A New Technique for Direct Percutaneous Endoscopic Jejunostomy Using Double Balloon Endoscopy and Magnetic Anchors in a Porcine Model

Abstract

Introduction: While direct percutaneous endoscopic jejunostomy (D-PEJ) is a stable and safe access to maintain enteral feeding, it is not yet carried out globally because of the technical difficulty in the procedure. The jejunal lumen is much smaller than that of the stomach. In addition, the location of the jejunal loop is not stable in relation to the abdominal wall. We developed a new technique for D-PEJ using double balloon endoscopy (DBE) and magnetic anchors to resolve these problems. Method: Two magnetic anchors are prepared. One is a small magnet 5 mm in diameter for the inside anchor. The other is a column 15 mm in diameter for the outside anchor. The inside anchor is tied to the double balloon endoscope at 3 cm from the tip. A miniature pig is fasted for 48 hours. Under general anesthesia, the DBE is inserted to the jejunum. The appropriate puncture point is searched out and confirmed by visualizing a clear and discrete finger indentation in the jejunum corresponding to the point of light transmission across the abdominal wall. After the outside anchor is put on the abdominal wall, the inside anchor stick to the wall of the jejunum directly under the outside anchor with magnetic force. For jejunal wall fixation, 18G needle and 18G Seldinger needle are punctured into the jejunum from the abdominal wall beside the outside anchor. Nylon thread with a loop is put through the 18G needle into the jejunum. The fixing thread is put through the 18G Seldinger needle and through the loop. The fixing thread is caught by tightening the loop and pulled out. The jejunal wall is fixed to the abdominal wall by suturing the fixing thread. After incision, the needle stylet with a plastic sheath is punctured into the jejunum. The thread is inserted through the plastic sheath, into the jejunum, grasped by the snare, and pulled out through the overtube with the endoscope. 14Fr pull-type PEG tube with an intraluminal bumper was placed through the overtube. Results: D-PEJ was successfully placed and used for feeding for over one week in all 8 pigs. There was no procedure related complications. The mean procedure time was 89 minutes. Discussion: DBE enabled easy access to the jejunum and exact maneuver in the jejunum. The magnetic anchors were useful to fix the jejunal wall and to confirm the actual puncture point without fluoroscopy. PEG tube placement through the overtube was useful to prevent contamination of the tube and trauma of the intestinal wall. Conclusion: D-PEJ using the DBE and the magnetic anchors was a useful and safe technique.