Fluoroscopy-guided jejunal extension tube placement through existing gastrostomy tubes: analysis of 391 procedures

Abstract

Purpose: We aimed to evaluate the safety and efficacy of fluoroscopically placed jejunal extension tubes (J-arm) in patients with existing gastrostomy tubes.

Methods: We conducted a retrospective review of 391 J-arm placements performed in 174 patients. Indications for jejunal nutrition were aspiration risk (35%), pancreatitis (17%), gastroparesis (13%), gastric outlet obstruction (12%), and other (23%). Technical success, complications, malfunctions, and patency were assessed. Percutaneous gastrostomy (PEG) tube location, J-arm course, and fluoroscopy time were correlated with success/failure. Failure was defined as inability to exit the stomach. Procedure-related complications were defined as adverse events related to tube placement occurring within seven days. Tube malfunctions and aspiration events were recorded and assessed.

Results: Technical success was achieved in 91.9% (95% CI, 86.7%-95.2%) of new tubes versus 94.2% (95% CI, 86.7%-95.2%) of replacements (P = 0.373). Periprocedural complications occurred in three patients (0.8%). Malfunctions occurred in 197 patients (50%). Median tube patency was 103 days (95% CI, 71-134 days). No association was found between successful J-arm placement and gastric PEG tube position (P = 0.677), indication for jejunal nutrition (P = 0.349), J-arm trajectory in the stomach and incidence of malfunction (P = 0.365), risk of tube migration and PEG tube position (P = 0.173), or J-arm length (P = 0.987). A fluoroscopy time of 21.3 min was identified as a threshold for failure. Malfunctions occurred more often in tubes replaced after 90 days than in tubes replaced before 90 days (P < 0.001). A total of 42 aspiration events occurred (OR 6.4, P < 0.001, compared with nonmalfunctioning tubes).

Conclusion: Fluoroscopy-guided J-arm placement is safe for patients requiring jejunal nutrition. Tubes indwelling for longer than 90 days have higher rates of malfunction and aspiration.

Figure 1. a, b.

Digital fluoroscopy image (a) and spot radiograph (b) demonstrating looping of the J-arm in the stomach. Panel (a) shows an example of a small loop (open white arrow). The gastrostomy tube (solid black arrow) is in the distal body of the stomach. Tip end (open black arrow) is well beyond the ligament of Treitz. Panel (b) shows an example of a large loop. The loop reaches the gastric fundus (solid white arrow). The tip of the J-arm is at the ligament of Treitz (open black arrow). Gastrostomy tube (solid black arrow) is in gastric antrum.

Figure 2. a–c.

Digital fluoroscopy images showing placement of a J-arm through a PEG tube into the jejunum. Panel (a) shows a 5F angled-tip catheter advancing through the gastrostomy tube opening (open white arrow) with the tip directed towards the pylorus. The PEG tube is in the distal antrum of the stomach. (b), Under fluoroscopic guidance, the catheter is advanced through the duodenum and beyond the ligament of Treitz into the jejunum (open black arrow), with the assistance of a 0.035-inch guidewire. The open white arrow in panel (b) designates the location of the gastrostomy tube. The angled-tip catheter is removed while leaving the wire in place, after which the J-arm is advanced over the wire and placed in the jejunum. The wire is then removed, and a small volume of water-soluble contrast material is administered through the J-arm to confirm its position in the jejunum (solid white arrow, c). The tube is then flushed with water to remove any residual contrast agent (not shown) to prevent clogging. Locations of pylorus (open black arrow) and the ligament of Treitz (open white arrow) are shown. Note that the J-arm follows a straight course out of the stomach to the pylorus. The patient is slightly rotated to the right.

Figure 3. a, b.

Sagittal (a) and axial (b) unenhanced computer tomography images demonstrate the tube exiting the duodenal lumen (open arrow, a) with retroperitoneal leakage of orally administered water-soluble contrast material (white arrow, b), consistent with perforation of a duodenal ulcer by the jejunal extension tube.