Monday, November 23, 2015

How To Perform A Pull Percutaneous Gastrostomy Tube

A prior post detailed how to place a conventional gastrostomy tube as an interventional radiologist. However, a variant based on the approach endoscopists use is the pull percutaneous gastrostomy tube. Other names for this technique are the mushroom or Ponsky gastrostomy tube. The steps are as follows:

  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. Alternatively, use ultrasound to check for liver margin and a rectal enema to opacify the transverse colon. 
  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. Point the Kumpe straight back with the tip facing down, then flip it 180 degrees to lead away from the trachea.
  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. Use a 19G Chiba needle to access the stomach. Once intraluminal position confirmed, direct the needle posteriomedially towards the NG tube (ideally, nudge it under fluoro). 
  5. Leading with an 0.035” Amplatz, direct the wire retrograde up the esophagus. 
  6. An assistant will retrieve the wire from the mouth. Once outside, attach a snare (comes in kit) to the back end of the wire near the stomach and pull the snare through to the mouth. 
  7. Release the snare from the wire, then tie a hitch knot to the gastrostomy tube. 
  8. Pull the gastrostomy tube antegrade through the esophagus into the stomach. 
  9. Store a fluoro image with contrast injection to verify location.

Be mindful that a near absolute contraindication to this procedure is any patient with skull base, head and neck, or esophageal cancer / obstruction.

There are several benefits to placing a primary gastrostomy tube in this manner:
  • No T-Tacks to cut
  • 20 Fr instead of 14 Fr, so decreased risk of clogging
  • More durable
  • No pigtail within the gastric lumen, so less concern for gastric outlet obstruction
  • Generally less messy because no dilatation needed, and only one stick into the abdominal wall
Bard's Version of the Pull G-Tube (Copyright Bard)

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