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Technical Innovation |
1 All authors: Department of Radiology, North West Adelaide Health Service, The Queen Elizabeth Hospital Campus, 28 Woodville Rd., Woodville South, South Australia, 5011, Australia.
Received June 26, 2000;
accepted after revision August 22, 2000.
Address correspondence to R. P. Davies.
Introduction
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On reviewing the diagnostic CT study, we selected CT fluoroscopy rather than conventional fluoroscopy to guide placement. Factors considered included the reported difficulty in recatheterizing previous surgical jejunostomy sites [2] and the uncertainty in identifying unopacified bowel loops using conventional fluoroscopy.
Eight-millimeter collimated helical CT scan slices (using 120 kVp, 300 mA, and a rotation time of 0.75 sec) were obtained through the lower abdomen by a CT scanner (Somatom Plus 4; Siemens Medical Systems, Forchheim, Germany). The previous jejunostomy site was scanned, but no suitable bowel loop was identified subjacent to the previous healing surgical jejunostomy scar. The stent site selected was 4 cm superior to this scar, where a loop of jejunum was seen just deep relative to the abdominal wall. Using 120 kVp, 50 mA, 5-mm collimated CT fluoroscopy (Combined Applications to Reduce Exposure; Vision CT; Siemens Medical Systems), a 23-gauge needle was advanced readily into the selected small-bowel loop. Brown fluid was aspirated. Under CT fluoroscopy, a Cope gastrostomy anchor needle (Cook, Bloomington, IN) was inserted into the small-bowel lumen without difficulty (Fig. 1A). After guidewire advancement and positioning of the first anchor, a 6-French dilator (Cook) was moved over the wire into the lumen. The second anchor then was placed, and the delivery wire was left in the lumen as a safety wire.
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An Amplatz 0.038-in extrastiff wire (Cook) was introduced through the 6-French dilator well into the distal bowel, and the position of both wires was confirmed with CT fluoroscopy. During gentle traction applied separately on each anchor suture, the track was dilated over the wire with the 14-French peel-away sheath supplied with the Malecot Russell gastrostomy set (Friction-Lock; Cook). Dilatation was readily achieved with a single advance of the sheath, and the Malecot Russell gastrostomy set then was inserted through the sheath. The position of the set was checked with CT fluoroscopy. The peel-away sheath was then retracted, the Malecot loops were reformed in the jejunal lumen, and the position of the loops was confirmed with CT fluoroscopy (Fig. 1B) before the sheath was removed.
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Ioversol 320 (Optiray; Mallinckrodt Medical, Victoria, Australia) diluted to 10% with normal saline was injected via the catheter to opacify the bowel loops. No leakage of contrast material into the peritoneum was evident (Fig. 1C). A 45-mm flanged stoma ring was positioned around the catheter entry point, and the catheter was secured to the flange of the stoma ring using 2.0-silk suture and a series of closely spaced clove hitches around the shaft of the catheter. After overnight observation of the patient, we began enteral feeding with the introduction of sterile water for 12 hr followed by increasing concentrations of enteral nutrition. The patient still had no complications related to the jejunostomy 30 days after the procedure.
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When conventional fluoroscopy is used, an anterior bowel loop may be opacified by gas, or a dependent loop may be opacified by water-soluble contrast material. Gas-filled loops are relatively compressible and mobile and, therefore, are more difficult to puncture. The structures traversed during fluoroscopically guided puncture of an iodinated contrast—filled bowel loop, such as other bowel and vascular structures, may not be shown on conventional fluoroscopy. The complication of colonic puncture has been reported [2].
CT-guided puncture eliminates these pitfalls because nonopacified fluid- or gas-filled small-bowel loops that are anteriorly positioned can be readily and confidently identified. Another technique providing optimal visualization of the bowel loop and the puncture site is direct percutaneous endoscopic jejunostomy in which the bowel and abdominal wall are transilluminated with the use of a long enteroscope. The failure rate of this technique has been reported as 14% [4].
In our patient, the site of the previous jejunostomy was scanned, but no suitable loop of bowel was present, deep relative to the previous surgical jejunostomy scar. The most suitable loop subjacent to the abdominal wall was approximately 4 cm superior to the scar. Finding this loop may not have been possible without CT, which supports the experience described by Cope et al. [2] of recatheterization of sites of previous surgical jejunostomies. Because in many patients the researchers could not locate the surgically fixed bowel with blind needle probing, Cope et al. suggest that the overlying scar may not have overlaid the surgically fixed loop in these patients. Cope et al. described placing tacking anchors as if in preparation for primary percutaneous jejunostomy because of the mobility of the accessed bowel loops.
Formation of a jejunopexy by placement of an anchoring device to tack the bowel loop to the anterior abdominal wall reduces jejunal mobility [2]. The potential for loss of the access track during dilatation and peritonism after insertion is reduced. The tack may also assist in recatheterization after inadvertent tube removal [2]. We could readily identify the anchors and bowel lumen during CT fluoroscopy. The entry point and angle were selected perpendicular to the underlying lumen, and dilatation was readily accomplished by a single advance of the 14-French peel-away sheath with two anchors in place. Placement of the second anchor also allowed positioning of a safety wire in the bowel lumen.
CT has been used widely for guiding interventional procedures. CT fluoroscopy has recently been advocated for interventional procedures [5, 6]. The CT fluoroscopy system uses a slip-ring helical CT scanner with a high-speed array processor that allows image reconstruction and display of images at three to six frames per second [5], resulting in near-real-time reconstruction and display of CT images. Various techniques can be used during CT fluoroscopy, including continuous real-time CT fluoroscopy, sliding-table CT fluoroscopy, and intermittent CT fluoroscopy [6]. We used the sliding-table fluoroscopy technique in which the patient was moved out of the scanning plane to allow consecutive insertion and manipulation of the guidewires, anchors, dilators, and drainage catheter after confirming the site and position with CT fluoroscopy.
To our knowledge, the use of CT fluoroscopy for percutaneous jejunostomy placement has not been described previously in the literature. CT fluoroscopy facilitates CT-guided puncture of mobile, unopacified small-bowel loops at the optimal angle and needle position while ensuring that nontargeted structures are undisturbed. The contrast and spatial resolution of CT fluoroscopy are sufficient to allow puncture of unopacified bowel. Guidance by CT fluoroscopy allows confident and speedy placement of the anchors, wires, and catheter. When we performed percutaneous jejunostomy in this patient, having direct visualization of the unopacified bowel lumen and of the position of the bowel lumen relative to the abdominal wall was clearly advantageous.
Conventional fluoroscopy gives better real-time control of guidewires and catheters than does CT fluoroscopy. In cases in which difficulties are encountered with guidewire manipulation and tract dilatation, the addition of portable fluoroscopy in the CT room might be an advantage. Factors that argue against this addition are the increased complexity and requirements for access and floor space in the CT suite.
Reports in the literature vary regarding reduction of procedure times with CT fluoroscopy. Froelich et al. [7] found CT reduced procedure times, but Silverman et al. [8] did not find an increase in efficacy or reduction in total turnaround times. Our total CT fluoroscopy screening time was approximately 50 sec. The procedure time from needle insertion to confirmation of tube placement was 21 min, which is similar to the procedure time using conventional fluoroscopy.
Visualization of the surrounding structures contributed to improved confidence. Furthermore, CT fluoroscopy decreased the screening time, in that image reconstruction was immediate and the bowel loop could be identified more accurately without having to compensate for the differences in patient respiration that affect conventional CT. Using fluoroscopy gives us the ability to see wire and catheter movement in real time, a great advantage compared with serial static radiography. CT fluoroscopy has a similar advantage over conventional static CT images. These factors contribute to increased patient safety.
There is the potential for an increased radiation dose using CT fluoroscopy. Silverman et al. [8] describe the radiation dose during CT fluoroscopy and recommend using lower CT parameters (80 kVp, 135 mA), which can deliver adequate image quality, as well as using intermittent CT fluoroscopy to minimize radiation doses during abdominal procedures. We do not formally measure the dose during CT fluoroscopy. The minimum achievable fluoroscopy time should be used as a protective measure against radiation.
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  A.L. J. Slappy, J. A. Odell, R. A. Hinder, and J. M. McKinney Jejunopexy for Selectively Placed Fluoroscopically Guided Percutaneous Jejunal Feeding Tubes Ann. Thorac. Surg., August 1, 2006; 82(2): 756 - 758. [Abstract] [Full Text] [PDF]
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