Direct Percutaneous Endoscopic Jejunostomy: Who, When, How, and What to Avoid

introduction direct percutaneous endoscopic jejunostomy (DPEJ) was first described by Shike in 1987 as a method establishing long term enteral feeding in cancer patients with previous gastric resection.1 DPEJ is an endoscopic procedure that places a percutaneous feeding tube directly into the jejunum similar to a percutaneous endoscopic gastrostomy (PEG) that places a feeding tube directly into the stomach. There are several approaches to long-term jejunal access, each with unique advantages and disadvantages (Table 1). Percutaneous endoscopic gastrostomy with jejunal extension (PEGJ) remains the most common endoscopic approach due to high reported initial success rates, but tube malfunction is common and requires frequent reinterventions. Percutaneous gastrojejunal feeding tubes are increasingly being placed fluoroscopically, which while not requiring sedation, does involve radiation exposure and may have similarly high tube malfunction rates. Direct percutaneous jejunostomy can also be performed through interventional radiology (IR-J), though there are only limited reports in the literature and it is not widely available.2 There are several surgical jejunostomy (SJ) methods including laparoscopic and needle-catheter techniques, which have success rates approaching 100%. However they require multiple skin incisions, general anesthesia, and if attempted laparoscopically may need conversion to open surgery.3 While DPEJ is not yet widely practiced, advantages include longer durability compared to PEGJ and less invasiveness than surgical methods with similar rates of complications. DPEJ placement does not require special equipment and is similar in technique to the widely practiced PEG, and thus should be more widely available. This article will review the current state of DPEJ, specifically addressing when and in whom it should be considered, the technical approaches to placement, and complications to avoid.