AJR 2001; 176:159-160
© American Roentgen Ray Society
Direct Percutaneous Transperitoneal Duodenostomy
An Alternative Form of Enteral Feeding
James H. Turner1,2 and
Gerhard R. Wittich1
1
Department of Radiology, University of Texas Medical Branch, 301 University
Blvd., Galveston, TX 77555.
2
Present address: Department of Radiology, Denver Health Medical Center, 777
Bannock St., Denver, CO 80204.
Received May 5, 2000;
accepted after revision June 23, 2000.
Address correspondence to G. R. Wittich.
Introduction
Over the last few decades, various ways of placing feeding tubes into the
gastrointestinal tract have become available, namely surgical, percutaneous
endoscopic, and radiologic imaging-guided percutaneous placements
[1,2,3].
Most commonly, imaging-guided gastrostomy or enterostomy is performed on
patients with an impaired swallowing mechanism caused by neurologic insult and
for mechanical obstruction caused by malignancy of the upper gastrointestinal
tract. In patients with altered upper gastrointestinal anatomy, the standard
methods of placement may not be possible. In such cases, variations of the
standard placements have been devised. The transhepatic approach for
gastrostomy placement, direct percutaneous jejunostomy, and translumbar
duodenostomy have been described
[4,
5]. We report a case of
transperitoneal duodenostomy as an alternative for enteral feeding in a
patient with altered upper gastrointestinal anatomy.
Subject and Methods
The patient was a 43-year-old man with a history of congenital esophageal
atresia and tracheoesophageal fistula treated with a colonic interposition
graft as a child. As an adult, he developed a stricture in the graft, which
was treated with resection of the graft and a gastric pull-up. The patient
required long-term enteral access and nutrition because of an anoxic brain
injury that occurred during a prolonged hospital stay. The referral was made
from the gastroenterology service, which had been unable to place a feeding
tube endoscopically.
A portable C-arm (Stenoscope Plus; General Electric Medical Systems,
Milwaukee, WI) was brought to the CT suite. With the patient on the CT table
(9800 HiLight Advantage; General Electric Medical Systems), the C-arm was used
to place a Dotter retrieval basket (Cook, Bloomington, IN) through the mouth
into the second portion of the duodenum (Figs.
1A and
1B). Using CT guidance, we
found a narrow anatomic window to allow percutaneous puncture with an
18-gauge, Pencil Point needle (Cook). The needle was passed medial and
inferior to the right lobe of the liver and to the right of any loops of small
intestine. The needle passed inferior to the large intestine. A Rosen
guidewire (Cook) was passed through the needle. The guidewire was grasped with
the basket and pulled into the gastric remnant. The percutaneous tract was
dilated with dilators and a vanSonnenberg 10-French feeding tube (Boston
Scientific, Watertown, MA) was placed over the guidewire
(Fig. 1C). The patient returned
30 days later, and a 14-French gastrostomy feeding tube (Cook) was advanced
into the jejunum. The tube functioned well until the patient's death 5 months
later.
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Fig. 1B. —43-year-old man who underwent esophagectomy and gastric
pull-up. Fluoroscopic image of basket in second portion of duodenum shows
18-gauge Pencil Point needle (Cook, Bloomington, IN) used to make percutaneous
puncture.
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Discussion
In patients who have had a gastrectomy or gastric pull-up, the jejunum or
duodenum becomes a potential target for percutaneous placement of feeding
tubes. Access to a jejunal loop is feasible using fluoroscopic, sonographic,
or CT guidance, particularly if the loop is fixed in position as a result of
adhesions. However, placement of a feeding tube into a mobile jejunal loop can
be technically challenging. Conversely, the second portion of the duodenum is
fixed in a retroperitoneal position and, therefore, presents an easier target.
A disadvantage of the translumbar route is the inconvenient posterior position
of the feeding tube. Disadvantages of the transhepatic route include
complications such as ascending cholangitis or vascular injury. An anterior
transperitoneal route to duodenal puncture is feasible with careful imaging
guidance. We have successfully placed duodenal feeding tubes using an anterior
supramesocolic approach after defining the inferior margin of the liver with
sonography and after identifying the transverse colon with radiography. The
patient described here presented a special anatomic challenge because of the
cranial position of the transverse mesocolon. Using CT guidance, a narrow but
safe inframesocolic, extrahepatic window was found. Fluoroscopic placement of
a large retrieval basket into the second portion of the duodenum facilitated
puncture of the duodenum as well as insertion of a guidewire and feeding
tube.
With the advent of imaging-guided percutaneously placed feeding tubes,
there has been discussion as to whether fixation of the anterior wall of the
gastrointestinal tract (gastropexy or enteropexy) should be performed with
placement of the feeding tube. Gastropexy or enteropexy allows large-bore
tubes (14-French or larger) to be placed initially, and it facilitates
replacement of the feeding tube should it become dislodged
[6]. However, older series
report good function of the feeding tubes without gastropexy or enteropexy
[7,
8]. Therefore, fixation of the
stomach or small intestine to the anterior abdominal wall is not an absolute
requirement for a functional percutaneous feeding tube.
CT facilitates accurate anatomic localization. The transperitoneal route
was successful in this patient because we were able to avoid loops of small
intestine to the left and the large intestine superiorly. Without CT such
precise localization might not have been possible. We conclude, therefore,
that combined CT and fluoroscopic guidance for transperitoneal percutaneous
puncture of the duodenum may provide a safe alternative for enteral access in
patients with altered upper gastrointestinal anatomy.
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Introduction
Subject and Methods
