Indications
| Indication | Clinical Context |
|---|---|
| Long-term enteral nutrition | Neurologic dysphagia (stroke, ALS, dementia, Parkinson's disease); head and neck cancer pre- or post-treatment; trauma; burns; malignancy with swallowing dysfunction |
| Gastric decompression | Chronic obstruction (gastric outlet obstruction, distal small bowel obstruction, carcinomatosis); gastroparesis with refractory symptoms |
| Medication administration | When oral route is unavailable and enteral route is required for long-term medications |
| Prior failed PEG | Endoscopic gastrostomy technically unfeasible (post-esophagectomy, oropharyngeal obstruction, gastric anatomy not accessible endoscopically) |
Contraindications
| Type | Contraindication |
|---|---|
| Absolute | No safe gastric window (fixed hepatomegaly or colon interposition that cannot be displaced); massive unresectable ascites (extremely high leak risk); uncorrectable coagulopathy |
| Relative | Prior gastric surgery with significantly altered anatomy; active peptic ulcer disease; obesity with very thick abdominal wall (consider CT guidance); pregnancy (transperitoneal access) |
Colon interposition — assess and manage, do not abort prematurely: A single view showing apparent colon interposition does not mandate aborting. Reposition the patient; use oral barium or rectal contrast under fluoroscopy to confirm colon position; insufflate the stomach aggressively to displace the colon. Only fixed hepatomegaly without any alternative window is a true reason to abort.
Relevant Anatomy
Stomach Anatomy and Access Target
The anterior gastric body and antrum is the standard target — most accessible, provides a safe transabdominal window, and allows antegrade contrast verification. The fundus is adjacent to the diaphragm and spleen and should be avoided. The proximal body may be overlapped by the left lobe of the liver in some patients. The IR (PRG) technique uses a retrograde transabdominal approach — direct access from the anterior abdominal wall into the stomach, in contrast to the antegrade transoral pull-through (PEG) technique used in endoscopy.
Danger Structures
The transverse colon is the most important structure to identify and displace before needle insertion — it is mobile and can be positioned in front of the stomach without causing symptoms, making it invisible on physical examination. It must be identified on fluoroscopy using barium or rectal contrast before any needle is advanced. The liver right lobe can overhang the anterior stomach — it is fixed and cannot be displaced; if it occupies the only potential access window, the procedure should be aborted. The left lobe of the liver can extend into the epigastric region and must also be confirmed clear on imaging review before access. The epigastric vessels in the anterior abdominal wall are avoided by accessing lateral to the rectus or by Doppler assessment.
Pre-Procedure Checklist
Imaging Review
- CT scan review is mandatory — confirm liver and colon position relative to the anterior stomach; identify a safe transabdominal window; assess for ascites that would increase leak risk
- Plan colon visualization strategy for the day of procedure (oral barium the night before, rectal contrast, air displacement)
Labs
- CBC, coagulation panel (INR <1.5, platelets >50,000 — SIR Category 2)
- IV antibiotics: cefazolin (Ancef) 1 g IV at least 1 hour before procedure (preferred over ceftriaxone)
- NPO 6 hours; moderate sedation or MAC anesthesia
Consent Considerations
Discuss: inadvertent colon or bowel puncture (0.5–1% — most serious complication; requires surgical consultation), peritonitis, bleeding, tube dislodgement (highest risk in first 2 weeks before tract maturation), peristomal site infection (~5–10%), aspiration risk, internal bumper erosion, and buried bumper syndrome with long-term tubes.
Procedure Overview
The following is a high-level summary. Full step-by-step retrograde and push-type technique are available in RadCall Pro.
- Gastric distension — place nasogastric tube and insufflate the stomach with air to appose the anterior gastric wall to the anterior abdominal wall; confirm on fluoroscopy with gastric rugal folds visible
- Colon visualization and safe window confirmation — confirm the transverse colon is not in the planned access path using oral barium, rectal contrast, or fluoroscopic air displacement; document a safe window image before proceeding
- T-fastener gastropexy — place T-fastener anchors in a triangular or rectangular pattern around the intended tube site under fluoroscopic guidance; these tacks appose the stomach to the anterior abdominal wall, preventing gastric withdrawal during tube passage and reducing post-procedure peritoneal leak
- Intragastric position confirmation — inject small volume of contrast through a T-fastener needle to confirm intragastric position; visualize gastric rugae and free contrast flow within the lumen
- Access and wire placement — advance access needle into the gastric lumen between the T-fasteners under fluoroscopic guidance; confirm intraluminal position; advance wire with generous coil in stomach
- Tube placement — advance gastrostomy tube over wire; inflate retention balloon with sterile water; gently pull back until gastric wall is apposed to abdominal wall; confirm intragastric position fluoroscopically; apply external fixator plate
- Contrast check — inject contrast through tube to confirm intragastric position and absence of peritoneal extravasation; T-fastener sutures cut at 5–7 days after tract maturation
Complications
| Complication | Rate | Recognition & Management |
|---|---|---|
| Inadvertent colon puncture | 0.5–1% | Most serious complication; feculent output through tube is diagnostic; CT for confirmation; surgical consultation for full-thickness colonic injury; small injuries with catheter traversing colon may be managed by gradual tube withdrawal as tract matures |
| Peritonitis | <1% | Gastric leak peritoneal; surgical consultation; T-fastener gastropexy substantially reduces this risk |
| Peristomal site infection | ~5–10% | Local wound care; topical antiseptics; systemic antibiotics for cellulitis; prevented by pre-procedure antibiotics |
| Tube dislodgement | Highest in first 2 weeks | Do not replace without imaging if tract is <2 weeks old — no mature fistula tract; IR fluoroscopic replacement; gastric contents in peritoneum may cause peritonitis |
| Hemorrhage | <1% significant | Avoid epigastric vessels; Doppler assessment if uncertain; embolization for active arterial bleeding |
| Aspiration | Procedure-related or related to feeds | Head-of-bed elevation during and after feeds; consider jejunal extension tube for high-aspiration-risk patients |
Post-Procedure Care
Tube Management
- T-fastener sutures cut at 5–7 days after fistula tract maturation — do not remove before this
- Flush tube with water before and after feeds; keep tube clamp open during feeding
- Peristomal site care: rotate tube daily; clean with soap and water; avoid occlusive dressings
Discharge and Follow-up
- Patient/caregiver tube care education before discharge — flushing, rotation, dressing changes
- Return to IR for tube dislodgement, leaking around tube, or inability to flush
- Routine tube exchange typically every 3–6 months for balloon-retained tubes
When to Escalate
- Feculent or stool-colored tube output — suspect colonic fistula; CT with oral and rectal contrast; surgical consultation
- Peritoneal signs after tube placement — urgent CT; surgical consultation for peritonitis; ensure tube is secured and positioned correctly
- Tube dislodgement in first 2 weeks — do not blindly reinsert; no mature tract; urgent IR for fluoroscopic-guided replacement; risk of feeding into peritoneum without imaging guidance
- Unable to place because of unsafe gastric window — consider CT-guided placement for improved anatomic delineation; discuss with proceduralist; if fixed hepatomegaly without alternative window, formal surgical gastrostomy consultation
References
- SIR Quality Improvement Guidelines for Adult Percutaneous Abscess and Fluid Drainage. (Adapted for G-tube).
- Neeff M, et al. Radiologic versus endoscopic gastrostomy: a randomized controlled study. Eur Radiol. 2015;25(9):2741–2748.
- Kandarpa K, et al. Handbook of Interventional Radiologic Procedures, 5th ed.