Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy

Abstract

Background: Approaches to the creation of a percutaneous jejunostomy (PEJ) include enteroscopy with jejunal transillumination, fluoroscopy with small bowel distension and tract dilation, and jejunal enteral tube placement through a percutaneous endoscopic gastrostomy. Although all have been successful, the combination of enteroscopy and fluoroscopy may improve visualization and the success of PEJ placement. This is a description of such a technique and its successful use in 7 patients. Methods: The procedure was performed with the patient under conscious sedation in a manner similar to standard PEG placement. The proximal jejunum was visualized and a standard snare was passed though the enteroscope and was opened. A needle and guidewire were directed percutaneously though the snare by using fluoroscopic guidance. Under direct endoscopic visualization the snare was closed around the guidewire. A standard 20F push-type “gastrostomy” tube was passed over the guidewire and through the mouth and the dome seated in the jejunum. A bumper was passed externally over the tube and tightened at the skin. Results: PEJ placement was successful in all 7 patients. The average length of the procedure was 40 minutes (range 22-64 minutes). There were no major complications. Mean follow-up was 124 days (range 28-308 days). Feeding tubes remained functional until removal (2), death (1), or surgical removal for an unrelated reason (1). Three tubes are still in use. Conclusions: Percutaneous endoscopic jejunostomy tube placement can be performed successfully with enteroscopy and fluoroscopy. This technique is safe and efficient and provides distal enteral nutritional support for patients in whom PEG cannot be used.