Mini-laparoscopically guided percutaneous gastrostomy and jejunostomy

BACKGROUND: Percutaneous endoscopic tube placement can be problematic under certain circumstances: absence of transillumination of the abdominal wall, percutaneous jejunostomy in patients with a PEG tube and recurrent aspiration, enteral feeding access after gastrectomy, and obstruction of the upper GI tract. As an alternative in these problematic situations, a technique was developed for placing feeding tubes under visual control by using mini-laparoscopy. METHODS: Placement of a feeding tube with mini-laparoscopy with the patient under conscious sedation was considered for 17 patients in whom standard PEG placement was impossible. Techniques used were the following: combined mini-laparoscopy/endoscopy for placement of a percutaneous gastrostomy or jejunostomy, and mini-laparoscopic-guided direct tube placement in cases of obstruction of the upper GI tract. OBSERVATIONS: In 13 patients, mini-laparoscopic-assisted tube placement was successful. In 4 patients, adhesions or peritoneal carcinomatosis prevented laparoscopic visualization of the stomach or small bowel. The combined mini-laparoscopic/endoscopic approach allowed a successful insertion of gastric tubes in 6 patients and jejunal tubes in 4 patients. Direct insertion of a percutaneous endoscopic jejunostomy tube without enteroscopy was feasible in all 3 patients with obstruction of the upper GI tract. No complication occurred. CONCLUSIONS: Mini-laparoscopy-assisted tube placement is a simple and safe alternative when endoscopic percutaneous tube placement is problematic or not feasible.     

Advances in Enteral Nutrition Techniques

The increasing use of enteral nutrition in hospitals has led to an expanded role for the gastroenterologist and surgeon in providing enteral access. New concepts in immunonutrition and gut support in critically ill patients have popularized early postoperative feeding. There is an ongoing need to update physicians on the diverse enteral access techniques now available. In addition to standard percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) techniques, this review focuses on reflux prevention through double-lumen feeding-suction tubes, and describes the use of steerable catheters for rapid insertion of nasojejunal and PEJ tubes without endoscopy. Low-profile "button"-type devices, one-step button placement, replacement gastrostomy devices, and special enteral techniques for patients with cancer are also reviewed.     

Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension

BACKGROUND: Jejunostomy tubes can be placed endoscopically by means of percutaneous gastrostomy with jejunal extension (PEG-J) or by direct percutaneous jejunostomy. These 2 techniques were retrospectively compared in patients requiring long-term jejunal feeding. METHOD: An endoscopy database was used to identify all patients who underwent endoscopic jejunal feeding tube placement from January 1996 to May 2001. Patients with a history of upper GI surgery were excluded. There were 56 patients with a direct percutaneous jejunostomy and 49 with a percutaneous gastrostomy with jejunal extension. Patients in the direct percutaneous jejunostomy group received a 20F direct jejunostomy tube; a 20F PEG tube with a 9F jejunal extension was used in the percutaneous gastrostomy with jejunal extension group. Medical records for the period of 6 months after establishment of jejunal access were reviewed. Complications and need for further endoscopic intervention within this time frame were recorded. The duration of feeding tube patency (number of days from established jejunal access to first endoscopic reintervention) was compared for both groups. RESULTS: Feeding tube patency was significantly longer in patients who had a direct percutaneous jejunostomy compared with those with a percutaneous gastrostomy with jejunal extension. Within the 6-month period, 5 patients with a direct percutaneous jejunostomy required endoscopic reintervention for tube dysfunction compared with 19 patients who had a percutaneous gastrostomy with jejunal extension (p < 0.0001). CONCLUSIONS: For patients who require long-term jejunal feeding, a direct percutaneous jejunostomy with a 20F tube provides more stable jejunal access compared with a percutaneous gastrostomy with jejunal extension with a 9F extension and has a lower associated rate of endoscopic reintervention.     

经皮内镜胃造瘘和空肠造瘘术研究进展

经皮内镜胃造瘘(PEG)和空肠造瘘术(PEJ)人工肠内营养可有效避免患者营养状况进一步恶化,提高患者生活质量。随着对治疗目的更清晰的认识以及内镜技术的进步,PEG/PEJ适应证增加而禁忌证相对减少,操作技术及并发症防治研究有了许多进展。     

Tube dysfunction following percutaneous endoscopic gastrostomy and jejunostomy

Percutaneous endoscopic gastrostomy (PEG) and jejunostomy (PEJ) have supplanted their surgical counterparts in many institutions. Previous reports have claimed advantages in placing PEJ tubes because of reduced gastroesophageal reflux, prevention of aspiration, and improved tube anchoring distally. We reviewed the records of 191 patients who underwent placement of PEG/J tubes. Data collected included incidence of tube dysfunction, need for tube replacement or removal, and aspiration after PEG or PEJ tube placement. Tube dysfunction, defined as peritube leakage, plugging, fracture, or migration, occurred in 36% of patients over a mean follow-up period of 275 days and was significantly more common and likely to necessitate tube replacement in PEJ patients. Tube trade-out or removal and aspiration within a 30-day period after tube placement occurred in 28% and 10% of patients, respectively. These complications were significantly more common in PEJ patients than in PEG patients. Because of the increased incidence of tube dysfunction and the failure to prevent aspiration in predisposed patients, PEJ tube placement is not routinely indicated in patients requiring tube feedings.     

Direct percutaneous endoscopic jejunostomy: a case series in pediatric patients.

BACKGROUND: Direct percutaneous endoscopic jejunostomy (DPEJ) is a well-known approach to deliver postpyloric enteral nutrition support to individuals who cannot tolerate gastric feeding. DPEJ addresses many of the shortcomings of jejunal feeding tubes placed through percutaneous endoscopic gastrostomy tubes. The safety and efficacy of DPEJ in adults has been previously reported. There are no reports on the use of DPEJ in pediatric patients. OBJECTIVE: Our purpose was to report on 5 pediatric patients who underwent DPEJ placement between January 2000 and January 2003 over the available follow-up periods. DESIGN: Retrospective case series. SETTING: University of Utah Health Sciences Center and the Medical University of South Carolina. PATIENTS: Five patients, age range 4 to 17 years. MAIN OUTCOME MEASUREMENTS: Rate of successful tube placement, major and minor complications, and outcomes including weight gain and recurrent aspiration after DPEJ placement. RESULTS: All 5 attempted DPEJs were placed successfully with 2 minor complications of peristomal leakage and peristomal skin infection. One DPEJ was replaced 2 years after placement because of fungal degradation. The mean weight gain among all patients was 10.3 kg in a mean of 22.6 months. LIMITATIONS: Retrospective, small series. CONCLUSIONS: DPEJ placement appears to be a safe and effective approach to enteral nutritional support in pediatric patients requiring long-term access to the jejunum. No major complications occurred and all patients gained weight after tube placement.     

Use of a 19-gauge injection needle as a guide for direct percutaneous endoscopic jejunostomy tube placement

BACKGROUND: Direct percutaneous endoscopic jejunostomy (DPEJ) tube placement is becoming an accepted means of achieving enteral nutrition. However, during DPEJ placement it can be difficult to maintain the position of the small bowel for insertion of the plastic sheath with stylet, thus limiting the success of the procedure. The results of a technique designed to overcome this problem are presented. METHODS: During DPEJ placement, a 19-gauge injection needle was passed into the bowel at the site of transillumination. The needle was snared tightly, fixing the small bowel against the abdominal wall. The plastic sheath with stylet was then inserted adjacent to the 19-gauge needle and into the small bowel and was subsequently snared to facilitate guidewire passage. A 24F, pull-type PEJ tube was then placed in standard fashion. RESULTS: A DPEJ was placed successfully in 24 of 26 (92.3%) patients with this technique. There was one (4%) major complication: inadvertent small bowel perforation during DPEJ placement. The average time to complete a procedure was 23.3 minutes; the mean time to achieve the dietary goal after DPEJ placement was 39 hours. One patient died of an unrelated illness 6 days after DPEJ placement; 23 were discharged with jejunal feeding. CONCLUSIONS: A DPEJ can be performed successfully by using a 19-gauge injection needle as guide for tube placement.     

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.     

Percutaneous endoscopic jejunostomy: long-term follow-up of 23 patients

This study reports our experience with the placement and long-term follow-up of 26 percutaneous endoscopic jejunostomy (PEJ) tubes in 23 patients over a 2-year period. Eighty-four percent of the PEJ tubes failed and were functional for an average of only 39.5 days. The reasons for failure were: (1) separation of the inner PEJ tube from the outer gastrostomy tube (59%); (2) clogging (32%) due to small PEJ tube diameter; and (3) kinking and knotting (9%). Upper gastrointestinal bleeding occurred in 30% of the patients (7 of 23). Only one patient required blood transfusions (2 units). The etiology of the bleeding was not determined. These patients had a previous history of acid-peptic disease and bleeding occurred despite cimetidine treatment. In contrast, only 1 of the 16 nonbleeding patients had acid-peptic disease (p less than 0.0001) and none were on cimetidine. The frequency of aspiration pneumonia decreased from 13 episodes during nasogastric tube feedings to 5 episodes during PEJ tube feedings. Improvement in the design of the PEJ tubes may increase the longevity and effectiveness of the tubes.     

Endoscopic Management of Bleeding Gastric Varices—an Updated Overview

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

The provision of a percutaneously placed enteral tube feeding service

There is overwhelming evidence that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost. Short-term enteral access is usually achieved via naso-enteral tube placement. For longer term tube feeding there are recognised advantages for enteral feeding tubes placed percutaneously. The provision of a percutaneous enteral tube feeding service should be within the remit of the hospital nutrition support team (NST). This designated team should provide a framework for patient selection, pre-assessment and post-procedural care. Close working relations with community-based services should be established. An accredited therapeutic endoscopist should be a member of the NST and direct the technical aspects of the service. Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Specialist units should be identified where a more comprehensive service is provided, including direct jejunal placement (DPEJ), as well as radiological and laparoscopically placed tubes. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment. Careful adherence to the important technical details of tube insertion will reduce peri-procedural complications. Post-procedural complications remain relatively common, however, and an awareness of the correct approach to managing them is essential for all clinicians involved in providing a percutaneous enteral tube feeding service. Finally, ethical considerations should always be taken into account when considering long-term enteral feeding, especially for patients with a poor quality of life.     

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.     

Enteral Access by Double-Balloon Enteroscopy: An Alternative Method of Direct Percutaneous Endoscopic Jejunostomy Placement

Background  

Although direct percutaneous endoscopic jejunal feeding tube placement is an increasingly accepted method of providing small-bowel access for long-term enteral nutrition, it is reliant on push enteroscopy and remains a technically challenging procedure with significant failure rates. Double-balloon enteroscopy, with its ability to provide controlled small-bowel intubation may facilitate direct percutaneous endoscopic jejunal tube placement.     

Application of percutaneous endoscopic gastrostojejunostomy in a case of amyotrophic lateral sclerosis associated with the superior mesenteric artery syndrome

A 64‐year‐old woman who was diagnosed as suffering from amyotrophic lateral sclerosis (ALS) of bulbar type was admitted to our hospital for long‐term care. After admission, she underwent percutaneus endoscopic gastrostomy (PEG) and enteral feeding was initiated. However, the PEG alimentation was disrupted by aspiration pneumonia owing to the superior mesenteric artery syndrome (SMAS), diagnosed by gross anatomy and endoscopic studies. Conservative treatment for SMAS was not successful and sepsis developed. After recovery from this, an operation was recommended, but it was rejected by her and her family members. We therefore selected the method of placing a thin jejunostomy tube through the PEG, called percutaneous endoscopic gastrojejunostomy (PEGJ) and pulling it endoscopically into the proximal jejunum, thereby allowing delivery of nutrients. Thereafter, she was well and showed gradual improvement of nutritional parameters such as serum albumin and total cholesterol, as well as the lymphocyte subset. It is concluded that PEGJ is effective for long‐term enteral nutrition in ALS patients complicated with SMAS.     

Endoscopic techniques for enteral nutrition: standards and innovations

Enteral nutrition has been increasingly used in clinical practice during the past decades. Today, nasogastric, nasoenteric, and transcutaneous gastric or enteral feeding tubes are well established as a routine endoscopic intervention. After clinical introduction of percutaneous endoscopic gastrostomy (PEG) in 1980, the sutureless 'pull' PEG has become a widespread endoscopic technique for transcutaneous gastric long-term nutrition. Multiple new techniques have been introduced since then, and today even long-term jejunal nutrition can be achieved with modified techniques. The introducer PEG (first reported in 1984) has not become an established procedure, but new techniques with an endoscopic gastropexy might be a more effective approach. To increase the quality of life of the patients, skin-level devices were designed and successfully introduced in 1984. A new development has been the one-step feeding tubes which provide the patients with a permanent tube. The standard techniques for long-term enteral feeding, new developments of feeding tubes, and future concepts are discussed in this review.     

A 94-year-old woman with nontuberculous mycobacterium who developed small intestinal intussusception associated with a percutaneous endoscopic jejunostomy tube

We report a 94-year-old woman, who underwent percutaneous endoscopic Jejunostomy (PEJ) tube feeding for enteral nutrition, developed the intussusception of the small intestine. She suffered from nontuberculous mycobacterium (NTM), and her lung inflammation deteriorated due to aspiration pneumonia and malnutrition. Because of old age, dysphagia, esophageal hiatus hernia, gastro-esophageal reflux and her bedridden condition due to severe osteoporosis, oral nutritional supplementation is nearly impossible. To reduce the aspiration risk, we chose PEJ instead of percutaneous endoscopic gastrostomy (PEG) as the route of tube feeding. Six months after the placement of a PEJ tube, aspiration pneumonia was diagnosed and she was readmitted to our hospital. During hospitalization, she had sudden diarrhea, vomiting, and lower abdominal pain. Abdominal CT scan and radiographs using contrast medium showed small intestinal intussusception related to the PEJ tube. We observed the clinical course without performing surgery, pulling it back towards the stomach and placing an ileus tube, because the small intestine was not completely obstructed. Two months later, although she suffered from aspiration pneumonia once more, she remained in a stable condition without further intervention so that she could move to aother hospital. Recently PEJ has been expected to prevent aspiration pneumonia, but we believe that it can be a risk factor for intussusception. Although the PEJ can be a good parenteral nutrition route for frail elderly with dysphagia, we need to consider possible complications including intussusception.     

Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy

AIM:To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy(PEG)could be a valuable option for patients with complicated anatomy.METHODS:A retrospective analysis of twelve patients(seven females,five males;six children,six young adults;mean age 19.2 years)with cerebral palsy,spastic quadriparesis,severe kyphoscoliosis and interposed organs and who required enteral nutrition(EN)due to starvation was performed.For all patients,standard PEG placement was impossible due to distorted anatomy.All the patients qualified for the laparoscopyassisted PEG procedure.RESULTS:In all twelve patients,the laparoscopy-assisted PEG was successful,and EN was introduced four to six hours after the PEG placement.There were no complications in the perioperative period,either technical or metabolic.All the patients were discharged from the hospital and were then effectively fed using bolus methods.CONCLUSION:Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.     

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

BACKGROUND: Complications after esophagectomy may prevent oral intake, lead to dependence on total parenteral nutrition, and lengthen hospital stay. Direct percutaneous endoscopic placement of a jejunostomy tube allows enteral feeding in the presence of postoperative complications and eliminates the need for total parenteral nutrition. METHODS: A total parenteral nutrition database was used to identify patients who received total parenteral nutrition because of complications after esophagectomy. Records of all patients subsequently referred for percutaneous endoscopic jejunostomy placement were reviewed. RESULTS: Twenty-five patients with postesophagectomy complications were referred for percutaneous endoscopic jejunostomy placement. A percutaneous endoscopic jejunostomy was successfully placed in 21 patients (84%), all of whom were weaned off total parenteral nutrition. Six patients (29%) in whom percutaneous endoscopic jejunostomy placement was successful died during hospitalization at a mean of 20 days (range 5-40 days) after the procedure for reasons unrelated to percutaneous endoscopic jejunostomy tube insertion. The remaining 15 patients were discharged while receiving nutrition by means of the percutaneous endoscopic jejunostomy. Ten of them had subsequent removal of the percutaneous endoscopic jejunostomy at a mean of 131 days (range 20-281 days). There were no major percutaneous endoscopic jejunostomy-related complications. Minor complications occurred in 4 patients (19%). CONCLUSION: Percutaneous endoscopic jejunostomy placement may be considered in patients with complications after esophagectomy. In these patients, percutaneous endoscopic jejunostomy placement avoids the need for total parenteral nutrition.     

Endoscopic Clips Prevent Displacement of Intestinal Feeding Tubes: A Long-Term Follow-Up Study

Background Displacement of jejunal feeding tubes is a major problem in enteral feeding. Although endoscopic clips have been used to prevent migration of the tube during placement, the long-term effect of the clips on tube displacement is unknown. Objectives The purpose of this study was to examine the long-term effect of endoscopic clips on preventing displacement of the jejunal feeding tube. Design A retrospective study. Setting A single tertiary medical center. Main outcome measurements The success rate of the procedure and the functional duration of the feeding tube. Results About 93% of patients had a percutaneous endoscopic gastrostomy jejunal (PEGJ) tube successfully placed with use of endoscopic clips. About 7% had tube migration and repeat procedures were successful. The mean functional duration of the tube was 55 days. Limitations Retrospective, single-center. Conclusions Use of endoscopic clips can prevent migration during placement of the feeding tube and can also reduce tube displacement in the long term.