What are the considerations for inserting a catheter to the Treitz ligament region?

Catheter Insertion to the Treitz Ligament Region

For catheter placement to the Treitz ligament region (duodenojejunal junction), fluoroscopic guidance with wire-directed advancement through the pylorus and beyond the ligament of Treitz is the standard approach, typically performed for gastrojejunal feeding access or diagnostic/therapeutic procedures in the proximal small bowel. 1

Anatomic Considerations

The ligament of Treitz marks the duodenojejunal junction and serves as the anatomic boundary between upper and lower gastrointestinal bleeding (proximal versus distal). 1 This landmark is critical for:

• Defining the target location for jejunal feeding tubes that must extend beyond this point to prevent gastric reflux 1
• Identifying the transition from the fixed retroperitoneal duodenum to the mobile intraperitoneal jejunum 2

Technical Approach for Catheter Placement

Fluoroscopy-Guided Wire Technique

The preferred method uses a stiff angiographic catheter or metal cannula advanced through a vascular sheath, with the wire directed through the pylorus and advanced into the small intestine beyond the ligament of Treitz under fluoroscopic guidance. 1

Key technical steps include:

• Position the initial gastric puncture toward the pylorus to create a shorter, more direct route through the pylorus, minimizing gastric looping and preventing proximal migration 1
• Use a stiff guidewire (or sometimes two wires) to overcome the acute angle when the gastrostomy tube faces away from the pylorus 1
• Advance the catheter beyond the Treitz ligament under continuous fluoroscopic visualization to confirm proper positioning in the proximal jejunum 1, 3
• Confirm final catheter tip position at the desired location distal to the ligament of Treitz before securing 1

Alternative Punctured Tube Technique

A novel approach using a punctured Miller-Abbott tube with guidewire advancement has demonstrated:

• 100% technical success for placement beyond the Treitz ligament versus 40% with conventional methods 3
• Significantly reduced procedure time (15.3 ± 5.93 minutes versus 35.8 ± 8.13 minutes, p < 0.001) 3
• No clinical disadvantages from the puncture site 3

Infection Prevention Protocols

Strict aseptic technique must be maintained throughout catheter insertion and care. 1

Critical infection control measures:

• Perform hand hygiene with alcohol-based hand rubs or antiseptic soap before and after any catheter manipulation 1, 4
• Disinfect skin with 2% chlorhexidine-based preparation (preferred), allowing it to air dry completely before insertion 1, 4
• Wear sterile gloves for central catheter and arterial catheter insertion 1
• Maintain aseptic technique throughout the procedure 1
• Cover the catheter site with sterile gauze or transparent semi-permeable dressing 1

Site Selection for Venous Access

When venous access is required for catheter advancement:

The right internal jugular vein is the preferred access site because it offers a more direct route to the cavo-atrial junction and is associated with lower complication rates compared to other sites. 1

Site-specific considerations:

• Avoid subclavian vein access in patients who may need permanent vascular access due to risk of central venous stenosis 1
• Left internal jugular placement is associated with poor flow rates and high rates of stenosis/thrombosis 1
• Femoral access should be reserved for emergency situations or when upper sites are unavailable, as it carries higher infection and thrombosis risks 1
• Ultrasound guidance should be used when available to minimize insertion complications 1

Post-Insertion Management

Immediate Verification

• Obtain chest x-ray after subclavian or internal jugular insertion to confirm catheter tip position and exclude complications before use 1
• Document operator, date, time of insertion on standardized forms 1

Ongoing Catheter Care

• Inspect catheter sites visually or by palpation through intact dressing regularly 1
• Change dressings when soiled or if the patient develops fever, tenderness, or signs of infection 1, 4
• Do not routinely replace catheters solely to reduce infection risk 1
• Flush tubes with approximately 40 mL water after each use to prevent occlusion 5

Common Pitfalls and How to Avoid Them

Gastric looping is the most common technical failure when advancing catheters toward the Treitz ligament. 1 Prevent this by:

• Puncturing the stomach in the direction of the pylorus initially 1
• Using sufficiently stiff guidewires to maintain forward direction 1
• Positioning the gastrostomy to the right of midline and lower in the antrum 1

Catheter tip malposition can occur without fluoroscopic confirmation. 1 Always verify:

• Final position beyond the Treitz ligament with imaging before use 1, 3
• Adequate depth of insertion (at least 19 cm for femoral catheters to minimize recirculation) 1

Infection risk increases with improper technique. 1, 4 Maintain vigilance by:

• Never palpating insertion sites after antiseptic application unless using aseptic technique 1
• Removing catheters immediately if exit site, tunnel tract, or systemic infection develops 1, 4
• Avoiding submersion of catheter sites in water 1, 4