Percutaneous endoscopic gastrostomy and placement of a jejunal extension tube

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.

Tips and tricks for deep jejunal enteral access: modifying techniques to maximize success

Endoscopic insertion of enteral feeding tubes is a major advance in the delivery of nutrition therapy. Since the first report of percutaneous endoscopic gastrostomy (PEG) in 1980 (Gauderer et al. J Pediatr Surg. 15:872-5, 1980), insertion techniques and equipment have been refined and improved. Despite this progress, deep jejunal enteral access remains a difficult procedure, and many endoscopists do not have experience with the techniques of nasojejunal (NJ) placement, percutaneous endoscopic gastrojejunostomy (PEGJ), or direct percutaneous endoscopic jejunostomy (DPEJ) (Shike and Latkany, Gastrointest Endosc Clin N Am. 8:569-80, 1998). The difference between an exasperating experience and a rewarding procedure lies in mastering the "tips and tricks" that make insertion easy. While the basic techniques are described elsewhere (McClave and Chang 2011), we review several universal basic principles to enhance deep jejunal access, which should promote a more efficient and successful procedure.

Spectrum of morbidity related to bolster placement at time of percutaneous endoscopic gastrostomy: buried bumper syndrome to leakage and peritonitis

Setting the external bolster at the time of placement of percutaneous endoscopic gastrostomy (PEG) is a key factor in the spectrum of morbidity and complications related to the procedure. Setting the bolster too tight results in various gradations of buried bumper syndrome, whereas setting the bolster too loose can lead to leakage and acute peritonitis. Aspects of the initial technique, awareness of contributing factors, and strategies for monitoring and surveillance of the PEG once placed are all important in preventing more serious sequelae.

Acute complications associated with bedside placement of feeding tubes

Several types of feeding tubes can be placed at a patient's bedside; examples include nasogastric, nasointestinal, gastrostomy, and jejunostomy tubes. Nasoenteral tubes can be placed blindly at bedside or with the assistance of placement devices. Nasoenteric tubes can also be placed via fluoroscopy and endoscopy. Gastrostomy and jejunostomy tubes can be placed using endoscopic techniques. This paper will describe the indications and contraindications for different types of tubes that can be placed at the bedside and complications associated with tube placement. Complications associated with nasoenteral tubes include inadvertent malpositioning of the tube, epistaxis, sinusitis, inadvertent tube removal, tube clogging, tube-feeding-associated diarrhea, and aspiration pneumonia. Complications from percutaneous gastrostomy and jejunostomy tube placements include procedure-related mishaps, site infection, leakage, buried bumper syndrome, tube malfunction, and inadvertent removal. These complications will be reviewed, along with a discussion of incidence, cause, treatment, and prevention approaches.