Gastrostomy tube migration is a minor complication of percutaneously inserted radiologic gastrostomy. Here, we retrospectively report a case of rapid exchange of a percutaneous radiologic gastrostomy tube via off-label use of a pigtail catheter for nutrition supply during a very early episode of coronavirus disease 2019 (COVID-19) in an outpatient clinic. Institutional review board approval was waived for this retrospective study.

A 77-year-old female patient presented with accidental migration of a percutaneous gastrostomy tube on January 31, 2020, when COVID-19 had just been declared an outbreak in Wuhan Province of China. The patient’s past history included Alzheimer disease, hypertension, lacunar cerebral infarction, mild pneumonia, and leukemia. She was bedridden in a district nursing home. A percutaneous gastrostomy procedure had been performed for dysphagia 2 months beforehand at our institution (Fig. 1). She had no high-risk travel history to epidemic areas and no symptoms of fever or cough. A physical examination revealed that her previous gastrostomy tube (balloon-occluded type catheter; Create Ltd.) had been completely removed from the front abdominal wall tract.

Figure 1. A balloon-occluded tube (Create Ltd.) is deployed in the stomach of an elderly female patient during a percutaneous radiologic gastrostomy procedure.

Our interventional radiologists decided to exchange the gastrostomy tube in the outpatient clinic. After sterile preparation, the patient was laid on the table in a digital subtraction angiography suite (Philips Azurion 7M20; Philips) in a supine position. The doctors, nurses, and technicians all wore enhanced personnel protection equipment higher than our daily practice level, along with gowns and masks, also wearing facial shields. Under fluoroscopic guidance, we attempted to reinsert the previous 16-Fr balloon occluded-type gastrostomy tube into the stomach through the original transperitoneal tract. The procedure failed due to spasm of the tract. At the same time, the patient could not tolerate the serious pain during this process. At this critical moment, there was no dilator larger than 18-Fr or at least a 4-Fr oversize peel-away sheath available at hand. However, the gastrostomy tube was successfully exchanged after we changed our approach. Briefly, a 0.035-inch hydrophilic guide wire (Radiofocus) was introduced through the old tract. Next, a 16-Fr pigtail multiple side hole drainage catheter (Argon Medical Device Inc.) was deployed over the wire into the stomach. The gastric rugal fold was visualized by an injection of contrast medium to confirm the location of the catheter tip (Fig. 2). The catheter was sealed at the access site with a suture. After successful gastrostomy exchange, the patient was discharged on the same day.

Figure 2. Image after the rapid exchange of the percutaneous gastrostomy tube with a pigtail drainage catheter (Argon Medical Device Inc.) in the same person.

The gastrostomy tube continued to work well at a 6-month follow-up.

At the very beginning of the COVID-19 pandemic, the world knew little about this disease, let alone how to prevent and treat it. At that time, all elective operations were suspended by hospital administrations, and only emergent operations could be performed with strict approval¹.

During this minimally invasive procedure, all healthcare workers were required to use enhanced personal protective equipment, perform the procedure with an absolutely sterile process, and always wear a gown as well as a face shield. Surgical masks were worn throughout the procedure. Careful hand hygiene was required pre- and post-procedure, it was necessary to appropriately deal with the contained materials, and complete disinfection management was required after each procedure².

In our daily practice, patients are usually admitted as inpatients for G-tube exchange procedures due to insurance coverage in China. However, given this special pandemic situation and the patient’s difficulty in movement, an outpatient procedure was performed with fewer hospital examinations, decreasing the risk of in-hospital viral cross-contamination.

Minor complications after percutaneous radiologic gastrostomy include superficial infections, tube dislodgement, tube occlusion, and leakage.³ The rate of tube dislodgement is about 1.3%% to 4.5%. Because of the previous spasm and retraction of the tract, the original 16-Fr gastrostomy balloon occluded-type tube (Create Ltd.) could not be reinserted through the wire. Though there was no oversize peel-away sheath or enough diameter dilator available at hand, a multi-side hole pigtail drainage catheter (Argon Medical Device Inc.) was alternatively introduced into the stomach over the guidewire. In such a situation, a pigtail catheter has several advantages. In particular, it has a tapered tip and a stiffened shaft, so it can easily enter through the tract into the stomach. We needed neither a larger peel-away sheath nor T-fasteners to hold the stomach in place while pushing this catheter in. Although this was an off-label use of a pigtail catheter, we were able to exchange the migrated gastrostomy catheter in the outpatient clinic during the COVID-19 pandemic.⁴

This case indicates that interventional radiologists can play an essential role in saving patients who need minimally invasive image-guided procedures even during the unprecedented conditions of the COVID-19 pandemic.

The authors would like to express great gratitude to Dr. J.H. Shin for his kind suggestions and revisions of this manuscript.

None.

No potential conflict of interest relevant to this article was reported.