Use of stent retrieval rat tooth forceps for percutaneous endoscopic gastrostomy/jejunostomy tube placement.

Abstract

To the Editor: Percutaneous endoscopic gastrostomy/jejunostomy (PEG/J) is a two-tube system in which a jejunal feeding tube is passed through a gastrostomy tube to allow concurrent jejunal feeding and gastric decompression. 1 Both the design of PEG/J systems and modifications of its technique have made this enteral access an important one for patients with gastroparesis or those at a high risk for gastric-feeding aspiration. 2 Although several approaches have been described for successful PEG/J placement, the procedure is technically demanding and is frequently associated with recoiling of the j-tube into the stomach at deployment. In our experience, the Olympus stent retrieval rat tooth forceps (Olympus, Melville, NY) has been very helpful for successful and easy placement of PEG/J tubes. After placement of a 24-french Wilson–Cook pull-type PEG tube in the standard fashion, an Olympus stent retrieval rat-tooth forceps (2.8-mm channel; 180 cm in length) is used to grasp the tip of the 12-french j-tube (Wilson–Cook) after passing it through the PEG port. Using the rat-tooth forceps, the j-tube is then dragged into the jejunal portion of the small bowel under endoscopic guidance. The biopsy forceps and j-tube are maintained in the jejunum while the endoscope is pulled back into the stomach by slow exchange. After ascertaining the absence of j-tube looping in the stomach, the biopsy forceps is released and withdrawn slowly into the endoscope, without disrupting the j-tube position within the small bowel. We routinely use this technique for PEG/J placement on all of our patients who require jejunal feeding. This technique has several advantages. First, after placing the j-tube in the jejunum, slow exchange of the endoscope with biopsy forceps prevents recoiling of the j-tube into the stomach secondary to scope withdrawal. Second, although the use of a guidewire is standard practice during PEG/J placement, the technique can be arduous, time-consuming, and is a two-step process that requires passage of a j-tube over the guidewire once the guidewire is in the small bowel. Moreover, the guidewire is very flexible and recoils frequently into the stomach or the proximal small bowel, precluding successful passage of the j-tube over it. The technique adopted by us for PEG/J placement does not require the use of a guidewire. This shortens procedure time, the need for additional conscious sedation, and (in our experience) is technically less demanding than the standard guidewire technique. Third, the diameter of the rat-tooth forceps is large enough to grasp the j-tube directly and provides firm anchorage during navigation of the endoscope through small bowel loops. This degree of anchorage is not achievable with the use of conventional biopsy forceps, particularly when taking into consideration the width of the j-tube (12-french). With increased use of PEG/J systems, easier techniques are needed to minimize the chances of j-tube retraction into the stomach. The method that we described is a one-step process that is easy, safe, less time-consuming, and not associated with any undue complications. David A. Sabol, M.D. Shyam Varadarajulu, M.D.