The Case of Dr. Joaquín Medrano
The complete procedure of conversion from percutaneous gastrostomy to percutaneous gastrojejunostomy made by the Dr. Joaquín Medrano, interventional radiologist at the Miguel Servet University Hospital in Zaragoza (Spain), can be seen in the online surgical training app SurgSchoolThis is a complex clinical case in which a standard percutaneous gastrostomy is insufficient after a diagnosis of gastroduodenal obstruction with a retention stomach.
La conversion to percutaneous gastrojejunostomy It is indicated when gastric nutrition is not feasible due to impaired gastric emptying, persistent vomiting, or a high risk of aspiration. In these scenarios, the combined access allows for simultaneous gastric aspiration and distal jejunal nutrition, optimizing clinical management.
Clinical context and indication
The patient had a 14 Fr multi-perforated pigtail percutaneous gastrostomy tube placed days earlier as an enteral feeding device. Subsequently, gastric and duodenal involvement with impaired gastroduodenal flow was diagnosed, resulting in continuous vomiting and gastric retention.
In this context, maintaining exclusively gastric feeding would perpetuate the condition. The interventional strategy consists of transforming the existing access into a percutaneous gastrojejunostomy, allowing:
– Aspiration of gastric contents.
– Distal enteral nutrition in the jejunum.
– Reduced risk of pulmonary aspiration.
Technical planning
The main advantage of the procedure is to take advantage of the mature tract of the recent gastrostomy.
The planning includes:
– Continuous fluoroscopy.
– Control with water-soluble contrast to delineate the duodenal frame.
– Availability of hydrophilic guides (Terumo type), rigid guides and super stiff guides (Amplatzer).
– Progressive dilators of the tract.
The initial objective is to exchange the 14 Fr catheter for an introducer that allows gastric manipulation and controlled insufflation.
Access and navigation strategy
El Dr. Joaquín Medrano The procedure begins with passing a guide wire through the existing gastrostomy and replacing it with a 10 Fr introducer, allowing the introduction of air and contrast, and navigating with a curved catheter into the antrum and duodenal frame.
The critical point is navigating beyond the duodenal bulb into the proximal jejunum. In patients with anatomical abnormalities or gastric retention, advancement may be hindered by folds and changes in axis.
The technique combines:
– Initial use of hydrophilic guide to find the path.
– Strategic injection of contrast to “chart the way”.
– Switch to a rigid or super stiff guide (Amplatzer) once the jejunum is reached, providing support for the final exchange.
Patience is crucial at this stage. Progression must always be monitored fluoroscopically, avoiding loops or false trajectories.
Exchange and placement of the final device
Once the jejunal position is confirmed with contrast, the exchange is carried out for a more rigid guide wire and progressive dilation of the tract.
The procedure ultimately requires the placement of two functional systems:
- Tube with jejunal orifices for distal nutrition.
- Additional gastric catheter for aspiration.
The correct placement of the openings in each segment is crucial. The distal end must be clearly positioned in the jejunum, while the proximal fenestrations allow for gastric drainage.
The final check is performed with a contrast agent, confirming:
– Free passage in jejunum.
– Absence of extravasation.
– Correct intraluminal position.
Critical points and risks
Potential complications include:
– Duodenal perforation.
– False path.
– Migration or malposition of the probe.
– Early obstruction due to kinking.
The risk increases in very distended stomachs or those with altered anatomy.
The key preventative measures are:
– Systematic use of contrast to confirm trajectory.
– Switch to rigid guide only after secure distal positioning.
– Progressive dilation to minimize trauma.
Tips & Pearls in Digestive Interventional Radiology
Never force the probe forward if the guidewire is not clearly distal and aligned.
Intermittent contrast injection helps to visualize the duodenal axis in real time.
In cases where passage is difficult, it may be helpful to slightly withdraw and refocus the tip to avoid loss of curve.
Choosing a super stiff guide makes it easier to swap out the final material when it has higher friction.
Frequent errors
Attempting to advance the final probe without sufficient rigid guide support may result in loss of access.
Failure to confirm jejunal position before the final exchange is a common cause of technical failure.
Underestimating the required caliber for dual function (aspiration and nutrition) can lead to subsequent obstruction.
Results and monitoring
Successful conversion allows for immediate jejunal nutrition and simultaneous gastric drainage, improving vomiting control and patient comfort.
The follow-up includes:
– Clinical verification of enteral tolerance.
– Radiological control if dysfunction is suspected.
– Education of the clinical team on the management of the dual system.
In patients with non-surgical gastroduodenal obstruction, this technique offers an effective and reproducible minimally invasive solution.
For whom is this procedure especially useful?
To interventional radiology residents that begin in advanced digestive access points.
To young assistants who wish to perfect distal exchange and navigation techniques.
To specialists with experience in digestive intervention that seek to optimize results in complex stenoses.
