Surgical jejunostomy, DEPJ or PEGJ

Dr Simon GabeSt Mark’s Hospital, London

Jejunal feeding

NJ PEGJ Surgical jejunostomy Direct PEJ

PEGJWhich one?

Different tubes

Different patients

Local expertise

DEPJ

Surgical jejunostomy

Different answers for different patients

First jejunostomy

tube placement

Likely very long term (will need

repeated tubes)

Jejunal hypersensivity

?

Medications required?

Full thickness SB biopsy required?

Gastro-jej tubes

PEGJ tubes

For Against

Placed under

sedation (no GA)

Availability

No new puncture

Short/medium term trial

Poor PEG aspiration

Jej tube falls back

Repeated

procedures needed

24 year old woman¨ Atopy (asthma, eczema, hayfever), 2008¨ Urticaria vasculitis, Raynaud’s & peripheral neuropathy, 2013¨ Nausea, vomiting, recurrent dehydration & hospital admissions, 2014-16

¤ Gastroparesis (breath test & radionuclide meal), diagnosed Jan 2017¤ SIBO (hydrogen breath test), 2017¤ Recurrent hypoglycaemia off enteral nutrition, since 2017

¨ ?Ehlers-Danlos hypermobility type (III), 2017

NJ feeding PEGJ (Freka)

MIC KEY gastrojejunostomy•Dec 2017 – Feb 2018•Feb – March 2018•March – March 2018 (x2)

NJ feeding•March 2018 (x3)

PEGJ (Freka)•May – July 2018•July – Aug 2018•Aug – Sept 2018

2017April DecJune MayMarch March Sept

2018 2018

Options

Continue PEGJ

Surgical jejunostomy DPEJ

Surgical jejunostomy: approaches

Direct Witzel tunnell

Different tubes: surgicalNeedle catheter jejunostomy Surgical jejunostomy

MIC Jejunostomy Feeding Tube

Which type of surgery?

Open surgery Laparoscopic surgery

¨ More invasive¨ Surgical procedure to remove

¨ Less invasive¨ Witzel tunnel much shorter

Surgical or endoscopic?

Surgical jejunostomy Direct PEJ

¨ Laparoscopic possible¨ More invasive¨ Surgical procedure to remove¨ Tube has more limited lifespan

¨ Endoscopic procedure under GA¨ Less invasive¨ Can be removed endoscopically¨ Tube may last longer

DPEJ placement

Handy things ….

Localization of a superficial jejunal loop

¨ DBE inserted past the ligament of Treitz into the proximal jejunum

¨ Superficial jejunal loop identified by:¤ Trans-illumination¤ Digital indentation

Step 1

Insertion of ‘‘Seeker’’ Needle

¨ A 21G (green) seeker needle is inserted into the jejunum¨ Keep a negative pressure on the syringe¨ The needle is visualised by the endoscopist

Step 2

Snaring of seeker needle, jejunopexy & insertion of trocar

¨ Seeker needle grasped using a 25-mm snare ¤ Anchors the jejunum to the abdo wall

¤ Minimizes risk of jejunal loop displacement during trocar insertion

¨ Jejunopexy (x2) performed with T bar sutures

¨ Large PEG trochar inserted adjacent to the 21G needle¨ Trocar sheath snared

Step 3

Thread grasped & attached to PEG tube

¨ Thread ¤ Placed through the trochar¤ Snared¤ Pulled out though the mouth (enteroscope withdrawal)

Step 4

DPEJ pull-through & bumper site check

¨ Freka PEG tube attached to the thread

¨ Thread & feeding tube are pulled through

¨ Position of internal bumper confirmed by direct vision

¨ Distance between internal bumper & skin exit site noted

¨ External connectors applied

Step 5

Needle catheter jejunostomy

For Against

Sutured to the skin

Can be accidentally pulled out

Medium term (weeks/months)

feeding

Easy removal

Best post surgery ¨ Upper GI¨ Intestinal transplant

Surgical jejunostomy

For Against

More invasive (open>laparoscopic)

Further surgery to remove

Silicone tube degrades quickly in some patients

Cannot keep replacing surgically

Silicone tube more comfortable

Witzel tunnel: no tracking of jejunal fluid

Allows jejunal biopsy when appropriate

DPEJ

For Against

GA procedure with DBE

Limited expertise

Cannot perform full thickness biopsy

Possible to perforate/pass through small bowel / colon

Much less trauma

Freka PEG tube works best (9F)

Endoscopic replacement with no further bowel trauma

Suggested approaches

Trial of therapy• NJ• PEGJ

Post upper GI surgery• Needle catheter jejunostomy

Dysmotility: 1st jej tube• Surgical placement 9F PEG tube & jejunal biopsy

• Tube can then be replaced by DBE• DPEJ• Surgical jejunostomy (open/laparoscopic) & jejunal biopsy• PEGJ

Dysmotility: previous GI surgery• Surgical jejunostomy (open/laparoscopic)

There is a need for better jejunal feeding tubes to be developed

Pros Cons

Needle catheter jejunostomy

Best post surgery (upper GI, intestinal transplant)Medium term (weeks/months) feedingEasy removal

Sutured to the skinCan be accidentally pulled out

Surgical jejunostomySilicone tube more comfortableWitzel tunnel: no tracking of jejunal fluidAllows jejunal biopsy when appropriate

More invasive (open>laparoscopic)Further surgery to removeSilicone tube degrades quickly in some patientsCannot keep replacing surgically

GastrojejunostomyNo additional abdominal puncture in patients with an existing PEGEndoscopic placement under sedation

Can be difficult to get jej extension beyond ligament of TreitzJejunal extension can fall back External connections can be confusingCan require frequent replacementGastrostomy venting much less effective (jej tube in place)

Direct PEJ

Much less traumaFreka PEG tube works best (9F)Endoscopic replacement with no further bowel trauma

GA procedure with DBELimited expertiseCannot perform full thickness biopsyPossible to perforate/pass through small bowel / colonReplacement requires DBE approach with GA