AJR 2005; 184:227-229
© American Roentgen Ray Society
Percutaneous Decompression of the Bowel with a Small-Caliber Needle: A Method to Facilitate Percutaneous Abdominal Access
Sheldon Wiebe1,
Justine Cohen1,
Bairbre Connolly1 and
Peter Chait1
1 All authors: Department of Diagnostic Imaging, The Hospital for Sick Children
and University of Toronto, 555 University Ave., Toronto, ON M5G 1X8,
Canada.
Received January 15, 2004;
accepted after revision March 19, 2004.
Address correspondence to P. Chait.
Abstract
OBJECTIVE. In our pediatric interventional practice, we have found
that occasionally a loop of bowel is interposed between the stomach and the
anterior wall of the abdomen, preventing safe needle access for procedures
such as placement of a gastrostomy tube. The use of a small-caliber needle to
aspirate air from the colon or small bowel, for bowel decompression, may be a
safe way to aid in establishing a safe access route for the subsequent
percutaneous introduction of larger needles or tubes.
CONCLUSION. Our retrospective review of patients who have undergone
bowel-gas aspiration during an interventional procedure shows that the
aspiration of air from the colon with a small-caliber needle is technically
easy and may permit completion of an abdominal procedure.
Introduction
Gastrostomies are indicated commonly in patients with feeding difficulties
who require long-term nutritional support or gastric decompression.
Occasionally the colon, usually the transverse colon or splenic flexure, is
interposed between the stomach and the anterior abdominal wall
(Fig. 1). Less frequently,
dilated small bowel can be in the way. Air insufflation of the stomach via the
nasogastric tube during a gastrostomy procedure usually will displace the
colon sufficiently inferiorly to permit access. However, occasionally this
does not happen, and safe access is not possible
[1]. The purpose of this
article is to describe the technique we use to deflate bowel distended with
gas. The technique of aspirating gas from bowel has been performed under
direct visualization by surgeons and is applied to our imaging-guided
procedure.
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Fig. 1. —Preliminary supine radiograph of 13-month-old boy shows
air-filled colon interposed between anterior wall of stomach and anterior
abdominal wall. Nasogastric tube is within stomach. Tip of forceps is at skin
site of proposed site of gastrostomy tube insertion (arrow).
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Materials and Methods
Study Group
After we obtained ethics review board approval for the study, we reviewed
the Image-Guided Therapy Centre database and the radiology reporting system to
identify patients in whom percutaneous aspiration of bowel gas was performed
to facilitate a subsequent interventional gastrointestinal procedure. The
medical records of those patients identified were reviewed to evaluate any
possible complication that could have resulted from this adjunctive step in
the procedure.
Technique
A small needle, such as a 27- or 25-gauge needle, is introduced into the
distended loop of bowel under anteroposterior or lateral fluoroscopy
(Fig. 2A). The position of the
needle tip within the lumen of the bowel is confirmed with contrast material,
and then gas is aspirated from the lumen using a T-piece and syringe
(Fig. 2B). This decompresses
the bowel sufficiently to permit safe access to the organ of interest. The
intervention then proceeds as planned (Figs.
3A and
3B). Usual antibiotic
prophylaxis is used without any additional coverage.
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Fig. 2A. —Radiographs of 13-month-old boy. Lateral view shows 27-gauge
needle in air-filled colon with a drop of contrast material at needle tip
(arrow). Some contrast material also is seen layering in dependent
colon to confirm needle is in lumen.
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Fig. 2B. —Radiographs of 13-month-old boy. Image shows partially
deflated colon with 27-gauge needle in lumen and partially inflated stomach
containing nasogastric tube. Note tip of forceps is at proposed site of
gastrostomy tube placement (arrow).
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Fig. 3A. —Radiographs of 13-month-old boy. Images show 18-gauge needle
is in gastric lumen with a drop of contrast material at needle tip, just
before placement of wire and retention suture (arrow, A).
Deflated colon is displaced inferiorly beneath inflated stomach allowing safe
access to anterior gastric wall (B).
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Fig. 3B. —Radiographs of 13-month-old boy. Images show 18-gauge needle
is in gastric lumen with a drop of contrast material at needle tip, just
before placement of wire and retention suture (arrow, A).
Deflated colon is displaced inferiorly beneath inflated stomach allowing safe
access to anterior gastric wall (B).
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Results
Fourteen patients who had undergone percutaneous aspiration of bowel gas
were identified through the Image-Guided Therapy Centre database and the
radiology reporting system. These patients were eight boys and six girls who
ranged in age from 2 to 36 months (mean, 10.5 months). Nine of the 14 patients
underwent a gastrostomy tube insertion; three, a gastrojejunostomy tube
insertion; one, a liver biopsy; and one, cholangiography. In 11 of the 12
patients requiring enterostomy access, the tubes were positioned without
difficulty with the aid of colon decompression in 10 and small-bowel
decompression in one. The 12th patient who underwent gastrostomy tube
insertion required both colon and small-bowel decompression. Two patients
required air aspiration of the colon before access to the liver: for
cholangiography (when accessing the gallbladder) in one patient and for a
liver biopsy in the second. In 11 instances, a 27-gauge needle was used, and
in one a 25-gauge needle was used. Fluoroscopy times ranged from 3.8 to 31 min
(average, 8.8 min; median, 6.7 min). Two patients who required
gastrojejunostomy tubes had prolonged fluoroscopy times, reflecting the
difficulty of insertion in some patients and skewing the figures.
The medical records of 13 of the 14 patients showed there was no instance
of fever, unusual abdominal tenderness, peritonitis, intraabdominal
collections, or puncture site infections. No blood per rectum or gastrocolic
fistulas occurred. One ill infant, intubated with complex congenital heart
disease and severe comorbidity, had a gastric leak after gastrostomy tube
placement. This finding was confirmed with a contrast-enhanced study. She
developed peritonitis, a small amount of free air, metabolic acidosis, and
sepsis, from which she died. No autopsy was performed. Although she had a
definite confirmed gastric leak, one cannot include or exclude a colonic
leak.
Discussion
The feared complication of puncturing the colon is peritoneal spill of
colonic contents and gas resulting in peritonitis. This did not occur in 13 of
the 14 patients in our series when fine-caliber needles (25- or 27-gauge) were
used for bowel aspiration. One can only speculate whether it occurred in the
one patient with a documented gastric leak. Others have used a similar
technique preoperatively without colonic spillage or sequelae
[2]. Experience in general
surgery with sutures for anastomoses of the bowel itself using needles larger
than 25- or 27-gauge suggests puncture of the bowel with fine needles is well
tolerated. Presumably, the tiny puncture site seals immediately when the
needle is withdrawn. Extra vigilance, however, is needed after the procedure
to monitor for signs of peritonitis. Should it occur, whether one is dealing
with a complication of the original enteric intervention or from the colonic
micropuncture, may be unclear.
This simple technical step enables the interventionalist to complete a
procedure when safe access otherwise would be obstructed by bowel.
References
- Chait PG, Weinberg J, Connolly BL, et al. Retrograde percutaneous
gastrostomy and gastrojejunostomy in 505 children: a 4 1/2-year experience.
Radiology1996; 201:691
-695[Abstract/Free Full Text]
- Soulsby R, Radley S. Simple equipment for decompression of the
colon during laparotomy for large bowel obstruction. Colorectal
Dis 2002;4:262
-263[Medline]
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Abstract
Introduction
