Percutaneous Gastrostomy, Percutaneous Gastrojejunostomy, Jejunostomy, and Cecostomy

Ji Hoon Shin

Andrew J. Lipnik

Ho-Young Song

Daniel B. Brown

Percutaneous Enteral Tubes

Although temporary enteral tubes (e.g., nasogastric [NG] and nasojejunal) may be placed through natural orifices, percutaneously placed feeding tubes offer the best options for patients who require long-term nutrition. Percutaneous radiologic gastrostomy (PRG) is associated with low morbidity and mortality rates. These minimally invasive procedures are generally simpler, associated with higher technical success rates, and have lower complication rates than percutaneous endoscopic gastrostomy (PEG) or surgical placement techniques.

Types of Tubes

1. Dedicated single function (feeding or decompression alone)

a. Gastrostomy (G-tube)

(1) Simplest technically, requiring the least manipulation

(2) Shortest tube, providing for less clogging over time

(3) Preserves gastric function, allowing for high diet variety and simplicity in maintenance

(4) Can be converted into gastrojejunostomy tube after percutaneous tract matures (10 to 21 days)

b. Jejunostomy (J-tube)

(1) Bypasses stomach, requires elemental diet and slow pump infusion to prevent dumping syndrome

(2) A higher level of tube care is required.

(3) Single lumen gastrojejunostomy (GJ)

(a) Catheter placed via the stomach with tip at or beyond the ligament of Treitz

(b) Simpler to place under fluoroscopy than direct J-tube

2. Split function: Double lumen gastrojejunostomy (DLGJ)

a. Requires elemental diet and slow jejunal infusion using a pump

b. Gastric lumen required for either of the following:

(1) Decompression in patients with gastroparesis or gastric outlet obstruction

(2) Medications that are only absorbed by the stomach

Percutaneous Gastrostomy

Indications (1,2,3,4,5,6)

1. Nutritional support for patients with inadequate oral intake due to dysphagia, risk of aspiration, or obstruction secondary to

a. Stroke and neuromuscular disorders

b. Esophageal mass/neoplasm

c. Lesions of the head, neck, and mediastinum (including recent surgery or radiation)

2. Diversion of feedings from esophageal leaks caused by recent surgery or trauma

3. Decompression of gastroenteric contents and/or need for jejunal feeding

a. Gastric outlet or proximal small bowel obstruction

b. Patients with gastroparesis (e.g., diabetic gastropathy, scleroderma)

4. Intestinal access for biliary procedures (e.g., patients with Roux-en-Y anastomosis)

Contraindications (1,2,3,4,5,6)

Absolute

1. Unsatisfactory anatomy (e.g., no safe percutaneous access to stomach secondary to interposed colon or liver)

2. Uncorrectable coagulopathy

Relative

1. Prior gastric surgery with anatomic distortion (e.g., subtotal gastrectomy or gastric bypass). Access to the stomach may be extremely difficult and require advanced techniques and/or CT guidance.

2. Massive ascites. Preprocedural paracentesis and gastropexy can help reduce the incidence of peritoneal leakage.

3. Gastric or abdominal wall varices due to portal hypertension

4. Inflammatory, neoplastic, or infectious involvement of the gastric wall (may result in poor wound healing and tract formation)

5. Severe gastroesophageal reflux. Feedings should be delivered into the jejunum via PGJ or percutaneous jejunostomy (PJ) tube.

6. Ventriculoperitoneal shunt

Preprocedure Preparation

1. Review surgical history and prior imaging for evidence of altered gastric anatomy, safe percutaneous access route, and ascites.

2. Review and correct as necessary any coagulopathy.

3. Approximately 200 mL of dilute barium suspension is given 12 hours before the procedure to outline the colon. Alternatively, colonic gas is typically sufficient to outline the colon, or when not present, a small amount of air or contrast can be instilled retrograde per rectum at the time of the procedure.

4. Maintain nil per os (NPO) status for 8 hours prior to procedure.

5. An NG tube (preferably placed bedside the evening before the procedure) is necessary for insufflating air to bring the stomach into apposition with the anterior abdominal wall, displacing adjacent viscera, and facilitating safe gastrostomy tube placement. If there is difficulty placing the NG tube at bedside, an angiographic catheter placed under fluoroscopic guidance immediately prior to the procedure may be used for insufflation.

6. Conscious sedation should be given judiciously in patients with head and neck malignancies or respiratory compromise in neuromuscular disorders such as amyotrophic lateral sclerosis (ALS). In fact, the ability to safely and comfortably place radiologic gastrostomy tubes with minimal sedation is a particular advantage in this patient population.

Procedure

1. Prepare the left subcostal area and epigastrium in a sterile manner.

2. Glucagon (0.5 to 1.0 mg) or Butylscopolamine (20 mg) intravenously (IV) may be administered to diminish gastric peristalsis.

3. Insufflate air into the stomach via NG tube until adequate gastric distention is achieved fluoroscopically.

4. Although the need for routine gastropexy remains debated, clinical scenarios suggesting an impaired ability to form a mature tract (e.g., patients on chronic steroids) or at high risk for peritoneal leakage (patients with ascites) mandate secure gastropexy (1,2,7,8).

5. If gastropexy is not employed, it may be necessary to continue air insufflation during the procedure to keep the stomach distended—so it is wise to limit
the volume of air used initially. In patients with partial gastrectomy or other surgeries involving a vagotomy, it will be more challenging to maintain gastric distension during tube placement. Conversely, the presence of adhesions often simulates a gastropexy.

6. After air insufflation, frontal and oblique views of the upper abdomen are helpful to determine the depth to the anterior gastric wall and location of the transverse colon. Rarely, lateral imaging may be needed.

7. Choose the puncture site—distal body of the stomach, equidistant from the lesser and greater curvatures to minimize the risk of arterial injury (Fig. 51.1). Avoid punctures that transgress the colon or left lobe of the liver. The risk of hemorrhage is minimized by avoiding the inferior epigastric artery as it courses the junction of the medial two-thirds and lateral one-third of the rectus muscle (Fig. 51.1).

8. Infiltrate local anesthesia (1% lidocaine) down to the peritoneal surface; a small skin incision is made.

9. Many operators routinely use gastropexy devices (Saf-T-Pexy T-Fasteners [Halyard Health, Alpharetta, GA], or 18-gauge slotted needle preloaded with a T-fastener [Boston Scientific, Natick, MA]). Two to four T-fasteners are deployed to fix the anterior gastric wall to the abdominal wall (1,2). Gastric puncture is performed with the kit needle preloaded with an anchor system. An intragastric position is confirmed both by aspiration of air into a syringe and injection of contrast with visualization of gastric rugae. A stylet is introduced through the needle, advancing the anchor into the stomach. The stylet and needle are subsequently removed and the stomach is gently approximated to the anterior abdominal wall by gentle traction on the anchor suture. Alternatively, the needle is removed over a safety guidewire (GW) to retain original access. If gastropexy is not employed, a Seldinger needle is used for a new gastric puncture.

10. Whatever the choice, the puncture should be made with a brief, deliberate thrust so as not to push the anterior gastric wall away from the anterior abdominal wall. Usually, the puncture needle is directed slightly toward the pylorus, to facilitate future conversion to a PGJ if needed (Fig. 51.2). When placing a pulltype gastrostomy tube under fluoroscopy, access can be directed slightly toward the gastroesophageal junction to facilitate cannulation of the esophagus.

11. Once the gastric lumen is entered, the needle position is confirmed by injection of contrast, outlining gastric rugal folds. With the Seldinger needle tip within the stomach, a stiff 0.035-in. GW is inserted and looped in the stomach.

12. Fascial dilators, of adequate diameter to accommodate the feeding tube, are introduced over the 0.035-in. GW to make a tract (Fig. 51.2

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