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Locke J, Norwood DA, Forrister N, Ahmed AM, Aryan M, Oster R, Reddy S, Kabir Baig KK, Peter S. Safety and efficacy of direct percutaneous endoscopic jejunostomy tube placement compared with surgical jejunostomy: a tertiary care analysis. Gastrointest Endosc 2024; 99:981-988.e5. [PMID: 38103750 DOI: 10.1016/j.gie.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/06/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND AND AIMS Jejunostomy tube placements provides enteral access for feeding in eligible patients who cannot meet their nutritional needs by mouth. They can be surgically placed laparoscopically (lap-J) or with the use of a conventional open laparotomy approach (open-J). Recently, direct percutaneous endoscopic jejunostomy (DPEJ) has emerged as an alternative owing to its low cost and shorter recovery times. We sought to retrospectively compare the procedural success rates and adverse events of these methods. METHODS Patients were identified by querying our health system patient database and the departmental database of patients who underwent DPEJ. The patients were divided into 3 cohorts based on the procedure: DPEJ, lap-J, or open-J. Patient age and body mass index, procedural success rate, and adverse event rate were compared among the 3 groups. RESULTS A total of 201 patients met inclusion criteria (65 DPEJ, 111 lap-J, and 25 open-J). Procedural success rates were similar among the 3 groups (DPEJ 96.9%, lap-J 99.1%, open-J 100%; P = .702). Rates of infection and bleeding were also similar among the 3 groups. There were no cases of GI perforation. Tube dysfunction for any reason that required complete removal or replacement within 90 days occurred more often in the surgical groups than in the DPEJ group (DPEJ 0%, lap-J 35.1%, open-J 40.0%; P < .001). This was driven largely by increased rates of tube clogging and tube dislodgement in the surgical groups. CONCLUSIONS DPEJ is a safe and effective alternative to surgical jejunostomy in eligible patients and may be associated with decreased adverse event rates at 90 days.
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Affiliation(s)
- John Locke
- Division of Internal Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Dalton A Norwood
- Division of Preventive Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Nicholas Forrister
- Division of Internal Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Ali M Ahmed
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, Alabama, USA
| | - Mahmoud Aryan
- Division of Internal Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Robert Oster
- Division of Preventive Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Sushanth Reddy
- Division of Surgical Oncology, University of Alabama, Birmingham, Alabama, USA
| | | | - Shajan Peter
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, Alabama, USA
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Ramai D, Heaton J, Fang J. Safety of Percutaneous Endoscopic Jejunostomy Placement Compared With Surgical and Radiologic Jejunostomy Placement: A Nationwide Inpatient Assessment. J Clin Gastroenterol 2023:00004836-990000000-00235. [PMID: 38019077 DOI: 10.1097/mcg.0000000000001948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/27/2023] [Indexed: 11/30/2023]
Abstract
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.
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Affiliation(s)
- Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT
| | - Joseph Heaton
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, NJ
| | - John Fang
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT
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Bourgeois A, Gkolfakis P, Fry L, Arvanitakis M. Jejunal access for enteral nutrition: A practical guide for percutaneous endoscopic gastrostomy with jejunal extension and direct percutaneous endoscopic jejunostomy. Best Pract Res Clin Gastroenterol 2023; 64-65:101849. [PMID: 37652649 DOI: 10.1016/j.bpg.2023.101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/02/2023] [Indexed: 09/02/2023]
Abstract
For patients requiring long-term (>4 weeks) jejunal nutrition, jejunal medication delivery, or decompression, a percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) or a direct percutaneous endoscopic jejunostomy (DPEJ) may be indicated. PEG-J is the preferred option if a PEG tube is already in place or if simultaneous gastric decompression and jejunal nutrition are needed. DPEJ is recommended for patients with altered anatomy due to foregut surgery, high risk of jejunal extension migration, and whenever PEG-J fails. Successful placement rates are lower for DPEJ but recent publications have reported improvements, partly due to the use of balloon-assisted enteroscopy. Both techniques are contraindicated in cases of active peritonitis, uncorrectable coagulopathy, and ongoing bowel ischaemia, and relative contraindications include, among other, peptic ulcer disease and haemodynamic or respiratory instability. In this narrative review, we present the most recent evidence on indications, contraindications, technical considerations, adverse events, and outcomes of PEG-J and DPEJ.
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Affiliation(s)
- Amélie Bourgeois
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Lucia Fry
- Internal Medicine, Gastroenterology and Geriatrics, Frankenwaldklinikum Kronach, Germany
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.
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Aryan M, Colvin T, Mulki R, Daley L, Patel P, Locke J, Ahmed AM, Kyanam Kabir Baig KR, Mönkemüller K, Peter S. Direct percutaneous endoscopic jejunostomy tube placement in patients post Roux-en-Y gastric bypass, a single tertiary care center experience. Endosc Int Open 2022; 10:E1282-E1290. [PMID: 36118633 PMCID: PMC9473825 DOI: 10.1055/a-1905-0339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/19/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Mahmoud Aryan
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Tyler Colvin
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Ramzi Mulki
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Alabama, United States
| | - Lauren Daley
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Parth Patel
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - John Locke
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Ali M. Ahmed
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Alabama, United States
| | | | | | - Shajan Peter
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Alabama, United States
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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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Martínez-Alcalá García Á, Jovanovic I, Ahmed AM, D'Assuncao M, Kröner T, Mönkemüller K. Extreme endoscopy: direct jejunostomy, re-anastomosis of bowel, percutaneous assisted transprosthetic endoscopic drainage in Roux-en-Y gastric bypass. Endoscopy 2022; 54:E13-E14. [PMID: 33592646 DOI: 10.1055/a-1346-7877] [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: 12/10/2022]
Affiliation(s)
- Álvaro Martínez-Alcalá García
- Department of Gastroenterology, Hospital Universitario Infanta Leonor, Madrid, Spain.,Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Ivan Jovanovic
- Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA.,University of Belgrade, Belgrade, Serbia
| | - Ali M Ahmed
- Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Marco D'Assuncao
- Department of Surgery, Hospital Sirio Libanes, Sao Paulo, Brasil
| | - Thomas Kröner
- Division of Gastroenterology, Mayo Clinic, Jacksonville, USA
| | - Klaus Mönkemüller
- Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA.,University of Belgrade, Belgrade, Serbia.,Department of Gastroenterology, Ameos Teaching University Hospital (Otto-von-Guericke University - Magdeburg), Halberstadt, Germany
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Abstract
Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed.
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Bernardes C, Pinho R, Rodrigues A, Proença L, Carvalho J. Direct percutaneous endoscopic jejunostomy using single-balloon enteroscopy without fluoroscopy: a case series. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 109:679-683. [PMID: 28724303 DOI: 10.17235/reed.2017.4717/2016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method to provide enteral nutrition to individuals when gastric feeding is not possible or contraindicated. The aim of this study was to analyze the efficacy and safety of DPEJ tube placement with the Gauderer-Ponsky technique by the pull method, using single-balloon enteroscopy (SBE) without fluoroscopy. METHODS This is a retrospective analysis of patients undergoing SBE for DPEJ placement in a referral hospital between January 2010 and March 2016. Technical success, clinical success and procedure related complications were recorded. RESULTS Twenty-three patients were included (17 males, median age 71 years, range 37-93 years). The most frequent indications for DPEJ were gastroesophageal cancer (n = 10) and neurological disease (n = 8). Eighty-seven percent of the patients had a contraindication to percutaneous endoscopic gastrostomy (PEG) and PEG was unsuccessful in the remaining patients. The technical success rate was 83% (19/23), transillumination was not possible in three patients and an accidental exteriorization of the bumper resulting in a jejunal perforation occurred in one patient. The clinical success was 100% (19/19). The median follow-up was five months (range 1-35 months). Apart from the case of jejunal perforation and the two cases of accidental exteriorization, there were no other complications during follow-up. The 6-month survival was 65.8% and the 1-year survival was 49.3%. CONCLUSION DPEJ can be carried out successfully via SBE without fluoroscopy with a low rate of significant adverse events. Although, leaving the overtube in place during the bumper pulling can be useful for distal jejunal loops, it can be safely removed in proximal loops to minimize complications.
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Affiliation(s)
- Carlos Bernardes
- Department of Gastroenterology, Centro Hospitalar de Lisboa Central, Portugal
| | - Rolando Pinho
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
| | - Adélia Rodrigues
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia/Espinho, Portugal
| | - Luísa Proença
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
| | - João Carvalho
- Department of Gastroenterology and Hepatology, Centro Hospitalar de Vila Nova de Gaia/Espinho
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Shelnut DJ, Sims OT, Zaibaq JN, Oh H, Venkata KV, Peter S. Predictors for outcomes and readmission rates following double balloon enteroscopy: a tertiary care experience. Endosc Int Open 2018; 6:E751-E757. [PMID: 29876513 PMCID: PMC5988547 DOI: 10.1055/a-0602-3967] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 03/07/2018] [Indexed: 12/19/2022] Open
Abstract
AIM The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting positive diagnostic yield, therapeutic yield, and readmission. METHODS We conducted a retrospective cohort study of patients (n = 420) who underwent DBE at a tertiary care center between 2012 and 2016 at a tertiary referral center. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and t-test analyses were used to compare patient characteristics. Logistic regression was used to predict outcomes of interest. RESULTS Of patients included in the study, 59 % were male with a mean age of 61.49 (SD = 15.15) Altered anatomy was noted in 14 %, while 5 % and 13 % of patients had end stage renal disease (ESRD) and current use of anticoagulation, respectively. The most common indication for DBE was obscure gastrointestinal bleed (OGIB) (33 %). Forty-nine patients had obscure and overt gastrointestinal bleeding (GIB) and 22 % had occult GIB with iron deficiency. The cohort's rate of positive diagnostic yield was 73 % and 35 % for therapeutic yield. The 30-day and 6-month readmission rates were both 11 %. A higher proportion of those readmitted were male (75 % vs 57 %, P = 0.027) and had longer procedural time (38.68 vs 46.57, P = 0.011). Likewise, occult GIB with iron deficiency anemia and iron deficiency alone (OR = 2.45, CI: 1.233 - 4.859, P = 0.011), inpatient status (OR 2.42, CI 1.344 - 4.346, P = 0.003), and longer procedural time (OR = 1.02, CI: 1.004 - 1.029, P = 0.008) were associated positively with readmission. CONCLUSION DBE procedures have relevant efficacy for both diagnostic and therapeutic yield while evaluating small bowel disease. Readmission rates are low and more in those with GI bleed and iron deficiency with longer index procedural times.
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Affiliation(s)
- Danielle Jarrard Shelnut
- University of Alabama at Birmingham, Tinsley Harrison Internal Medicine Residency, Birmingham, Alabama
| | - Omar T. Sims
- University of Alabama at Birmingham, Department of Social Work, College of Arts and Sciences/Department of Health Behavior, School of Public Health/Center for AIDS Research/Comprehensive Center for Healthy Aging, Birmingham, Alabama
| | - Jenine N. Zaibaq
- University of Alabama at Birmingham, Tinsley Harrison Internal Medicine Residency, Birmingham, Alabama
| | - Hyejung Oh
- Troy University, Dothan Campus Ringgold Standard Institution, Department of Human Services & Social Work, College of Health and Human Services, Dothan, Alabama
| | | | - Shajan Peter
- University of Alabama at Birmingham, Division of Gastroenterology and Hepatology, Birmingham, Alabama
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Direct Percutaneous Endoscopic Jejunostomy for the Management of Gastroparesis in Pregnancy. Obstet Gynecol 2018; 131:871-874. [PMID: 29630025 DOI: 10.1097/aog.0000000000002583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Providing meaningful nutrition in cases of refractory hyperemesis during pregnancy can be challenging; although intragastric enteral nutrition is the most common approach, it is contraindicated in certain cases and carries the risk of increased nausea and vomiting. CASE A 36-year-old primigravid woman with a history of gastroparesis presented at 16 weeks of gestation with nausea and vomiting. With no improvement with conventional approaches and signs of malnutrition, a direct percutaneous endoscopic jejunostomy was placed. Her nutritional status improved, and the pregnancy ended in the delivery of a healthy neonate. CONCLUSION Direct percutaneous endoscopic jejunostomy in pregnancy is an option in patients in whom intragastric feeding is contraindicated and may offer a more secure approach than percutaneous gastrojejunostomy.
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Balloon-assisted ultrasonic localization: a novel technique for direct percutaneous endoscopic jejunostomy. Eur J Clin Nutr 2018; 72:618-622. [PMID: 29459788 DOI: 10.1038/s41430-018-0115-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 01/23/2018] [Accepted: 01/26/2018] [Indexed: 01/24/2023]
Abstract
Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method for the establishment of enteral nutrition (EN) pathway. However, the identification of stomal puncture points for DPEJ is difficult. Here we present a case treated with an improved technique for DPEJ puncture-point localization, which was named DPEJ with balloon-assisted ultrasonic localization (DPEJ-BAUL). There were four steps after insertion of an endoscope into the jejunum: (1) a balloon dilatation catheter was inserted through the endoscope working channel; (2) the balloon was fully filled with water; (3) the site of puncture was selected with an ultrasonic probe percutaneously locating the water-filled balloon; and (4) a jejunostomy tube was placed by introducer technique. Rapid localization of a puncture site was possible with BAUL and the DPEJ procedure was successful. The patient's nutritional status was improved with EN and no postoperative complications were observed. DPEJ-BAUL is a feasible and effective technique to increase the technical success rate of DPEJ in patients with negative transillumination test results.
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12
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Mönkemüller K, Olano C, Rickes S. Direct percutaneous endoscopic jejunostomy - Should we move on to single- and double-balloon enteroscopy techniques? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:677-678. [PMID: 28929778 DOI: 10.17235/reed.2017.5182/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful technique to access the jejunum in order to: a) provide enteral nutrition to individuals when the gastric route is absent or contraindicated; and b) to decompress the jejunum in patients with malignant small bowel obstruction. Traditionally, DPEJ is performed using a colonoscope or enteroscope, which is advanced as deep as possible into the jejunum. The insertion technique of the feeding tube is identical to the one used for a gastrostomy tube (Ponsky-Gauderer method).
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Affiliation(s)
| | - Carolina Olano
- Gastroenterology, Hospital de Clinicas, Universidad de la Republica, Uruguay
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13
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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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Belsha D, Thomson M, Dass DR, Lindley R, Marven S. Assessment of the safety and efficacy of percutaneous laparoscopic endoscopic jejunostomy (PLEJ). J Pediatr Surg 2016; 51:513-8. [PMID: 26778843 DOI: 10.1016/j.jpedsurg.2015.11.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/02/2015] [Accepted: 11/26/2015] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Dalis Belsha
- Centre of Paediatric Gastroenterology, Sheffield Children Hospital
| | - Mike Thomson
- Centre of Paediatric Gastroenterology, Sheffield Children Hospital.
| | | | | | - Sean Marven
- Paediatric Surgical Unit, Sheffield Children Hospital
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Lim AH, Schoeman MN, Nguyen NQ. Long-term outcomes of direct percutaneous endoscopic jejunostomy: a 10-year cohort. Endosc Int Open 2015; 3:E610-4. [PMID: 26716121 PMCID: PMC4683153 DOI: 10.1055/s-0034-1392806] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 07/13/2015] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Amanda H. Lim
- Departments of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Mark N. Schoeman
- Departments of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Nam Q. Nguyen
- Departments of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia,University Department of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia,Corresponding author Nam Q. Nguyen, PhD Department of Gastroenterology and HepatologyRoyal Adelaide HospitalNorth TerraceAdelaideSouth Australia 5000Australia+61-8-82235885
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Pinho R. The Vanishing Frontiers of Therapeutic Enteroscopy. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2015; 22:133-134. [PMID: 28868394 PMCID: PMC5580178 DOI: 10.1016/j.jpge.2015.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Pinho RT, Rodrigues MAR, Proença MLS. Overtubes and fluoroscopy for direct percutaneous endoscopic jejunostomy: useful, although not always needful and sometimes harmful. Dig Endosc 2015; 27:399-400. [PMID: 25559885 DOI: 10.1111/den.12426] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Rolando Taveira Pinho
- Department of Gastroenterology, Centro Hospitalar de Vila Nova de Gaia, Vila Nova de Gaia, Portugal
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