tubes had feeding channels of 10 to 12F. There were no complications. Feedings began on the day of placement.

CONCLUSIONS

Ultrathin endoscopes can be used to place jejunal feeding tubes by means of the transgastric route. The procedure is simple, quick, and safe. In some patients, the use of conscious sedation can be avoided.

Bedside videoscopic placement of feeding tubes: development of fiberoptics through the tube

OBJECTIVE

Transpyloric small intestine feeding tube placement can be difficult and tedious. Currently accepted techniques are associated with disadvantages and risk. The purpose of this study is to describe the development of a new technique: bedside videoscopic placement using fiberoptics through the tube.

DESIGN

Prospective, descriptive case study.

SETTING

Intensive care unit in a teaching hospital.

PATIENTS

Subjects were divided into two groups: a) group 1: eight healthy volunteers (seven male, one female); b) group 2: nine critically ill patients (six male, three female; eight of these patients were intubated).

INTERVENTIONS

Standard 12-Fr (4.0-mm) feeding tubes (n = 19) were placed. Two patients from group 2 had feeding tubes placed on two separate occasions. The feeding tubes were inserted by the oral (n = 8) or nasal (n = 11) route under direct vision, using a 6.7-Fr (2.2-mm) fiberoptic scope through the feeding tube.

MEASUREMENTS AND MAIN RESULTS

We visualized enteric structures clearly through the feeding tube in all subjects and patients. Based on visual landmarks, we advanced the feeding tube through the pylorus and into the duodenum in all individuals. Transpyloric tube placement was confirmed videoscopically (n = 19) and radiographically (n = 18). In three subjects from group 1, the feeding tube entered the first part of the duodenum, while, in the remainder of the subjects, the tube passed into or beyond the second portion of the duodenum. In eight (73%) of 11 attempts on the nine critically ill patients from group 2, the feeding tubes were advanced to the distal duodenum or jejunum. The time required for placement in group 2 ranged from 2 to 43 mins (mean 18 +/- 12 [SD]). The feeding tubes remained in place 10 +/- 4 days and patients met their estimated caloric needs within 24 hrs. Residual volumes of nutrition in the small bowel were < 5 mL. There were no documented episodes of aspiration.

CONCLUSION

This new technique has the potential for rapid, accurate, and safe feeding tube placement in patients requiring nutritional support.