What are the alternative feeding tube options if aspiration persists after Percutaneous Endoscopic Gastrostomy (PEG) tube placement?

Alternative Feeding Tube Options for Persistent Aspiration After PEG Tube Placement

For patients experiencing persistent aspiration after PEG tube placement, direct percutaneous endoscopic jejunostomy (PEJ) is the preferred alternative feeding tube option due to lower tube dysfunction and reintervention rates compared to other jejunal feeding methods. 1

Primary Options for Post-PEG Aspiration

Jejunal Feeding Options

• Jejunal tube through existing PEG (JET-PEG): A jejunal extension tube can be placed through an existing PEG and guided endoscopically beyond the ligament of Treitz 1

• Direct Percutaneous Endoscopic Jejunostomy (PEJ): A separate jejunal tube placed directly into the jejunum endoscopically 1

• Percutaneous Laparoscopic Jejunostomy (PLJ): Jejunal access placed using laparoscopic techniques when endoscopic placement isn't feasible 1

• Radiologically Inserted Gastrojejunostomy (RIGJ): Placed under fluoroscopic guidance, may have fewer tube displacements than PEG-J 2

Comparative Effectiveness

Direct PEJ vs. JET-PEG

• Direct PEJ is superior: Tube dysfunction and need for reinterventions are significantly lower with direct PEJ compared to JET-PEG when long-term jejunal feeding is indicated 1

• Success rate: Direct PEJ placement has been reported with 86% success rate, even in patients with prior abdominal surgery 3

• Aspiration reduction: Direct PEJ can drastically reduce aspiration rates to approximately 3% in long-term follow-up 3

PEG-J Considerations

• Tube migration: PEG-J systems have reported jejunal tube migration rates of approximately 6% 4

• Tube clogging: Occurs in approximately 18% of PEG-J placements 4

• Unintentional removal: Reported in about 11% of cases 4

Important Clinical Considerations

• Conflicting evidence on aspiration prevention: There are conflicting data about whether jejunal feeding via PEJ or JET-PEG definitively reduces the rate of reflux and aspiration 1

• Continued risk: Some studies show aspiration can continue even after conversion to jejunal feeding, with reports of continued aspiration in patients switched to jejunostomy tubes specifically to prevent aspiration 5

• Tube dysfunction concerns: Tube dysfunction (defined as peritube leakage, plugging, fracture, or migration) occurs more frequently with jejunal tubes than with gastric tubes 6

Decision Algorithm for Selecting Alternative Feeding Access

1. First consideration: Direct PEJ for patients with persistent aspiration after PEG placement 1

2. If endoscopic access is limited: Consider percutaneous laparoscopic jejunostomy (PLJ) 1

3. If radiological expertise is available: Radiologically inserted gastrojejunostomy (RIGJ) may be considered, as it shows fewer tube displacements than PEG-J 2

4. For temporary solutions: JET-PEG can be used but has higher rates of tube dysfunction 1

Practical Management Tips

• Tube maintenance: Regular flushing of jejunal tubes is essential as they have higher rates of clogging than gastric tubes 4

• Monitoring: Regular assessment for tube migration is needed, especially with JET-PEG systems 4

• Feeding regimen: Continuous rather than bolus feeding is typically better tolerated with jejunal tubes 1

• Tube replacement timing: Direct PEJ tubes may remain functional for longer periods (average 113 days) before requiring replacement 3