Nonvascular interventions in the abdomen



7.18: Nonvascular interventions in the abdomen


Arul AS Babu, Aswin Padmanabhan, Shyamkumar N. Keshava



Percutaneous gastrostomy


Introduction


Certain diseases like motor neuron disease and stroke with bulbar palsy may render the patient unable to swallow and take nutrition orally. Providing good nutrition plays an important role in improving quality of life and longevity of patients who are bedridden with chronic illness. Nasogastric tubes placed are temporary arrangements as they have high chances of being displaced, getting occluded and causing significant discomfort. A gastrostomy tube placement for good nutrition has significantly longer survival time in comparison to Total Parenteral Nutrition (TPN).


There are broadly three techniques of gastrostomy placement – radiological, endoscopic and surgical. Amongst these, radiological and endoscopic methods have not shown overall significant difference in outcome though certain clinical scenarios may obviate one technique over the other. Surgical technique of gastrostomy placement is usually reserved for patients as an add on when performing surgery for other reasons. In this chapter, we shall investigate radiologically inserted gastrostomy (RIG) techniques.


Indications





  1. 1. Maintenance of nutrition for patients who cannot take adequate food orally. For example, degenerative neuromuscular conditions, caustic material intake, large oropharyngeal tumours.
  2. 2. Diversion in case of oesophageal perforation – for healing.
  3. 3. Distal obstruction-E: gastric outlet obstruction (jejunostomy).

Contraindications





  1. 1. Inadequate access window through the anterior abdominal wall, for example, massive hepatosplenomegaly.
  2. 2. Uncorrectable coagulation parameters.
  3. 3. Large volume ascites.

Patient preparation


Gastrostomy tubes are placed with long-term nutrition in mind and so a physical tube in the abdomen is inevitable. Patients and relatives need extensive counselling regarding the procedure and also maintenance of tube and a prior informed consent should be taken.




  1. 1. Anterior abdominal wall preparation by shaving off body hair and betadine bath the previous day.
  2. 2. Oral mouthwash using alcohol-based solution the previous day.
  3. 3. Single-dose antibiotic before the procedure.

Technique and material required


RIG may be done by two techniques – Push-type gastrostomy Technique and Pull-type gastrostomy Technique. The choice of technique depends upon availability of oral access to the stomach.


The gastrostomy tube requirements for pull technique and push technique are different. For pull-type, we use 24-Fr silicon tube of a PEG set for endoscopic use (PEG-24-PULL-S; Wilson-Cook Medical, Winston-Salem, USA). This tube consists of a mushroom catheter tip at the proximal end with inner and outer bolsters for fixation with tubing clamp. For push-type, Cope gastrointestinal suture anchor set (Cook, Bloomington, IN, USA) and 18-Fr silicon balloon catheter (ENTUIT Gastrostomy BR, Wilson-Cook Medical, Winston-Salem, USA).


Pull-type gastrostomy technique

This technique is preferred when there is access to the stomach through the oral cavity, for example, Motor Neuron disease-associated dysphagia in which swallowing is the concern unlike oesophageal tumour when there is no access. A Nasogastric tube is placed at the outset and stomach is inflated with air until its shadow is clearly seen under fluoroscopy. The stomach is then percutaneously accessed with an 18 G needle. After placing a sheath, a wire and catheter is negotiated into the oral cavity through the GE junction. The gastrostomy tube is railroaded after exchange with an Amplatz stiff wire. After pulling the tube out through the gastrostomy opening, it is fixed with the help of a button which comes in the package (Fig. 7.18.1).


Image
Fig. 7.18.1 (A–E) Diagrammatic representation of pull technique. (A) Gastric puncture in air-inflated stomach. (B) Glide wire snared out through mouth. (C) Through long sheath, folded stiff Amplatz wire introduced and linked with gastrostomy tube with square knot. (D) Whole assembly pulled out from stomach end until the mushroom end felt to abut inner gastric wall. (E) Tube fixed and fastened with external bolster.

Push-type gastrostomy technique

This technique is used when access to stomach through the oropharyngeal route is not possible. In this technique, stomach is punctured using specialized introducer needle preloaded with anchors which have threads attached to them. Once the anchor is in place, they are thread from the anchor is tied on the anterior abdominal wall. This step brings the stomach close to the anterior wall and is called gastropexy. Further, another puncture is made just next to the gastropexy needle with a 18 G needle. After serial dilatation over the wire, a push-type gastrostomy tube is placed through this opening (Fig. 7.18.2).


Image
Fig. 7.18.2 (A–C) Diagrammatic representation of push technique. (A) Gastric anchors inserted into stomach for gastropexy. (B) Stomach re-punctured to introduce guidewire. (C) After serial dilatation of tract, balloon catheter pushed through peel-away sheath and fastened to stomach wall.

Postprocedure care and follow-up





  • • Feeding can be started after 24 hours. It is preferably to start with thin fluids and later move to well-crushed food which can be fed through the tube.
  • • Tube dressing may be removed after 24 hours. A clean cloth may be used to clean the surrounding area regularly.
  • • Care must be taken not to displace the tube or pull the tube as position change may lead to tube coming out or dumping syndrome.
  • • The tube may be used for 6 months to 1 year depending about the natural degradation of the material.

Complications





  1. 1. Tube malfunction: Regular feeding may cause crusting within the lumen causing blockage. Tube may be replaced in these cases with fresh tube-usually that of push type.
  2. 2. Infections: May be divided into minor and major. Routine care may be required with antibiotics and wound care. Major infections may warrant tube removal. Severe infections like necrotizing fasciitis may occur. Infections can be prevented by meticulous cleaning of the access site, antibiotic prophylaxis and good technique.
  3. 3. Peristomal leaking: Maybe controlled by regular dressing. If significant, tube may be needed to be replaced.
  4. 4. Peritonitis: If the contents may inadvertently leak to the peritoneal cavity.

Conclusion


Percutaneous gastrostomy is an important step toward treatment of patients with chronic illnesses who cannot take oral feeds. Radiologically guided gastrostomy tube placement is one of the three techniques for placing gastrostomy tubes. Attention to detail and meticulous technique will help improve outcome and reduce complications of the procedure.


Balloon dilatation and stenting for bowel obstruction


Introduction


Intraluminal balloon dilatation and stenting of the gastrointestinal tract are performed to relieve gastrointestinal obstruction caused by benign/malignant pathologies. In principle, they are similar to angioplasty and stenting of the blood vessels in that the procedure involves accessing the lumen, safely crossing the obstructive lesion, balloon dilatation and stenting. Intraluminal procedures using fluoroscopic guidance are generally limited to the oesophagus, stomach, pyloroduodenal junction and colon.


Indications


Oesophagus


Oesophageal balloon dilatation




  1. 1. Benign strictures: inflammatory/infectious esophagitis, corrosive strictures, postradiotherapy strictures, Schatzki ring and radiation strictures.
  2. 2. Achalasia

Oesophageal stenting




  1. 1. Inoperable malignant oesophageal stricture (for palliation).
  2. 2. Tracheoesophageal fistula.
  3. 3. Benign stricture refractory to balloon dilatation.

Stomach/duodenum




  1. 1. Malignant stricture with obstruction.
  2. 2. Obstruction due to extrinsic compression.
  3. 3. Malignant anastamotic stricture.

Colon




  1. 1. Malignant colonic stricture (as palliation in inoperable cases where colostomy is undesirable).
  2. 2. Malignant colonic fistulas not amenable to surgery.

Contraindications


General

There are no absolute contraindications, the relative contraindications are:




  1. 1. Uncorrectable coagulopathy.
  2. 2. Radiation therapy in the preceding 6 weeks (increases risk of haemorrhage and perforation).
  3. 3. Perforation/peritonitis.

Oesophagus




  • • Malignancy involving upper oesophageal sphincter.

Gastric/duodenal




  • • Concomitant distal small bowel obstruction.

Colon




  • • Lesions within 2 cm of the anal sphincter.
  • • Proximal lesions (e.g. Caecum) – may be more amenable for colonoscopic approach.

Preprocedure evaluation


Imaging

Upper GI Series: For oesophagus, gastric and duodenal procedures to evaluate extent and appearance (benign/malignant) of stricture.Contrast Enema: For preprocedure evaluation of colonic lesions to assess extent and appearance. Look for presence of fistulas. CT: Useful to evaluate extraluminal pathology, extrinsic compression, presence of distal small bowel obstruction, presence of peritonitis and pneumoperitoneum.


Endoscopy/colonoscopy whenever possible can help in assessing extent of lesion and obstruction, apart from obtaining tissue sample for histopathological evaluation.


Laboratory parameters

Platelet count, Prothrombin time with INR (International Normalized ratio) should be checked for all patients. For those who present with symptoms of obstruction, electrolyte imbalance should be ruled out prior to procedure.


Procedure


Equipment required




  • • Water soluble ionic contrast agent.
  • • 4F and 5F directional catheters (like multipurpose catheter).
  • • Soft 0.035 hydrophilic guidewires, J tipped guidewire, Benston wire for crossing the obstructive lesion.
  • • 180–260 cm 0.035-inch Amplatz wire for tracking balloon catheter and stent delivery device.
  • • Balloon dilatation catheter (when balloon dilatation is intended) of various diameters 6–20 mm, large calibre 30–40 mm balloons for use in achalasia (e.g. Rigiflex II, Boston Scientific, USA).
  • • Stents: Covered SEMS are used for treatment of fistulas such as tracheoesophageal fistula/colovesical fistula. Non covered stents may be used for malignant strictures. Wallstent, Ultraflex stent (Boston Scientific, USA) are few of the commercially available variants.

Anaesthesia




  • • Sedation with fentanyl and midazolam with local anaesthetic spray is generally sufficient for these procedures. General anaesthetic maybe required in select patients.

Technique

Oesophageal and Gastroduodenal Procedures: The oral cavity is anaesthetized with lidocaine spray and a 4F catheter with guidewire is negotiated into the oral cavity up to the level of obstruction. The guidewire is removed and contrast is instilled under fluoroscopy to confirm intraluminal position of catheter and assess extent of stricture. The stricture is then crossed with catheter-guidewire manipulation. The guidewire is exchanged for a stiffer Amplatz wire. The stent delivery system is advanced over the Amplatz wire and stent is deployed. The stent is sized such that it has a proximal and distal landing zone of 2 cm within the normal lumen. If only balloon dilatation is intended, the balloon is tracked over the Amplatz wire and slow, sustained balloon inflation is performed to obtain luminal dilatation. Post balloon plasty/stenting contrast instillation is performed to ensure lumen patency and exclude complications.


Colonic procedures: Similar to oesophageal procedures the colon is accessed through the anus with catheter and guidewire, the obstructive lesion is crossed and balloon dilatation or stenting is done over a stiff guidewire.


Postprocedure care




  • • Clear liquids may be started immediately postprocedure in oesophageal stenting and after 2 hours in gastroduodenal stenting. An upper GI series should be obtained 24 hours postprocedure to assess stent patency, if no obstruction is found then normal diet can be started. PPI should be initiated if oesophageal stent straddles across the GE junction. Patients should be encouraged to chew the food well, and take carbonated beverages to avoid food impaction in the stent.
  • • In patients of colonic stenting abdominal radiograph is obtained 24–48 hours after procedure to assess stent position, expansion and presence of bowel obstruction. Stool softeners should be started after procedure.

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Mar 15, 2026 | Posted by in OBSTETRICS & GYNAECOLOGY IMAGING | Comments Off on Nonvascular interventions in the abdomen

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