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Indications / Contraindications
Indications
- Poor gastric distension despite air insufflation precluding safe retrograde transabdominal access
- Cannot identify safe stomach wall window to avoid colon or liver interposition via retrograde approach
- Patient/clinical preference for endoscopic approach; GI/surgery coordination preferred
- Esophageal or oropharyngeal anatomy that allows oral wire passage but stomach not safely accessible from outside
- Complex head/neck cancer patients where combined ENT + GI/IR approach is planned — though note tumor seeding risk below
vs. Retrograde Push Technique:
The retrograde push technique (gastrostomy.html) is IR's preferred method — no endoscopy required, less sedation, less radiation, equivalent safety. The pull technique requires GI endoscopy and general/deep sedation. Default to push; use pull when push is not feasible.
Contraindications
- Same absolute contraindications as retrograde technique: no safe gastric window, massive ascites, uncorrectable coagulopathy
- Severe trismus or pharyngeal obstruction preventing safe oral scope passage (relative — transnasal endoscopy may be used)
- Completely obstructing esophageal mass where wire cannot be passed orally
- High aspiration risk without secured airway protection
Tumor Seeding Warning:
Pull technique carries a risk of seeding head/neck cancer cells from oropharynx/esophagus to the abdominal tube site (estimated 0.5–3%). Many centers prefer retrograde technique for H&N cancer patients specifically to avoid this. Counsel patients and discuss with oncology/tumor board before proceeding.
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Pre-Procedure Checklist
GI/endoscopy team confirmed and available for simultaneous procedure. This is a two-person coordinated procedure — schedule accordingly.
Anesthesia/MAC arranged. General anesthesia or deep MAC required given endoscopy component. Confirm with anesthesia team prior to scheduling.
Airway protection plan. Anesthesia team manages airway (LMA or intubation depending on aspiration risk). Aspiration risk assessment critical for H&N cancer patients.
CT review. Same as retrograde approach — review liver and colon position relative to stomach. Identify safe transabdominal window.
Consent: tumor seeding risk (for head/neck cancer patients, 0.5–3%), aspiration, standard G-tube risks (peritonitis, bleeding, tube dislodgement, peristomal infection, buried bumper syndrome).
Antibiotics: ceftriaxone 1g IV 1 hour before procedure.
Labs. CBC, coagulation (INR <1.5, Plt >50K).
NPO 6+ hours. General/MAC anesthesia protocol.
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Relevant Anatomy
Stomach Anatomy & Target
- Same target as retrograde technique: anterior gastric body/antrum — most accessible, safest window
- Trans-oral wire path: pharynx → esophagus → stomach → under endoscopic visualization throughout
- Endoscopist controls wire placement and illuminates the anterior stomach wall with the endoscope light (transillumination technique) to guide IR's abdominal puncture site
- Avoid fundus (adjacent to spleen/diaphragm) and areas of liver overlap — same as retrograde
Transillumination Principle
- Transillumination: Endoscope light pressed against anterior stomach wall → visible as glow through abdominal wall in a darkened room → confirms safe puncture site
- Finger-press confirmation: IR presses finger firmly against transilluminated site → endoscopist sees indentation of stomach wall → bidirectional confirmation of correct location
- Both transillumination AND finger indentation must be positive before needle insertion — this two-step check is the safety equivalent of the gastropexy/fluoroscopy confirmation in the retrograde technique
- Danger structures (liver, colon) same as retrograde — review CT for position before starting
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Technique
Coordinated IR + GI endoscopist pull technique + community cards
Supplies — IR
Fluoroscopy (or US for access site)
Sterile field
ChloraPrep
1% lidocaine
18G introducer needle
Retrieval snare (loop snare, 15–25 mm)
PEG pull kit (bumper/crossbar style tube)
#11 scalpel
Silk suture
Omnipaque contrast
Supplies — GI Endoscopist
GI endoscope
Biopsy channel snare
Endoscope light for transillumination
Steps
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Patient positioning & anesthesia
Supine. General anesthesia or deep MAC administered by anesthesia team. Endoscopist at head of table. IR at patient's left side. Coordinate airway management before endoscope insertion.
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Endoscopy & gastric insufflation
GI physician passes endoscope through oropharynx into stomach under direct vision. Insufflates stomach with air via endoscope — same effect as NG tube air insufflation in the retrograde technique.
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Transillumination
Endoscopist presses endoscope tip firmly against anterior stomach wall in the body/antrum. IR team darkens the room and looks for the transilluminated glow through the abdominal wall, confirming a safe percutaneous access site.
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Finger-press bidirectional confirmation
IR physician presses one finger firmly against the transilluminated site on the abdominal wall. Endoscopist directly visualizes the indentation of the gastric wall. BOTH positive = safe to proceed. This is the essential two-step safety confirmation before any needle insertion.
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IR puncture
Prep and drape abdominal wall. Local anesthetic. 18G needle puncture through abdominal wall into stomach at the confirmed transillumination site, guided by fluoroscopy or US. Pass a wire or suture thread through the needle into the gastric lumen.
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Endoscopic snare capture
Endoscopist advances snare through the biopsy channel into the stomach. Snares the wire/thread inside the stomach and holds it securely. Confirm snare has captured wire under direct endoscopic vision before proceeding.
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Wire exteriorization
Endoscopist withdraws the scope slowly and carefully, bringing the snared wire/thread out through the patient's mouth. The wire now exits at both the mouth and the abdominal puncture site.
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Attach & pull G-tube
Pull-type PEG tube is attached to the oral end of the wire/thread. IR pulls the wire/thread at the abdominal end continuously and smoothly, drawing the PEG tube from the mouth → esophagus → stomach → out through the abdominal wall. Smooth, steady tension — no jerking.
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Position & secure
PEG tube emerges at abdominal wall. Endoscopist confirms inner bumper position under direct vision in stomach — bumper should be gently apposed to gastric mucosa, not ischemic (can rotate tube slightly). Adjust external crossbar/flange to sit 1–2 cm from skin, not flush.
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Final confirmation
Endoscopist confirms inner bumper position. IR confirms external flange position. Fluoroscopy can verify position but is often not required if endoscopic visualization is adequate. Document tube length at skin mark.
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Troubleshooting
Problem
Poor transillumination (obese patient)
Likely cause: Thick abdominal wall attenuating endoscope light.
Next step: Use brighter endoscope light setting. Darken room maximally. Switch to US to confirm stomach position and safe access window. May proceed with finger-press indentation technique alone if transillumination not visible but indentation is clear. CT guidance is an option in extreme cases.
Problem
Snare misses wire in stomach
Likely cause: Wire in suboptimal position, obscured by air/secretions, or snare size mismatch.
Next step: Reposition endoscope for better angle. Suction air and secretions. Try a different snare size (15–25 mm options). Confirm wire is still inside gastric lumen under fluoroscopy. Re-pass wire if needed.
Problem
Tube tears or breaks during pull
Likely cause: Jerky or asymmetric pulling; tube defect.
Next step: Ensure smooth, continuous tension without jerking. If tube tears within esophagus: endoscopic retrieval of remnant. If tear occurs at abdominal wall: call for backup PEG kit. Never leave tube fragments in esophagus or stomach.
Problem
Cannot pass endoscope (obstructing tumor)
Likely cause: Obstructing oropharyngeal or esophageal tumor preventing scope passage.
Next step: Switch to retrograde push technique (preferred IR approach — does not require oral access). Transnasal ultrathin endoscope may allow passage past high oropharyngeal tumors. If complete esophageal obstruction: retrograde push is the only percutaneous option.
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Complications
Pull-Technique Specific
- Tumor seeding at abdominal site (0.5–3% for head/neck cancer pull technique) — malignant cells dragged from oropharynx/esophagus to tube site; most feared complication; leads to cutaneous metastasis at gastrostomy site
- Aspiration during procedure — general/MAC anesthesia with airway protection minimizes this risk; H&N patients at highest risk
- Buried bumper syndrome — inner bumper too tight initially causes pressure necrosis → bumper erodes into gastric mucosa; requires endoscopic or surgical removal
Standard G-tube Complications (shared with retrograde)
- Peristomal infection (most common delayed complication)
- Tube dislodgement — same protocol as retrograde; within 4 weeks = emergency
- Peritonitis (rare — from inner bumper erosion or tract leak)
- Bleeding — minor from dilation site; major rare
- Tube migration or occlusion; granulation tissue at site
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Post-Procedure Care
Immediate (0–24h)
- Tube position check at 24h: Contrast injection through tube to confirm intragastric position before initiating feeds
- Feeds at 24h: Start at 20 mL/hr once position confirmed; advance over 24–48h
- Monitor for fever, abdominal pain, peritonitis signs
- Ensure inner bumper is not too tight — patient should be able to rotate tube slightly against skin
Ongoing Care
- Tube flushing: 30 mL water flush before and after each feed and medication; q4h if continuous feeding
- Site care: Daily cleaning around tube with mild soap and water. No submerging for 4 weeks.
- T-fastener removal: N/A for pull technique (no T-fasteners placed)
- Tube exchange: At 4–6 months (balloon-retained replacement); same protocol as push gastrostomy
Tube Dislodgement — Same Protocol as Retrograde Gastrostomy
- Dislodgement within 4 weeks = EMERGENCY. Do NOT attempt reinsertion at bedside. Return to IR for urgent fluoroscopic replacement or surgical referral immediately.
- Dislodgement after 4 weeks: Mature fistula tract — bedside Foley catheter replacement acceptable as bridge. Return to IR within 2–4 hours before tract closes.
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Critical Pearls
✦
Retrograde push = IR default. Pull technique = when push is not feasible. Know both, but always default to the retrograde transabdominal approach in IR. The pull technique is a specialized alternative, not a first choice.
✦
Tumor seeding is a real risk for H&N cancer patients undergoing pull technique. Many multidisciplinary H&N oncology programs specifically prefer the retrograde approach to eliminate this risk. Discuss with tumor board before committing to the pull technique in any head/neck cancer patient.
✦
Transillumination + finger indentation = two-step safety confirmation. Both must be positive before needle insertion. Transillumination alone is insufficient — the indentation check confirms you are at the correct stomach wall location, not just overlying bowel or fat.
✦
Buried bumper syndrome from too-tight inner bumper. At end of procedure, the endoscopist should confirm the inner bumper can be rotated slightly and is gently apposed to mucosa — not ischemic or blanching. External flange should be 1–2 cm from skin, not flush.
✦
Coordinate early — this is a two-team procedure. Scheduling pull gastrostomy requires coordinating IR + GI endoscopy + anesthesia + the appropriate procedure room (fluoroscopy-capable and endoscopy-capable simultaneously). Last-minute scheduling is not ideal for this technique.
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Push vs. Pull Technique Comparison
| Feature | Retrograde Push (IR Default) | Antegrade Pull (PEG) |
|---|---|---|
| Endoscopy required | No | Yes (GI team) |
| Sedation level | Moderate sedation | General/MAC |
| Procedure time | 30–45 min | 45–60 min |
| Fluoroscopy | Yes (primary guidance) | Minimal/optional |
| Tumor seeding risk | None | 0.5–3% (H&N cancer) |
| Colon avoidance method | Fluoroscopic visualization | Transillumination + finger-press |
| IR independent | Yes | No — requires GI team |
| Preferred for H&N cancer | Yes (no seeding risk) | No (seeding risk) |
| Gastropexy (T-fasteners) | Yes (standard) | No |
| When pull is preferred | — | Retrograde gastric access not safe; complex anatomy; GI preference |
Enteral Access Decision Context
- Standard gastric access needed → Retrograde push gastrostomy (see gastrostomy.html)
- Retrograde push not feasible, oral access available → This page (pull technique)
- Aspiration risk / gastroparesis with existing G-tube → GJ tube conversion (see gj-tube.html)
- No stomach present / GJ tube fails → Direct jejunostomy (see j-tube.html)
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- ASGE Guidelines on Enteral Nutrition
- ASGE Technology Committee on PEG
- SIR Standards of Practice
Primary References
- Gauderer MW et al. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980;15(6):872-875.
- Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc. 1981;27(1):9-11.
- Schrag SP et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointest Liver Dis. 2007;16(4):407-418.