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Endoscopic-Fluoroscopic Insertion of Nasojejunal Feeding Tube Using a Long Biliary Guidewire

ByRami Musallam, MD andKlaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Kaylee Goin

Figure 1. Endoscopic-fluoroscopic ewire guided placement of nasojejunal feeding tube. A. Once the ultraslim scope has passed the stenosis advance as much wire as possible into the jejunum. B. Remove stomach air while removing the scope. C. Kangaroo feeding tube being advanced through the guide wire. D. By gently pulling guidewire a direction is given to tube tip. E. The main trick is to pull and push on the wire, short strokes, and also let the wire “vibrate” with the fingertips holding it tight, while pushing and pulling. F. Contrast check of tube position.

Experienced teaching points

Clinical Pearls

  1. When passing an endoscope and feeding tube is impossible due to a stenotic pylorus or duodenum, use a transnasal ultraslim scope paired with fluoroscopy to deploy a long biliary guidewire (0.035 or 0.025 inch) deep into the jejunum.
  2. Always suction all air out of the stomach before scope retrieval; advancing the feeding tube through a collapsed stomach prevents looping that complicates tube advancement.
  3. Lubricate both the inside of the feeding tube (e.g., with 5-10 ml of olive oil) to glide over the guidewire, and the outside with gel for smooth transnasal introduction.
  4. While advancing the tube, apply countertraction by gently pulling on the guidewire with short, vibrating strokes to direct the tube tip and prevent kinking.

Kaylee Goin

Surgical Tech, Roanoke Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Rami Musallam, MD

Gastroenterology Fellow, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Placement of nasojejunal feeding tubes may be complicated and cumbersome (1). There are many nasojejunual tubes available including Dobhoff tube, Kangaroo feeding tube, Cook NJFT, and others. Often the tube is placed orally and then advanced endoscopically (e.g. UAB Raptor technique) (2). This technique is useful if a regular gastroscope can be advanced with the tube passing the second portion of the duodenum. However, any tube placed orally needs to be transferred to the nostril of the nose after the procedure is done. In addition, if patients have a stenotic pylorus or duodenum, passing a scope with tube is impossible. In this situation, using an ultraslim scope is a great option. A 60-year-old female patient with stenotic duodenum due to chronic calcific pancreatitis and gastric outlet obstruction required nasojejunal feeding tube. Herein we present the key steps to place a nasojejunal feeding tube using an ultraslim scope (transnasal endoscopy) with guidewire placement into jejunum and fluoroscopy-assisted deployment of the feeding tube.

Steps:

1. Perform transnasal endoscopy with ultraslim scope

2. Advance scope through pyloric and duodenal bulb stricture into third portion of duodenum

3. Advance long 0,035 inch biliary guidewire (e.g. Jagwire, or 0,025 in Olympus Visiglide) through scope into the jejunum.

Top tip: advance as much wire as possible, looping is OK. The extra wire will help you pull-and-straighten while pushing the feeding tube.

4. Remove scope, leaving wire in jejunum.

Top tip: always suction all air out of stomach during scope retrieval. It is easier to advance a tube through a collapsed stomach. If the stomach is distended, the looping may complicate tube advancement.

5. Advance feeding tube over the wire (through the nose).

Top tip: we always lubricate the inner side of tube with olive oil (5 to 10 ml), so it advances smoothly over the wire. In addition, we apply lubricating gel on top of tube when introducing it through the nose.

6. While pushing the tube gently pull on the wire, countertraction.

7. Water soluble Contrast injection through the tube shows excellent position in proximal jejunum, past ligament of Treitz.

Top tip: always flush with water after injecting contrast into tube to remove the stickiness of contrast and prevent clogging.

References

Brandt CP, Mittendorf EA. Endoscopic placement of nasojejunal feeding tubes in ICU patients. Surg Endosc. 1999 Dec;13(12):1211-4. doi: 10.1007/pl00009623. PMID: 10594268.

Martínez-Alcalá A, Mönkemüller K. The University of Alabama at Birmingham (UAB) Raptor method for direct percutaneous endoscopic gastrostomy with jejunal extension tube placement. Endoscopy. 2022 Mar;54(3):E96-E97. doi: 10.1055/a-1388-5247. Epub 2021 Mar 30. PMID: 33784754.

None of the authors has any conflict of interest with any of the devices or instruments mentioned in this article.

About the authors

Rami Musallam

Rami Musallam, MD

Gastroenterology Fellow, PGY-5

Carilion Clinic / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Rami J. K. Musallam, MD, is a gastroenterology fellow at Carilion Clinic and Virginia Tech Carilion School of Medicine. He earned his medical degree from the Islamic University of Gaza Faculty of Medicine and completed his internal medicine residency at Case Western Reserve University in Cleveland. He has published on gastroesophageal reflux disease, primary sclerosing cholangitis, and endoscopic procedures.

More articles by Rami →

Klaus Mönkemüller

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

More articles by Klaus →

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