Andrew T Strong, MD, Gautam Sharma, Matthew Davis, MD, Michael Mulcahy, MD, Suriya Punchai, Colin O’Rourke, PhD, Stacy Brethauer, MD, John Rodriguez, MD, Jeffrey Ponsky, MD, Matthew Kroh, MD. Cleveland Clinic
INTRODUCTION: Patients with altered foregut anatomy requiring enteral access pose unique challenges. Direct percutaneous endoscopic jejunostomy (PEJ) is a viable alternative to operative jejunostomy tube placement.
METHODS AND PROCEDURES: All direct PEJ procedures performed by surgical endoscopists from May 2003 to June 2015 were retrospectively reviewed. Exclusion criteria were tube placement through an established tract or jejunal extension to prior PEG at the index operation. A total of 59 cases were identified. Demographic, procedural, and 30-day follow-up data were collected. The study was approved by the Institutional Review Board.
RESULTS: Mean age of our cohort was 50.3+/-16.9 years, and 35 (59.3%) were female. The mean Charlson co-morbidity score was 1.51+/-1.8 (median 1.0). All but 3 patients had prior forgeut surgery. Nineteen patients (34.5%) had undergone prior bariatric surgery, all of whom had Roux-en-Y gastrojejunostomy anatomy, and 18 had an antecolic roux limb. There were 11 patients (18.6%) who had undergone total gastrectomy and 7 patients (11.9%) who had undergone esophagectomy with either colonic or gastric conduit. Three patients (5.1%) had undergone gastric fundoplication.
Dehydration or malnutrition was the primary indication for PEJ in 29 patients (50.8%) and in 47 patients (79.7%) this was first-ever enteral access. Conscious sedation was used in 32 cases (54.2%), and 30 (50.8%) were performed in the endoscopy suite. The majority of patients had a 20 French tube placed (n=41, 69.5%). There were 20 patients (41.6%) with 30-day follow up. Two patients (3.4%) had complications during the index hospitalization and four additional patients suffered perioperative tube complications, giving a total complication rate of 10.1%. Of these, one required endoscopic replacement for dislodgement.
CONCLUSIONS: For patients with surgically altered foregut anatomy, direct PEJ offers a less invasive alternative to operative jejunostomy tube. Direct PEJ can be placed in the endoscopy suite or operating room with a low risk of intraoperative and perioperative complications.
|Upper GI cancer||7(12.3%)|
|Bariatric surgery complications||4(6.8%)|
|Prior tube malfunction||4(6.8%)|
|Leakage around tube||1(2.1%)|