Percutaneous gastrostomy. Ken U. Ekechukwu, MD, MPH, FACP.

What is percutaneous gastrostomy?
Per is Latin for through. Cutaneous comes from cutis, Latin for skin. Gastro derives from gaster, Greek for stomach. Stomy is from stomatos, Greek for mouth. Thus, ‘percutaneous gastrostomy’ means making a hole (or opening/mouth) in the stomach through the skin. It is the deliberate construction of a track from the skin to the stomach through which a feeding tube or catheter is inserted into the stomach to provide an access for nourishing a patient, bypassing the mouth and the esophagus.

How is percutaneous gastrostomy done?
The patient will have nothing by mouth starting the midnight preceding the procedure. This empties the stomach, allowing a clean field and the use of sedation for the procedure. The patient is taken to the interventional radiology (IR) suit on the morning of the procedure and placed on a procedure table. A nurse or the physician sprays a local anesthetic at the back of the patient’s throat to numb it. Then a tube is passed through the mouth into the stomach so it can be inflated with air. Sometimes this is done on the floor before the patient arrives the IR suite. The upper part of the abdomen and the lower chest are scrubbed with antiseptic lotion to prevent wound or blood infection. The patient receives a prophylactic  intravenous antibiotic and medications for conscious sedation. Then another intravenous medicine is given to temporarily slow movements of the stomach and the intestines and keep air in the stomach. The stomach is filled with air through the tube in it and a small cut is made on the anesthetized skin over the mid or lower stomach. A needle is passed through the skin incision into the stomach, through which 2 or 3 T-shaped fasteners are deployed into the stomach. These fix the anterior wall of the stomach against the posterior surface of the anterior abdominal wall and keep the stomach from slipping away during later maneuvers. A wire is passed through the needle into the stomach and dilators are passed over the wire to dilate the needle track. Then a feeding tube is passed over the wire into the stomach and anchored to the skin. Finally, iodinated radiocontrast is injected into the stomach through the tube to confirm that the tip of the tube is in the stomach and that there is no leakage around it. A collecting bag  is attached to the tube to collect air and liquid for 12 to 24 hours to make sure that all is well. The tube may be used thereafter, if all is well.

Who needs percutaneous gastrostomy?
1. Those who cannot eat food by mouth for more than 30 days for any reason.
2. Those whose stomach has difficulty emptying itself.

What are the contraindications to percutaneous gastrostomy?
Contraindications to percutaneous gastrostomy are conditions that make the procedure a hazard. They include the following:
1. Uncorrectable coagulopathy. This means ‘thinning’ of the blood that predisposes to hemorrhage during or after the procedure. 
2. No safe access. Scars from past surgery or injury to the abdomen can distort the intra-abdominal anatomy. 
3. Gastric tumors. Gastric cancer can grow through the gastrostomy track to the surface of the abdomen, if the track was unwittingly created close to or through the cancer.
4. Abdominal varices. These are large collateral or bypass blood vessels on or in the abdomen that can be injured during gastrostomy. They may occur in patients with cirrhosis of the liver or total obstruction of the inferior and superior vena cava. 
5. Massive ascites. The abdomen is full of liquid due to failure of the liver, the kidneys or the heart; it is a relative contraindication, because the fluid can be emptied shortly before the procedure.
6. Ventriculoperitoneal shunt. A small tube connects the ventricles in the brain with the peritoneal cavity in the abdomen. The shunt can become infected and the infection spread up the tube into the brain; it, too, is a relative contraindication.
7. Severe gastroesophageal reflux. The cause of heart burn. In this case the tip of your tube should be placed past the stomach to avoid inundating the stomach with liquid that may reflux into the esophagus.

How is gastrostomy tube cared for?
It is easy to care for the tube at home. Just remember to flush it well after every use with water. Some recommend using any carbonated drink (any soda drink) to flush the tube because such drinks make lots of bubbles that help clear the tube. If the tube is used to administer crushed tablets, they must be pulverized well before administration and the tube scrupulously irrigated after  use. A clogged tube, if unsalvageable, should be replaced.

How long can a gastrostomy tube be worn and how is it cared for?
A patient’s condition and their health-care provider’s opinion will decide when to stop using a gastrostomy tube. Removing the tube is easy. This can be done by a home health care provider or at the hospital. Typically, the holes in the stomach and skin seal in 48 hours after removing the tube.