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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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Balassone V, Di Matteo FM, Imondi C, Capriati T, De Angelis P. Endoscopic ultrasound-guided gastrojejunostomy with lumen-apposing metal stent in a boy with neurological impairment requiring jejunal feeding. VideoGIE 2022; 7:262-264. [PMID: 35815166 PMCID: PMC9263758 DOI: 10.1016/j.vgie.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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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 A, Mönkemüller K. The University of Alabama at Birmingham (UAB) Raptor method for direct percutaneous endoscopic gastrostomy with jejunal extension tube placement. Endoscopy 2022; 54:E96-E97. [PMID: 33784754 DOI: 10.1055/a-1388-5247] [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)
- Alvaro Martínez-Alcalá
- Department of Gastroenterology, Hospital Universitario Infanta Leonor, Madrid, Spain.,Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham (UAB), Alabama, USA
| | - Klaus Mönkemüller
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham (UAB), Alabama, USA.,University of Belgrade, Belgrade, Serbia.,Ameos Klinikum University Teaching Hospital, Halberstadt, Germany
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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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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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Abstract
Enteral access is the foundation for feeding in patients unable to meet their nutrition needs orally and have a functional gastrointestinal tract. Enteral feeding requires placement of a feeding tube. Tubes can be placed through an orifice or percutaneously into the stomach or proximal small intestine at the bedside or in specialized areas of the hospital. Bedside tubes can be placed by the nurse or the physician, such as in the intensive care unit. Percutaneous feeding tubes are placed by the gastroenterologist, surgeon, or radiologist. This article reviews the types of enteral access and the associated complications.
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Affiliation(s)
- Mark H DeLegge
- Department of Medicine, Medical University of South Carolina, 25 Courtenay Street, Charleston, SC 29425, USA; DeLegge Medical, 4057 Longmarsh Road, Awendaw, SC 29429, USA.
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Srinivasa RN, Chick JFB, Hage AN, Shields JJ, Saad WE, Majdalany BS, Srinivasa RN. Transnasal Snare Technique for Retrograde Primary Jejunostomy Placement After Surgical Gastrojejunostomy. Cardiovasc Intervent Radiol 2017; 40:1940-1944. [PMID: 28879520 DOI: 10.1007/s00270-017-1777-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/21/2017] [Indexed: 12/31/2022]
Abstract
PURPOSE To report a transnasal snare technique for retrograde primary jejunostomy placement after surgical gastrojejunostomy. MATERIALS AND METHODS Two patients underwent the transnasal snare technique for retrograde primary jejunostomy placement. Patients included two females, age 58 and 62. In both patients, a gooseneck snare was inserted in a transnasal fashion. After insertion of the snare into the jejunum, the location was confirmed with ultrasound. The snare was then targeted using a Chiba needle through which a 0.018-inch wire was advanced and snared through the nose. The wire was exchanged for a 0.035-inch Amplatz wire over which the tract was serially dilated followed by insertion of the jejunostomy catheter through a peel-away sheath. Technical success, complications, and follow-up were recorded. RESULTS Primary jejunostomy placement was technically successful in both patients. No minor or major complications occurred. Both patients received enteral nutrition the day following placement. Follow-up was at 54 and 38 days for patients 1 and 2, respectively. CONCLUSION The transnasal snare technique provides a novel alternative for primary jejunostomy insertion allowing for targeting of the jejunum with improved procedural success and no complications.
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Affiliation(s)
- Rajiv N Srinivasa
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health Systems, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jeffrey Forris Beecham Chick
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health Systems, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Anthony N Hage
- University of Michigan Medical School, Medical Science Building I, 1301 Catherine St., Ann Arbor, MI, 48109-5624, USA
| | - James J Shields
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health Systems, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Wael E Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health Systems, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Bill S Majdalany
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health Systems, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Ravi N Srinivasa
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health Systems, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, 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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Shenoy J, Adapala RKR. Study of Feeding Jejunostomy as an Add on Procedure in Upper Gastrointestinal Surgeries. Indian J Surg 2016; 77:275-82. [PMID: 26730009 DOI: 10.1007/s12262-012-0795-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Accepted: 12/02/2012] [Indexed: 12/26/2022] Open
Abstract
Jejunostomy is usually indicated as an additional procedure during major surgery of upper digestive tract to administer enteral nutrition in post-operative period. Complications associated with it can be mechanical, infectious, gastrointestinal or metabolic. The aim of the study was to evaluate safety of post-operative feeding jejunostomy in different types of major upper gastrointestinal surgeries. It was a prospective study conducted during the period between August 2009 and September 2011. Post-operative cases of major upper gastrointestinal surgeries who receive jejunostomy feeds were included in the study. Sampling was done by convenient method with sample size of 50 cases. Post-operatively, patients were monitored according to standard orders of enteral nutrition. Total calorie and protein intake through feeding jejunostomy was calculated regularly, and complications were assessed in terms of frequency, type, duration, management, and final outcome in different types of upper gastro intestinal surgeries. Analysis was done using chi square test with the help of statistical package SPSS vers.13. P < 0.05 was considered as significant. Complications observed were gastrointestinal -8 (16 %), mechanical -6 (12 %), infectious -4 (8 %) and metabolic -4 (8 %). Duration of complications ranged from 1 to 7 days (mean, 4 days). All types of complications observed during study were less severe and could be managed by simple measurements. Haemoglobin, serum albumin and weight of the patient at the time of discharge were improved for all patients when compared to pre-operative values. All patients received target calories and proteins through feeding jejunostomy. Considering benefits of enteral feeding via jejunostomy tube with minor and acceptable complications, we conclude that feeding jejunostomy is a preferred route of nutritional administration in those who undergo major upper gastro intestinal surgeries.
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Affiliation(s)
- Jayarama Shenoy
- Department of Surgery, Kasturba Medical College, Manipal University, Mangalore, India
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Li G, Shen X, Ke L, Tong Z, Li W. Established enteral nutrition pathway in a severe acute pancreatitis patient with duodenum fistula: a case report. Eur J Clin Nutr 2015; 69:1176-7. [DOI: 10.1038/ejcn.2015.135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 06/05/2015] [Accepted: 06/12/2015] [Indexed: 12/19/2022]
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Velázquez-Aviña J, Beyer R, Díaz-Tobar CP, Peter S, Kyanam Kabir Baig KR, Wilcox CM, Mönkemüller K. New method of direct percutaneous endoscopic jejunostomy tube placement using balloon-assisted enteroscopy with fluoroscopy. Dig Endosc 2015; 27:317-22. [PMID: 25211635 DOI: 10.1111/den.12352] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/20/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIM Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method to provide nutrition to patients with a variety of gastrointestinal (GI) problems. The present study describes a new method of DPEJ using balloon-assisted-enteroscopy. METHODS This observational, retrospective, single-arm case study conducted at a tertiary care hospital during a 15-month period included 25 patients (12 females, 13 males, mean age 54 years, age range 31-79 years) with necrotizing pancreatitis, n = 7; complex upper GI surgery, n = 6; complex fistula, n = 6; impossibility to place a gastrostomy tube, n = 5; and bowel obstruction, n = 1. The new DPEJ technique focused on three key components: (i) use of balloon-assisted overtube; (ii) use of fluoroscopy; (iii) leaving the overtube in place during the entire procedure (and also for DPEJ removal). RESULTS Technical success was 96%. Mean time of the procedure was 30.5 min (range 24 to 45 min). Clinical success was 100% (24/24); all DPEJ could be used for their intended purpose. CONCLUSIONS This new method of inserting a DPEJ using balloon enteroscopy and fluoroscopy was safe and successful. Future comparative studies are now warranted.
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Affiliation(s)
- Jacobo Velázquez-Aviña
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, USA
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Ao P, Sebastianski M, Selvarajah V, Gramlich L. Comparison of Complication Rates, Types, and Average Tube Patency Between Jejunostomy Tubes and Percutaneous Gastrostomy Tubes in a Regional Home Enteral Nutrition Support Program. Nutr Clin Pract 2014; 30:393-7. [DOI: 10.1177/0884533614554263] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Peter Ao
- Department of Medicine, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Meghan Sebastianski
- Epidemiology Coordinating and Research (EPICORE) Centre, University of Alberta, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Vijeyakumar Selvarajah
- Division of Gastroenterology, Grey Nuns Hospital, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Leah Gramlich
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
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