Percutaneous gastrostomy in patients who fail or are unsuitable for endoscopic gastrostomy

Purpose: Percutaneous endoscopic gastrostomy (PEG) is not possible or fails in some patients. We aimed to categorize the reasons for PEG failure, to s tudy the success of percutaneous radiologic gastrostomy (PRG) in these pati ents, and to highlight the associated technical difficulties and complicati ons. Methods: Forty-two patients (28 men, 14 women; mean age 60 years, range 18- 93 years) in whom PEG failed or was not possible, underwent PRG. PEG failur e or unsuitability was due to upper gastrointestinal tract obstruction or o ther pathology precluding PEG in 15 of the 42 patients, suboptimal transill umination in 22 of 42 patients, and advanced cardiorespiratory decompensati on precluding endoscopy in five of 42 patients. T-fastener gastropexy was u sed in all patients and 14-18 Fr catheters were inserted. Results: PRG was successful in 41 of 42 patients (98%). CT guidance was req uired in four patients with altered upper gastrointestinal anatomy. PRG fai led in one patient despite CT guidance. In the 16 patients with high subcos tal stomachs who failed PEG because of inadequate transillumination, interc ostal tube placement was required in three and cephalad angulation under th e costal margin in six patients. Major complications included inadvertent p lacement of the tube in the peritoneal cavity. There was one case of hemorr hage at the gastrostomy site requiring transfusion and one case of superfic ial gastrostomy site infection requiring tube removal. Minor complications included superficial wound infection in six patients, successfully treated with routine wound toilette. Conclusion: We conclude that PRG is a safe, well-tolerated and successful m ethod of gastrostomy and gastrojejunostomy insertion in the technically dif ficult group of patients who have undergone an unsuccessful PEG. In many su ch cases optimal clinical evaluation will suggest primary referral for PRG as the preferred option.