I have had superior mesenteric artery syndrome for six years without a nasogastric (NG) tube; how do I arrange for nasogastric/nasojejunal tube placement?

How to Arrange Nasogastric/Nasojejunal Tube Placement for Superior Mesenteric Artery Syndrome

For superior mesenteric artery syndrome (SMAS) after six years without tube placement, you need a nasojejunal (NJ) tube placed beyond the duodenal obstruction, not a standard nasogastric tube, and this should be done via endoscopic or fluoroscopic guidance by gastroenterology or interventional radiology.

Why Nasojejunal Rather Than Nasogastric

In SMAS, the third portion of the duodenum is compressed between the superior mesenteric artery and aorta 1, 2, 3. A standard NG tube that terminates in the stomach will not bypass this obstruction and will fail to provide adequate decompression or nutrition 1. You specifically need post-pyloric access into the jejunum to deliver nutrition beyond the point of compression 3.

Step-by-Step Approach to Getting the Tube Placed

1. Contact Gastroenterology or Interventional Radiology

• Request consultation for endoscopic or fluoroscopic-guided nasojejunal tube placement 4, 5
• Specify that you have SMAS and need post-pyloric access for both decompression and enteral nutrition
• Success rates exceed 90% with guided placement versus 56-92% with blind bedside attempts 5

2. Pre-Procedure Requirements

Before the procedure, you'll need 5:

• INR testing (required for all patients)
• Activated PTT if you're on heparin
• Single dose of first-generation cephalosporin antibiotic immediately before placement 4

3. Placement Technique Options

The most effective methods are 5:

Endoscopic-guided placement:

• Endoscope advanced into distal duodenum/proximal jejunum
• Guide wire passed through biopsy channel into jejunum
• Endoscope removed, feeding tube passed over wire into small intestine
• Success rate >90% 5

Fluoroscopic-guided placement:

• Similar technique using fluoroscopy for visualization
• Equally effective with >90% success rate 5

4. Confirmation Before Use

• Mandatory radiographic confirmation of tube position before initiating feeds 5
• Bedside auscultation is unreliable and can miss malposition (lung, pleural cavity, coiled in esophagus) 5

Important Considerations for SMAS Specifically

Short-Term vs Long-Term Access

• NJ tubes are appropriate for <4 weeks of anticipated use 4
• Given your six-year history, you may ultimately need percutaneous endoscopic gastrojejunostomy (PEG-J) or direct percutaneous endoscopic jejunostomy (DPEJ) for long-term access 4, 1
• One case report showed successful transition from NG to PEG-J in SMAS with symptom resolution 1

Tube Securing

• Request nasal bridle placement to prevent dislodgement, as 40-80% of nasoenteric tubes become dislodged with standard taping 5
• This is critical given the difficulty of NJ placement and your chronic condition

Feeding Considerations

• Small bowel feeding requires reduced and cycled feeding rates to prevent dumping syndrome 4
• Continuous pump feeding is preferred over bolus for jejunal access 4

Common Pitfalls to Avoid

1. Don't accept a standard NG tube - it won't bypass the duodenal obstruction in SMAS
2. Don't attempt blind bedside placement - success rates are poor for NJ tubes and you'll waste time with repeated failures 5
3. Don't use weighted tubes - unweighted tubes have higher success rates for spontaneous small bowel passage 5
4. Don't start feeding without radiographic confirmation - malposition can cause serious complications 5

If Conservative Management Fails

Recent literature emphasizes that if nutritional rehabilitation via NJ tube fails to restore mesenteric fat pad and resolve symptoms, duodenojejunostomy is the preferred surgical approach with significant symptom reduction and improved quality of life 3. After six years, you should discuss with your gastroenterologist whether surgical intervention might be more definitive than continued tube management 6, 3.

Practical Next Steps

1. Call gastroenterology or interventional radiology this week
2. Explain you have SMAS diagnosed six years ago
3. Request: "I need endoscopic or fluoroscopic-guided nasojejunal tube placement for enteral nutrition and decompression"
4. Ask about transition plan to PEG-J if symptoms persist beyond 4 weeks 4