Top Tips for Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Tube Placement.

Direct percutaneous endoscopic jejunostomy (DPEJ) provides post-pyloric enteral access in patients unable to meet long-term nutritional needs per os in situations where gastric feeding is neither tolerated nor feasible. Specific conditions associated with feeding intolerance due to due to nausea, vomiting, or ileus include gastric outlet obstruction, gastroparesis, or complications of acute or chronic pancreatitis; infeasibility may be due to high aspiration risk or prior gastric surgery. Since performing DPEJ is not an ACGME requirement for GI fellows or early career gastroenterologists, not all trainees are taught this technique. Hence, provider expertise for teaching and performing this technique varies widely across centers. In this article, we provide top tips for successful performance of DPEJ.

Giant bile duct dilatation in newborn: A case report.

BACKGROUND: Giant congenital biliary dilation (CBD) is a rare condition observed in clinical practice. Infants born with this condition often experience a poor overall health status, and the disease progresses rapidly, leading to severe biliary obstruction, infections, pressure exerted by the enlarged CBD on abdominal organs, disturbances in the internal environment, and multiple organ dysfunction. The treatment of giant CBD using laparoscopy is challenging due to the high degree of variation in the shape of the bile duct and other organs, making it difficult to separate the bile duct wall from adjacent tissues or to control bleeding. CASE SUMMARY: Herein, we present the details of an 11-d-old male newborn who was diagnosed with giant CBD. The patient was admitted to the neonatal surgery department of our hospital due to a history of common bile duct cyst that was detected more than 3 mo ago, and also because the patient had been experiencing yellowish skin for the past 9 d. The abnormal echo in the fetal abdomen was first noticed by the patient's mother during a routine ultrasound examination at a local hospital, when the patient was at 24 wk + 6 d of pregnancy. This finding raised concerns about the possibility of congenital biliary dilatation (22 mm × 21 mm). Subsequent ultrasound examinations at different hospitals consistently confirmed the presence of a congenital biliary dilatation. No specific treatment was administered for biliary dilatation during this period. A computed tomography scan conducted during the hospitalization revealed a large cystic mass in the right upper quadrant and pelvis, measuring approximately 9.2 cm × 7.4 cm × 11.3 cm. Based on the scan, it was classified as a type I biliary dilatation. CONCLUSION: The analysis reveals that prenatal imaging techniques, such as ultrasound and magnetic resonance imaging, play a crucial role in the early diagnosis, fetal prognosis, and treatment plan for giant CBD. Laparoscopic surgery for giant CBD presents certain challenges, including difficulties in separating the cyst wall, anastomosis, and hemostasis, as well as severe biliary system infection and ulceration. Consequently, there is a high likelihood of converting to laparotomy. The choice between surgical methods like hepaticojejunostomy (HJ) or hepaticoduodenostomy has not been standardized yet. However, we have achieved favorable outcomes using HJ. Preoperative management of inflammation, biliary drainage, liver function protection, and supportive treatment are particularly vital in improving children's prognosis. After discharge, it is essential to conduct timely reexamination and close follow-up to identify potential complications.

A clinical consensus paper on jejunal tube feeding in children.

BACKGROUND: Feeding problems are common in children with complex medical problems or acute critical illness and enteral nutrition may be required. In certain situations, gastric tube feeding is poorly tolerated or may not be feasible. When feed intolerance persists despite appropriate adjustments to oral and gastric enteral regimens, jejunal tube feeding can be considered as an option for nutrition support. METHODS: A multidisciplinary expert working group of the Australasian Society of Parenteral and Enteral Nutrition was convened. They identified topic questions and five key areas of jejunal tube feeding in children. Literatures searches were undertaken on Pubmed, Embase, and Medline for all relevant studies, between January 2000 and September 2022 (n = 103). Studies were assessed using National Health and Medical Research Council guidelines to generate statements, which were discussed as a group, followed by voting on statements using a modified Delphi process to determine consensus. RESULTS: A total of 24 consensus statements were created for five key areas: patient selection, type and selection of feeding tube, complications, clinical use of jejunal tubes, follow-up, and reassessment. CONCLUSION: Jejunal tube feeding is a safe and effective means of providing nutrition in a select group of pediatric patients with complex medical needs, who are unable to be fed by gastric tube feeding. Appropriate patient selection is important as complications associated with jejunal tube feeding are not uncommon, and although mostly minor, can be significant or require tube reinsertion. All children receiving jejunal tube feeding should have multidisciplinary team assessment and follow-up.

Retrograde Migration of a Percutaneous Endoscopic Gastro-Jejunal Tube Into the Esophagus.

Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic gastro-jejunal (PEG-J) tube placement are both common procedures regularly performed on patients requiring nutritional support. These procedures may be complicated by infection, hemorrhage, fistulization, or tube migration. We present an extremely rare case of a patient with a PEG-J tube that migrated into the esophagus.

A Case Report and Literature Review of Gastric Stump Carcinoma: An Uncommon Entity Following the Billroth II Procedure.

Gastric stump carcinoma is a rare phenomenon and could occur in individuals after a distal gastric resection. Regardless of the surgical approach, it can lead to certain complications. However, the Billroth II gastrojejunostomy procedure has been noted to have some specifically interesting complications due to the anatomical changes it triggers. These changes, such as bacterial overgrowth and enterogastric reflux, can cause metaplasia. We discuss a case of an 81-year-old male with a history of peptic ulcer disease (PUD) status post-Billroth II gastrojejunostomy 30 years prior who presented with a four-day history of bright red blood per rectum. On esophagogastroduodenoscopy (EGD), he was found to have friable, ulcerated mucosa at the anastomosis site. Biopsy results revealed CDX2-positive cells, indicating gastric adenocarcinoma. Although it is well-known that the anatomical changes of gastrojejunostomy will undoubtedly change the microbiome of the stomach, physicians should also be mindful of the more feared complications such as gastric stump carcinoma.

Benefit of a laparoscopic jejunostomy feeding catheter insertion to prevent bowel obstruction associated with feeding jejunostomy after esophagectomy.

The placement of a jejunostomy catheter during esophagectomy may cause postoperative bowel obstruction. The proximity of the jejunostomy site to the midline might be associated with bowel obstruction, and we have introduced laparoscopic jejunostomy (Lap-J) to reduce jejunostomy's left lateral gap. We evaluated 92 patients who underwent esophagectomy for esophageal cancer between February 2013 and August 2022 to clarify the benefits of Lap-J compared to other methods. The patients were classified into two groups according to the method of feeding catheter insertion: jejunostomy via small laparotomy (J group, n = 75), and laparoscopic jejunostomy (Lap-J group, n = 17). Surgery for bowel obstruction associated with the feeding jejunostomy catheter (BOFJ) was performed on 11 in the J group. Comparing the J and Lap-J groups, the distance between the jejunostomy and midline was significantly longer in the Lap-J group (50 mm vs. 102 mm; P < 0.001). Regarding surgery for BOFJ, the distance between the jejunostomy and midline was significantly shorter in the surgery group than in the non-surgery group (43 mm vs. 52 mm; P = 0.049). During esophagectomy, Lap-J can prevent BOFJ by placing the jejunostomy site at the left lateral position to the midline and reducing the left lateral gap of the jejunostomy.

Factors associated with enteral autonomy after reanastomosis in infants with intestinal failure and ostomy: A descriptive cohort study.

BACKGROUND: To determine variables associated with outcomes in infants with intestinal failure (IF) and ostomy following reanastomosis (RA). METHODS: A single-center, descriptive cohort study of 120 infants with IF and a stoma from January 2011 to December 2020 with subsequent RA during initial hospitalization. The primary outcome was achievement of enteral autonomy (EA) following RA. Other outcomes were duration of hospital stay, and mortality. Penalized logistic regression and linear regression were used for data analysis. RESULTS: The median gestational age was 26 weeks, and the median birth weight was 890 g. Three infants died. The median duration between ostomy creation and RA was 80 days (interquartile range; 62.5, 100.5). For each additional day of discontinuity, the odds of EA decreased by 2% (odds ratio [OR] = 0.980; 95% confidence interval [CI]: 0.962, 0.999; P = 0.038), and death increased by 4.2% (OR = 1.042; 95% CI: 1.010, 1.075; P = 0.009). For each additional mL/kg/day of enteral feeds at RA, the odds of EA increased by 7.5% (OR = 1.075; 95% CI: 1.027, 1.126, P = 0.002) and duration of hospital stay decreased by 0.35 days (slope coefficient = -0.351; 95% CI: -0.540, -0.163; P < 0.001). CONCLUSION: Shorter duration of intestinal discontinuity and enteral nutrition before RA could positively influence EA and duration of stay in infants with IF and ostomy following RA.

The impact of jejunostomy feeding on nutritional outcomes after oesophagectomy.

BACKGROUND: Nutritional status is compromised long-term following oesophagectomy. Controversy surrounds the optimal route for nutrition support postoperatively and there is wide variation in the use of feeding jejunostomy tubes. METHODS: A retrospective service evaluation was conducted for all consecutive adults who underwent oesophagectomy for a cancer diagnosis within a specialist centre between April 2016 and July 2019 (n = 165). Nutritional and clinical outcomes were compared for patients who received jejunostomy feeding (n = 24), versus those who did not (n = 141). RESULTS: Patients with feeding jejunostomy lost significantly less weight at both 6 and 12 months postoperatively compared to those without jejunostomy (p ≤ 0.001 and p = 0.001, respectively). This remained statistically significant in multiple regression, controlling for age, gender, preoperative tumour staging and adjuvant treatment (p ≤ 0.001 and p = 0.03, respectively). Median length of home enteral feeding was 10 weeks after discharge in the jejunostomy group. We observed minor jejunostomy tube-related complications in four patients (16.7%). Of those readmitted within 90 days of surgery in the non-jejunostomy group, nutritional failure was a factor in 43.2% of these readmissions. "Rescue tube feeding" was required by 8.5% of the non-jejunostomy group within the first postoperative year, including 6.4% within 90 days of surgery. CONCLUSIONS: Use of short-term supplementary jejunal feeding in addition to oral intake after hospital discharge is beneficial for maintaining weight after oesophagectomy. We suggest a future randomised-controlled trial to confirm these findings.

Experience of Robotic Complex Revisional Bariatric Surgery in a High-Volume Center.

PURPOSE: A revisional bariatric surgery (RBS) is necessary in about 28% of the patients. The role of robotic surgery in RBS is still a subject of debate. We aim to report the outcomes of robotic-assisted RBS at our institution. MATERIALS AND METHODS: We identified patients who underwent robotic-assisted RBSs between January 1, 2016, and May 31, 2022. We analyzed patient demographics and indications for surgery. Measured outcomes included peri- and postoperative morbidity, comorbidity management, and weight loss outcomes. RESULTS: A total of 106 patients were included. Primary procedures were adjustable gastric band 44 (41.5%), sleeve gastrectomy 42 (39.6%), Roux-en-Y gastric bypass (RYGB) 18 (17%), duodenal switch (DS) 1 (0.9%), and vertical banded gastroplasty 1 (0.9%). RBSs performed included 85 (78.7%) RYGB, 16 (14.8%) redo-gastrojejunostomy, and 5 (4.6%) DS. The median time to revision was 8 (range 1-36) years, and the main indication was insufficient weight loss (49%). Median length of hospital stay was 2 (range 1-16) days, and 9 (8.5%) patients were readmitted during the first 30 days. Only 4 (3.7%) patients had early Clavien-Dindo grade III or higher adverse events. No anastomotic leaks were documented. Median excess weight loss was 35.1%, 42.23%, and 45.82% at the 6-, 12-, and 24-month follow-up. Of 57 patients with hypertension, 29 (50.9%) reduced their medication dosage, and 20/27 (74.1%) reduced their diabetes mellitus medication dosage. Finally, of the 75 patients with symptoms, 64 (85.3%) reported an improvement after the RBS. CONCLUSION: Robotic-assisted RBS is feasible, significantly improves patients' comorbidities and symptoms, and leads to considerable weight loss.

Clinical presentation, management and outcomes of bile duct injuries after laparoscopic cholecystectomy: a 15-year single-center experience in Vietnam.

Objectives: To evaluate the clinical presentation, management, and outcomes of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC). Methods: This is a case series of 28 patients with BDIs after LC treated at a tertiary hospital in Vietnam during the 2006-2021 period. The BDI's clinical presentations, Strasberg classification types, management methods, and outcomes were reported. Results: BDIs were diagnosed intraoperatively in 3 (10.7%) patients and postoperatively in 25 (89.3%). The BDI types included Strasberg A (13, 46.4%), D (1, 3.6%), E1 (1, 3.6%), E2 (4, 14.3%), E3 (5, 17.9%), D + E2 (2, 7.1%), and nonclassified (2, 7.1%). Of the postoperative BDIs, the injury manifested as biliary obstruction (18, 72.0%), bile leak (5, 20.0%), and mixed scenarios (2, 8.0%). Regarding diagnostic methods, endoscopic retrograde cholangiopancreatography (ERCP) was more useful in bile leak scenarios, while multislice computed tomography, magnetic resonance cholangiopancreatography, and percutaneous transhepatic cholangiography were more useful in biliary obstruction scenarios. All 28 BDIs were successfully treated. ERCP with stenting was very effective in the majority of Strasberg A BDIs. For more complex BDI types, hepaticocutaneous jejunostomy was a safe and effective approach. The in-hospital morbidities included postoperative pneumonia (2, 10.7%) and biliary-enteric anastomosis leakage (1, 5.4%). There was no cholangitis or anastomotic stenosis during the follow-up after discharge (median 18 months). Conclusions: The majority of BDIs are type A and diagnosed postoperatively. ERCP is effective for the majority of Strasberg A BDIs. For major and complex BDIs, hepaticocutaneous jejunostomy is a safe and effective approach.

Distal enteral feeding can replace total parenteral feeding to support nutrition in patients with high output stoma (jejunostomy) - A case series.

BACKGROUND: Ostomy/Stoma is a common entity in patients operated for small bowel perforation in developing countries. Delay in presentation, poor general condition, malnutrition and lack of health infrastructure in peripheral areas are some of the causes leading to severe sepsis at presentation. Exteriorising the perforation site as stoma/ostomy is the preferred salvage procedure. Proximal stoma/ostomy is high output and cause fluid and electrolyte imbalance. Also it is difficult to maintain nutrition with oral feeds, as partially digested food along with digestive enzymes gets lost through the stoma. Parenteral nutrition (PN) is widely used in these patients, which is expensive requires hospitalisation, also not without risks e.g. liver dysfunction and associated with complications of central line insertion. AIM: We hereby report our experience of managing three patients of high output jejunostomy with distal enteral feeding provided by feeding chyme and partially digested food into the distal stoma. METHOD: After confirming the distal patency of the bowel, we started feeding through distal lumen of stoma (known as distal enteral feeding) in our 3 patients with jejunostomies immediately in postoperative period along with PN. After few days we started decreasing PN, we gradually switched to complete enteral nutrition; and increasing distal feeding and then totally stopping the PN in few days only. We kept a watch on the different parameters of the patient like calories and protein intake, weight, electrolytes, liver function, etc. RESULTS: Distal enteral feeding improved their body weight, maintained their serum electrolytes and liver function tests including serum albumin. After achieving the good nutritional status, we were able to do successful surgical closure of stomas in all the three patients. CONCLUSION: In our experience, patients with high-output stomas can be nutritionally maintained with distal enteral feeding without the need of long term PN. Use of distal enteral feeding, if used appropriately and with proper monitoring, can nutritionally build up the patient avoiding the complications of PN.

Impact of gastro-jejunostomy tube in lung transplant patients: a propensity-matched analysis.

OBJECTIVES: During the postoperative phase of lung transplantation, the surgical creation of a gastro-jejunostomy (GJ) may be deemed necessary for patients with severe oesophageal dysmotility, prolonged oral intake difficulties stemming from use of a ventilator or marked malnutrition. We explored the effects of postoperative GJ tube on survival and bronchiolitis obliterans syndrome in lung transplant recipients. METHODS: We retrospectively reviewed all lung transplants performed at our institution between 2011 and 2022. Propensity score matching was performed to match patients who required a GJ tube with control patients on a 1:1 ratio. The preoperative, operative and postoperative outcomes of the patients were evaluated. RESULTS: After propensity score matching, 193 patients with GJ were compared to 193 patients without GJ. Patients with GJ had significantly higher rates of delayed chest closure (P = 0.007), and postoperative dialysis (P = 0.016), longer intensive care unit stays (P < 0.001), longer ventilator duration (P < 0.001), higher rates of pneumonia (P = 0.035) and higher rates of being treated for acute cellular rejection within 1 year of transplant (P = 0.008). Overall survival and freedom from bronchiolitis obliterans syndrome were not found to be significantly different between the matched groups (P = 0.09 and P = 0.3). CONCLUSIONS: GJ tube placement during the postoperative phase of lung transplantation did not compromise patient survival or freedom from bronchiolitis obliterans syndrome although the results reflect more difficult and complicated cases. This study indicates that the GJ tube may be a useful option for enteral feeding.

Factors Influencing Postoperative Complications Following Minimally Invasive Ivor Lewis Esophagectomy: A Retrospective Cohort Study.

BACKGROUND: Complications arising following minimally invasive Ivor Lewis esophagectomy often result from inadequate enteral nutrition, highlighting the need for proactive measures to prevent such issues. One approach involves identifying high-risk cases prone to complications and implementing percutaneous endoscopic jejunostomy (PEJ) tube placement during esophageal resection to ensure timely enteral nutrition. METHODS: In this single-center, retrospective cohort study, we examined patients who underwent minimally invasive esophagectomy for esophageal cancer at a high-volume center. The dataset encompassed demographic information, comorbidities, laboratory parameters, and intraoperative details. Our center utilized the EndoVac system pre-emptively to safeguard the anastomosis from harmful secretions and to enhance local oxygen partial pressure. All patients received pre-emptive EndoVac therapy and underwent esophagogastroduodenoscopy in the early postoperative days. The need for multiple postoperative EndoVac cycles indicated complications, including anastomotic insufficiency and subsequent requirement for a PEJ. The primary objectives were identifying predictive factors for anastomotic insufficiency and the need for multi-cycle EndoVac therapy, quantifying their effects, and assessing the likelihood of postoperative complications. RESULTS: 149 patients who underwent minimally invasive or hybrid Ivor Lewis esophagectomy were analyzed and 21 perioperative and demographic features were evaluated. Postoperative complications were associated with the body mass index (BMI) category, the use of blood pressure medication, and surgery duration. Anastomotic insufficiency as a specific complication was correlated with BMI and the Charlson comorbidity index. The odds ratio of being in the high-risk group significantly increased with higher BMI (OR = 1.074, p = 0.048) and longer surgery duration (OR = 1.005, p = 0.004). CONCLUSIONS: Based on our findings, high BMI and longer surgery duration are potential risk factors for postoperative complications following minimally invasive esophagectomy. Identifying such factors can aid in pre-emptively addressing nutritional challenges and reducing the incidence of complications in high-risk patients.

Pneumoperitoneum After Jejunostomy Tube Placement Managed by Needle Decompression: A Case Report.

Percutaneous endoscopic feeding tube placement is a commonly performed procedure in patients who cannot take food by mouth. While it is considered a safe and effective method of providing nutritional support, like any medical procedure, it can lead to complications. Feeding tube placement, including percutaneous endoscopic jejunostomy (PEJ), is associated with several complications, including bleeding, site infection, aspiration, buried bumper, tube dislodgement, and pneumoperitoneum. We report a case of a 20-year-old male with multiple medical issues who underwent a PEJ that was complicated by bowel distension. The patient developed tension pneumoperitoneum post-procedure, which was treated with a bedside needle decompression. This case report highlights the significance of promptly recognizing and intervening in complications that may arise during a frequently performed medical procedure, PEJ tube placement, to prevent serious consequences, including bowel ischemia.

Absorption of an engineered medium-chain fatty acid analogue in two short bowel syndrome minipig models.

BACKGROUND: Enteral drug therapy is challenging in short bowel syndrome with intestinal failure (SBS-IF) because of unpredictable absorption. SEFA-6179 is an enterally administered medium-chain fatty acid analogue under development for intestinal failure-associated liver disease. We investigate the pharmacokinetics of two SEFA-6179 formulations in two large-animal models of SBS-IF, including a new pseudojejunostomy model. METHODS: Twenty Yucatan minipigs were obtained. Half underwent pre-resection pharmacokinetic study with single-dose SEFA-6179 administration. All minipigs then underwent 90% jejunoileal resection, with either a jejunoileal anastomosis or bypass of the intraperitoneal colon with anastomosis just proximal to the rectum (pseudojejunostomy). On postoperative day 3, a single-dose pharmacokinetic study was performed. RESULTS: Both SBS-IF models were well tolerated. Compared with the jejunoileal anastomosis minipigs, pseudojejunostomy minipigs had a more severe malabsorptive phenotype with weight loss by postoperative day 4 (+0.1 vs -0.9 kg, P = 0.03) and liquid diarrhea (Bristol 5 vs Bristol 7, P = 0.0007). Compared with pre-resection minipigs, both jejunoileal and pseudojejunostomy minipigs had lower total plasma exposure of SEFA-6179 measured by area under the curve (jejunoileal: 37% less, P = 0.049; pseudojejunostomy: 74% less, P = 0.0001). Peak plasma concentration was also lower in the pseudojejunostomy group compared with pre-resection (65% less, P = 0.04), but not lower in the jejunoileal group (P = 0.47). CONCLUSION: In two SBS-IF minipig models, SEFA-6179 had substantially decreased absorption compared with pre-resection minipigs. Dose optimization for different intestinal anatomy and function may be required. We describe a new SBS-IF pseudojejunostomy model that may improve the translation of preclinical research to patients with SBS-IF who have enterostomies.

Jejunal access for enteral nutrition: A practical guide for percutaneous endoscopic gastrostomy with jejunal extension and direct percutaneous endoscopic jejunostomy.

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.