Surgical jejunostomy, DEPJ or PEGJ

Size: px

Start display at page:

Download "Surgical jejunostomy, DEPJ or PEGJ"

Robyn Rich
5 years ago
Views:

1 Surgical jejunostomy, DEPJ or PEGJ Dr Simon Gabe St Mark s Hospital, London

2 Jejunal feeding NJ PEGJ Surgical jejunostomy Direct PEJ

3 Surgical jejunostomy Different tubes PEGJ Which one? Local expertise Different patients DEPJ

4 Different answers for different patients Full thickness SB biopsy required? Jejunal hypersensivity? First jejunostomy tube placement Likely very long term (will need repeated tubes) Medications required?

5 Gastro-jej tubes

6 PEGJ tubes For Against Short/medium term trial No new puncture Availability Placed under sedation (no GA) Repeated procedures needed Jej tube falls back Poor PEG aspiration

7 24 year old woman Atopy (asthma, eczema, hayfever), 2008 Urticaria vasculitis, Raynaud s & peripheral neuropathy, 2013 Nausea, vomiting, recurrent dehydration & hospital admissions, 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 MIC KEY gastrojejunostomy NJ feeding PEGJ (Freka) NJ feeding PEGJ (Freka) Dec 2017 Feb 2018 Feb March 2018 March March 2018 (x2) March 2018 (x3) May July 2018 July Aug 2018 Aug Sept 2018 April 2017 June Dec March March May Sept

8 Options Continue PEGJ Surgical jejunostomy DPEJ

9 Surgical jejunostomy: approaches Direct Witzel tunnell

10 Different tubes: surgical Needle catheter jejunostomy Surgical jejunostomy MIC Jejunostomy Feeding Tube

11 Which type of surgery? Open surgery More invasive Surgical procedure to remove Laparoscopic surgery Less invasive Witzel tunnel much shorter

12 Surgical or endoscopic? Surgical jejunostomy Laparoscopic possible More invasive Surgical procedure to remove Tube has more limited lifespan Direct PEJ Endoscopic procedure under GA Less invasive Can be removed endoscopically Tube may last longer

13 DPEJ placement

14 Handy things.

15 Step 1 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

16 Step 2 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 3 Snaring of seeker needle, jejunopexy & insertion

Anchors the jejunum to the abdo wall Minimizes risk of

Jejunopexy (x2) performed with T bar sutures Large PEG

17 Step 3 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

18 Step 4 Thread grasped & attached to PEG tube Thread Placed through the trochar Snared Pulled out though the mouth (enteroscope withdrawal)

Position of internal bumper confirmed by direct vision Distance

19 Step 5 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

21 Needle catheter jejunostomy For Against Easy removal Can be accidentally pulled out Medium term (weeks/months) feeding Sutured to the skin Best post surgery Upper GI Intestinal transplant

22 Surgical jejunostomy For Against Cannot keep replacing surgically Allows jejunal biopsy when appropriate Witzel tunnel: no tracking of jejunal fluid Silicone tube more comfortable Silicone tube degrades quickly in some patients Further surgery to remove More invasive (open>laparoscopic)

23 DPEJ For Against Possible to perforate/pass through small bowel / colon Endoscopic replacement with no further bowel trauma Cannot perform full thickness biopsy Freka PEG tube works best (9F) Limited expertise Much less trauma GA procedure with DBE

24 Suggested approaches Trial of therapy NJ PEGJ Post upper GI surgery Needle catheter jejunostomy Dysmotility: 1 st 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)

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

26 Needle catheter jejunostomy Surgical jejunostomy Gastrojejunostomy Direct PEJ Pros Best post surgery (upper GI, intestinal transplant) Medium term (weeks/months) feeding Easy removal Silicone tube more comfortable Witzel tunnel: no tracking of jejunal fluid Allows jejunal biopsy when appropriate No additional abdominal puncture in patients with an existing PEG Endoscopic placement under sedation Much less trauma Freka PEG tube works best (9F) Endoscopic replacement with no further bowel trauma Cons Sutured to the skin Can be accidentally pulled out More invasive (open>laparoscopic) Further surgery to remove Silicone tube degrades quickly in some patients Cannot keep replacing surgically Can be difficult to get jej extension beyond ligament of Treitz Jejunal extension can fall back External connections can be confusing Can require frequent replacement Gastrostomy venting much less effective (jej tube in place) GA procedure with DBE Limited expertise Cannot perform full thickness biopsy Possible to perforate/pass through small bowel / colon Replacement requires DBE approach with GA

DIGESTIVE HEALTH ENTERAL FEEDING PRODUCTS

DIGESTIVE HEALTH ENTERAL FEEDING PRODUCTS HALYARD* MIC* AND MIC-KEY* INTRODUCER KITS HALYARD* MIC* and MIC-KEY* Introducer Kits provide physicians with an innovative solution to facilitate the primary