Entry of the needle tip within the stomach was recognized when the gastric rugae were opacified by the pooling of contrast medium. The stomach was then insufflated under fluoroscopic control with approximately 600-800 mL of room air through the 21G fine needle (Fig. 1A). After this point, the procedure was similar to what click this has been described for RPG. In addition to local anesthesia, intravenous sedation with 5 mg midazolam (Dormicum, Roche, Basel, Switzerland) and 50 mg pethidine (Demerol, Roche, Basel, Switzerland) was given to the patients. Gastropexy was performed using two T-fasteners (Cope gastrointestinal suture anchor set; Cook Incorporated, Bloomington, IN). An 18-gauge, 8 cm catheter needle was punctured directly through the gastric wall via a small incised area at the center of the skin between the two gastropexy fasteners.

A 100 cm stainless steel guide wire was inserted through the needle and gradual dilation of the tract was carried out by insertion a 14-Fr locking gastrostomy catheter (Wills-Oglesby percutaneous gastrostomy set, Mallinckrodt Institute Modification, Cook Incorporated, Bloomington, IN). Technical success was checked at the end of the procedure with 10 mL of water-soluble contrast medium injected via the pigtail catheter to ensure the gastrostomy catheter was correctly placed within the stomach (Fig. 1B-D). The T-fasteners were cut 14 days after the catheter insertion. Fig. 1 Modified radiology-guided percutaneous gastrostomy technique. RESULTS Successful insertion of gastrostomy was achieved in all the patients without any procedural complications.

An oral diet was successfully started after 24 hours for all the patients. No complications were attributed to the procedure on the 14-, 30- and 60-day follow up. DISCUSSION Radiologic percutaneous gastrostomy has been performed since the early 1980s (10-12). Although PEG is a currently acceptable method to construct an enteral access, RPG offers both the highest technical success rate and the lowest cost (13). However, both techniques are not feasible in cancer patients who have high grade narrowing of the oropharynx and/or upper esophagus and for whom endoscopic access or placement of catheter was not possible. In the conventional fluoroscopy-guided RPG, the stomach is directly distended with air by a nasogastric catheter or using the snare method as described by Rosenzweig et al.

(14). In our series, gastric insufflation was achieved via a percutaneously placed catheter. To ensure the safety of the puncture, important adjacent structures were outlined using ultrasound (for the outline of liver) and an air enema (for the outline of the transverse colon). This was our initial experience, and this technique was only applied to patients who had complete upper digestive tract obstruction, loss of nasogastric Batimastat access and no previous gastric surgery.