Disclosure:

1. Interventional Radiology Percutaneous CathetersIndications, Techniques & ManagementBy Dr. Steve J. Lengle, MD Disclosure: Dr. Lengle has no financial interest in any of the products or manufacturers mentioned.

2. Interventional Radiology • Interventional radiology is the medical specialty devoted to advancing patient care through the innovative integration of clinical and imaging-based diagnosis and minimally invasive therapy. Compared to surgery, IR has shorter recovery times and is less painful and less risky.

3. Interventional Radiology Percutaneous Catheters • The ideal management of percutaneous drainage catheters require three distinct categories of care • 1. Expert staff for evaluation and management of placement of appropriate size and type of catheter (if indicated). • 2. Close management of function, dressing/catheter position stability and sterility • 3. Appropriate evaluation for exchanging, upsizing, downsizing or removing catheter

4. Gastrointestinal Intervention • Case #1 • A 69 year old female is status post CVA. She has a long history of gastroparesis and GERD. During her swallowing evaluation, she shows free aspiration with all consistency of ingested food. What would be the best and safest long-term feeding tube for this patient? • Percutaneous Gastrostomy • Percutaneous Gastrojejunostomy • Surgical Jejunostomy • Nasojejunal tube • Nasogastric tube

5. Gastrointestinal Intervention • Gastrostomy Tube

6. Gastrointestinal Intervention • Indications for gastrostomy (G) or gastrojejunostomy (GJ) tube placement • Gastrostomy Tubes • Nutrition • Dysphagia • Cerebral vascular accident (CVA) • swallowing dysfunction • Ear, nose, throat (ENT) or neck malignancy • Dementia • comatose state

7. Gastrointestinal Intervention • Gastrostomy Tubes • Small bowel disease • Crohn's disease • Short gut syndrome • Gastric Decompression • Gastroparesis • Ileus • Obstruction secondary to malignancy

8. Gastrointestinal Intervention • Gastrojeunostomy tube

9. Gastrointestinal Intervention • Gastrojejunostomy Tubes: (Same as gastrostomy tubes, plus…) • Poor gastric emptying • Diabetes mellitus (DM) - gastroparesis • Partial gastric outlet obstruction • Gastroesophageal reflux (GER) • CVA • Trauma • Children (more common than adults, but not universal)

10. Gastrointestinal Intervention • Whether feeding tube should terminate in the stomach (G tube) or in the small bowel (GJ tube) controversial • G tubes • Allow bolus feedings • more convenient for ambulatory patients • large lumens with less frequent occlusion • G tubes have been associated with gastroesophageal reflux (GER)

11. Gastrointestinal Intervention • Prospective comparison of G and GJ tube placement by Hoffer et al • GJ tube placement had decreased incidence of post-procedural pneumonia • G tube placement was faster, cost less, and required less tube maintenance.

12. Gastrointestinal Intervention • Contraindications G/GJ tube placement • Absolute • S/P total gastrectomy • Gastric carcinoma • Uncorrectable coagulopathy • Relative • Ascites/Peritoneal dialysis • Gastric varices • Overlying viscera • Complex previous abdominal surgery.

13. Gastrointestinal Intervention • Ascites considered relative contraindication G / GJ tube • Fluid displace the stomach from abdominal wall • puncture difficult potentially dislodging the catheter following placement • high incidence of peri-catheter leakage following the procedure • Ultrasound guided paracentesis prior to procedure/with gastropexy • Reduce incidence peri-catheter leakage catheter dislodgement

14. Gastrointestinal Intervention • Prior partial gastrectomy can make G tube placement more difficult • Does not contraindicate the procedure • tube placement in patients partial gastrectomy can be performed successfully with only minor modifications of the standard procedure

15. Gastrointestinal Intervention • Results six recent large series fluoroscopy guided percutaneous gastrostomy / gastrojejunostomy tube placement • Technical success 95 to 100% • Most reporting technical success rates 99% better • 30 day mortalities adult patients 3.8 to 26%, • mortality attributable to procedure 0-2%. The major complication rate(including peritonitis, hemorrhage, tube migration, and sepsis) ranged from 0-6%,

16. Gastrointestinal Intervention • minor complication rates 3 to 21% • pain without peritoneal sign • external catheter leakage • stomal infection • asymptomatic catheter migration • leakage of ascitic fluid • late tube dislodgement

17. Gastrointestinal Intervention • These results compare favorably with those of endoscopic and surgical gastrostomy: Wollman et al performed meta-analysis of over 5000 patients who underwent radiologic, endoscopic, or surgical gastrostomy • Fluoroscopically guided techniques were associated with a higher success rate than endoscopic gastrostomy • Less morbidity than either endoscopic or surgical gastrostomy.

18. Gastrointestinal Catheter/Insertion site Care • The site should be kept clean and dry. Catheter should be kept secure and free of tension. • Gastropexy buttons removed after 2 weeks • Gastrostomy and gastrojejunostomy tubes exchanged every 3 months. • Inadvertently removed tubes need to be replaced as soon as is humanly possible, the tract will shut down within 12-24 hours and require a new puncture to replace the tube.

19. Gastrointestinal Catheter/Insertion site Care • Localized superficial wound inflammation and infections can be treated conservatively with topical agents but closely followed and antibiotics administered judiciously. • Pericatheter leakage may require tube manipulation (tighten the balloon/skin disc device) or changing/upsizing tube.

20. Gastrointestinal Intervention • Gastrostomy Tube

21. Gastrointestinal Catheter/Insertion site Care • Only approved feedings and medications (suspensions and elixirs) should be placed through the tubes. • NEVER crush time release meds and place though tube • Some medications can be COMPLETELY crushed and dissolved then placed through tube.

22. Percutaneous GI procedures • Case #1 • A 69 year old female is status post CVA. She has a long history of gastroparesis and GERD. During her swallowing evaluation, she shows free aspiration with all consistency of ingested food. What would be the best and safest long-term feeding tube for this patient? • Percutaneous Gastrostomy • Percutaneous Gastrojejunostomy • Surgical Jejunostomy • Nasojejunal tube • Nasogastric tube

23. Percutaneous Drainage procedures • Long term malignant effusion/ ascites management (Aspira/Pleurx) • Biliary • Transhepatic biliary • Percutaneous cholecystostomy • Thoracentesis • Paracentesis • Abscess / empyema drainage • Hematoma drainage • Urinary • Nephrostomy • Suprapubic cystostomy

24. Biliary Intervention • A 35 y/o Nuclear Engineer with a wife and 3 children presents with painless jaundice, fever, pruritis and a total bilirubin of 7. CT scan demonstrates an infiltrating mass at the head of the pancreas, ERCP failed to gain access to the Ampulla of Vater. Attempted brush biopsy was inconclusive. The patient shows no evidence of metastatic disease. • The best initial procedure for this patient would be: • Whipple procedure • Transhepatic biliary stenting with a metal stent • Transhepatic biliary drainage with antibiotic therapy followed by biopsy and surgical consultation • Hospice

25. Percutaneous Drainage procedures: Indications • Biliary obstruction with • Pruritus • Anorexia • Cholangitis • Sepsis • hyperbilirubinemia • Antineoplastics excreted by liver

26. Biliary Intervention Indications for biliary drainage/stenting • Decompress obstructed biliary tree • Jaundice • Anorexia • Pruritis • Cholangitis • Receive chemo excreted by liver • Access for local brachytherapy • Combine with dilation of biliary strictures/occlusions • Remove bile duct stones • Divert bile from or stent a bile duct defect

27. Biliary Intervention • Contraindication to biliary drainage • Coagulopathy is a relative contraindication • Risk vs benefit

28. Biliary Intervention • Complications (major) 2% • Sepsis • Cholangitis • Bile leak • Hemorrhage • Pneumothorax • Hemothorax

29. Biliary Intervention • Plastic versus metallic stents treatment of malignant biliary obstruction • metallic stents have a clear clinical advantage in terms of patency and rates of reintervention • 30-day reobstruction rate is almost double for plastic stents • Some studies suggested that physical properties of self-expanding metal stent are preferred for extrahepatic biliary duct

30. Biliary Intervention • Expanded polytetrafluoroethylene-fluorinated ethylene propylene (ePTFE-FEP)-covered biliary endoprosthesis shown to have primary patency rates at 3, 6, and 12 months were 90%, 76%, and 76%, respectively • Branch duct obstruction was observed in 10% of their patients

31. CAT SCAN

32. Biliary Intervention • CT scan • Mass in head of pancreas • Dilated (Courvosier) GB • Intra & extrahepatic biliary dilation

33. Biliary Intervention • Intrahepatic biliary dilation

34. Biliary Intervention • CT Coronal reconstruction

35. Biliary Intervention • Percutaneous • Transhepatic • Cholangiography

36. Biliary Intervention • Select best duct for drainage / geometry

37. Biliary Intervention • Negotiating CBD

38. Biliary Intervention • Negotiating CBD

39. Biliary Intervention • Access to duodenum

40. Biliary Intervention • Dilating obstructed distal CBD

41. Biliary Intervention • Dilating obstructed distal CBD

42. Biliary Intervention • Internal-External Biliary Drain in Place

43. Biliary Intervention • Biliary tree decompressed

44. Biliary Intervention • Positive CT guided biopsy for AdenoCA • Surgical consult X 2 • Not surgically resectable

45. Biliary Intervention • Biliary tree decompressed

46. Biliary Intervention • Duodenal patency confirmed

47. Biliary Intervention • Sheath and stent in duodenum

48. Biliary Intervention • Bare stent deployed to maintain cystic duct patency

49. Biliary Intervention • Dilate stent

50. Biliary Intervention • No contrast flows to duodenum with sheath injection