Gastrostomy

Abdominal Interventional Procedures

Gastrostomy - Minimally Invasive Surgical Solutions and Procedures and Gastrostomy

Gastrojejunostomy

With gastrojejunostomy, or transgastric jejunostomy, techniques similar to direct gastrostomy tube placement can be used to advance a feeding tube through the stomach and duodenum into the jejunum to allow gastrojejunostomy tube feedings . Because gastrojejunostomy tube placement is more difficult and more expensive than gastrostomy tube placement and because it is associated with a higher incidence of tube occlusion and dislodgement, the technique is probably best reserved for patients at higher risk of aspiration. When necessary, previously placed gastrostomy tubes can be converted to gastrojejunostomy tubes.

What is a percutaneous gastrostomy?

Percutaneous gastrostomy is a technique whereby a narrow plastic tube is placed through the skin, directly into your stomach. Once in place the tube can be used to give you liquid food directly into your stomach, to provide nutrition. Because it is done through the skin, it is called percutaneous, and gastrostomy means making an opening into the stomach.

Why do I need percutaneous gastrostomy?

There are several reasons why you may not be able to eat normally at the present time. There may be a blockage at the back of your throat or in your gullet (esophagus), and this is preventing food going down normally. It may be that you have had a stroke, and that this is causing you problems with swallowing, or your gullet may not be working properly for other reasons. If you have had a small plastic tube inserted through your nose, down into your stomach, it may not be large enough to get adequate amounts of food into your stomach. Obviously, if you do not receive enough nutrition, then you will become very ill.

Who has made the decision?

The doctors in charge of your case and the radiologist doing the percutaneous gastrostomy will have discussed the situation and feel that this is the best option. However, you will also have the opportunity for your opinion to be taken into account and if, after discussion with your doctors you do not want the procedure carried out, then you can decide against it.

Who will be doing the percutaneous gastrostomy?

A specially trained doctor called a radiologist will perform the procedure. Radiologists have special expertise in using x-ray and scanning equipment and also in interpreting the images produced. They need to look at these images whilst carrying out the procedure.

Where will the procedure take place?

The procedure is generally carried out in the x-ray department, in a special "screening" room, adapted for this sort of specialised procedure.

How do I prepare for percutaneous gastrostomy?

You need to be an in-patient in the hospital. You may receive a sedative beforehand to relieve anxiety, and possibly an antibiotic. You will be asked to put on a hospital gown. If you have any allergies you must let your doctor know. If you have ever reacted to intravenous contrast medium, the dye used in x-ray departments for kidney x-rays and CT scanning, you must also tell your doctor about this.

What actually happens during a percutaneous gastrostomy?

You will lie on the x-ray table, generally flat on your back. You need to have a needle put into a vein in your arm so that the radiologist can give you a sedative or pain killers. Once in place this needle will not cause any pain. You will have a monitoring device attached to your finger and will possibly receive oxygen through a small tube in your nose. You may also have a monitoring device attached to your chest.

The radiologist will keep everything as sterile as possible and may wear a theatre gown and operating gloves. The skin below your ribs will be cleaned with antiseptic and most of the rest of your body covered with a theatre towel. The radiologist will use the x-ray equipment or an ultrasound machine to decide on the most suitable point for inserting the feeding tube. This will generally be below your left lower ribs. The skin in this area will be anesthetised with local anesthetic. This can sting a little to start with, but rapidly wears off.

The radiologist will then pass a thin, hollow needle into your stomach using x-rays or ultrasound as a guide. Once the needle is in your stomach, some air will be put in, which makes room for a guidewire to be placed down through the needle into your stomach. The needle is then removed, leaving the guidewire in place, and then a series of small tubes are passed over the wire, one after another, to enlarge the pathway from the skin into your stomach. Once this pathway is wide enough, a tube (catheter) can be put in through the skin and into your stomach over the guidewire. The guidewire is then removed. The tube will be used to give you food, and is large enough to ensure that you receive adequate nutrition. Once this tube is in place the radiologist will secure the stomach to the muscles underneath the skin with stitches, to prevent the tube falling out. It is also necessary to secure the tube with stitches to the skin surface, again to make it secure.

Will it hurt?

Unfortunately, while the procedure is being done, it may hurt for a very short period of time, but any pain that you have will be controlled with painkillers. When the local anaesthetic is injected it will sting to start with, but this soon wears off, and the skin and deeper tissues should then feel numb. Later you will be aware of the tubes being passed into your stomach, but this should just be a feeling of pressure and not pain. There will be a nurse or some other member of staff standing next to you and looking after you. If the procedure does become painful for you then they will be able to arrange for you to have more painkillers through the needle in your arm. Generally, placing the catheter in the stomach takes only a short time and once in place it should not hurt at all.

How long will it take?

Every patient's situation is different and it is not always easy to predict how complex or how straightforward the procedure will be. It may be over in 30 minutes but occasionally it can take as long as 90 minutes. As a guide, expect to be in the x-ray department for about an hour and a half altogether.

What happens afterwards?

You will be taken back to your ward on a trolley. Nurses on the ward will carry out routine observations, such as taking your pulse and blood pressure, to make sure that there are no problems. If you have been up and about previously, then you will generally need to stay in bed for a few hours afterwards, until you have recovered.

It is important to try and look after the feeding tube. You should try not to make any sudden movements, for example getting up out of a chair or out of bed without remembering the tube. However, you will be able to lead a perfectly normal life with the tube in place.

How long will the tube stay in and what happens next?

This is a question which can only be answered by the doctors looking after you. It all depends on why you needed the tube in the first place. You do need to discuss this fully with your consultant. The tube needs to stay in place until you can eat and drink normally, and in some cases this might not be for a very long time.

The tube will have a little stopper at its end to stop it leaking. When it is time to put liquid food down the tube, the stopper is removed and liquid food is drawn up into a large syringe and sent down the tube to your stomach. You may be able to learn to do this yourself, or someone may need to do it for you. Once enough food has been put down the tube, it is necessary to clean the tube by passing clear salt water, called saline, through it, again using a syringe. The stopper is then placed back in the tube, which is then covered.

You will have a specially trained dietician looking after you, who will decide how much liquid food you need to put down the tube, and will show you how to look after the tube properly. He/she will also give you more information about the type of liquid food you are injecting. About two weeks after the procedure the nurses on the ward will take out the stitches on the skin surface, which are holding the tube in place. The tube should then stay in all by itself.

Are there are risks or complications?

Percutaneous gastrostomy is a very safe procedure. However, there are some risks and complications that can arise, as with any medical treatment.

The biggest problem could be not being able to get the tube into your stomach. This can sometimes happen if you have not been able to eat for a long time and your stomach has shrunk quite a lot. It may not be possible to find it with a small needle. If this happens you may need an operation to place the tube.

Sometimes there is a leak around the tube. This is less likely to happen if the stomach has been attached to the muscles beneath the skin, but it can still sometimes occur. This can lead to the skin around the tube becoming very red and sore. An attempt will be made to treat this but it may become necessary to remove the tube for healing to occur. You need to keep the area around the tube very clean and very dry.

Very rarely a blood vessel can be punctured accidentally when passing the needle into the stomach. This can result in bleeding. This may stop by itself, or if not, you may need a blood transfusion. Occasionally it may require another procedure to block the bleeding artery. This would be done by a radiologist using a fine plastic tube put into the artery. Very rarely, it may need an operation to stop the bleeding. However, this is a very rare complication.