A method for percutaneous radiologic gastrostomy tube placement without sedation as a bridge to lung transplantation

Abstract

Gastrostomy tube placement is an appropriate option for long-term nutritional support for patients who cannot tolerate oral intake. Common indications for a gastrostomy tube include head and neck tumors and neurological disorders. Several methods for gastrostomy tube insertion exist (eg, surgical, endoscopic, and radiologic) that require sedation or general anesthesia, which can pose risks of cardiopulmonary compromise and postsurgical pulmonary complications. Unlike other methods, our practice uses a percutaneous balloon-assisted gastrostomy tube insertion method for which we can perform without sedation. We report a case of a percutaneous radiologic gastrostomy procedure for a patient with end stage lung disease as a bridge to lung transplantation, who is not a candidate for sedation and is high-risk for general anesthesia. Through enteral feeds administered through the successfully placed gastrostomy tube, the patient showed steady improvement in weight gain over the course of several months before approval for listing by the lung transplant selection committee. Our case highlights how gastrostomy tube placement can be safely performed in patients who are not sedation candidates using the minimally invasive balloon-assisted gastrostomy tube insertion method and local anesthetic.

Keywords: Lung transplantation; Percutaneous radiologic gastrostomy; Pulmonary cachexia.

Fig. 1

Axial chest CT with IV contrast upon referral. Axial chest CT with IV contrast demonstrates cachexia and advanced primarily upper lobe emphysema without focal consolidation, masses or pulmonary nodules.

Fig. 2

(A) Preprocedure radiograph of abdomen. Radiograph prior to the procedure illustrates opacification of the transverse colon via barium given the night before (black arrows). A 5 French Kumpe (white arrow) used to insufflate the stomach with air is also visualized with its tip in the gastric fundus. (B) Gastropexy and gastric access via 18 gauge needle. Gastric body is insufflated with air through the 5 French Kumpe catheter. Two T-fasteners (black arrows) are used for gastropexy to anchor the stomach to the abdominal wall. An 18-gauge needle (white arrow) is inserted into the stomach through a dermatotomy with injection of contrast to confirm intraluminal position of the needle tip. (C) Wire access and start of tract dilation with balloon angioplasty. A guidewire (white arrows) is advanced into the stomach, and a Conquest balloon with an overlying G-tube is used to cannulate the stomach. Tract dilation with the balloon demonstrates a waist at the body wall (black arrow). (D) End of tract dilation with balloon angioplasty. Continuous inflation of Conquest balloon demonstrates complete dilation of the tract with an effacement of the waist at the gastric body wall. (E) Postprocedure radiograph of abdomen. Postprocedure image illustrates insertion of G-tube with an inflated retention balloon (black arrow) and injection of contrast to confirm intraluminal position.