Procedure:  Percutaneous antegrade gastrostomy tube placement          

Indication: Altered Mental Status;    

Date:     

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

Medications:  1 mg IV glucagon, 600 mg IV Clindamycin,  4 mg IV Zofran,     mgs IV Versed and     mcg IV fentanyl

Contrast:  15 mL nonionic  

Fluoroscopy time:     minutes

Catheter: 20 French MIC Kimberly-Clark gastrostomy tube

Complications:  None immediate.

 

Technique:

The risks, benefits, and alternatives to the procedure and sedation were explained to the patient.  The specific risk of damage to adjacent structures was detailed and accepted. Written informed consent was obtained.  A time out/call to order was performed prior to procedure initiation. 

The patient was assessed for conscious sedation and found to be an adequate candidate. A dedicated nurse monitored heart rate, blood pressure, and oxygen saturation throughout the procedure.

The anterior abdominal wall was prepped and draped in sterile fashion. Ultrasound was used to mark the liver edge.  Fluoroscopy was utilized to localize the transverse colon. IV glucagon was administered. Through a nasogastric tube, the stomach was insufflated with air.

Under fluoroscopic guidance, the stomach was punctured toward the GE junction with an 18 gauge needle. Contrast injection confirmed location. A 0.035-inch Amplatz wire was advanced into the stomach and negotiated across the gastroesophageal junction.   The guidewire was advanced out the oral cavity and grasped.

A 9F peel-away sheath was placed retrograde from the dermatotomy in the left upper quadrant.  A snare device was advanced “monorail” over the wire and pulled from the anterior abdominal wall out the oral cavity.  The gastrostomy tube was attached to the snare device and pulled through the esophagus into the gastric lumen. The disc was pulled firmly against the gastric wall utilizing fluoroscopic guidance. 

The catheter was cut to length and the hub attached. Contrast was injected to confirm location. A sterile dressing was applied.   

The catheter was placed to gravity drainage and orders written for NPO and no tube use for 24 hours.

The procedure was well tolerated, and the patient discharged from the angio suite in satisfactory condition.

 

Findings:

The tube enters the gastric body to the left of midline.  Contrast injection confirms appropriate intragastric location.

 

Impression: 

Uneventful percutaneous image guided placement of a 20 French antegrade gastrostomy tube as described.