title: Percutaneous transhepatic duodenostomy for a gastrectomy case with CT guidance and real-time visualization by an ultrasound and endoscopy.
abstract: After gastrectomy, the remnant stomach, a small stomach behind the lateral segment of the liver, is thought to be a relative contraindication to receiving a percutaneous endoscopy-guided gastrostomy (PEG). We successfully performed a percutaneous duodenostomy in a case with remnant stomach. We used a transhepatic pull method with computed tomography (CT) guidance and real-time visualization by using ultrasound (US) and an endoscopy. The procedure was as follows: 1. Full stretching of the remnant stomach; 2. Insertion of a fine injection needle into the duodenal lumen through the lateral segment of the liver without an intrahepatic vascular and biliary injury using real-time visualization through US; 3. Confirmation of the location of the fine needle using abdominal CT, which showed the fine needle penetrating through the lateral segment and the duodenal lumen; 4. Insertion of the thick needle of the PEG kit just laterally of the fine needle; 5. Confirmation of the location of the thick needle using a repeated CT; 6. Endoscopic confirmation of the location of the two needles; 7. Changing the direction of the thick needle using guidance with endoscopy, inserting the thick needle into the duodenal lumen, and removing the fine needle; 8. Insertion of the guide wire through the thick needle; and 9. Placement of the PEG tube using the pull method. Using a real-time US scan, we detected the puncture of the anterior wall of the duodenum or stomach and avoided intrahepatic major vascular and biliary injuries.
authors.affiliation: Department of Surgery, Unnan City Hospital, Unnan, Shimane, Japan. Electronic address: Yoshimoriwaki@gmail.com.
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Moriwaki
authors.affiliation: Department of Surgery, Unnan City Hospital, Unnan, Shimane, Japan; Department of Nutritional Support, Unnan City Hospital, Unnan, Shimane, Japan.
authors.forename: Jun
authors.initials: J
authors.lastname: Otani
authors.affiliation: Department of Surgery, Unnan City Hospital, Unnan, Shimane, Japan; Department of Nutritional Support, Unnan City Hospital, Unnan, Shimane, Japan.
authors.forename: Yoshiyuki
authors.initials: Y
authors.lastname: Sawada
authors.affiliation: Department of Surgery, Unnan City Hospital, Unnan, Shimane, Japan.
authors.forename: Junzo
authors.initials: J
authors.lastname: Okuda
authors.affiliation: Department of Surgery, Unnan City Hospital, Unnan, Shimane, Japan.
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Niwano
authors.affiliation: Department of Nutritional Support, Unnan City Hospital, Unnan, Shimane, Japan.
authors.forename: Tachiko
authors.initials: T
authors.lastname: Ntta
authors.affiliation: Department of Nutritional Support, Unnan City Hospital, Unnan, Shimane, Japan.
authors.forename: Chiaki
authors.initials: C
authors.lastname: Ohshima
mesh_terms: D000369:Aged, 80 and over; D004385:Duodenostomy / Q000379:methods*; D004386:Duodenum / Q000601:surgery*; D016099:Endoscopy, Gastrointestinal / Q000379:methods; D004750:Enteral Nutrition / Q000379:methods*; D005743:Gastrectomy / Q000009:adverse effects; D005774:Gastrostomy / Q000379:methods*; D006801:Humans; D008099:Liver; D008297:Male; D013270:Stomach / Q000601:surgery*; D014463:Ultrasonography / Q000379:methods
keywords: Hepatic injury; Percutaneous endoscopic gastrostomy (PEG)/Duodenostomy; Percutaneous transhepatic gastrostomy/duodenostomy; Ultrasound guidance