PEJ tube insertion is sometimes undertaken to bypass the stomach. It can be used to improve nutrition prior to surgery or occasionally as an alternative to stent insertion in those undergoing other forms of gastric cancer therapy such as radiotherapy or chemotherapy.
It is usually a temporary procedure to allow feeding, although can last for many months before needing replacement if at all.
This is normally inserted by an endoscopist with the aid of an assistant. You are "prepped" for an endoscopy in a similar way to a diagnostic test.
In the endoscopy room or theatre, you will be sedated and the endoscope will then be inserted through your mouth as far as the stomach.
An area of will then be identified for your PEJ placement. This is usually achieved by trans-illuminating the lining with the endoscope light which can be seen permeating from your abdominal wall.
The assistant will clean your skin with antiseptic or iodine and drape the area. You will then be given a local anesthetic in to the skin where it is to be placed.
To insert a PEJ tube a cut is made in your skin, no more than a centimetre usually through which a needle is passed deep and in to the wall.
Once the needle passes in to your stomach, the endoscopist will see this on their screen. The assistant will then pass a wire down through the needle in to the cavity.
The endoscopist can grab this wire with forceps or a snare. Once grabbed, the endoscope is removed and the wire pulled back with it until it protrudes from your mouth.
The assistant will then tie it on to the wire, which is then introduced down in to the stomach by pulling on the wire at the skin end.
The PEJ at this stage has a tapered point on it, allowing easy passage through the skin and out to the external world.
The tube is prevented from coming through the stomach completely by a button, bumper or balloon which fits neatly to the inner lining.
This is then cut to the required length and connectors placed. There are no sutures or stiches required for this procedure.
Once the gastric part of the is in place, an extension tube is passed through this.
The endoscopist then grabs this with a pair of endoscopic forceps, passing it through the exit of the stomach (pylorus) and in to the small bowel where is then advanced to the jejunum.
The extension attaches to the gastric introducer and the procedure is then complete.
Yes, there are small risks to this procedure. Like any operation there are risks from the sedation, from introducing infection, damaging organs in the area and inducing bleeding.
Fortunately these aren't that common, but do ask the person doing your procedure what their complication rate is.
Once placed you will normally not use it for 2-4 hours.
After this, water can be passed in to the tube. I normally advise 30 ml of water an hour for 4 hours.
As long as you are comfortable, feeding can commence.
This is a special artificial feed and will be guided by your dietician or nutrition team.
In many circumstances, a PEJ will remain in place long-term. It may be removed and replaced if it perishes or if it is used as a method of feeding prior to curative surgery.
The removal is very straightforward in most cases. This can be removed endoscopically or manually. The technique depends on the type inserted, but usually involves cleaning the skin around the insertion point, clipping the PEJ tube and then applying pressure to pull the bumper from the stomach (i.e pulling it away from the skin). Some require deflation of the inner bumper by cutting the surrounding or use of a syringe.
If the inner bumper or balloon (the 'donut ring') is buried in the lining, commonly referred to as a 'burried bumper', it will need to be removed endoscopically. The endoscopist can carefully cut the inner lining with a 'needle knife' or similar.