Miscellaneous Interventional Radiology Procedures

Gastrostomy Tube Placement

What is a gastrostomy?

A gastrostomy is a direct opening from your abdominal wall into your stomach through which you can be fed.

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When is it used?

This procedure is performed when you cannot swallow either because you have had a stroke or you have developed another problem that makes it hard for you to swallow. Most of the time gastrostomy is a temporary measure, but sometimes it is permanent.

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What happens during the procedure?

The procedure is performed in two basic ways. The first way, called percutaneous endoscopic gastrostomy (PEG) tube placement, is an outpatient procedure performed under mild sedation and a local anesthetic. Your doctor will guide a flexible endoscope through your mouth and into your stomach. An endoscope is a long, narrow tube with a camera and light on the end of it. It lets your doctor look into the inside of your stomach. Your doctor will fill your stomach with air to make it bigger. He or she will guide a needle through your skin and abdominal wall and into your stomach. The doctor then will place a wire through the needle, retrieve it with the endoscope and bring it out the mouth. The doctor will thread a tapered plastic tube over the wire through your mouth and pull it through the small hole in your abdomen. He or she will secure the tube to your skin.

The second approach, open or surgical gastrostomy, is performed in the operating room, usually under a general anesthetic. This puts you to sleep, relaxes your muscles, and keeps you from feeling pain. The surgeon will make a small incision in your upper abdominal wall and expose your stomach. Then he or she will make a cut through the wall of your stomach and place a tube through the skin into the stomach. The surgeon will then sew up the incision on your abdominal wall and fix the tube to the skin.

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What happens after the procedure?

If you have an open surgical gastrostomy, you will be taken back to your hospital room. You may stay in the hospital for one to three days, based on your condition. You may be fed directly into a vein for one or two days. Later, you will be fed by a nurse or instructed how to feed yourself through the gastrostomy tube. You may be shown how to care for the tube.

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What are the benefits of this procedure?

You will be able to get enough nutrition.

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What are the risks associated with this procedure?

The tube must stay in place for two months before it can be removed. You may need to have the tube changed periodically (every six to 12 months). The area around the tube may become infected after the operation. You should ask your doctor how these risks apply to you.

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When should I call the doctor?

Call the doctor at Emory immediately if:

  • The tube comes out — it must be replaced within a few hours.
  • You think the tube is becoming blocked.
  • You are unable to take food through the tube.
  • You have a lot of drainage around the tube.
  • You have increasing pain, redness or swelling near the tube.

Call the doctor during office hours if:

  • You have questions about the procedure or its result.
  • You want to make another appointment.

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Gastrojejunostomy Tube Placement

The current procedures for percutaneous endoscopic gastrojejunostomy (PEG-J) tube placement require fluoroscopy and are time consuming. There is a new, simple method, available at Emory University Hospital that takes less time.

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Jejunostomy Tube Placement

The laparoscopic jejunostomy can be a very helpful procedure in the management of patients requiring intensive nutritional rehabilitation. It eliminates the risk of aspiration associated with gastrostomy feedings. In addition, this is the preferred enteral administration route in patients whom may require a future procedure requiring gastric integrity such as a patient with an adenocarcinoma of the esophagus.

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Ascites Drainage, Including Peritoneal Catheter or Port Placement

A new method for drainage of ascites using ultrasound to guide the catheterization. The duration of drainage is from one to 12 days. The method provides very effective drainage. There are usually very few or no complications, though some patients may experience slight complications during drainage.

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Transcatheter Retrieval of a Foreign Body

The Nitinol Gooseneck snare system is commonly used in the retrieval of retained foreign bodies in various patients. Foreign bodies can be located in the vascular system, the urinary tract, the biliary system, the gastrointestinal tract and the peritoneal space. Retrievals are usually performed with use of standard angiographic/interventional techniques. This method has a high success rate. All procedures are performed quickly, safely and without difficulty.

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Abscess Drainage, Chest Tube Placement Under CT, Ultrasound or Fluoroscopic Guidance

Over the past 20 years, percutaneous abscess drainage (PAD) has evolved from revolutionary to routine, replacing open surgical abscess drainage in all but the most difficult or inaccessible cases. It was originally believed that only patients with simple fluid collections were candidates for PAD. However, researchers have convincingly demonstrated that both septated and viscous fluid collections may be successfully treated percutaneously, particularly with the adjunctive use of lytic agents. The simpler the abscess, the more likely PAD will be rapidly successful. An aggressive practical approach with relatively simple devices and techniques may yield a high success rate with few complications.

CT- and ultrasound-guided catheters are used to locate and drain pus sacs in patients, most of whom have failed to improve with conventional chest-tube drainage due to a poorly positioned tube. Patients are treated successfully, averting surgery or further drainage or infections. Compared to the tubes used to drain abdominal abscesses, these catheters need less irrigation, and the catheter can be withdrawn in one step.

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Paracentesis is a procedure during which fluid from the abdomen is removed through a needle. There are two reasons to take fluid out of the abdomen. One is to analyze it. The other is to relieve pressure.

Liquid that accumulates in the abdomen is called ascites. Ascites seeps out of organs for several reasons related either to disease in the organ or fluid pressures that are changing. Its many causes are listed below.

During paracentesis, special needles puncture the abdominal wall, with care taken not to hit internal organs. If fluid is needed only for analysis, just a bit is removed. If pressure relief is an additional goal, many quarts may be removed. Rapid removal of large amounts of fluid can cause blood pressure to drop suddenly. For this reason, the physician will often leave a tube in place so that fluid can be removed slowly, giving the circulation time to adapt.

A related procedure called colpocentesis removes ascitic fluid from the very bottom of the abdominal cavity through the back of the vagina. This is used mostly to diagnose female genital disorders like ectopic pregnancy that bleed or exude fluid into the peritoneal space.

Fluid is sent to the laboratory for testing, where cancer and blood cells can be detected, infections identified, and chemical analysis can direct further investigations.

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Thoracentesis is a procedure in which fluid between the chest cavity and lungs (pleural space) is collected through a needle (and sometimes a plastic catheter) inserted through the chest wall. This fluid, called pleural fluid, may then be sent to a laboratory to determine what may be causing the fluid to accumulate. Normally, only a small amount of pleural fluid is present in the pleural space. Accumulation of excess pleural fluid, or pleural effusion, can be caused by a variety of problems, including infection, inflammation, heart failure or cancer. If a large amount of fluid is present, it may prevent the complete expansion of a lung, making it difficult to breathe. The presence of fluid inside the lung cavity can be discovered during a physical examination and usually is confirmed by a chest X-ray.

Thoracentesis may be performed to:

  • Help determine the cause of fluid in the lung cavity
  • Relieve shortness of breath and pain caused by an accumulation of excess pleural fluid

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Biopsy of All Anatomical Sites With CT, Ultrasound, Fluoroscopic or Stereotactic Guidance

Many percutaneous biopsy procedures are performed with the help of some form of image guidance. Image guidance typically includes ultrasound and CT. Many breast biopsies are performed under guidance of stereotactic mammography.

CT scanning is being used more and more to guide biopsy of lung and liver lesions. Newer spiral or helical CT scanners are being equipped with so called "interventional CT" or "fluoro CT" packages to allow real-time CT imaging for the guidance of biopsy. Interventional CT allows the radiologist to observe the biopsy needle in real time as it approaches and reaches the target lesion within the patient’s body. This significantly shortens procedure times and increases diagnostic accuracy.

Ultrasound is also being used extensively to guide biopsy of the breasts and abdomen. Ultrasound allows the radiologist great flexibility for following the path of the needle to the lesion to be sampled. Ultrasound also provides real-time display of the images as they are acquired. Ultrasound does not use X-rays and may provide additional flexibility since virtually unlimited imaging can be performed. The radiologist will determine if the abnormality can be seen well enough on the ultrasound to enable guidance. In some cases, ultrasound can show that a breast lump is a cyst (benign pocket of fluid), thus avoiding the need to perform a biopsy.

Stereotactic mammography is often used to guide breast biopsy using either the prone stereotactic mammography or upright stereotactic mammography technique. "Stereotactic" means that the breast biopsy path is imaged from two slightly angled directions to help guide the needle. Several stereotactic pairs of X-ray images are made. Small samples of tissue are then removed from the breast using a hollow needle that is precisely guided to the correct location via X-ray imaging and computer coordinates.

MRI is being used at various locations to guide biopsy. New open MRI and "short bore" MRI systems provide Emory radiologists with much greater access to the patient during scanning. This has enabled the development of techniques and tools to allow MRI-guided biopsy. MRI can provide images in real time, which helps guide the trajectory of the needle as it approaches the target lesion. MRI provides excellent contrast resolution, which allows radiologists to differentiate between organ structures and abnormalities. Although use of MRI-guided biopsy is not yet widespread like CT- or ultrasound-guided biopsy, over time, MRI imaging will be used by more and more hospitals and diagnostic centers to guide biopsy.