Jejunostomy Tube Placement with Transgastric Endoscopic Guidance

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Purpose: To evaluate the feasibility of jejunostomy tube placement with transgastric endoscopic guidance. Methods: After a 48 hour fast, each pig was intubated and sedated with general anesthesia. A pediatric colonoscope was passed to the proximal jejunum, and a location for the jejunostomy tube placement was determined based on transillumination and digital pressure. An opening in the jejunal wall was made using a gold probe. A Jag wire was then passed into the peritoneal space, and the pediatric colonoscope was removed. An upper endoscope was then passed into the stomach and a needle knife was used to create a gastrotomy. The endoscope was then passed into the peritoneal space and the wire was found. A small incision was made in the abdominal wall, and a Kelley clamp was passed into the peritoneal space. Under direct vision, the tip of the wire was grasped by the Kelley clamp and pulled through the abdominal wall. The jejunal tube was passed into place and secured tightly under direct vision. Each pig was euthanized after the procedure. Results: Jejunostomy tube placement was successful in both of the 35 kg pigs that underwent the procedure. In the first pig, the jejunostomy tube was placed at 65 cm from the mouth and the procedure was completed in 90 minutes. In the second pig, the jejunostomy tube was placed at 60 cm from the mouth, and the procedure was completed in 85 minutes. After the jejunostomy tube was placed, the position was confirmed with contrast injection under fluoroscopy. There was no evidence of extraintestinal leakage of contrast. Conclusions: Direct percutaneous endoscopic jejunostomy may be problematic because of the mobility of the jejunum and difficulty in obtaining tranillumination, while percutaneous gastrostomy with jejunal extension often requires endoscopic reintervention, and surgical placement of a jejunostomy tube is more invasive. Our preliminary results indicate that jejunostomy tube placement is feasible under transgastric endoscopic guidance. This is a novel technique which allows one to directly observe a procedure from within the peritoneal cavity. Further studies could focus on closure of the gastrotomy and monitoring for leakage after survival surgery. Creating an opening in the jejunum was surprisingly straightforward, and a variant of this procedure could be to pass a narrow lumen endoscope through the jejunal opening into the peritoneal space so the wire can be directly guided into the Kelley clamp without the need for a gastrotomy.