What are the steps for J (Jejunostomy) tube placement?

J-Tube Placement Steps

Jejunostomy tube placement can be accomplished through multiple techniques, with image-guided (fluoroscopic or endoscopic) methods achieving 90-100% success rates and representing the preferred approach over bedside techniques. 1

Primary Percutaneous Jejunostomy (Direct J-Tube)

Image-Guided Fluoroscopic Technique

This approach is particularly useful when upper GI stenosis prevents endoscope passage. 1

Step 1: Target Loop Identification

• Advance an angiographic catheter into the proximal jejunum and insufflate with air and contrast agent 1
• Alternatively, place an angioplasty balloon or snare loop in the desired location to serve as a target 1
• Some operators use ultrasound guidance after injecting saline and contrast into the proximal jejunal loop 1

Step 2: Jejunal Loop Access and Fixation

• Access the jejunal loop with a needle 1
• Deliver a T-fastener device through the needle to secure the loop against the abdominal wall 1
• This fixation step is critical to prevent peritoneal contamination

Step 3: Tract Dilation and Tube Placement

• Advance a guidewire through the needle 1
• Dilate the tract over the wire 1
• Place the jejunostomy tube (most operators prefer a tapered Cope loop catheter) 1
• Inject contrast through the jejunostomy to confirm proper position 1

Endoscopic-Guided Direct PEJ Technique

Step 1: Enteroscopy and Visualization

• Perform enteroscopy to visualize the proximal jejunum 2
• Pass a standard snare through the enteroscope and open it 2

Step 2: Percutaneous Access

• Direct a needle and guidewire percutaneously through the snare using fluoroscopic guidance 2
• Close the snare around the guidewire under direct endoscopic visualization 2

Step 3: Tube Placement

• Pass a standard 20F push-type tube over the guidewire through the mouth 2
• Seat the dome in the jejunum 2
• Pass a bumper externally over the tube and tighten at the skin 2
• Average procedure time is 40 minutes (range 22-64 minutes) 2

Gastrojejunostomy (GJ-Tube) Placement

Through Existing Gastrostomy

Ultrathin Endoscope Technique (Preferred for Mature Tracts)

Step 1: Endoscope Advancement

• Pass an ultrathin endoscope (5-6 mm diameter) or pediatric bronchoscope (3-4 mm) through the mature gastrostomy tract into the small intestine 1, 3
• This technique often does not require conscious sedation 3

Step 2: Wire Placement

• Feed a guidewire (preferably a stiff Savary-Gilliard guidewire) through the endoscope deep into the small bowel beyond the ligament of Treitz 1, 4
• Remove the endoscope while leaving the wire in place 1

Step 3: J-Tube Insertion

• Pass the jejunal extension tube over the wire into position using fluoroscopic guidance 1, 4
• Remove the guidewire 1
• Median procedure time is 20 minutes (range 9-86 minutes) for J-tube extension through existing PEG 4

Critical Technical Point: Cut the external gastrostomy tube length to shorter than 10 cm and use a longer jejunal extension tube to allow deeper and more stable jejunal position. 1

Primary Gastrojejunostomy (Single-Step GJ Placement)

Fluoroscopic Transabdominal Approach

Step 1: Gastric Access

• Perform gastropexy using T-fasteners 1
• Advance a vascular sheath into the stomach 1
• Key positioning: Puncture the stomach to the right of midline and lower in the antrum to create a shorter, more direct route through the pylorus, minimizing gastric looping and preventing proximal migration 1

Step 2: Jejunal Wire Advancement

• Through the vascular sheath, use a stiff angiographic catheter or metal cannula to advance the wire into the small intestine beyond the ligament of Treitz 1
• If the jejunal tube coils in the stomach fundus, use a stiff wire or sometimes two wires to overcome this obstacle 1

Step 3: Tube Exchange

• Exchange the wire for the gastrojejunostomy tube 1

Endoscopic Transoral Approach

Step 1: Initial Gastrostomy

• Perform standard PEG placement using pull-through technique 4, 5

Step 2: Jejunal Tube Advancement

• Push the PEG tube up to the pylorus to facilitate jejunal tube passage into the duodenum without looping in the stomach 5
• Advance ultrathin endoscope through the PEG tube to the jejunum 4
• Place guidewire beyond ligament of Treitz 4
• Pass jejunal feeding tube over the wire 4
• Mean time for jejunal tube placement is 8.2 minutes 5

Post-Placement Confirmation

Mandatory verification steps:

• Inject contrast through the tube to confirm position 1
• Obtain plain abdominal radiograph to verify tip location at or beyond the ligament of Treitz 5
• Never rely on bedside auscultation alone 6
• Check pH of tube aspirate for alkaline pH consistent with small bowel placement 1, 6

Critical Pitfalls to Avoid

Technical Complications:

• The main obstacle in primary jejunostomy is intestinal mobility, making equipment advancement difficult 1
• When using surgical or endoscopy-guided gastrostomy tubes, the tube often faces away from the pylorus, causing the jejunal tube to coil in the stomach fundus 1
• Jejunal tubes have shorter longevity (3-6 months average) compared to gastric tubes 7

Management Errors:

• Never apply suction to jejunal tubes - this damages jejunal mucosa and causes fluid/electrolyte imbalances 7, 6
• For patients requiring both jejunal feeding and gastric decompression, use dual-lumen tubes or separate tubes 6
• Jejunal feeding requires continuous infusion rather than bolus feeding due to limited jejunal capacity 6
• Position external bumper approximately 1 cm from abdominal wall to prevent pressure necrosis 7

Success Rates and Outcomes

• Percutaneous gastrojejunostomy success rates: 90-100% 1
• Direct PEJ with enteroscopy and fluoroscopy: 100% technical success 2
• Ultrathin endoscope technique: 100% technical success with no major adverse events 4
• No significant differences in success or complication rates between endoscopy-guided and fluoroscopy-guided techniques 1