BACKGROUND
Patients with Ehlers–Danlos syndrome (EDS) present unique challenges during enteral access procedures. Their connective‑tissue laxity often results in a markedly capacious stomach, increasing the risk of tube coiling back into the gastric lumen. This risk is further amplified in those with a previous endoscopic PEG, where the tract frequently points toward the fundus, making jejunal access more difficult.

CASE PRESENTATION
A 22‑year‑old male with EDS required primary gastrojejunostomy (GJ) tube placement for long‑term enteral feeding after increasing intolerance with NJ feeding.
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Technical Considerations :
1. Patient positioning: The procedure is optimally performed from the left side of the patient to counteract the natural tendency of the tract to direct toward the fundus.
2. Sedation and analgesia: Conscious sedation with local anaesthetic was used.
In EDS, a bupivacaine–lidocaine mixture (3:1) is preferred, as lidocaine alone is often ineffective.
3. Preparation: An NG tube was placed to allow controlled gastric insufflation.


PROCEDURE
1. The stomach was insufflated, revealing significant gastric distension typical of EDS.
2. Three gastropexy sutures were placed along the far lateral greater curvature, ensuring the most favourable trajectory toward the pylorus.
3. The central access needle was directed toward the pylorus, avoiding the fundal orientation of the tract (Image A).
4. After partial or full gastric decompression, a catheter and guidewire were negotiated successfully into the jejunum (Image B).
5. A 20F peel‑away sheath was advanced over a stiff guidewire, which was then exchanged for a stiff hydrophilic wire to facilitate smooth passage.
6. A 16F × 45 cm balloon GJ tube was inserted with good position confirmed (Image C).
7. The tube can later be exchanged for a low‑profile MIC button once the tract matures.


OUTCOME
The patient tolerated the procedure well with no immediate complications. Jejunal feeding was initiated successfully, and no retrograde migration occurred during early follow‑up.

LEARNING POINTS
1. EDS patients often have a highly distensible stomach, increasing the risk of GJ tube coiling.
2. Left‑sided access improves alignment toward the pylorus and reduces procedural failure.
3. Local anaesthetic choice matters: lidocaine alone may be ineffective in EDS.
4. Multiple lateral gastropexies help stabilise the tract and optimise the trajectory.
5. Hydrophilic stiff wires facilitate safe advancement into the jejunum.