Percutaneous Gastrostomy and Jejunostomy Technique

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

Approach Considerations

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.

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Percutaneous Access to Stomach and Jejunum

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 intravenous (IV) administration of 1 g of cefazolin 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 by means of the pull technique, which drags oral flora through the skin tract. Most gastroenterologists routinely use prophylactic antibiotics, but many radiologists do not, though 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.

Push vs pull technique

Percutaneous gastrostomy placement is predominantly performed by using either the push (Sacks-Vine [11] ) technique or the pull (Ponsky-Gauderer [12] ) technique.

With the push technique, the feeding tube is pushed though the abdominal wall over a wire into the gut under fluoroscopic guidance. Usually, loop catheters or balloon catheters are placed. Initial tube placement often entails the use of a peelaway 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 this technique is traditionally performed by endoscopists, it can be successfully performed by interventional radiologists as well. Mushroom (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. [13]

Gastrostomy vs gastrojejunostomy vs jejunostomy

Direct gastrostomy tube placement entails the placement of a feeding catheter directly through the abdominal wall into the stomach (see the 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 ent Direct percutaneous gastrostomy tube placement entails placement of feeding catheter directly into stomach by using imaging guidance. 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 the image below). The procedure is probably best reserved for patients at higher risk for aspiration; gastrojejunostomy tube placement is more difficult and expensive than gastrostomy tube placement and is associated with a higher incidence of tube occlusion and dislodgment. When necessary, previously placed gastrostomy tubes can be converted into gastrojejunostomy tubes.

Also called transgastric jejunostomy, gastrojejuno Also called transgastric jejunostomy, gastrojejunostomy tube placement entails placement of feeding tube through stomach and duodenum, with tip terminating in jejunum. This method combines simplicity of gastric access with 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), though this method is used less frequently than gastrostomy or gastrojejunostomy access.

Percutaneous jejunostomy entails placement of feed Percutaneous jejunostomy entails placement of feeding tube directly into small bowel. This method is technically more difficult than percutaneous gastrostomy and is associated with 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 procedure

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. (See the image below.) Doppler sonographic assessment of the abdominal wall may help localize 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.

Abdominal photograph is superimposed on abdominal Abdominal photograph is superimposed on abdominal radiograph in same patient to illustrate important landmarks for gastric puncture. Margin of the left hepatic lobe is marked on skin (curved solid line) by using ultrasonographic guidance, and course of superior epigastric artery (dotted vertical line) is traced by using Doppler technique. Metal marker overlies intended access tract into gastric body and antral junction.

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.

Oblique and lateral fluoroscopy is often extremely helpful in confirming the location of the needle in the lumen (see the image below). A wire is introduced through this needle, and gastropexy anchors may be placed.

With anterior fluoroscopy alone, depth of needle c With anterior fluoroscopy alone, depth of needle cannot be determined when gastric access is achieved. With lateral or steep oblique fluoroscopic imaging, anterior gastric wall is shown as being indented (red marks on the right) just before needle enters gastric lumen.

Abdominal wall and gastric wall dilatation can be achieved by using either serial Teflon dilators or angioplasty balloons. Various catheters are available for both feeding and decompression. At the time of initial catheter placement, a peelaway 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 the image below). [14, 15]

Gastropexy anchors help secure anterior gastric wa Gastropexy anchors help secure anterior gastric wall to 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 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 (eg, pericatheter leakage).

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Postprocedural Care

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.

Institution of feeding

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/hr for 4 hours, tube feedings have been started at a rate of 50 mL/hr. However, there is evidence to indicate that direct gastrostomy tube feedings can be initiated 3 hours after tube placement, with the same degree of safety. [16]

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 jejunostomy access is created de novo for feeding purposes, many physicians wait 24-48 hours before using the tube for feeding.

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Complications

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 dislodgment

Dislodged tubes should be replaced as promptly as possible to maintain feeding access in patients who are, by definition, nutritionally impaired. Sinus tracts (see the image below) are usually catheterized easily by using angiographic catheters and wires, but occasionally they can be cannulated with feeding tubes themselves.

When gastrostomy tubes are dislodged, sinus tract When gastrostomy tubes are dislodged, 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.

Dislodged gastrostomy tubes can be replaced successfully through mature tracts within 1 day and often as late as 5 days after dislodgment. 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.

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 peelaway sheaths (see the image below), particularly if the tube has been dislodged for some time or if the tract is narrow.

Jejunostomy tube replacement. After tube dislodgem Jejunostomy tube replacement. After tube dislodgement, jejunostomy tracts may close more rapidly than gastrostomy tracts. This narrowed sinus tract required dilatation and peelaway sheath placement (left) to allow placement of 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 dislodgments, 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 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 the 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-rela 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 IV 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 cephalexin (250-1000 mg orally [PO] q6hr) and amoxicillin-clavulanate (500-875 mg PO q12hr). In patients with anaphylactic reactions to penicillin, clindamycin (150-450 mg PO q6hr) should be considered.

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