Endoscopic Placement of Jejunostomy Tube Extension After Diverted Esophagectomy

In this video, an esophagogastroduodenoscopy (EGD) was performed initially to locate the perforation and a 24 Fr G-tube was placed before any diversion or resection was performed. The proximal esophagus was then diverted to a spit fistula and the distal esophagus, or proximal stomach, was stapled. The GI system remained in discontinuity until further reconstruction.

A J-tube extension is needed in situations where the patient has gastroparesis, cannot tolerate G-tube feed, or there is a concern for a leak from the staples stump if overdistended. The endoscopic approach is favored when open or laparoscopic J-tube placement would be difficult or if the patient has a frozen abdomen. Endoscopic placement is faster and minimizes the chances of adhesions at the time of reconstruction. A pediatric bronchoscope, 12 Fr J-tube that can fit on a 24 Fr G-tube), oxygen tubing to fit on the suction port of the bronchoscope, a JAGWire with 0.035 in distal tip, 450 cm length, endoscopy tower, fluoroscopy unit, and set up is needed for the procedure.

To begin, the 24 Fr in situ G-tube was cut so that 5-10 cm remained outside the patient’s body. Then, a pediatric bronchoscope was inserted through the remnant G-tube. The suction port of the scope was connected to the oxygen tubing with flow at 10 L/min, which facilitates insufflating the stomach when the suction port is on.

The stomach was then entered, and a retroflexion view was possible as  shown in the video. The pylorus was identified and the duodenum was entered. The wire was then inserted and advanced under fluoroscopy as deep into the small bowel as could be done safely with little resistance. The bronchoscope was withdrawn keeping the wire in place.

Next, the 12 Fr J-tube extension was inserted through the G-tube over the wire. The wire was then carefully removed under fluoroscopy and the J-tube placement was confirmed by injecting contrast. Finally, the J-tube was secured on the G-tube remnant.

Three patients with Boerhaave’s syndrome underwent this procedure at the authors’ institution. Usually, the J-tube was placed around 14 days from the initial surgery. On follow-up, one patient had their J-tube intact with no complication, one had coiling of the tube requiring reintervention, and one was deceased. Endoscopic J-tube extension placement is a feasible alternative to open or laparoscopic J-tube placement in esophageal perforations. 

References

1. Omori A, Tsunoda S, Nishigori T, Hisamori S, Hoshino N, Ikeda A, Obama K. Clinical Benefits of Routine Feeding Jejunostomy Tube Placement in Patients Undergoing Esophagectomy. J Gastrointest Surg. 2022 Apr;26(4):733-741. doi: 10.1007/s11605-022-05265-5. Epub 2022 Feb 9. PMID: 35141836.
2. Weijs TJ, van Eden HWJ, Ruurda JP, Luyer MDP, Steenhagen E, Nieuwenhuijzen GAP, van Hillegersberg R. Routine jejunostomy tube feeding following esophagectomy. J Thorac Dis. 2017 Jul;9(Suppl 8):S851-S860. doi: 10.21037/jtd.2017.06.73. PMID: 28815083; PMCID: PMC5538975.

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