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Gastrostomy Tube

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Ep 252 How I Place Gastrostomy Tubes with Dr. Christopher Beck

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Pre-Procedure Prep

Indications

• Enteral feeding for long-term nutritional support
• Gastric decompression

Many more specific indications that fall into the above categories such as:
• Impaired swallowing
• Stroke
• Aspiration
• Esophageal obstruction

Contraindications

• Lack of safe access to the stomach; large hiatal hernia or prior surgery
• Uncorrectable coagulopathy
• Peritonitis
• Bowel ischemia
• Gastric varices
• Gastric cancer or peritoneal carcinomatosis
• Severe gastroesophageal reflux
• Ascites

Contraindications

Pre-Procedural Evaluation

• H&P
• Prior surgery or radiation to stomach or abdomen
• Labs: coagulation profile and CBC
• Prior Imaging - cross sectional of the abdomen
• Provide contrast to patient for oral intake day before procedure to opacify the colon

Gastrostomy Tube Podcasts

Listen to leading physicians discuss gastrostomy tube on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #252

How I Place Gastrostomy Tubes

In this episode, Dr. Aaron Fritts interviews Dr. Christopher Beck about gastrostomy tubes, including the evolution of his method, tips for patients who pull their tubes out, and why g-tubes are such a controversial topic in IR.

Episode #2

G-Tubes Two Ways

Special guests Peter Bream MD and Aaron Brandis MD discuss the Balloon-Assisted (BAG) and Per-oral (POG) techniques for the gastrostomy procedure.

Procedure Steps

Antibiotics

Push technique:
• 1-2 g cefazolin (Ancef) IV preprocedure
• Clindamycin if PCN allergy
Pull type:
• 1-2 g cefazolin (Ancef) IV preprocedure
• 500 mg cephalexin (Keflex) PO BID x 5 days following procedure
• Clindamycin for PCN allergy

Procedure

Many techniques for placing gastrostomy tube. Push method described below

Prep

• Work from patient's left and have US prepped for liver marking
• Place nasogastric tube if not already done
• 0.5-1.0 g of glucagon to reduce gastric motility and emptying
• Insufflate stomach with air
• Mark liver edge with US

Place T-fasteners

• Optimal G-tube placement is equal distance between greater and lesser curvature at mid to distal body of stomach
• Connect T-fasteners to connection tube with half-filled contrast syringe
• Choose entry site in AP projection and seat needle in soft tissue
• Advance T-fasteners with image intensifier in RAO position: keeps hands out of field and easier to visualize needle indenting the gastric wall
• Aspirate air, then injection contrast to identify gastric folds
• Place 1-3 T-fasteners

Gastrostomy Tube

• Advance 18 g needle into stomach
• Some angle toward antrum anticipating subsequent GJ conversion
• Place 0.035" wire - Amplatz Super Stiff (Boston Scientific)
• Serially dilate
• Advance sheath. Some telescoping sheaths are able to dilate and peel-away
• Place G-tube
• Inflate balloon with sterile water (reasonable to add contrast to solution for better visualization of balloon)
• Inject contrast to outline gastric folds and confirm intragastric position
• Pull balloon to anterior wall and secure disc

Post-Procedure

Post-Procedural Care

• Patient fasting x 12 hours
• Assessed the following day for peritoneal signs
• Instill 30-60 cc of saline through G-tube into stomach: check for resistance with injection or signs of discomfort
• G-tube is then cleared for enteral feeding

Complications

Minor:
• Tube occlusion: 4.5%
• Tube dislodgement: 1.3 - 4.5%
• Leakage around tube: 11%
• Superficial stomal infection: 25 - 45%

Major
• Death: 0.3%
• Peritonitis: 1.3%
• Hemorrhage: < 3%
• Severe skin infection: minimal
• Bowel perforation: minimal

Follow-Up

• If gastropexy tacks do not resorb, remove in 2 weeks
• Chage tube Q6 months or as needed
• First exchange should be with fluoroscopy
• Subsequent exchanges can be done without fluoroscopy

Gastrostomy Tube Demos

Watch video walkthroughs of gastrostomy tube on the BackTable VI expanded content network.

Gastrostomy Tube (G-Tube) Placement

Radiographically Placed Gastrostomy Feeding Tubes

References

[1] Bream P Jr, Krohmer SJ, Pillai AK, Bones Md BL, Dickey KW. Percutaneous Gastrostomy: How to Recognize, Avoid, or Get Out of Trouble. Tech Vasc Interv Radiol. 2018;21(4):255‐260. doi:10.1053/j.tvir.2018.07.007
[2] Karthikumar B, Keshava SN, Moses V, Chiramel GK, Ahmed M, Mammen S. Percutaneous gastrostomy placement by intervention radiology: Techniques and outcome. Indian J Radiol Imaging. 2018;28(2):225‐231. doi:10.4103/ijri.IJRI_393_17
[3] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483‐1501.e2. doi:10.1016/j.jvir.2018.06.007
[4] Covarrubias DA, O'Connor OJ, McDermott S, Arellano RS. Radiologic percutaneous gastrostomy: review of potential complications and approach to managing the unexpected outcome. AJR Am J Roentgenol. 2013;200(4):921‐931. doi:10.2214/AJR.11.7804
[5] Lyon SM, Pascoe DM. Percutaneous gastrostomy and gastrojejunostomy. Semin Intervent Radiol. 2004;21(3):181‐189. doi:10.1055/s-2004-860876
[6] Bream P Jr, Krohmer SJ, Pillai AK, Bones Md BL, Dickey KW. Percutaneous Gastrostomy: How to Recognize, Avoid, or Get Out of Trouble. Tech Vasc Interv Radiol. 2018;21(4):255‐260. doi:10.1053/j.tvir.2018.07.007
[7] BackTable, LLC (Producer). (2017, May 23). Ep 2 – G-Tubes Two Ways [Audio podcast]. Retrieved from https://www.backtable.com/shows/vi

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