a novel technique of endoscopic suturing for the fixation of the J-arm of a percutaneous endoscopy gastrointestinalostomy, primary author Philip Kozan, and co-authors Jennifer Fan, Anna H. Lee, Craig Gluckman, B. Raman Muthuswamy, and Danny Issa. Here we have our disclosures listed down below. A 77-year-old female presented with idiopathic gastroparesis and refractory nausea and vomiting. The patient had been on total parenteral nutrition, which was complicated by recurrent episodes of Lyme infection and sepsis. She had five hospitalizations and lost 30 pounds in six months. A prior PEGJF in place was complicated by J-arm dislodgement requiring multiple interventions and tube reposition. The patient lived three hours away from the nearest tertiary center providing additional barriers to medical care. We have included a representative diagram. The patient was referred to our center for further evaluation for severe malnutrition and PEGJ malfunction. Here we describe a novel technique of gastric sutures for this fixation of the J-arm of the PEGJ to prevent tube dislodgement. Upon gastroscope introduction to the stomach, we can see the previously placed PEGJ with the J-extension removed. The PEG was completely removed and a new PEG tube was placed. Here you can see the process of the new PEG tube placement with introduction of the wire, which is being grasped by a through-the-scope snare. The new peg was successfully placed along the anterior gastric body as seen here. We then thread the J-arm extension through the peg which was originally grasped with a snare. However, we switched to a rat-toothed forceps for improved traction. The J-arm was guided deep into the jejunum as seen here. A wire was thread through the J-arm to assist with deep jejunal intubation, and the gastroscope was slowly retracted back into the stomach, ensuring that the J-arm remained straight and taught through the pylorus without a loop in the stomach. The auto-suturing device was attached to a dual-channel gastroscope, which was then inserted with the stitch loaded and the arm closed. We then placed the initial stitch on the greater curvature of the gastric body. and the suture is threaded over and under the J-arm multiple times, with passage of the stitch two times as seen here. It is important for complete visualization of the driver to not compromise the J-tube on accident. The suture was looped twice around the J-arm. This method allowed for additional slack and flexibility without risking tube dislodgement. Finally, the second suture is placed on the opposing wall of the first stitch, in this case on the lesser curvature of the agostric anterior wall. The cinch was then passed through the double channel and the stitch was anchored in place ensuring that the suture was tight enough to guide the J-arm to the pylorus but loose enough as to not obstruct the J-arm. Here we see the final product with a jam pointing directly into the pylorus with a stitch preventing looping formation in the stomach. Since completion of the procedure, the patient has had significant clinical improvement. Her nausea and vomiting have resolved. She has not had further hospitalizations and reports an improvement in her quality of life along with a gain of 10 pounds. Here, we summarize our endoscopic methods used during this procedure. This case highlights a known and challenging complication of PEG-J malfunction and J-arm dislodgement slash looping in the stomach. To overcome this challenge, endoscopic suturing was used to fixate the J-arm using loose, full-thickness stitches cinched to the gastric wall. This novel technique may be considered for patients to prevent frequent tubary positions and patients with limited access to tertiary medical centers. Endoscopic suturing for the fixation of a J-arm of a PEG-J tube is a novel, minimally invasive technique that can prevent tube dislodgement and the need for re-intervention. Future controlled studies are warranted to evaluate the long-term outcomes of this method.

endoscopic suturing

PEG-J tube

J-arm fixation

gastroparesis

malnutrition