Volume 13 Issue 4 - April 2015
                     
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Direct Percutaneous Jejunostomy
     
  Direct percutaneous jejunostomy is indicated for enteral feeding when access to the jejunum is not possible via the stomach due to:
Prior gastric or gastroesophageal surgery
Gastric ulcer or malignancy
Gastric outlet obstruction
Inadequate window for gastric access
Repeated retraction of gastrojejunostomy tubes

  Direct percutaneous jejunostomy tubes may also be used for:
Lumanl Drainage
Diagnostic and/or therapeutic biliary or intestinal interventions



Percutaneous Jejunostomy Procedure
Contraindications
Complications
Scheduling
Further Information
References

Table 1. Indications for Percutaneous Jejunostomy
Enteral feeding in patients with:
  • Prior gastric surgery
  • Gastric malignancy or ulcer
  • Gastric outlet obstruction
  • Repeated retraction of GJ tube back into stomach
Palliative drainage for bowel or biliary obstruction
Access for biliary or intestinal interventions
 
Enteral feeding is indicated in a number of situations in which a patient is unable to consume sufficient nutrition normally or it is unsafe for them to do so. Such patients include those who are critically ill as well as those with chronic illness. If nutritional support is required for 30 days or less, nasogastric or nasojejunal tube feeding is generally used. For longer periods, direct enteral access is preferable because of the discomfort of nasogastric tubes and their associated risk of infection.

In most cases, interventional radiologists are able to access the jejunum percutaneously by placing a gastrojejunostomy (GJ) tube, in which a catheter is advanced into the jejunum via a gastric puncture. This approach is technically easier than direct access because the jejunum is not fixed in place. However, in some cases GJ tube placement cannot be achieved or is not practical because of prior or planned gastric surgery, obstruction of the gastric outlet, gastric malignancy, or other problems. In other cases, a GJ tube can spontaneously and repeatedly retract into the stomach despite correct placement. In these cases, a direct percutaneous jejunostomy may be preferred.

Jejunostomy tubes are recommended primarily for enteral feeding in patients with pancreatitis, gastroparesis, or gastroesophageal reflux disease associated with recurrent aspiration. In addition, jejunostomy tubes may be used for drainage or for access to allow biliary or intestinal interventions (Table 1).

Percutaneous Jejunostomy Procedure
Direct percutaneous jejunostomy was first introduced in 1987 as an image-guided procedure using fluoroscopy. While it is technically challenging and its use has been limited, there are several published reports that demonstrate its safety and effectiveness, with a technical success rate of >90%. In recent years, demand for this procedure has been growing.

Figure 1. Jejunal tube placement in a 60-year-old man in need of enteral access for nutrition after esophageal and gastric surgery for cancer. (A) Needle placement into a jejunal loop under CT-guidance. (B) CT image shows wire that was advanced through the needle into the jejunum. (C) CT image shows feeding tube within the jejunum and the access port on the abdomen.

From experience at our institution, CT guidance is superior to fluoroscopy for performing direct percutaneous jejunostomy. The procedure is usually performed with local anesthesia and sedation but general anesthesia may be needed, depending on the patient’s clinical status. Prior to the procedure, patients must fast for several hours. To begin the procedure, the bowel is dilated with air through a nasojejunal tube, and CT imaging is used to select a safe route into a proximal loop of the jejunum close to the anterior abdominal wall. A needle is then inserted through the abdominal wall into the jejunum under CT guidance (Figure 1A). A T-fastener is deployed by passing a wire through the needle into the jejunum, and its position is confirmed by CT imaging (Figure 1B). The bowel loop is pulled close to the abdominal wall, to which it is affixed with a suture. The tract is then serially dilated to allow the passage of the feeding tube (Figure 1C).

Following the procedure, patients may be admitted into the hospital for observation and care due to the risk of enteral content leakage. Feeding through the jejunostomy tube is initiated 24-48 hours after the procedure.

Contraindications
Certain anatomic and pathologic conditions may increase the risk of complications for this procedure. Absolute contraindications include uncontrolled coagulopathy and the absence of a safe access route. Relative contraindications include ascites.


Complications
Mild catheter-site discomfort is expected for several hours after tube placement. Complications may also include leakage and infection, which the patient and health care provider can routinely monitor during dressing changes. Pericatheter leakage has been reported at a rate of 0.19 per 100 catheter-days and inadvertent dislodgement of jejunostomy tubes at 0.17 per 100 catheter-days. Additionally, jejunostomy tubes may become occluded, in which case they can be replaced. They can also be replaced soon after accidental displacement, although the tracts may close up within hours.


Scheduling
Direct percutaneous jejunostomy is offered though the Interventional Radiology Clinic on the main campus of Massachusetts General Hospital. Appointments can be made through ROE (inside Partners network) or ROE Portal (outside Partners network) or by calling 617-726-8396.


Further Information
For further information on CT-guided direct percutaneous jejunostomy, please contact Ashraf Thabet, MD, Interventional Radiology, Department of Radiology, Massachusetts General Hospital, at 617-726-8396.

We would like to thank Ashraf Thabet, MD, and David G. Forcione, MD, Gastrointestinal Unit, Massachusetts General Hospital, for their assistance and advice on this issue.

References

Cope C, et al. (1998). Direct percutaneous jejunostomy: techniques and applications--ten years experience. Radiology 209:747-54

Davies RP, et al. (2001). Percutaneous jejunostomy using CT fluoroscopy. AJR. American journal of roentgenology 176:808-10

Kim CY, et al. (2013). Comparison of primary jejunostomy tubes versus gastrojejunostomy tubes for percutaneous enteral nutrition. Journal of vascular and interventional radiology : JVIR 24:1845-52

Kim YJ, et al. (2013). Safety and efficacy of radiological percutaneous jejunostomy for decompression of malignant small bowel obstruction. Eur Radiol 23:2747-53

McPherson SJ, et al. (1998). Percutaneous transjejunal biliary intervention: 10-year experience with access via Roux-en-Y loops. Radiology 206:665-72

Richard HM, et al. (2008). Percutaneous fluoroscopically guided jejunostomy placement. J Trauma 65:1072-7

Sparrow P, et al. (2008). Direct percutaneous jejunostomy--an underutilized interventional technique? Cardiovasc Intervent Radiol 31:336-41

Yang ZQ, et al. (2007). Fluoroscopically guided percutaneous jejunostomy: outcomes in 25 consecutive patients. Clin Radiol 62:1061-5; discussion 6-8




©2015 MGH Department of Radiology

Janet Cochrane Miller, D. Phil., Author
Raul N. Uppot, Editor


 

 

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