NOVEL TECHNIQUE FOR DIRECT PERCUTANEOUS ENDOSCOPIC JEJUNOSTOMY TUBE PLACEMENT USING SINGLE BALLOON ENTEROSCOPY WITH FLUOROSCOPY IN PATIENTS WITH SURGICALLY ALTERED UPPER GI TRACT ANATOMY

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method to deliver nutrition in patients with a variety of problems such as: malignancies causing gastric outlet obstruction, gastroparesis, pancreatitis, high risk of aspiration and malnutrition, malnutrition in the setting of prior complex post-upper GI tract surgery such as gastric resection or Roux-en-Y gastric bypass. DPEJ using standard colonoscopes or push technique remains a technically challenging procedure, with success rates in expert hands being around 68%. Hereby we present the key steps to successfully conduct a DPEJ using single balloon enteroscopy technique.

This new method of DPEJ placement focuses on three key components:

1. Use of balloon-assisted overtube, which allows for deep jejunal intubation, providing endoscopic stabilization during the procedure, while the overtube is held in place and the scope is moved to and fro to find the best spot for puncture;

2. Use of fluoroscopy, leading to increased success of finding an adequate jejunal loop for puncture, especially in cases with gastrojejunostomy anstomoses;

3. Leaving the overtube in place during the entire procedure (and also for DPEJ removal), which decreases the risk of GI luminal damage during pulling of PEG and during scope manipulation, as the overtube “shields” the inside of the GI tract. Often there are bowel kinks, anastomoses or even stenosis where the DPEJ button may become entangled and tear or perforate the GI tract during the pulling maneuver.

In sum, we believe that the combination of all these aspects may increase the safety and success of this technique.