Where should the distal end of a gastrojejunostomy (GJ) tube be located?

Distal End Gastrojejunostomy Tube Location

The distal end of a gastrojejunostomy (GJ) tube should be positioned beyond the ligament of Treitz in the proximal jejunum. 1, 2, 3

Optimal Positioning Technique

Gastric Component Placement

• Position the gastrostomy puncture site to the right of midline and lower in the antrum to create a shorter, more direct route for the jejunal tube through the pylorus 1, 2, 3
• This strategic positioning minimizes gastric looping and helps prevent proximal migration of the jejunal component 1, 2

Jejunal Component Advancement

• Advance the wire and subsequently the jejunal tube through the pylorus into the small intestine beyond the ligament of Treitz using a stiff angiographic catheter or metal cannula 1, 2, 3
• The ligament of Treitz serves as the critical anatomic landmark - the tube must pass beyond this point to ensure proper postpyloric positioning 1, 2, 3

Confirmation of Proper Position

Imaging Verification

• Use fluoroscopic guidance during placement to confirm the jejunal extension tube is positioned beyond the ligament of Treitz 1, 2
• Inject contrast material through the tube to definitively confirm proper positioning 1, 2, 3

Clinical Verification

• Check pH of tube aspirate for alkaline pH consistent with small bowel placement 3

Critical Distance Considerations

• Place the jejunal component approximately 20-30 cm distal to the ligament of Treitz for optimal feeding access 4
• Do not place the GJ tube farther down from the ligament of Treitz than necessary, as excessive distal placement increases the risk of jejuno-jejunal intussusception, which can serve as a lead point for this rare but serious complication 5

Common Pitfalls and Prevention

Preventing Tube Migration

• The right-of-midline, lower antral gastrostomy position is essential to prevent the jejunal tube from coiling in the stomach fundus during advancement 1, 2
• When the gastrostomy tube faces away from the pylorus, use a stiff wire or sometimes two wires to overcome the obstacle of advancing the jejunal component 1, 3

Avoiding Placement Errors

• Never rotate a gastrojejunostomy tube - it should only be moved in and out during maintenance care to prevent dislodgement of the jejunal component 1
• Ensure the tube is not positioned too distally beyond what is necessary, as this increases mechanical complications 5

Success Rates

• Percutaneous gastrojejunostomy placement achieves 90-100% success rates when proper technique is followed 1, 2, 3
• No significant differences exist in success or complication rates between endoscopy-guided and fluoroscopy-guided techniques 1, 3