Upper Endoscopy for GI Fellows by Douglas G. Adler

Author:Douglas G. Adler
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Direct Percutaneous Endoscopic Jejunostomy Tubes (DPEJ)

DPEJ is indicated for jejunal feeds when an existing PEG is not present, for persistent dysfunction of PEGJ tubes and, most importantly, when expertise in placing a DPEJ exists. DPEJ tubes have greater durability as the larger bore tubes clog less and do not migrate or kink as frequently when compared to PEGJ [28, 29]. DPEJ may also reduce aspiration in high-risk patients [30]. DPEJ, however, is performed much less frequently than PEGJ, at least in part due to the perceived risk and need for greater technical expertise. Direct percutaneous jejunostomy is considerably more difficult technically than percutaneous gastrostomy despite similar methods. Success rates are lower and complications rates are higher when compared to PEG tubes [5: 4–8]. Success rates for endoscopic jejunostomy range from 68 to 100% [31].

Direct percutaneous endoscopic jejunostomy (DPEJ) is a modification of the pull PEG technique. A pediatric colonoscope or enteroscope is advanced into the small bowel. Transillumination and finger palpation is performed over the jejunum instead of the stomach. A sounding needle and/or trocar is passed through the anterior abdominal wall into the jejunum. An insertion wire is advanced through the trocar and grasped. The procedure is then completed as per the pull type PEG (Figs. 9.4, 9.5, video 9.1) [32, 33]. Both single balloon enteroscopy (SBE) and double balloon enteroscopy (DBE) allow for deeper intubation of the small bowel, compared to standard push enteroscopy, increasing the likelihood of reaching an appropriate site for DPEJ insertion. A recent study showed successful DPEJ placement in 10/10 patients using the DBE under general anesthesia (GA) after failed conventional placement with a pediatric colonoscope using conscious sedation [34]. In another study, Despott et al. also reported successful DPEJ tube placement by DBE under GA in nine of the ten consecutive cases, with failure in one case secondary to inadequate trans-illumination [35]. The mean procedure time was 35 min, and no procedure-related complications were reported [35]. Similarly, in yet another study single balloon enteroscopy (SBE) demonstrated success in 11 of 12 DPEJ procedures attempted with conscious sedation [36]. Initial data suggest that balloon assisted enteroscopy is a safe and effective innovation for DPEJ.

Fig. 9.4 a DPEJ placement. b DPEJ placement. From Ref. [28]. With permission from Elsevier

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