Endoscopic placement of direct percutaneous jejunostomy tubes in patients with complications after esophagectomy

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Safety and efficacy of direct percutaneous endoscopic jejunostomy placement in patients with previous upper gastrointestinal resection: A retrospective cohort study

BACKGROUND

Percutaneous jejunal enteral access can be obtained with percutaneous endoscopic gastric jejunostomy (PEGJ) and direct percutaneous endoscopic jejunostomy (DPEJ) tubes. PEGJ may not be feasible in patients with previous gastric resection (PGR) and DPEJ may be the only option. Our aim is to determine if DPEJ tubes can be placed successfully in patients with history of gastrointestinal (GI) surgery and if success rates are comparable to DPEJ or PEGJ in those without prior GI surgery.

METHODS

We reviewed all tube placements performed from 2010 to present. Procedures were performed using a pediatric colonoscope. Previous upper GI surgery was defined as PGR or esophagectomy with gastric pull-up. Adverse events (AEs) were graded per American Society for Gastrointestinal Endoscopy criteria. Mild events included unplanned medical consultation or hospitalization <3 days, and moderate events included repeat endoscopy without surgical intervention.

RESULTS

Successful placement rates were high regardless of GI surgical history. Patients receiving a DPEJ with a history of GI surgery were significantly less likely to experience an AE compared with those receiving DPEJ with no history and compared with PEGJ patients with or without a history.

CONCLUSIONS

DPEJ placement in patients with previous upper GI surgery has very high success rate. It is associated with lower AE rates than patients receiving DPEJ without previous gastric surgery, or PEGJ regardless of previous gastric surgery. Patients with a history of upper GI surgery requiring enteral access may benefit from DPEJ over PEGJ placement considering its very high success rate and lower incidence of AEs.

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

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

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

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

Enteral Feeding Access Has an Impact on Outcomes for Patients with Esophageal Cancer Undergoing Esophagectomy: An Analysis of SEER-Medicare

BACKGROUND

Optimal nutrition after esophagectomy is challenging due to alterations in eating, both from the tumor and during surgical recovery. Enteral nutrition via feeding tube is commonly used. The impact of feeding tubes on post-esophagectomy outcomes was examined in a large national data set.

METHODS

Patients with esophageal cancer (1998-2013) undergoing esophagectomy were extracted from the Surveillance Epidemiology and End Results-Medicare database. Chi-square and t tests were used to compare categorical and continuous variables. Time trend analyses were performed with Cochran-Armitage survival using log-rank and multivariable analysis with generalized linear modeling.

RESULTS

The study examined 2495 patients. The majority had enteral feeding access (71%, n = 1794) during the perioperative period. Mortality among the patients with feeding tubes was lower at 30 days (5.4% vs 8.4%), 60 days (9.0% vs 13.0%), and 90 days (12.2% vs 15.8%). In the multivariable analysis, the patients with feeding tubes had improved short-term survival at 30 days (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.46-0.93), 60 days (OR, 0.64; 95% CI, 0.49-0.85), and 90 days (OR, 0.70; 95% CI, 0.54-0.90). The hospital stay was shorter for the patients undergoing enteral feeding tube placement (17.9 vs 19.5 days; p = 0.04). Discharge destination (home vs health care facility) showed no difference.

CONCLUSIONS

Feeding tubes in patients undergoing esophagectomy were associated with an increase in short-term survival up to 90 days after surgery. Feeding tube placement was not associated with higher rates of non-home discharges and did not prolong the hospital stay.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of the safety and efficacy of percutaneous laparoscopic endoscopic jejunostomy (PLEJ)

INTRODUCTION AND AIMS

Gastric feeding may not be possible in the neurologically impaired child with foregut dysmotility. Post-duodenal feeding can be crucial, thereby avoiding the need for parenteral nutrition. The aim of this study is to evaluate the technical success, complication and clinical outcome of our institution's technique in creating a jejunostomy using the percutaneous laparoscopic-endoscopic jejunostomy (PLEJ) technique.

METHODS

Retrospective review of all paediatric patients (<18) with PLEJ between January 2008 and April 2015 was conducted. Patients were identified using the electronic procedure code and clinic letters. Data were collected in regard to the procedure technical success, short and long-term complications and clinical outcomes.

RESULTS

Sixteen patients (age range, 2-17years) were identified. The procedure was successful in all cases. At a median follow up of 25months, eleven patients (68%) had significant improvement of their symptoms of feeding intolerance/aspirations and are permanently PLEJ fed and two (13%) were regraded to gastric feeds. Two patients moved from total parenteral nutrition to partial parenteral nutrition while on PLEJ feeds. All patients had experienced weight gain and either went up or maintained their weight centile. The only major complication was small bowel volvulus encountered in two patients with abnormal gastrointestinal anatomy requiring surgical intervention.

CONCLUSIONS

In our small case series, PLEJ placement was safe as it provides valuable visualization of the bowel loops intraabdominally. It is a technically feasible and successful approach for children requiring long-term jejunal feeding especially those with foregut dysmotility.

Long-term outcomes of direct percutaneous endoscopic jejunostomy: a 10-year cohort

STUDY AIM

To assess the clinical outcomes of patients who received direct percutaneous endoscopic jejunostomy (DPEJ) for enteral feeding.

MATERIALS AND METHODS

This is a 10-year cohort study in a single tertiary center. Main outcome measurements were technical success, and short- and long-term outcomes. DPEJ was attempted in 83 patients (51 men; 55 ± 2 years) for dysphagia (n = 35), gastroparesis with recurrent aspiration (n = 30), and levodopa drug infusion for severe Parkinson's disease (n = 18).

RESULTS

DPEJ was successful in 75 (90 %) patients. All technical failures were related to the inability to find adequate trans-illumination, and were not influenced by BMI, age, gender, or indication. Peri-operative (30-day) adverse events occurred in 11 (13 %) patients, including wound infection (3), leakage around the stoma (4), minor bleeding requiring no intervention (2), and aspiration (1). There was one case (1.2 %) of gastric perforation after PEJ insertion for levodopa drug infusion trial. This 60-year-old woman required an emergency laparotomy with nil complications, and levodopa drug infusion recommenced successfully. One case of intestinal perforation (1.2 %) occurred after jejunostomy tube replacement at 6 months of insertion, which was successfully managed with surgery. There were no peri-operative deaths. Adequate delivery of enteral feeding or Duodopa drug was achieved in 66/73 (90 %) patients, with evidence of weight gain or improvement in Parkinson's disease. Seven (8 %) continued to have clinical regurgitation but not aspiration. After a median follow-up of 84 months, 27 (33 %) patients died of their underlying diseases. Seven (8 %) had marked improvement in their underlying disease and had PEJ removed after 5 months (range 1 - 8 months).

LIMITATIONS

Single center study.

CONCLUSIONS

DPEJ is associated with a high technical success rate (90 %), a relatively low rate of peri-operative adverse events (13 %) and an improvement in long-term nutritional support in the majority of patients (90 %). DPEJ should be the procedure of choice to gain enteral access for feeding or drug delivery prior to considering surgery.

Endoscopic Management of Esophageal Anastomotic Leaks After Surgery for Malignant Disease

BACKGROUND

Esophageal anastomotic leaks after cancer surgery remain a major cause of morbidity and mortality. Endoscopic interventions, including covered metal stents (cSEMS), clips, and direct percutaneous endoscopic jejunostomy (dPEJ) tubes are increasingly used despite limited published data regarding their utility in this setting. This study aimed to determine the efficacy and safety of a multimodality endoscopic approach to anastomotic leak management after operation for esophageal or gastric cancer.

METHODS

We performed a retrospective review of prospectively maintained databases of gastric and esophageal operations at our hospital between January 2003 and December 2012. Included patients had an operation for esophageal or gastric cancer, demonstrated evidence of an anastomotic leak at the esophageal anastomosis, and underwent attempted endoscopic therapy. Healing was defined as clinical and radiographic leak resolution.

RESULTS

Forty-nine patients with leaks underwent endoscopic management. Of the 49 patients, 31 (63%) received cSEMS, 40 (82%) had dPEJ tubes inserted, and 3 (6%) received clips. Twenty-three (47%) patients underwent a combined approach. Overall, 88% of patients achieved healing in a median of 83 days. Twenty-two of 23 patients (96%) who underwent a multimodality endoscopic approach healed. Only 1 patient had a major complication associated with stent erosion into the pulmonary artery, which was successfully treated with operative repair.

CONCLUSIONS

Esophageal anastomotic leaks after esophageal and gastric cancer operations can be managed successfully and safely with endoscopic therapy. Combining cSEMS for leak control and dPEJ tube placement for nutritional support was highly effective in achieving healing, without the need for surgical repair.

Enteral nutrition access devices

The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, performing a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such situations, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the ASGE Governing Board. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to endoscopy in patients requiring enteral feeding access by using the keywords "endoscopy," "percutaneous," "gastrostomy," "jejunostomy," "nasogastric," "nasoenteric," "nasojejunal," "transnasal," "feeding tube," "enteric," and "button." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Feeding jejunostomy: does the benefit overweight the risk (a retrospective study from a single centre)

BACKGROUND

The purpose of this study was to review the efficacy and safety of feeding jejunostomy in terms of achieving the nutritional goals in patients undergoing esophagectomy for carcinoma of oesophagus and complications associated hence with.

METHODS

A total of 463 patients underwent esophagogastrectomy for carcinoma oesophagus during this period. All these patients underwent Witzel feeding jejunostomy for post-operative enteral nutrition. Enteral feeding was started after 24 h of surgery and increased gradually till target caloric and protein value was achieved. Nutritional goals achieved were reviewed. All complications related to jejunostomy were recorded.

RESULTS

The study comprised of 463 patients who underwent elective esophagogastrectomy. Mean age was 58 +/- 8.4 in male patients and 55 +/- 4.2 years in female patients. Patients spend a mean of 19 +/- 8.4 (range 10-49) days on jejunostomy feed. The targeted calorie requirement was achieved by post-operative day 3 in 408 (88.12%) patients. The catheter blockage was one of the main complications during the course of feeding. Seven patients required relaparotomy for catheter blockage.

CONCLUSION

Feeding jejunostomy is an effective, safe, economic and well tolerated method of providing nutrition to the patients of esophagogastrectomy. Feeding jejunostomy should be done in every patient undergoing esophagectomy at the time of laparotomy.

Benefits versus risks: a prospective audit. Feeding jejunostomy during esophagectomy

BACKGROUND

The purpose of this prospectively collected database is to evaluate the safety, efficacy, and utility of postoperative jejunostomy feeding in terms of achieving nutritional goals and evaluating gastrointestinal and mechanical complications in patients undergoing esophagectomy.

METHODS

The study included 204 consecutive patients who underwent esophagectomy for various benign and malignant conditions. All patients underwent Witzel feeding jejunostomy at the time of laparotomy. Patients were followed prospectively to record nutritional intake, type of feed administered, rate progression, tolerance, and complications either mechanical or gastrointestinal.

RESULTS

Feeding jejunostomy could be performed in 99.5% patients; 6.0% of the patients had a blocked catheter during the course of feeding. The target calorie requirement could be achieved in 78% of patients by third day. In all, 95% of patients could be successfully fed exclusively by jejunostomy catheter during the postoperative period. Minor gastrointestinal complications developed in 15% of the patients and were managed by slowing the rate of infusion or administering medication. Patients spent a mean of 16.67 +/- 22.00 days (range 0-46 days) on jejunostomy feeding after surgery; however, 13% required prolonged jejunostomy feeding beyond 30 days. Altogether, 64% of the patients with an anastomotic leak and 50% of the patients with postoperative complications required catheter jejunostomy feeding beyond 30 days. The mean duration for which jejunostomy tube feeding was used was significantly higher for patients who developed anastomotic disruptions (33.05 +/- 16.24 vs. 14.69 +/- 19.04 days; p = 0.000) and postoperative complications (26.67 +/- 25.56 vs. 14.52 +/- 18.64 days; p = 0.000) when compared to those without disruption or complications. There were no serious complications related to the feeding catheter that required reintervention. There was no difference in the mean body weight or weight deficit at the end of 10 days and at 1 month in patients who developed complications or anastomotic disruption when compared to their counterparts. No patient died as a result of a complication related to the feeding jejunostomy.

CONCLUSIONS

Tube jejunostomy feeding is an effective method for providing nutritional support in patients undergoing esophagectomy, and it allows home support for the subset who fail to thrive. Prolonged tube feeding was continued in patients developing anastomotic disruptions and postoperative complications. Feeding jejunostomy has a definitive role to play in the management of the patients undergoing esophagectomy.

Direct Percutaneous Endoscopic Jejunostomy: High Completion Rates with Selective Use of a Long Drainage Access Needle

Background. Direct percutaneous endoscopic jejunostomy (DPEJ) insertion is a useful technique for artificial nutritional support in selected patients. However, it is technically difficult and most case series report significant procedural failure rates. Methods. We reviewed our case series of DPEJ insertions, done in a tertiary care referral centre from 2002 to 2008. Patients were selected for DPEJ if they required artificial enteric nutritional support but were unsuitable for endoscopic gastrostomy. Our technique includes selective usage of a long drainage access needle for gut luminal puncture, selective fluoroscopic guidance and selective usage of general anaesthesia. Results. Of 40 consecutive patients undergoing attempted DPEJ insertion, 39/40 (97.5%) had a successful procedure. Sixteen cases (40%) required the drainage access needle for completion, nineteen cases (47.5%) were done with fluoroscopy, and five cases (12.5%) were done under general anaesthesia. There were no procedural complications. Conclusions. This technique led to a high completion rate and low complication rate. With appropriate care and expertise, DPEJ insertion is reliable and safe.

DPEJ placement in cases of PEG insertion failure

BACKGROUND AND STUDY AIMS

PEG placement is routinely used for enteral feeding; in some cases PEG is not feasible or indicated due to technical difficulties, such as gastric herniation, organ interposition, or presence of gastroparesis. In these cases, surgical gastrostomy or jejunostomy are possible alternatives; more recently, direct percutaneous jejunostomy (DPEJ) has been proposed to avoid surgical intervention. The aim of the study was to evaluate the necessity, technical feasibility and outcome of DPEJ in a group of patients consecutively proposed for PEG placement.

PATIENTS AND METHODS

In each patient proposed for PEG placement, an upper gastrointestinal endoscopy was performed, and then a pull traction removal gastrostomy tube (18-20 F) was inserted. When PEG was not feasible or contraindicated, a variable stiffness pediatric videocolonscope was used to reach the jejunum: then DPEJ was performed with the same technique and materials as PEG. In both groups enteral feeding was started 24h after the endoscopic procedure, using an enteral feeding pump and the same nutritional schedules.

RESULTS

In a 1-year period 90 patients were proposed for PEG placement; PEG could not be performed for technical reasons in 8 (gastric herniation in 1; organ interposition in 7) and gastroparesis in 1. In one patient both PEG and DPEJ were not feasible for organ interposition. The duration of the endoscopic procedure was slightly longer in DPEJ (mean 20 min versus 15 min). No complications related to the endoscopic procedure were observed in both DPEJ and PEG patients. No nutritional complication were observed in the DPEJ group.

CONCLUSION

In our experience, PEG was not feasible or contraindicated in about 10% of patients proposed for. In these patients, DPEJ was placed: the procedure resulted to be feasible and safe with the use of a pediatric videocolonscope to easily reach the jejunum. The insertion of DPEJ did not change the nutritional management of enteral feeding. However, long-term effects or complications remain to be evaluated in larger studies.

Success rate of direct percutaneous endoscopic jejunostomy in patients who are obese

BACKGROUND

Direct percutaneous endoscopic jejunostomy (DPEJ) is increasingly used as a method for obtaining jejunal enteral access. The most cited reason of unsuccessful placement is poor transillumination, which may be related to obesity. Whether obesity affects failure and complication rates has not been previously described.

OBJECTIVE

To compare the success rate and adverse events (AEs) associated with DPEJ placement in patients who were overweight and patients who were obese compared with patients who were normal or underweight defined by body mass index (BMI).

DESIGN

Retrospective database review.

SETTING

A tertiary-referral center.

PATIENTS

Eighty DPEJ placements between February 2000 and September 2005.

MAIN OUTCOME MEASUREMENTS

DPEJ placement success in patients who were overweight/obese (BMI >or= 25) versus patients who were normal or underweight (BMI <25). Secondary end points included procedure time and AEs.

RESULTS

Eighty DPEJs were placed in 75 patients. Of these DPEJs, 65 (81%) succeeded and 15 (19%) failed. Success rates were 23 of 24 for patients who were underweight (96%), 25 of 31 for patients with normal BMI (81%), 8 of 11 for patients who were overweight (73%), and 6 of 10 for persons who were obese (60%) (odds ratio 3.43, 95% CI 1.03-11.44; P< .05 for BMI >or= 25 vs BMI<25). Overall, AEs were not significantly different for patients with BMI <25 versus BMI >or=25 (24/55 vs 9/21, respectively; P= .64). However, 4 of the 5 severe AEs occurred in patients with a BMI >or= 25 (P= .07).

LIMITATIONS

Retrospective single center.

CONCLUSIONS

DPEJ placement in patients who were overweight or obese was feasible, but procedural success was less frequent, and a trend toward more frequent major AEs was seen than in persons with normal or decreased BMI. BMI was an easily assessed preprocedural factor for DPEJ success and complication rates.

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.

Abdominal CT as a predictor of outcome before attempted direct percutaneous endoscopic jejunostomy

BACKGROUND

Direct percutaneous endoscopic jejunostomy (DPEJ) placement succeeds in 72% to 86% of attempts. Failure is most often because of inadequate transillumination or gastroduodenal obstruction. Even in failed cases, patients are exposed to the risks of anesthesia, exploratory percutaneous needle punctures, and the cost burden of suboptimal resource utilization. Hence, a preprocedure predictor of outcome would be useful.

OBJECTIVE

To evaluate whether review of clinically available abdominal CTs can predict the outcome of subsequent DPEJ attempts.

DESIGN

Retrospectively conducted blinded review of abdominal CTs performed within 30 days before attempted DPEJ. Objective anatomic features potentially pertinent to DPEJ success were scored, and a prediction of the anticipated procedural outcome was made.

SETTING

A large tertiary referral center.

PATIENTS

A total of 115 patients who underwent attempted DPEJ and who also had an abdominal CT in the preceding 30 days.

MAIN OUTCOME MEASUREMENTS

Reviewer's overall prediction of success, 3 objective anatomic measurements.

RESULTS

For the overall prediction of success, a CT performed poorly, with a sensitivity of 60%, a specificity of 53%, a positive predictive value of 71%, and a negative predictive value of 40%. Mean abdominal-wall thickness was significantly greater in the failures than the successes (27 vs 21 mm, P = .02), and just 39% of the procedures in patients with an abdominal-wall thickness >3 cm were successful.

LIMITATIONS

Retrospective.

CONCLUSIONS

Failed DPEJ attempts were associated with greater patient abdominal-wall thickness, and this should be taken into consideration before attempted DPEJ. Otherwise, review of existing abdominal CTs appears to have limited utility in predicting DPEJ outcome.

Direct Percutaneous Endoscopic Jejunostomy Placement in a Patient with Intracorporeal Left Ventricular Assist Device

We present a case involving a patient who required enteral feeding after implantation of an abdominally positioned left ventricular assist device. The position of the device occupied most of the abdomen, precluding percutaneous endoscopic gastrostomy tube placement. However, in the case presented, direct percutaneous endoscopic jejunostomy (DPEJ) tube placement was achieved without interfering with the intracorporeal device. To our knowledge, there are no previous reports in the literature of successful DPEJ placement in a patient with an abdominally positioned heart assist device. DPEJ should be considered as a long-term enteral feeding route when structural barriers prevent percutaneous gastric access.

Endoscopic approaches to enteral nutritional support

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.

Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts

BACKGROUND

Clinical utilization of direct percutaneous endoscopic jejunostomy (DPEJ) is increasing. However, little data exist regarding important clinical outcomes with DPEJ.

OBJECTIVE

To describe the indications, success, and complications of DPEJ in a large cohort of >300 consecutive attempted DPEJ cases at our institution.

METHODS

Institutional databases identified 316 consecutive attempted DPEJ placements between January 1996 and August 2004. The medical records of consenting patients were abstracted for demographics, indication, success, complications, and follow-up. A scheme for classifying complication severity was designed.

RESULTS

Three hundred and seven attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%). The most common indications for DPEJ included resectable distal esophageal cancer, other malignancies causing obstruction, gastroparesis, prior esophageal or gastric resection, and high aspiration risk. Overall, 81 adverse events (AEs) were associated with DPEJ placement or removal in 69 (22.5%) cases. There were 14 serious AEs, 20 moderate AEs, and 47 mild AEs. Serious AEs included 7 bowel perforations, 3 jejunal volvuli, 3 major bleeds, and 1 aspiration. The only death was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 9 chronic enterocutaneous fistulae. Many of the 47 mild AEs were site infections requiring oral antibiotics (23) or persistent site pain (14).

CONCLUSIONS

DPEJ was associated with a moderate or severe complication in approximately 10% of cases. While DPEJ is a useful technique to gain enteral access that obviates the need for surgery and is more reliable than percutaneous gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved.