Percutaneous Gastrostomy and Jejunostomy 

Although surgeons and gastroenterologists have traditionally provided enteral access services, interventional radiologists can safely, effectively, and successfully perform these procedures as well. Experience with percutaneous radiologically guided gastrostomy and gastrojejunostomy access is extensive, and experience with direct percutaneous jejunostomy access is growing. This article reviews issues and highlights areas of controversy important to radiologists providing these services.^{[1, 2, 3, 4, 5]}

Enteral access options

First described in 1837, surgical gastrostomy was the mainstay of direct enteral feeding access for decades. Although laparoscopic techniques for gastrostomy and jejunostomy tube access have evolved since then, their use is limited because of the acceptance of less invasive endoscopic and radiologic alternatives. Surgical gastrostomy or jejunostomy is most frequently performed when patients are already undergoing laparotomy for related or unrelated abdominal problems.

The advent in 1980 of percutaneous endoscopic gastrostomy (PEG) dramatically changed the approach to gastrostomy access, and this minimally invasive procedure largely replaced surgical gastrostomy. Endoscopic gastrostomy has been accepted widely and remains the most common form of gastrostomy access. Endoscopic gastrojejunostomy and direct endoscopic jejunostomy also have been described, but these methods are less widely used and less accepted than PEG.

In 1983, 3 independent interventional radiology groups described a percutaneous imaging-guided alternative to surgical and endoscopic gastrostomy. Since then, reports from multiple large series have described the procedure. Compared with endoscopy, fluoroscopic guidance allows the safe placement of gastrostomy tubes and allows easier initial placement of gastrojejunostomy tubes. More recently, direct jejunostomy access was described. The degree to which individual radiology practices offer these services varies.

Patient and family counseling

Whether to proceed with percutaneous enteral access is often a multidisciplinary decision, and the patient and the patient's family should be involved. Depending on the underlying clinical problem and patient prognosis, the wishes of the patient and the patient's family often weigh heavily on decisions regarding the appropriateness of enteral tube access.

Many patients and families have strong opinions regarding the placement and use of feeding tubes and about their perceived role as life-prolonging measures. Physicians should provide the most objective medical advice possible to allow patients to make their own decisions. Physicians should refrain from imposing their own personal judgments when ethical and moral issues overshadow the medical ones.

Indications for enteral access

• Although percutaneous enterostomy catheters are most commonly placed for nutritional support, other indications have evolved for specific clinical scenarios.
• As a general rule, enteral or parenteral feeding is advised when a patient is unable to eat for 7-14 days or longer. In the setting of a functional gut, enteral feeding is preferred to parenteral options.

  • When the need for enteral feeding is anticipated to be 30 days or shorter, feedings through a nasogastric tube or a more distal nasoenteric tube are usually appropriate. Because such tubes are associated with considerable discomfort and because sinusitis and epistaxis are common complications, direct enteral access is preferred when feeding needs extend beyond 30 days.
  • The choice of access route (gastrostomy, gastrojejunostomy, or jejunostomy) and the choice of placement technique (surgical, endoscopic, or radiologic) often depend on individual patient issues and the specialty, experience, and preference of the treating physician.
• Patients with either functional or mechanical bowel obstructions often require tube decompression. When decompression is needed for prolonged periods (eg, in patients with severe diabetic gastroparesis or peritoneal carcinomatosis), direct enteral tube placement offers advantages over nasogastric or nasoenteric tube placement. Because the stomach and small bowel are grossly dilated in these settings, both gastrostomy and jejunostomy tube placements are technically straightforward.
• Interventional radiologists may use imaging-guided access to the bowel to facilitate other gastrointestinal or biliary interventions. In the setting of previous biliary-jejunal anastomotic procedures, percutaneous access into the afferent jejunal limb can facilitate the treatment of biliary strictures and stones. In patients with obstructing esophageal neoplasms, gastrostomy access and retrograde esophageal catheterization may facilitate the placement of palliative stents.

Although the risks and potential benefits of enteral access catheter placement must be weighed in each patient, certain anatomic and pathologic conditions may increase the likelihood of complications. The following are contraindications to percutaneous feeding tube placement:

Absolute contraindications

• Uncorrectable coagulopathy
• Absence of a safe access route

Relative contraindications

• Unfavorable anatomy

  • Interposition of the colon between the stomach and anterior abdominal wall
  • Interposition of the liver between the stomach and anterior abdominal wall
  • A high (intrathoracic) position of stomach
  • Previous gastrectomy
• Massive ascites
• Gastric neoplasm
• Active gastritis or peptic ulcer disease
• Gastric varices

• Percutaneous enteral access procedures can be performed safely and comfortably with local anesthesia. In cooperative patients, moderate sedation may be unnecessary.
• In high-risk patients with cardiopulmonary disease, this procedure offers a significant advantage over endoscopic and surgical gastrostomy, which usually require moderate sedation and general anesthesia, respectively.

Catheters commonly used for radiologic enteral access include Cope loop catheters, balloon catheters, and mushroom (or bumper) catheters. No catheter is ideal in all situations, and the choice of catheter frequently depends on the physician's preference and individual patient considerations. Interventional radiologists most commonly use the first 2 types of above-mentioned catheters.

Specific devices include the Wills-Oglesby gastrostomy catheter, Mallinckrodt gastrostomy catheter, Carey-Alzate-Coons gastrojejunostomy tube, and Shetty jejunostomy tube (all from Cook, Inc), and the Mic-Key gastrostomy and gastrojejunostomy catheters, along with the Mic-Key low-profile gastrostomy feeding skin-level "button" device (all from Kimberly Clark Healthcare).

Cope loop catheters (see image below)

• Used almost exclusively by interventional radiologists, Cope loop catheters can be placed by employing the Seldinger technique, often without the need for peel-away sheaths. Experience with these catheters is extensive in the radiology community.
• Some older loop catheters were associated with duodenal perforation, but such complications have not been reported with newer commercially available catheters.
• Compared with conventional Foley catheters, these catheters may be associated with fewer complications, but they appear to be less durable than mushroom catheters.
• Loop catheters are typically 16F or smaller in diameter. Catheters of this size are more likely to become occluded than larger balloon or mushroom catheters.^[9]

Balloon catheters (see image below)

• Used for radiologic, endoscopic, and surgical gastrostomy, balloon catheters are also used widely as replacement catheters for dislodged or occluded feeding tubes.
• When placed or replaced percutaneously, these catheters may require the use of a peel-away sheath that is larger than the catheter by as much as 4F.
• Because the antegrade migration of the device can result in gastric outlet obstruction, some physicians advocate the use of catheters with external ring fasteners.
• Silicone catheters are believed to be more durable than latex Foley catheters, although the latter are also commonly used to replace dislodged feeding tubes. The incidence of latex allergies in enteral access patients is unknown, but silicone catheters may have an additional advantage in this regard.

Mushroom (bumper) catheters

• Traditionally used only for pull-technique endoscopic gastrostomy placement, mushroom (or bumper) catheters also can be placed by using interventional radiologic techniques.
• Unless placed endoscopically, the catheters are typically not used as replacement catheters for dislodged or occluded tubes.
• Catheter removal techniques include endoscopic extraction, firm external catheter retraction, or cutting the catheter at the skin and allowing the inner component to be eliminated intestinally.
• Because these catheters must pass through the mouth, this type of tube may predispose patients to a higher rate of infection than that of catheters placed via the push technique.

Fasting and nasogastric decompression

• All patients undergoing de novo placement of gastrostomy, gastrojejunostomy, or jejunostomy tubes should fast for several hours (ideally, overnight) prior to the procedure. Leakage of a small amount of gastric or intestinal contents is not unusual during the creation of a new tract, and fasting may reduce the risk of peritonitis.
• Because nasogastric tubes are usually necessary for gastric insufflation during tube placement, some physicians choose to use these tubes for enteric suction to facilitate emptying prior to the procedure.

Antibiotics

• A prospective, randomized trial of prophylactic antibiotics showed that cefazolin (1 g intravenously administered) reduced the rate of infection from 28.6% to 7.4% in the setting of endoscopically placed gastrostomy tubes. For radiologically placed gastrostomy tubes, the reported infection rate without routine antibiotic use has been found to be 1-4%.
• The reason for this disparity is not clear, but it may be due to the fact that endoscopically placed gastrostomy tubes are frequently introduced using the pull technique, which drags oral flora through the skin tract. Most gastroenterologists routinely use prophylactic antibiotics, but many radiologists do not, although the selective use of antibiotics in immunocompromised patients may be valuable. To the author's knowledge, no clinical trial to date has been performed to evaluate the role of prophylactic antibiotics independent of the tube placement technique.

Percutaneous approaches

• Percutaneous gastrostomy placement is predominantly performed by using either the push, or Sacks-Vine, technique or the pull, or Ponsky-Gauderer, technique.
• With the push technique, the feeding tube is pushed though the abdominal wall over a wire into the gut, using fluoroscopic guidance. Usually, loop catheters or balloon catheters are placed. Initial tube placement often entails the use of a peel-away sheath. Most radiologic gastrostomy and gastrojejunostomy access procedures and all radiologic jejunostomy access procedures use the push technique.
• With the pull technique, the feeding tube is advanced through the patient's mouth into the stomach and is pulled out through the abdominal wall using a snare introduced through a fluoroscopically guided direct gastric puncture site. Although traditionally performed by endoscopists, interventional radiologists can successfully perform the pull technique as well. Mushroom, or bumper, catheters are usually placed with this method. This technique is particularly useful in the placement of large-bore gastrostomy or gastrojejunostomy catheters in children.^[6]

Access options

• Direct gastrostomy tube placement entails the placement of a feeding catheter directly through the abdominal wall into the stomach (see image below). Direct gastrostomy tube placement is technically straightforward and more likely to be successful than gastrojejunostomy or direct jejunostomy tube placement. Direct percutaneous gastrostomy tube placement entails placement of a feeding catheter directly into the stomach by using imaging guidance. A balloon catheter is illustrated.
• With gastrojejunostomy, or transgastric jejunostomy, techniques similar to direct gastrostomy tube placement can be used to advance a feeding tube through the stomach and duodenum into the jejunum to allow gastrojejunostomy tube feedings (see image below). The procedure is probably best reserved for patients at higher risk of aspiration, because gastrojejunostomy tube placement is more difficult and expensive than gastrostomy tube placement and is associated with a higher incidence of tube occlusion and dislodgement. When necessary, previously placed gastrostomy tubes can be converted into gastrojejunostomy tubes. Also called transgastric jejunostomy, gastrojejunostomy tube placement entails the placement of a feeding tube through the stomach and duodenum, with the tip terminating in the jejunum. This method combines the simplicity of gastric access with the benefits of direct small-bowel tube feedings.
• Initial direct tube access into the jejunum can be achieved by means of direct percutaneous jejunostomy (see image below), although this method is used less frequently than gastrostomy or gastrojejunostomy access. Percutaneous jejunostomy entails the placement of a feeding tube directly into the small bowel. This method is technically more difficult than percutaneous gastrostomy and is associated with a higher risk.
• Occasionally, a catheter, balloon, or snare is advanced into the jejunum and used as a fluoroscopic target for direct jejunal puncture. This technique appears to be safe, but it is technically more difficult than gastrostomy or gastrojejunostomy and is probably best reserved for specific difficult clinical situations.

Typical procedural technique

• The patient should be anesthetized appropriately, as discussed in the Anesthesia section above.
• Fluoroscopic visualization, gastric puncture, and tract dilatation are greatly facilitated by gaseous distention of the stomach. Typically, this is performed through a nasogastric tube, which can be placed before the procedure on the nursing floor or in the interventional radiology suite under fluoroscopic guidance. In the rare patient in whom nasogastric access cannot be achieved (eg, patients with esophageal strictures or facial trauma), gastric distention may be performed through a needle introduced into the stomach under imaging guidance.
• In addition to fluoroscopic localization of the stomach, many interventional radiologists find ultrasonographic examination of the abdomen to be extremely helpful in avoiding transhepatic access in patients with a large left hepatic lobe. Doppler sonographic assessment of the abdominal wall may help in localizing the superior epigastric artery so that a puncture site can be selected to minimize the risk of bleeding. Gray-scale ultrasonography is usually helpful in identifying the location of the liver. Visualization of the air-filled transverse colon is usually easy with fluoroscopy, but some interventional radiologists prefer to administer a dilute barium suspension into the gut 1 day prior to the procedure to aid visualization and minimize the risk of colonic puncture. The Image below illustrates the collective anatomic information that can be obtained by using fluoroscopy, ultrasonography, and Doppler ultrasonography. An abdominal photograph is superimposed on an abdominal radiograph in the same patient to illustrate the important landmarks for gastric puncture. The margin of the left hepatic lobe is marked on the skin (curved solid line) by using ultrasonographic guidance, and the course of the superior epigastric artery (dotted vertical line) is traced by using a Doppler technique. A metal marker overlies the intended access tract into the gastric body and antral junction.
• Oblique and lateral fluoroscopy is often extremely helpful in confirming the location of the needle in the lumen (see image below). A wire is introduced through this needle, and gastropexy anchors may be placed. With anterior fluoroscopy alone, the depth of the needle cannot be determined when gastric access is achieved. With lateral or steep oblique fluoroscopic imaging, the anterior gastric wall is shown as being indented (red marks on the right) just before the needle enters the gastric lumen.
• Abdominal wall and gastric wall dilatation can be achieved by using either serial Teflon dilators or angioplasty balloons. A variety of catheters are available for both feeding and decompression. At the time of initial catheter placement, a peel-away sheath is often necessary to facilitate tube placement.

Gastropexy

• Described independently in 1986 by both Brown and Cope, percutaneous gastropexy involves the placement of a threaded metal or nylon fastener into the stomach through a needle (see image below).^{[7, 8]} Gastropexy anchors help secure the anterior gastric wall to the anterior abdominal wall during tract dilatation and balloon gastrostomy tube placement. Cope gastric anchors are illustrated here (bottom right), just inferior to the gastrostomy retention balloon.
• The fastener helps to appose the anterior gastric wall to the anterior abdominal wall. In the radiology literature, opinions regarding the use of routine gastropexy are mixed. Several large series have shown success both with and without routine gastropexy. The technique seems particularly promising in the setting of ascites, which was previously considered a contraindication to percutaneous gastrostomy. However, gastropexy can contribute to abdominal wall and gastric wall ischemia and can predispose patients to infections and other complications, such as pericatheter leakage.

Postprocedural observation

• With respect to percutaneous gastrostomy and gastrojejunostomy tubes, early postprocedural complications are uncommon. Accordingly, these procedures can be safely performed on an outpatient basis, followed by several hours of postprocedural observation before the patient is discharged home or to a nursing facility. Because many patients referred for feeding tube access have other ongoing medical problems, a large number of them are already hospitalized.
• Because the risk of enteral content leakage is believed to be higher with direct jejunostomy tube placement than with other methods, most interventional radiologists prefer to admit new patients in need of a jejunostomy tube to the hospital for postprocedural observation and care.
• Mild catheter site discomfort is expected for a period of between several hours to days after enterostomy tube placement. Patients with worsening pain or signs and symptoms of peritonitis should be referred for surgical consultation. Even if postprocedural peritonitis develops, most patients can effectively be treated with nonsurgical means as long as the tube is correctly positioned in the stomach or jejunum.

Instituting feeds

• For gastrostomy tubes, a conservative and anecdotal approach has been to withhold feedings for 24 hours after tube placement. Then, after water is infused at a rate of 50 mL per hour for 4 hours, tube feedings have been started at a rate of 50 mL per hour. However, evidence now indicates that direct gastrostomy tube feedings can be initiated 3 hours after tube placement, with the same degree of safety.^[10]
• No universal guidelines exist with respect to the timing of the first feeding through new gastrojejunostomy tubes. Experience from large series indicates that feedings can safely begin 4 hours after tube placement. Results of smaller series suggest that the immediate initiation of tube feedings also is safe.
• Because the published experience with percutaneous radiologic jejunostomy tube placement is limited, no universal guidelines exist for the initiation of tube feedings. When de novo jejunostomy access is created for feeding purposes, many physicians wait 24-48 hours before using the tube for feeding.

Follow-up care

• Tube sites should be checked on a daily basis for leakage or signs of infection. The patient and his or her family or health care provider can evaluate the site at the time of routine dressing changes.
• If gastropexy anchors are placed, the sutures are usually removed 10-21 days after initial tube placement. Some physicians choose to bury these sutures below the skin surface rather than remove them at a later date.
• As long as tubes are functioning well, routine changes are not necessary. In patients with recurrent tube dislodgement or occlusion, scheduled tube changes may reduce the need for more urgent tube maintenance procedures. For more information, see eMedicine article Gastrostomy Tube Replacement.

Although catheters are intended for long-term, problem-free enteral access, some sites become infected, and many catheters become either occluded or dislodged. Interventional radiologists who seek to develop enteral access services should also be able to manage common problems related to feeding tubes.

Catheter occlusion

• Occluded enteral catheters are occasionally opened by vigorous flushing or with Fogarty balloon catheters, but most require catheter exchange over a wire to restore patency. Such exchanges require no specific preprocedural care (eg, antibiotics or fasting), and the tubes can be used immediately for feeding after a successful exchange.
• In patients with recurrent and frequent tube occlusions, catheter care and tube choice should be reviewed carefully. These patients may benefit from more frequent and vigorous catheter flushing or from tubes with larger inner lumina.

Catheter dislodgement

• Dislodged tubes should be replaced as promptly as possible to maintain feeding access in patients who are, by definition, nutritionally impaired. Sinus tracts (see image below) are usually catheterized easily by using angiographic catheters and wires, but occasionally they can be cannulated with feeding tubes themselves. Dislodged gastrostomy tubes can be replaced successfully through mature tracts within 1 day and often as late as 5 days after dislodgement. Dislodged jejunostomy tubes may require particularly expedient attention to obviate surgical replacement, because the tracts can close in just hours. No specific preprocedural care (eg, antibiotics or fasting) is necessary. Tubes can be used for feedings immediately after their successful replacement. When gastrostomy tubes are dislodged, the sinus tract (top right) can be readily identified and recanalized for up to several days. With sinus tracts of this diameter, feeding tubes can often be reinserted directly. When tracts are narrower, angiographic catheters and wires are often used, and tract dilatation may be necessary for tube replacement.
• In the setting of mature tracts, dislodged tubes can often be replaced without imaging guidance; however, many cases require fluoroscopy. Tube replacement may necessitate the use of peel-away sheaths (see image below), particularly if the tube has been dislodged for some time or if the tract is narrow. Jejunostomy tube replacement. After tube dislodgement, jejunostomy tracts may close more rapidly than gastrostomy tracts. This narrowed sinus tract required dilatation and peel-away sheath placement (left) to allow placement of a silicone balloon catheter (right).
• Compared with the use of mature tracts, catheter replacement through immature tracts is less likely to be successful. Enterostomy tracts usually mature within 2 weeks of tube placement, and many physicians believe that tube and tract interventions after that time have an increased margin of safety.
• In patients with frequently recurring catheter dislodgements, catheter care and tube choice should be carefully reviewed and modified, if necessary. These patients may benefit from larger catheters, larger retention balloons, or more durable silicone feeding catheters.

Other tube tract issues

• Although mature tracts occasionally become disrupted without explanation during uneventful tube exchanges performed by experienced interventional radiologists, disruption appears to be an uncommon event. When the tracts are disrupted, tube replacement usually serves as definitive therapy.
• Literature regarding the best techniques for catheter replacement is lacking, and individual operator preferences vary widely. However, radiologic replacement is considered simple and expeditious, and it is often preferred. When necessary, mature tracts of problem catheters can be dilated safely, with or without imaging guidance, to accommodate larger tubes.

Leakage at the tube site

• Patients perceive external pericatheter leakage as being particularly problematic. Excessive external tube motion may contribute to the expansion of the tube entry site, and external rings or fasteners may be helpful in this regard. The use of larger catheters and the further inflation of intraluminal balloons may be useful in preventing the exit of enteric contents, as may the use of purse-string sutures.
• If stomal-site enlargement is related to skin breakdown due to infection, appropriate antibiotics should be administered.
• The placement of longer tubes, such as gastrojejunostomy tubes through gastrostomy sites, also may help minimize fluid contact at the stomal site and facilitate healing.

Tube-site infections

• Tube-site infections are not uncommon and can usually be treated if they are recognized early.
• Cellulitis is the most common catheter-related infection (see image below). The most common presentations of cellulitis are erythema and tenderness surrounding the catheter. Patients rarely have constitutional symptoms, and infections often resolve rapidly with local wound care and oral antibiotics. Regarding tube-site infections, most catheter-related infections involve local cellulitis, as shown here, with erythema and tenderness. These infections frequently respond to local wound care and oral antibiotics.
• A rare but fulminant feeding tube–related infection is necrotizing fasciitis. Only a few cases have been reported in the literature. When this complication occurs, it seems to develop within 3-14 days after initial tube placement, when patients present with a high temperature, progressive cellulitis, and crepitus. Patients who are obese and those who have diabetes or heart disease appear to be most predisposed to this problem. Aggressive treatment is necessary and should include intravenous antibiotics and, occasionally, surgical debridement.
• Although enteral tube-site infections are often polymicrobial, Staphylococcus aureus and beta-hemolytic streptococci are commonly involved organisms. In addition, fungal superinfection is not uncommon. Unless a specific organism is identified by means of cultures, the first-line therapy should be directed toward common bacterial organisms. First-line oral antibiotics include Keflex (cephalexin 250-1000 mg by mouth [PO] q6h) and Augmentin (amoxicillin/clavulanate 500-875 mg PO q12h). In patients with anaphylactic reactions to penicillin, Cleocin (clindamycin 150-450 mg PO q6h) should be considered.

Aspiration risk

• Depending on the patient's risk of aspiration with tube feedings, the placement of a tube into the small bowel (by means of either gastrojejunostomy or direct jejunostomy) may be preferred to direct gastrostomy tube placement.
• Compared with nasogastric feeding, nasojejunal feeding is desirable and is associated with a greater number of administered calories and a lower risk of pneumonia. Although any tube placed through the gastroesophageal junction promotes gastroesophageal reflux and theoretically predisposes patients to aspiration, more distal enteric feeding may reduce this risk.
• With direct enteral tube placement, the salutary effect of small-bowel tube placement is less convincing than it is with nasally introduced tubes. Gastrostomy tubes do not predispose patients to gastroesophageal reflux, but many patients fed through gastrostomy tubes are at some risk of aspiration because of underlying disease. Although gastrojejunal and direct jejunal feeding tubes may reduce the risk of aspiration, the added benefit is debatable. The use of gastrojejunostomy tubes is probably best reserved for patients with known gastroesophageal reflux or documented aspiration.

Clinical comparison of alternative techniques

A literature review indicates that radiologically guided gastrostomy compares favorably with surgical and endoscopic gastrostomy, with similar or improved success and complication rates. The results of a meta-analysis by Wollman et al are summarized in Table 1 (see below).^[11]

Table 1. Comparisons of Procedural Success and Complication Rates (Open Table in a new window)

Economic comparison of alternative techniques

Although comparative analyses of procedural costs are complicated and may be difficult to reproduce, the overall costs of radiologic gastrostomy appear to be similar to those of endoscopic gastrostomy and less than those of surgical gastrostomy. For gastrojejunostomy access, radiologic methods are less expensive than either endoscopic or surgical techniques. The results of a cost analysis performed by Barkmeier and colleagues in 1998 are summarized in Table 2 (see below).^[12]

Table 2. Procedural Costs in US Dollars (Open Table in a new window)