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38 Interventions oftheBiliary Tract
475
Patient preparation includes the following steps [15]:
• Adequate antibiotic coverage—usually a combination of
Piperacillin and Tazobactam is administered intravenously as manipulations in an obstructed system carry a
risk of cholangitis and venous reux of bile.
• Preferably fasting for at least 4 hours prior to the
procedure.
• Intravenous analgesics for anxiety and pain alleviation.
38.4.2 Indications
• Provide adequate biliary drainage for:
– Relieving acute or recurrent cholangitis
– Palliation of symptoms of jaundice, such as pruritus
– Optimization of bilirubin level for chemotherapy
administration
• PTBD is preferred over endoscopic drainage in patients
with:
– Unsuccessful endoscopic drainage
– Obstruction in the proximal biliary tree
– Surgically altered upper gastrointestinal tract anatomy
• Divert bile from site of leakage and permit placement of
stent in bile duct defect
• Provide portal of access to biliary tract for therapeutic
purposes:
– Dilation of biliary strictures
– Removal of bile duct stones
– Stent placement in malignant lesions
– Brachytherapy/phototherapy
– Endoluminal tissue sample or foreign body retrieval
38.4.3 Contraindications
Absolute contraindication for procedure is an uncorrected
bleeding diathesis, while the presence of ascites is a relative
contraindication [15].
38.4.4 Technique
PTBD is performed under ultrasound as well as uoroscopy
guidance.
– The choice of duct for the puncture depends upon the
expertise level of the radiologist and whether it will drain
at least one-sixth of the hepatic parenchyma or not.
– The targeted lobe should not be atrophic or have portal
vein involvement as it would not be effective enough in
relieving the obstruction [16].
– If either the right or the left secondary conuence is
involved, drainage of the contralateral lobe is preferred
to ensure that at least half of the functional liver parenchyma is drained.
– Patients with involvement of both secondary conu-
ences are poor candidates for PTBD as they require
placement of multiple catheters in both lobes for normalization of serum bilirubin. When such patients
develop cholangitis, drainage is done for the segment
that shows cholangitic abscesses on imaging. If there
are no cholangitic abscesses on imaging, sequential
drainage of multiple segments can be done until there
is symptomatic improvement.
– The differences between right- and left-sided PTBD
are summarized in Table38.3.
• Puncture of the Biliary System
– Under ultrasound guidance, the appropriately dilated
ductal system is punctured using an 18G puncture needle
as peripheral as possible to reduce the risk of bleeding.
Bile is aspirated to ensure proper position of the needle.
– Check cholangiogram is done using low osmolar
water-soluble contrast (Iohexol) and only 5–10ml of
contrast is injected to avoid venous reux of bile, cholangitis and sepsis.
– A 0.035″ hydrophilic guide wire is then passed through
the needle and its position is monitored using
uoroscopy.
– The needle is removed and angiographic catheter is
positioned over the guidewire and is manipulated
across the obstruction. However, multiple attempts of
manipulation should be avoided.
– If catheter is not manipulated beyond the obstruction,
external biliary drainage is done. Internalization can
then be attempted after 3–4days once the biliary system is decompressed. However, if it passes beyond the
site of obstruction, a Ring biliary catheter is used for
ensuring both internal and external biliary drainage
(Fig.38.1) [15].
• Selection of the Target Duct for Puncture
– Site of obstruction is dened as high (involving the pri-
mary biliary conuence) and low (involving biliary
duct below cystic duct insertion). PTBD is preferred
for high obstruction, while endoscopic drainage is preferred for low obstruction.
38.4.5 Post-Procedure Care
Major complications such as cholangitis, sepsis and bleeding
can occur following PTBD.Hence, adequate post-procedure
monitoring is necessary. Proper post-procedure care is also
essential to increase the success rate of the procedure.
476
P. Garg et al.
Table 38.3 Differences between right- and left-sided PTBD
Right-sided PTBD Left-sided PTBD
Advantages Less radiation exposure to the radiologist
Larger segment of liver drained
Disadvantages Painful as intercostal nerves get stimulated
Increased risk of catheter slippage due to movement during respiration
Easier to perform
Preferred in ascites
Reduced risk of peri-catheter leak
Better patient compliance
More radiation exposure to radiologist
Fig. 38.1 Steps of
percutaneous transhepatic
biliary drainage procedure.
(a) USG-guided puncture of
segment V hepatic duct using
an 18G needle and needle
position conrmed on
cholangiogram. (b) Crossing
the stenosis using an angled
angiographic catheter and
hydrophilic 0.035″ guidewire
(arrow). (c) Angled
angiographic catheter
advanced into the third part of
the duodenum. (d)
Angiographic catheter is
exchanged for an 8.5F
internal-external drainage
catheter over an extra-stiff
guidewire
a
c
d
b
• Patient should bekept admitted under observation for at
least 24hours.
• Vitals (heart rate and blood pressure) should be carefully
evaluated for detection of sepsis.
• Presence of severe abdominal pain or distension suggests
intraperitoneal bleed or biliary leak.
• Patient is to be evaluated for drain output, perihepatic
uid as well as relief of biliary dilatation using USG.
• Prophylactic intravenous antibiotics should be adminis-
tered for at least 1week.
• Adequate analgesia and tube care to avoid dislodgement
of tube.
• Adequate skin care and dressing to avoid peri-catheter
skin excoriation.
• After discharge, patient should be followed up on outpa-
tient basis.
38.4.6 Complications
Since PTBD is a challenging and invasive procedure, postprocedure complications are a common occurrence [16].
Minor complications:
• Pain
• Peri-catheter leak leading to excoriation
• Catheter dislodgement
Major complications:
• Cholangitis
• Biliary sepsis
• Haemorrhage and haemophilia
• Biliary peritonitis
38 Interventions oftheBiliary Tract
477
• Iatrogenic pancreatitis
• Pleural effusion/pneumothorax due to inadvertent pleural
puncture
Peri-catheter leak is common and usually occurs due to
catheter dislodgement. A check cholangiogram helps in
ascertaining the position of the catheter and its side holes. If
displaced, the catheter should be positioned in such a way
that side holes are located both distal and proximal to the
obstruction and do not extend into the parenchymal tract.
Persistent peri-catheter leak even after proper positioning
requires upsizing of the catheter.
In the immediate post-procedure period, if the patient
becomes hemodynamically unstable, haemorrhage or sepsis
should be suspected. The incidence rate of sepsis is 5% after
PTBD [17]. Cholangitis presents with Charcot’s triad (fever,
jaundice and pain) and biliary stasis (persistent dilatation),
peribiliary hypoechogenicity and cholangiolar peribiliary
abscess on USG.It is managed with administration of appropriate antibiotics and image-guided drainage of cholangiolar
abscess [18]. Broad-spectrum antibiotics should be usedto
cover gram-negative bacteria as well. The prevention strategy for cholangitis is to avoid repeated manipulations and
use minimal amount of iodinated contrast media as cholangitis is a potentially life-threatening entity.
The rate of haemorrhage during the procedure varies from
0.6 to 12% [19]. The major source of bleeding is hepatic
artery and portal vein branches because of their close vicinity to the biliary tract [17]. It can lead to localized haematoma, haemoperitoneum as well as haemobilia. Haemobilia
can occur secondary to iatrogenic stula between hepatic
artery and portal vein. There is anincreased risk of bleeding
in patients with advanced age, cirrhosis, non-dilated system
and multiple manipulations [20]. The source of bleeding can
be determined as hepatic artery bleeding would cause signicant hemodynamic instability along with pulsatile and continuous bleeding as compared to portal vein bleeding [17].
Minor oozing can be controlled by capping the drainage
catheter for 48 hours or by upsizing the catheter. Major
bleeding due to hepatic arterial injury or stula needs percutaneous transhepatic or transarterial embolization.
38.5 Biliary Stenting
Stenting across the obstruction facilitates biliary drainage
into the duodenum. The two broad types of biliary stents are
plastic and metallic stents. Plastic stents are retrievable stents
that are typically inserted through endoscopic route as they
require a large bore access. They can be used in both benign
and malignant obstructions. Metallic stents require smaller
calibre access than plastic stents and thus can be inserted
through percutaneous access. They are not retrievable once
placed within the biliary system and are therefore used only
as palliative treatment in unresectable cancers.
38.5.1 Indications
Provide biliary drainage in unresectable malignancies
involving the biliary tract for:
• Relieving acute or recurrent cholangitis
• Palliation of symptoms of jaundice, such as pruritus
• Optimization of bilirubin level for chemotherapy
administration
The contraindications and complications of biliary stent-
ing are similar to that of PTBD.
38.5.2 Technique
Self-expanding metallic stents are used for percutaneous
biliary stenting. Uncovered stents are more commonly used
than covered stents, although both have similar patency rates
[21]. While uncovered stents are more prone to obstruction
due to tissue ingrowth, covered stents are more prone to
migration. Single stent is placed if the site of obstruction is
distal to the primary conuence (Fig. 38.2). Stents with
diameter of 10mm and length of 100 mm are usually used
and they are deployed such that the proximal end is at least
2–3cm proximal to the obstruction and the distal end is at
least 1cm into the duodenum. Balloon angioplasty is avoided
in malignant strictures due to risk of bleeding from the
tumour.If the primary conuence is involved by the tumour,
two separate stents are placed into the right and the left
hepatic ducts. Drainage of at least 50% of the liver parenchyma is essential for a favourable clinical outcome. Bilobar
stenting can be performed in two different congurations:
• T-type: One stent is deployed from the right or the left
hepatic duct into the CBD.Subsequently, the second stent
is deployed through the struts of the rst stent across the
primary conuence into the contralateral duct. The advantage of this technique is that only one lobe needs to be
accessed percutaneously for deploying both stents.
• Y-type: In this technique, bilobar biliary access is obtained
and stents are deployed from both the right and the left
hepatic duct into the common bile duct. As compared to
the Y-type, the T-type stenting has a higher technical success rate and lower complication rate. However, the stent
patency rates are higher with Y-type stenting [22]. The
Y-type stenting technique has two variations:
– Side-by-side stenting: The two stents are deployed par-
allel to each other in the common bile duct (Fig.38.3).
478
P. Garg et al.
a
b
a
b
Fig. 38.2 Metallic stent placement for malignant biliary obstruction.
(a) Coronal reformatted contrast-enhanced CT image of a 68-year-old
man shows a heterogeneously enhancing mass (asterisk) in the pylorus
of the stomach inltrating into the hepatic hilum and causing intrahepatic biliary radical dilation (arrow). Endoscopic biopsy revealed carcinoma of the pylorus. (b) A self-expanding metallic stent (10×100 mm)
was placed in the common bile duct as a palliative treatment for biliary
obstruction
– Stent-in-stent: One stent is rst deployed fully, follow-
ing which the second stent is deployed from the contralateral hepatic duct through the struts of the rst
stent into its lumen. Various studies have shown that
side-by-side stenting has longer duration of patency as
compared to the stent-in-stent technique [23, 24].
In patients with benign strictures of the common bile duct
or operable malignant strictures in whom permanent metallic
stent placement is not desirable, a rendezvous procedure can
be done if the stricture cannot be crossed by the endoscopic
route. In this technique, the stricture is crossed through percutaneous access and a guidewire is placed across the stenosis into the duodenum. The guidewire can then be retrieved
Fig. 38.3 Parallel biliary stent placement for hilar obstruction. (a)
Axial contrast-enhanced CT image of a 45-year-old lady with jaundice
shows a heterogeneously enhancing mass (black arrow) in the hepatic
hilum, suggestive of hilar cholangiocarcinoma, causing bilobar intrahepatic biliary radical dilation (white arrows) with involvement of the
primary conuence. (b) Parallel Y-stenting done from both right and
left lobe access for relieving the biliary obstruction
endoscopically and a plastic stent placed across the
stricture.
38.6 Management ofBenign Biliary
Stricture
Benign biliary strictures occur usually due to iatrogenic
injury during hepatobiliary surgeries. CBD strictures are
managed surgically. Percutaneous transhepatic dilatation is
the mainstay of treatment for anastomotic site strictures that
develop after hepaticojejunostomy as they cannot be accessed
38 Interventions oftheBiliary Tract
479
through the endoscopic route and revision surgery is often
difcult (Fig.38.4).
Intrahepatic biliary radical dilation is often mild in
benign strictures as compared to malignant obstruction.
Therefore, micropuncture set may be required to obtain
access to the biliary duct. The stricture is crossed using a
guidewire and a 10-12F internal-external drainage catheter
is placed across the stricture. Subsequently, serial catheter
upsizing is performed every 2–4 weeks up to 16-18F
depending upon the duct diameter. Balloon angioplasty of
the stricture using 8–10mm balloons is performed during
each upsizing to facilitate catheter placement. The large
bore catheter is kept in situ for at least 6months, following
which the catheter is removed if the cholangiogram shows
good antegrade ow across the anastomotic site. An external
drainage catheter is placed proximal to the stricture and
capped. This catheter is then removed after one week to
check if cholangiogram shows good antegrade ow and
there is no elevation of serum bilirubin. Follow-up for any
recurrent symptoms or elevation in serum bilirubin is done
1, 3, 6 and 12months after catheter removal and then yearly
thereafter. A study by DePietro etal. showed that the patency
rate using this technique is 84% one year after catheter
removal [25]. In case of recurrent stricture, the procedure is
repeated and large bore catheter is placed for a longer duration of up to 12months.
Retrievable covered stents that can be deployed and
retrieved through percutaneous route have recently come up
as an alternative to serial dilatation and catheter upsizing. All
retrievable stents are covered stents to prevent tissue ingrowth
that may hamper the retrieval. The covered stent is placed
across the stricture for a duration of 3–6months along with a
pigtail catheter in the biliary system to maintain the percutaneous access. This technique has been shown to have reduced
catheter indwelling time and lower recurrence rate than the
catheter upsizing technique, due to the larger diameter of the
stent as compared to the internal-external drainage catheter
and chronic outward force exerted by the stent on the stricture [26].
38.7 Intraluminal Procedures Through Percutaneous Biliary Access
38.7.1 Endobiliary Biopsy
Various techniques of endobiliary sampling include brush
cytology and forceps biopsy. Percutaneous endoluminal
sampling is performed if endoscopic sampling is not feasible. Once the percutaneous biliary access is obtained, sampling is done under either uoroscopic or cholangioscopic
guidance. Brush cytology is obtained by repeatedly passing
the cytology brush across the site of stenosis. Forceps biopsy
yields better samples than brush cytology.
38.7.2 Intraluminal Brachytherapy
Intraluminal brachytherapy delivers a high dose of radiotherapy to the tumour while not exceeding the normal tissue tolerance of surrounding organs.
Indications
Fig. 38.4 Schematic representation of percutaneous transhepatic dilatation of anastomotic site stricture that develops after
hepaticojejunostomy
• Radical treatment: stand-alone treatment in small inoper-
able tumours, or in combination with external beam
radiotherapy and/or chemotherapy in advanced disease
for unresectable patients
• Adjuvant treatment: after non-radical excision, possibly
combined with external beam radiotherapy
• Palliative treatment: to facilitate the outow of bile (irre-
spective of the size of the tumour, including large inoperable tumours with signicant extraductal disease)
Through the PTBD access, Iridium-192 applicator is
introduced into the site of the tumour and high-dose rate
radiotherapy is administered [27].
38.7.3 Gallstone Extraction
Percutaneous extraction can be performed for gallstones that
are located in the gall bladder, intrahepatic biliary radicals or
CBD.However, it requires a large bore access and is indi-
480
cated only in patients who are poor candidates for surgery
and endoscopic removal is not feasible, such as after hepaticojejunostomy. The most commonly used technique is pushing the stones into the duodenum using a partially inated
angioplasty balloon. Angioplasty of the sphincter of Oddi is
done prior to this manoeuvre using 8–14mm balloon catheters, depending upon the diameter of the largest stone. Stones
can also be extracted using a Dormia basket with or without
intraluminal lithotripsy to fragment the stones [27].
38.8 Percutaneous Cholecystostomy
Percutaneous cholecystostomy involves obtaining percutaneous access into the gall bladder for drainage of its contents
(Fig.38.5).
P. Garg et al.
38.8.1 Indications
• Acute cholecystitissecondary to gall stones: Percutaneous
cholecystostomy may be used as a temporizing measure
in patients of acute cholecystitis who are critically ill and
therefore cannot undergo surgery. After the patient’s condition is stabilized, cholecystectomy will still be
requiredas the denitive treatment.
• Acalculous cholecystitis: It may occur in critically ill
patients and percutaneous drainage is the denitive treatment option.
• Relief of biliary obstruction: Cholecystostomy can provide a means of accessing the biliary tree in patients with
obstructive jaundice in whom the bile ducts are minimally
dilated and the level of obstruction is distal to the insertion of the cystic duct. This is done in critically ill patients
with biliaryobstruction as a bedside procedure.
38.8.2 Technique
The gallbladder is punctured under USG guidance. There are
two approach routes available for puncturing the
gallbladder.
Fig. 38.5 Schematic diagram demonstrating transhepatic percutaneous cystostomy
– It has a higher risk of bleeding complications as the
liver parenchyma is traversed.
• Transperitoneal Approach.
– The gallbladder is punctured at the point where it lies
closest to the anterior abdominal wall.
– It is less commonly done as it is associated with a
higher risk of bile leak into the peritoneum.
– The trocar technique is generally used for the insertion
of the catheter.
If surgery is not considered as in acalculous cholecystitis,
the catheter can be removed once the patient’s signs and
symptoms resolve and sufcient time has elapsed for the
tract to mature. This is said to be at least two weeks when the
transhepatic route is used and three weeks when the transperitoneal approach is used. Removal of the catheter before
tract maturation may result in leakage of bile and
peritonitis.
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– It is usually done using the Seldinger technique, in
which the access is obtained using a puncture needle
and secured using a guidewire. 10F pigtail catheter is
inserted over the guidewire following serial dilatation.
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Non-vascular Interventions
oftheGastrointestinal Tract
RishabhJain andS.H.Chandrashekhara
39
Key Messages
1. Percutaneous radiological gastrostomy (PRG), in the
absence of bowel obstruction/perforation, superiorly
displaced stomach, and immunosuppression, can be
considered for nutrition in patients with high risk of prolonged malnutrition and aspiration.
2. Push technique in PRG is associated with more periintervention complications than the pull-through
technique.
3. Percutaneous jejunostomy has the same indication as
PRG and is considered where gastrostomy tube is not
suitable or has been ineffective in preventing aspiration.
4. Specic complications that can be catastrophic in percutaneous jejunostomy are small bowel and colonic perforation which can be avoided by using CT for guidance
instead of uoroscopy.
5. Percutaneous cecostomy can be used in cases of impending perforation due to cecal dilatation and is of particular
use when colonic decompression is unsuccessful.
6. Percutaneous cecostomy looks particularly promising in
cases of Ogilvie’s Syndrome.
7. Cecopexy is an integral part of percutaneous cecostomy
and must be done using T-fasteners in order to prevent
leakage into the peritoneal cavity.
8. Fluoroscopy-guided balloon dilatation of esophageal
strictures is preferred to endoscopic bougienage as it
causes less tears.
9. Plastic stents for dilatation of esophageal strictures are
associated with a higher complication rate and are being
gradually replaced by retrievable metallic stents.
R. Jain
Department of Interventional Radiology, Institute of Liver
and Biliary Sciences, Delhi, India
S. H. Chandrashekhara (
Department of Radiodiagnosis and Interventional Radiology,
IRCH, All India Institute of Medical Sciences, Delhi, India
*)
10. Evolution of stents for esophageal dilation like selfexpanding stents, conical wall stents, and stents with
ared ends has reduced the rates of migration.
11. Development of covered metallic prostheses has shown
promise in the management of esophageal strictures
with coexisting tracheoesophageal stula.
39.1 Introduction
The development of minimally invasive interventions of the
gastrointestinal tract has been a game changer, be it for therapeutic purposes, prophylaxis against life-threatening events
like aspiration or bowel perforation, or end-of-life palliative
care. By obviating the need for extensive surgeries, they have
also contributed to a decrease in surgery and anesthesiarelated morbidity.
In this chapter, we discuss the commonly performed
interventions of the gastrointestinal tract, their indications,
the techniques, and complications.
39.2 Percutaneous Gastrostomy
Gastrostomy provides an alternative method for nutritional
support in individuals who have difculty with prolonged
oral intake. Maintaining gastrointestinal function is vital for
nutritional supplementation and maintaining the quality of
life. Gastrostomy tubes can be placed via surgical, endoscopic, or radiological methods. Among these, surgical gastrostomy has the highest overall complication rate at 29%,
whereas percutaneous endoscopic gastrostomy (PEG) and
radiological gastrostomy each have a complication rate of
about 15%. Of the radiological methods, percutaneous radiological gastrostomy (PRG) is the safest and least invasive.
Two approaches are available for radiologically guided gastrostomy: the “push-type gastrostomy,” which is the traditional
percutaneous approach involving access through the abdominal wall to the stomach, and the “pull-type gastrostomy,”
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_39
483
484
R. Jain and S. H. Chandrashekhara
adapted from the PEG technique, which involves placing the
gastrostomy catheter through an internal/external approach.
39.2.1 Indications
It is recommended for patients at high risk of malnutrition
who are unlikely to regain their ability to eat orally in the
near future. Additionally, it is used for patients needing longterm gastric decompression. Examples include:
• Neurogenic cause of abnormal swallowing reex—
patients with high risk of aspiration—cerebrovascular
event, traumatic brain injury, cerebral palsy, etc.
• Malignancy of the head and neck region.
• Surgery of the oral cavity/larynx.
• Systemic sclerosis.
• Severe burns.
39.2.2 Contraindications
Absolute Contraindications
• Uncorrected coagulopathy.
• Active peritonitis.
• Bowel ischemia.
• Patients with portal hypertension and high-risk gastric
varices—potential for catastrophic bleeding.
Relative Contraindications
• Ascites.
• Partial gastrectomy.
• Surgeries with risk of aspiration—large hiatus hernia,
gastric volvulus, esophagostomy with gastric pullthrough, colonic interposition.
• Diaphragmatic denervation with superiorly displaced
stomach.
• Prolonged immunosuppression.
39.2.3 Pre-procedural Work-Up
• Platelets >50,000/μL, PT INR <1.5, aPTT <40.
• CT to rule out ascites and anatomical variations like hiatus hernia, interposition of colon, enlarged liver, and situs
inversus.
• Antiseptic mouth rise on the day of procedure in pull
type.
• Local preparation of abdomen (shaving and betadine
scrub).
• Broad-spectrum IV antibiotic on the day of the
procedure.
39.2.4 Technique
Push-Type PRG
Push-type technique uses the Seldinger technique to insert
the gastrostomy tube into the stomach, bypassing the pharynx. The rst step requires gastropexy to securely fasten the
gastric and abdominal walls together.
The stomach is insufated with air via the nasogastric
tune after navigating past any neoplastic mass or stricture
with a combination of angiographic catheters and wires. An
ultrasound (USG) is used to outline the left lobe of the liver
on the skin, after which the epigastric area is cleaned and
prepared. Two to three access sites are marked on the skin in
a small triangular formation directly above the stomach,
positioned equidistant from each curvature and between the
left hepatic lobe outline and the palpable left costal margin.
T fasteners are then inserted into the stomach at these
marked sites under uoroscopic guidance, using a controlled, brisk push.
The intragastric conrmation of the T-fasteners is veried
by aspirating air into a syringe partially lled with contrast
and then injecting a small amount of contrast to visualize the
dependent gastric rugal folds. After performing the gastropexy of the stomach, an 18-G needle is inserted at the center
of the marked triangle, and the intragastric conrmation process is repeated. Following this, an extra-stiff Amplatz guidewire is inserted, coiling within the fundus and body of the
stomach to ensure a secure placement within the stomach
lumen. Sequential dilatation of the tract is done with the largest being 2-4F wider than the expected size of the gastrostomy tube followed by placement of the gastrostomy tube
into the stomach.
Once the catheter tip is conrmed to be beyond the outer
sheath, the gastrostomy balloon is inated with dilute iodinated contrast, up to 6–10mL depending on the catheter size.
The outer sheath is then peeled away and the gastrostomy
catheter is pulled until the inner balloon is ush with the gastric wall. The external retainer on the catheter is advanced
until it is ush with the skin around the stoma.
In the situation where the upper aerodigestive tract is
obstructed, preventing the passage of an NG tube for insufation, direct puncture of the stomach wall is done under
USG and uoroscopy guidance after identifying the borders
of the left lobe of the liver and colon. A linear high-frequency
USG probe is employed to locate the collapsed stomach. The
anterior wall of the stomach is then targeted using an 18-G
needle and tip conrmed by injecting contrast. Subsequently,
600–800mL of room air is pushed via the needle to inate
the stomach. Gastropexy is subsequently to oppose the anterior abdominal wall with the stomach wall using three
T-fasteners as described previously. A stiff guidewire is
introduced into the gastric lumen through the 18-G needle
and serial tract dilatation is done.
39 Non-vascular Inter ventions oftheGastrointestinal Tract
485
The peel-away sheath is advanced to the gastric lumen
over the stiff guidewire, the trocar of the sheath along with
the stiff guidewire is removed, and the gastrostomy tube is
inserted through the peel-away sheath. Once the tip of the
tube is beyond the sheath (as seen on uoroscopy), the sheath
is peeled away and the tube is adjusted as described above.
39.2.5 Post-procedures Advice Following
theProcedure
The gastrostomy tube is advised to be used for feeding after
24 h. Till then, feeding can be given through the alreadyinserted NG tube. After 24h, diluted milk followed by saline
infusion is done. The patient is observed for 2h. If there are
no features of peritonitis and the patient tolerates feeding
well, then a proper diet can be started. A liquid diet, preferably 200ml 6 times a day or as suggested by a dietician, is
started. After every feed, 50ml of saline ush is given from
the same tube for cleaning. Hot uids should be avoided via
a gastrostomy tube.
39.2.6 Pull-Type PRG
The stomach is inated with approximately 1000ml of air
using a three-way stopcock through an indwelling nasogastric tube. Under uoroscopic guidance, an 18G puncture
needle is used to create a gastric puncture in the lower third
of the stomach, positioned centrally to avoid damaging the
gastroepiploic artery. The puncture site is selected to be equidistant from the greater and lesser curvatures, and lateral to
the rectus muscle or in the midline to avoid puncturing the
epigastric arteries. Gastric puncture is conrmed either by
aspirating air into a syringe or ushing with contrast media.
The needle is then exchanged over a wire (J wire/Terumo
hydrophilic wire) for a 5F sheath.
A 65cm, 4 or 5F catheter is introduced over the guidewire. Usually, this allows for direct retrograde access to
the esophageal lumen with the guiding catheter. The
catheter- guidewire combination is then either exited
through the mouth or withdrawn with forceps when the
guidewire reaches the nasopharynx. If needed, an 18 G
needle directed toward the gastroesophageal junction and
manipulation of the hydrophilic guidewire may successfully advance the guidewire into the esophagus. The
hydrophilic guidewire is then replaced with a super stiff
guidewire, and a 9F, 65cm long sheath is inserted and
exited through the mouth.
An extra-long, super-stiff Amplatz guidewire is folded
and doubled at its midpoint. This guidewire is introduced ret-
rogradely through the 9F sheath, from the stomach end to
exit through the tip of the sheath at the mouth end. After
applying a water-soluble lubricant, the feeding tube wire and
the folded end of the guidewire are connected with a square
knot. The entire assembly is then pulled through the anterior
abdominal wall under uoroscopic guidance until the mushroom end of the feeding tube is felt to contact the gastric
wall. Finally, the outer bolster of the feeding tube is secured
and fastened.
39.2.7 Comparison Between Push-Type
andPull-Type Gastrostomy Tubes
Overall, periprocedural complications are more frequent
with push-type gastrostomy tubes compared to pull-type
tubes. Minor complications occur in 10.2% of push-type and
22.4% of pull-type gastrostomy tube placements. These
complications include dislodgement, pericatheter leakage,
tube occlusion, supercial stomal infections, and minor
bleeding related to the tube [1]. If a push-type tube becomes
dislodged, it can be easily reinserted because the T-fasteners
remain in place for 2weeks, providing gastropexy for tube
reinsertion. The anchor sutures resorb spontaneously over
2weeks, and the tract is typically well-matured by then [2].
Major complications occur in 1–5% of pull-type versus
5–10% of push-type gastrostomy tubes and include periprocedural hemorrhage, aspiration pneumonia, pneumoperitoneum due to bowel perforation, and deep abscesses
(Figs.39.1 and 39.2).
Pull-type percutaneous radiological gastrostomy (PRG) is
considered more secure than the conventional push-type
tubes because the retention device in the pull-type does not
deate, unlock, or become displaced during feeding. Pulltype gastrostomy is generally preferred for patients with
nonobstructive neuromuscular esophageal dysmotility
disorders.
In patients with advanced head, neck, and upper aerodigestive tract cancers, the push-type technique is often preferred due to the luminal compromise that complicates the
per-oral passage of a pull-type tube. PRG has demonstrated
safety and efcacy for enteral access, with a success rate of
up to 98% in patients who previously had failed endoscopic
gastrostomy placements [3, 4]. Kumar etal. reported technical success in 29 out of 31 patients with head and neck squamous cell carcinoma and esophageal cancers [2]. An
advantage of the push-type PRG is that it can be placed
without stomach air insufation; direct stomach puncture
can be performed with a 22 G percutaneous needle, followed by air insufation, gastropexy, and tube placement
(Figs.39.3, 39.4 and 39.5).