Percutaneous transhepatic duodenostomy for a gastrectomy case with CT guidance and real-time visualization by an ultrasound and endoscopy

• Published in: Nutrition (Burbank, Los Angeles County, Calif.) Vol. 31; no. 9; pp. 1168 - 1172
• Main Authors: Moriwaki, Yoshihiro, M.D., Ph.D, Otani, Jun, M.D., Ph.D, Sawada, Yoshiyuki, M.D., Ph.D, Okuda, Junzo, M.D, Niwano, Toshiyuki, M.D, Ntta, Tachiko, A.S, Ohshima, Chiaki, B.N.S
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-09-2015; Elsevier Limited
• Subjects: Aged, 80 and over; Coma; Computed tomography; Duodenostomy - methods; Duodenum - surgery; Endoscopy; Endoscopy, Gastrointestinal - methods; Enteral Nutrition - methods; Gastrectomy - adverse effects; Gastroenterology and Hepatology; Gastrostomy - methods; Hepatic injury; Humans; Liver; Male; Ostomy; Patients; Percutaneous endoscopic gastrostomy (PEG)/Duodenostomy; Percutaneous transhepatic gastrostomy/duodenostomy; Stomach; Stomach - surgery; Ultrasonic imaging; Ultrasonography - methods; Ultrasound guidance; United States > US; Percutaneous endoscopic gastrostomy (PEG)/Duodenostomy; Ultrasound guidance; Hepatic injury; Percutaneous transhepatic gastrostomy/duodenostomy
• ISSN: 0899-9007; 1873-1244
• DOI: 10.1016/j.nut.2015.04.004

Abstract After gastrectomy, the remnant stomach, a small stomach behind the lateral segment of the liver, is thought to be a relative contraindication to receiving a percutaneous endoscopy-guided gastrostomy (PEG). We successfully performed a percutaneous duodenostomy in a case with remnant stomach. We used a transhepatic pull method with computed tomography (CT) guidance and real-time visualization by using ultrasound (US) and an endoscopy. The procedure was as follows: 1. Full stretching of the remnant stomach; 2. Insertion of a fine injection needle into the duodenal lumen through the lateral segment of the liver without an intrahepatic vascular and biliary injury using real-time visualization through US; 3. Confirmation of the location of the fine needle using abdominal CT, which showed the fine needle penetrating through the lateral segment and the duodenal lumen; 4. Insertion of the thick needle of the PEG kit just laterally of the fine needle; 5. Confirmation of the location of the thick needle using a repeated CT; 6. Endoscopic confirmation of the location of the two needles; 7. Changing the direction of the thick needle using guidance with endoscopy, inserting the thick needle into the duodenal lumen, and removing the fine needle; 8. Insertion of the guide wire through the thick needle; and 9. Placement of the PEG tube using the pull method. Using a real-time US scan, we detected the puncture of the anterior wall of the duodenum or stomach and avoided intrahepatic major vascular and biliary injuries.