Examination

Gastrostomy Catheter Placement

 

Clinical History

[Stroke and poor swallow function ]

 

Operators:

Sarel Gaur MD

 

Medications:

Lidocaine at site.

 

Contrast:

[ ] ml of iodinated contrast intra-enteric

 

Fluoro time:

[ ] minutes

 

Access site(s):

Epigastrium

 

Device(s):

20 F Kimberly-Clark Gastrostomy Feeding Tube

 

Complications:

None

 

Procedure:

1. Informed Consent was obtained.

2. Patient was brought to the IR suite and placed supine on the table

3. RN was monitoring vital signs throughout.

4. The pt’s stomach was insufflated using a 60 cc syringe attached to a three way stopcock attached to an intragastric catheter.

5. The pt’s air filled stomach was identified under fluoroscopy.  An entry site was marked in the region of the distal gastric body.

6. Three additional sites for the gastropexy sutures were chosen in a triangular configuration surrounding the entry site.

7. The skin was sterilized with chlorhexidine solution and a draped with a large sterile sheet.

8. Lidocaine was used for local anesthesis.

9. Under intermittent fluoroscopic guidance and using iodinated contrast, three gastropexy sutures were placed around the entry site to secure the anterior wall of the stomach to the anterior abdominal wall.

10. Under fluoroscopoic guidance, an 18 gauge needle was advanced through the entry site and intragastric placement confirmed using contrast.

11. Through the needle an Amplatz wire was advanced and positioned under fluoroscopy.  The needle was removed.

12. A telescoping peel away sheath was placed over the Amplatz.

13. The wire and inner dilator was removed and the 20 F Kimberly Clark gastrostomy catheter was advanced into the stomach.

14. Contrast was used to confirm placement of the distal tip within the stomach.

15. The retention balloon was inflated with sterile water.

16. The anterior retention bracket was advanced to the skin level.

17. A drain sponge was placed at the gastrostomy access site.

18. The procedure was terminated.

19. The patient was transported back to the holding area.

Maximal Sterile Barrier Technique was including: 

Cap, mask, sterile gown, gloves, large sterile sheet, hand scrub with sterillium, 2% chlorhexidine for epidermal antisepsis

 

Comparison

[ ]

 

Findings

Contrast study demonstrating opacification of rugae.  Placement of a gastrostomy catheter with tip in the stomach.

 

Impression

Successful placement of a 20 French Kimberly-Clark Gastrostomy catheter.  The catheter will be ready to use after 24 hours, or on [ ] at [ ].

 

 

 

Examination

Gastrojejunostomy Catheter Placement

 

Clinical History

[Stroke and poor swallow function ]

 

Operators:

Sarel Gaur MD

 

Medications:

Lidocaine at site.

 

Contrast:

[ ] ml of iodinated contrast intra-enteric

 

Fluoro time:

[ ] minutes

 

Access site(s):

Epigastrium

 

Device(s):

20 F Kimberly-Clark Gastrojejunostomy Feeding Tube

 

Complications:

None

 

Procedure:

 

1. Informed Consent was obtained.

2. Patient was brought to the IR suite and placed supine on the table

3. RN was monitoring vital signs throughout.

4. The pt’s stomach was insufflated using a 60 cc syringe attached to a three way stopcock attached to an intragastric catheter.

5. The pt’s air filled stomach was identified under fluoroscopy.  An entry site was marked in the region of the distal gastric body.

6. Three additional sites for the gastropexy sutures were chosen in a triangular configuration surrounding the entry site.

7. The skin was sterilized with chlorhexidine solution and a draped with a large sterile sheet.

8. Lidocaine was used for local anesthesis.

9. Under intermittent fluoroscopic guidance and using iodinated contrast, three gastropexy sutures were placed around the entry site to secure the anterior wall of the stomach to the anterior abdominal wall.

10. Under fluoroscopoic guidance, an 18 gauge needle was advanced through the entry site and intragastric placement confirmed using contrast.

11. Through the needle an Amplatz wire was advanced and positioned under fluoroscopy.  The needle was removed.  The amplatz was advanced until it’s tip was in the proximal jejunum

12. A telescoping peel away sheath was placed over the Amplatz.

13. The wire and inner dilator was removed and the 20 F Kimberly Clark gastrojejunostomy catheter was advanced into the small bowel.

14. Contrast was used to confirm placement of the distal tip within the proximal jejunum.

15. The retention balloon was inflated with sterile water.

16. The anterior retention bracket was advanced to the skin level.

17. A drain sponge was placed at the gastrostomy access site.

18. The procedure was terminated.

19. The patient was transported back to the holding area.

Maximal Sterile Barrier Technique was including: 

Cap, mask, sterile gown, gloves, large sterile sheet, hand scrub with sterillium, 2 % chlorhexidine for epidermal antisepsis

 

Comparison

[ ]

 

Findings

Contrast study demonstrating opacification of small bowel loops.  Placement of a gastrojejunostomy catheter with tip in the stomach.

 

Impression

Successful placement of a 20 French Kimberly-Clark Gastrojejunostomy catheter.  The catheter will be ready to use after 24 hours, or on [ ] at [ ].

 

 

 

Examination

Gastrostomy Tube Replacement

 

Clinical History

Poor catheter function

 

Operators:

Sarel Gaur MD

 

Medications:

Lidocaine at site.

 

Contrast:

[ ] ml of iodinated contrast intra-enteric

 

Fluoro time:

[ ] minutes

 

Access site(s):

Epigastrium

 

Device(s):

20 F Kimberly-Clark Gastrostomy Feeding Tube

 

Complications:

None

 

Procedure:

 

1.    Informed Consent was obtained.

2.    Patient was brought to the IR suite and placed supine on the table

3.    RN was monitoring vital signs throughout.

4.    The pt presented with a foley catheter in the existing gastrostomy stoma.

5.    An Amplatz wire was advanced through the foley catheter and monitored fluoroscopically.

6.    The foley was removed and a 4F angiographic catheter was advanced over the wire.

7.    Contrast was injected.  Rugae were identified, confirming intragastric location.

8.    The catheter was removed and a new 20 F Kimberly-Clark Gastrostomy catheter was advanced over the wire.

9.    Contrast confirmed placement of the catheter within the stomach.

10.  A drain sponge was placed at the catheter access site.

11.  The procedure was terminated.

12.  The patient was transported back to the holding area.

Maximal Sterile Barrier Technique was including: 

Cap, mask, sterile gown, gloves, large sterile sheet, hand scrub with sterillium, 2 % chlorhexidine for epidermal antisepsis

 

Comparison

[ ]

 

Findings

Contrast study demonstrating opacification of rugae.  Placement of a gastrostomy catheter with tip in the stomach.

 

Impression

Successful re-placement of a 20 French Kimberly-Clark gastrostomy catheter.  The catheter is ready to use.

​

PROCEDURES:

GastroJejunostomy Placement

 

DATE OF PROCEDURE:

7/8/2016

 

INDICATION:

Failure to Thrive

 

MEDICATIONS:

( )  mcg IV fentanyl

( ) mg IV Versed

 

OPERATORS:

Sarel Gaur MD, Fellow

 

CONTRAST:

( ) mls of Omnipaque 350 (into enteric tract)

 

FLUOROSCOPY TIME:

( ) minutes

 

ACCESS SITE:

Epigastrium- Gastric Body

 

COMPLICATIONS:

None.

 

PROCEDURE:

 

1. The risks, benefits, and alternatives to the procedure and sedation were explained to the patient, and written informed consent obtained.

2. Constant physiologic monitoring was performed by personnel from radiology nursing.

3. A timeout / call to order was performed in adherence to departmental protocol.

4. A scout image of the upper abdomen was saved.

5. The site for gastric access was marked using a Kelly clamp.

6. Three surrounding sites were chosen for insertion of T-fasteners

7. The tube was placed in a horizonatal position to place the T-fasteners.

8. The three T-fasterners were inserted using fluoroscopic guidance to ensure placement within the stomach.

9. The tube was then repositioned PA.

10. An 18g access needle was inserted into the stomach, with fluoroscopic confirmation.

11. Through the needle, an 80 cm Amplatz was advanced.

12. The needle was removed, and a 7F 10cm vascular access sheath was advanced.

13. An additional 150 cm Amplatz was advanced into the stomach as a safety wire

14. At this point, attention was paid to negogiating the wire into the jejunum.  This was accomplished using a 4F Kumpe catheter and glidewire (+/- Sos)

15. The vascular sheath and safety wire were removed and a 20F telescoping peel away sheath dilator was advanced into the stomach.

16. The dilators were used and then removed and a 18F, 45 cm gastrojejunostomy catheter was inserted through the sheath and over the wire.

17. Fluoro was used to place the catheter tip into the proximal jejunum.

18. Contrast was infused into both lumens to confirm placement in the jejunum and stomach respectively.

19. The retention balloon was filled with 9 cc of sterile water and 1 cc of contrast.  The balloon infusion port was obliterated using dermabond.

20. The anterior retention bracket was advanced to the skin level.

21. A sterile dressing was placed.

22. The procedure was terminated.

 

IMPRESSION:

Successful placement of an 18F, 45 cm Gastrojejunostomy Catheter.