Percutaneous gastrostomy placement for ALS patients in IR
Barbara Wilkey, MD
Bob Ryu, MD
Purpose: The purposes of this document are
1) To provide education pertaining to the process of percutaneous gastrostomy placement in IR and this population’s common peri-procedure management concerns.
2) To provide peri-procedure management suggestions.
Content: This content is a combination of published literature and peer recommendation (Interventional Radiology and Anesthesiology).
The procedure
Most common indications: enteral access for nutritional supplementation because of dysphagia; percutaneous insertion of a large bore tube into stomach or small bowel for enteral feeding
Length of procedure: 30-45 minutes of IR MD time.
Antibiotic prophylaxis: Ancef or clindamycin
Imaging: ultrasound (briefly), fluoroscopy
Contrast agents: intra-gastric iodinated contrast
Ancillary procedures: nasogastric tube placement for gastric insufflation
Preprocedural testing: CT/KUB, routine laboratory tests including comprehensive blood chemistries (Cr, etc), hematology (plt >50K, nl WBC), coagulation parameters (INR<2).
Patient positioning: supine, left upper quadrant and epigastrium. The IR MD is generally positioned on the patient’s left side.
Procedural details: Fluoroscopic guidance is used to pass a small 5F nasogastric catheter for gastric insufflation. Ultrasound is performed to identify the left lobe of the liver. After gastric insufflation, percutaneous access to the gastric lumen is obtained with fluoroscopic guidance. A gastropexy is created, where the gastrostomy tube is then placed. Confirmation of intraluminal position performed. The gastrostomy is left to gravity drainage, while the nasogastric tube is removed.
The patient with ALS who requires this procedure is likely advanced in their disease process. Specific management should be tailored to the needs of the individual patient. General anesthesia is not usually necessary for these procedures as they are quick and not too uncomfortable. MAC is PREFERRED.
The pre-anesthesia assessment starts with a standard evaluation, with careful attention to the following:
1) Neurologic status. What is the bulbar involvement? What is the patient’s activity tolerance?
2) Presence or absence of autonomic dysfunction.
3) Cooperativeness for sedation.
4) Ability to manage secretions.
Room Setup standard set up plus IV pumps for any necessary infusions.
Anesthesia induction:
- These cases are generally done with light sedation as general anesthesia can worsen underlying respiratory insufficiency and the procedure is not very painful. Please minimize use of medications that cause respiratory depression.
- If general anesthesia is necessary please note that succinylcholine use may result in hyperkalemic arrest. Also, patients are very sensitive to non-depolarizing muscle relaxants.
Maintenance of general anesthesia with inhaled anesthetics is generally appropriate. If patient is to have MAC medications are at the discretion of the attending anesthesiologist. Opioids are not really necessary as a component of sedation and can decrease an already compromised respiratory system. If Ketamine is used an anti-sialagogue should be considered.
Emergence/extubation/disposition is at the discretion of the anesthesia team. Patients are admitted to the neurology service after PACU. The gastrostomy tube may not be used for 24 hours, until it is cleared by the IR service.
Procedural Risks
-Peritonitis (rare but potentially fatal)
- Insertion site bleeding
- Gastrostomy tube malposition/clogging
- Aspiration