Percutaneous endoscopic gastrostomy (PEG) and radiologic percutaneous gastrostomy (RPG) are two currently established methods to provide enteral feeding to this group of patients (4-9). selleck chem Vandetanib However, PEG is not feasible in patients who have high-grade narrowing or obstruction of the upper digestive tract and this precludes the passage of an endoscope. For conventional fluoroscopy-guided RPG, the stomach is first distended with air introduced via the nasogastric tube. Percutaneous access to the stomach is achieved by the use of fluoroscopy to puncture the gasfilled stomach. In some difficult cases where the esophageal narrowing is tight, a fine bore catheter is introduced via a coaxial guidewire system as a substitute for a nasogastric tube for the purpose of air insufflation.

However, in the cases with complete esophageal obstruction that prevents placement of either a nasogastric tube or a guidewire, the percutaneous access to the stomach has to be monitored with a combined approach using ultrasound, an air enema and fluoroscopic guidance. In this report, we describe a modified combined radiology-guided approach to perform percutaneous gastrostomy in patients with complete obstruction of the upper gastrointestinal tract. MATERIALS AND METHODS From December 2005 to June 2010, fourteen patients with complete obstruction of the pharynx or esophagus and who were unable to obtain PEG or conventional fluoroscopy-guided percutaneous gastrostomy underwent modified radiology-guided percutaneous gastrostomy (MRPG). This cohort included two female patients and twelve male patients.

The age range was 41-68 years (mean age 49.8 years). Thirteen patients had hypopharyngeal cancers and one had upper thoracic esophageal cancer. The Institutional Review Board of our hospital approved this retrospective study and informed consent was waived due to the retrospective and anonymous nature of the analysis. In this new approach, ultrasound was first performed to outline the margin of the left lobe of the liver. The liver margin was marked on the skin. Then the patients received intravenous administration of 20 mg of hyoscine-N-butylbromide (Buscopan, Boehringer, Ingelheim, Germany). Simultaneously, a fluoroscopically-controlled air enema using 300 mL of room air via the rectum was performed, which outlined the anatomic position of the transverse colon. Next, the position of the collapsed stomach was estimated by the presence of any localized collection of air at the left subdiaphragmatic region. The presumed collapse stomach was then punctured using a 21G fine needle under fluoroscopic guidance with special care to avoid puncturing the Cilengitide liver or transverse colon.