Monday, April 20, 2015

How To Place A Percutaneous Gastrostomy Tube

Gastrostomy tubes and their variants can be placed endoscopically, surgically, or percutaneously. The interventional radiologist can help determine which approach is best for patients. In particular, patients with pharyngeal issues, such as head and neck cancers, are good candidates for percutaneous placement. Here is one approach, which utilizes a Wills-Oglesby pigtail gastrostomy tube.

  1. Verify an appropriate window for the gastrostomy tube on pre-procedure imaging. In particular, make sure that the transverse colon does not lie between the anterior abdominal wall and the stomach.
  2. Check if the patient has a nasogastric tube. If not, using anesthetic gel and a glidewire, a Kumpe catheter can be fluoroscopically guided into the stomach. Have an assistant use the tube to insufflate the stomach.
  3. Once the stomach is sufficiently inflated, anesthetize the skin. A good location is midway along the greater curve as the passes will aim towards the fundus.
  4. A fastener is used to enter the stomach and pull it up towards the anterior abdominal wall. The introducer needle is used to initially access the stomach. Attach contrast to the needle and advance the needle under fluoro. Watch it tent the gastric wall, and then enter the gastric lumen. Intraluminal position can be confirmed by seeing the needle tip move freely, aspiration of gas, and injection of contrast outlining gastric rugae.
  5. Once intraluminal position is confirmed, the fastener is advanced through the needle, the needle withdrawn, and the fastener pulled back to lift the stomach up. If additional fasteners are desired, repeat Step 4.
  6. After the stomach is fastened, make a dermatotomy and then pass another needle into the stomach. Confirm intraluminal position as in #4. Pass a 0.035 inch wire into the stomach and watch it coil around the greater curvature past the fasteners.
  7. Withdraw the needle and serially dilate over the wire up to the size of the catheter. Work quickly as the stomach will begin to lose gas and deflate.
  8. Insert the catheter, withdraw the wire, pull the string to pig the catheter, and inject contrast to confirm final position. Suture the catheter into place. 

One protocol to clear the gastrostomy tube is to wait one day, then check the patient. If the patient is afebrile, without leukocytosis, and without peritoneal signs, start trial feeds. If the patient tolerates the trial feeds well after another day, clear the tube for full feeds.