Traction (geology)

Percutaneous

Geomorphology

Surgery

Melena

Abscess

Balloon

Geology

Medicine

Jejunostomy

Gastrointestinal bleeding

Parenteral nutrition

The American Journal of Gastroenterology

Case Presentation: Direct percutaneous endoscopic jejunostomy (DPEJ) is a recently established method for jejunal feeding, however the optimal method of tube removal has not been described. Removal can be performed endoscopically by removing the intraluminal bumper or by external traction. We present two case reports of complications after DPEJ removal by the traction method. A 77 year-old male presented with melena and a drop in hemoglobin from 13.0 to 8.8 g/dL 24 hours after DPEJ tube (20Fr BARD) removal by the traction method. He was taking aspirin, but no other anticoagulants. Extended EGD revealed a visible vessel at the site of the previously placed DPEJ. Three hemoclips were placed, however the patient had continued melena and a decrease in hemoglobin despite blood transfusion. Repeat EGD showed an adherent clot next to a hemoclip with active oozing. Bleeding was arrested with epinephrine injection and hemoclip placement. A follow-up EGD 4 days later showed no evidence of recurrent bleeding at the DPEJ site. The second patient is a 45 year-old male who presented with epigastric abdominal pain and a WBC count of 19.8 × 109/L six days after traction DPEJ removal of the same type of tube which had been placed 9 weeks prior. Abdominal CT scan showed a 10.5 × 4.7 cm subcapsular fluid collection over the left lobe of the liver with nondependent air tracking toward the DPEJ removal site, consistent with a subcapsular abscess. 200 cc of purulent fluid was subsequently drained; culture of the fluid grew Enterococcus, Enterobacter Cloacae, and Prevotella Oris. A sinogram was negative for connection with the bowel. A drainage catheter was left in place for two weeks with resolution of the abscess cavity on follow-up sinogram. Discussion: Although traction removal is the standard for removal of PEG tubes, it has been hypothesized that removal of DPEJ tubes by the traction method may be associated with a higher complication rate secondary to the thinner wall of the jejunum and the slower rate of spontaneous mucosal closure. A prior review of 36 patients who received DPEJs at our institution reported two persistent enterocutaneous fistulas following tube removal by both traction and endoscopic methods. The two complications reported here have not been previously reported. A review of DPEJ removals at our institution is planned to better characterize the frequency of complications associated with endoscopic versus traction removal.

COMPLICATIONS AFTER TRACTION REMOVAL OF DIRECT PERCUTANEOUS ENDOSCOPIC JEJUNOSTOMY (DPEJ)