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Balloon-Assisted, Fluoroscopically Guided Percutaneous Gastrostomy Tube Placement 

Balloon-Assisted, Fluoroscopically Guided Percutaneous Gastrostomy Tube Placement
Chapter:
Balloon-Assisted, Fluoroscopically Guided Percutaneous Gastrostomy Tube Placement
Author(s):

Joseph Farnam

, Jason Iannuccilli

, and Gregory Soares

DOI:
10.1093/med/9780199986071.003.0093
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Brief Description

Fluoroscopic placement of gastrostomy tubes requires creation and dilation of a percutaneous tract through which the tube is placed. Given the relatively large caliber of these tubes, aggressive dilation of the percutaneous tract is necessary prior to their insertion. Tract dilation is most commonly performed via the use of several sequential dilators or a single telescoping serial dilator. We have found these methods to be cumbersome and relatively time-consuming, and as a result, this portion of the procedure can result in considerable patient discomfort as well as technical complications. Fascial dilatation requires substantial axial force in order to generate enough radial force for tissue dilatation. This force can kink or dislodge the guidewire from the gastric lumen, preventing subsequent passage of the gastrostomy tube over the wire or possible tube insertion outside of the stomach within the peritoneum. Excessive damage to the stomach or inadvertent injury to the duodenum can result. In addition, gastropexy T-fasteners can become dislodged during forceful serial dilation, further increasing the chance of extragastric tube placement and leakage of enteric contents into the peritoneum. We recently began using a simple technique that allows rapid dilation of the percutaneous tract using a balloon catheter and subsequent insertion of the gastrostomy tube in a single step, which reduces procedural time and minimizes patient discomfort. The use of balloon catheter dilatation eliminates axial force by applying a direct radial force that can be accomplished with one or two insufflations. In our experience, this technique is better tolerated by patients under conscious sedation and results in fewer technical complications.

Applications of the Technique

  1. 1. Any patient requiring percutaneous gastrostomy or gastrojejunostomy tube placement.

  2. 2. Patients with excessive or fibrotic soft tissues, such as obese patients and/or those with a history of prior abdominal surgeries.

  3. 3. Patients with a narrow window for gastric access, where there is greater risk for collateral damage to adjacent structures.

Challenges of the Procedure

  1. 1. Removal of the balloon catheter from the lumen of the gastrostomy tube can be difficult if the balloon is not completely deflated.

  2. 2. Advancement of the gastrostomy tube through the tract will be difficult if the balloon catheter is not sized appropriately.

  3. 3. Adequate dilation of the access tract may be impossible if skin nick is too small.

Potential Pitfalls/Complications

  1. 1. If the tract is not adequately dilated and sized appropriately and appropriate guidewire access is not maintained to the gastric lumen, the gastrostomy tube may be inadvertently placed outside of the stomach. The balloon must be inflated throughout the entire course of the gastrostomy tract.

  2. 2. If the entire tract length is not dilated, the gastrostomy tube will not pass.

  3. 3. Risk of hemorrhage: This should be no different than with the conventional technique for tract dilation using serial dilators.

  4. 4. Risk of infection: This should be no different than with the conventional technique for tract dilation using serial dilators. Administration of prophylactic antibiotics is standard in our practice during this procedure.

Steps of the Procedure

  1. 1. Pre-procedure workup: A specific indication is established, patient history is reviewed, a brief physical examination is performed, and pertinent laboratory data are reviewed.

  2. 2. Pre-procedure imaging: Cross-sectional imaging is obtained and reviewed to assess the position of the stomach with respect to the solid organs and transverse colon to determine whether a feasible window exists for safe creation of a percutaneous tract through which the tube will be placed.

  3. 3. Positioning and patient preparation: The patient is placed on the fluoroscopy table in supine position. Ultrasound is used to identify the liver margin, which is physically marked on the overlying skin surface with indelible marker. A nasogastric tube is inserted, and the stomach is insufflated with air.

  4. 4. Pexy placement: Under fluoroscopic guidance, the stomach is punctured below the liver edge and costal margin, and two to four gastropexy T-fasteners are placed.

  5. 5. Wire access: A small skin incision is made (approximately 8 mm) centrally through which the pexied gastric wall is again punctured with an 18 gauge needle to introduce a 0.035-in. guidewire into the gastric lumen.

  6. 6. Catheter selection: A noncompliant balloon catheter is selected with a maximum diameter that is approximately 2 mm larger than the gastrostomy tube (to accommodate an 18 Fr gastrostomy tube, we utilize an 8-mm balloon). Balloon length should be selected such that the entire tract is dilated on a single inflation—generally 4 cm is sufficient.

  7. 7. Gastrostomy tube loading: The gastrostomy tube is preloaded onto the shaft of the balloon catheter, which allows balloon dilation of the tissue tract over the wire and subsequent rapid insertion of the tube through the tract by forward advancement as the balloon is simultaneously deflated.

  8. 8. Balloon catheter placement: The preloaded apparatus is advanced over the guidewire into the stomach and then positioned to place the balloon portion in the soft tissue tract. The proximal margin of the balloon should be visualized just outside of the skin.

  9. 9. Tract dilation: The balloon is inflated to completely cover the entire length of the percutaneous tract, from distal to proximal. The balloon is sufficiently inflated within the tissues until any visible “waist” is eliminated.

  10. 10. Gastrostomy tube advancement: As the balloon is deflated, the gastrostomy catheter and balloon catheter are rapidly advanced in unison over the wire into the stomach lumen. The anchoring balloon on the gastrostomy tube is inflated and pulled snugly to the gastric wall. Both the guidewire and the balloon catheter are removed from the gastrostomy tube lumen, leaving the tube in place within the stomach.

Example

See Figures 93.193.3.

Figure 93.1 An 18 Fr gastrostomy tube placement is demonstrated by progressive dilatation using a 22 Fr telescoping serial dilator and an 18 Fr peel-away sheath (Kimberly-Clark, Irving, TX).

Figure 93.1 An 18 Fr gastrostomy tube placement is demonstrated by progressive dilatation using a 22 Fr telescoping serial dilator and an 18 Fr peel-away sheath (Kimberly-Clark, Irving, TX).

Figure 93.2 (A) Device apparatus: Balloon catheter is shown on 0.035-in. guidewire, preloaded with a gastrostomy tube. Insertion technique is demonstrated with placement of the balloon portion into the intended gastrostomy tract (B), subsequent inflation of the balloon catheter with gastrostomy tube hubbed to the margin of the inflated (C), followed by simultaneous deflation and advancement of the entire device (D). (E) The gastrostomy tube is inflated. (F) Both the balloon catheter and the guidewire are removed, and the gastrostomy tube is secured to skin.

Figure 93.2 (A) Device apparatus: Balloon catheter is shown on 0.035-in. guidewire, preloaded with a gastrostomy tube. Insertion technique is demonstrated with placement of the balloon portion into the intended gastrostomy tract (B), subsequent inflation of the balloon catheter with gastrostomy tube hubbed to the margin of the inflated (C), followed by simultaneous deflation and advancement of the entire device (D). (E) The gastrostomy tube is inflated. (F) Both the balloon catheter and the guidewire are removed, and the gastrostomy tube is secured to skin.

Figure 93.3 An 18 Fr gastrostomy tube placement is demonstrated using a catheter balloon (Conquest 8-mm diameter × 4-cm length [Bard, Tempe, AZ]), requiring two balloon inflations for tract dilatation.

Figure 93.3 An 18 Fr gastrostomy tube placement is demonstrated using a catheter balloon (Conquest 8-mm diameter × 4-cm length [Bard, Tempe, AZ]), requiring two balloon inflations for tract dilatation.

Reference and Suggested Reading

1. Itkin M, DeLegge MH, Fang JC, et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). J Vasc Interv Radiol. 2011;22:1089–2011.Find this resource: