Asymptomatic Small Bowel Loop Interposition during Direct Percutaneous Endoscopic Jejunostomy Placement.

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

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. We report a prospective series of ten consecutive cases of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunal placement, accompanied by a step-by-step illustrated overview of the technique. Direct percutaneous endoscopic jejunal tube placement by double-balloon enteroscopy was successful in nine of the ten attempted cases. In the first case, direct percutaneous endoscopic jejunal placement was abandoned due to inadequate transillumination; there were no procedure-related complications in any of our patients. This first reported prospective case series of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunal placement shows a promisingly high success rate; larger comparative studies are required to clearly establish any advantages over the originally described push enteroscopy method.

Percutaneous endoscopic gastrostomy (PEG) or PEG tube with transgastric jejunostomy tube (PEG-J) feeding has not been shown to decrease aspiration pneumonia. The aim of this study was to determine if direct percutaneous endoscopic jejunostomy (DPEJ) tube placement results in a decreased incidence of aspiration pneumonia in high-risk patients. The design was a retrospective review of all patients receiving DPEJ tube for aspiration pneumonia from 1999 to 2005. Demographics, incidence of aspiration pneumonia, and outcomes were collected and compared before and after the DPEJ placement. Eleven patients (4 women, 7 men) were identified; their mean age was 44.9 years (range, 18-94 years). The etiologies for recurrent aspiration pneumonia were neurologic disease (9), esophageal surgery (1), and severe debilitation (1). The mean follow-up was 20.9 months (range, 6-48 months). The patients' mean weight increased from 43.8 kg (range, 19-55 kg) to 48.3 kg (range, 30-65 kg) after placement (P < .001). The total number of documented aspiration pneumonia episodes for all patients decreased from 29 (mean, 3.64; range, 1-6) before DPEJ placement to 3 (mean, 0.27; range, 0-2) after DPEJ placement (P < .001). The mean number of aspiration pneumonia events per month prior to the DPEJ placement was 3.39 and postplacement was 0.42 (P < .001). DPEJ placement appears to decrease recurrent aspiration pneumonia in patients with history of aspiration pneumonia.

Tu1593 Placement of Percutaneous Endoscopic Jejunostomy With Single-Balloon Enteroscopy

Success rate of direct percutaneous endoscopic jejunostomy in patients who are obese

Numerous procedures have been developed to provide adequate enteral nutrition to patients with gastrointestinal disorders. Previously, operative placement of a feeding gastrostomy or jejunostomy tube was the accepted means of gaining chronic enteral access. However, improved technology and experience with endoscopic techniques have quickly replaced primary operative placement of enteral access. Direct percutaneous endoscopic jejunostomy (D-PEJ) is a procedure that was designed to deliver enteral feeding solutions for patients with proximal disease after unsatisfactory results from percutaneous endoscopic gastrostomy tubes with jejunal extensions (PEG-J). As with any procedure, it is associated with complications. We present the first reported case of a colojejunal fistula resulting from a D-PEJ placement. While D-PEJ has been shown to be relatively safe, complications related to the inherent limitations of the procedure need to be considered when the patient experiences unusual post-procedure symptoms and worked up appropriately.

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method to provide nutrition to patients with a variety of gastrointestinal (GI) problems. The present study describes a new method of DPEJ using balloon-assisted-enteroscopy. This observational, retrospective, single-arm case study conducted at a tertiary care hospital during a 15-month period included 25 patients (12 females, 13 males, mean age 54 years, age range 31-79 years) with necrotizing pancreatitis, n = 7; complex upper GI surgery, n = 6; complex fistula, n = 6; impossibility to place a gastrostomy tube, n = 5; and bowel obstruction, n = 1. The new DPEJ technique focused on three key components: (i) use of balloon-assisted overtube; (ii) use of fluoroscopy; (iii) leaving the overtube in place during the entire procedure (and also for DPEJ removal). Technical success was 96%. Mean time of the procedure was 30.5 min (range 24 to 45 min). Clinical success was 100% (24/24); all DPEJ could be used for their intended purpose. This new method of inserting a DPEJ using balloon enteroscopy and fluoroscopy was safe and successful. Future comparative studies are now warranted.

Percutaneous endoscopic feeding tube placement as suggested by its name is an endoscopy-guided artificially created ostomy connecting the gastric cavity and the skin surface. Enteral nutrition has been shown to be superior to parenteral nutrition in improving immunity and nutrition, but enteral access can be a challenge in patients who cannot swallow safely. The need for a percutaneous enteral access arises in patients who are expected to be dependent on tube feeds for a long time, usually for more than 1 month. The most common source of tube feeding is via a nasogastric (NG) or orogastric tube extending into the stomach or naso-jejunal (Dobhoff) tube which extends into the proximal small bowel. The tube is used for delivering tube feeds, water, and medications to the gut. The most common requirements for such a nutritional access are cancers involving upper airways, oral cavity, pharynx, or esophagus; dementia and cerebrovascular accidents with loss of ability to swallow. The procedures performed by gastroenterologists for enteral access include percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrojejunostomy (PEGJ), and direct percutaneous endoscopic jejunostomy (DPEJ). The most commonly employed technique is the PEG.

Objective To evaluate the uncertainty of the small bowel dose-volume and the normal tissue complication probability (NTCP) during intensity-modulated radiotherapy (IMRT) for rectal cancer, and to provide a reference for the dose limit and protection of the small bowel during IMRT for rectal cancer. Methods A total of 20 patients with rectal cancer who received postoperative adjuvant radiotherapy from March 2014 to August 2015 were enrolled in this study, including 10 patients receiving CT scan in the supine position and 10 patients in the prone position. All patients received computed tomography (CT) scan before the treatment and at weeks 1, 2, 3, and 4 of treatment, and they were defined as Plan, 1W, 2W, 3W, and 4W CT groups, respectively. The small bowel loop (BL) and peritoneal space (PS) were delineated on the images. The IMRT plan based on the Plan CT was copied to the 1W, 2W, 3W, and 4W CT groups, and then the small bowel dose-volume and NTCP were assessed for all CT groups. The paired t-test was used for comparison between groups. The Pearson method was used to analyze the correlation between NTCPC (chronic NTCP) and dose-volume. Results A total of 89 CT images of 20 patients were obtained. In all the patients, the volumes of BL and PS were 251.21 cm3 and 1324.16 cm3, respectively, and the shift% was 23.15% and 11.34%, respectively. The V15 of BL and PS was 184.86 cm3 and 792.45 cm3, respectively, and the shift% was 31.69% and 3.70%, respectively. The V30 of BL and PS was 88.01 cm3 and 645.73 cm3, respectively, and the shift% was 37.66% and 10.49%, respectively. The V15 of BL in 35% of patients and V15 of PS in 20% of patients, the Dmax of BL in 50% of patients, and the NTCP of 15% of patients in the course of treatment exceeded the safety limits. The 1-4W CT groups had a significantly higher NTCPC than the Plan CT group (4.02% vs. 3.20%, P=0.104), and their SD% was 41.68%. There was a significant correlation between NTCPC and V30-V50 of BL (R>0.400, P=0.000). The NTCPA (acute NTCP) and NTCPC in the supine position were significantly higher than those in the prone position (62.30% vs. 56.74%, P=0.061; 4.88% vs. 3.22%, P=0.145). Conclusions Small bowel motility leads to an uncertainty of the adverse event assessment during IMRT for rectal cancer. The change in BL is significantly larger than that in PS and the change in BL and PS in the supine position is significantly larger than that in the prone position. Using the prone position and minimizing V15 and V30 when designing the treatment plan can reduce the NTCPA and NTCPC in the small bowel. Key words: Rectal neoplasms/intensity-modulated radiotherapy; Small bowel; Normal tissue complication probability

Endoscopic or percutaneous approach for advanced biliary stenoses at the hepatic hilum?

Percutaneous endoscopic gastrostomy (PEG) tube placement is a procedure frequently done in the intensive care unit. The use of a traditional endoscope can be difficult in cases of esophageal stenosis and theoretically confers an increased risk of infection due to its complex architecture. We describe a technique using the bronchoscope, which allows navigation through stenotic esophageal lesions and also minimizes the risk of endoscopy-associated infections. Prospective series of patients who had PEG tube placement guided by a bronchoscope. Procedural outcomes including successful placement, duration of the entire procedure, time needed for passage of the bronchoscope from the oropharynx to the major curvature, PEG tube removal rate, and mortality were collected. Procedural adverse events, including infections and long-term PEG-related complications, were recorded. A total of 84 patients underwent bronchoscope-guided PEG tube placement. Percutaneous endoscopic gastrostomy tube insertion was completed successfully in 82 (97.6%) patients. Percutaneous endoscopic gastrostomy tube placement was performed immediately following percutaneous tracheostomy in 82.1%. Thirty-day mortality and 1-year mortality were 11.9% and 31%, respectively. Overall, minor complications occurred in 2.4% of patients, while there were no major complications. No serious infectious complications were identified and no endoscope-associated hospital acquired infections were documented. The use of the bronchoscope can be safely and effectively used for PEG tube placement. The use of bronchoscope rather than a gastroscope has several advantages, which include the ease of navigating through complex aerodigestive disorders such as strictures and fistulas as well as decreased health-care utilization. In addition, it may have a theoretical advantage of minimizing infections related to complex endoscopes.

Controversy remains about the treatment of patients with mild delayed gastric emptying (90 min < emptying half-time [T(1/2)] < 180 min) who undergo antireflux surgery. This retrospective, nonrandomized study reviewed the records of patients treated from January 1996 through October 2003, during which time we applied two treatment algorithms for patients with mild delayed gastric emptying. The goal of this study was to determine whether the most recent treatment algorithm was effective in reducing the need for a concomitant gastric drainage procedure, pyloroplasty. Eighteen patients with mild delayed gastric emptying underwent antireflux surgery plus pyloroplasty (group A) before 2001, and 13 patients with mild delayed gastric emptying underwent antireflux surgery plus gastric decompression with percutaneous endoscopic gastrostomy placement (group B) starting in 2001. We reviewed indications for the procedure, complications, and outcomes. Primary outcome measures for this study were recurrence of gastroparesis symptoms and need for pyloroplasty. The average T(1/2) was similar for both groups A and B: 129 min and 123 min, respectively. Eleven of 13 patients (85%) in group B experienced resolution of gastroparesis symptoms, improved gastric emptying times, or both; only 1 patient (8%) underwent subsequent pyloroplasty for treatment failure. Only one serious percutaneous endoscopic gastrostomy-related event occurred (tube migration), and no patients died. Significantly fewer patients in group B required total pyloroplasty (8% vs. 56% in group A; P < 0.008), and significantly fewer required pyloroplasty for symptomatic control (15% vs. 56% in group A; P < 0.03). A treatment algorithm incorporating percutaneous endoscopic gastrostomy tube placement at the time of antireflux surgery for gastric decompression successfully managed antireflux surgery patients with mild delayed gastric emptying. This approach allows for a more selective use of pyloroplasty.

Gastric volvulus is an uncommon life-threatening condition, caused by abnormal rotation of more than 180° of the stomach along its long axis. Typical presentation includes patients > 50 years old, pre-existing hiatal, diaphragmatic hernias, or previous surgery. This condition carries a high morbidity, which necessitates prompt recognition and management with surgery or endoscopy. Here, we present a successful case of endoscopic detorsion of gastric volvulus and percutaneous endoscopic gastrostomy placement for gastropexy in an elderly patient.

The authors describe a technique for percutaneous endoscopic shunt placement to treat clinically symptomatic spinal cysts. Seven patients underwent the procedure--five with syringomyelia, one with a symptomatic perineurial cyst, and one with a large arachnoid cyst. In all patients the shunt was successfully placed, and clinical improvement occurred in six. In four patients the entire procedure was performed endoscopically, whereas in three conversion to an open surgical exposure was required for safe access of a syrinx cavity. Overall, however, the pleural or peritoneal catheter was successfully placed endoscopically in all seven patients. There were two cases of postoperative positional headaches of which one required valve revision. In one case the catheter migrated and required repositioning. Percutaneous endoscopic shunt placement appears feasible in appropriately selected patients.

Pancreatic fistula have been a source of significant morbidity and mortality after left-sided pancreatectomy. The majority of fistulas are classified as Grade A and resolve quickly with no intervention. Grade C pancreatic fistulas, which require percutaneous or operative drainage, are less common and may be associated with morbidity and mortality. We used postoperative endoscopic pancreatic stent placement as an adjunctive strategy in the management of refractory Grade C pancreatic fistulas. Patients undergoing endoscopic pancreatic stent placement for persistent, refractory peripancreatic fluid collections/pancreatic fistula after left-sided pancreatectomy were identified. Eight patients underwent endoscopic pancreatic stent placement for refractory Grade C pancreatic fistulas. Six patients had percutaneous catheter placement; two patients had transgastric drainage. Endoscopic retrograde cholangiopancreatography (ERCP) showed extravasation of contrast from the distal end of the pancreatic duct in seven patients. Pancreatic stents were placed in all patients at a median time of 48 days postoperation and left for a median of 47 days. Before stent removal, ERCP demonstrated pancreatic fistula closure. Median time to complete resolution of the fistula was 41 days after stent placement. Endoscopic pancreatic stents were associated with resolution of Grade C fistulas. After distal pancreatectomy, pancreatic stent placement should be considered in the postoperative period for refractory pancreatic fistulas.