PROCEDURE: Percutaneous image guided antegrade gastrostomy tube placement          

 

INDICATION:    

DATE:    

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

MEDICATIONS:  Glucagon     mg IV, Versed     mg IV, and Fentanyl     mcg IV

CONTRAST:    

FLUOROSCOPY TIME:     minutes

CATHETER: 20F Kimberly Clark gastrostomy tube

COMPLICATIONS: None

 

TECHNIQUE: The risks, benefits, and alternatives to the procedure and sedation were explained.  The specific risk of damage to adjacent structures was detailed and accepted.  Written informed consent was obtained.  

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. 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 over the wire and pulled from the anterior abdominal wall out the oral cavity. The peel-away sheath was removed.  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 capped 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:

  1. There is a safe window for percutaneous gastric access free of liver and overlying bowel.
  2. Contrast injection through the tube confirms intraluminal gastric location.

 

IMPRESSION: 

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

 

PLAN:  NPO for 24 hours with G-tube to gravity drainage.  After 24 hours, flush tube with 20 ml of saline every hour x 4 – if there is no pericatheter leak or pain the tube may be used for enteral feeds at the direction of the primary team.