Tips and Tricks for Deep Jejunal Enteral Access: Modifying Techniques to Maximize Success

Abstract

Endoscopic insertion of enteral feeding tubes is a major advance in the delivery of nutrition therapy. Since the first report of percutaneous endoscopic gastrostomy (PEG) in 1980 (Gauderer et al. J Pediatr Surg. 15:872–5, 1980), insertion techniques and equipment have been refined and improved. Despite this progress, deep jejunal enteral access remains a difficult procedure, and many endoscopists do not have experience with the techniques of nasojejunal (NJ) placement, percutaneous endoscopic gastrojejunostomy (PEGJ), or direct percutaneous endoscopic jejunostomy (DPEJ) (Shike and Latkany, Gastrointest Endosc Clin N Am. 8:569–80, 1998). The difference between an exasperating experience and a rewarding procedure lies in mastering the “tips and tricks” that make insertion easy. While the basic techniques are described elsewhere (McClave and Chang 2011), we review several universal basic principles to enhance deep jejunal access, which should promote a more efficient and successful procedure.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.

    Gauderer MW, Ponsky JL, Izant Jr RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980;15:872–5.

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Shike M, Latkany L. Direct percutaneous endoscopic jejunostomy. Gastrointest Endosc Clin N Am. 1998;8:569–80.

    PubMed  CAS  Google Scholar 

  3. 3.•

    McClave S, Chang W-K. Techniques in enteral access. In: Ginsberg G, editor. Clinical Gastrointestinal Endoscopy. Philadelphia: Saunders; 2011. Provides a concise but thorough technical review of endoscopic gastrostomy placement.

  4. 4.

    Larson DE, Burton DD, Schroeder KW, et al. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology. 1987;93:48–52.

    PubMed  CAS  Google Scholar 

  5. 5.

    Gibson SE, Wenig BL, Watkins JL. Complications of percutaneous endoscopic gastrostomy in head and neck cancer patients. Ann Otol Rhinol Laryngol. 1992;101:46–50.

    PubMed  CAS  Google Scholar 

  6. 6.

    DiSario JA, Foutch PG, Sanowski RA. Poor results with percutaneous endoscopic jejunostomy. Gastrointest Endosc. 1990;36:257–60.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    McClave SA, Chang WK. Complications of enteral access. Gastrointest Endosc. 2003;58:739–51.

    PubMed  Article  Google Scholar 

  8. 8.

    Maple JT, Petersen BT, Baron TH, et al. Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts. Am J Gastroenterol. 2005;100:2681–8.

    PubMed  Article  Google Scholar 

  9. 9.

    Foutch PG, Talbert GA, Waring JP, et al. Percutaneous endoscopic gastrostomy in patients with prior abdominal surgery: virtues of the safe tract. Am J Gastroenterol. 1988;83:147–50.

    PubMed  CAS  Google Scholar 

  10. 10.

    Rees RG, Payne-James JJ, King C, et al. Spontaneous transpyloric passage and performance of ‘fine bore’ polyurethane feeding tubes: a controlled clinical trial. JPEN J Parenter Enteral Nutr. 1988;12:469–72.

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Lord LM, Weiser-Maimone A, Pulhamus M, et al. Comparison of weighted vs unweighted enteral feeding tubes for efficacy of transpyloric intubation. JPEN J Parenter Enteral Nutr. 1993;17:271–3.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Payne-James JJ, Rees RG, Doherty J, et al. 7 g weighted versus unweighted polyurethane nasoenteral tubes—spontaneous transpyloric passage and clinical performance: a controlled randomised trial. Clin Nutr. 1990;9:109–12.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Brandt CP, Mittendorf EA. Endoscopic placement of nasojejunal feeding tubes in ICU patients. Surg Endosc. 1999;13:1211–4.

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Seder CW, Stockdale W, Hale L, et al. Nasal bridling decreases feeding tube dislodgment and may increase caloric intake in the surgical intensive care unit: a randomized, controlled trial. Crit Care Med. 2010;38:797–801.

    PubMed  Article  Google Scholar 

  15. 15.

    Gunn SR, Early BJ, Zenati MS, et al. Use of a nasal bridle prevents accidental nasoenteral feeding tube removal. JPEN J Parenter Enteral Nutr. 2009;33:50–4.

    PubMed  Article  Google Scholar 

  16. 16.

    Seder CW, Janczyk R. The routine bridling of nasojejunal tubes is a safe and effective method of reducing dislodgement in the intensive care unit. Nutr Clin Pract. 2008;23:651–4.

    PubMed  Article  Google Scholar 

  17. 17.

    Chung RS, Schertzer M. Pathogenesis of complications of percutaneous endoscopic gastrostomy. A lesson in surgical principles. Am Surg. 1990;56:134–7.

    PubMed  CAS  Google Scholar 

  18. 18.

    Szary NM, Arif M, Matteson ML, et al. Enteral feeding within three hours after percutaneous endoscopic gastrostomy placement: a meta-analysis. J Clin Gastroenterol. 2011;45:e34–8.

    PubMed  Article  Google Scholar 

  19. 19.

    Bechtold ML, Matteson ML, Choudhary A, et al. Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis. Am J Gastroenterol. 2008;103:2919–24.

    PubMed  Article  Google Scholar 

  20. 20.

    McClave SA. Personal drawing.

  21. 21.

    DeLegge MH. Enteral access—the foundation of feeding. JPEN J Parenter Enteral Nutr. 2001;25:S8–S13.

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Baskin W. Percutaneous endoscopic gastrostomy & placement of a jejunal extension tube. Tech Gastrointest Endosc. 2001;3:30–41.

    Article  Google Scholar 

  23. 23.

    Hollister I. Tube attachment devices. 2014 [cited 2014 June 8]; Available from: http://www.hollister.com/us/files/pdfs/907468.pdf.

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Conflict of Interest

Matthew Bechtold, Robert Martindale, Douglas Nguyen, and David C. Evans have nothing to disclose.

Steven A. McClave is a consultant for Covidien and has received research grants from Abbot and Nestle.

Lena B. Palmer has received travel and compensation for participation in the Regional Advisory Board from NPS Pharmaceuticals.

Human and Animal Rights and Informed Consent

This article does not contain any studies with animal subjects performed by any of the authors. With regard to the authors’ research cited in this paper, all procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000 and 2008.

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Correspondence to Lena B. Palmer.

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This article is part of the Topical Collection on Nutrition and Obesity

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Palmer, L.B., McClave, S.A., Bechtold, M.L. et al. Tips and Tricks for Deep Jejunal Enteral Access: Modifying Techniques to Maximize Success. Curr Gastroenterol Rep 16, 409 (2014). https://doi.org/10.1007/s11894-014-0409-x

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Keywords

  • Jejunal access
  • Enteral feeding
  • Post-pyloric placement