DOI:10.2214/AJR.04.0964
AJR 2006; 186:574-576
© American Roentgen Ray Society
Percutaneous Radiologic Gastrostomy Using Push-Type Gastrostomy Tubes with CT and Fluoroscopic Guidance
Toshinobu Tsukuda1,
Takeshi Fujita1,
Katsuyoshi Ito1,
Tomio Yamashita2 and
Naofumi Matsunaga1
1 Department of Radiology, Yamaguchi University School of Medicine, 1-1-1 Minami
Kogushi, Ube, Yamaguchi, Japan 755-8505.
2 Department of Radiology, UBE Industries Central Hospital, Yamaguchi, Japan
755-0151.
Received June 18, 2004;
accepted after revision April 20, 2005.
Address correspondence to T. Tsukuda.
Abstract
OBJECTIVE. The purpose of this study was to evaluate the safety and
feasibility of percutaneous radiologic gastrostomy with endoscopic push-type
gastrostomy tubes using CT and fluoroscopic guidance.
CONCLUSION. Percutaneous radiologic gastrostomy using CT and
fluoroscopic guidance with push-type tubes is a safe and effective means of
gastric feeding that has few complications and offers an alternative to
introducer-placed gastrostomy tubes.
Keywords: gastrointestinal radiology • interventional radiology • stomach
Introduction
Percutaneous gastrostomy is a well-established technique for patients
requiring enteral nutrition from many causes including swallowing disorders.
Percutaneous gastrostomy may be achieved by an endoscopic
[1] or a radiologic
[2] approach. Push-over-wire
Sachs-Vine gastrostomy tubes (push-type tubes) or pull-string Ponsky-Gauderer
type gastrostomy tubes (pull-type tubes) are usually used for endoscopic
gastrostomy; however they are rarely used for radiologic placement without the
aid of endoscopy [3,
4]. Recently, we developed a
new technique of percutaneous gastrostomy using CT and fluoroscopic guidance
for placing commercially available endoscopic push-type gastrostomy tubes. In
this technique, tubes were advanced over the guidewire, through the mouth,
down the esophagus, and out of the gastrostomy site.
Materials and Methods
Between April 1999 and January 2004, percutaneous radiologic gastrostomy
using CT and fluoroscopic guidance was performed in 21 consecutive patients
(15 men and six women; age range, 65-83 years; mean age, 73.2 years) with
cerebral infarction (n = 14), cerebral hemorrhage (n = 6),
and encephalitis (n = 1) at the UBE Industries Central Hospital.
Indications for gastrostomy included neurologic conditions with swallowing
disturbance. When gastrostomy was required in patients with swallowing
disturbance in the department of neurology at our institution, they were
referred to the radiology department and a gastrostomy tube was placed using
our new technique as the first-line choice for enteral feeding tube
placement.
Before the procedure, enteral nutrition through a nasogastric tube was not
provided to patients for at least 8 hr. A 14-French nasogastric tube (Safed
stomach catheter, Terumo Medical Products) was inserted from the mouth. At the
CT unit with the patient in the supine position, the patient's stomach was
inflated with air by a disposable syringe through the nasogastric tube. After
obtaining a computed scanogram to ensure that the stomach was inflated
sufficiently (Fig. 1A), we
punctured the stomach under CT guidance, avoiding the left lobe of the liver
and colon. The skin was locally anesthetized with lidocaine, and an incision
was made in the abdominal wall. An 18-gauge sheathed needle (Surflo, Terumo
Medical Products) was inserted through the incision into the stomach. The
inner stylet was removed, and a 0.035-inch, 260-cm-long guidewire (Radifocus
guidewire, Terumo Medical Products) was inserted through the needle into the
stomach. The correctly placed guidewire was confirmed in the stomach by CT
scan (Fig. 1B).
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Fig. 1A —73-year-old-woman with cerebral infarction. Inflation of stomach was
confirmed by computed scanogram. Then, puncture route was determined under CT
guidance. Sheathed needle was inserted into stomach.
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|
After removing the 18-gauge sheathed needle, a 6-French angiographic
introducer (Radifocus Introducer IIH, Terumo Medical Products) was inserted to
the stomach over the guidewire to dilate the gastrostomy tract. Then, the
patient was transferred to the fluoroscopic imaging unit. A snare wire
(SD5L-1, Olympus) was passed into the stomach through the nasogastric tube.
The guidewire was captured with the snare wire within the stomach and pulled
through the mouth (Fig. 1C).
The nasogastric tube and the angiographic introducer were removed. At this
stage, a guidewire extended from the mouth through the esophagus and exited
the stomach through the gastrostomy puncture site.
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Fig. 1C —73-year-old-woman with cerebral infarction. Guidewire was captured
with snare wire within stomach on fluoroscopic image (C) and
corresponding diagram (D) and pulled through mouth. Push-type
gastrostomy tube was pushed over guidewire into stomach from oral side and out
puncture site.
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A 20-French endoscopic push-type gastrostomy tube (Neofeed PEG kit, Top)
was pushed over the guidewire into the stomach from the oral side and out the
puncture site (Fig. 1D). The
gastrostomy tube was then secured with a locking ring, the dilator portion of
the tube was cut off, and a universal feeding adapter was fitted. The
guidewire was removed, and a contrast material was injected into the
gastrostomy tube to confirm that the tube was correctly positioned in the
stomach. No sedation or pharyngeal topical anesthetic was used during the
procedure. Prophylactic antibiotics were not used for this procedure. Tube
feeding was initiated 3 days after tube placement. Procedure time from arrival
at the CT unit to completion of the entire procedure was recorded for all
patients.
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Fig. 1D —73-year-old-woman with cerebral infarction. Guidewire was captured
with snare wire within stomach on fluoroscopic image (C) and
corresponding diagram (D) and pulled through mouth. Push-type
gastrostomy tube was pushed over guidewire into stomach from oral side and out
puncture site.
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Results
The percutaneous radiologic gastrostomy was technically successful in all
patients. The median procedure time was 46 ± 13 (SD) min (range, 34-93
min). In two patients, two punctures were required because the stomach was not
fully inflated at the time of the first puncture. No major complications
related to the procedure were encountered. In four patients, peristomal
inflammation occurred, although abscess or peritonitis did not develop. The
average follow-up time interval was 67 days (range, 5-390 days). No tubes
failed because of blockage and neither tube dislodgement nor intraperitoneal
leakage occurred during follow-up periods. The 30-day mortality was 14% (three
patients). These three patients died as a result of the underlying
disease.
Discussion
Percutaneous gastrostomy using the endoscopic
[1] or radiologic
[2] approach was introduced at
the beginning of the 1980s Surgical gastrostomy has been less popular because
of a higher rate of complications than percutaneous gastrostomy
[5]. Recently, percutaneous
endoscopic gastrostomy has been performed at many medical facilities because
of widespread use of the endoscope operated by skilled endoscopists.
However, there are some potential drawbacks to percutaneous endoscopic
gastrostomy. In large patients, percutaneous endoscopic gastrostomy is not
possible owing to the inability to transilluminate the abdominal wall. In some
patients whose transverse colon lies between the stomach and abdominal wall,
percutaneous endoscopic gastrostomy has the risk of colonic perforation
[6]. Moreover, postprocedural
pneumonia is more frequently encountered in percutaneous endoscopic
gastrostomy than in the radiologic approach because of aspiration during the
endoscopic examination [4,
7].
Endoscopists at our institution were constantly busy, so patients in the
department of neurology were referred to the department of radiology for
interventional gastrostomy. We decided to use our CT unit and the push-type
gastrostomy tubes that were used by the endoscopists at our institution. All
patients in the study underwent gastrostomy by this method.
In this study, puncture of the transverse colon and the left hepatic lobe
was avoided as a result of using CT guidance and frequently using sonography
and barium given the night before to opacify the colon. The guidewire can be
accurately advanced to the stomach under CT guidance. When the fluoroscopy
room is separated from the CT unit, it may be troublesome to transport the
patient. In our study, about 15-20 min was necessary for CT guidance and
transporting the patient. This problem will be resolved by installation of an
angio-CT unit in the same room, although such a system may not be available in
most hospitals.
A push technique, pull technique, or introducer technique is used for
percutaneous gastrostomy. Introducer-type tubes are usually used for
radiologic gastrostomy, whereas push-type or pull-type tubes are used for
endoscopic gastrostomy. In our study, push-type tubes were placed. Push- or
pull-type tubes are rarely used for radiologic placement without the aid of
endoscopy. Szymski et al. [3]
reported using pull-type tubes and Clark et al.
[4] reported using push-type
tubes for radiologic gastrostomy. They both describe a slightly different
procedure from our study, one in which the wire from the gastrostomy is
advanced retrograde, fluoroscopically, up the esophagus and out the mouth.
This contrasts with our process in which a nasogastric tube is introduced
and used for placement of a snare wire, which is used to pull the guidewire
out the mouth. There are many potential benefits for use of push- or pull-type
tubes. These tubes, with a large bore, will reduce the occurrence of tube
occlusion. Moreover, push- and pull-type tubes can be placed without the use
of gastropexy devices.
However, there are some drawbacks to push- and pull-type tubes. Wound
infection is more frequently encountered using push- and pull-type tubes than
introducer-type tubes owing to contamination of the wound with oropharyngeal
bacteria because the tube traverses the mouth and pharynx during the procedure
[8]. In this study, there was
peristomal inflammation in four patients, although no patients developed
abscess or peritonitis.
In conclusion, our results show that percutaneous radiologic gastrostomy
using CT and fluoroscopic guidance with push-type tubes is a safe and
effective means of gastric feeding with few complications. This technique
provides an alternative to the more frequently used introducer-placed
gastrostomy tubes.
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Abstract
Introduction
