Percutaneous endoscopic gastrojejunostomy (PEGJ) tube placement is a technically simple
procedure that is the most commonly used method of endoscopic jejunostomy. However,
it only allows the placement of jejunostomy tubes with a diameter of 3 - 4 mm (9 -
12 Fr), which are prone to luminal occlusion and migration [1]
[2]
[3]. In addition, it has been reported that PEGJ tubes may not prevent aspiration resulting
from frequent retrograde tube migration into the stomach and reflux of intestinal
contents [1]
[2]
[3]. Direct percutaneous endoscopic jejunostomy (DPEJ) appears to be a better alternative
to PEGJ, as it allows placement of the larger-diameter DPEJ tube in the proximal jejunum
and is associated with a reduced risk of pulmonary aspiration. However, the smaller
lumen, mobility, active peristalsis of the jejunal loop, and difficulty in transillumination
make this procedure much more difficult than PEGJ tube placement. To overcome the
above challenges, we anchored the jejunum against the abdominal wall with a 21-gauge
finder needle before passing the needle and trochar (Figures 1, 2). In addition to stabilizing the jejunum, the finder needle penetrates the soft tissue
easily and is less likely to cause visceral trauma. We carried out DPEJ tube placement
using this method in 21 patients for the indications listed in Table 1. The method was successful and resulted in proper placement of DPEJ tubes in 17 patients
(a success rate of 81 %). In four patients, DPEJ tube placement could not be completed
due to an inability to achieve adequate transillumination. No significant or major
complications were associated with the procedure. Minor complications in two patients
included cellulitis and cutaneous leakage of enteral contents. On the basis of this
experience, it appears that DPEJ tube placement with this method is a safe and effective
means of providing prolonged jejunal nutrition. Similar observations have been reported
by other investigators [4]
[5]. We believe that the application of this modified technique could lead to wider
acceptance of DPEJ tube placement in clinical gastroenterology.
Table 1 Indications for direct percutaneous endoscopic jejunostomy tube placement
|
Patients |
|
n |
% |
| Gastroesophageal regurgitation |
12 |
57 |
| Pulmonary aspiration |
4 |
19 |
| Gastroparesis |
3 |
14 |
| Gastric resection |
2 |
10 |
|
Total
|
21 |
|
Figure 2 The jejunostomy tube (J) in the jejunal lumen. After the jejunum has been anchored
with the finder needle, a long needle with a trochar is inserted parallel to the finder
needle. The long needle is then snared endoscopically and the finder needle is withdrawn.
A guide wire is passed through the trocar into the jejunum, snared, and pulled out
of the mouth with the endoscope. The tapered end of a standard 20-Fr percutaneous
endoscopic gastrostomy (PEG) tube is mounted onto the end of the guide wire and pushed
through the mouth into the stomach. The guide wire is then gradually withdrawn, pulling
the PEG tube (J) out through a small abdominal incision.
Endoscopy_UCTN_Code_TTT_1AO_2AK
