931

Technical Note

Direct Percutaneous Jejunostomy Robin R. Gray,1 Chia-Sing Ho,2 Allan Yee,2 Walter Montanera,3 and D. P. Jones4

Percutaneous gastrostomy appears to be a safe method of providing enteric alimentation for patients with a wide variety of disorders in whom oral feeding is not possible or desirable (1-6]. However, percutaneous gastrostomy may not be possible in some patients because of the unfavorable position of the stomach or because of previous partial or total gastrectomy. We describe a patient with previous gastric surgery in whom enteric feeding was achieved by direct percutaneous jejunostomy.

Case Report

A 60-year-old man underwent pharyngolaryngectomy in April, 1985, for laryngeal carcinoma. A gastric pullup operation was per-formed with high anastomosis at the level of the posterior tongue. The initial postoperative course was unremarkable. but over the next several months the patient developed dysphagia in the oropharynx. He was found to have an anastomotic stricture for which he under-went bougienage on three occasions. The strictures improved, but the dysphagia persisted. The patient lost a significant amount of weight and was considered a candidate for percutaneous feeding gastrostomy. A direct percutaneous jejunostomy was performed since only a small portion of the stomach was present below the diaphragm because of the previous surgery.

l.klder fluoroscopic guidance, a nasogastric tube was passed through the surgical anastomosis into the intrathoracic stomach and through the pylorus, which was just below the hemidiaphragm. The liver margin was identified using sonography, and gas in the trans-verse colon was identified fluoroscopically. One milligram of IV glu-cagon (Lilly, Indianapolis IN) was given to slow peristalsis. The small bowel was then filled with room air through the nasogastric tube. Using a fluoroscopic ·c· -arm, a loop of bowel was identified imme-diately adjacent to the anterior abdominal wall (Fig. 1A). This was previously identified as a proximal loop of jejunum on a barium examination. In addition, the bolus of air that was injected through the nasogastric tube could be followed to this proximal jejunal loop fluoroscopically.

After administering local anesthesia. a 21-gauge needle from a Cope-type introducer set (Cook, Bloomington, IN) was inserted

Received May 27. 1987: accepted after revision July 14, 1987.

through the anterior abdominal wall into the jejuna! lumen (Fig. 1 B). Injection of contrast material confirmed the position of the needle tip within the jejuna! lumen and a 0.018-in. (0.046-cm) guidewire was inserted. The introduction catheter was used to exchange the first guidewire for a 0.038-in. (0.097-cm) "J"-tipped guidewire. The tract was dilated using radiopaque dilators (Cook). The dilators passed easily over the guidewire, entering the jejuna! lumen without the jejuna! wall backing away. An 8-French Cope-loop nephrostomy catheter (Cook) was then advanced into the jejuna! lumen and fixed to the anterior abdominal wall. Injection of contrast material showed that the catheter tip was in a good position and that no leakage had occurred (Fig. 1C).

The patient was started on direct jejuna! feedings 3 days later. He was well and gaining weight up to 13 months after the procedure. The only catheter-related complication has been the formation of a small amount of granulation tissue at the site of catheter insertion on the skin. This was treated with silver nitrate cauterization. The catheter had always functioned well and was exchanged prophylac-tically at 6 months.

Discussion

Percutaneous gastrostomy and gastrojejunostomy are safe and effective means of providing enteral feeding in patients in whom oral feeding is not possible (1-6]. If the stomach has been surgically removed or is made inaccessible, enteral feeding can be accomplished by placing a feeding tube directly into the jejunum.

Surgically placed tube jejunostomy is associated with sig-nificant complications including aspiration, leakage, sepsis, peritonitis, and bowel obstruction (7, 8]. In one study, seven of 73 patients with standard surgical tube jejunostomy died as a direct result of complications of the jejunostomy (8).

Glaser et al. (9) described an endoscopically guided per-cutaneous jejunostomy in a patient with previous partial gas-tric resection. Radiologic methods use sonography and fluo-roscopy to better localize the colon and liver adjacent to the proposed site of puncture.

'Department of Radiology. Wellesley Hospital, lkliversity of Toronto. 160 Wellesley St. E .. Toronto. Ontario. Canada. M4Y 1J3. Address reprint requests to R. R. Gray.

•Department of Radiology. Toronto General Hospital, lkliversity of Toronto, 101 College St .. Toronto, Ontario, Canada, MSG 1L7. 3 0epartment of Radiology, Toronto East General Hospital. 825 Coxwell Ave .. Toronto, Ontario. Canada. M4C 3E7. •Department of Surgery. Wellesley Hospital, University of Toronto, 160 Wellesley St. E .. Toronto. Ontario. Canada. M4Y 1J3.

AJR 149:931- 932, November 1987 0361-803X/87/1495-0931

Fig. 1.-A, Lateral view of upper abdomen with horizontal radiographic beam. Tip of forceps marks site of puncture. A loop of jejunum has beendistended with air and lies immediately adjacent to anterior abdominal wall (arrows).

B, A 21-gauge needle is used for percutaneous jejunal puncture.C, Final position of percutaneous jejunostomy feeding catheter.

Percutaneous puncture of the jejunum is difficult becauseof the mobility ofthejejunum, its compliance, and the difficultyof maintaining it in a distended state. Intraluminal support isimportant. In total, five direct percutaneous jejunostomieshave been attempted at our institutions, including the onedescribed above. These were attempted in different patients,

all of whom had inaccessible or excised stomachs. The twomost recent patients (including the one described) had suc-cessful catheterization and jejunal feeding by the methoddescribed. In these two cases, glucagon and injected air were

used to distend the jejunum and provide intraluminal support.In the first three patients, jejunal punctures were attempted

using an intrajejunal balloon to provide intraluminal support.This is analogous to a method of percutaneous gastrostomyusing an intragastric balloon [3]. In the first two patients,attempts at jejunal puncture were unsuccessful. The thirdresulted in successful puncture and catheterization of thejejunum with successful jejunal feeding. In this case, the openend of an 8-cm-long, cylindrical, toy rubber balloon was tiedto a nasogastric tube using a silk suture. The balboon-naso-

gastric tube assembly was then inserted through the noseand advanced to the proximal jejunum under fluoroscopicguidance. The balloon was inflated with approximately 1 2 mlof contrast material, providing a target for percutaneouspuncture of the jejunum. A needle was then advanced per-cutaneously and directed at the balloon. Rupture of theballoon and leakage of contrast material indicated penetrationof the anterior jejunal wall. This was followed by passage ofa guidewire and catheter insertion as described above.

Because of great freedom of movement of the small bowel

within the abdomen, a potential complication of a percuta-

neously placed jejunal tube is dislodgment of the tube as thebowel changes position in the abdomen. This is known tooccur in patients with percutaneous gastrostomy [4-6]. Dis-lodgment is prevented by using a self-retaining Cope-loop-type catheter for feeding.

Leakage of intestinal contents or feeding solution is apotential complication of a percutaneously inserted jejunos-tomy tube. This is a known complication of surgical tubejejunostomy [8]. With time, a fibrous tract forms along theintraperitoneal portion of the catheter so that intraperitoneal

contamination or leakage does not occur, even if the catheterbecame dislodged.

Volvulus of the small bowel around the feeding catheter is

a complication of surgical jejunostomy [7] and gastrostomy[1 0]. This can result in small bowel obstruction or necrosis[7, 10]. It is therefore important that the catheter be snuggedup against the parietal peritoneum.

Care must be taken that the site of puncture is in theproximal jejunum rather than in the ileum in order to avoid ashort bowel syndrome. Use of an intrajejunal balloon willensure localization of the puncture to the proximal jejunum.Alternatively, a continuous column of air can be seen fromthe nasogastric tube to the site of puncture if air is injecteddirectly into the jejunal lumen. This distance should be short,thus ensuring a puncture of the proximal jejunum.

All three of our patients with successful catheterizations

had had previous abdominal surgery. We hypothesize thatperitoneal adhesions, which would likely be present aftersurgery, serve to further support the jejunum and facilitatethe puncture. Any leakage from the catheter would be con-

fined locally by adhesions.

REFERENCES

1 . Ho CS. Percutaneous gastrostomy for jejunal feeding. Radiology1983;149:595-596

2. Wills JS, Oglesby JT. Percutaneous gastrostorny. Radiology 1983;149:449-453

3. vanSonnenberg E, Cubberley DA, Brown LK, Wittich GA, Lyon JW, Stauf-fer AE. Percutaneous gastrostomy: use of intragastnc balloon support.

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4. Ho CS, Gray AA, GoldfInger M, Rosen lE, McPherson A. Percutaneousgastrostomy for enteral feeding. Radiology 1985;1 56:349-351

5. Wills JS, Oglesby JT. Percutaneous gastrostomy: further experience.Radiology 1985;1 �4:71-74

6. van5onnenberg E, Wittich GA, Cabrera OA. Percutaneous gastrostomyand gastroenterostomy: 2. Clinical experience. AJR 1986;146:581-586

7. Haun JL, Thompson JS. Comparison of needle catheter versus standardtube jejunostomy. Am Surg 1985;51 :204-207

8. Adams MB, Seabrook GA, Quebbeman EA, Condon AE. Jejunostomy, a

rarely indicated procedure. Arch Surg 1986;121 :236-2389. Glaser D, deTamowsky GO, Mason AT. Percutaneous endoscopic jeju-

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