Percutaneous Gastrostomy and Jejunostomy

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Although surgeons and gastroenterologists have traditionally provided enteral access services, interventional radiologists can safely, effectively, and successfully perform these procedures as well. Experience with percutaneous radiologically guided gastrostomy and gastrojejunostomy access is extensive, and experience with direct percutaneous jejunostomy access is growing. This article reviews issues and highlights areas of controversy important to radiologists providing these services. ^{[1, 2, 3, 4, 5, 6]}

First described in 1837, surgical gastrostomy was the mainstay of direct enteral feeding access for decades. Although laparoscopic techniques for gastrostomy and jejunostomy tube access have evolved since then, their use is limited because of the acceptance of less invasive endoscopic and radiologic alternatives. Surgical gastrostomy or jejunostomy is most frequently performed when patients are already undergoing laparotomy for related or unrelated abdominal problems.

The advent in 1980 of percutaneous endoscopic gastrostomy (PEG) dramatically changed the approach to gastrostomy access, and this minimally invasive procedure largely replaced surgical gastrostomy. Endoscopic gastrostomy has been accepted widely and remains the most common form of gastrostomy access. Endoscopic gastrojejunostomy and direct endoscopic jejunostomy also have been described, but these methods are less widely used and less accepted than PEG.

In 1983, three independent interventional radiology groups described a percutaneous imaging-guided alternative to surgical and endoscopic gastrostomy. Since then, reports from multiple large series have described the procedure. Compared with endoscopy, fluoroscopic guidance allows the safe placement of gastrostomy tubes and allows easier initial placement of gastrojejunostomy tubes. Subsequently, direct jejunostomy access was described. The degree to which individual radiology practices offer these services varies.

Although percutaneous enterostomy catheters are most commonly placed for nutritional support, other indications have evolved for specific clinical scenarios.

As a general rule, enteral or parenteral feeding is advised when a patient is unable to eat for 7-14 days or longer. In the setting of a functional gut, enteral feeding is preferred to parenteral options.

When the need for enteral feeding is anticipated to be 30 days or shorter, feedings through a nasogastric tube or a more distal nasoenteric tube are usually appropriate. Because such tubes are associated with considerable discomfort and because sinusitis and epistaxis are common complications, direct enteral access is preferred when feeding needs extend beyond 30 days.

The choice of access route (gastrostomy, gastrojejunostomy, or jejunostomy) and the choice of placement technique (surgical, endoscopic, or radiologic) often depend on individual patient issues and on the specialty, experience, and preference of the treating physician.

Patients with either functional or mechanical bowel obstructions often require tube decompression. When decompression is needed for prolonged periods (eg, in patients with severe diabetic gastroparesis or peritoneal carcinomatosis), direct enteral tube placement offers advantages over nasogastric or nasoenteric tube placement. Because the stomach and small bowel are grossly dilated in these settings, both gastrostomy and jejunostomy tube placements are technically straightforward.

Interventional radiologists may use imaging-guided access to the bowel to facilitate other gastrointestinal or biliary interventions. In the setting of previous biliary-jejunal anastomotic procedures, percutaneous access into the afferent jejunal limb can facilitate the treatment of biliary strictures and stones. In patients with obstructing esophageal neoplasms, gastrostomy access and retrograde esophageal catheterization may facilitate the placement of palliative stents.

Although the risks and potential benefits of enteral access catheter placement must be weighed in each patient, certain anatomic and pathologic conditions may increase the likelihood of complications.

Absolute contraindications for percutaneous feeding tube placement include the following:

Relative contraindications for percutaneous feeding tube placement include the following:

Clinical comparison of alternative techniques

A meta-analysis by Wollman et al found that radiologically guided gastrostomy compared favorably with surgical and endoscopic gastrostomy, with similar or improved success and complication rates (see Table 1 below). ^[7]

Table 1. Comparisons of Gastrostomy Success and Complication Rates (Open Table in a new window)

Measure

Surgical

Percutaneous Endoscopic

Radiologic 

No. of patients

721

4194

837

No. of series

11

48

9

Success rate, %

100

95.7

99.2

Procedural mortality, %

2.5

0.5

0.3

Major complication rate, %

19.9

9.4

5.9

Minor complication rate, %

9.0

5.9

7.8

In a study comparing percutaneous primary jejunostomy tubes for postpyloric enteral feeding with percutaneous gastrojejunostomy tubes, Kim et al found that the two tube types were similar with regard to technical success and incidence of complications but that jejunostomy tubes had a lower rate of dysfunction and a higher rate of leakage. ^[8]

Economic comparison of alternative techniques

Although comparative analyses of procedural costs are complicated and may be difficult to reproduce, the overall costs of radiologic gastrostomy appear to be similar to those of endoscopic gastrostomy and less than those of surgical gastrostomy. For gastrojejunostomy access, radiologic methods are less expensive than either endoscopic or surgical techniques. The results of a cost analysis performed by Barkmeier et al in 1998 are summarized in Table 2 (see below). ^[9]

Table 2. Procedural Costs (in USD) of Gastrostomy and Gastrojejunostomy (Open Table in a new window)

Procedure

Surgical

Endoscopic

Radiologic

Gastrostomy

3694

1861

1985

Gastrojejunostomy

3045

3158

2201

In a retrospective review that included 559 adults who underwent fluoroscopically guided gastrojejunostomy (n = 473) or gastrostomy (n = 86) tube insertion, Zener et al evaluated 30-day mortality and complication rates associated with percutaneous insertion using a single-puncture, dual-suture anchor gastropexy and peelaway sheath technique. ^[10] Major complication rate and procedure-related mortality were low with this technique. Overall complication rate was higher for gastrojejunostomy tube insertion, probably because of a higher incidence of minor complications.

Richard HM, Widlus DM, Malloy PC. Percutaneous fluoroscopically guided jejunostomy placement. J Trauma. 2008 Nov. 65 (5):1072-7. [Medline].

Kang WM, Yu JC, Ma ZQ, Liu XH. [Clinical application of percutaneous endoscopic gastrostomy/jejunostomy in critically ill patients]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2008 Jun. 30 (3):253-6. [Medline].

Wang ZM, Jiang ZW, Diao YQ, Wu SM, Ding K, Li N, et al. [Clinical application of percutaneous endoscopic gastrostomy/jejunostomy]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2008 Jun. 30 (3):249-52. [Medline].

Virnig DJ, Frech EJ, Delegge MH, Fang JC. Direct percutaneous endoscopic jejunostomy: a case series in pediatric patients. Gastrointest Endosc. 2008 May. 67 (6):984-7. [Medline].

Sy K, Dipchand A, Atenafu E, Chait P, Bannister L, Temple M, et al. Safety and effectiveness of radiologic percutaneous gastrostomy and gastro jejunostomy in children with cardiac disease. AJR Am J Roentgenol. 2008 Oct. 191 (4):1169-74. [Medline].

Spelsberg FW, Hoffmann RT, Lang RA, Winter H, Weidenhagen R, Reiser M, et al. CT fluoroscopy guided percutaneous gastrostomy or jejunostomy without (CT-PG/PJ) or with simultaneous endoscopy (CT-PEG/PEJ) in otherwise untreatable patients. Surg Endosc. 2013 Apr. 27 (4):1186-95. [Medline].

Wollman B, D’Agostino HB, Walus-Wigle JR, Easter DW, Beale A. Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology. 1995 Dec. 197 (3):699-704. [Medline].

Kim CY, Engstrom BI, Horvath JJ, Lungren MP, Suhocki PV, Smith TP. Comparison of primary jejunostomy tubes versus gastrojejunostomy tubes for percutaneous enteral nutrition. J Vasc Interv Radiol. 2013 Dec. 24 (12):1845-52. [Medline].

Barkmeier JM, Trerotola SO, Wiebke EA, Sherman S, Harris VJ, Snidow JJ, et al. Percutaneous radiologic, surgical endoscopic, and percutaneous endoscopic gastrostomy/gastrojejunostomy: comparative study and cost analysis. Cardiovasc Intervent Radiol. 1998 Jul-Aug. 21 (4):324-8. [Medline].

Zener R, Istl AC, Wanis KN, Hocking D, Kachura J, Alshehri S, et al. Thirty-day complication rate of percutaneous gastrojejunostomy and gastrostomy tube insertion using a single-puncture, dual-anchor technique. Clin Imaging. 2018 Jan 10. 50:104-108. [Medline].

Given MF, Lyon SM, Lee MJ. The role of the interventional radiologist in enteral alimentation. Eur Radiol. 2004 Jan. 14 (1):38-47. [Medline].

Han K, Kim MD, Kwon JH, Kim YS, Kim GM, Lee J, et al. Randomized Controlled Trial Comparing Radiologic Pigtail-Retained Gastrostomy and Radiologic Mushroom-Retained Gastrostomy. J Vasc Interv Radiol. 2017 Dec. 28 (12):1702-1707. [Medline].

Ingraham CR, Johnson GE, Albrecht EL, Padia SA, Monroe EJ, Perry BC, et al. Value of Antibiotic Prophylaxis for Percutaneous Gastrostomy: A Double-Blind Randomized Trial. J Vasc Interv Radiol. 2018 Jan. 29 (1):55-61.e2. [Medline].

Sacks BA, Vine HS, Palestrant AM, Ellison HP, Shropshire D, Lowe R. A nonoperative technique for establishment of a gastrostomy in the dog. Invest Radiol. 1983 Sep-Oct. 18 (5):485-7. [Medline].

Ponsky JL, Gauderer MW, Stellato TA, Aszodi A. Percutaneous approaches to enteral alimentation. Am J Surg. 1985 Jan. 149 (1):102-5. [Medline].

Raval MV, Phillips JD. Optimal enteral feeding in children with gastric dysfunction: surgical jejunostomy vs image-guided gastrojejunal tube placement. J Pediatr Surg. 2006 Oct. 41 (10):1679-82. [Medline].

Brown AS, Mueller PR, Ferrucci JT Jr. Controlled percutaneous gastrostomy: nylon T-fastener for fixation of the anterior gastric wall. Radiology. 1986 Feb. 158 (2):543-5. [Medline].

Cope C. Suture anchor for visceral drainage. AJR Am J Roentgenol. 1986 Jan. 146 (1):160-2. [Medline].

Choudhry U, Barde CJ, Markert R, Gopalswamy N. Percutaneous endoscopic gastrostomy: a randomized prospective comparison of early and delayed feeding. Gastrointest Endosc. 1996 Aug. 44 (2):164-7. [Medline].

Measure

Surgical

Percutaneous Endoscopic

Radiologic 

No. of patients

721

4194

837

No. of series

11

48

9

Success rate, %

100

95.7

99.2

Procedural mortality, %

2.5

0.5

0.3

Major complication rate, %

19.9

9.4

5.9

Minor complication rate, %

9.0

5.9

7.8

Procedure

Surgical

Endoscopic

Radiologic

Gastrostomy

3694

1861

1985

Gastrojejunostomy

3045

3158

2201

Richard Duszak, Jr, MD Professor and Vice Chair, Department of Radiology and Imaging Sciences

Richard Duszak, Jr, MD is a member of the following medical societies: Alpha Omega Alpha, Society of Interventional Radiology, American College of Radiology, American Medical Association, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Douglas M Coldwell, MD, PhD Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine

Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Heart Association, SWOG, Special Operations Medical Association, Society of Interventional Radiology, American Physical Society, American College of Radiology, American Roentgen Ray Society

Disclosure: Received consulting fee from Sirtex, Inc. for speaking and teaching; Received honoraria from DFINE, Inc. for consulting.

Kyung J Cho, MD, FACR, FSIR William Martel Emeritus Professor of Radiology (Interventional Radiology), Frankel Cardiovascular Center, University of Michigan Health System

Kyung J Cho, MD, FACR, FSIR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Fredric A Hoffer, MD, FSIR Affiliate Professor of Radiology, University of Washington School of Medicine; Member, Quality Assurance Review Center

Fredric A Hoffer, MD, FSIR is a member of the following medical societies: Children’s Oncology Group, Radiological Society of North America, Society for Pediatric Radiology, Society of Interventional Radiology

Disclosure: Nothing to disclose.

Percutaneous Gastrostomy and Jejunostomy

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