Transnasal stent-assisted targeting technique for percutaneous jejunostomy placement in patients with hiatal hernias

PURPOSE

To report the transnasal stent-assisted targeting technique for percutaneous jejunostomy placement in patients with hiatal hernias.

MATERIALS AND METHODS

Four patients, including three (75%) females and one (25%) male, with mean age of 77.5 years (range 73-78 years), and with a hiatal hernia and intrathoracic stomach precluding gastrostomy placement and loop snare placement into the mid-jejunum underwent the transnasal stent-assisted targeting technique for percutaneous jejunostomy placement. In all patients, a duodenal stent was inserted into the jejunum in a transnasal fashion. The stent was partially unsheathed in an anterior loop of jejunum and percutaneously targeted using an 18-gauge needle through which a guidewire was advanced, trapped within the stent, and removed through the nose. The tract was serially dilated and a jejunostomy was placed. Technical success, procedure time, fluoroscopy time, radiation exposure, complications, time to enteral feeding, and follow-up were recorded.

RESULTS

Technical success was 100% (4/4) with all four patients requiring only one needle pass before successful jejunal cannulation. Mean procedure time was 108 min. Mean fluoroscopy time was 44 min. Mean dose area product was 3969.3 μGym². No minor or major complications occurred. All four patients received enteral feeding one day after the procedure. Mean follow-up was 366 days.

CONCLUSION

The transnasal stent-assisted targeting technique is a novel method for primary jejunostomy placement in patients with hiatal hernias.

Percutaneous jejunostomy

Direct percutaneous jejunostomy is considered in patients where percutaneous gastrostomy is not feasible (stomach removed or inaccessible). Percutaneous jejunostomy is more difficult than gastrostomy techniques. Direct jejunostomy is performed under fluoroscopic guidance, using a nasojejunal tube to distend the jejunum. The jejunal loop is punctured using a Cope suture anchor, under ultrasound guidance. Water-soluble contrast material is injected through the needle to document intralumenal position, and an anchor is inserted. With the guide wire in place, the track is dilated and a 10-F pigtail catheter inserted into the proximal jejunum. Fluoroscopy can also be used to aid puncture using dilute contrast material, if used via the nasogastric tube. Antiperistaltic agents can also be used to aid jejunal puncture. The cumulative procedure-related mortality from the three reported series in the literature is 2.4%, with minor complications occurring in 10 to 11%. Although jejunostomy is not performed frequently, this is a feasible procedure for interventional radiology.