PICTURES IN DIGESTIVE PATHOLOGY

 

Ultrasound-assisted technique for challenging jejunostomy balloon-tube replacements

 

 

Ana Ponte, Rolando Pinho, Sónia Fernandes, Carlos Fernandes, Iolanda Ribeiro, Joana Silva, Jaime Rodrigues and João Carvalho

Department of Gastroenterology. Centro Hospitalar Vila Nova de Gaia. Espinho, Portugal

 

 

The authors present a case of a 38-year-old man with a 4-hour history of accidental removal of a jejunostomy balloon-tube replacement (PEG-18-BRT-S, Cook Medical Inc., Bloomington, USA). The patient had undergone a direct percutaneous endoscopic jejunostomy (DPEJ) ten months ago, before chemoradiotherapy treatment for an esophageal squamous-cell carcinoma (uT3N2cM0). His past medical condition included alcoholic liver disease and distal gastrectomy from a life-threatening duodenal bleeding ulcer. As partial stoma closure prevented replacement of the balloon-tube, a smaller diameter (14 Fr) catheter was gently introduced to evaluate the patency of the jejunostomy tract (Fig. 1A). Abdominal ultrasound was used to verify proper placement of the catheter into the jejunal loop (Fig. 1B), further confirmed after intestinal distension upon instillation of water. A guide-wire was then introduced through the catheter which was subsequently removed leaving the guide-wire in place. After local anaesthesia with lidocaine, the DPEJ stoma was enlarged with a small scalpel incision. An identical balloon-tube was then gently advanced over the guide-wire (Fig. 2A) under ultrasound control, which confirmed its progression into the jejunal lumen (Fig. 2B). After replacement of the balloon-tube (Fig. 3A), the guide-wire was removed and the balloon was inflated (Fig. 3B).

 

 

 

 

DPEJ is a demanding and time-consuming technique (1-4). Most DPEJ-related complications are similar to those of percutaneous endoscopic gastrostomy (PEG) tubes, including unintentional removal (1,2,5). Late dislodgements occur when the fistula has maturated, usually after 4 weeks, preventing peritoneal leakage (2,5). Following tube displacement, the gastrocutaneous tract is prone to closure within 12-24 hours and efforts should be attempted to keep the fistula opened (2,5). Since partial closure of the stoma may prevent replacement of PEG and DPEJ tubes, some rescue techniques have been described to overcome these difficulties (5). This ultrasound-assisted technique also represents a valuable alternative approach for safe and successful replacements in the more fragile and complication-prone jejunostomy tracts.

 

Acknowledgment

Ultrasound equipment was gently provided by General Electrics.

 

References

1. Aktas H, Mensink PB, Kuipers EJ, et al. Single-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy. Endoscopy 2012;44:210-2. DOI: 10.1055/s-0031-1291442.         [ Links ]

2. Westaby D, Young A, O'Toole P, et al. The provision of a percutaneously placed enteral tube feeding service. Gut 2010;59:1592-605. DOI: 10.1136/gut.2009.204982.         [ Links ]

3. Velázquez-Aviña J, Beyer R, Díaz-Tobar CP, et al. New method of direct percutaneous endoscopic jejunostomy tube placement using balloon-assisted enteroscopy with fluoroscopy. Dig Endosc 2015;27:317-22. DOI: 10.1111/den.12352.         [ Links ]

4. Pinho RT, Rodrigues MA, Proença ML. Overtubes and fluoroscopy for direct percutaneous endoscopic jejunostomy: Useful, although not always needful and sometimes harmful. Dig Endosc 2015;27:399-400. DOI: 10.1111/den.12426.         [ Links ]

5. Ponte A, Pinho R, Carvalho J. Thinking outside the box of the gastrostomy kit: Stylet-assisted technique for challenging gastrostomy tube replacements. Clin Gastroenterol Hepatol 2015;13(9):e137-8. DOI: 10.1016/j.cgh.2015.01.011.         [ Links ]