Abstract
Purpose: 30 year old male with mental retardation, cerebral palsy and seizures was admitted in October 2004 for respiratory distress from pneumonia. He was intubated and after extubation, he developed dysphagia. A gastroenterologist attempted percutaneous endoscopic gastrostomy tube (PEG) placement but was unsuccessful since no transillumination was seen. Surgery was then consulted. They tried to do an endoscopic PEG in the operating room without success. Upon laparotomy the stomach was found to be higher than normal in the area under the costal margins and could not be pulled down. After multiple attempts to reposition the stomach, PEG placement was determined to be impossible due to a result of increased tension on the stomach. A jejunostomy tube was therefore placed 20 cm distal to the ligament of Treitz. The patient has had about 30 feeding tube changes over the following 3 years due to chronic tube leakage. He suffered from extensive skin breakdown and infections surrounding the jejunostomy tube making it difficult for the family to take care of him. The patient's father as well as medical staff had changed the jejunostomy tubing as a standard blind procedure and time after time, leakage continued to occur. Different sized tubes were attempted without success. When he was referred to us we took him to GI lab for endoscopic evaluation and replacement of the jejunostomy tube. After entering approximately 2 cm through the stoma with a 6 mm slim nasal upper endoscope, a division with an afferent and efferent limb was seen. The limb slightly to the right and straight ahead was assumed to be the afferent limb from the stomach. Instead we took a very sharp left turn and advanced 50 cm down with the endoscope. A Savary guidewire was placed through the scope, the scope withdrawn, and then a 45 cm jejunal feeding tube was threaded over it. Radiology confirmed that this was the efferent limb. Leakage from the feeding tube has since reduced dramatically and the skin has healed. When jejunostomy feeding tubes repeatedly leak despite multiple tube changes, it is recommended to perform an endoscopic guided tube change with an upper nasal endoscope. In this case, during blind tube changes, the tube most likely repeatedly entered the pathway of least resistance, which was in the limb leading towards the stomach. This caused tube feeds to travel back out the tube or exit the space surrounding the tube.
Published Version
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