Samuel Ibrahim, MD, Manish Singh, MD, Bipan Chand, MD, Mathew Kroh, MD, Stacy Brethauer, MD, Philip Schauer, MD. Advanced Laparoscopic and Bariatric Surgery, Cleveland Clinic, Cleveland, Ohio · http://clevelandclinic.org
Gastric resection with intestinal reconstruction for both benign and malignant processes as well as roux –n-Y gastric bypass (RYGB) for weight loss are commonly performed in the US . Patients infrequently require post-operative enteral feeding access. However, when needed access may be accomplished via endoscopic, radiologic or by surgical means. These patients infrequently present with recalcitrant nausea, dehydration and failure to thrive leading to poor oral intake and malnutrition. We present our experience with placement of direct endoscopic percutaneous Roux Limb Jejunostomy tubes.
Material & Methods
A retrospective review of patients presenting with failure to thrive after gastric bypass or gastrectomy and who underwent direct PEJ between January 2005 and July 2010 was conducted. All patients underwent diagnostic upper endoscopy and subsequent direct percutaneous jejunostomy tube placement via a pull technique into the Roux limb 10-20 cm distal to the gastrojejunostomy. All patients were started and discharged on home tube feedings. Study outcomes included type of gastric surgery, indications and complications of enteral access and duration of therapy.
Eleven patients underwent attempts as PEJ tube placement and all were successful. Seven patients were status post gastric bypass and four status post gastrectomy. Types of gastrectomies included total gastrectomy with roux en Y reconstruction and antrectomy with either Billroth I or Billroth II reconstruction. The average age was 51and the interval between the gastric surgery and PEJ placement ranged from 3 weeks to 39 years. The majority of indications included gastroparesis, persistent nausea and vomiting and failure to thrive. One patient who had previous gastric resection suffered a CVA and required enteral feedings. Mean duration of PEJ tube placement was 6.1 months, with 2 tubes still in place at the time of this study. One patient expired due to an unrelated condition with the PEJ tube in place. The only PEJ related complication was cellulitis in one patient. Only one readmission occurred after PEJ placement for a patient with refractory nausea.
Post gastrectomy and post gastric bypass patients infrequently require enteral access for feeding. Failure to thrive secondary to poor oral intake can be managed with short term enteral feeds. Direct PEJ placement is feasible in this patient population and has an overall low morbidity rate.
Program Number: P076