percutaneous non vascular GI Interventions.pptx

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1. PERCUTANEOUS NON VASCULAR GI INTERVENTIONS Dr. Shameema II yr Resident.

2. Therapeutic Interventional techniques Percutaneous Gastrostomy. Percutaneous Jejunostomy. Esophageal Stenting. Gastroduodenal Stenting. Colorectal Stenting. Percutaneous Enterocutaneous fistula closure

3. Percutaneous Gastrostomy An opening made in the stomach via percutaneous route connecting stomach to the abdominal wall so that a feeding tube or gut decompression tube can be passed into the stomach. INDICATIONS: Neurological related swallowing disorders Eg : CVA, cerebral palsy child, trauma and neurosurgery. Esophageal stricture or atresia, Carcinoma. Major head & neck surgeries. Any condition which requires prolonged tube feeding for > 4 weeks. Decompression of stomach or small intestine in pts with chronic intestinal obstruction secondary to carcinomatosis. Retrograde dilatation of gastroplasty stoma constructed for weight reduction in obese patients. CONTRAINDICATIONS: Abnormal Coagulation parameters. Massive ascites. Gastric Varices. Total Gastrectomy Active peritonitis

4. TECHNIQUE Percutaneous Endoscopic Gastrotomy: Flexible feeding tube is inserted through abdominal wall and into the stomach via endoscope. Alternatively a tube can be placed under radiological guidance, known as a  radiologically inserted gastrostomy (RIG)   or percutaneous radiological gastrostomy (PRG)

5. PERCUTANEOUS ENDOSCOPE GASTROSTOMY Reduced Morbidity & mortality compared to open. The fiber optic endoscope is passed into stomach & directed towards the anterior abdominal wall& transillumination occurs at the end of scope The stomach is insufflated with air. Finger is pressed against the abdominal wall where the light is located, indentation can be seen through the scope. 25 gauge needle is inserted. Once the needle pierces the stomach air bubbles are present in the syringes. A larger 16 gauge needle is inserted along side the 25 gauge needle, 25 gauge needle is removed. A guide wire is inserted & grasped by the scope. The feeding tube is attached to the string and is pulled downward into the stomach and out through the anterior gastric and abdominal wall.

6. 1 2 3 4 PERCUTANEOUS ENDOSCOPE GASTROSTOMY

7. 6 5 7 8

8. PERCUTANEOUS RADIOLOGICAL GASTROSTOMY The procedure requires following hardwares : 18G needle Suture anchoring set J guidewire 0.038 inch Superstiff guidewire Gastrostomy tube (18-24F)

9. Cope Gastrointestinal Suture Anchor Set

10. STEPS INVOLVED IN GASTROSTOMY Pre procedure preparation : Overnight fasting STEP 1 : If the nasogastric tube is present already , under fluoroscopic guidance a 5F angiographic catheter is passed into the stomach, STEP2 : 40 mg of Buscopan is administrated, the stomach is totally distended with 750–1200 mL atmospheric air so that anterior wall of the stomach abuts the abdominal wall. STEP3 :Then, puncture is made with18 G needle, preferably in lateral projection. STEP4 :Following gastric puncture, iodinated contrast medium is injected to see the needle location. STEP5 :Once satisfied with needle position, T-fastener present (preloaded) inside the needle is subsequently pushed into the gastric lumen. The needle is then withdrawn out of the stomach leaving the T-faster in place.

11. STEP6 :T-fastener is retracted tightly so that the anterior wall of stomach closely approximates the abdominal wall and T-faster is then sutured to the abdominal wall. STEP7: The stiff guidewire is still inside the stomach and the stomach wall is retracted to the anterior abdominal wall with suture anchor, the tract is dilated over the guidewire serially using Seldinger technique. STEP8 :larger bore catheter like 18F–20F Malecot catheter or pigtail catheter is inserted as gastrostomy tube. Next day, iodinated contrast study is done, prior to start of feeding. Sutured T-fasteners are mostly removed after 10–15 days, to fall inside the stomach lumen

12. T Fastener The key to this technique is T –Fastener, a nylon suture attached to a metal bar, which can be preloaded with puncture needle.

13. COMPLICATIONS. MINOR MAJOR Pain &fever Hemorrhage Wound contamination Peritonitis Pericatheter seepage Aspiration Pneumonitis Tube dislodgement It is better to advance the tube beyond the duodenal cap into jejunum to avoid Gastroesophageal Reflux and Aspiration. To Avoid Complications: Prior oral barium would help to opacify colon; help to deliniate colon and stomach. Keeping the stomach fully distended during procedure Ascites if present need to be drained prior to the procedure.

14. Buried Bumper Syndrome Rare, but important complication in patients underwent percutaneous gastrostomy tube. Here the tube may get lodged anywhere between the gastric wall and the skin , leads to life threatening complications like hemorrhage, peritonitis, hollow viscus perforation , abscess formation and necrosis

15. Percutaneous Jejunostomy INDICATIONS: When Percutaneous gastrostomy not possible. TECHNIQUE: Catheterize the duodenum or proximal jejunum through 120cm long jejunal tube via nose. Distend & opacify jejunal loops. Puncture the jejunal loops with 18G Needle preloaded with suture anchor set. Using seldinger technique dilate the tract, insert 18F–20F Malecot catheter or pigtail catheter as jejunostomy tube.

16. Both Gastrostomy and jejunostomy tubes are present . Break noted in jejunostomy tube.

17. Esophageal stenting Main purpose of this stenting to restore oral feeding and improve quality of life. INDICATIONS: Inoperable malignant esophageal obstruction/ fistula Primary or secondary tumors within the mediastinum causing extrinsic esophageal compression Esophageal perforation (iatrogenic/traumatic) • Benign esophageal strictures: Esophageal stenting is indicated in refractory benign stenosis after 5 repeated endoscopic dilations and for long stenosis (>2 cm).20 U

18. Types of stent Metallic—Nitinol stents Partially covered stents—better embedding and anchoring Fully covered stents—chances of migration are high; used for benign conditions Uncovered self-expandable metallic stent (SEMS)—tumor ingrowth is major problem. Covered stents: covered stents are coated with plastic lining either from inside or outside Uncovered stent is less chances of migration, particularly through the gastroesophageal (GE) junction.

19. Technique: Under fluoroscopic guidance , thin barium suspension to locate the abnormal segment and length of stricture. local lidocaine aerosol spray to desensitize the pharyngeal mucosa. Hydrophilic guidewire is introduced to cross the stictured segment. Once the strictured segment is crossed, the hydrophilic guidewire is exchanged with stiff metallic guidewire. Dilate the strictured segment through balloon catheter. Use covered stent ( 4-5 cm longer than strictured segment), so that stent cover entire abnormal segment & also proximal & distal end of stent cover the normal segments of esophagus. Once the stent is positioned, Patient is given thin barium suspension again to confirm the stent location and patency.

20. FIGS. 5A TO E: Technique of esophageal stenting. Barium swallow shows irregular narrowing in mid third of thoracic esophagus with proximal hold up of barium column (A) (Arrow). Dilatation of the stricture with bougie (B). Completely deployed Choostent seen in situ (Note: Lead markers placed on the patient's back for exact localization of stricture) (C). Esophagogram showing freeflow of contrast across the stent (D and E).

21. Lateral x ray shows, Distal esophageal covered stent traversing the OG Junction

22. Complications Early Complications Chest pain Bleeding . Late Complications Re-intervention - due to tumor in-growth with uncovered stents and tumor over growth with covered stents. Hemorrhage, stent migration and stent fracture. CT to identify the complications: Esophageal perforation. Stent leakage, stent fracture, tracheal compression by the stent and stent migration. MDCT also helps in identifying tumor overgrowth and tumor ingrowth.

23. Guidelines for Esophageal stenting Uncovered stents - gastroesophageal junction strictures Covered stents - nongastroesophageal junction strictures & esophageal fistulas. SEMS – Palliative for dysphagia in advanced esophageal carcinoma. Partially covered stents - malignant esophageal fistula and strictures caused by villous tumors. Plastic stents - benign strictures and removed after 4–16 weeks to prevent epithelial hypertrophy and stent incarceration. Antireflux stents have similar efficacy of SEMS with benefit in gastroesophageal reflux Combined stent and brachytherapy is a safe palliative option in patients with inoperable advanced esophageal carcinoma.

24. Gastroduodenal stenting INDICATIONS: Unresectable Gastric or duodenal Tumor recurrence who had surgical anastomosis and present with symptoms of gastric outlet obstruction. Benign gastroduodenal strictures. CONTRAINDICATIONS: Presence of perforation Additional distal or multisegment intestinal obstruction due to extensive peritoneal carcinomatosis. Commonly used stents is Wall stent - More flexibile to overcome the tortuosity and good radial force.

25. TECHNIQUE STEP1 : thin barium suspension is performed to look for abnormal segment. STEP2 : Nasogastric suction is done in case of distended stomach cuz of long standing obstruction to prevent Aspiration. STEP3 : Use lidocaine spray to densensitize pharyngeal mucosa. STEP4: Hydrophilic guidewire is introduced to cross the stictured segment. STEP5 : Dilate the tract using metallic guide wire. STEP6 : Stent of appropriate size based on preliminary contrast study is advanced over the metallic guidewire. It is recommended to “ overstent ” the stricture segment to include at least 2 cm distal and 2 cm proximal normal segments to prevent recurrence of obstruction by tumor ingrowth.

26. Technique of duodenal stenting. Contrast study showing narrowing of D2 segment, proximal to ampulla (A) (arrow), Guidewire negotiated across the stricture (B), Completely deployed Wall stent seen in situ (C) and barium study showing freeflow of contrast across the stent (D).

27. Guidelines for Duodenal Stents Self-expandable metallic stent (SEMS) are standard of care for malignant duodenal stenosis, when surgery is not possible. Biliary decompression is done prior to duodenal stenting in case of biliary dilatation. MDCT in Duodenal Stent Evaluation . Stent evaluation is done by using water as oral contrast. Perforation is seen as retroperitoneal or intraperitoneal free air on CT. The free gas at distal tip of stent should raise the suspicion of perforation. Stent fracture is seen as buckling of stent and may be associated with incomplete or complete duodenal obstruction. Cause for post-stent duodenal bleed can be found out.

28. COLORECTAL STENTING INDICATIONS: As temporary procedure to decompress the colon in patients with an acute obstruction. as palliative procedure to relieve symptoms of colonic obstruction in patients with unresectable malignancy. CONTRAINDICATIONS: Clinical or radiologic evidence of perforation More proximal lesions within the colon. More commonly used colonic stents are Wall stent, Ultraflex stent, and Memotherm stent.

29. MDCT in Colonic Stent Evaluation CT helps to rule out perforation both before and after colonic stenting. Colonic perforation may be seen as pneumoperitoneum and adjacent fluid collection. Marked colonic edema suggesting colonic ischemia in patients with post stent colonic dilatation. During follow-up scans, tumor ingrowth within stenting can be demonstrated on CT.

30. PERCUTANEOUS ENTEROCUTANEOUS FISTULA CLOSURE USING N BUTYL 2 CYANOACRYLATE Mechanism ogGlue polymerizes and produces a cast , when it comes in contact with body fluids. Prerequisites Fistula should be low output The fistulous tract should be short in length . Tract should be linear, nonbranching . No associated abscess cavity • Nonepithelialized tract (if the tract is epithelialized, it is traumatized the tract to make the surface raw).

31. TECHNIQUE It is an OP procedure and no anesthesia is required. Before the procedure, it is advisable to administer intravenous antibiotics covering gram-negative gastrointestinal flora. The potency (i.e. “stickiness”) of glue requires dilution prior to its use. Dilution of glue is usually done by mixing with lipiodol that delays polymerization and improves visibility during injection under fluoroscopy. Various combination of dilution (range: 1:1 to 1:3) has been suggested. If the mixture is too strong that causes premature polymerization and catheter occlusion whereas very dilute mixture increases the risk of distal embolization.

32. contrast fistulogram study the tract is catheterized either with angiographic catheter (4F) or using venflon (18–20G). After flushing the catheter with 50% dextrose solution, the diluted glue is injected, starting from inside and gradually withdrawing the catheter outside, while continuously injecting the glue. After the procedure, recatheterization of the tract is not done; otherwise the glue may get dislodged. If the fistula has not closed, another session of glue injection is tried.

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