Percutaneous endoscopic gastrostomy/jejunostomy tube placement, a novel approach

L.S. Leichus; R. Patel; F.C. Johlin

doi:10.1016/S0016-5107(96)80251-3

Percutaneous endoscopically placed gastrostomy (PEG) and jejunostostomy (PEJ) tubes have been employed for many years, however, placing a jejunostomy tube via a gastrostomy tube has often required a great deal time and persistence. We have recently devised a new method that allows the endoscopist to place the PEJ farther into the small intestine in a shorter period of time with less chance of the PEJ looping in the stomach. We used a 24 French Percutaneous Endoscopic Gastrostomy set and a 12-24 Jejunal feeding set (Wilson Cook Medical Inc. Winston-Salem NC). After the PEG is placed in standard fashion and the bolsters applied the gastrostomy tube is trimmed to between 10 and 14 inches from the skin. A snare is then inserted via the gastrostomy tube into the stomach. The insertion is monitored with an endoscope which is in place in the proximal stomach. The snare is next opened in the stomach and the endoscope is subsequently passed through the open snare. The endoscope is then advanced as far possible into the proximal intestine and a guide wire is then passed through the endoscopic channel. As the curved tip wire is passed into the proximal intestine it is rolled between the endoscopists thumb and forefinger in order to pass it as far past the ligament of treitz as possible, typically 30 cm. The endoscope is then slowly withdrawn as the wire is fed into the endoscopic channel. As the endoscope is brought back into the stomach it is retracted past the open snare which is then closed snug on the wire. The endoscope is removed and the oral end of the guide wire is held by the endoscopist. At this time the assistant pulls the closed snare out through the gastrostomy tube and the wire, which now takes the shape of a "U", is visible exiting the orifice of the PEG. The snare is released and the assistant gently tugs on the proximal and distal end of the wire. When the endoscopist feels the light tug on the oral wire the assistant is notified that the proximal end of the wire has been identified. This end of the wire is then pulled through he gastrostomy tube while the distal end of the wire is left in the proximal intestine. The PEJ is then threaded over the wire under fluoroscopy until it is seated in the gastrostomy tube. This method has been employed in our endoscopy unit over the last six months. The subjects selected for this procedure have mostly included patients with intractable nausea and vomiting secondary to severe diabetic gastroparesis. We have been able to successfully use the large diameter PEG for intermittent gastric decompression while supplying their needed calories via the jejunostomy tube with an isotonic feeding formula. Another advantage of this method that fluoroscopy time has greatly been reduced from an average of 22 minutes to 2 minutes. This novel approach to placement of a PEJ via a gastrostomy tube is an important and simple procedure that does not require any new or difficult skills. It is an efficient method of placing a PEJ that utilizes an important intermediary step that has not previously been described.

Percutaneous endoscopic gastrostomy/jejunostomy tube placement, a novel approach

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