The difficult-to-place feeding tube: successful endoscopic placement using a mucosal clip

Background : Delivery of enteral feeding beyond the ligament of Treitz is often desirable, as it diminishes enterogastric reflux and potential for pulmonary aspiration of enteral feeding solution. However, standard or fluoroscopically guided techniques often fail. We describe three such cases in which enteral feeding tube placement was achieved endoscopically and secured using an endoscopic clip-fixing device. Methods : A standard feeding tube attached to a mucosal clip by a silk suture was advanced endoscopically into the small intestine. Using a through-the-endoscope clip-fixing device, the tube was attached to the bowel wall. Results : Three patients underwent the above procedure : a postgastrectomy patient with a functionally obstructed jejunal pouch and a previously failed fluoroscopically guided placement had a nasojejunal feeding tube successfully placed beyond the obstruction ; a cancer patient with duodenal obstruction due to SMA syndrome, a surgical gastrostomy, and a previously failed fluoroscopic attempt had a dual lumen pergastrostomy feeding tube placed beyond the obstruction ; and a patient with a refractory benign esophageal stricture underwent esophageal dilation followed by successful feeding tube placement into the proximal jejunum. In all patients, the tube functioned well without subsequent occlusion or dislodgement. Conclusions : Endoscopic placement of feeding tubes using a clip-fixing device is a useful technique in patients with normal and abnormal anatomy in whom reliable delivery of enteral feeding beyond the ligament of Treitz is desired.