Clinical History
This pertains to interventional radiology for nutritional support.
Imaging Findings
A patient with terminal pharyngeal cancer with worsening was referred dysphagia. She had undergone radiotherapy previously and insertion of a tracheostomy tube, but the increasing tumour bulk implied
that she was only able to swallow liquids. Radiological insertion was requested, as the gastro-enterologists deemed the patient unsuitable for percutaneous endoscopic gastrostomy (PEG). After
informed consent, the patient was positioned supine, given topical throat anaesthesia and a mouthguard and was pre-oxygenated with 4 l/min of nasal O2. The patient was sedated by titration of
increments of 1 mg midazolam and 25 mcg fentanyl. The administration of sedation was guided by frontal lobe EEG activity [1] using a bispectral index monitor (Aspect medical systems/Philips, Reigate,
UK). In addition to this, standard monitoring done by a dedicated nurse involed performing pulse oximetry, measuring non-invasive blood pressure and performing an ECG. A 20Fr. push-gastrostomy tube
designed for endoscopic insertion (Fig. 1) was used. In order to reduce the risk of wound infection from the per-oral passage, 2 g of cefotaxime was given iv prior to the procedure. A 7Fr. vascular
Headhunter catheter (Cordis, Johnson & Johnson, South Ascot, UK) and hydrophilic guidewire (Radiofocus, Terumo, Knowsley, UK) were passed through the mouth into the stomach (Fig. 2), 20 mg
hyoscine bromide was given iv and the stomach was inflated with room air. The puncture site was identified using fluoroscopy and infiltrated with 10 ml of 1% lidocaine (Fig. 3). Gastropexy was not
performed. A small skin incision was made and the stomach was punctured with a sheathed 18G needle from a gastrostomy kit. After the insertion of a wire, a 4Fr. vascular sheath with a haemostatic
valve (Radiofocus Introducer, Terumo, Knowsley, UK) was inserted (Fig. 4). The sheath secures access while the valve prevents air from escaping. A 4Fr. Headhunter catheter was inserted through the
sheath, and the cardia was cannulated retrogradely with a 0.035", 260 cm guidewire from the gastrostomy set (Fig. 5). The catheter and the wire were then advanced up the oesophagus and brought out
through the mouth. After the removal of the antegrade inflation catheter, a 14Fr. push-PEG (MIC.Kimberly-Clark/Vygon, Cirencester, UK) was advanced per-orally over the wire until the tapered dilator
shaft exited through the skin. After the removal of all catheters and wires, the tube was pulled into the stomach and the external fixation disk and connectors were attached (Fig. 6). After 6 hours,
water was administered through the tube and feeding commenced the following day.
Discussion
Per-oral image-guided gastrostomy combines the success rate and versatility of radiologically inserted gastrostomy (RIG) with the robust tubes of endoscopic gastrostomy (PEG) and has shown to be an
extremely successful technique [2,3]. This technique does not require gastopexy, thereby reducing the incidence of pain and confusion of ward staff about the removal of sutures. The tubes described
have the additional advantage of being designed for traction removal through the skin, thus avoiding a repeat endoscopy. However, a small proportion due to anatomical position and ageing of tube
material, particularly if made of silicone, may still require endoscopic removal. The administration of a single dose of prophylactic cephalosporins recommended for PEG insertion [4] must also be
done for this technique, because the tube passes through the mouth. This also carries a small, but documented, risk of seeding of cells from upper GI-tumours into the skin site [5]. In cases where
the tumour is curable and the patient requires gastrostomy insertion prior to radical surgery, a percutaneous gastrostomy (RIG) should be performed. PIG gastrostomy has replaced RIG as the standard
radiological technique in our department and is now used as a routine alternative to PEG.
Differential Diagnosis List
Per-oral image-guided gastrostomy (PIG).
Final Diagnosis
Per-oral image-guided gastrostomy (PIG).