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Feeding Tube Placement: Percutaneous Endoscopic Jejunostomy (PEJ) 1111.e1

Feeding Tube Placement: Percutaneous Endoscopic Jejunostomy (PEJ)
VetBooks.ir Procedure

• PEJ tube that is 6-12 Fr in diameter (e.g.,
Difficulty level: ♦♦♦
Wilson-Cook Medical, Global Veterinary • Clip and prep left side of animal from
Overview and Goal Products, Compat brand by Novartis) approximately the eighth intercostal space
Placement of a jejunal feeding tube using and 35-150 cm in length. PEJ kits with (ICS) to just cranial to the stifle and from
endoscopic assistance, rather than laparotomy gastrostomy tubes are also available (e.g., dorsal spinous process to ventral midline.
or laparoscopy, to provide postgastric enteral Mila International Inc. Medical Instrumenta- • General anesthesia, with endotracheal
feeding to nutritionally deficient or debilitated tion for Animals). Various diameters and intubation
animals. The jejunostomy tube is placed using lengths are based on supplier and animal size; • Animal is positioned in right lateral
a concurrent/existing percutaneous endoscopic internally coated catheters have an internal recumbency.
gastrostomy (PEG) tube. Percutaneous endo- lubricant that activates when flushed with • A PEG tube is placed (p. 1109).
scopic jejunostomy (PEJ) tube placement is sterile water (1 mm = 3 Fr). • Endoscope is passed to stomach from oral Procedures and Techniques
done uncommonly, usually only at specialty • Weighted PEJ tubes are less commonly used; cavity.
hospitals, because of the cost, stocking of they have a tungsten bulb at the tip that • A snare or retrieval basket is passed through
supplies, and experience required and because adds weight to help prevent migration of the PEG tube to the stomach.
needs are often accommodated by surgical or the tube back to the stomach. • Endoscope is then maneuvered through the
laparoscopic-assisted placement of jejunal • A 0.021-0.037-mm (50-150 cm) flexible snare or basket.
feeding tubes. Enteral feeding provides nutrients guide wire is matched to selected PEJ feeding • Pylorus is then visualized, and the endoscope
to help maintain intestinal epithelial function tube. is passed through to the mid-duodenum.
and enzyme production for improved overall • Fluoroscopy is preferred, especially while • Guide wire is passed through the operating
health of the gastrointestinal (GI) tract, reduces staff is learning the technique. Flash (then channel of the endoscope and continued
intestinal bacterial translocation, maintains glu- saved) images on the preview monitor forward blindly along the lumen of the small
tamine synthesis, and improves and maintains of digital radiographic equipment can intestine until it is estimated that the tip is
GI immunologic barrier functions. help in identifying the location of the in the proximal third of the jejunum.
distal tip of the PEJ if fluoroscopy is not • Guide wire is fed through the endoscope
Indications available. while the endoscope is slowly withdrawn
• Postgastric feeding is advised for animals with • Elizabethan collar or other restraint to from the body; the position of the guide wire
uncontrolled vomiting from any cause. prevent patient’s removal of tube. in the body remains the same.
• After gastric or biliary surgery • Orthopedic stockinette appropriate to • Guide wire should then be in the center of
• Pancreatitis size of animal to create a sweater-like the snare or basket. This is tightened and
• Disorders causing persistent gastroparesis effect withdrawn through the PEG tube to the
(e.g., after intestinal surgery) exterior (proximal tip is in jejunum, and
• Animals at increased risk of active or passive Anticipated Time distal end exits out the PEG tube).
gastroesophageal reflux and aspiration (e.g., About 40-80 minutes (including placement • Location of the proximal tip of the guide
prolonged recumbency, pharyngeal dysfunc- of PEG tube) wire is checked with fluoroscopy.
tion, altered mentation) • PEJ tube is flushed with copious amounts
Preparation: Important of water to activate lubricant.
Contraindications Checkpoints • PEJ tube is passed over the guide wire
• Unresolved peritonitis • Test or check integration of guide wire, until it extends a length adequate for the
• Relative concern for peritoneal fluid PEG tube, and PEJ tube for compatibility proximal tip to be in the proximal third of
• Unacceptable anesthetic risks of diameters and lengths. the jejunum.
• Large-volume peritoneal effusion • Plan for coordination of staff regarding • PEJ tube location is assessed with fluoroscopy
• High risk of delayed wound healing anesthesia, endoscopy, and fluoroscopy/ or radiography with test infusion of a few
radiography. milliliters of water-soluble contrast agent
Equipment, Anesthesia • Discuss with client the potential that the PEJ (iohexol); the PEJ tube may be repositioned
• General anesthesia is required with endo- tube may become occluded or may migrate as needed.
tracheal intubation. back to stomach despite best efforts and cost • Guide wire is removed slowly while the PEJ
• Postprocedural analgesia (see inside back of catheters. is held stable.
cover of book for protocols) • Check or estimate the fill volume of catheter • PEJ tube is secured to animal’s body or to
• Oral speculum before placement. the PEG tube as it exits the left side of the
• Sterile, water-soluble lubricant for endoscope abdomen.
passage Possible Complications and
• Supplies as needed to place PEG tube Common Errors to Avoid Postprocedure
• 2-0 monofilament suture material • Stoma site infection • Place Elizabethan collar on the animal to
• Iohexol as water-soluble radiographic contrast • Premature removal by animal of tube (teeth, prevent removal of tube(s).
agent rubbing on objects in environment) • To protect tubes, place and adjust orthopedic
• Flexible video or fiberoptic endoscope • Peritonitis if adhesion of body wall to stockinette sweater over animal’s body,
and ancillary equipment appropriate to stomach breaks down including two holes cut for the forelimbs;
patient size. Endoscopic snare or grasping • Diarrhea induced by enteral formula this should be comfortable to reduce stimulus
forceps • Reflux of enteral feeding for premature removal by animal.
• Vacuum source for endoscopic suction • PEJ tube migration back to the stomach • Monitor recovery from anesthesia.
• PEG tube that is 18-24 Fr in diameter, as and possible vomition of the tube • Instill the volume of sterile water needed
a kit with PEJ or as a separate item (e.g., • Complications occur with about the same to fill tube every 2 hours to keep tube
Pezzer mushroom-tip catheter) frequency as use of PEG tubes. patent.

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