Overtubes and fluoroscopy for direct percutaneous endoscopic jejunostomy: useful, although not always needful and sometimes harmful

Percutaneous endoscopic jejunostomy: when, how, and when to avoid it

PURPOSE OF REVIEW

The current review summarizes current evidence regarding the indications, contraindications, and technical aspects of placing a direct percutaneous endoscopic jejunostomy (DPEJ), as well as procedure-related and patient-related outcomes.

RECENT FINDINGS

DPEJ is indicated for patients who require long-term (>4 weeks) jejunal nutrition due to existing altered foregut anatomy (e.g., previous gastrectomy) or because the gastric route is not an option (e.g., due to high risk of aspiration, intolerance, gastroparesis). DPEJ may also offer decompression of the gastrointestinal tract in cases of small bowel obstruction (e.g., peritoneal carcinomatosis). Absolute contraindications include active peritonitis, uncorrectable coagulopathy, and ongoing bowel ischemia. Technically, the 'pull' technique using a paediatric colonoscope will be sufficient for most cases. Recent publications demonstrate high rates of technical success (>85%), while patient outcomes do not differ among patients undergoing percutaneous endoscopic gastrostomy (PEG) and those undergoing DPEJ. Obesity is a risk factor for technical failure, while age more than 80 years, diabetes mellitus, and ongoing inflammatory status may be considered risk factors for DPEJ-associated mortality.

SUMMARY

DPEJ is a safe and efficacious modality for long-term jejunal nutrition with an acceptable risk of mild complications. Careful patient selection and respect of preprocedural, periprocedural, and postprocedural precautions are of the utmost importance to ensuring a favourable outcome.

Direct percutaneous endoscopic jejunostomy using single-balloon enteroscopy without fluoroscopy: a case series

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.

Balloon-assisted ultrasonic localization: a novel technique for direct percutaneous endoscopic jejunostomy

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.

Multicenter survey on the use of device-assisted enteroscopy in Portugal

BACKGROUND

Device-assisted enteroscopies (DAEs) are recent endoscopic techniques that enable direct endoscopic small-bowel evaluation.

OBJECTIVE

The objective of this article is to evaluate the implementation of DAEs in Portugal and assess the main indications, diagnoses, diagnostic yield, therapeutic yield and complication rate.

METHODS

We conducted a multicenter retrospective series using a national Web-based survey on behalf of the Portuguese Small-Bowel Study Group. Participants were asked to fill out two online databases regarding procedural data, indications, diagnoses, endoscopic therapy and complications using prospectively collected institutional data records.

RESULTS

A total of eight centers were enrolled in the survey, corresponding to 1411 DAEs. The most frequent indications were obscure gastrointestinal bleeding (OGIB), inflammatory bowel disease and small-bowel tumors. The pooled diagnostic yield was 63%. A relation between the diagnostic yield and the indications was clear, with a diagnostic yield for OGIB of 69% (p = 0.02) with a 52% therapeutic yield. Complications occurred in 1.2%, with a major complication rate of 0.57%. Perforations occurred in four patients (0.28%).

CONCLUSION

DAEs are safe and effective procedures, with complication rates of 1.2%, the most serious of which is perforation. Most procedures are performed in the setting of OGIB. Diagnostic and therapeutic yields are dependent on the indication, hence appropriate patient selection is crucial.