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

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.Since enteral nutrition is the preferred method of nourishment for all patients with adequate intestinal length and function, a variety of access methods to the gastrointestinal tract has been developed (1). Endoscopy-guided percutaneous gastrostomy (PEG) tubes are commonly placed in patients in whom oral intake is contraindicated. However, a PEG tube may not be preferred in mechanically ventilated or critically ill patients due to risk of aspiration; in these, administration of the nutrients directly into the jejunum through a nasojejunal tube or a percutaneously placed jejunostomy tube is recommended so that the stomach is bypassed and the risk for aspiration is decreased (2). Other indications for direct administration of nutrients into the jejunum include malfunction of the swallowing mechanism, gastric outlet obstruction, gastroparesis, pancreatitis, and the presence of esophageal fistulas or enteric foregut leaks (3–8).Jejunal feeding tubes can be placed via the nasogastric route, but are not tolerated in the long-term as they can have irritating effects on the nostrils, nasopharynx, and esophagus, and predispose the patient to reflux (9). Hence, a wide variety of other methods for placing jejunal tubes are available, including surgical, fluoroscopy-guided, and endoscopy-guided placement (5). The conversion of an already existing PEG tube into percutaneous endoscopic gastrojejunostomy (PEGJ) tube is also available (10, 11). Another method is placement of a jejunal extension tube (J-arm) through a PEG tube; this is most commonly done endoscopically, usually at the same time that the gastrostomy tube is placed, and known as the gastrojejunostomy tube (12). However, endoscopic advancement of jejunal extension tube through a PEG tube can be difficult, particularly when the operator has no access to fluoroscopy to determine its exact position within the bowel (11). Furthermore, the need for jejunal tube feeds can become apparent only after placement of the PEG tube, at which point the patient may return to the endoscopic suite or to the fluoroscopic suite for jejunal extension tube placement.At our institution, placement of a J-arm through an existing PEG tube by the radiologist under fluoroscopic guidance followed by affixation of the tube to the existing PEG tube has been a routine procedure for almost 10 years. The method does not involve removal of the PEG tube, and omits the use of endoscopy, which makes conscious sedation unnecessary and avoids the complications related to endoscopic placement. The purpose of our study was to establish the safety and efficacy of jejunal extension tube placement utilizing only fluoroscopic guidance.