A 76-year-old man suffered a large right hemispheric cerebrovascular accident 3 months after implantation of an abdominally positioned left ventricular assist device (LVAD), (HeartMate, Thoratec Corporation, Pleasanton, CA) for ischemic cardiomyopathy. The LVAD pump was surgically implanted behind the posterior rectus abdominal muscle on the left side in the preperitoneal space. Because of neurologic dysphagia, enteral access was required. The LVAD position within the abdomen made percutaneous endoscopic gastrostomy (PEG) tube placement impossible (Figure 1). Alternatively, direct percutaneous endoscopic jejunostomy (DPEJ) was performed.
A single intravenous dose of a first-generation cephalosporin was administered before endoscopy. DPEJ was performed as described by Shike et al.1 as a modification of PEG placement. Using conscious sedation (Fentanyl 100 μg intravenously, Versed 3 mg intravenously), a variable stiffness pediatric colonoscope (Olympus PCF, Olympus America Inc., Melville, NY) was advanced to the jejunum. En route it was confirmed that no transillumination or indentation through the abdominal wall overlying the stomach could be appreciated due to the position of LVAD. A suitable incision point in the extreme left lower abdomen, 1 to 2 cm caudal to the LVAD pocket, was localized using digital indentation and abdominal transillumination. Glucagon 0.50 mg was intravenously administered in 0.25-mg doses to reduce intestinal peristalsis. After sterile preparation and drape, the midlength anesthetic needle in the PEG kit (MIC PEG, Ballard Medical Products, Draper, UT) was inserted percutaneously into the jejunum using a technique previously described.2,3 No additional abdominal wall incision was created. A trocar was inserted adjacent and parallel to the sound needle. A looped wire was threaded through the trocar into the jejunum, grasped with an endoscopic snare, and drawn up thorough the mouth as the endoscope was withdrawn. A 20 F gastrostomy tube was secured to the wire and drawn in to the jejunum (Figure 2). There were no procedural complications. Tube feeding was initiated within 24 hours. Two weeks later, at the time of hospital dismissal, he was tolerating continuous jejunal feedings at 65 ml/hour.
This is the first report of DPEJ placement in a patient with an LVAD. There is one published report of PEG placement after extracorporeal LVAD implantation.4 In that case, the device was outside of the abdominal cavity and thus only two cannulas, which were visible coming through the skin, needed to be avoided. In our case, the abdominally implanted pump, the driveline that crossed the midline, and the immediate space around the device had to be avoided.
Percutaneous endoscopic jejunostomy feeding is desirable when gastric feeding is not feasible due to gastric outlet obstruction or severe dysmotility, or for patients at high risk for aspiration. In this case, the position of the LVAD prohibited transabdominal gastric access. Bueno et al.5 described the use of DPEJ in patients with intrathoracic stomach after esophagectomy. Compared with gastric feeding tubes, difficulties in placement of jejunal feeding tube placement relate to the longer distance from the mouth, which can be overcome with the use of enteroscopes or colonoscope. Direct percutaneous endoscopic jejunostomy may be augmented with the aid of fluoroscopy in directing the puncture.6 In our experience, the use of a sound needle aids in stabilizing the mobile intestine for trocar placement.2,3
Direct percutaneous endoscopic jejunostomy should be considered as a long-term enteral feeding route when structural barriers prevent percutaneous gastric access. The presence of an intracorporeal LVAD does not necessarily preclude DPEJ placement, assuming a loop of bowel in the pelvis can be identified.
1. Shike M, Latkany L: Direct percutaneous endoscopic jejunostomy. Gastrointest Endosc Clin N Am
8: 569–580, 1998.
2. Fan AC, Baron TH, Rumalla A, Harewood GC: Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension. Gastrointest Endosc
56: 890–894, 2002.
3. Varadarajulu S, Delegge MH: Use of a 19-gauge injection needle as a guide for direct percutaneous endoscopic jejunostomy tube placement. Gastrointest Endosc
57: 942–945, 2003.
4. Slaughter MS, Pappas P, Tatooles A: Percutaneous endoscopic gastrostomy tube in a patient with a left ventricular assist device. ASAIO J
49: 611–612, 2003.
5. Bueno JT, Schattner MA, Barrera R, et al:
Endoscopic placement of direct percutaneous jejunostomy tubes in patients with complications after esophagectomy. Gastrointest Endosc
57: 536–540, 2003.
6. Shetzline MA, Suhocki PV, Workman MJ: Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy. Gastrointest Endosc
53: 633–638, 2001.