Keywords
Fluoroscopy-guided percutaneous gastrostomy - percutaneous radiological gastrostomy
- per-oral image-guided gastrostomy - pull-type gastrostomy - push-type gastrostomy
Introduction
Gastrostomy provides an alternative access for nutritional support in patients with
long-term impairment of oral intake. It is well tolerated for nutritional supplementation,
generally provides improved quality of life when compared to available alternatives,
and limits disorders of intestinal motility by maintaining gastrointestinal tract
function.[1]
Gastrostomy tubes can be placed surgically, endoscopically, and radiologically. Surgical
gastrostomy has the highest total complication rate of 29% compared to approximately
15% for percutaneous endoscopic gastrostomy (PEG) or radiological gastrostomy.[2] Percutaneous radiological gastrostomy (PRG) is the least invasive compared to other
techniques, and major complications are the fewest with radiological gastrostomy.[2] The term PRG is used generically to indicate percutaneous access to stomach or jejunum
under fluoroscopic guidance.[3]
Since the introduction of PRG in 1981, several different techniques were subsequently
developed. The techniques for percutaneous insertion and the equipment used have been
refined since then and it is now considered as the gold standard for gastrostomy insertion.[4] Radiologically-guided techniques can be divided into two classes. The first is the
“push-type gastrostomy,” namely the conventional percutaneous gastrostomy with an
external/internal access through the abdominal wall into the stomach. The second is
the “pull-type gastrostomy,” which has been adapted from the PEG technique with an
internal/external placement of the respective gastrostomy catheter.[5]
The purpose of this study is to describe the technical aspects of routine PRG catheter
placement and to provide procedural variations based on different etiologies as well
as to assess the technical feasibility and outcome of PRG.
Materials and Methods
This was a retrospective study conducted among 29 patients who underwent PRG over
a period of 8 years in a tertiary-level academic institution. The clinical details
of each patient were collected from the online medical records department of the institution
(Clinical workstation, GE Healthcare, USA). Pull type was performed in 27 patients
(27/29) and push type was performed in 2 patients (2/29).
Ultrasound abdomen screening was done to look for anatomical variations and to plan
the procedure. In patients who had already undergone abdominal computed tomography
(CT) for tumor screening or other purposes, CT images were also reviewed to plan the
procedure.
Techniques
Patients were usually admitted in hospital at least 12 h before the procedure and
kept fasting for at least 6 h. The coagulation profile was checked in all cases and
nasogastric tube was placed shortly before the procedure to allow air insufflation.
In our protocol the pre-procedural preparation for both the techniques remain the
same [Table 1] except additional antiseptic mouthwash given for patients undergoing pull type.
Both types of procedures were done under intravenous sedation and local anesthesia.
Table 1
Pre-procedural workup for PRG
|
Lab results and prior Imaging studies:
|
|
Platelets >50,000/μL, PT INR <1.5, aPTT <40
|
|
Imaging to preclude ascites and anatomical variations like hiatus hernia, interposition
of colon, enlarged liver and situsinversus etc.,
|
|
Patient preparation before the procedure:
|
|
Antiseptic mouth rise on the day of procedure in pull type
|
|
Local preparation of abdomen (shaving and betadine scrub)
|
|
Premedication
|
|
Broad spectrum i.v antibiotics on the day of procedure
|
Pull-type percutaneous radiological gastrostomy (Pull-type-PRG)
The “pull-through gastrostomy” was performed using the 24-Fr silicon tube of a PEG
set for endoscopic use (PEG-24-PULL-I-S; Wilson-Cook Medical, Winston-Salem, USA).
This tube consists of a mushroom catheter tip at the proximal end with inner and outer
bolsters for fixation with tubing clamp.
The stomach was distended with atmospheric air through an indwelling nasogastric tube
(approx. 1000 ml). Gastric puncture performed under fluoroscopic guidance with 18G
puncture needle in lower one-third of body in the middle of the stomach (equidistant
from the greater and lesser curvatures) to avoid injury to gastroepiploic artery and
lateral to the rectus muscle, or in the midline to avoid puncture of epigastric arteries.
These are the preferred sites for gastric puncture [6]
[Figure 1].
Figure 1 (A and B): (A and B) Site of puncture - Lower one-third of body of stomach equidistant from
greater and lesser curvature lateral to rectus muscle to avoid injury to epigastric
or gastroepiploic arteries
After gastric puncture confirmed by aspiration of air into a syringe or flushing with
contrast media, the needle was exchanged over a wire (J wire/Terumo hydrophilic wire)
for a 5-Fr sheath (Input TS Introducer Sheath, Medtronic). A 65-cm, 4/5-Fr guiding
catheter (Cobra/headhunter, Cordis, Miami, FL, USA) was introduced over guidewire.
On the basis of different probing techniques, the pull-type PRG can be divided into
the direct retrograde and the antegrade fixation technique.[5]
In most cases, the anatomy allowed for a simple direct retrograde access to the esophageal
lumen with the guiding catheter. In such cases, a hydrophilic guidewire (0.035 in.;
180 cm, Terumo, Eschborn, Germany) with 4/5-Fr Cobra/headhunter guiding catheter combination
was used to enter the esophagus from the stomach retrogradely until the catheter guidewire
combination exited through the mouth [5] or pulled out through mouth with the help of forceps, when guidewire reaches at
the level of nasopharynx. Sometimes a combination of 18 G needle directing towards
the gastro-esophageal junction and manipulation of the hydrophilic guide wire was
successful to advance the guide wire into the esophagus. The hydrophilic guidewire
was exchanged for super stiff guidewire (0.035 in.; 260 cm, Amplatz, Cook, Winston-Salem,
USA) and short sheath for 65 cm, 9-Fr long sheath (Super arrow flex sheath, Teleflex,
Westmeath, Ireland) exiting through mouth. An extra-long super stiff Amplatz guidewire
was folded and doubled in the midway. This was introduced through the 9-Fr long sheath
in a retrograde fashion from stomach end to exit through tip of sheath in mouth end.
After lubrication with a water-soluble lubricant, the blue wire of the feeding tube
and folded end of guidewire were linked together by a square knot and whole assembly
pulled out through the anterior abdominal wall under fluoroscopy guidance, until mushroom
end was felt to abut the gastric wall. Instead of using stiff guidewire and 9-Fr long
sheath combination, an extra-long hydrophilic wire folded in midway can be used through
9/10-Fr suction tubing for pulling the feeding tube. The feeding tube was cut at the
marking of X, and after cleaning the stromal site with antiseptic swabsticks, the
outer bolster was secured and fastened.
In cases with difficult anatomy where the glide wire could not be negotiated into
the esophagus retrogradely, the glide wire was snared using a loop snare (Bard snare
retrieval kit 20 mm) from the oral route [Figure 2] and [Figure 3], with the remaining steps being identical to the direct retrograde technique. This
technique is slightly different from antegrade fixation technique described by Yang
et al.
Figure 2 (A-E): Diagrammatic representation of pull technique. (A) Gastric puncture in air inflated
stomach. (B) Glide wire snared out through mouth. (C) Through long sheath, folded
stiff Amplatz wire introduced and linked with gastrostomy tube with square knot. (D)
Whole assembly pulled out from stomach end until the mushroom end felt to abut inner
gastric wall. (E) Tube fixed and fastened with external bolster
Figure 3 (A-E): Pull technique. (A) Gastric puncture. (B) Inset short sheath with guidewire. (C)
Snaring of guidewire from oral route. (D) Guidewire placement across stomach, esophagus,
and exiting though mouth. (E) Mushroom end of tube fixed and fastened after confirmation
with contrast injection
Percutaneous radiological push-type gastrostomy (Push-type-PRG)
In this technique, the gastrostomy tube is inserted directly by using the Seldinger
technique into the stomach (without passing through the pharynx), after the gastric
and abdominal wall have been securely fastened together (gastropexy). The stomach
is distended with air and gastric puncture site similar to pull type. Gastropexy done
by puncturing the stomach with 17G introducer needles preloaded with anchors (Cope
gastrointestinal suture anchor set, Cook, Bloomington, IN, USA) [Figure 4]. After confirming intragastric position, the anchors were deployed by pushing the
guidewire into the gastric lumen. The needle is withdrawn and the anchor pulled and
fastened as the stomach snug against the anterior abdominal wall.
Figure 4 (A-C): Diagrammatic representation of push technique. (A) Gastric anchors inserted into
stomach for gastropexy. (B) Stomach re-punctured to introduce guidewire. (C) After
serial dilatation of tract, balloon catheter pushed through peel away sheath and fastened
to stomach wall
After fastening the sutures to approximate the gastric wall to abdominal wall, the
gastric wall re-punctured close to anchors and after serial dilatation of the tract
using dilators up to 18-Fr, an 18-Fr silicon balloon catheter (ENTUIT Gastrostomy
BR, Wilson-Cook Medical, Winston-Salem, USA) was pushed into gastric lumen through
peel away sheath, and latter was removed. The retention balloon was inflated with
a small volume of saline, retracted to the anterior gastric wall and secured in place
by a retention disc advanced to the overlying skin.
Both types of procedures were completed with a contrast injection in order to confirm
correct intraluminal tube position and to exclude extravasation or other complications
and are considered as technically successful.
Feeding was usually started after 48 h with a test bolus of oral rehydration solution
to minimize the risk related to leakage of gastric content into the peritoneal cavity
along the tract. If there were no signs of leakage or other complications, a formula
diet was started. Instructions were given to nursing personal to flush the tube after
each feed. Further imaging was only performed if clinically indicated, including suspicion
of tube malfunctioning or dislodgement.
Follow-up
Patient records were examined in clinical workstation regarding procedure-related
mortality rate and complications. The average follow-up period was 10 months. Complications
of PRG tube placement are classified as minor or major according to the Society of
Interventional Radiology classification system for complications by outcome.
Minor complications were defined as superficial stromal infection (aspiration), pneumonia,
and minor hemorrhage requiring nominal therapy, including overnight admission for
observation only.[7] Simple tube displacement, tube occlusion, and leakage around the tube are also considered
minor.[7],[8] Pneumoperitoneum was categorized as minor complication if it was nonsymptomatic
or symptomatic but resolved without intervention.[5]
Major complications were defined as any complication requiring surgery, minor or prolonged
hospitalization, intensive care, hemorrhage requiring blood transfusion, tube dislodgement
into the peritoneal cavity, or deep stromal infection may or may not necessitating
tube removal,[7],[8] and symptomatic pneumoperitoneum requiring repeat intervention (i.e., drainage placement).[5]
Statistical analysis
Descriptive summary statistics were presented as means (standard deviation) for continuous
variables and as frequencies with percentages for categorical variables. All statistical
analyses were performed using Statistical Package for the Social Sciences software.
Results
Between December 2009 and June 2017, a total of 29 patients were supplied with radiological
gastrostomies (22 males, 7 females; age: mean ± SD, 55.8 ± 14.9 years; range: 16–83
years). Of the 29 patients, 27 (93%) were served with the fluoroscopy-guided pull-type
technique and 2 patients (7%) with push technique.
Patient data, underlying diseases, and indications for gastrostomy are summarized
in [Table 2]. Myasthenia gravis 11 patients (39%) and motor system disease 9 patients (31%) are
the two common indications. Rarely in one post cordectomy patient of bilateral abductor
palsy, PRG was done to initiate swallowing exercise [Figure 5].
Table 2
Percutaneous Radiological Gastrostomy (PRG)
|
No of patients
|
29
|
|
Age
|
|
|
Range
|
16-83y
|
|
Average±Std
|
55.8±14.9
|
|
Male
|
22(76%)
|
|
Female
|
7(24%)
|
|
Diagnosis and indication
|
|
|
Myasthenia gravis
|
11(39%)
|
|
Motor system disease
|
9(31%)
|
|
Bulbar onset ALS
|
3(10%)
|
|
Inflammatory myopathy
|
2(7%)
|
|
HIE post MI
|
1(3%)
|
|
Medullary infarct
|
1(3%)
|
|
Bil Abductor palsy post cordectomy
|
1(3%)
|
|
Carcinoma base of tongue
|
1(3%)
|
|
Interventional technique
|
|
|
Pull type
|
27(93%)
|
|
Push type
|
2(7%)
|
|
Intraprocedural problem
|
|
|
Slippage of feeding tube
|
1(3%)
|
|
Complications
|
|
|
Minor
|
7(24%)
|
|
Superficial infection
|
2(7%)
|
|
Tube block/displacement
|
2(7%)
|
|
Leakage from tube
|
1(3%)
|
|
Deformed PEG tube
|
1(3%)
|
|
Pnemoperitonium
|
1(3%)
|
|
Major
|
3(10%)
|
|
Abscess
|
2(7%)
|
|
Gastric perforation with features of mild peritonism
|
1(3%)
|
|
Mortality
|
|
|
Procedure related
|
Nil
|
|
Non procedural related
|
3(10%)
|
Figure 5: Indications for PRG in our study group
All intended pull-type and push-type gastrostomies were successfully completed by
the techniques described here. In pull-type-PRG patients, four types of minor complications
occurred among 7 patients (24%). Two cases with superficial skin infections was treated
conservatively. One patient developed tube block within 10 days and was relieved by
forceful saline flushing of tube. One patient developed tube leakage and other had
deformed tube (after 1 year); both were managed by replacing and upgrading the tube
from 24 to 26-Fr [Figure 6].
Figure 6: Flowchart of postprocedural complications and management in our study group
In push-type-PRG, both patients developed minor complications (2/2). One patient showed
tube dislodgement due to inadvertent deflation of balloon. It was corrected by tube
re-positioning and re-inflation of balloon under fluoro guidance using guidewire.
Another patient developed pneumoperitoneum, which was managed conservatively [Figure 7]. Three patients (10.3%) had developed major complications.
Figure 7 (A-D): Complications. (A) Peristromal abscess after pull technique. (B) Pneumoperitoneum
after push technique. (C) Massive pneumoperitoneum after pull technique. (D) Dislodged
tube due to inadvertent deflation of balloon in push technique
In one patient (pull-type), the feeding tube slipped out during the first attempt
of placement, subsequently the stomach was re-punctured and the tube was placed successfully
in second attempt in the same sitting. The patient developed massive pneumoperitoneum
with features of mild peritonism due to gastric perforation [Figure 7]. The patient managed conservatively with antibiotics and feeding started on seventh
postprocedure day.
Two patients (pull-type) suffered from moderate local pain at the puncture sites with
fever. Both showed focal abscess around the tubes with volume approximately measuring
<4 cc [Figure 7]. Both were treated conservatively with antibiotics. There was no complication related
to hemorrhage or peri-interventional mortality.
Three patients died on postprocedure follow-up, one on third day due to type 2 respiratory
failure and other on fourth day, due to sepsis and other medical problems, and third
patient died after few months due to sudden cardiac arrest and respiratory failure.
Discussion
For fluoroscopy-guided gastrostomy, numerous gastrostomy devices and techniques have
been described in the literature. The initially described Foley catheters have been
demonstrated to have increased morbidity rate due to tube leakage, breakage, migration,
proximal small bowel obstruction, and gastric wall penetration.[9] Gastrostomy buttons (balloon and mushroom types) consist of a low-profile catheter
with a feeding hub, designed for mature tracts; however, de novo placement of balloon-retained button-type gastrostomies has been performed with a
98% success rate.[10] In Cope loop retention device, T-fasteners were used for gastropexy to facilitate
introduction of gastrostomy catheters.
The fluoroscopy-guided percutaneous pull-through gastrostomy described in this study
combines the advantages of both the ease, speediness and the high technical success
rate with the beneficial design of the gastrostomy tubes that were traditionally used
with endoscopic assistance. Some authors describe this technique as per-oral image-guided
gastrostomy (PIG) hybrid technique.[11] It uses larger bore catheter (24-Fr and above) and does not require gastropexy.[12] It combines advantages of both traditional methods with a higher success and lower
re-intervention rate [13] with reduced infectious risk complications related to T-fasteners.[14]
Pull-type PRG are more secure than the conventional push-type tubes, as the pull-type
retention device cannot be deflated, unlocked, or injected with the feeding bolus
[12] and is preferred for patients with nonobstructive, neuromuscular esophageal dysmotility
disorders.
For inflation of stomach, some authors recommend CO2 as it is more readily absorbed
and less uncomfortable for the patient.[15] However, most of the recent studies for PRG are not using CO2, as it is tedious
and time-consuming.
Several techniques have been described for guidewire placement by transabdominal access
into the stomach and across esophagus though the mouth. The hydrophilic guidewire
(glide wire) can be captured by different types of snares (readymade or artificial
using guidewire) through oral route or through transabdominal route. In our institution,
we prefer pulling the glide wire inserted through stomach by transabdominal route
and snared out through oral cavity. Alternatively, the esophagus can also be cannulated
with glide wire retrogradely by directing the puncture needle itself toward the lower
gastroesophageal junction.
However, there are some drawbacks to the pull-type technique. Wound infection is more
frequently encountered using pull type than push type owing to contamination of wound
with oropharyngeal bacteria contamination of the tube as it traverses through the
mouth and pharynx during the procedure.[16] To minimize this, prophylactic antibiotics can be given on the day of procedure
and antiseptic mouthwash a day before and on the day of procedure. Statistically significant
reduction in the incidence of peristromal infection has been noted with prophylactic
antibiotics.[17] In our study group, two patients developed peristromal abscess and both were managed
conservatively with antibiotics. However, sometimes it may necessitate percutaneous
drainage with or without removal of gastrostomy tube.[7]
Push-type technique, which some authors describe as radiologically inserted gastrostomy
technique (RIG),[13] is preferred for patients with head and neck or upper gastrointestinal malignancies
causing proximal esophageal obstruction. As it obviates the need for catheter passage
from oral cavity to stomach, it also reduces the possibility of implant metastasis.[18] Yoshitaka et al.[19] showed that percutaneous radiologic gastrostomy is feasible even for patients in
whom a nasogastric tube cannot be inserted.
In push-type gastrostomy, instead of double puncture, a single puncture of the stomach
can be done, creating a single tract for both T-fasteners (suture anchors) and guidewire
over which dilatation and tube insertion can be performed. Postprocedure, the T-fasteners
can be released, as gastrostomy balloon tube was retracted and fixed externally, which
affix the gastric wall to the abdominal wall. It minimizes the procedure time and
infectious risk related to T-fasteners.[8] Inadvertent deflation of balloon is a frequent complication, in such situation pig-tail
retained (Cope loop) can be used.
In our series, one patient with amyotrophic lateral sclerosis died on third day due
to type 2 respiratory failure. A retrospective analysis from brain-derived neurotrophic
factor and ciliary neurotrophic factor trials showed that morbidity with PEG increases
with worsening respiratory function, and it also recommended that the procedure should
be undertaken before forced vital capacity (FVC) falls below 50% predicted;[20] however, subsequent studies have shown conflicting results.[21],[22] Chavada et al.[7] also concluded that FVC did not predict survival of postgastrostomy procedure. PEG
insertion may be regarded as safe even in patients with low FVC and can be offered
even for patients with respiratory dysfunction.[23]
The results presented in this study describe our experience with pull and push techniques.
As most referrals for gastric feeding tube insertion that come to our department are
for patients with neurological or neuromuscular disorders, pull technique might serve
as a simpler alternative to the endoscopic method with lesser complications.
Our data analysis demonstrated high technical success rate and low peri-interventional
complication. However, limitations of our study include retrospective analysis, small
sample size, unequal distribution of cases, limited experience with push technique,
adequate data not available for its technical feasibility, and complications related
to cases with upper GI, head and neck malignancies.
Conclusion
PRG is effective, safe, and easy to perform, with low morbidity and mortality rates
and high technical success rate in selected patients. The limitation of smaller tube
size leading to higher rates of tube blockage can be overcome with the pull-type PRG
(PIG) technique. Our study describes a new technique for pull-type gastrostomy.
