Abstract
Percutaneous endoscopic gastrostomy (PEG) is the first choice for administration of enteral nutrition in patients who find oral intake difficult. However, in patients with a history of upper gastrointestinal tract surgery such as gastrectomy or esophagectomy, PEG is sometimes difficult because the anatomical location of the stomach is different from the original position. Herein we describe two cases of successful percutaneous endoscopic duodenostomy (PED). In both cases, the duodenum was selected for feeding tube insertion, because it was technically impossible to insert the feeding tube into the stomach.
The first case is an 85-year-old woman with a history of Billroth I reconstruction after distal gastrectomy. As the transverse colon was located close to the duodenum in the CT image, a water-soluble contrast agent was injected through the nasogastric tube 3 hours before PED. Using this procedure, the colon was visualized at the time of duodenal tube insertion. By using the fluoroscopic image, it was possible to puncture the duodenum while avoiding puncturing the overlapping colon (colonic radiography-assisted PED).
The second case is a 71-year-old man with a history of subtotal esophagectomy with gastric tube reconstruction through the posterior mediastinal route. As some part of the duodenum appeared to be overlapped by the colon in the CT image, a colonoscope was inserted, and the transverse colon was moved toward the direction of the pelvis by manipulating the scope shaft. Simultaneously, an upper endoscope was inserted and PED was performed (colonoscopy-assisted PED). To avoid gastroesophageal reflux, a jejunal feeding tube was inserted through the duodenal fistula using an ultrathin endoscope.
In both cases, there were no serious complications after injecting the nutrients through the duodenal fistula. PED can therefore be a useful choice if PEG is difficult, such as in cases with previous upper gastrointestinal tract surgery.
