Direct percutaneous endoscopic jejunostomy using a transgastrostomic endoscope in patients with previous endoscopic gastrostomy

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Direct percutaneous endoscopic jejunostomy (DPEJ) is an effective method for preventing aspiration following percutaneous endoscopic gastrostomy (PEG) [1]. Although DPEJ provides a stable access to maintain enteral feeding, it requires an endoscope of more than 160 cm long for tube placement [2].

We attempted DPEJ using a transgastrostomic endoscope in post-PEG patients. A small-caliber endoscope (GIF XP-240 or GIF XP-260; Olympus Optical Co., Ltd., Tokyo, Japan) was inserted and advanced to the jejunum through the mature gastrocutaneous tract ([Fig. 1]). After conducting the jejunopexy with a double lumen gastropexy device (Create Medic Co., Ltd., Yokohama, Japan), a Seldinger needle was inserted through the abdomen toward an open snare using fluoroscopic guidance ([Fig. 2]). Next, a loop wire was inserted through the outer sheath of the Seldinger needle, grasped by the snare ([Fig. 3]), and pulled out with the endoscope through the gastrocutaneous tract. The loop wire was then grasped in the stomach by an orally inserted endoscope ([Fig. 4]) and pulled out through the mouth. Finally, a jejunostomy tube was placed in the jejunum by the pull-through technique ([Fig. 5]).

Fig. 1 A small-caliber endoscope is inserted through the gastrocutaneous tract and advanced to the jejunum. The site of placement of the jejunostomy tube is determined by finger indentation and transillumination.

Fig. 2 The jejunum is fixed by a double lumen gastropexy device. A Seldinger needle then punctures the abdomen and is inserted toward an open snare.

Fig. 3 A loop wire is inserted through the outer sheath of the Seldinger needle and grasped with the snare.

Fig. 4 The loop wire is grasped by an orally inserted endoscope and pulled out through the mouth with the endoscope.

Fig. 5 A jejunostomy tube is connected to the loop wire and placed in the jejunum by the pull-through technique.

A total of 30 DPEJ procedures were attempted in 29 patients, resulting in 28 (93.3 %) successful placements. One unsuccessful placement was due to jejunum migration away from the abdominal wall during the puncture. The other failure was due to a lack of transillumination. Maple et al. reported that the two major reasons for unsuccessful placement were lack of transillumination and the inability to pass the endoscope up to the jejunum [3]. The reason for the higher rate of success in the present study is that insertion of the endoscope through a gastrostomy is easy and causes little distension of the stomach. Less distension of the stomach facilitates the placement of the jejunostomy tube. DPEJ using a transgastrostomic endoscope should be recommended in cases with previous gastrostomy.

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References

• 1 Shike M, Latkany L, Gerdes H, Bloch A S. Direct percutaneous jejunostomies for enteral feeding.  Gastrointest Endosc. 1996;  44 536-540
• 2 Shike M, Latkany L. Direct percutaneous jejunostomy.  Gastrointest Endosc Clin N Am. 1998;  8 569-580
• 3 Maple J T, Petersen B T, Baron T H. et al . Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts.  Am J Gastroenterol. 2005;  100 2681-2688