Radiologically inserted gastrostomy (RIG)

A radiologically inserted gastrostomy (RIG) is a procedure where a tube is inserted percutaneously in the stomach, principally to provide nutritional support for patients with swallowing disorders 1.

Indications
  • inadequate oral intake due to dysphagia (neurologic disorder, oesophagal obstruction, head & neck masses)
  • oesophagal leak
  • decompression from gastric content
  • gastroparesis
Contraindications
Absolute contraindications

Some generally accepted absolute contraindications are 2:

  • severe coagulopathy
  • dangerous percutaneous access to stomach (e.g. interposed colon)
Relative contraindications
  • massive ascites
  • gastric varices
  • infection or neoplasia on the percutaneous tract
  • prior gastric surgery
  • severe gastro-esophageal reflux
Procedure details

Prior to the procedure, review prior imaging studies to chose the best percutaneous approach. The patient should be NPO for the past 8 hours 2.

  1. place a nasogastric tube 
  2. administer conscious sedation
  3. insufflate air in the nasogastric tube to distend the stomach. Enough air should be used to distend the stomach and oppose the gastric wall to the anterior abdominal wall (about 250-500cc).
  4. choose the puncture site in the body of the stomach, equidistant from the lesser and greater curvatures
  5. infiltrate local anesthesia with about 10cc of 1% lidocaine on the percutaneous tract
  6. make a small skin incision with a No. 11 scalpel
  7. use a gastropexy device (eg. a 17G needle preloaded with a Cope suture anchor) to puncture the stomach. One should feel and see the anterior stomach wall tenting upon pressure, then a give a sharp jab to enter the gastric lumen
  8. confirm correct location by aspiration of air in a syringe
  9. advance a stylet in the gastropexy device, to discharge the anchor in the stomach
  10. the stylet and the gastropexy needle are then removed and the stomach is approximated to the anterior abdominal wall by a gentle traction
  11. use your needle to make another gastric puncture, which will serve to put the gastrostomy tube. For simple gastrostomy, one should aim vertically down or slightly towards the fundus. However, if conversion to a gastrojejunostomy is anticipated, the needle should be directed towards the pylorus to have less resistance
  12. confirm intraluminal localization with a small amount of contrast, which will outline gastric folds
  13. insert a 0.038-inch J-tipped stiff guidewire and loop it in the stomach, and withdraw the needle
  14. introduce serial fascial dilatators over the guidewire to dilate the muscular layers of the stomach, while taking care to keep tension on the anchor and to keep the guidewire inside the stomach lumen
  15. insert the selected gastrostomy tube over the wire, using a peel-away sheath, which is then peeled
  16. inflate the gastrostomy balloon with the required amount of sterile water (eg. 5-10cc)
  17. confirm the proper position of the tube, then apply a small tension on the gastric wall by pulling the tube, while applying the retention disc on the skin, which will fix the anterior gastric wall to the anterior abdominal wall
  18. fix the retention disc on the skin with a non-resorbable suture

Some interventional radiologists perform RIG without gastropexy, using a single puncture. 

Complications

The procedure complications include 2,3:

See also

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Article information

rID: 65800
Synonyms or Alternate Spellings:
  • Percutaneous radiological gastrostomy
  • radiological gastrostomy
  • percutaneous gastrostomy
  • gastrostomy
  • RIG

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