Radiologic percutaneous gastrostomy and related enterostomies

Radiologic Percutaneous Gastrostomy and Related Enterostomies Eric vanSonnenberg, MD, Gerhard R. Wittich, MD, and Brian W. Goodacre, MD

Radiologic percutaneous gastrostomy (PG) provides access to the gastrointestinal tract for nutrition, decompression, or enteric manipulation. The procedure is common and may be performed de novo, if the patient is not a candidate for PG, or after unsuccessful percutaneous endoscopic gastrostomy attempt. Outgrowths of PG include percutaneous gastroenterostomy or direct puncture of the duodenum, jejunum, or ileum; percutaneous cecostomy is used for decompression of the colon. An interplay of fluoroscopy, ultrasound, and computed tomography permits guidance for virtually any patient to undergo PG. PG is popular because the likelihood of success is very high, and the complication rate is quite low. Copyright 9 2001 by W.B. Saunders Company

adiologic percutaneous gastrostomy (PG) has become a

R standard Interventional Radiology procedure. PG was de-

veloped over 15 years ago and was predominantly indicated for nutrition. 1-4 In the ensuing years, a variety of methods has evolved that now permits literally any patient to undergo PG, and for various other indications (eg, small bowel or large bowel decompression, access to strictures).5-7 Patients who are poor candidates for percutaneous endoscopic gastrostomy (PEG), in whom the procedure is contraindicated, or in whom PEG has been unsuccessful, may still undergo radiologic PG. 1 PG is effective in pediatric patients as well. 8 In addition, numerous spin-off procedures have developed; these include percutaneous gastrojejunostomy (Fig 1), percutaneous duodenostomy, percutaneous jejunostomy, percutaneous ileostomy, and percutaneous cecostomy. Combined radiologic percutaneous biliary drainage (PBD) and PG techniques permit feeding to be established through the biliary tract as well (Fig 2). PG also may serve as a conduit for esophageal or small bowel procedures. Currently radiologic PG and its spin-offs should be regarded as core nonvascular Interventional Radiology techniques.

liver before PG to avoid inadvertent hepatic puncture; a recent computed tomography (CT) may serve this purpose as well. A plain abdominal radiograph or fluoroscopy serves to identify and avoid the colon. Thus, fluoroscopy and US suffice for the majority of cases. Techniques also have been developed such that CT and US have found primary guidance roles for PG in certain clinical situations in which fluoroscopy is inadequate for guidance. 9-1~ Thus, patients with complete pharyngeal or esophageal obstruction, ~t those with large obstructing cervical osteophytes, massive colonic dilation, overlying viscera or tumor and patients with partial gastrectomy lz all may undergo successful PG by CT guidance 9 (Fig 3). Although not common, US has been used for portable PG. For PG alone, CT guidance is sufficient. However, for percutaneous gastroenterostomy, usually the patient needs to be transferred to fluoroscopy, where cannulation of the pylorus and small intestine can be accomplished.

Materials for PG Materials for PG and related procedures include a nasogastric tube (NGT), guidewires, 18g needle, a series of fascial dilators, and any of a variety of radiologically designed PG catheters. The

Imaging for PG The basic imaging modality for PG and related procedures is fluoroscopy. Ultrasound (US) typically is used to outline the

From the Departments of Radiology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, and Harvard Medical School, Boston, MA. Address reprint requests to Eric vanSonnenberg, MD, Department of Radiology, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115. Copyright 9 2001 by W.B. Saunders Company 1096-2883/01/0301-0004535.00/0 doi: 10.1053/tgie.2001.19908

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Fig 1. Percutaneous gastrojejunostomy: Note the contrast in the balloon that anchors the PGE tube. The transgastric catheter passes through the duodenum and over the ligament of Treitz and has the tip residing in the jejunum.

Techniques in Gastrointestinal Endoscopy, Vol 3, No 1 (January), 2001: pp 16-21

Fig 2. Percutaneous jejunostomy through the biliary tract: This patient had combined biliary and duodenal obstruction from pancreatic carcinoma. There are 2 catheters entering the left hepatic ductal system. The tip of the biliary drainage catheter terminates in the duodenum just beyond the obstruction. Note that the percutaneous gastrojejunal catheter passes beyond the ligament of Treitz for feeding.

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Fig 3. CT-guided PG. (A) The left lobe of the liver wraps over the stomach obviating a safe access route. There is also a small amount of ascites. (13) A CT-guided lateral approach into the stomach permits initial access. (C) The distended stomach now permits access into the stomach for PG.

RADIOLOGIC PERCUTANEOUS GASTROSTOMY

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Fig 4. Percutaneous gastrostomy catheters: Both catheters have locking sutures and are 12F in diameter (Cook, Inc, Bloomington, IN and Boston Scientific, Natick, MA).

catheters preferably have locking mechanisms in the form of pigtails, locking loops, or umbrella-like fixation devices. Catheter sizes vary from 10F to 20F. 13 Both PG (Fig 4) and percutaneous gastroenterostomy catheters are available (Fig 5). A specific device for radiologic PG is T-tacks. 2 These tacks serve to appose the anterior wall of the stomach to the anterior wall of the abdomen, thereby avoiding leakage of gastric contents into the peritoneum and facilitating catheter insertion (Fig 6).

Technique for P G Preprocedure requisites for PG include normalized coagulation factors, a cooperative patient, informed consent, and lack of ascites. If ascites is present, it may be removed by image-guided catheter placement if necessary. Antibiotics are not used routinely. PG technique begins with insertion of an NGT into the stomach. The NGT is insufflated with air until the stomach is well distended. The volume of air depends on the patient's tolerance, individual capacity, and whether there has been prior surgery. Intravenous glucagon is used to achieve gastroparesis. T-tacks are inserted to appose the anterior gastric wall to the anterior abdominal wall; 1 to 4 tacks may be used. Not all groups use T-tacks. 14 With the stomach still distended, an 18g needle is used to puncture the gastric wall on its anterior surface. If PG is the goal, the puncture may be made in any direction. However, if gastrojejunostomy or gastroenterostomy is chosen, the puncture should be directed towards the pylorus as a so-called downhill puncture to facilitate cannulation of the small intestine. After a small amount of air is aspirated for confirmation of gastric position of the puncture needle, a 0.035- or 0.038-in guidewire is inserted through the needle. For PG alone, the guidewire may be coiled completely within the stomach; for percutaneous gastroenterostomy, the guidewire is passed through the pylorus beyond the ligament of Treitz. A series of fascial dilators is used to dilate the tract. A catheter loaded on a metal cannula is then passed either into the stomach or through the stomach and into the small bowel over the guidewire. The catheter is then locked (Fig 7). The sutures on the T-tacks are fixed over the cotton pledget, and the T-tacks remain in place. The NGT may be removed at

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Fig 5. Various percutaneous gastroenterostomy catheters. Each has a locking device and sideholes in the stomach plus a jejunal catheter (Boston Scientific, Natick, MA and Cook, Inc, Bloomington, IN).

that time or later the same day after further gastric drainage. Feeding commences the same or next day.

Spin-Off Procedures Numerous enterostomy procedures have sprung from the core PG technique. Thus, decompression of small bowel obstruction (Fig 8) may be achieved either by percutaneous gastrojejunos-

Fig 6. T-tack devices for PG/PGE: note both short and long metal tacks.

VANSONNENBERG, WI'FI'ICH, AND GOODACRE

Fig 7. Technical performance of percutaneous gastroenterostomy. (A) A nasogastric tube has been inserted into the stomach, and air has been insufflated. A metal clamp overlies the point of proposed puncture by fluoroscopic guidance. Previous ultrasound had outlined the left lobe of the liver. Incidental note of an IVC filter. (B) Deployment of T-tacks--note position of first tack and of 2 T-tacks. (C) Fascial dilator is being inserted over a guidewire, the latter having passed into the stomach, through the pylorus, and well into the fourth portion of the duodenum. (D) PGE catheter has now been positioned with its tip beyond the ligament of Treitz.

Fig 8. Percutaneous gastroenterostomy for decompression of small bowel obstruction. Note the PGE catheter passing through the stomach, over the ligament of Treitz, with its tip positioned well into the jejunum. This was a 56-year-old woman with small bowel obstruction caused by metastatic ovarian carcinoma.

RADIOLOGIC PERCUTANEOUSGASTROSTOMY

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tomy, percutaneous gastroduodenostomy, direct percutaneous jejunostomy (Figs 9 and 10), or direct ileostomy. Percutaneous cecostomy (PCC) is used to temporize colonic obstruction or Ogilvie's syndrome. PCC may be performed by fluoroscopic or CT guidance. Massive colonic distention usually occurs in poor operative candidates, such that percutaneous (or endoscopic) temporizing may be a prudent initial step. With gastric outlet or duodenal obstruction, percutaneous access to the stomach may be inadequate to feed or decompress the small bowel. If the patient has simultaneous biliary obstruction, percutaneous biliary drainage can bypass both the biliary and gastrointestinal (GI) obstructions, and thereby serve as a conduit into the GI tract from the biliary system. Access to the esophagus and small bowel from the stomach may be performed to dilate strictures or insert stents. Although not a primary access route, under difficult circmnstances this route may provide the only possible access to these GI structures.

Results Radiologic PG is an effective and safe procedure. Success rates are recorded from 95% to 99%. 2,13,14 The procedure

Fig 10. Simultaneous percutaneous gastrostomy and direct jejunostomy. This patient initially had gastric outlet obstruction, as well as small bowel obstruction caused by metastatic cervical carcinoma. Note the PG catheter and the percutaneous jejunostomy catheter.

Fig 9. Direct percutaneous jejunostomy. The catheter has been inserted directly into a jejunal loop for percutaneous access. Contrast has been injected that outlines distal jejunal loops.

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may be successfully completed despite an obstructing pharyngeal or esophageal carcinoma that might prevent insertion of an NGT, or if there is inability to retain air in the stomach that occurs after surgical removal of the pylorus, and/or with surgical gastroenterostomy or obstructing cervical osteophytes. Anatomic positioning of the colon that shields the stomach may prevent safe puncture with fluoroscopy. Similarly, flexion contractures, severe kypho-scoliosis, or problematic body habitus such as obesity, may be limitations to safe access to the procedure. CT guidance may obviate these impediments and allow successful PG. Reported complications of PG include bleeding from inadvertent puncture of a gastric vessel, accidental puncture of the overlying colon or liver, leakage of gastric contents into the peritoneal cavity, tube dislodgment (Fig 11), reflux of the PG catheter into the esophagus, or wound infection, as

VANSONNENBERG, Wt-FFICH, AND GOODACRE

Acknowledgment The authors thank Caryn Gallagher and Rob Denning for preparation of the manuscript.

References

Fig 11. PG catheter dislodgment. Note the PG catheter has spontaneously retracted from the stomach, and is in the peritoneal cavity. T-tacks might have prevented this problem. may occur with any procedure in which a catheter enters the skin. Complication rates vary from 3.2% to 6.9% for minor complications to 0.5% to 2.2% for major complications. 2,~2,13 Mortality is exceedingly rare (0.3% to 0.5%). 2,~3

RADIOLOGIC PERCUTANEOUS GASTROSTOMY

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