Percutaneous Gastrostomy and Jejunostomy Periprocedural Care

Updated: Jan 13, 2016
  • Author: Richard Duszak, Jr, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR  more...
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Periprocedural Care

Patient Education and Consent

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.

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Equipment

Catheters commonly used for radiologic enteral access include Cope loop catheters, balloon catheters, and mushroom (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 two catheter types mentioned above.

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

Used almost exclusively by interventional radiologists, Cope loop catheters (see the image below) can be placed by employing the Seldinger technique, often without the need for peelaway sheaths. Loop catheters are typically 16 French or smaller in diameter. Catheters of this size are more likely to become occluded than larger balloon or mushroom catheters. [10]

Commonly used by radiologists, Cope loop catheters Commonly used by radiologists, Cope loop catheters (illustrated with metal introducer stiffener) are easily placed into stomach. However, their small lumina and small side holes predispose them to catheter occlusion.

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, current loop catheters may be associated with fewer complications, but they appear to be less durable than mushroom catheters.

Balloon catheters

Used for radiologic, endoscopic, and surgical gastrostomy, balloon catheters (see the image below) 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 peelaway sheath that is larger than the catheter by as much as 4 French. Because the antegrade migration of the device can result in gastric outlet obstruction, some physicians advocate the use of catheters with external ring fasteners.

Commonly used for surgical, endoscopic, and radiol Commonly used for surgical, endoscopic, and radiologic gastrostomy access, balloon catheters provide secure intraluminal retention and are simple to place and replace.

Silicone catheters are believed to be more durable than latex Foley catheters, though 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 (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, they may predispose patients to a higher rate of infection than is seen with catheters placed via the push technique.

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Patient Preparation

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.

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Monitoring & Follow-up

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 Gastrostomy Tube Replacement.

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