• Previous surgery (e.g., abdominal hernia mesh repair).
• Large hiatus hernia and superior stomach position in the thorax.
• Posterior location of the stomach and/or long access tract in obese patients can be a risk factor for tube dislodgement and risk of intraperitoneal feeding and peritonitis.
• Colonic interposition or distention can increase the risk of bowel puncture.
• Large left lobe of liver anterior to the stomach.
• Cachexia: higher risk of double puncture of the anterior and posterior stomach wall and injury to posterior structures.
• Typically, gastric access is achieved in the left upper quadrant preferably at least one or two centimetres below the lowest palpable rib. This location decreases the risk of RIG tube irritating subcostal nerves and is better tolerated by the patients.
• Anatomical constraints can preclude some RIG insertion techniques and CT guidance can be considered for these cases.

• Inability to take adequate nutrients orally for more than four weeks.
• Common conditions requiring a gastrostomy feeding tube include: neurological disorders e.g., motor neurone disease, dysphagia post cerebrovascular accident or acquired brain injury, cerebral palsy, slow recovering vegetative state.
• Chronic pulmonary disease e.g., cystic fibrosis.
• Upper GIT cancers e.g., head and neck, oesophageal .
• Failure to thrive (paediatrics).
• Metabolic disorders.
• Chronic small-bowel obstruction requiring decompression gastrostomy.

• Non-functioning i.e., ileus, bowel ischaemia.
• Incurable disease in terminal phase (prognosis
• Advanced dementia.
• Anorexia nervosa.
• Severe ascites.
• Extensive tumour infiltration of stomach.
• Uncorrectable coagulation disorder.
• Inability of patient/carer to comply with required care including appropriate home environment.
• Life expectancy <30 days.

• Review of previous surgical treatments.
• Always assess previous CT scan, in order to plan for the procedure.
• Review of the CT of the abdomen to assess left liver lobe anatomy, colon position, large vessels or large hiatus hernia presence. Decision can be made at this point if to proceed with fluoroscopic insertion or with CT or dyna CT guidance. In case of significant bowel distention and antero-gastric position of the colon, flatus tube can be considered in the morning on the day of the procedure.
• Antibiotic prophylaxis

• Ultrasound
• Sterile drapes
• 1% lidocaine
• Sterile water
• Gastrostomy set

• Supine

• Time out
• Positioning patient
• Sterile wash and drapes
• Ultrasound guided punction

• Mark the left liver edge, costal margin and inferior epigastric artery using US. This can be also done after air inflation of the stomach.
• Prepare left subcostal area and epigastrium in sterile technique.
• Prepare local anaesthetic, e.g. 1% lidocaine mixed with longer lasting local anesthetic (for example 1% xylocaine or 2.5 mg/ml bupivacaine)
• It is reported that antibiotic prophylaxis may reduce the risk of infection, especially in the population of patients with head and neck cancers (e.g. Co-Amoxicillin 1.2g iv, or in case penicillin allergy teicoplanin can be considered). Antibiotic prophylaxis, in line with local protocols, is recommended)
• Consider iv 20 mg Buscopan or Glucagon 0.5 to 1.0 mg IV to reduce gastric peristalsis.
• Check nasogastric tube and colon position under fluoroscopy or ultrasound scan.
• Insufflate the stomach with air through the nasogastric tube. Usually, 500 to 1000 mL of air is required to distend the stomach (air can be also gradually topped up, during the procedure).
• Screen in AP position to mark the puncture sites towards the air in the distal body of the stomach using small anesthetic needles.
• Avoid colon and liver margin.
• Place 3 local anaesthetic needles advanced up to the stomach wall in a shape of a triangle, around the target position.
• Technique with t-fasteners (gastropexy) is recommended:
• alternate between AP and lateral views to perform gastropexy needle puncture,
• perform 4 gastropexy punctures (3-2 if there is limited access space) on lateral view fluoroscopy. To demonstrate intragastric position aspirate the air, and follow with contrast injection through the needle
• secure the gastropexy with "not too loose not too tight technique " at the skin.
• Top up air if needed prior to 18-gauge angio needle puncture. Make a 0.5-1 cm incision on the skin preferentially in longitudinal plane to minimize transecting the inferior epigastric artery. Dissect the skin incision with blunt-nosed hemostat and proceed with the gastric puncture on lateral view fluoroscopy. Aspirate the air and inject contrast to demonstrate intragastric position. If jejunal tube is planned, the puncture should be performed towards the pylorus. Advance stiff wire through the angio needle.
• Advance telescopic peel-away sheath over the stiff wire. It is crucial to make sure that the tract and thick gastric wall is dilating and not pushed away from the anterior abdominal wall. At this point, the wire can be dislodged from the stomach. Usually, gastropexies are helpful to prevent from this.
• While removing the peel-away sheath dilator you can ask the assistant to inject small amount of sterile gel into the sheath to avoid fast gastric decompression and to prevent gastric content to irritate the skin.
• Introduce the gastrostomy tube over the wire. It is easier to advance the tube, if it is preloaded with sterile lubricant gel.
• Peel away half way the sheath and fill the balloon with sterile water for injection.
• Make sure that maximal water volume is in the balloon, to avoid balloon losing its shape and sliding into a newly formed tract.
• Complete peeling away the sheath and pull the tube immediately, until the balloon is against the anterior abdominal wall, securing the tract.
• Inject contrast through the RIG to outline the gastric rugal folds and demonstrate the final tube position.
• It is recommended to avoid skin suture, to avoid suture infection.
• Document the volume of water in the balloon, tube length at the skin site and number of gastropexies used. This will help ward staff to assess the tube later and note any signs of tube dislodgment .
• Minimal dressing should be applied to avoid soaking with gastric content and to prevent from irritation of the skin and the tract.

• If bigger caliber tube or more robust fixation in the stomach is required, bumper PEG tube can be placed using fluoroscopic, rendez-vous technique under general anaesthetic.
• After stomach insufflation with air, percutaneous stomach puncture is performed towards the stomach fundus.
• Wire is advanced through the needle and the needle is removed.
• Wire is directed by catheter retrogradely, into the esophagus and out, through the mouth, for through-and¬through access
• If the esophageal cannulation is challenging; primarily, loop snare can be advanced orally into the stomach lumen.
• After stomach insufflation with air, percutaneous, 18-gauge needle puncture can be performed directing the needle through the open snare (25 mm loop snare or above),
• The 260 cm stiff wire is advanced through the needle and the needle is removed,
• The wire is snared to come out through the mouth, for a through-and-through access.
• The gastric tract is dilated percutaneously to accommodate the tube size. Long sheath (60-90 cm) is used to maintain through-and-through access (above 9F), introduced from the stomach side.
• Wire is removed.
• Snare is now advanced from the percutaneous stomach puncture (through the sheath) to come out through the mouth.
• Small loop suture at the external end of the PEG tube is attached to the snare from the mouth side. The PEG tube is now pulled against the sheath and together with the sheath pulled from the stomach side into the mouth, esophagus, stomach and out- through the skin leaving the disk in the stomach. Support is needed from the mouth to push the disk into the mouth and throat.
• The tube is cut to fit.
• No gastropexies are required with this technique.

• If it is difficult to appreciate the inflated balloon under fluoroscopy, water for injection can be mixed with 1 ml of contrast to better opacify the balloon. The balloon should not be however inflated with more dense contrast solution due to higher risk of balloon damage.
• Primary button tube technique was introduced in some centers. This requires balloon tract measurement and 18F sheath tract dilatation [12].
• Saline causes the erosion of the balloon and may be a reason for the balloon to burst. Saline should not be used for balloon inflation.
• The gastropexies should be at least 2 cm away from the balloon to avoid balloon damage.
• If the patient feels significant discomfort due to one of the gastropexies being too tight or showing signs of infection, the gastropexy can be cut, allowing the other gastropexies are in place.
• Due to some of the gastropexies being secured with absorbable suture, it is infrequent for the gastropexy to fell off prematurely. This can be expected especially if bleeding and hematoma occur. When non-absorbable sutures are used, it is advised to remove them after 10-14 days, when the tract is established.
• The tract usually forms in 10-14 days and it is advised not to deflate the balloon earlier (maturation 4-6 weeks).
• Two experienced practitioners should perform complex cases.
• If telescopic dilator is unavailable, the tract can be subsequently dilated up to F larger, compared to the tube size. Dilatation with a balloon can be also considered.
• If esophageal access is impossible stomach can be insufflated directly via CT or US guided 21G needle puncture.
• In case direct jejunostomy is indicated, due to inaccessible stomach or after gastrectomy, surgical procedure using a Witzel tunnel or percutaneous jejunostomy can be considered. Mobility of the small intestine, small intestine's compliance, difficult distension and close proximity of the vital structures should be taken into consideration for percutaneous insertion
• To exclude bowel perforation, x-ray is not recommended due to pneumoperitoneum being common finding after the procedure.

• Superficial peristomal infection 25-45%
• Leakage 11.4%
• Tube occlusion 4.5%
• Tube dislodgement 1.3-4.5%
• Hemorrhage 1.4%
• Peritonitis 1.3%
• Death 0.3%
• Colonic perforation rare
• Severe skin infection rare

Very low threshold for checking CT abdomen in patients that have significant post procedure pain.

Indications for replacing gastrostomy tubes

• Tube dislodged including balloon failure.
• Tube not functioning adequately: leaking, blocking regularly, blocked, and unable to restore patency.
• Tube showing signs of significant deterioration: cracked, flattened, discoloured, split.
• Tube is causing stoma site complications i.e., skin level device too tight causing pressure necrosis.
• Patient factors: replacement with a skin level device for aesthetic reasons in paediatrics, growth in children with a skin level device becoming too tight.