Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques

Abstract

Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.

Keywords: Enteral nutrition; Gastrostomy; Indications and techniques; Percutaneous endoscopic gastrostomy; Percutaneous endoscopic jejunostomy.

Figure 1

Case of percutaneous endoscopic gastrostomy failure. Subsequent computed tomography scan showed colonic interposition between the stomach with nasogastric tube and the anterior abdominal wall due to fecal stasis.

Figure 2

Steps of percutaneous endoscopic gastrostomy placement with “pull” technique. A: Location of the puncture site via transillumination; B: Avoidance of bowel interposition confirmed by the absence of bubbles at aspiration; C: Introduction of the trocar; D: Introduction of the guidewire; E: Grasping the guidewire with an endoscopic snare; F: Final result.

Figure 3

Graphic representation of percutaneous endoscopic gastrostomy placement technique. A: “Pull” technique; B: “Introducer” technique.

Figure 4

Percutaneous endoscopic gastrostomy displacement and development of colocutaneous fistula. A: Computed tomography scan image showing percutaneous endoscopic gastrostomy balloon located in the transverse colon (red arrow); B: Endoscopic view of the percutaneous endoscopic gastrostomy balloon within the colon; C: Endoscopic closure of the colonic fistulous orifice with clips.

Figure 5

Wound infections. A: Superficial infection of the abdominal wall; B: Wound infection with abscess formation within the anterior abdominal wall.

Figure 6

Gastrocutaneous fistula. A: External appearance of a gastrocutaneous fistula in the first case; B: Endoscopic appearance of the gastrocutaneous fistulous orifice; C: Endoscopic closure of the gastric fistulous orifice with an over-the-scope metal clip in the first case (OTSC – Ovesco Endoscopy AG, Tubingen, Germany); D: Endoscopic appearance of a large gastrocutaneous fistula, with detection of the gauze placed from the outside at the cutaneous end of the tract (red arrow) in the second case; E: Endoscopic placement of four metal clips at the margins of the fistulous orifice; F: Placement of an endoloop over the metal clips to achieve complete closure of the fistulous orifice.

Figure 7

Percutaneous endoscopic transgastric jejunostomy placement. A: Endoscopic appearance of the percutaneous endoscopic transgastric jejunostomy with jejunal extension entering from the percutaneous endoscopic transgastric device towards the jejunum; B: Final fluoroscopic appearance of the percutaneous endoscopic transgastric jejunostomy with distal end of the jejunal extension into the proximal jejunum after injection of contrast medium.

Figure 8

Graphic representation. A: Percutaneous endoscopic gastrostomy with jejunal extension; B: Direct percutaneous endoscopic jejunostomy.