18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

102

The Techniques for Percutaneous Radiologic Gastrostomy and

Percutaneous Transesophageal Gastrotubing

Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD

Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital

Introduction

Percutaneous endoscopic gastrostomy (PEG) was first described for feeding

purposes by Gauderer in 1980 and has become a general technique worldwide for

placing indwelling feeding and decompressive tubes [1-2].

The image-guided technique percutaneous radiologic gastrostomy (PRG) is

performed for patients when PEG cannot be performed [3]. Other contraindications

for PEG also exist and have led to the development of the percutaneous

transesophageal gastrotubing (PTEG) technique [2]. PTEG was developed in Japan as

an alternate route of access into the gastrointestinal tract. By avoiding placement into

the abdominal cavity, PTEG can overcome contraindications for PEG [2, 4].

This article discusses the indication, technique, clinical outcome, and applied

procedures for both PRG and PTEG.

Indication

Indication for PRG

The patients who are at high-risk of malnutrition, are unlikely to recover their ability

to feed orally in the short term, or require long-term gastric decompression should be

considered for gastrostomy [3].

PRG is indicated for conditions where PEG cannot be performed because of a

significant stenosis of the upper GI tract, a large hiatus hernia, or substantial obesity

where trans-illumination is difficult [3, 5].

Contraindications for PEG are described below in the indications for PTEG.

Indication for PTEG

PTEG has been performed for patients in whom PEG would be technically difficult to

place or is contraindicated. These include prior gastrectomy, tumor invasion of the

anterior gastric wall, massive ascites, presence of other organs between the stomach

and abdominal wall, ventriculoperitoneal shunts, continuous ambulatory peritoneal

dialysis catheters, and high-risk patients (pneumonia, 85 years of age or older). They

are all recognized as absolute or relative contraindications for PEG [2, 4].

Head and neck lesions, coagulopathy, and right recurrent nerve paralysis are

recognized as contraindications for PTEG.

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

103

Procedure Technique

Both procedures are performed under conscious sedation using intravenous

premedication, such as pentazocine hydrochloride, and under local anesthesia, such as

lidocaine hydrochloride.

The Technique for PRG

A nasogastric tube is inserted, and then, air is injected via the nasogastric tube to

dilate the stomach. The puncture site of the dilated stomach is determined by

fluoroscopy. If gastric peristalsis is active, scopolamine butylbromide or glucagon are

intramuscularly administered as a sedative. Ultrasonography is used to confirm that no

other organs, such as the liver or transverse colon, intervene between the stomach and

abdominal wall.

The gastric wall should then be secured close to the abdominal wall with 2-point

anchoring using a gastropexy device (T-fastener, Cope Gastrointestinal Suture Anchor

Set; Cook Medical, Bloomington, IN, USA) (Fig. 1A). A needle, pre-loaded with a T-

fastener, is passed into the stomach, and the T-fastener is then pushed through the

needle into the stomach.

Following this, the gastric wall is percutaneously punctured under fluoroscopic

guidance with an 18-gauge needle with a sheath, and the puncture site is dilated using a

dilator with a peel-away sheath over the guidewire (Fig. 1B). Finally, a gastrostomy tube

is inserted into the stomach, and the indwelling tube is secured with a nylon suture at

the puncture site [3, 6] (Fig. 1C).

The Technique for PTEG

The technique for PTEG was established with the use of a PTEG kit (Sumitomo

Bakelite, Tokyo, Japan; Fig. 2A). A rupture-free balloon (RFB) catheter made of

chloroethylene is used to prevent rupture and increase visibility during ultrasonography

(US) (Fig. 2B). The patient lies supine on a fluoroscopy table with the main operator

standing on the left side.

RFB is inserted through the nose and advanced to the cervical esophagus. The RFB is

inflated with approximately 10–15 mL of dilute contrast media and positioned in the

cervical esophagus above the level of the clavicle. Traction is then maintained on the

balloon to keep it in the cervical esophagus.

US should reveal that the inflated RFB, which displaces the vessels (carotid artery

and internal jugular vein) laterally and the thyroid medially, is detected just under the

skin (Fig. 3A, B). The RFB is punctured percutaneously by an 18-gauge needle with a

sheath under US guidance, and a guidewire is inserted into the RFB through the needle

(Fig. 4A). Correct puncture is confirmed if the contrast media escapes from the RFB

with the removal of the inner needle.

The RFB and guidewire are advanced to the lower esophagus under fluoroscopy, and

the RFB is then removed (Fig. 4B). The puncture site is dilated using a dilator with a

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

104

peel-away sheath over the guidewire (Fig. 4C), and then, an indwelling tube is

appropriately inserted into the stomach via the esophagus through the sheath. Finally,

the sheath is peeled away, and the indwelling tube is secured with a nylon suture at the

puncture site (Fig. 4D, E).

The nasogastric tube is removed at the completion of the procedure. Local skin care

and catheter maintenance are the same as for other gastrostomy tubes [2, 4, 7].

Clinical outcomes

RPG

Radiologically inserted gastrostomy was first described in 1981 by Preshaw [8]. It is

a Seldinger technique wherein the stomach is insufflated with air following the passing

of a nasogastric tube or peroral catheter. Consistently high success rates for placement

of RIG tubes have been reported (95–100 %) [9-12].

Minor complications, such as superficial peristomal infection (25–45%), leakage

(11.4%), tube occlusion (4.5%), and tube dislodgement (1.3–4.5%), have also been

reported. Major complications, such as hemorrhage (1.4%), peritonitis (1.3%), and death

due to the procedure (0.3%), have also been noted [3].

PTEG

In 1994, Oishi et al developed the PTEG method that involves percutaneous insertion

of a tube through the cervical esophagus so the patient feels little discomfort after

tube placement [13]. They described the results of PTEG placement in 115 patients with

a 100% technical success without any major complications, and minor complications, such

as tube obstructions, stomal leakage, wound infection, unrecovered tube migration, and

minor bleeding, occurred in only 27 patients (23.5%) [4].

Several other reports from countries outside Japan indicated a high technical success

rate of PTEG for decompression and enteral feeding [14-15]. Furthermore, according

to a multicenter prospective study in 33 patients with malignant gastrointestinal

obstruction, the technical success rate was 100%, and the procedure was considered

effective (more comfortable than NGT) in 30 of 33 patients. The one recorded

complication was a tracheoesophageal fistula that caused grade 2 aspiration pneumonia

[7].

Applied procedures

PRG

If nasogastric tube insertion was unsuccessful, the stomach was punctured directly

with a fine needle (23- to 21-G needle) under US guidance and air was injected to dilate

the stomach, and then, all the steps following stomach dilation were performed [6].

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

105

PTEG

In patients with malignant gastrointestinal obstruction, decompression by PTEG may

be insufficient because full drainage of the small bowel could not be achieved by only

gastrotubing. In those patients, ileus tube insertion via the PTEG route is a possible

procedure after adequate fistula formation (Fig. 5A, B).

Conclusion

In conclusion, PRG and PTEG are safe and effective nonvascular interventional

procedures for patients in whom PEG would be technically difficult to place or was

contraindicated.

Conflict of Interest: The authors declare that they have no conflict of interest.

Abbreviations

PEG: percutaneous endoscopic gastrostomy

PTEG: percutaneous transesophageal gastrotubing

RFB: rupture-free balloon

References

1) Gauderer MWL, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a

percutaneous endoscopic technique. J Pediatr Surg. 1980; 15: 872-875.

2) Percutaneous transesophageal gastrostomy tube for decompression of malignant

obstruction: report of the first case and our series in the US. Mackey R, Chand B,

Oishi H, Kameoka S, Ponsky JL. J Am Coll Surg. 2005; 201: 695-700.

3) CIRSE Standards of Practice Guidelines on Gastrostomy. Sutcliffe J, Wigham A,

Mceniff N, Dvorak P, Crocetti L, Uberoi R. Cardiovasc Intervent Radiol. 2016; 39:

973-987.

4) A nonsurgical technique to create an esophagostomy for difficult cases of

percutaneous endoscopic gastrostomy. Oishi H, Shindo H, Shirotani N, Kameoka S.

Surg Endosc. 2003; 17: 1224-1227.

5) Itkin M, Delegge MH, Fang JC, McClave SA, Kundu S, Janne B, et al.

Multidisciplinary practical guidelines for gastrointestinal access for enteral

nutrition and decompression from the Society of Interventional Radiology and

American Gastroenterological Association (AGA) Institute, with endorsement by

Canadian Intervention. J Vasc Interv Radiol. 2011; 22: 1089-1106.

6) Percutaneous radiologic gastrostomy in patients with malignant

pharyngoesophageal obstruction. Inaba Y, Yamaura H, Sato Y, Kashima M, Kato M,

Inoue D, Kurinobu T, Sato T. Jpn J Clin Oncol. 2013; 43: 713-718.

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

106

7) Phase II study of percutaneous transesophageal gastrotubing for patients with

malignant gastrointestinal obstruction; JIVROSG-0205. Aramaki T, Arai Y, Inaba

Y, Sato Y, Saito H, Sone M, Takeuchi Y. J Vasc Interv Radiol. 2013; 24: 1011-1017.

8) A percutaneous method for inserting a feeding gastrostomy tube. Preshaw RM.

Surg Gynecol Obstet. 1981; 152: 658-660.

9) Shin JH, Park A-W. Updates on percutaneous radiologic

gastrostomy/gastrojejunostomy and jejunostomy. Gut Liver. 2010; 4: S25-31.

10) de Baere T, Chapot R, Kuoch V, Chevallier P, Delille JP, Domenge C, et al.

Percutaneous gastrostomy with fluoroscopic guidance: single-center experience in

500 consecutive cancer patients. Radiology. 1999; 210: 651-654.

11) Ryan JM, Hahn PF, Boland GW, McDowell RK, Saini S, Mueller PR. Percutaneous

gastrostomy with T-fastener gastropexy: results of 316 consecutive procedures.

Radiology. 1997; 203: 496-500.

12) Percutaneous gastrostomy and gastrojejunostomy with gastropexy: experience in

701 procedures. Dewald CL, Hiette PO, Sewall LE, Fredenberg PG, Palestrant AM.

Radiology. 1999; 211: 651-656.

13) Oishi H, Murata J, Kameoka S. Percutaneous transesophageal gastric tube

drainage. Development and perspective of rupture-free balloon catheter for

puncture. J Jpn Surg Soc 1998; 99: 275.

14) Percutaneous transesophageal gastrostomy tube placement: an alternative to

percutaneous endoscopic gastrostomy in patients with intra-abdominal metastasis.

Singal AK, Dekovich AA, Tam AL, Wallace MJ. Gastrointest Endosc. 2010; 71:

402-406.

15) Percutaneous transesophageal gastrostomy (PTEG): a safe and effective

technique for gastrointestinal decompression in malignant obstruction and massive

ascites. Udomsawaengsup S, Brethauer S, Kroh M, Chand B. Surg Endosc. 2008;

22: 2314-2318.

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

107

Figure 1

1A: The gastric wall was

secured close to the abdominal

wall with 2-point anchoring

using a gastropexy device

(T-fastener).

1B: The puncture site is dilated

using a dilator with a peel-away

sheath over the guidewire.

1C: A gastrostomy tube (15.5-Fr

Malecot-type gastrostomy tube;

Cook Medical, Bloomington, IN,

USA) was inserted.

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

108

Figure 2.

2A: PTEG kit including straight-type guidewire (first guidewire) (1), RFB (2), 18-gauge

puncture needle with sheath (3), J-type guidewire (second guidewire) (4), 8-F dilator

(5), 16-F peel-away sheath (6), and indwelling tube (7).

2B: A RFB is inflated with approximately 10–15 mL of dilute contrast media.

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

109

Figure 3.

US reveals that the inflated RFB placed at the cervical esophagus, which displaces the

vessels (carotid artery and internal jugular vein) laterally, is detected just under the

skin.

1, esophagus; 2, thyroid gland; 3, trachea; 4, carotid artery; 5, jugular vein; 6, RFB

3A: Ultrasonography (US) before RFB inflation

3B: After RFB inflation

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

110

Figure 4.

4A: A J-type guidewire is inserted into the RFB through the outer sheath of the

puncture needle.

4B: A J-type guidewire and the RFB catheter are advanced to the lower esophagus.

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

111

4C: The puncture site is dilated using a dilator with a peel-away sheath over the

guidewire.

4D: An indwelling tube is appropriately inserted into the stomach via the esophagus.

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

112

4E: An indwelling tube is secured with nylon suture at the puncture site.

Figure 5.

18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)

113

5A, B: PTEG was performed in patients with malignant gastrointestinal obstruction. A

14-F ileus tube was inserted via the PTEG route after one week.