Gastrostomy Tube

Gastrostomy Tube

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Pre-Procedure

Indications:
• Enteral feeding for long-term nutritional support
• Gastric decompression

Many more specific indications that fall into the above categories such as:
• Impaired swallowing
• Stroke
• Aspiration
• Esophageal obstruction

Contraindications:
• Lack of safe access to the stomach; large hiatal hernia or prior surgery
• Uncorrectable coagulopathy
• Peritonitis
• Bowel ischemia
• Gastric varices
• Gastric cancer or peritoneal carcinomatosis
• Severe gastroesophageal reflux
• Ascites

Preprocedural evaluation:
• H&P
• Prior surgery or radiation to stomach or abdomen
• Labs: coagulation profile and CBC
• Prior Imaging - cross sectional of the abdomen
• Provide contrast to patient for oral intake day before procedure to opacify the colon

Procedure

Antibiotics:
Push technique:
• 1-2 g cefazolin (Ancef) IV preprocedure
• Clindamycin if PCN allergy
Pull type:
• 1-2 g cefazolin (Ancef) IV preprocedure
• 500 mg cephalexin (Keflex) PO BID x 5 days following procedure
• Clindamycin for PCN allergy

Procedure:
Many techniques for placing gastrostomy tube. Push method described below

Prep
• Work from patient's left and have US prepped for liver marking
• Place nasogastric tube if not already done
• 0.5-1.0 g of glucagon to reduce gastric motility and emptying
• Insufflate stomach with air
• Mark liver edge with US

Place T-fasteners
• Optimal G-tube placement is equal distance between greater and lesser curvature at mid to distal body of stomach
• Connect T-fasteners to connection tube with half-filled contrast syringe
• Choose entry site in AP projection and seat needle in soft tissue
• Advance T-fasteners with image intensifier in RAO position: keeps hands out of field and easier to visualize needle indenting the gastric wall
• Aspirate air, then injection contrast to identify gastric folds
• Place 1-3 T-fasteners

Gastrostomy tube
• Advance 18 g needle into stomach
• Some angle toward antrum anticipating subsequent GJ conversion
• Place 0.035" wire - Amplatz Super Stiff (Boston Scientific)
• Serially dilate
• Advance sheath. Some telescoping sheaths are able to dilate and peel-away
• Place G-tube
• Inflate balloon with sterile water (reasonable to add contrast to solution for better visualization of balloon)
• Inject contrast to outline gastric folds and confirm intragastric position
• Pull balloon to anterior wall and secure disc


Post-Procedure

Postprocedural care:
• Patient fasting x 12 hours
• Assessed the following day for peritoneal signs
• Instill 30-60 cc of saline through G-tube into stomach: check for resistance with injection or signs of discomfort
• G-tube is then cleared for enteral feeding

Complications:
Minor:
• Tube occlusion: 4.5%
• Tube dislodgement: 1.3 - 4.5%
• Leakage around tube: 11%
• Superficial stomal infection: 25 - 45%

Major
• Death: 0.3%
• Peritonitis: 1.3%
• Hemorrhage: < 3%
• Severe skin infection: minimal
• Bowel perforation: minimal

Follow-up:
• If gastropexy tacks do not resorb, remove in 2 weeks
• Chage tube Q6 months or as needed
• First exchange should be with fluoroscopy
• Subsequent exchanges can be done without fluoroscopy

Related Procedures

No related procedures.

 

References

[1] Bream P Jr, Krohmer SJ, Pillai AK, Bones Md BL, Dickey KW. Percutaneous Gastrostomy: How to Recognize, Avoid, or Get Out of Trouble. Tech Vasc Interv Radiol. 2018;21(4):255‐260. doi:10.1053/j.tvir.2018.07.007
[2] Karthikumar B, Keshava SN, Moses V, Chiramel GK, Ahmed M, Mammen S. Percutaneous gastrostomy placement by intervention radiology: Techniques and outcome. Indian J Radiol Imaging. 2018;28(2):225‐231. doi:10.4103/ijri.IJRI_393_17
[3] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483‐1501.e2. doi:10.1016/j.jvir.2018.06.007
[4] Covarrubias DA, O'Connor OJ, McDermott S, Arellano RS. Radiologic percutaneous gastrostomy: review of potential complications and approach to managing the unexpected outcome. AJR Am J Roentgenol. 2013;200(4):921‐931. doi:10.2214/AJR.11.7804
[5] Lyon SM, Pascoe DM. Percutaneous gastrostomy and gastrojejunostomy. Semin Intervent Radiol. 2004;21(3):181‐189. doi:10.1055/s-2004-860876
[6] Bream P Jr, Krohmer SJ, Pillai AK, Bones Md BL, Dickey KW. Percutaneous Gastrostomy: How to Recognize, Avoid, or Get Out of Trouble. Tech Vasc Interv Radiol. 2018;21(4):255‐260. doi:10.1053/j.tvir.2018.07.007
[7] BackTable, LLC (Producer). (2017, May 23). Ep 2 – G-Tubes Two Ways [Audio podcast]. Retrieved from http://www.backtable.com/podcasts

Join The Discussion

 

Demos

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Balloon Assisted Gastrostomy (BAG)

This video details a medical procedure developed at Vanderbilt University by Peter R. Bream, Jr. This procedure allows a large bore (20 Fr) gastrostomy tube to be placed de novo using ultrasound and fluoroscopic guidance. The novel technique uses a standard high pressure angioplasty balloon.

Radiographically Placed Gastrostomy Feeding Tubes

This demo description is not yet available.

 

Tools

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Literature

Literature is not yet available for this procedure.

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Gut and Liver (Sep 2010)

Updates on Percutaneous Radiologic Gastrostomy/Gastrojejunostomy and Jejunostomy.

Indications, contraindications, patient preparations, techniques, complications, and aftercare of radiologic gastrostomy. Available tube types and their perceived advantages are also discussed.

American Journal of Roentgenology (Apr 2013)

Radiologic percutaneous gastrostomy review of potential complications and approach to managing the unexpected outcome

The purpose of this article is to review the major and minor complications associated with gastrostomy tube placement and to present appropriate and effective management strategies.

Seminars in Interventional Radiology (Sep 2004)

Percutaneous Gastrostomy and Gastrojejunostomy

This article discusses traditional methods of gastrotomy tube placement in comparison to techniques for routine percutaneous radiological gastrostomy catheter placement.

 

Podcasts

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Dr. Peter Bream

Dr. Aaron Brandis

Balloon-Assisted (BAG) and Per-oral (POG) techniques for the gastrostomy procedure.

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