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18. PTEG/PEG (Yozo Sato, MD, PhD, Yoshitaka Inaba, MD, PhD)
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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.
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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
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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].
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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.
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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.
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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.
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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.
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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
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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.
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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.
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4E: An indwelling tube is secured with nylon suture at the puncture site.
Figure 5.
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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.
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