A 64‐year‐old woman who was diagnosed as suffering from amyotrophic lateral sclerosis (ALS) of bulbar type was admitted to our hospital for long‐term care. After admission, she underwent percutaneus endoscopic gastrostomy (PEG) and enteral feeding was initiated. However, the PEG alimentation was disrupted by aspiration pneumonia owing to the superior mesenteric artery syndrome (SMAS), diagnosed by gross anatomy and endoscopic studies. Conservative treatment for SMAS was not successful and sepsis developed. After recovery from this, an operation was recommended, but it was rejected by her and her family members. We therefore selected the method of placing a thin jejunostomy tube through the PEG, called percutaneous endoscopic gastrojejunostomy (PEGJ) and pulling it endoscopically into the proximal jejunum, thereby allowing delivery of nutrients. Thereafter, she was well and showed gradual improvement of nutritional parameters such as serum albumin and total cholesterol, as well as the lymphocyte subset. It is concluded that PEGJ is effective for long‐term enteral nutrition in ALS patients complicated with SMAS.

Background: The fistula tract angle formed by percutaneous endoscopic gastrostomy (PEG) was examined. Also, the previous literature on fistula tract disruption is reviewed and the possible influence of the fistula tract angle on fistula tract disruption by non‐endoscopic catheter change is discussed. Methods: A total of 15 patients aged 24–80 years were examined.The fistula tract angle was measured as the angle of elevation between the tangent line at the orifice of the PEG stoma and the longitudinal axis of the catheter. Results: Values of the angle ranged from 56 to 90° (mean 77.6°), with four cases (27%) having angles below 70°.With one case of pan‐peritonitis after catheter insertion at 90°, laparotomy revealed that the angle of the fistula tract was low at 62° and that the catheter had broken through the tract just below the abdominal wall. Conclusion: This study suggests that the fistula tract angle might be a potential risk factor for fistula tract disruption by non‐endoscopic catheter change.