Feeding Tubes

procedures

Push-type G-tube Placement

• Pre-scan and mark liver margin and superior epigastric artery if visible.

• If no NGT or OGT, can place a 5 Fr catheter (e.g. Kumpe) through the nose or mouth into the stomach.

• Make sure all supplies are prepped and ready to use prior to inflating the stomach. Some give 0.5-2 mg glucagon (often 1 mg) to reduce gastric motility and loss of air out of the stomach.

• Inflate stomach with air (amount varies but often 250-800 mL). Use hemostat or clamp to plan access and mark skin with fluoro. Oblique as needed to ensure no bowel is between the stomach and anterior abdominal wall.

  • Choose the G-tube site in the distal body of the stomach equidistant between lesser and greater curvature and avoiding the superior epigastric artery.

• People vary in terms of number and placement of gastropexy t-tacks. Most common is three in a triangle around the g-tube or two.

• Anesthetize skin and subcutaneous tissues. Can aspirate with lidocaine needle to see whether the needle enters the stomach further confirming good access sites.

• Make a small incision at the planned g-tube site.

  • Some recommend making the incision vertical rather than horizontal to reduce injury to the superior epigastric artery.

  • Some also make small nicks for the t-tack sites while others do not since the introducer needle is often sharp enough. and use US to mark liver boundary and assess for overlying bowel

• Place gastropexy t-tacks.

  • Two common types: Avanos Medical (formerly “Kimberly clark”) and Cope t-tacks

  • Attach contrast syringe with extension tubing to the access t-tact introducer needle. Hold the needle with a clamp and reconfirm site/trajectory with fluoro in AP.

  • Move the II to RAO to hold the needle with hand out of the field of view. Advance needle under fluoro looking for gastric wall tenting and popping into the lumen. Confirm by aspirating air and injecting contrast.

  • Secure t-tact under gentle tension with clamp to the drape.

  • Repeat for other t-tacks

• Access stomach for g-tube the same as above either using the needle that comes with the Cope t-tacks or other needle (e.g. AMC or Yueh). If difficult access, can start with a micropuncture set.

  • Access stomach angled towards fundus unless planning conversion to G-J in future, then point toward pylorus. 

• Introduce J- or floppy tipped stiff guidewire (e.g. Amplatz). Some suggest the “3-wall rule” that you should have enough wire looped in the stomach to preserve access that it contacts 3 walls.

• Withdraw needle and dilate tract via serial dilators or balloon (e.g. 8-10 x 40-80 mm Conquest) with g-tube behind. Helpful to lubricate everything with lidocaine jelly.

• Inflate retention balloon with 7-10 mL sterile water. Some add a small amount of contrast (e.g. 0.5 mL) to help with visualization.

• Secure the gastrostomy tube watching under fluoro to ensure the balloon opposes the gastric wall.

• Inject contrast to confirm adequate positioning within the gastric lumen. Flush the contrast out of the tube after injection.

• Secure gastropexy t-tacks.

• (Optional) Some will tie silk suture or place tape around the external retention bumper to help prevent loosening.

• (Optional) Some place a small piece of tape over the balloon port to discourage accidental injection of the balloon port.

Pull-type G-tube Placement

• Pre-scan and mark liver margin and superior epigastric artery if visible.

• If no NGT or OGT, can place a 5 Fr catheter (e.g. Kumpe) through the nose or mouth into the stomach.

• Make sure all supplies are prepped and ready to use prior to inflating the stomach. Some give 0.5-2 mg glucagon (often 1 mg) to reduce gastric motility and loss of air out of the stomach.

• Inflate stomach with air (amount varies but often 250-800 mL). Use hemostat or clamp to plan access and mark skin with fluoro. Oblique as needed to ensure no bowel is between the stomach and anterior abdominal wall.

  • Choose the G-tube site in the distal body of the stomach equidistant between lesser and greater curvature and avoiding the superior epigastric artery.

• Anesthetize skin and subcutaneous tissues. Can aspirate with lidocaine needle to see whether the needle enters the stomach further confirming good access sites.

• Make a small incision at the planned g-tube site.

  • Some recommend making the incision vertical rather than horizontal to reduce injury to the superior epigastric artery.

• Access stomach (e.g. AMC or Yueh).

• Advance a working wire (e.g. Amplatz or Bentson) and exchange the access needle for an angled catheter (e.g. Kumpe) if needed. Often the needle is helpful enough to point towards the GE junction and gain wire access to the esophagus.

• Use the wire and catheter to gain access through the gastroesophageal junction into the esophagus. Angled glidewire or roadrunner can be helpful.

• Advance catheter to the mouth and advance the working wire (e.g. Amplatz) out of the mouth.

• Advance the gastrostomy tube over the wire through the mouth and pull out through the skin.

• Secure in place, cut tube, and assemble.

• Inject contrast to confirm adequate positioning within the gastric lumen. Flush the contrast out of the tube after injection.

Percutaneous Transesophageal G-tube Placement

• Pre-ultrasound to determine side of neck to prep. Often the cervical esophagus lies just left of midline so the left neck is prepped.

• If no NGT or OGT, can place a 5 Fr catheter (e.g. Kumpe) through the nose or mouth into the stomach.

• Pass wire (e.g. Amplatz) through NGT and exchange for 18-22 mm esophageal balloon catheter, e.g. XXL Esophageal dilatation balloon (Boston Scientific), Impact balloon (Braun), Coda balloon (Cook).

• Retract balloon until meets resistance at the cricopharyngeus muscle.

  • Some suggest inflating the balloon with air rather than fluid to avoid risk of nausea and aspiration with rupturing the fluid-filled balloon.

• Puncture balloon under US guidance with 21G needle.

  • Classic approach is anteromedial to the carotid and IJ lateral to the thyroid. However, others have described success with access lateral and under the carotid and IJ to avoid nerves and thyroid arteries that course in the space for the classic approach.

• Advance long 0.018” wire (e.g. Nitrex) through the needle into stomach.

• Remove esophageal dilation balloon and exchange needle for 5-6 Fr sheath via percutaneous esophageal access.

• Pass 0.035” wire (e.g. Amplatz) into stomach followed by dilation of the percutaneous track to 12 Fr.

• Advance 14 Fr x 45 cm multipurpose drain with pigtail formed in the stomach.

• Tube can be used immediately and patients can eat and drink as normal.

GJ-tube Placement

• Start the same as a push-type g-tube placement except gaining access to the stomach pointing towards the pylorus.

• Advance curved catheter (e.g. Kumpe, MPA, C2, H1, Bern).

• Use the catheter and a hydrophilic wire (e.g. angled glidewire, roadrunner, glidewire advantage) to gain access passed the pylorus to the proximal jejunum. Some advocate for the roadrunner since the gastric secretions tend not to make the raodrunner as sticky as glidewires.

• Exchange for a stiff hydrophilic wire.

• Advance gastrojejunostomy tube. Lidocaine jelly can help.

• Inflate retention balloon with 7-10 mL sterile water. Some add a small amount of contrast (e.g. 0.5 mL) to help with visualization.

• Secure the gastrostomy tube watching under fluoro to ensure the balloon opposes the gastric wall.

• Inject contrast to confirm adequate positioning within the gastric and jejunal lumens. Flush the contrast out of the tube after injection.

• Secure gastropexy t-tacks if fresh placement.

G to GJ-tube Conversion

• Most successful with prior percutaneous G-tube placement as other accesses tend to point towards the GE junction rather than the pylorus.

  • Nearly 100% successful with prior IR G-tube placement, 78% with prior PEG, 83% with prior surgical G-tube using Stamm procedure, nearly impossible with prior surgical G-tube using Witzel procedure.

• Remove prior G-tube either over wire or cut tube near the skin if prior PEG and Kumpe through track to establish wire access.

• Can use 15 or 16 Fr peel away sheath to point access towards the pylorus.

• Use Kumpe and hydrophilic wire (e.g. Roadrunner, glidewire) to gain access to the duodenum over to the jejunum.

• Exchange for stiff working wire.

  • If wire loops in stomach (“loop of death”), exchange wire for glide cath while preserving access to the duodenum and reduce the loop using the glide cath.

  • Alternatively, re-establish linear access with a Kumpe along side the existing wire access.

• Place GJ tube.

• Confirm placement with contrast injection.

J-tube Placement

• Insufflate bowel via NG tube.

• Access the jejunum, ideally in the LUQ under ultrasound or CT guidance.

  • Alternatively, can pass a wire and catheter or balloon catheter by mouth into the jejunum to target fluoroscopically.

  • Some access directly with 17G needle. Others are more conservative starting with a 22G needle.

• Contrast injection through needle to confirm access.

• Advance hydrophilic wire and 5 Fr catheter to secure access.

• Place t-fasteners. Some recommend four in square to ensure stable pexy.

• Advance stiff working wire.

• Serial dilation of percutaneous track.

• Placement of a locking pigtail catheter, e.g., 12-16 Fr MPD (Cook).

  • Often people start with a pigtail catheter for fresh percutaneous placement with option to convert to balloon retention tube later.

• Secure in place and confirm positioning with contrast injection.