This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Endoscopic technique. We present a technique for percutaneous endoscopic gastrostomy tube placement followed by placement of the journal extension tube. PACT-J placement is a standard procedure for a variety of conditions such as gastroparesis, gastric outlet obstruction, intestinal dysmotility. It is usually performed as a two-step procedure. First, placement of a PACT-J using endoscopic translumination following by the two placements with the pull method, trimming the PACT-J to approximately 20 centimeters. This is followed by insertion of the J-extension tube through the PACT-J which is then grasped by the upper endoscope with an endoscopic lip in the stomach and guided through the pylorus to the position distal to the ligament of traits. PACT-J placement common issues. Two common problems of the J-tube placement can occur which are related to the length of the PACT-J portion. First, inability to advance the J-tube distal enough and setting of a relatively short PACT-J results in a significant gastric J-tube loop. Second, on the other hand, a too long PACT-tube can prevent adequate J-tube insertion into the jejunum. Solution. We present the technique for PACT-J tube placement which allows optimal PACT-tube length independent on the depth of the J-tube insertion. Description of the technique. Following translumination with the endoscope and marking the optimal position for the PACT-J tube, the skin is disinfected and lidocaine is injected in the usual PACT-tube placement fashion. A 1 cm skin incision is made to facilitate the PACT-tube placement and the introducer needle is inserted perpendicular to the skin. The sheet of the introducer needle is grasped with a snare and the needle is exchanged for a wire which is eventually grasped with a snare. Following the endoscope withdrawal and adjusting the PACT-tube to the wire, the PACT-tube is pulled through the abdominal wall in the usual PACT-tube pull fashion. The wound is cleaned and the outer bumper is placed. Next, only the introducer of the PACT-tube is cut, leaving the majority of the silicone PACT-tube intact. The tip of the J-tube extension is lubed up and inserted through the PACT-tube. The strain of the J-tube extension is grasped using an endoclip and slowly maneuvered through the pylorus into the duodenum using the Pediatric Colonoscope. While slowly inserting the Pediatric Colonoscope through the duodenum and eventually the dejunum, the J-tube extension is slowly threaded into the PEP tube, mainly by passive pulling from the Advancing Pediatric Colonoscope, which can be further facilitated by gentle pushing as well. Once the J-tube still reaches the silicone portion of the PEP tube and further insertion of the Pediatric Colonoscope is feasible and required to pass the ligament of trites, the PEP tube is carefully sliced using the pointed tip of the scissors for 5 to 10 cm and cut off. The J-tube is further inserted through the PEP tube while meanwhile the Pediatric Colonoscope advanced. These steps are repeated until the J-tube is sufficiently inserted into the dejunum. Using this method, the silicone PEP tube is never cut too long or too short for the J-tube extension. Finally, the sling of the J-tube extension is clipped to the dejunum mucosa and the Pediatric Colonoscope is carefully withdrawn. We can see during the scope withdrawal in this video that the J-tube extension is placed without any tight inculations or loops. This CT scan shows a stable position of the J-tube extension distal to the ligament of trites 4 weeks following the tube placement without any proximal tube migration. The image shows the J-tube extension going directly to the small bowel without forming any gastric loop. Conclusions. This technique allows optimal J-tube placement without gastric looping or a too short dejunal J-tube insertion. We have used this technique in 5 patients that were followed over 6 weeks and no procedure-related adverse events were noticed. Two patients had abdominal imaging at 4 weeks documenting optimal J-tube placement without any J-tube loops or too short J-tube resulting in proximal J-tube migration.

Braintree

percutaneous endoscopic gastrostomy tube placement

PACT-J extension

J-tube placement length

gastric looping