# Gastrostomy and Gastrojejunostomy Tube Placement

## Introduction

Percutaneous image-guided **gastrostomy** and **gastrojejunostomy (GJ)** tube placement are common IR procedures performed to provide long-term enteral access for nutrition, hydration, medication administration, and gastric decompression. Radiologic gastrostomy has comparable or superior safety profiles to endoscopic (PEG) and surgical approaches, with the advantage of avoiding general anesthesia and sedation in many patients.

## Indications

### Gastrostomy

**Dysphagia** due to head and neck cancer, stroke, neurodegenerative disease, or traumatic brain injury. Long-term enteral nutrition when oral intake is insufficient or unsafe. **Gastric decompression** in patients with malignant bowel obstruction. Medication administration in patients unable to swallow.

### Gastrojejunostomy

| Feature | Gastrostomy (G-tube) | Gastrojejunostomy (GJ-tube) |
|---------|---------------------|---------------------------|
| Feeding location | Stomach | Jejunum (past ligament of Treitz) |
| Decompression | Yes | Yes (via gastric port) |
| Aspiration risk | Higher | Lower |
| Bolus feeding | Yes | No (continuous only) |
| Tube complexity | Single lumen | Dual lumen |
| Common issue | Occlusion | Jejunal limb retraction |
| Exchange interval | 3-6 months | More frequent |

Patients at high risk for **aspiration** (impaired gastric motility, severe GERD, recurrent aspiration pneumonia). **Gastroparesis** with intolerance of gastric feeding. Post-**Whipple** or other upper GI surgery where gastric access alone is insufficient. Simultaneous gastric decompression (via gastric port) and jejunal feeding (via jejunal port).

## Contraindications

**Absolute**: interposed colon (hepatic flexure between the abdominal wall and stomach), uncorrectable coagulopathy, peritonitis. **Relative**: massive ascites (drainage first), prior upper abdominal surgery with adhesions, gastric varices, total gastrectomy.

## Preprocedural Planning

Review cross-sectional imaging (CT) to assess stomach position, interposed organs, and abdominal wall anatomy. NPO for at least **6-8 hours** prior to the procedure. Correct coagulopathy: INR less than 1.5, platelets greater than 50,000. Administer prophylactic **antibiotics** (cefazolin 1 g IV) within 1 hour of the procedure. Confirm informed consent with discussion of risks including peritonitis, hemorrhage, and tube malfunction.

![CT scout image showing planned gastrostomy site with relation to the colon and liver](gastrostomy-planning-ct.png)

## Technique: Percutaneous Radiologic Gastrostomy

### Gastropexy and Stomach Insufflation

Place a **nasogastric tube** or use an existing NG tube to insufflate the stomach with air. Identify the stomach on fluoroscopy; the anterior gastric wall should approximate the anterior abdominal wall. Perform **gastropexy** using T-fastener anchors (typically 3-4 fasteners placed in a square or triangular configuration around the planned puncture site). Gastropexy creates adhesion between the stomach and abdominal wall, reducing risk of peritoneal leak.

### Tube Placement

Puncture the stomach through the gastropexy site using a needle under fluoroscopic guidance. Advance a guidewire into the stomach and coil it within the gastric lumen. Dilate the tract sequentially to the desired catheter size. Place a **locking pigtail gastrostomy tube** (typically 12-16 French) and confirm position with contrast injection. Secure the tube externally and connect to gravity drainage initially.

### Primary Button Gastrostomy

Low-profile **skin-level devices** can be placed primarily or as replacements for standard tubes. Preferred for ambulatory patients and children; less visible and less prone to dislodgement.

## Technique: Gastrojejunostomy

Perform gastrostomy as described above. Through the gastrostomy access, advance a catheter and guidewire through the pylorus and into the jejunum. Position the guidewire **past the ligament of Treitz** into the proximal jejunum. Place a **dual-lumen GJ tube** with the gastric port in the stomach and the jejunal port beyond the ligament of Treitz. Confirm position with contrast injection showing both gastric and jejunal ports.

![Fluoroscopic image showing GJ tube with gastric pigtail and jejunal extension beyond the ligament of Treitz](gj-tube-fluoro.png)

## Postprocedural Care

### Initial Management

Keep tube to gravity drainage for **24 hours** to assess for bleeding or complications. Begin tube feeds at a low rate (e.g., 20 mL/hr) after 24 hours if no complications; advance as tolerated. T-fasteners are typically cut at the skin surface at **10-14 days** and pass spontaneously into the GI tract.

### Ongoing Tube Maintenance

Flush tube with **30 mL warm water** before and after each feeding and medication administration. For GJ tubes, flush both lumens independently. External bolster should be snug but not tight against the skin; leave 1-2 mm play to prevent buried bumper syndrome. Monitor the stoma site for signs of infection, granulation tissue, or leakage.

### Tube Exchanges

Initial tube should remain in place for **4-6 weeks** to allow tract maturation before the first exchange. Routine exchanges every **3-6 months** depending on tube type and institutional protocol. GJ tubes have higher rates of jejunal limb retraction and may require more frequent exchanges.

## Complications

### Early Complications (within 30 days)

**Peritonitis**: 1-2%; from intraperitoneal leak around the tube site; gastropexy reduces this risk. **Hemorrhage**: usually minor oozing at the stoma site; rarely requires intervention. **Pneumoperitoneum**: small amount of free air is expected from insufflation; large or increasing amounts suggest perforation. **Tube malposition or dislodgement**.

### Late Complications

**Tube occlusion**: flush regularly; replace if recurrent. **Peristomal infection**: local wound care and antibiotics; rarely requires tube removal. **Granulation tissue**: treated with silver nitrate application. **Buried bumper syndrome**: internal bumper erodes into the abdominal wall; requires endoscopic or surgical removal. **GJ tube jejunal limb migration**: most common GJ-specific complication; often requires replacement.

![Peristomal granulation tissue around a gastrostomy site requiring silver nitrate treatment](peristomal-granulation.png)

## Special Populations

### Patients with Ascites

Large-volume paracentesis prior to tube placement to reduce risk of leakage. Gastropexy is especially important to create a seal between the stomach and abdominal wall. Consider GJ tube in patients with recurrent ascites to minimize peristomal leak.

### Head and Neck Cancer Patients

Often require prophylactic gastrostomy before chemoradiation. Coordinate timing with oncology team; ideally place before treatment-induced mucositis.

## Key Clinical Pearls

Gastropexy with T-fasteners is the single most important step in preventing peritonitis from intraperitoneal leak; never skip this step. Always insufflate the stomach adequately to displace the transverse colon and bring the anterior gastric wall in contact with the abdominal wall. GJ tubes are prone to jejunal limb retraction; educate patients and nursing staff to monitor for signs of malposition (feeding intolerance, abdominal distension). Tube dislodgement within the first 2 weeks is an emergency; the immature tract can close rapidly, and intraperitoneal spillage can occur.

## References

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