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NJ tube placement

The module covers:

  1. Different types of NJT
  2. How to do it
  3. Aftercare

Different types of NJT

  1. Freka Endolumina- is 8Fr and it is placed through the biopsy channel of the scope (TTS- through the scope)
  2. Corflo- is 10F and is placed over a guide wire and it does not go through the biopsy channel
  3. Flocare Bengmark Naso-Intestinal tube- inserted non-endoscopically using normal peristalsis-see the video link below

How to do it

TTS type ( Freka Endolumina)

  1. It comes with a length of 270cm and 8Fr (2.6mm outer diameter) and so is compatible with the instrument channel of the endoscope ( >=2.8mm)
    The Freka NJT
    Picture1: The Freka NJT
  2. Insert the scope orally and advance it as far as possible through the stomach towards the intestine
    reka NJT going through the biopsy channel and the endoscope being removed subsequently keeping the NJT in :Courtesy Fresenius Kabi
    Picture2-4: Freka NJT going through the biopsy channel and the endoscope being removed subsequently keeping the NJT in
  3. Once the desired position has been reached, advance the intestinal tube (NJT) through the instrument channel of the scope to reach under observation a position distal to the ligament of Treitz. The distal tip of the tube may be moistened with sterile water to assist insertion.
  4. Approx 100-105cm mark should be at the incisor level when the tip is in jejunum.
  5. Withdraw the scope with rotating /jiggling motion otherwise the friction between the scope and the NJT will pull the tube out
  6. Feed more NJT as the scope comes out
  7. Assistant holds the end of the scope as it comes out of the mouth and then holds the NJT at lips while the scope is removed
  8. So now the NJT is placed but coming out through the mouth which needs to be re-routed through the nostril.

    Picture5 and 6: The NJT is being re-routed through the nose: Courtesy Fresenius Kabi
  9. Pass a NG  tube (16 size) / blue re-routing catheter  through the nostril
    Re-routing catheter, silicone oil, adhesive dressing and Magill's forceps
    Picture 7: Re-routing catheter, silicone oil, adhesive dressing and Magill’s forceps
  10. Grab it from oropharynx with a Magill’s forceps ( +/-  using laryngoscope) and pull out through mouth
  11. Ensure that the tube is in position against the rear wall of the pharynx without any loops.
  12. Cut the end of the NG tube with a scissors/ No cutting if it is a re-routing catheter
    The NJT is passes easily through the re-routing catheter when lubricated with silicone oil
    Picture 8: The NJT is passes easily through the re-routing catheter when lubricated with silicone oil
  13. Thread the NJ tube  into the lumen of the NG  tube or the opening of the re-routing catheter
  14. Pull out the NG tube from the nostril and at the same time looking inside the mouth (+/- with the help of a  laryngoscope and of the Magill’s forceps). Make sure the NJ tube is not slipping out of the oesophagus upwards.
  15. The NJT is now in trans-nasal position
  16. Cut the NJT to desired length and advance the fastening screw over the NJT

    Picture 9 and 10: The fixing of the Luerlock connector: Courtesy Fresenius Kabi
  17. Insert the metal pin of the Luerlock connector as far as possible into the NJT and screw the fastening screw tightly to the stop.
  18. Thread in the connectors
  19. Tape the NJ tube at nostril with a y shaped Elastoplasts (stem of the Y on bridge of the nose limbs surround the NJT) and also at the side of the cheek and also behind the ear.
  20. Record the length of the tube at nostril and document in the tube care plan.

Corflo PEJ

  1. This is a bigger tube and has to guided over a guide wire
  2. Insert the scope orally and advance it as far as possible through the stomach towards the intestine
  3. Once the desired position has been reached, advance the guide wire through the instrument channel of the scope to reach under observation a position distal to the ligament of Treitz.
  4. Approx 100-105cm mark should be at the incisor level when the tip is in jejunum.
  5. Withdraw the scope keeping the guide wire in
  6. Feed more guide wire as the scope comes out
  7. Assistant holds the end of the scope as it comes out of the mouth and then holds the guide wire at lips while the scope is removed
  8. So now the guide wire  is placed but coming out through the mouth which needs to be re-routed through the nostril.
    Re-routing catheter
    Picture 11: Re-routing catheter
  9. Pass a supplied re-routing catheter  through the nostril
  10. Grab it from oropharynx with a Magill’s forceps ( +/-  using laryngoscope) and pull out through mouth
  11. Ensure that the tube is in position against the rear wall of the pharynx without any loops.
  12. Thread the guide wire  into the lumen of the re-routing catheter
  13. Pull out the re-routing catheter  from the nostril and at the same time looking inside the mouth (+/- with the help of a  laryngoscope and of the Magill’s forceps). Make sure the guide wire  is not slipping out of the oesophagus upwards.
    The Corflo NJT with pre-fitted connector
    Picture 12: The Corflo NJT with pre-fitted connector
  14. Next thread the NJT over the guide wire. Before threading the NJT over the guidewire, flush the tube with 20 ml of water, using a syringe inserted into the access port. Also dip the distal end of NJT in water. These steps are crucial as this flushing and dipping activates the C-19 lubricant to facilitate tube passage over the guidewire.
  15. It comes ready with the attachment. So just fix it with adhesive dressings.

Aftercare

  1. AXR to confirm the position- the NJT should be free of tension and straight i.e. without loops, in a position distal to the ligament of Treitz.
  2. Remember to flush the NJT with 30ml of cool boiled water before and after the feed or at least once a day.
  3. It can remain in position for up to four weeks if the tube and the nose are carefully cared for. If enteral feeding is needed after this a PEG-J is recommended.

Here is the link for Naso-jejunal tube insertion video:
No video found so far. One good link is given below for non-endoscopic naso-jejunal tube insertion. http://www.youtube.com/watch?v=HUv13Xy0GwE

Acknowledgement/Bibliography:

  1. Guidelines for enteral feeding in adult hospital patients : BSG 2003
  2. Niv E et al. Post-pyloric feeding. World J Gastroenterol. 2009 Mar 21;15(11):1281-8.
  3. DiSario JA. Endoscopic approaches to enteral nutritional support. Best Pract Res Clin Gastroenterol. 2006;20(3):605-30.
  4. Product guide of the respective companies- Fresenius Kabi, Merck Serono and Nutricia

Article printed from Gastroenterology Education and CPD for trainees and specialists: http://www.gastrotraining.com