Direct percutaneous endoscopic jejunostomy tube placement in patients post Roux-en-Y gastric bypass, a single tertiary care center experience

Abstract

Background and study aims Obesity prevalence continues to rise in the United States with Roux-en-Y gastric bypass (RYGB) surgery being one of the most common bariatric procedures. With this trend, more patients with altered upper gastrointestinal (UGI) anatomy have required endoscopic intervention including direct percutaneous endoscopic jejunostomy (DPEJ) placement. We aimed to assess the safety and success rates of DPEJ in RYGB patients.

Patients and methods All patients at a tertiary care referral center who underwent DPEJ during an 8-year period were queried from a prospectively maintained registry of all enteroscopy procedures. Duplicate cases and altered upper UGI anatomy subtypes other than RYGB were excluded. The final cohort consisted of two groups: RYGB vs native anatomy (NA). Demographic, procedural, readmission, follow-up, and complication data were recorded. Comparative analysis was performed.

Results Seventy-two patients were included where 28 had RYGB and 44 had NA. Both groups had similar baseline and pre-procedure data. Procedure success rate was 89 % in RYGB patients and 98 % in NA patients (P = 0.13). There were no intraprocedural complications. Early and late postprocedural complication rates were similar between the groups (both 4 % vs 7 %). Average follow-up times in the RYGB and NA groups were 12.97 ± 9.35 and 13.44 ± 9.21 months, respectively. Although readmission rates at 1 and 6 months were higher in the NA versus the RYGB group (21 % vs 7 % and 25 % vs 15 %), these differences were not significant.

Conclusions DPEJ can be successful and safely placed in RYGB patients with no significant difference in procedure success, complication, or readmission rates when compared to control.

Publication History

Received: 19 May 2022

Accepted after revision: 19 July 2022

Accepted Manuscript online:
20 July 2022

Article published online:
14 September 2022

• References

• 01 Hales CM, Carroll MD, Fryar CD. et al. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief; 2020: 1-8
• 2 Premkumar A, Samaan JS, Samakar K. Factors associated with bariatric surgery referral patterns: a systematic review. J Surg Res 2022; 276: 54-75
• 3 Mitchell BG, Gupta N. Roux-en-Y gastric bypass. Treasure Island: StatPearls Publishing; 2022
• 4 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 Surgery 2017; 21: 446-452
• 5 Shetzline MA, Suhocki P v, Workman MJ. Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy. Gastrointest Endosc 2001; 53: 633-638
• 6 Shike M, Latkany L. Direct percutaneous endoscopic jejunostomy. Gastrointest Endosc Clin N Am 1998; 8: 569-580
• 7 Arvanitakis M, Gkolfakis P, Despott EJ. et al. Endoscopic management of enteral tubes in adult patients – Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 81-92
• 8 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
• 9 Maple JT, Petersen BT, Baron TH. et al. Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts. Am J Gastroenterol 2005; 100: 2681-2688
• 10 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
• 11 Despott EJ, Gabe S, Tripoli E. et al. Enteral access by double-balloon enteroscopy: an alternative method of direct percutaneous endoscopic jejunostomy placement. Digest Dis Sci 2011; 56: 494-498
• 12 Al-Bawardy B, Gorospe E, Alexander J. et al. Outcomes of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy tube placement. Endoscopy 2016; 48: 552-556
• 13 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
• 14 del Piano M, Ballarè M, Carmagnola S. et al. DPEJ placement in cases of PEG insertion failure. Digest Liver Dis 2008; 40: 140-143
• 15 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
• 16 Tang S, Wu R. Percutaneous endoscopic gastrostomy (pull method) and jejunal extension tube placement. Video J Encyclopedia GI Endosc 2014; 2: 40-45
• 17 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. Digest Endosc 2015; 27: 317-322
• 18 Lim R, Beekley A, Johnson DC. et al. Early and late complications of bariatric operation. Trauma Surgery Acute Care Open 2018; 3: e000219
• 19 Seeras K, Acho RJ, Lopez PP. Roux-en-Y Gastric Bypass Chronic Complications. Treasure Island (FL): StatPearls Publishing; 2022
• 20 Griffith PS, Birch D, Sharma A. et al. Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity. Canadian J Surgery 2012; 55: 329-336
• 21 Mundi MS, Vallumsetla N, Davidson JB. et al. Use of home parenteral nutrition in post–bariatric surgery–related malnutrition. J Parent Enter Nutr 2017; 41: 1119-1124
• 22 Nuzzo A, Czernichow S, Hertig A. et al. Prevention and treatment of nutritional complications after bariatric surgery. Lancet Gastroenterol Hepatol 2021; 6: 238-251
• 23 Deliwala SS, Chandan S, Kumar A. et al. Direct percutaneous endoscopic jejunostomy (DPEJ) and percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) technical success and outcomes: Systematic review and meta-analysis. Endosc Int Open 2022; 10: E488-E520
• 24 Wong Kee Song LM, Baron TH. 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
• 25 Simoes PK, Woo KM, Shike M. et al. Direct percutaneous endoscopic jejunostomy: procedural and nutrition outcomes in a large patient cohort. J Parent Enter Nutr 2018; 42: 898-906
• 26 Keller U. Nutritional Laboratory Markers in Malnutrition. J Clin Med 2019; 8: 775
• 27 Kudsk K, Tolley E, DeWitt R. et al. Preoperative albumin and surgical site identify surgical risk for major postoperative complications. J Parent Enter Nutr 2003; 27: 1-9
• 28 Levitt D, Levitt M. Human serum albumin homeostasis: a new look at the roles of synthesis, catabolism, renal and gastrointestinal excretion, and the clinical value of serum albumin measurements. Int J Gen Med 2016; 9: 229-255