Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method for the delivery
of nutrition in patients with a variety of gastrointestinal (GI) problems [1]
[2]
[3]. However, DPEJ using standard colonoscopes or the push technique remains a technically
challenging procedure, with success rates of about 68 % in expert hands [2]. Herein, we present the key steps to conducting a successful DPEJ using a single-balloon
enteroscopy technique.
A 62-year-old woman presented with severe necrotizing pancreatitis mandating intensive
care therapy. The pancreas necrosis progressed into a huge collection, resulting in
partial gastric outlet obstruction ([Fig. 1 a]). Despite endoscopic drainage, the patient remained nauseated and was unable to
tolerate oral feeding. We were consulted to place a direct percutaneous jejunostomy
(PEG) tube.
Fig. 1 Direct percutaneous endoscopic jejunostomy. a Computed tomography demonstrated severe necrotizing pancreatitis. b Endoscopic view of catheter for string delivery. c The string was caught and then pulled through the overtube, which was then left in
situ. d Inspection of the button. The scope was pushed through the overtube. Reaching the
jejunostomy site was thus quite easy and safe, as the overtube served as a giant working
channel, and protected the upper gastrointestinal tract from tearing damage.
The patient was placed in the supine position, and the therapeutic double-balloon
enteroscope was used in single-balloon mode (i. e. no balloon was attached to the
tip of the scope) ([Video 1]). The scope and overtube were then advanced to about 80 cm distal to the pylorus.
A jejunal loop was then carefully located using both endoscopic and fluoroscopic guidance
([Video 1]). PEG tube placement was performed using the Ponsky method (pull-type technique
using a 20 Fr PEG-kit; Cook Medical, Bloomington, Indiana, USA) ([Video 1]). Once the string had been endoscopically grasped by the snare, the scope and string
were pulled back out through the overtube ([Fig. 1 b, c], [Video 1]). A key element of the technique is the overtube, which is left in situ. The string
was attached to the PEG tube and, as the string was pulled back out through the skin
incision, the PEG tube was pulled through (i. e. inside) the overtube ([Video 1]). The scope was advanced into the overtube and was used to help push the PEG button,
and subsequently to inspect the jejunum for correctness of PEG tube placement ([Fig. 1 d], [Video 1]). An enteral diet was started 12 hours later.
Video 1 This new method of percutaneous endoscopic jejunostomy (DPEJ/PEG) tube placement
focuses on three key components: 1) use of a balloon-assisted overtube, which provides
endoscopic stabilization during the procedure; 2) use of fluoroscopy, leading to increased
success of finding an adequate jejunal loop for puncture; 3) leaving the overtube
in place during the entire procedure (and also for PEG tube removal), which decreases
the risk of gastrointestinal (GI) luminal damage during pulling of the PEG tube and
during scope manipulation, as the overtube “shields” the inside of the GI tract.
This new method of PEG tube placement focuses on three key components: 1) use of a
balloon-assisted overtube, which provides endoscopic stabilization during the procedure;
2) use of fluoroscopy, leading to increased success of finding an adequate jejunal
loop for puncture; 3) leaving the overtube in place during the entire procedure (and
also for PEG tube removal), which decreases the risk of GI luminal damage during pulling
of the PEG tube and during scope manipulation, as the overtube “shields” the inside
of the GI tract. The combination of all these aspects may increase the safety and
success of this technique.
Endoscopy_UCTN_Code_TTT_1AO_2AK
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
