Introduction
Background
Malnutrition, swallowing disturbances, and prolonged weight loss negatively impact
the body, contributing to poor functional and clinical outcomes. They are significant
causes of morbidity and mortality in patients with advanced diseases, and nutritional
supplementation remains the cornerstone to maintain daily requirements. There has
been a paradigm shift in the approach to nutrition, traditionally seen as an adjunct;
it has bonafide therapeutic benefits by attenuating immune and host responses. Enteral
nutrition has demonstrated better clinical outcomes, reduced infection risk, and cost
efficiency than parenteral nutrition; hence it is considered the preferred method
to deliver nutrition in a patient with a functional gastrointestinal system [1 ]
[2 ]
[3 ]. Among various jejunal strategies, endoscopic guided techniques, PEG with a jejunal
extension (PEG-J) and direct percutaneous endoscopic jejunostomy (DPEJ) have shown
superior results to nasojejunal or parental feeding [3 ]. Additionally, compared to surgical options, endoscopic guided procedures have less
exposure to anesthesia, rapid recovery times, lower costs, and can benefit a variety
of patients with complicated GI anatomy (previous Billroth II, Roux-en-Y, bariatric,
bowel resection, or pancreatic reconstruction), gastric atony, or gastrointestinal
obstruction [4 ].
The indication for enteral feeding tubes are patients with a functioning gastrointestinal
tract unable to meet their oral caloric intake for long-term nutrition [5 ]. The goal is to deliver feeds deep into the jejunum; the mean distance in one study
was 70 cm (60cm–90 cm) past pylorus or anastomosis. Recent studies looking at nutritional
support in these patients have shown reduced rates of pneumonia and increased nutrition
delivery in post-pyloric feeding with minimal significant adverse events and safe
insertion mechanisms. However, the best method of jejunal feeding remains unclear
due to insufficient evidence. PEG-J are placed through an existing gastrostomy, and
various placement methods have been described, either transorally or through the gastrostomy
tract. The jejunal tube that serves as an extension to the PEG tube measures 9 Fr
to 12 Fr in diameter, roughly 60 cm in length, and is typically dragged into the jejunum
by endoscopic forceps or fluoroscopically. In contrast, DPEJ includes positioning
an enteroscope or pediatric colonoscope into the jejunum and inserting the tube via
direct puncture of the jejunum [6 ]. In addition, several studies have used balloon-assisted enteroscopy (single or
double) along with fluoroscopy to augment dexterity and success rates [7 ]
[8 ]
[9 ].
The American Society for Gastrointestinal Endoscopy (ASGE) and the European Society
of Gastrointestinal Endoscopy (ESGE) support PEG-J and DPEJ as alternatives in patients
that require long-term post-pyloric feeding. However, the lack of convincing clinical
evidence has important implications for patients and gastroenterologists alike and
has limited its adoption [7 ]
[10 ]
[11 ]
[12 ]. The evolving demand for jejunal feeding necessitates a review looking at its success
and complication rates. Therefore, we conducted a systematic review and meta-analysis
to test our hypothesis and assess the success and safety factors of DPEJ and PEG-J
in jejunal feeding.
Material and methods
Protocol and registration
This review has been in accordance with Preferred Reporting Items for Systematic Reviews
and Meta-Analyses Statement (PRISMA) and Meta-analyses of Observational Studies in
Epidemiology (MOOSE) reporting standards (Supplementary Table 1 and Supplementary Table 2 ) [13 ]
[14 ].
Eligibility criteria, literature search, and search strategy
An expert librarian conducted a systematic literature search using a priori protocol
to identify studies enrolling patients that received a direct percutaneous endoscopic
jejunostomy (DPEJ) or percutaneous endoscopic gastrostomy with a jejunal extension
(PEG-J). The search strategies included “direct percutaneous endoscopic jejunostomy,”
“percutaneous endoscopic gastrostomy,” “PEJ,” “PEG-J,” “EPJ,” and “jejunal feeding”
with Boolean operators. The search was run in June 2021 across multiple databases,
including Ovid EBM Reviews, Ovid Embase (1974 +), Ovid Medline (1946 + including epub
ahead of print, in-process, and other non-indexed citations), Scopus (1970 +), Web
of Science (1975 +), and PubMed. The search was restricted to articles in English
and identified searches were exported to a reference manager (EndNote) to filter duplicates.
We cross-checked the reference lists of identified sources for additional relevant
studies, including the grey literature. Any discrepancy was resolved by a third reviewer
(SD). Complete search strategy can be found in Supplementary Table 3 . Conference abstracts were excluded due to a lack of usable data.
Study selection
This meta-analysis included studies that evaluated the outcomes of jejunal feeding
strategies for nutritional support, specifically studies with primary direct PEJ (DPEJ)
or gastrostomy with jejunal extension tubes (PEG-J). Studies reporting surgical jejunal
feeding strategies, performance in pediatric age groups (< 18 years), and non-English
studies were excluded. Studies were restricted to full-text manuscripts as we considered
abstracts to have insufficient information and high bias to be included in our assessment.
Two authors decided on the final selection (SD, SC).
Data abstraction and quality assessment
Two reviewers (AP, MH) independently extracted eligible information into an a priori
designed Google Excel sheet. The Qumseya scale for quality assessment of cohort studies
for systematic reviews and meta-analyses consisted of nine questions [15 ]. We assessed each study for its design, measurements, outcomes, and patient characteristics.
Each risk of bias was judged on a maximum score of 10. Studies with less than six
were considered low, 6 to 7 were moderate, and > 8 were considered high quality [15 ].
Outcomes assessed
Efficacy outcomes
Technical success was defined as the ability to successfully insert a feeding tube
into the proximal jejunum by DPEJ or PEG-J. Overall technical success (placement rate)
for either procedure was successful attempts/total attempts [5 ]
[6 ]
[7 ]
[11 ]
[12 ]. Clinical success was the effective use of a jejunal tube for feeding patients in
whom TS was achieved with water or enteral feed delivered into the small intestine
within 24 hours [5 ]
[6 ]
[7 ]
[11 ]
[12 ].
Safety outcomes
Complications and adverse events were categorized into “malfunction,” “major,” and
“minor.” Malfunction included dislodgement, displacement, peristomal leakage, kinking,
clogging, or buried bumper syndrome. Major adverse events included any adverse event
that required endoscopic, surgical, or radiological intervention after achieving clinical
success. Minor was defined by insertion site infections, fever, abdominal pain, or
controlled bleeding. Peristomal infection was defined as observed local inflammatory
signs such as erythema, induration, and exudate with pain or tenderness. Ease of endoscopic
placement was assessed by the number of attempts to place a jejunal feeding tube.
Statistical analysis
Statistical analysis was performed using Comprehensive Meta-Analysis (CMA 3.0) software
(Biostat, Englewood, New Jersey, United States). Pooled estimates and corresponding
95 % confidence intervals (CI) for dichotomous variables were calculated using the
random-effects inverse variance/DerSimonian-Laird method [16 ].
Heterogeneity was measured by Cochrane Q and I2
statistics, with values of < 30 %, 31 % to 60 %, 61 % to 75 %, and > 75 % suggesting
low, moderate, substantial, and considerable heterogeneity, respectively [17 ]
[18 ]. A funnel plot combined with Egger’s tests was performed to assess publication bias.
P ≤ 0.05 combined with asymmetry in the funnel plots was used to measure significant
publication bias, and if < 0.05, the trim-and-fill computation was used to evaluate
the effect of publication bias on the interpretation of the results. We additionally
calculate the prediction intervals using the CMA software. Three levels of impact
were reported based on the concordance between the reported results and the actual
estimate if there was no bias. The impact was reported as minimal if both versions
were estimated to be the same, modest if the effect size changed substantially, but
the final finding would remain the same and severe if the bias threatens the conclusion
of the analysis [19 ]. Sensitivity analysis to evaluate an individual study’s effect on the collective
outcome was completed. We also explored heterogeneity through meta-regression from
continuous variable modifiers and subgroup analysis from dichotomous variable modifiers.
Results
Study characteristics
An initial search identified 451 studies. After screening 67 full-text articles, 29
studies were eligible for qualitative and quantitative synthesis. All studies assessed
successful placement and adverse effects. Study locations included Australia, Belgium,
Italy, Germany, Netherlands, Portugal, the United States, and the United Kingdom.
Variations in the type of jejunal feeding were seen; five used PEG-J and 24 used DPEJ.
Five DPEJ studies used device-assisted enteroscopy (single-balloon two and double-balloon
three). Among 29 studies, 1874 patients (983 males and 803 females); were included,
with the mean age 60 ± 19 years and BMI 23.1 ± 5.5. The mean procedure duration was
45.2 ± 34.1 min, with longer times in unsuccessful attempts, altered anatomy, and
patients with a BMI > 25. The mean follow-up duration of endoscopically placed jejunal
feeding was 530 ± 517 days, while the mean time to tube malfunction was 162 ± 135
days. The mean weight gain was 4.6 ± 4.4kg. Study and baseline clinical characteristics
have been summarized in [Table 1 ], [Table 2 ], and [Table 3 ].
Table 1
Study procedure characteristics.
Author/Year
Design
Total patients (n )
Procedure type
Endoscope manufacturer
Reported technique
Use of Fluoroscopy
Anesthesia Used
Peri-procedural antibiotics
Tube manufacturer
Size of the tube (PEG, PEG-J, and DPEJ)
Mechanisms for unsuccessful placement
Procedure time – minutes (mean ± SD)
Ponsky 1984
[20 ]
Prospective, single-center, < 1984, USA
10
PEG-J
N/A
Modified Gauderer and Ponsky technique
No
Local anesthesia/sedation
N/A
N/A
16 or 18-Fr PEG tube
None
N/A
Shike 1987
[21 ]
Prospective, single-center, < 1987, USA
11
DPEJ
N/A
Modified Gauderer and Ponsky technique
No
Local anesthesia/Sedation
N/A
N/A
N/A
N/A
Kaplan 1989
[22 ]
Prospective, single-center, Jan 1985 – Dec 1987, USA
23
PEG-J
N/A
Modified Gauderer and Ponsky technique
No
Local anesthesia with sedation (22)
General anesthesia (1)
Yes
Cefazolin 1 gm IV prior to procedure
N/A
18-Fr PEG tube with 9-Fr J-tube
None
N/A
Shike 1991
[41 ]
Prospective, single-center, < 1991, USA
6
DPEJ
N/A
Shike modification
No
Local anesthesia
Yes
Cefazolin 1 gm IV prior to procedure
N/A
N/A
N/A
Mellert 1993
[42 ]
Prospective, single-center, Jan 1990 – Jun 1992, Germany
44
DPEJ
200-cm-long endoscope (Fujinon EN7-MR2)
Modified Gauder and Ponsky technique
No
Local anesthesia/Sedation
Yes
Mezlocillin 2 gm before procedure
PEG kit (PEG Universal Intestinal, Fresenius, FRG)
N/A
N/A
Shike 1996
[43 ]
Prospective, single-center, < 1996, USA
150
DPEJ
N/A
Modified Gauderer and Ponsky technique
No
Local anesthesia/Sedation
Yes
Cefazolin 1 gm IV prior to procedure
PEG kit (Sandoz Nutrition, Minneapolis,
Minn.)
14 to 28-Fr
N/A
Rumalla 2000
[23 ]
Retrospective, single center, Oct 1998 – Jan 2000, USA
36
DPEJ
Pediatric colonoscope (Olympus PCF, Olympus America Inc, Melville, NY) or push enteroscopy
(Olympus SIF-lOO)
Shike modification
No
Local anesthesia
N/A
PEG tube (MIC PEG, Ballard
Medical Products, Draper, Utah)
20-Fr PEG tube
N/A
Barrera 2001
[26 ]
Retrospective, single-center, 28 months, USA
17
DPEJ
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Shetzline 2001
[28 ]
Prospective, single-center, < 2001, USA
7
DPEJ
Push enteroscope (VSB 3430, Pentax, Orangeburg, NY)
Modified Gauderer and Ponsky technique
Yes
Local anesthesia
Yes
PEG tube (standard kit, Bard Interventional Products, Billerica, Mass)
20-Fr PEG tube
40.7 ± 14
Varadarajulu 2003
[44 ]
Prospective, single-center, consecutive, Jan 2000 – Dec 2001, USA
26
DPEJ
N/A
Standard Pull technique
No
Local anesthesia
Yes
Cefazolin 1 gm IV prior to procedure
Pull-type PEG kit (Microvasive Endoscopy, Boston Scientific Corp., Nztick, Mass)
24-Fr PEG tube (24)
20-Fr PEG tube (2)
23.3 ± 16.1
Bueno JT 2003
[27 ]
Retrospective, single-center, February 1996–2001, USA
25
DPEJ
N/A
Shike modification
No
N/A
Yes
Cefazolin or Clindamycin
N/A
20-Fr PEG tube
N/A
Maple 2005
[45 ]
Retrospective, multicenter, consecutive, January 1996 – August 2004, USA
286
DPEJ
N/A
Modified Gauder and Ponsky technique
No
Local anesthesia/Sedation
Yes
Cefazolin 1 gm IV
PEG tube kit (Kimberly-Clark/Ballard Medical Products, Draper, UT)
20-Fr PEG tube
No transillumination/finger indentation (79)
Inability to pass scope to the jejunum (8)
Difficulty passing scope and no transillumination (6)
Adverse response to sedation (4)
Equipment failure (1)
N/A
Del Piano M 2008
[29 ]
Prospective, single center, consecutive, April 2003 – March 2004, USA
9
DPEJ
Pediatric video colonoscope (Olympus PCF-160 AL, Olympus Medical System Corp., Tokyo,
Japan)
Pull technique
No
N/A
N/A
PEG tube kit (Kimberly Clark, Ballard Medical Products, Draper, Utah, USA)
18 to 20-Fr PEG tube
20
Mackenzie 2008
[30 ]
Retrospective, single-center, consecutive, February 2000 – September 2005, USA
75
DPEJ
N/A
Modified Gauder and Ponsky technique
No
N/A
Yes
Cefazolin 1 gm IV
PEG tube kit (EndoVive; Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass)
20-Fr PEG tube
BMI > 25: 40 ± 25.8
BMI < 25: 37 ± 18.1
Panagiotakis 2008
[31 ]
Retrospective, single-center, 1999–2005, USA
11
DPEJ
N/A
Shike modification
No
N/A
N/A
PEG kit (Boston Scientific, Natick, MA).
20-Fr PEG tube
None
Moran 2009
[32 ]
Retrospective, single-center, consecutive, January 2002 – April 2008, United Kingdom
40
DPEJ
N/A
Shike modification
Yes
Sedation (35)
General anesthesia (5)
Yes
Co-amoxiclav 2.2 gm
Fresenius PEG kit
15-Fr PEG
20.8 ± 4.1
Aktas 2012
[33 ]
Case-series, single-center, consecutive, December 2009 – December 2010, Netherlands
11
SBE-DPEJ
Olympus SIF-Q160Y enteroscopy (Olympus, Tokyo, Japan)
Shike modification
No
Sedation/General anesthesia
Yes
PEG feeding tube (Fresenius Kabi AG, Germany)
15-Fr PEG
into the jejunum
47 ± 33.5
Song 2012
[46 ]
Prospective, single-center, USA
10
DBE-DPEJ
Pediatric colonoscopes (PCF-Q180AL, Olympus, America, Center Valley, PA)
Standard Pull technique
Yes, if altered gut
Sedation/General anesthesia
N/A
PEG kit (MIC PEG Kit, Kimberly-Clark, Roswell, GA)
20-Fr feeding tube
None
29 ± 12..2
Toussaint 2012
[34 ]
Case series, single-center, consecutive, October 2008 – May 2011, Belgium
12
DPEJ
Enteroscopy (SIF-100; Olympus Optical Co. [Europa], Hamburg, Germany)
Shike modification
N/A
General anesthesia
Yes
Cefazolin 2 gm, ciprofloxacin 4 gm, or amoxicillin 2 gm before the procedure
Tube (Flocare Nutricia, Nutricia Medical Devices, Schiphol, The Netherlands)
18-Fr feeding tube
N/A
Lim 2015
[47 ]
Prospective, single-center, 2003–2012, Australia
83
DPEJ
Pediatric colonoscope (Olympus PCF 160AL)
N/A
N/A
Local anesthesia
N/A
MIC PEG kit (Kimberly-Clark, Roswell, GA 30076, USA).
20-Fr PEG tube
N/A
Velázquez-Aviña 2015
[35 ]
Retrospective, single center, Jan 2013 – Mar 2014, USA
25
SBE-DPEJ
Double-balloon enteroscope (Fujinon EN-450T5, Fuji; Fujifilm, Saitama, Japan) used
in single-balloon mode
Modified Gauder and Ponsky technique
Yes
General Anesthesia
Yes
Cefazolin 2 gm IV before procedure
PEG-kit (Cook, Winston Salem, NC, USA)
20-Fr PEG tube
30.5 ± 10
Al-Bawardy 2016
[36 ]
Retrospective, single-center, single-center, July 2010 – November 2013, USA
94
DBE-DPEJ
Double-balloon enteroscope with a large working channel (EN-450T5; Fujinon, Inc.,
Saitama, Japan)
Modified Gauder and Ponsky technique
Yes, if altered gut
General anesthesia/Sedation
Yes
Cefazolin
PEG kit (MIC-KEY gastrostomy tube; Halyard, Alpharetta, Georgia, USA)
20-Fr PEG tube
Native Gut (3):
Altered Gut (4):
Native Gut: 31 ± 18
Altered Gut: 33 ± 20
Bernardes 2017
[37 ]
Retrospective, single-center, January 2010 – February 2016, USA
23
SBE-DPEJ
SIF-Q180 enteroscope (Olympus, Tokyo, Japan),
Modified Gauder and Ponsky technique
No
Sedation
Yes
1 gm IV ceftriaxone before the procedure
N/A
20-Fr
N/A
Strong 2017
[24 ]
Retrospective, single center, May 1, 2003 – June 30, 2015, USA
59
DPEJ
N/A
Modified Gauder and Ponsky technique
N/A
General anrsthesia (27)
Sedation (27)
Yes
N/A
10-Fr (1)
16-Fr (8)
18-Fr (2)
20-Fr (41)
None
23 ± 10
Kirstein 2018
[39 ]
Retrospective, single-center, 2009–2015, Germany
39
PEG-J
N/A
Modified Gauder and Ponsky technique
N/A
General anesthesia/ Sedation
Yes
N/A
N/A
N/A
27.7 ± 6.1
Ridtitid 2018
[38 ]
Retrospective, single-center, Jul 2010 – Jun 2012, USA
102
PEG-J
N/A
Modified Gauder and Ponsky technique
Yes
N/A
N/A
PEG tube (EndoVive Safety; Boston Scientific, Natick, Mass)
24-Fr PEG tube with 12-Fr J-tube
N/A
Simoes 2018
[40 ]
Retrospective, single-center, January 2009 – March 2015, USA
452
DPEJ
Pediatric colonoscope or an
adult esophagogastroduodenoscope
Shike modification
N/A
N/A
N/A
20-Fr PEG tube
Inadequate transillumination
Stenosis preventing passage of enteroscope
Inability to localize appropriate spot for tube placement
Extrinsic compression
Successful
60.7 ± 38.6
Non-successful
71.4 ± 37.8
Cococcia 2020
[25 ]
Retrospective, single-center, Mar 2010 – Mar 2020, Italy
73
PEG-J
N/A
Standard Pull technique
N/A
N/A
N/A
AbbVie 15 Fr or 20 Fr (AbbVie Inc., North Chicago, IL, USA)
Boston Scientific 20 Fr tube TTP J-Tube (Boston Scientific Corporation, Natick, MA,
USA).
15-Fr with 9-Fr J-tube (7)
20-Fr with 9-Fr J-tube (30)
20-Fr with 8.5-Fr J-tube (36)
N/A
N/A
Nishiwaki 2021
[48 ]
Retrospective, Multi-center, consecutive, April 2004 – March 2019, USA
115
DPEJ
Enteroscopy (SIF Q240 or SIF Q260, Olympus Medical Co, Tokyo, Japan)
Standard Pull technique
Yes
N/A
Yes
3 days post-placement
PEG button kit (One Step Butto, Boston Scientific Co, Natick, Mass, USA)
Safety PEG kit (Standard PEG system, Ponsky PEG, Bard Access Systems, Inc, Salt Lake
City, Utah, USA).
N/A
25.4 ± 12.7
BMI, body mass index; cal, calories; CVA, cerberocascular accident; DPEJ, direct percutaneous
endoscopic jejunostomy; Fr, French; GI, gastrointestinal; IV, intravenous; J-tube,jJejunostomy
tube; N/A, not applicable; PEG, percutaneous endoscopic gastrostomy; PEJ, percutaneous
endoscopic jejunostomy; PEG-J, jejunal extension through PEG; SD, standard deviation.
Table 2
Study safety characteristics.
Author/Year
Mechanisms for failure after initiating feeds
Major adverse event – All-cause mortality
Major adverse event requiring intervention – surgery or repeat endoscopy
Minor adverse events
Short term (< 30 days)
Long term (> 30 days)
Ponsky 1984
[20 ]
None
None
None
None
None
None
Shike 1987
[21 ]
N/A
N/A
None
N/A
Kaplan 1989
[22 ]
N/A
11 deaths
Aspiration pneumonia (3)
Upper GI Bleed (7)
Shike 1991
[41 ]
N/A
None
None
None
Mellert 1993
[42 ]
None
None
Shike 1996
[43 ]
None
One death from complication
62 death entire f/u
Rumalla 2000
[23 ]
N/A
N/A
Tube site pain (13)
Site drainage (12)
Barrera 2001
[26 ]
N/A
3 deaths from primary disease
None
None
Shetzline 2001
[28 ]
None
1 from infection
None
Varadarajulu 2003
[44 ]
None
1 death from sepsis
None
Bueno JT 2003
[27 ]
None
6 deaths unrelated to PEG placement
None
Site infection (2)
Ileus (1)
Diarrhea (1)
Site infection (2)
Persistent ileus (1)
Diarrhea (1)
None
Maple 2005
[45 ]
N/A
6 deaths (1 attributable to DPEJ)
Bowel perforation (7)
Major bleeding (3)
Jejunal volvulus (3)
Aspiration (2)
enterocutaneous fistula (9)
Severe pain requiring removal (5)
Site infection needing drainage (2)
Jejunal hematoma (1)
Jejuno-colonic fistula (1)
Del Piano M 2008
[29 ]
None
None
None
None
Mackenzie 2008
[30 ]
N/A
1 death
Peristomal infection
Pain
Panagiotakis 2008
[31 ]
None
3 death unrelated to DPEJ
Aspiration
Peristomal infection
Moran 2009
[32 ]
None
14 deaths
None
Aktas 2012
[33 ]
Unintentionally placed in the afferent loop (1)
None
None
Song 2012
[46 ]
None
None
None
N/A
Toussaint 2012
[34 ]
Intolerance to feeds (1)
3 deaths during f/u unrelated to the procedure
Jejunal Volvulus (1)
Jejunocolic fistula (1)
Migration (2)
None
Jejunocolic fistula (1)
Migration of tube (2)
Lim 2015
[47 ]
None
27 death from underlying disease
Gastric Perforation (1)
Peristomal infection (3)
Peristomal leakage (4)
Minor bleeding (2)
Aspiration (1)
Velázquez-Aviña 2015
[35 ]
None
None
None
Al-Bawardy 2016
[36 ]
N/A
None
N/A
Bernardes 2017
[37 ]
None
None
None
None
Strong 2017
[24 ]
None
None
Leakage around the tube with skin maceration (1)
Tube blockage without need for repeat endoscopy (1)
Tube dislodgement with repeat endoscopy and replacement (1)
Re-endoscopy (16)
Tube exchange (17)
Tube Leakage (10)
Tube blockage (4)
Tube dislodgment (10)
Bowel Obstruction (1)
Volvulus (1)
Permanent Removal (4)
Kirstein 2018
[39 ]
N/A
N/A
Local infection (2)
Obstipation (2)
N/A
N/A
Ridtitid 2018
[38 ]
N/A
N/A
Jejunal tube clogging (47)
Jejunal tube kinking (24)
Jejunal tube dislogement (52)
Buried Bumper (2)
Simoes 2018
[40 ]
Intolerance to feeds
- peritoneal carcinomatosis
202 death by the end of f/u
Bleeding requiring endoscopy (5)
Small bowel obstruction (1)
Intra-abdominal abscess with CT guided drainage (2)
Intussusception/SBO (1)
Respiratory failure (1)
N/A
Cococcia 2020
[25 ]
N/A
N/A
Nishiwaki 2021
[48 ]
N/A
Pneumonia with respiratory failure (1)
Fistula infection (5)
Peristomal leakage (23)
Pneumonia (28)
Diarrhea (7)
Vomiting (6)
Granuloma (4)
Ileus (2)
BMI, body mass index; cal, calories; CVA, cerberocascular accident; DPEJ, direct percutaneous
endoscopic jejunostomy; Fr, French; GI, gastrointestinal; IV, intravenous; J-tube,jJejunostomy
tube; N/A, not applicable; PEG, percutaneous endoscopic gastrostomy; PEJ, percutaneous
endoscopic jejunostomy; PEG-J, jejunal extension through PEG; SD, standard deviation.
Table 3
Baseline patient characteristics.
Author/Year
Procedure type
Total patients (n)
Age
Male/female
Follow-up duration (days)
BMI (mean ± SD)
Indication for procedure
Native gut
Altered gut
Outcome
Feeding used and calories
Ponsky 1984
[20 ]
PEG-J
10
NR
N/A
N/A
N/A
Severely neurological impairment with aspiration and need for long-term enteral nutrition
Native gut (10)
None
Shike 1987
[21 ]
DPEJ
11
NR
N/A
N/A
N/A
Nutritional support in patients with GI malignancy
None
Altered Gut (10)
Gastric carcinoma s/p gastrectomy (5)
Pancreatic cancer s/p Whipple (2)
Non-operable pancreatic cancer with prior PEG (2)
Esophagectomy and gastric pull up (1)
900–2400 calories/day
Kaplan 1989
[22 ]
PEG-J
23
67 ± 11
23 /0
141
N/A
Recurrent aspiration pneumonia (23)
Native Gut (22)
Altered Gut (1)
Placement of the PEJ tubes
Acute and chronic complications
Overall survival of the patients after PEJ placement
Tube feeds started the next day
75 to 100 mL/hr
Shike 1991
[41 ]
DPEJ
6
60 ± 5
2 /4
180
N/A
Native Gut (6)
Gastric cancer (2)
Ovarian cancer (1)
Pancreatic cancer (1)
Brain tumor (1)
Tongue cancer (1)
None
N/A
Mellert 1993
[42 ]
DPEJ
44
60 ± 20
N/A
30–510
N/A
Native gut (2)
Altered Gut (39)
Partial or total gastrectomy (19)
Esophageal resection and esophagojejunostomy (13)
Esophageal perforation (3)
Fistula (2)
N/A
Shike 1996
[43 ]
DPEJ
150
63 ± 12
93 /57
113 ± 173
N/A
Gastric outlet obstruction (56)
Recurrent/potential aspiration (51)
Anorexia (16)
Proximal small bowel obstruction (16)
Gastroesophageal anastomotic leak (6)
Gastroparesis (5)
Native Gut (66)
Altered Gut (84)
Tube feeds started as soon as awake
Rate 50–75 mL/hour
30 to 40 kcal/kg/day
Rumalla 2000
[23 ]
DPEJ
36
52 ± 14
14 /22
179 ± 109
N/A
Native Gut (28)
Altered Gut (8)
Technical success of the procedure
Procedure-related complications
Need for reintervention for jejunal access
2835–9425 kJ/day
Rate 60–125 mL/hour
Barrera 2001
[26 ]
DPEJ
17
59 ± 17
11 /6
60
N/A
Native gut (13)
Altered Gut (4)
anastomotic leak
duodenal obstruction
Technical success of the procedure
Procedure-related complications
Ability to provide adequate nutritional support
Tube feeds started at 24 hours
Mean 1,988 Kcal/day (1440–2700)
Shetzline 2001
[28 ]
DPEJ
7
47 ± 16
4 /3
146 ± 81
N/A
Aspiration pneumonia (1)
Neurological disease (1)
Duodenal obstruction (2)
Native gut (4)
Altered gut (3)
N/A
Varadarajulu 2003
[44 ]
DPEJ
26
46 ± 25
12 /14
220 ± 122
N/A
Native gut (10)
Gastroparesis (5)
Severe Pancreatitis (5)
Altered Gut (16)
gastrojejunostomy (5)
gastrectomy (2)
pancreatico-duodenectomy (2)
esophageal resection with gastric pull up (1)
small bowel transplant (1)
Pancreatic-renal transplant (1)
Technical success of the procedure
Procedure-related complication
Ability to provide adequate nutritional support
Tube feeds started at 24 hours
Bueno JT 2003
[27 ]
DPEJ
25
65 ± 11
18 /7
151 ± 104
N/A
Anastomotic leak (21)
Aspiration (4)
Chylous leak (2)
Prolonged ileus (2)
None
Altered Gut (25)
Tube feeds started at 24 hours
Mean 1667 kcal/day (1500–3180)
Maple 2005
[45 ]
DPEJ
286
59 ± 17
145 /141
251
N/A
High risk for aspiration
Status-post gastric resection
Esophagogastrectomy
Gastric outlet obstruction
Obstructed or non-functioning gastrojejunostomy
Gastric dysmotility
Native Gut (151)
Altered Gut (58)
Tube feeds started at 24 hours
Del Piano M 2008
[29 ]
DPEJ
9
68 ± 8
NR
720
N/A
PEG not feasible/indicated
Native gut (1)
Altered Gut (8)
organ interposition (7)
gastric herniation (1)
Tube feeds started after 24 hours
Mackenzie 2008
[30 ]
DPEJ
75
41 ± 18
21 //54
210 ± 261
N/A
Native Gut (68)
Altered Gut (7)
N/A
Panagiotakis 2008
[31 ]
DPEJ
11
50 ± 22
7 /4
627 ± 450
N/A
Native gut (10)
Neurological disease (9)
Severe debility (1)
Altered gut (1)
Weight before and after DPEJ placement
Complications of DPEJ placement
Aspiration events before and after the DPEJ placement
N/A
Moran 2009
[32 ]
DPEJ
40
69 ± 15
23 /17
1080
N/A
Unable to maintain nutrition orally and if conventional endoscopic gastrostomy insertion
was inappropriate
Native Gut (19)
Altered Gut (21)
gastric/esophageal malignancy postoperative recurrence
Postoperative malnutrition
Acute cerebrovascular disease with gastric resection
N/A
Aktas 2012
[33 ]
SBE-DPEJ
11
54 ± 17
7 /4
N/A
N/A
Recurrent aspiration (5)
Gastric dysmotility (4)
Duodenal cancer (2)
Gastric Cancer (1)
Native gut (8)
Prior PEG or PEG-J in 4 patients
N/A
Song 2012
[46 ]
DBE-DPEJ
10
59 ± 19
2 /8
30
25 ± 6.25
Native gut (6)
Pancreaticoduodenectomy (1)
Roux-en-Y gastric bypass(2)
Roux-en-Y esophagojejunostomy (1)
N/A
Toussaint 2012
[34 ]
DPEJ
12
54 ± 13
4 /8
255 ± 114
17.6 ± 2.9
Native gut (12)
None
Tube feeds started 24 hours after tube placement
Lim 2015
[47 ]
DPEJ
83
55 ± 2
51 /32
2520
23.8 ± 0.5
Dysphagia related to GI malignancy (17)
Neuromuscular disease (13)
Refractory gastroparesis (30)
Dysphagia from prior surgery (5)
Treatment of parkinsons with intrajejunal infusion (18)
Native gut (45)
GI malignancy
Neuromuscular disease
Parkinson’s disease
Gastroparesis
Altered gut (30)
prior PEG tube (29)
prior GI surgery (5)
Rates of technical success
short term and long term complications
long term clinical effects
N/A
Velázquez-Aviña 2015
[35 ]
SBE-DPEJ
25
54 ± 24
13 /12
188 ± 95
20.9 ± 3.3
Enteral feeding that could not be provided by gastrostomy (5)
Status post-gastrectomy or gastric pull up (6)
Complex fistula (6)
Necrotizing Pancreatitis (7)
Sarcoma with bowel obstruction (1)
Native gut
Altered gut
Tube feeds started at 12 hours
Al-Bawardy 2016
[36 ]
DBE-DPEJ
94
55 ± 20
39 /55
30
23 ± 6.4
Gastroparesis (29)
Malnutrition and altered gut anatomy (17)
Recurrent aspiration with PEG (14)
Failed PEG (16)
Esophageal cancer (7)
Necrotizing Pancreatitis (6)
Partial duodenal obstruction/perforation (5)
Native gut (58)
Gastroparesis (29)
Esophageal malignancy (7)
Necrotizing Pancreatitis (6)
Partial duodenal obstruction/perforation (5)
Altered gut (36)
Placement of DPEJ
Cause of placement failure
Procedure-related adverse events
Adverse events over 1 month period
N/A
Bernardes 2017
[37 ]
SBE-DPEJ
23
68 ± 16
17 /6
345 ± 294
N/A
Unsuccessful PEG tube (3)
Gastric outlet obstruction (7)
Severe PUD (1)
Severe Gastroparesis (1)
Necrotizing Pancreatitis (1)
Technical success
Effective use of PEJ for feeding in those with technical success
Procedure-related complications
Adverse events until death or removal of the tube
Enteral diet started the same day
Strong 2017
[24 ]
DPEJ
59
50 ± 17
24 /35
89
24.6 ± 8.2
Severe dehydration/malnutrition (29)
Gastroparesis (9)
Cancer of the upper esophageal tract (7)
Complication of bariatric surgery (4)
Malfunction of prior enteral access (4)
Other (6)
Native gut (2)
Altered Gut (57)
Tube feeds started at 24 hours
Kirstein 2018
[39 ]
DPEJ
39
65 ± 5
22 /17
421
21.9 ± 3.4
ALS with the need for enteral nutrition
None
Altered Gut (39)
N/A
Ridtitid 2018
[38 ]
PEG-J
102
51 ± 18
31 /71
495 ± 173
Native Gut (86)
chronic pancreatitis (53)
Cancer with malnutrition (12)
chronic vomiting (21)
recurrent acute/necrotizing pancreatitis (10)
impaired swallowing (6)
Altered Gut (16)
Tube feeds initiated 12–24 hours
1.5 cal/mL daily
Simoes 2018
[40 ]
DPEJ
452
61 ± 21
316 /136
634 ± 664
23.1 ± 5.5
Anastomotic leak or proximal stricture
Aspiration prevention
Weight loss
Gastroparesis
Malignant gastric outlet obstruction
Extrinsic GI tract compression
Native Gut (220)
Altered Gut (260)
prior esophagectomy with anastomosis
Partial gastrectomy with anastomosis/roux-en-y or gastrojejunal loop anastomosis
Total gastrectomy with esophagojejunal anastomosis
Whipple’s procedure
Tube feeds initial within 24 hours
1775 calories (384–3744 daily)
Cococcia 2020
[25 ]
PEG-J
73
70 ± 10
29 /44
683 ± 262
N/A
Parkinson’s disease requiring levodopa-carbidopa intestinal gel
Conditions with dysphagia or persistent vomiting – Huntington’s chorea, cerebral vasculopathy,
subarachnoid hemorrhage, Angelman syndrome
Native Gut (73)
None
N/A
Nishiwaki 2021
[48 ]
DPEJ
115
81 ± 3
59 /56
696 ± 343
N/A
Cerebrovascular disease requiring enteral nutrition
Malignant GI tumors
Neuromuscular disease
Gastric outlet obstruction
Prior foregut surgery
No transillumination at PEG
Native gut (61)
Altered Gut (54)
Tube feeds initiated the day after the procedure
BMI, body mass index; cal, calories; CVA, cerberocascular accident; DPEJ, direct percutaneous
endoscopic jejunostomy; Fr, French; GI, gastrointestinal; IV, intravenous; J-tube,jJejunostomy
tube; N/A, not applicable; PEG, percutaneous endoscopic gastrostomy; PEJ, percutaneous
endoscopic jejunostomy; PEG-J, jejunal extension through PEG; SD, standard deviation.
Quality assessment
Scores for methodological quality assessment are shown in Supplementary [Fig.1 ]. Five studies were adjudged as low quality [20 ]
[21 ]
[22 ]
[23 ]
[24 ], 16 as moderate quality [25 ]
[26 ]
[27 ]
[28 ]
[29 ]
[30 ]
[31 ]
[32 ]
[33 ]
[34 ]
[35 ]
[36 ]
[37 ]
[38 ]
[39 ]
[40 ], and eight as high quality [41 ]
[42 ]
[43 ]
[44 ]
[45 ]
[46 ]
[47 ]
[48 ]. Among 29 studies, 11 were prospective [20 ]
[21 ]
[22 ]
[28 ]
[29 ]
[41 ]
[42 ]
[43 ]
[44 ]
[46 ]
[47 ] and 18 were retrospective [23 ]
[24 ]
[25 ]
[26 ]
[27 ]
[30 ]
[31 ]
[32 ]
[33 ]
[34 ]
[35 ]
[36 ]
[37 ]
[38 ]
[39 ]
[40 ]
[45 ]
[48 ]. Two studies were multi-centered [45 ]
[48 ].
Fig. 1 Forest plot of pooled DPEJ and PEG-J technical success.
Meta-analysis outcomes
We evaluated procedural and safety outcomes for DPEJ and PEG-J. Technical success
(TS): DPEJ – 22 studies, 1614 patients with a pooled TS of 86.6 % (CI, 82.1–90.1,
I2
73.1 %), while PEG-J – three studies, 138 patients had a pooled TS of 94.4 % (CI,
85.5–97.9, I2
33.0 %). The difference between both was not statistically significant, p = 0.09 ([Fig. 1 ]). The true effect size in 95 % of all comparable populations falls in the interval
0.65–0.96 (DPEJ) and 0.00–1.00 (PEG-J).
Clinical success (CS): DPEJ – 24 studies, 1413 patients with a pooled CS of 96.9 %
(CI, 95.0–98.0, I2
12.7 %), while PEG-J – five studies, 241 patients had a pooled CS of 98.7 % (CI, 95.5–99.6,
I2
< 0.001 %). The difference between both was not statistically significant, P = 0.2 ([Fig. 2 ]). The true effect size in 95 % of all comparable populations falls in the interval
0.92–0.99 (DPEJ) and a common effect size within the PEG-J group.
Fig. 2 Forest plot of pooled DPEJ and PEG-J clinical success.
Malfunction: DPEJ – 24 studies, 1364 patients had a pooled malfunction rate of 10.8 %
(CI, 7.0–1.6 %, I2
77.8 %), while PEG-J – five studies, 241 patients had a pooled malfunction rate of
23.6 % (CI, 7.5 %–54.1 %, I2
90.8 %). The difference between both was not statistically significant, P = 0.2 ([Fig. 3 ]). The true effect size in 95 % of all comparable populations falls in the interval
0.02–0.44 (DPEJ) and 0.00–0.97 (PEG-J).
Fig. 3 Forest plot of pooled DPEJ and PEG-J malfunction rates, major and minor adverse events.a Malfunction rate.
Fig. 3 Forest plot of pooled DPEJ and PEG-J malfunction rates, major and minor adverse events.b Major adverse event rate,
Fig. 3 Forest plot of pooled DPEJ and PEG-J malfunction rates, major and minor adverse
events. c Minor adverse event rate.
Major adverse events: DPEJ – 24 studies, 1417 patients had a pooled major adverse
events rate of 5.0 % (CI, 3.3–7.6, I2
49.4%), while PEG-J – five studies, 241 patients had a pooled major adverse events
rate of 1.3 % (CI, 0.3–5.2, I2
< 0.001 %). There was a statistical significance, P = 0.04 ([Fig. 3 ]). The true effect size in 95 % of all comparable populations falls in the interval
0.01–0.19 (DPEJ) and a common effect size within the PEG-J group.
Minor adverse events: DPEJ – 25 studies, 1473 patients had a pooled minor adverse
events rate of 15.4 % (CI, 10.1–22.9, I2
85.2 %), while PEG-J – four studies, 202 patients had a pooled minor adverse events
rate of 25.0 % (CI, 14.3–40.0, I2
67.6 %). The difference between both was not statistically significant, P = 0.16 ([Fig. 3 ]). The true effect size in 95 % of all comparable populations falls in the interval
0.02–0.60 (DPEJ) and 0.02–0.84 (PEG-J).
Ease of endoscopic placement: 8 studies (DPEJ 7, PEG-J 1), 646 patients. First attempt
successful placement was 87.6 % (95 % CI, 77.5 %–93.6 %, I2
57.8 %) and second attempt successful placement at 90.2 % (95 % CI, 75.0 %–96.7 %,
I2
< 0.001 %).
Subgroup analysis
Technical success: DPEJ by device-assisted (single or double-balloon) enteroscopy
had a pooled TS of 91.1 % (CI, 85.3–94.7, I2
< 0.001), while non-device-assisted enteroscopy had a pool TS of 86.9 % (CI, 82.1–90.6,
I2
76.2 %). The difference between both was not statistically significant, P = 0.2.
Malfunction rate: DPEJ by device-assisted enteroscopy had a malfunction rate of 4.60 %
(CI, 1.40–14.4, I2
38.9 %), while non-device-assisted enteroscopy had a malfunction rate of 14.4 % (CI,
9.3–21.7, I2
85.3 %). The difference between both was not statistically significant, P = 0.07.
Major adverse event rate: DPEJ by device-assisted enteroscopy had a major adverse
event rate of 3.5 % (CI, 1.3–9.1, I2
< 0.001), while non-device-assisted enteroscopy had a major adverse event rate of
4.5 % (CI, 2.9–7.1, I2
53.4 %). The difference between both was not statistically significant, P = 0.7.
Minor adverse events rate: DPEJ by device-assisted enteroscopy had a minor adverse
event rate of 5.5 % (CI, 1.7–16.3, I2
37.6 %), while non-device-assisted enteroscopy had a minor adverse event rate of
19.3 % (CI, 13.4–27.0, I2
= 85.5 %). There was a statistical significance, P = 0.03.
Altered anatomy – DPEJ TS was 87.8 % (CI, 84.9–90.2, I2
< 0.001) and PEG-J was 81.6 % (CI, 58.1–93.4, I2
< 0.001). The difference between both was not statistically significant, P = 0.4.
Native anatomy – DPEJ TS was 85.6 % (CI, 80.1–89.8, I2
36.4%) and PEG-J was 97.4 % (CI, 90.0–99.3, I2
< 0.001). There was a statistical significance of P = 0.01.
Validation of Meta-analysis Results
Sensitivity analysis
We completed a one-study removal sensitivity analysis to assess if one study had a
dominant effect on the meta-analysis. Statistical significance and direction of findings
for all outcomes remained unchanged.
Heterogeneity
The I2 was moderately consistent > 75 % across outcomes suggesting considerable heterogeneity
of our sample.
Publication bias
There was asymmetry on the funnel plot in which small negative studies were missing,
suggesting publication bias. Egger’s test 1.93, 95 % CI 0.82–3.03, P < 0.001.
Discussion
To the best of our knowledge, this is the first systematic review and meta-analysis
assessing the technical success, complications, and outcomes of direct percutaneous
endoscopic jejunostomy (DPEJ) and percutaneous endoscopic gastrostomy with jejunal
extension (PEG-J), using all existing studies since its initial description by Ponsky
and Shike [20 ]
[21 ]. Amongst 29 studies (n = 874), we found that DPEJ and PEG-J facilitated successful
clinical feeding rates with high fidelity and consistent placement rates. DPEJ had
fewer malfunction and failure rates, while PEG-J had higher placement rates. Subgroup
analysis revealed that DPEJ performance could be enhanced using device-assisted (balloon)
enteroscopy, resulting in higher placement rates in native or altered anatomy, lower
malfunction and failure rates, and lower overall adverse events (major and minor).
However, the differences were statistically insignificant between both groups. Overall,
both DPEJ and PEG-J were found to have high success rates on first or second attempt
placement.
The growing demand for conditions that require post-pyloric nutrition has expanded
to include refractory gastroparesis, partial or complete gastric outlet obstruction,
acute or chronic pancreatitis, and partial gastrectomy. It has also recently found
applicability in short bowel syndrome, dysmotility, and malignant chronic bowel obstruction
[49 ]
[50 ]. Gastroenterology practices have seen referrals for DPEJ increase due to their reliability
compared to gastric feeding, making jejunal feeding more relevant than before [32 ]. Data suggests that enteral feeding started < 24 hours after elective gastrointestinal
surgery reduces infection rates, length of stay, and mortality [51 ].
ASGE and ESGE recommend DPEJ and PEG-J as an accepted alternative to nasogastric or
surgical jejunal feeding; however, patient selection is vague and often depends on
anatomy, procedural know-how, and risk stratification to identify factors that may
contribute to early failure [7 ]
[11 ]. Head-to-head, DPEJ has fewer long-term complications and longer tube patency, but
PEG-J has higher success rates but more significant malfunction [53 ]. These observations and society recommendations are supported by a low quality of
evidence, serving as the basis for our study.
Societal guidelines have stressed the importance of careful attention, dexterity,
and stabilization for successful placement. In patients with native anatomy, DPEJ
is reserved for when the PEG-J fails, but instances of first-line are unknown and
remain under the purview of hospital protocols [7 ]
[11 ]. Additionally, a substantial number of patients with surgically altered anatomy
require enteral access and endoscopic expertise, impacting technical success. In our
analysis, 621 patients (DPEJ 503, PEG-J 118) with altered anatomy had successful jejunal
tube placement. DPEJ had higher placement rates PEG-J in these settings supporting
similar success in smaller studies; however, the difference was not statistically
significant. Most of the patients had a history of Billroth II or Roux-en-Y reconstruction,
which involves dislodging the proximal jejunum from the retroperitoneal space and
closer to the anterior abdominal wall. In cases of failure, most commonly in morbidly
obese patients, balloon-enteroscopy can be an alternative. Our study reported higher
success rates and fewer adverse outcomes, including tube malfunction in device-assisted
(balloon use) than non-device-assisted enteroscopy during DPEJ; however, these were
not statistically significant. Although there was a statistically significant difference
in minor adverse events, suggesting that there is a significant learning curve and
potential for improvement in device-assisted enteroscopy for DPEJ placement. Six DPEJ
studies reported using fluoroscopy [28 ]
[32 ]
[35 ]
[36 ]
[46 ]
[48 ].
Our analysis showed similar CS rates in patients with successful PEG-J and DPEJ placement
without difference between the two, suggesting acceptable patency rates; however,
CS was loosely defined amongst studies. Initiation of tube feeds was often within
24 hours, with Varadarajulu et al. reporting a mean time of 39 hours to achieve the dietary goal; however, meaningful
clinical data such as patient tolerance, feeding rates, gastric residuals, or sequential
data lack amongst known studies. Combined CS was 97.2 % (DPEJ 97.1 %, PEG-J 98.3 %),
suggesting that these devices can tolerate and deliver the required caloric needs,
but sophisticated mechanisms to support prolonged feeding are still required. The
average time to malfunction or replacement was 162 ± 135 days. Although this finding
was reported in a few studies [22 ]
[24 ]
[25 ]
[27 ]
[28 ]
[37 ]
[38 ]
[40 ]
[45 ]
[47 ], the wide confidence interval highlights the high variability in the duration of
patency and function of endoscopically placed jejunal tubes. Weight gain was also
reported in a few studies [21 ]
[31 ]
[38 ]
[47 ], with a mean weight gain of 4.6 ± 4.4 Kg, confirming their clinical utility. These
findings near mirror PEG tube success rates suggesting that they are primed for widespread
adaptability.
In terms of assessing tube malfunction, complications, or adverse events, studies
reported safety outcomes heterogeneously, especially regarding the definition of peri-procedural
complications. Tube malfunction can have various dispositions, including endoscopic,
radiologic, or surgical revisit or bedside adjustments; however, these aspects were
not delineated in our studies, so we grouped all cases into a separate group – malfunction.
We used a combination of ASGE and ESGE based definitions to cast our net wide and
capture as many safety-related events into malfunction, major and minor adverse events.
PEG tubes have an overall complication rate of 16.7 %, with higher rates in frail
patients [11 ]. In our study, the DPEJ malfunction rate was 11.9 %, while PEG-J was 17.4 %. The
use of balloon enteroscopy further brought down malfunction rates; however, these
findings were insignificant. PEG-J relies on safe and effective PEG tube placement,
and higher malfunction rates could be due to sub-optimal PEG placement but often due
to the J-arm size [45 ].
Major adverse events that required endoscopic, radiologic, or surgical revisit were
seen in 5 % of DPEJ placements; the use of device-assisted enteroscopy showed no difference.
Minor adverse events were reported with a high heterogeneity due to variability in
the definition, with fewer events reported amongst DPEJ placements. Peri-procedural
infections were <1% with 61 % of studies using peri-procedural antibiotics. Major
adverse events outside tube dysfunction included major bleeding including hematoma
(16), fistula (15), perforation (10), volvulus (8), severe infection such as peritonitis
or abscess formation (7), and obstruction (6). Minor adverse events included outside
tube leakage was minor bleeding (78), pain (27), aspiration (17), minor bleeding (11),
ileus (4), and ulcers (2). We were able to obtain short and long-term outcomes; however,
the data was unanalyzable. Most common < 30-day complications were leakage, infections,
aspiration, volvulus, obstruction, bleeding, perforation, fistula. Long-term (> 30
days) complications included tube dysfunction/malfunction, fistulas, buried bumper
syndrome, ileus, and pneumonia.
Bleeding can occur during trocar insertion from inadvertent damage to the abdominal
blood vessels, most can be managed with external pressure and intraperitoneal bleeding
is rare. The majority of the patients included had high comorbidity indexes, and anticoagulant
use cannot be ruled out, contributing to bleeding. These findings are consistent with
the incidence rates from the known literature (4.8 %–26.2 %) [7 ]
[54 ]. Most studies used the modified Gauderer and Ponsky or Shike technique, and no head-to-head
studies exist. Fluoroscopy was used in a few studies [28 ]
[32 ]
[35 ]
[36 ]
[38 ]
[46 ]
[48 ], primarily in repositioning or troubleshooting tube malfunction. Commonly used PEG
tube sizes were 20 (13); however, a wide range can be seen in our study from 10–28
Fr, with J-arms from 8–12 Fr. In our study, the mean procedure time was 45.8 ± 34
minutes, with longer times in altered gut or patients with a BMI > 25 [30 ]
[36 ]. Tube life span can range between 1 to 2 years, but replacement occurs much earlier
because of degradation and malfunction; 27 % require exchange or removal by 60 days;
however, Lim et al. had a mean duration of 8 months, alluding to the ability of jejunal
tubes to remain patent with appropriate care and management [23 ]
[24 ]
[55 ].
This study is the first meta-analysis exploring technical feasibility and adverse
effects of endoscopic jejunal feeding, as such gives credence to the existing literature
and what is known that endoscopic jejunal tube placement can be placed with high fidelity
and may be a viable source of nutrition in a wide range of clinical indications. We
were able to include a wide range of studies since inception, making this a comprehensive
review. Procedure details and patient characteristics were delineated. Our sub-group
analysis includes device-assisted data for jejunal feeding for endoscopists in the
modern era. Perhaps future studies can improve TS by considering ultrasound-guided
placement.
Our meta-analysis has several limitations as well, most of which are inherent to any
meta-analysis. Heterogeneity was high in most of our analyses, possibly from technique
variation, endoscopist expertise, clinical indication, and type/size of tubes used).
We could not calculate the TS as all studies did not uniformly report the number of
successful placement attempts. A jejunal conduit can be placed for feeding or venting
but was only defined in one study [43 ]. Clinical success was defined as successful initiation and tolerance of feeds that
were often started between four and not more than 24 hours after successful placement,
but this can vary as the tube may initially be left unclamped to vent the small bowel
and decompress the insufflated air. A few studies defined technical success as successful
placement and tolerance of feeds. Additionally, many studies did not require a second-look
procedure to confirm placement. The majority of included studies were retrospective
and small, and our findings require more extensive comparative data, but the potential
for publication bias cannot be excluded due to a lack of negative studies. Despite
successful placement in a few reports, our study results are not generalizable to
the pediatric population or pregnant women [6 ]
[7 ]. Additionally, only a few studies reported outcomes in obese patients, pancreatitis,
limiting the clinical utility of these findings. Zopf et al., Fan et al., and Nishiwaki
et al. are the only studies comparing DPEJ and PEG-J; however, the heterogeneous reporting
precludes a pooled analysis [48 ]
[56 ]
[57 ]
[58 ]. Follow-up data for clinical success and true jejunal feeding longevity lack, which
is the duration from insertion to replacement, and does not necessarily reflect time-to-failure
were additional limitations in accruing follow-up data. Lastly, patient selection
is an important consideration to optimize the expected outcome.
Conclusions
Our analysis shows that jejunal feeding by DPEJ or PEG-J has high clinical and technical
success with good patient tolerance and safety outcomes with a similar technical and
clinical success profile. We found that DPEJ had fewer malfunction rates and more
successful placement in cases of altered anatomy, although it was associated with
higher peri-procedural major adverse events. The use of balloon enteroscopy enhanced
its performance, suggesting a safe approach for future studies. PEG-J can be used
concurrently for decompression and is technically less challenging, with higher placement
rates in native anatomy. More prospective and head-to-head studies are needed to characterize
the utility of each jejunal feeding procedure.
