G-Tube Placement with Balloon Technique and Dictation

PROCEDURE: IMAGE GUIDED RETROGRADE GASTROSTOMY TUBE PLACEMENT

INDICATION: Head and neck cancer with tracheostomy requiring G-tube placement.

OPERATOR: John Doe, MD (Attending)/Jane Doe, MD (Fellow)    

MEDICATIONS:

1. Fentanyl 150 mcg IV
2. Glucagon     mg IV
3. Ancef 1 g IV
4. Zofran 4 mg IV

CONTRAST: 20 mL of nonionic contrast

FLUOROSCOPY TIME: 5.8 minutes

CATHETER: 18 French ballooned G-Tube

DEVICE: 8 mm x 10 cm Conquest balloon

COMPLICATIONS: None

PROCEDURE:

The risks, benefits, and alternatives to the procedure and sedation were explained to the patient. The specific risks of bleeding, infection, and damage to liver or bowel were discussed and accepted. Written informed consent was obtained.

The anterior abdominal wall was prepped and draped in sterile fashion. The abdomen was evaluated with ultrasound and the liver margin was marked on the skin surface. The patient was given glucagon IV, and the stomach was inflated with air via a previously placed nasogastric tube.  The stomach was visualized fluoroscopically in multiple projections to exclude the presence of overlying bowel.

The skin and subcutaneous tissues overlying the stomach were infiltrated with 2% Lidocaine without lidocaine. Stay suture needles were advanced into the stomach under lateral fluoroscopic visualization, and intragastric position was confirmed by injection of contrast into the stomach. Stay sutures were placed to tack the anterior wall of the stomach against the anterior abdominal wall.  A dermatotomy was then made between the stay sutures, and a needle was inserted into the stomach through which an Amplatz stiff wire was passed.  

An 8mm by 100 mm Conquest balloon was preloaded through an 18 French Kimberly-Clark gastrostomy tube.  This combination was placed over the wire and the balloon positioned partially within the gastric lumen  traversing the skin tract.    The balloon was inflated. It was then deflated and the gastrostomy tube and balloon combination advanced over the wire such that the gastrostomy tube enters the gastric lumen. The gastrostomy balloon was inflated with 10 mL saline. The Conquest balloon was removed over the wire. Contrast injection confirmed location.  

The patient tolerated the procedure well, without immediate complication.

FINDINGS: 

Scout image of the abdomen demonstrates an enteric tube projecting over the stomach. Using fluoroscopy, a safe percutaneous window was identified free of overlying colon. Contrast injection confirms intraluminal position. 

The newly placed gastrostomy tube courses between the stay sutures and enters the gastric body to the left of midline.

IMPRESSION:  

Successful image guided placement of a retrograde gastrostomy tube as described above.

PLAN: Gastrostomy tube to gravity drainage x 24 hours. If patient tolerates this (no pain, bleeding, or pericatheter leakage), may initiate saline trial with 20 ml normal saline flushed through tube every hour x 4. If patient tolerates this, may initiate tube feeds per primary team.