Radiologically inserted gastrostomy (RIG)

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

Indications

• inadequate oral intake due to dysphagia (neurologic disorder, esophageal obstruction, head & neck masses)
• esophageal leak
• decompression of gastric contents
• gastroparesis

Contraindications

Absolute contraindications

Some generally accepted absolute contraindications are ²:

• severe coagulopathy
• dangerous percutaneous access to the stomach (e.g. interposed colon)

Relative contraindications

• massive ascites
• gastric varices
• infection or neoplasia along the percutaneous tract
• prior gastric surgery
• severe gastro-esophageal reflux

Procedure details

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

1. place a nasogastric tube
2. administer conscious sedation
3. insufflate air via 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 along 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 aspirating air into a syringe
9. advance a stylet in the gastropexy device, to discharge the anchor in the stomach
10. the stylet and gastropexy needle are then removed and the stomach is approximated to the anterior abdominal wall by gentle traction on the anchor
11. make another gastric puncture which will be used for the gastrostomy tube. For a 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
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 before withdrawing 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
16. inflate the gastrostomy balloon with the required amount of sterile water (eg. 5-10cc)
17. confirm proper position of the tube, then apply gentle 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-absorbable suture

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

Complications

Potential complications include ^2,3:

• peritonitis
• hemorrhage
• wound infection
• gastrointestinal perforation
• aspiration
• buried bumper syndrome

See also

• percutaneous endoscopic gastrostomy