Feeding Jejunostomy Techniques and Types
Direct percutaneous endoscopic jejunostomy (DPEJ) is the preferred technique for long-term jejunal feeding due to superior tube patency and lower reintervention rates compared to PEG with jejunal extension (PEG-J). 1
Types of Jejunostomy Techniques
- Direct Percutaneous Endoscopic Jejunostomy (DPEJ): Provides direct access to the jejunum through the abdominal wall, offering more stable long-term jejunal access 1
- PEG with Jejunal Extension (PEG-J/JET-PEG): Uses a gastrostomy tube with a jejunal extension that passes through the pylorus 2
- Laparoscopic Jejunostomy (PLJ): Minimally invasive surgical approach with low complication rates (4% 30-day complication rate) 3
- Needle Catheter Jejunostomy (NCJ): Typically placed during major abdominal surgery with a fine-bore catheter 2
- Surgical Open Jejunostomy: Traditional surgical approach using techniques such as Witzel (longitudinal or transverse) 4
- Percutaneous Sonographically Guided Jejunostomy (PSJ): Used when endoscopic access is difficult 2
- Percutaneous Fluoroscopically Guided Jejunostomy (PFJ): Radiological approach when endoscopic access is limited 2
Indications for Jejunal Feeding
- Jejunal feeding is indicated when gastric feeding is contraindicated or not feasible: 2, 5
- High risk of aspiration
- Gastroesophageal reflux disease
- Gastroparesis or impaired gastric emptying
- Post-gastric surgery
- Gastric outlet obstruction
- Need for simultaneous gastric decompression and jejunal feeding
Technical Considerations
- DPEJ vs PEG-J: DPEJ demonstrates significantly longer feeding tube patency and fewer reinterventions (8.9% vs 38.8% within 6 months) compared to PEG-J 1
- Tube Size: Larger tubes (20F) for direct jejunostomy are associated with fewer clogging issues compared to smaller jejunal extensions (9F) used in PEG-J 1
- Placement Approach: 2
- Endoscopic placement is preferred when feasible
- Laparoscopic placement shows excellent outcomes with no conversions to open surgery in large series
- Surgical placement during other abdominal procedures is common
Feeding Methods with Jejunostomy
- Continuous feeding is required for jejunal tubes due to lack of reservoir capacity 2, 5
- Bolus feeding must be avoided with jejunal tubes to prevent dumping syndrome 2, 5
- Start with low flow rates (10-20 ml/h) and increase gradually based on tolerance 2
- Full nutritional targets may take 5-7 days to achieve due to limited intestinal tolerance 2
Complications
Early complications (within 30 days) occur in approximately 19% of patients: 6
- Tube clogging (10.9%)
- Tube dislodgement (4.1%)
- Leakage (2.7%)
- Small bowel obstruction (2.7%)
- Site infection (1.3%)
Late complications (beyond 30 days) occur in approximately 20.5% of patients: 6
- Tube clogging (8.2%)
- Tube dislodgement (8.2%)
- Site infection (4.1%)
- Leakage (1.3%)
Serious complications are rare but include: 4
- Enterocutaneous fistulas
- Intraabdominal abscesses
- Intestinal ischemia
- Pneumatosis intestinalis
Best Practice Recommendations
- For short-term jejunal feeding (<2-3 weeks), nasojejunal tubes are appropriate 2
- For long-term feeding (>2-3 weeks), DPEJ is preferred over PEG-J due to superior tube patency 1
- For patients undergoing major upper GI surgery, NCJ placement should be considered, especially in malnourished patients 2
- For patients with severe chronic small intestinal dysmotility, a percutaneous gastrojejunostomy is preferred over direct jejunostomy due to lower risk of leakage, retention, pain, and skin problems 2
- Laparoscopic approach should be considered when feasible due to low complication rates and excellent outcomes 3
Pitfalls to Avoid
- Avoid bolus feeding through jejunostomy tubes to prevent dumping syndrome 2, 5
- Do not use kitchen-made (blenderized) diets for jejunostomy feeding due to risk of tube clogging and infection 2
- Monitor for metabolic complications including hyperglycemia (29%), hypokalemia (50%), hypophosphatemia, and hypomagnesemia 4
- Regular assessment of tube position and function is essential to detect early displacement or obstruction 6
- Ensure adequate flushing protocols to prevent tube clogging, which is one of the most common complications 5, 6