SIR 2024
Gastrointestinal Interventions
Siddhant Thukral, MD (he/him/his)
Integrated IR/DR Resident
Duke Universtiy Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Brendan Cline, MD
Assistant Professor of Radiology
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Charles Y. Kim, MD, FSIR
Professor and Chief of Interventional Radiology
Duke University
Financial relationships: Full list of relationships is listed on the CME information page.
James Ronald, MD, PhD
Associate Professor of Radiology
Duke University Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
A percutaneous transesophageal gastrostomy (PTEG) can be an effective means of gastric access for venting or feeding when conventional percutaneous gastrostomy is infeasible due to anatomy. In most cases described in the United States literature, PTEG is performed under general anesthesia (GA) {1-4}, a potential barrier for some practices and patients. One potential reason for reliance on GA is concern that, without use of a rupture-proof balloon, fluid released during esophageal balloon puncture will induce intraprocedural coughing and aspiration at the key moment when esophageal wire access is sought. Therefore, the purpose of this study was to describe feasibility of insufflating the esophageal balloon with air rather than dilute contrast to facilitate PTEG under moderate sedation.
Materials and methods:
Six patients (n=1 male, mean age= 54.5, range 39-62) underwent PTEG under moderate sedation. All PTEGs were placed for palliative venting. A non-rupture-proof balloon catheter (32 mm Coda n=2, 18 mm Atlas n=1, 16 mm Atlas n=2, 14 mm Atlas n=1) was advanced through the nose over the guidewire into the esophagus at the level of the thoracic inlet and insufflated with approximately 10-20 mL of air. The balloon was punctured under real-time ultrasound guidance and a wire was inserted through the needle and into the lumen of the ruptured balloon and then down the esophagus. Following tract dilation, a 12 French (n=1) or 14 French (n=5) 40 cm pigtail drainage catheter was placed.
Results:
During PTEG the median dose of fentanyl was 225 mcg (range 100-250) and of midazolam was 1.5 mg (range 1-4.5). At the time of balloon puncture, there were no episodes of coughing or reports of acute patient discomfort. All procedures were technically successful, and all patients reported improvement in symptoms of bowel obstruction after the procedure. There was one mild severity adverse event (cellulitis around the PTEG entry site treated with antibiotics) that occurred 64 days after placement. PTEGs remained in place for a median of 30 days (range 8-99) before death (n=3), removal (n=1), or discharge to hospice with loss to follow up (n=2).
Conclusion:
By using air rather than dilute contrast to prevent intraprocedural coughing when the balloon is punctured, PTEG can be safely performed under moderate sedation without use of a rupture-proof balloon. The ability to perform PTEG under moderate sedation rather than GA may allow this procedure to be offered in a more timely manner and to patients with terminal illnesses who do not wish to undergo endotracheal intubation.