Updates on percutaneous radiologic gastrostomy/gastrojejunostomy and jejunostomy

Abstract

Gastrostomy placement for nutritional support for patients with inadequate oral intake has been attempted using surgical, endoscopic, and, more recently, percutaneous radiologically guided methods. Surgical gastrostomy has been superseded by both endoscopic and radiologic gastrostomy. We describe herein the indications, contraindications, patient preparations, techniques, complications, and aftercare with regard to radiologic gastrostomy. In addition, we discuss the available tube types and their perceived advantages. There remain some controversies regarding gastropexy performance and primary percutaneous gastrojejunostomy. Percutaneous jejunostomy is indicated for patients whose stomach is inaccessible for gastrostomy placement or for those who have had a previous gastrectomy.

Keywords: Enteral feeding; Gastrojejunostomy; Gastrostomy; Interventional procedures; Jejunostomy.

Fig. 1

A Cope suture anchor. (A) The anchor, which is made of a short metal bar (arrows) attached to a surgical suture (arrowheads), is preloaded into a 17-gauge puncture needle. (B) The anchor (arrow) is deployed when a guide wire (long arrows) is advanced through the puncture needle. The distal end of the suture string (arrowhead) is attached to the suture needle for fixation to the skin.

Fig. 2

Percutaneous radiologic gastrostomy with multiple gastropexy. Three sets of anchors (arrows) are inserted into the stomach at the corners of a triangle. The puncture is done at the center of the triangle and a 14-Fr pigtail-retained tube is inserted successfully (not shown).

Fig. 3

Gastric puncture (asterisks) is performed at the mid to distal gastric body, equidistant from the greater and lesser curvatures. It should be lateral to the rectus muscle or in the midline to avoid puncture of epigastric arteries (1 and 2 indicate the superior and inferior epigastric arteries, respectively).

Fig. 4

Percutaneous radiologic gastrostomy with a one-anchor technique (courtesy by K.H. Lee, M.D.). (A, B) The stomach is inflated with a vascular catheter (arrow) and a puncture needle preloaded with an anchor (arrowheads) is advanced under frontal and lateral fluoroscopic guidance. Gastric tenting (long arrows) made by the anterior stomach wall is clearly seen in a lateral view. (C) With a brief thrust, the anterior stomach wall is punctured. (D) With advancement of a guide wire (arrows), the anchor (arrowheads) is deployed within the stomach. (E) By traction of the anchor (arrow), the anterior stomach wall is apposed to the abdominal wall. (F) The puncture tract is dilated serially with dilators (arrows). (G, H) A 14-Fr pigtail-retained tube is placed and its intragastric location is confirmed with contrast-agent injection in frontal and lateral views.

Fig. 5

Embolotherapy for massive bleeding after percutaneous radiologic gastrostomy. (A, B) Bleeding (contrast-agent extravasation, arrows) persisted from the right gastroepiploic artery (arrowheads in A) even after attempts at endoscopic hemostatic with clips (long arrows). Embolotherapy was performed successfully with Gelfoam particles and coils (arrowheads in B).

Fig. 6

Example of primary percutaneous radiologic gastrojejunostomy in a patient with recurrent aspiration pneumonia. A 16.5-Fr, 80-cm, double-lumen gastrojejunostomy tube was then placed. A friction-lock Malecot retention device (arrows) is present to prevent inadvertent removal. The shorter lumen (arrowhead) within the stomach is for gastric suction. Contrast-agent investigation through the longer lumen reveals good opacification of the proximal jejunum without regurgitation into the stomach.