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for access. An alternative method is use of ultrasound for puncture aer instillation of saline into the small
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bowel.
▶ Access in patients with malignant bowel obstruction is less technically challanging because the target is
dilated rather than decompressed. Malignant small-bowel obstruction is most commonly related to peritoneal
carcinomatosis from ovarian or colon cancer.
Management
▶ In patients who have had prior jejunostomy catheters, the previously catheterized loop is usually adherent to
the anterior abdominal wall and will be easier to access than a freely mobile loop.
▶ Placement of at least one anchor is helpful to promote pexy to the anterior abdominal wall and to x the bowel
to facilitate tract dilation and catheter placement.
▶ Procedure risks include peritonitis, catheter dislodgement, pericatheter leakage, and wound infection.
Further Reading
Kim YJ, Yoon CJ, Seong NJ, etal. Safety and ecacy of radiological percutaneous jejunostomy for decompression of malignant
small bowel obstruction. Eur Radiol. 2013; 23(10):2747–2753.
Yi F, Ge L, Zhao J, etal. Meta-analysis:total parenteral nutrition versus total enteral nutrition in predicted severe acute
pancreatitis. Intern Med. 2012; 51(6):523–530.
158
History
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▶ Ovarian Carcinoma (Malignant Large-Bowel Obstruction)
Figure54.4 was taken 5days aer the procedure shown in Figures54.1–54.3.
Case 54
Figure 54.1
Figure 54.3
Figure 54.2
Figure 54.4
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Case 54 Percutaneous Cecostomy Catheter Placement
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Figure 54.5
Figure 54.6
Figure 54.7
Findings
▶ Transverse diameter of the right colon in a patient with peritoneal carcinomatosis secondary to ovarian
carcinoma (arrows) and distal obstruction measures 11cm (Fig. 54.5).
▶ ree retention sutures (Fig. 54.6, arrows) have been placed to x the mobile cecum to the anterior abdominal wall
prior to catheter placement. An 18-gauge needle has been advanced between the retention sutures into the cecum.
▶ A16 French drainage catheter has been placed into the cecum (Fig. 54.7). Contrast injection conrms
intraluminal position. Note the colon is immediately decompressed aer catheter placement.
▶ Sagittal reconstruction from a pelvic computed tomography (CT) scan 5days later (Fig. 54.8) when the patient
presented with cellulitis and sepsis shows extensive subcutaneous emphysema. Two of the retention suture
bumpers are seen within the subcutaneous air (arrows). e other radio-opacity traversing the air represents
the cecostomy catheter.
Teaching Points
▶ Retention sutures are commonly used when a catheter is placed in a mobile viscous within the abdomen (e.g.,
push-type gastrostomy, cecostomy, percutaneous jejunostomy). Analagous to a “buried bumper,” when there is
tension on retention sutures, they can invaginate into the subcutaneous tissues.
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Figure 54.8
▶ Indications for cecostomy placment includes diversion of fecal stream in incontinent children with
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neurologic disorders (e.g., spina bida, paralysis) and mechanical or pseudo-obstruction of the large
bowel.
▶ Acute colonic distension greater than 10-12cm is considered a risk factor for perforation.
Management
▶ Cecostomy to treat mechanical or pseudo-obstruction is most eective when the catheter is placed into gas
within the colon rather than stool, as the latter is dicult to drain through a catheter. Because most of the
drainage is gaseous, small holes should be made in the drainage collection system so that the bag does not
become distended, preventing adequate drainage.
▶ Surgical intervention to treat malignant bowel obstruction is associated with high morbidity and mortality, up
to 42% and 32%, respectively. Patients with carcinomatosis, ascites, and multilevel obstruction are unlikely to
benet from surgery for obstruction.
Further Reading
Feuer DJ, Broadley KE, Shepherd JH, etal. Surgery for the resolution of symptoms in malignant bowel obstruction in advanced
gynaecological and gastrointestinal cancer. Cochrane Database Syst Rev. 2000; (4):CD002764.
161
Case 55
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History
▶ Squamous Cell Carcinoma of the Tongue, Gastrostomy Tube Was Requested for Enteral Feeds. What
Procedure is Being Performed?
Figure 55.1
Figure 55.2
Figure 55.3
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Case 55 Percutaneous Pull-through Gastrostomy
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Figure 55.4
Figure 55.5
Figure 55.6
Figure 55.7
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Findings
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▶ Anteroposterior and lateral spot lms aer air insuation via nasogastric tube (Fig. 55.4) show a distended
air-lled stomach anterior to loops of small and large bowel.
▶ An 18-gauge needle attached to a contrast syringe has been advanced into the body of the stomach (Fig.55.5).
Contrast injected is seen pooling in the fundus (arrow).
▶ Awire has been manipulated from the stomach up the esophagus and out of the mouth (Fig.55.5 lateral)
to snare the 24 French gastrostomy tube, which was then pulled though the mouth and positioned with the
retention bulb (arrows, Fig. 55.6) in the body of the stomach.
▶ Computed tomography (CT) 6months aer catheter placement (Fig. 55.7) shows tumor seeding the skin at
the site of the gastrostomy tube (arrows).
Teaching Points
▶ Percutaneous gastrostomy may be performed by “pull-through” technique, in which through-and-through
access is obtained from the anterior abdominal wall out of the mouth and the catheter is pulled through
the mouth to its nal position in the stomach. “Push-type” gastrostomy refers to a catheter placed directly
through the abdominal wall into the stomach. Push type is oen performed in conjunction with percutaneous
gastropexy.
▶ For patients at high risk for gastroesophageal reux and aspiration, transgastric jejunostomy catheters may
be safer because feeds enter the gastrointestinal tract at or distal to the ligament of Treitz minimizing the
liklihood of reux. For patients who require both gastric drainage and enteral feeds, a double-bore catheter
with lumina in both the stomach and a jejenum is also available.
▶ Using the pull-through technique, large-bore catheters (20–28 French) may be placed in patients who require
gastric decompression. e large size of these catheters allows for drainage of a limited oral diet, which can
contribute to quality of life.
▶ An unusual complication of pull-through gastrostomy is tumor implantation at the tube site. is is most
common in patients with untreated squamous cell carcinoma of the head and neck or gastric cancer.
Management
▶ Preliminary ultrasound may be performed to identify the le hemiliver to avoid transhepatic catheter
placement. Some operators give oral contrast the day before to opacify bowel to prevent perforation at the
time of the procedure.
▶ Immediately aer placement there is oen a period of gastroparesis related to the procedure. Feeding may
safely be started 12–24 hours aer placement.
▶ Because it is not uncommon to be asked to convert a feeding gastrostomy catheter to transgastric jejunostomy
catheter, the initial puncture should be made with this in mind. Adirect anterior puncture into the antrum,
for example, would make this conversion very dicult and catheter position tenuous.
▶ Use of prophylactic antibiotics is recommended for pull-through gastrostomy and controversial for push-type
catheters.
Further Reading
Covarrubias DA, O’Connor OJ, McDermott S, etal. Radiologic percutaneous gastrostomy:review of potential complications
and approach to managing the unexpected outcome. Am J Roentgenol. 2013; 200(4):921–931.
Yang Y, Schneider J, Düber C, etal.Comparison of uoroscopy-guided Pull-type percutaneous radiological gastrostomy
(Pull-type-PRG) with conventional percutaneous radiological gastrostomy (Push-type-PRG):clinical results in 253 patients.
Eur Radiol. 2011; 21(11):2354–2361.
164
History
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▶ A63-Year-Old Female with Ovarian Cancer and Abdominal Distension
Figure 56.1
Case 56
Figure 56.2
Figure 56.3
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Case 56 Tunneled Drainage Placement for Relief
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of Recurrent Ascites
Figure 56.4
Figure 56.5
Figure 56.6
Findings
▶ Single computed tomography (CT) image (Fig. 56.4) shows marked ascites with centralization of the bowel
loops in the pelvis.
▶ Ultrasound at the time of tunneled peritoneal drainage catheter placement (Fig. 56.5) shows free-owing ascites
without loculation. An 18-gauge needle (arrow) has been advanced into the ascites in the midline pelvis.
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Figure 56.7
▶ Atunneled, multi-sidehole catheter (Fig. 56.6, arrows) was placed into the dependent pelvic ascites to provide
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access for intermittent drainage.
▶ Six weeks aer placement, CT (Fig. 56.7) demonstrates good control of the ascites. e catheter is seen
traversing the so tissue of the anterior abdominal wall (arrow).
Teaching Points
▶ Malignant ascites is common in patients with gastric, colon, endometrial, ovarian, pancreatic, and breast
cancers, lymphoma, and mesothelioma. With most tumor types, prognosis is poor, with life expectancy
measured in weeks to months.
▶ Symptoms include abdominal distention and discomfort, shortness of breath, pain, nausea, loss of appetite,
early satiety, and reduced mobility, which can signicantly decrease quality of life.
▶ Placement of a drainage catheter allows for the patient to drain ascites intermittently at home, obviating the
need for frequent hospital visits for paracentesis. is has been shown to have a positive eect on overall
quality of life and symptoms, including nausea, dyspnea, and appetite loss.
▶ When performing paracentesis or placing a catheter, the course of the inferior epigastric arteries should
be considered. Ultrasound, if available, is helpful to identify the vessels. Alternatively, midline access or an
approach lateral to McBurny’s point is generally safe.
Management
▶ Tunneled peritoneal catheters (including the Tenckho © shown here) with multiple sideholes are an
alternative to frequent large-volume paracenteses for palliation of recurrent or malignant ascites. ese are the
same type of catheters typically placed surgically for peritoneal dialysis.
▶ In the setting of malignant ascites, diuretic therapy (typically used for nonmalignant ascites) has little role.
Options for palliation generally include repeated paracentesis, nontunneled or tunneled catheter placement,
and peritoneovenous shunt (see Case 52). Potential benets of tunneled catheters compared to serial
paracentesis and nontunneled catheters include stability and possibly decreased risk of infection.
▶ If the output decreases to less than 50 cc/drainage for three attempts over several days, and the ascites is
clinically resolved, removal of the catheter should be considered.
▶ Complications include bacterial peritonitis, which usually necessitates removal of the catheter, catheter
dislodgement, tunnel infection, and catheter blockage.
Further Reading
Akinci D, Erol B, Cici TT, etal. Radiologically placed tunneled peritoneal catheter in palliation of malignant ascites. Eur J
Radiol. 2011; 80(2):265–268.
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