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CC BY-NC-ND 4.0 · Endosc Int Open 2022; 10(04): E488-E520
DOI: 10.1055/a-1774-4736
Review

Direct percutaneous endoscopic jejunostomy (DPEJ) and percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) technical success and outcomes: Systematic review and meta-analysis

Smit S. Deliwala
1   Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, United States
,
Saurabh Chandan
2   Gastroenterology and Hepatology, CHI Health Creighton University Medical Center, Omaha, Nebraska, United States
,
Anand Kumar
3   Gastroenterology & Hepatology, Lenox Hill Hospital, New York, New York, United States
,
Babu Mohan
4   Gastroenterology & Hepatology, University of Utah, Salt Lake City, Utah, United States
,
Anoosha Ponnapalli
1   Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, United States
,
Murtaza S. Hussain
1   Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, Michigan, United States
,
Sunil Kaushal
5   Gastroenterology, Mclaren Health Corporation, Flint, Michigan, United States
,
Joshua Novak
6   Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
,
Saurabh Chawla
6   Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States
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Abstract

Background and study aims Endoscopic methods of delivering uninterrupted feeding to the jejunum include direct percutaneous endoscopic jejunostomy (DPEJ) or PEG with jejunal extension (PEG-J), validated from small individual studies. We aim to perform a meta-analysis to assess their effectiveness and safety in a variety of clinical scenarios.

Methods Major databases were searched until June 2021. Efficacy outcomes included technical and clinical success, while safety outcomes included adverse events (AEs) and malfunction rates. We assessed heterogeneity using I2 and classic fail-safe to assess bias.

Results 29 studies included 1874 patients (983 males and 809 females); mean age of 60 ± 19 years. Pooled technical and clinical success rates with DPEJ were 86.6 % (CI, 82.1–90.1, I2 73.1) and 96.9 % (CI, 95.0–98.0, I2 12.7). The pooled incidence of malfunction, major and minor AEs with DPEJ were 11 %, 5 %, and 15 %. Pooled technical and clinical success for PEG-J were 94.4 % (CI, 85.5–97.9, I2 33) and 98.7 % (CI, 95.5–99.6, I2  < 0.001). The pooled incidence of malfunction, major and minor AEs with DPEJ were 24 %, 1 %, and 25 %. Device-assisted DPEJ performed better in altered gastrointestinal anatomy. First and second attempts were 87.6 % and 90.2 %.

Conclusions DPEJ and PEG-J are safe and effective procedures placed with high fidelity with comparable outcomes. DPEJ was associated with fewer tube malfunction and failure rates; however, it is technically more complex and not standardized, while PEG-J had higher placement rates. The use of balloon enteroscopy was found to enhance DPEJ performance.

Supplementary material



Publication History

Received: 05 August 2021

Accepted after revision: 19 October 2021

Article published online:
14 April 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Braunschweig CL, Levy P, Sheean PM. et al. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 2001; 74: 534-542
    CrossrefPubMedGoogle Scholar
  • 2 Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ 2004; 328: 1407
    CrossrefPubMedGoogle Scholar
  • 3 Shike M. Enteral feeding. Shills M, Shike M, Ross AC, Caballero B, Cousins RJ. Modern Nutrition in Health and Disease. Philadelphia, Pa: Lippincott, Williams and Wilkins; 2005. 10. 1554-1566
    Google Scholar
  • 4 Han-Geurts IJ, Lim A, Stijnen T. et al. Laparoscopic feeding jejunostomy: a systematic review. Surg Endosc 2005; 19: 951-957
    CrossrefPubMedGoogle Scholar
  • 5 Samarasena JB, Kwak NH, Chang KJ. et al. The PEG-Pedi-PEG technique: a novel method for percutaneous endoscopic gastrojejunostomy tube placement (with video). Gastrointest Endosc 2016; 84: 1030-1033
    CrossrefPubMedGoogle Scholar
  • 6 Yolsuriyanwong K, Chand B. Update on endoscopic enteral access. Tech Gastrointest Endosc 2018; 20: 172-181
    CrossrefPubMedGoogle Scholar
  • 7 Gkolfakis P, Arvanitakis M, Despott EJ. et al. Endoscopic management of enteral tubes in adult patients – Part 2: Peri- And post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 178-195
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Adler DG, Gostout CJ, Baron TH. Percutaneous transgastric placement of jejunal feeding tubes with an ultrathin endoscope. Gastrointest Endosc 2002; 55: 106-110
    CrossrefPubMedGoogle Scholar
  • 9 Sibille A, Glorieux D, Fauville JP. et al. An easier method for percutaneous endoscopic gastrojejunostomy tube placement. Gastrointest Endosc 1998; 48: 514-517
    CrossrefPubMedGoogle Scholar
  • 10 Parsi MA, Jirapinyo P, Abu Dayyeh BK. et al. Techniques and devices for the endoscopic treatment of gastroparesis (with video). Gastrointest Endosc 2020; 92: 483-491
    CrossrefPubMedGoogle Scholar
  • 11 Kwon RS, Banerjee S, Desilets D. et al. Enteral nutrition access devices. Gastrointest Endosc 2010; 72: 236-248
    CrossrefPubMedGoogle Scholar
  • 12 Zhu Y, Shi L, Tang H. et al. Current considerations of direct percutaneous endoscopic jejunostomy. Can J Gastroenterol 2012; 26: 92-96
    CrossrefPubMedGoogle Scholar
  • 13 Moher D, Liberati A, Tetzlaff J. et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 2009; 6: e1000097
    CrossrefPubMedGoogle Scholar
  • 14 Stroup DF, Berlin JA, Morton SC. et al. Meta-analysis of observational studies in epidemiology. A proposal for reporting. JAMA 2000; 283: 2008-2012
    CrossrefPubMedGoogle Scholar
  • 15 Qumseya BJ. Quality assessment for systematic reviews and meta-analyses of cohort studies. Gastrointest Endosc 2021; 93: 486-494.e1
    CrossrefPubMedGoogle Scholar
  • 16 Higgins JP, Thompson SG, Spiegelhalter DJ. A re-evaluation of random-effects meta-analysis. J R Stat Soc Ser A Stat Soc 2009; 172: 137-159
    CrossrefPubMedGoogle Scholar
  • 17 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-560
    CrossrefPubMedGoogle Scholar
  • 18 Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication Bias in meta-anal- ysis. Biometrics 2000; 56: 455-463
    CrossrefPubMedGoogle Scholar
  • 19 Viechtbauer W. Publication bias in meta-analysis: Prevention, assessment and adjustments. Psychometrika 2007; 72: 269-271
    CrossrefPubMedGoogle Scholar
  • 20 Ponsky JL, Aszodi A. Percutaneous endoscopic jejunostomy. Am J Gastroenterol 1984; 79: 113-116
    PubMedGoogle Scholar
  • 21 Shike M, Schroy P, Ritchie MA. et al. Percutaneous endoscopic jejunostomy in cancer patients with previous gastric resection. Gastrointest Endosc 1987; 33: 372-374
    CrossrefPubMedGoogle Scholar
  • 22 Kaplan DS, Murthy UK, Linscheer WG. Percutaneous endoscopic jejunostomy: long-term follow-up of 23 patients. Gastrointest Endosc 1989; 35: 403-406
    CrossrefPubMedGoogle Scholar
  • 23 Rumalla A, Baron TH. Results of direct percutaneous endoscopic jejunostomy, an alternative method for providing jejunal feeding. Mayo Clin Proc 2000; 75: 807-810
    CrossrefPubMedGoogle Scholar
  • 24 Strong AT, Sharma G, Davis M. et al. Direct percutaneous endoscopic jejunostomy (DPEJ) tube placement: a single institution experience and outcomes to 30 days and beyond. J Gastrointest Surg 2017; 21: 446-452
    CrossrefPubMedGoogle Scholar
  • 25 Cococcia S, Rovedatti L, Lenti MV. et al. Safety and durability of PEG-J: a single-centre experience. Scand J Gastroenterol 2020; 55: 1377-1380
    CrossrefPubMedGoogle Scholar
  • 26 Barrera R, Schattner M, Nygard S. et al. Outcome of direct percutaneous endoscopic jejunostomy tube placement for nutritional support in critically ill, mechanically ventilated patients. J Crit Care 2001; 16: 178-181
    CrossrefPubMedGoogle Scholar
  • 27 Bueno JT, Schattner MA, Barrera R. et al. Endoscopic placement of direct percutaneous jejunostomy tubes in patients with complications after esophagectomy. Gastrointest Endosc 2003; 57: 536-540
    CrossrefPubMedGoogle Scholar
  • 28 Shetzline MA, Suhocki PV, Workman MJ. Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy. Gastrointest Endosc 2001; 53: 633-638
    CrossrefPubMedGoogle Scholar
  • 29 Del Piano M, Ballarè M, Carmagnola S. et al. DPEJ placement in cases of PEG insertion failure. Dig Liver Dis 2008; 40: 140-143
    CrossrefPubMedGoogle Scholar
  • 30 Mackenzie SH, Haslem D, Hilden K. et al. Success rate of direct percutaneous endoscopic jejunostomy in patients who are obese. Gastrointest Endosc 2008; 67: 265-269
    CrossrefPubMedGoogle Scholar
  • 31 Panagiotakis PH, DiSario JA, Hilden K. et al. DPEJ tube placement prevents aspiration pneumonia in high-risk patients. Nutr Clin Pract 2008; 23: 172-175
    CrossrefPubMedGoogle Scholar
  • 32 Moran GW, Fisher NC. Direct percutaneous endoscopic jejunostomy high completion rates with selective use of a long drainage access needle. Diagn Ther Endosc 2009; 2009: 520879
    CrossrefPubMedGoogle Scholar
  • 33 Aktas H, Mensink PBF, Kuipers EJ. et al. Single-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy. Endoscopy 2012; 44: 210-212
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Toussaint E, Van Gossum A, Ballarin A. et al. Percutaneous endoscopic jejunostomy in patients with gastroparesis following lung transplantation: Feasibility and clinical outcome. Endoscopy 2012; 44: 772-775
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Velázquez-Aviña J, Beyer R, Díaz-Tobar CP. et al. New method of direct percutaneous endoscopic jejunostomy tube placement using balloon-assisted enteroscopy with fluoroscopy. Dig Endosc 2015; 27: 317-322
    CrossrefPubMedGoogle Scholar
  • 36 Al-Bawardy B, Gorospe EC, Alexander JA. et al. Outcomes of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy tube placement. Endoscopy 2016; 48: 552-556
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Bernardes C, Pinho R, Rodrigues A. et al. Direct percutaneous endoscopic jejunostomy using single-balloon enteroscopy without fluoroscopy: A case series. Rev Esp Enfermedades Dig 2017; 109: 679-683
    PubMedGoogle Scholar
  • 38 Ridtitid W, Lehman GA, Watkins JL. et al. Short- and long-term outcomes from percutaneous endoscopic gastrostomy with jejunal extension. Surg Endosc 2017; 31: 2901-2909
    CrossrefPubMedGoogle Scholar
  • 39 Kirstein MM, Körner S, Schneider A. et al. Percutaneous endoscopic gastrostomy with and without jejunal extension in patients with amyotrophic lateral sclerosis. Eur J Gastroenterol Hepatol 2018; 30: 257-262
    CrossrefPubMedGoogle Scholar
  • 40 Simoes PK, Woo KM, Shike M. et al. Direct percutaneous endoscopic jejunostomy: procedural and nutrition outcomes in a large patient cohort. J Parenter Enter Nutr 2018; 42: 898-906
    CrossrefPubMedGoogle Scholar
  • 41 Shike M, Wallach C, Likier H. Direct percutaneous endoscopic jejunostomies. Gastrointest Endosc 1991; 37: 62-65
    CrossrefPubMedGoogle Scholar
  • 42 Mellert J, Naruhn MB, Grund KE. et al. Surgical endoscopy. Surg Clin North Am 1989; 69: 1123-1335
    CrossrefPubMedGoogle Scholar
  • 43 Shike M, Latkany L, Gerdes H. et al. Direct percutaneous endoscopic jejunostomies for enteral feeding. Nutr Clin Pract 1997; 12: S38-S42
    CrossrefPubMedGoogle Scholar
  • 44 Varadarajulu S, Delegge MH. Use of a 19-gauge injection needle as a guide for direct percutaneous endoscopic jejunostomy tube placement. Gastrointest Endosc 2003; 57: 942-945
    CrossrefPubMedGoogle Scholar
  • 45 Maple JT, Petersen BT, Baron TH. et al. Direct percutaneous endoscopic jejunostomy: Outcomes in 307 consecutive attempts. Am J Gastroenterol 2005; 100: 2681-2688
    CrossrefPubMedGoogle Scholar
  • 46 Song LWK, Baron TH, Saleem A. et al. Double-balloon enteroscopy as a rescue technique for failed direct percutaneous endoscopic jejunostomy when using conventional push enteroscopy (with video). Gastrointest Endosc 2012; 76: 675-679
    CrossrefPubMedGoogle Scholar
  • 47 Lim A, Schoeman M, Nguyen N. Long-term outcomes of direct percutaneous endoscopic jejunostomy: a 10-year cohort. Endosc Int Open 2015; 03: E610-E614
    Article in Thieme ConnectPubMedGoogle Scholar
  • 48 Nishiwaki S, Kurobe T, Baba A. et al. Prognostic outcomes after direct percutaneous endoscopic jejunostomy in elderly patients: comparison with percutaneous endoscopic gastrostomy. Gastrointest Endosc 2021; 94: 48-56
    CrossrefPubMedGoogle Scholar
  • 49 Buchman AL. Use of percutaneous endoscopic gastrostomy or percutaneous endoscopic jejunostomy in short bowel syndrome. Gastrointest Endosc Clin N Am 2007; 17: 787-794
    CrossrefPubMedGoogle Scholar
  • 50 Piccinni G, Angrisano A, Testini M. et al. Venting direct percutaneous jejunostomy (DPEJ) for drainage of malignant bowel obstruction in patients operated on for gastric cancer. Support Care Cancer 2005; 13: 535-539
    CrossrefPubMedGoogle Scholar
  • 51 Lewis SJ, Egger M, Sylvester PA. et al. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ 2001; 323: 773-776
    CrossrefPubMedGoogle Scholar
  • 52 DeLegge MH, Patrick P, Gibbs R. Percutaneous endoscopic gastrojejunostomy with a tapered tip, nonweighted jejunal feeding tube: improved placement success. Am J Gastroenterol 1996; 91: 1130-1134
    PubMedGoogle Scholar
  • 53 Shike M. Predicting the success of percutaneous endoscopic jejunostomy placement: The endoscope light outshines the CT scan. Gastrointest Endosc 2006; 63: 431-432
    CrossrefPubMedGoogle Scholar
  • 54 Nishiwaki S, Iwashita M, Goto N. et al. Predominant copper deficiency during prolonged enteral nutrition through a jejunostomy tube compared to that through a gastrostomy tube. Clin Nutr 2011; 30: 585-589
    CrossrefPubMedGoogle Scholar
  • 55 Wolfsen HC, Kozarek RA, Ball TJ. et al. Tube dysfunction following percutaneous endoscopic gastrostomy and jejunostomy. Gastrointest Endosc 1990; 36: 261-263
    CrossrefPubMedGoogle Scholar
  • 56 Fan AC, Baron TH, Rumalla A. et al. Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension. Gastrointest Endosc 2002; 56: 890-894
    CrossrefPubMedGoogle Scholar
  • 57 Zopf Y, Rabe C, Bruckmoser T. et al. Percutaneous endoscopic jejunostomy and jejunal extension tube through percutaneous endoscopic gastrostomy: A retrospective analysis of success, complications and outcome. Digestion 2009; 79: 92-97
    CrossrefPubMedGoogle Scholar
  • 58 Gkolfakis P, Arvanitakis M. Percutaneous endoscopic gastrostomy and direct percutaneous endoscopic jejunostomy: 2 sides of the same coin. Gastrointest Endosc 2021; 94: 57-59
    CrossrefPubMedGoogle Scholar