Indications and Contraindications
A gastrostomy tube is a rubber catheter/tube that extends from outside the skin overlying the stomach and into the lumen of the stomach. The tube can be inserted surgically, endoscopically, or percutaneously by an interventional radiologist using fluoroscopy.
Gastrostomy tubes are most commonly inserted in patients with dysphagia and provide an alternate means for enteric nutrition. Examples include patients with dysphagia from head and neck cancer, prior stroke, traumatic brain injury, neuromuscular disorders, as well as advanced dementia. Patients who are malnourished despite the ability to safely and effectively ingest food and drink orally (i.e. those with inflammatory bowel disease, radiation enteritis, connective tissue disorders, etc.), as well as those with gastric outlet obstruction or proximal small bowel obstruction can also benefit from gastrostomy tube placement as a means of nutrition and bowel decompression, respectively.
Uncorrected coagulopathy is the most common absolute contraindication to percutaneous gastrostomy tube placement due to increased risk of hemorrhage. Other absolute contraindications include large-volume ascites, hemodynamic instability, peritonitis, and sepsis. Relative contraindications include hepatomegaly and/or splenomegaly, gastric varices, bowel interposition, and peritoneal dialysis.
Procedural Details
Approximately 12 hours prior to percutaneous gastrostomy tube placement, patients will ingest an enteric contrast agent by mouth, if possible, or via a nasogastric tube. Following ingestion, contrast will gradually move through the gastrointestinal tract and eventually reach the colon. Contrast within the colon can be seen under fluoroscopy, helping the interventional radiologist to avoid unintended puncture of the bowel during gastrostomy tube placement.
Percutaneous gastrostomy tube placement is most often performed under conscious sedation whereby two medications, typically fentanyl and versed, are administered intravenously. In certain situations, general anesthesia or a single anesthetic or anxiolytic will be administered. If not already placed prior to the procedure, a nasogastric tube is advanced into the stomach. The tube is then used to insufflate the stomach with air under fluoroscopic visualization, which serves to displace adjacent bowel and allows for easier needle puncture of the stomach. Once the stomach is inflated with air, the interventional radiologist will choose an appropriate skin entry site for the gastrostomy tube and anesthetize the region with lidocaine; the target puncture site should be within the lower body of the stomach between the greater and lesser curvatures. Two to four T-fasteners will then be advanced from the skin into the stomach, which will secure the stomach against the abdominal wall. Once secured, a small skin incision is made and a needle is advanced between the T-fasteners into the stomach under fluoroscopy. Once within the stomach, contrast is injected through the needle to confirm its position. A guidewire is then advanced through the needle and coiled within the stomach. The tract between the skin and stomach is then sequentially dilated using plastic tissue dilators or an angioplasty balloon. A gastrostomy tube is then advanced through a peel-away sheath or over an angioplasty balloon into the lumen of the stomach. Contrast is then injected into the tube to confirm appropriate positioning. Once confirmed, a retention balloon at the end of the gastrostomy tube is inflated with dilute contrast and pulled against the stomach wall. The tube is then secured to the skin and a sterile dressing is applied. The tube then remains open to an external drain bag overnight to allow for the stomach to decompress and rest. If there is no evidence of peritonitis or other complication after 12-24 hours, tube feeds can be started. The tube will need to be changed at routine intervals, often times every 3-6 months, or more frequently if required.
This fluoroscopic image shows a percutaneously inserted gastrostomy tube appropriately positioned within the stomach. Contrast injected through the gastrostomy tube is seen outlining the gastric folds. The gastrostomy balloon has been filled with dilute contrast.
Results
Percutaneous fluoroscopically-guided gastrostomy tube placement by an interventional radiologist has been shown to be both safe and effective. Technical success rates have ranged from 98 to 100% in several studies [1]. A meta-analysis of nearly 6,000 patients undergoing gastrostomy tube placement found percutaneous fluoroscopically guided placement to be associated with the fewest major complications (5.9%) compared with endoscopic (15.4%) and surgical (19.9%) placement [2]. Major complications include peritonitis, sepsis, deep soft tissue infection, hemorrhage, aspiration, peritoneal tube placement, as well as death. Minor complications include leakage around the tube, superficial skin infection, tube dislodgment, tube occlusion, as well as tube fracture or balloon rupture.
1. Lyon, Stuart M., and Diane M. Pascoe. "Percutaneous Gastrostomy and Gastrojejunostomy." Seminars in Interventional Radiology 21.03 (2004): 181-89. Web.
2. Wollman B, D’Agostino HB, Walus-Wigle JR, Easter DW, Beale A. Radiologic, endoscopic and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology 1995;197:699–704