Brief reportPercutaneous transhepatic duodenostomy for a gastrectomy case with CT guidance and real-time visualization by an ultrasound and endoscopy

•We performed a percutaneous transhepatic endoscopic duodenostomy for a gastrectomy case.•We used the pull method with computed tomography, real-time ultrasound guidance and an endoscopy.•Using a real-time ultrasound scan, we detected the puncture of the anterior wall of the duodenum or stomach.•Ultrasound is useful for avoiding intrahepatic vascular and biliary injuries.•Computed tomography is useful for avoiding the situation of the punctured needle.

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.