Percutaneous gastrostomy and gastrojejunostomy with gastropexy: experience in 701 procedures

Clinical experience of percutaneous endoscopic gastrostomy in Taiwanese patients--310 cases in 8 years

Although percutaneous endoscopic gastrostomy (PEG) has become a popular method for long-term tube feeding worldwide, there are only a few reports about its application in Taiwan. From May 1997 to May 2005, we performed 302 PEG insertions successfully in 310 attempts (97.4% success rate) using modified Ponsky's pull method with 24-Fr feeding tubes. All the patients received PEG for tube feeding except for two patients with cancerous peritonitis for decompression. The underlying diseases in these 308 patients who received PEG for tube feeding were 161 cerebrovascular accidents (52.3%), 62 head and neck cancers (20.1%), 21 cases of Parkinsonism (6.8%), and others. There were 11 major complications (3.6%) and 57 minor complications (18.9%). Ten patients (3.3%) died within 30 days after PEG insertion. However, no procedure-related mortality occurred. In conclusion, PEG is an effective method for tube feeding and drainage with a high success rate. PEG insertion was often indicated for patients with dysphagia caused by cerebrovascular accident, head and neck cancer, and Parkinsonism in Taiwan. It is a relatively safe procedure, with a 3.6% rate of major complications and 18.9% rate of minor complications.

Fluoroscopically guided percutaneous jejunostomy: outcomes in 25 consecutive patients

AIM

To assess the feasibility and safety of fluoroscopically guided percutaneous jejunostomy.

MATERIAL AND METHODS

Between May 1999 and August 2006 percutaneous jejunostomy was attempted in 25 patients. A 5 F vascular catheter (n=20) or a 7.5 F multifunctional coil catheter (n=5) was used to insufflate the jejunum. The distended jejunum was punctured using a 17 G needle (n=19) or a 21 G Chiba needle (n=6) with the inserted catheter as a target. A 12 or 14 F loop feeding tube was inserted after serial dilations. The technical success, complications, 30-day mortality, and in-dwelling period of the feeding tube placement were evaluated.

RESULTS

The technical success rate was 92% (23/25). Technical failures (n=2) resulted from the inability to insufflate the jejunum secondary to failure to pass the catheter through a malignant stricture at the oesophagojejunostomy site and thus subsequent puncture of the undistended jejunum failed, or failure to introduce the Neff catheter into the jejunum. Pericatheter leakage with pneumoperitoneum was a complication in three patients (12%) and was treated conservatively. The 30-day mortality was 13% (3/23); however, there was no evidence that these deaths were attributed to the procedure. Except for four patients who were lost to follow-up and two failed cases, 15 of the 19 jejunostomy catheters were removed because of patient death (n=12) or completion of treatment (n=3), with a mean and median in-dwelling period of 231 and 87 days, respectively.

CONCLUSIONS

Fluoroscopically guided percutaneous jejunostomy is a feasible procedure with a high technical success and a low complication rate. In addition to a 17 G needle, a 21 G needle can safely be used to puncture the jejunum.

Retrograde percutaneous enterostomies in children using a needle system with valve mechanism

The technique of enterostomy access frequently uses a needle preloaded with a suture anchor to appose the bowel wall to the abdominal wall. Two of the intrinsic disadvantages of this method are the possible dislodgment of the suture anchor out of the needle hub during the process of guide-wire insertion and the escape of air with subsequent deflation of the viscus, which may necessitate a second puncture. The use of a Check-Flo performer assembly with a valve mechanism provides a leakproof system. It avoids possible dislodgment of the suture anchor during deployment, maintains viscus distension, and may be useful for trainees to do the procedure in a controlled manner.

Acute complications associated with bedside placement of feeding tubes

Several types of feeding tubes can be placed at a patient's bedside; examples include nasogastric, nasointestinal, gastrostomy, and jejunostomy tubes. Nasoenteral tubes can be placed blindly at bedside or with the assistance of placement devices. Nasoenteric tubes can also be placed via fluoroscopy and endoscopy. Gastrostomy and jejunostomy tubes can be placed using endoscopic techniques. This paper will describe the indications and contraindications for different types of tubes that can be placed at the bedside and complications associated with tube placement. Complications associated with nasoenteral tubes include inadvertent malpositioning of the tube, epistaxis, sinusitis, inadvertent tube removal, tube clogging, tube-feeding-associated diarrhea, and aspiration pneumonia. Complications from percutaneous gastrostomy and jejunostomy tube placements include procedure-related mishaps, site infection, leakage, buried bumper syndrome, tube malfunction, and inadvertent removal. These complications will be reviewed, along with a discussion of incidence, cause, treatment, and prevention approaches.

Enteral access in home care

Enteral nutrition is the delivery of nutrients through the gastrointestinal tract. For those patients who cannot or will not swallow, an enteral access device (EAD) is required. Some of these devices can be passed through the oral or nasal cavity into the stomach or small bowel. Alternatively, the devices can be percutaneously placed by an endoscopist or a radiologist into the stomach or small bowel. Knowledge of the appropriate use of these devices, the appropriate maintenance management of these devices, and the appropriate treatment of EAD-related complications is essential for the clinician to understand in order to provide effective nutrition therapy.

Long-term results with a new introducer method with gastropexy for percutaneous endoscopic gastrostomy

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) using the pull-technique is the standard method for enteral feeding in patients with swallowing disorders. A different introducer technique with endoscopically controlled gastropexy is available avoiding oropharyngeal passage with the internal bumper. The aim of the study was to assess long-term safety of this technique.

MATERIAL AND METHODS

Between January 1999 and November 2001, 684 patients received a PEG in our prospective cohort trial. In 92.5% of cases a PEG was applied using the pull-through technique. In 6.7% of the patients (40 males, 6 females, mean age 60.6 yr) primary PEG application using the pull-through technique was not possible and an endoscopical controlled introducer PEG (Cliny PEG 13 CH (=13 F), AP Nenno, Germany) with two gastropexies was placed. Data collection criteria included application success, infectious complications (within 180 days), other complications (within 180 days), and mortality (within 180 days). Procedure, catheter change, and follow-up were standardized.

RESULTS

PEG placement was successful in all patients. During initial follow-up we saw a low rate of minor problems. In one case a peristomal peritonitis was seen due to detachment of two gastropexy sutures. During long-term follow-up only one local infection requiring antibiotic treatment occurred on day 14. We observed no treatment related mortality. In most of the patients the primary catheter was changed into a secondary system as scheduled. The average observation period was 131.8 days (range: 15-180 days).

CONCLUSION

The Cliny PEG 13 CH can be placed safely in an endoscopically controlled introducer procedure with dual gastropexy. Long-term follow-up of the patients revealed only minor complications. Primary indication is given in patients in whom PEG placement using the pull-through technique is not possible.

Interventional radiology techniques for provision of enteral feeding

Gastrostomy placement in patients who are unable to maintain their nutrition orally has been attempted using a variety of techniques over the past century. This includes surgical, endoscopic, and, more recently, percutaneous radiologically guided methods. Surgical gastrostomy placement was the method of choice for almost a century, but has since been superseded by both endoscopic and radiological placement. There are a number of indications for gastrostomy placement in clinical practice today, with fewer contraindications due to the recent innovations in technique placement and gastrostomy catheter type. We describe the technique of gastrostomy placement, which we use in our institution, along with appropriate indications and contraindications. In addition, we will discuss the wide variety of catheter types available and their perceived advantages. There remains some debate with regard to gastropexy performance and the use of primary gastrojejunal catheters, which we will address. In addition, we will discuss the advantages and disadvantages of the three major types of gastrostomy placement currently available (i.e., surgical, endoscopic, and radiological) and their associated complications.

Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: A comparison of indications, complications and outcomes in 370 patients

OBJECTIVE

Percutaneous access to the stomach can be achieved by endoscopic or fluoroscopic methods. Our objective was to compare indications, complications, efficacy and outcomes of these two techniques.

METHODS

Records of 370 patients with feeding tubes placed either endoscopically by gastroenterology, or fluoroscopically by radiology, at our university-based tertiary care center over a 54-month period were reviewed.

RESULTS

177 gastrostomies were placed endoscopically and 193 fluoroscopically. Nutrition was the most common indication in each group (94 and 92%), but the most common underlying diagnosis was neurologic impairment in the endoscopic group (n=89, 50%) and malignancy in the fluoroscopic group (n=134, 69%) (p<0.001). Complications in the first 30 days were more common with fluoroscopic placement (23% versus 11%, p=0.002), with infection most frequent. Correlates of late complications were inpatient status (OR 0.26, 95%CI: 0.13-0.51) and a diagnosis of malignancy (OR 2.2, 95%CI: 1.03-4.84). Average follow-up time was 108 days in the fluoroscopic group and 174 days in the endoscopic group.

CONCLUSIONS

Both endoscopic and fluoroscopic gastrostomy tube placement are safe and effective. Outpatient status was associated with greater early and late complication rates; minor complications such as infection were greater in the fluoroscopic group, while malignancy was associated with late complications.

Complications des gestes interventionnels percutanés sous contrôle radioscopique, échographique ou scanographique

The purpose of this article is to describe potential complications following the most common image-guided (fluoroscopy, ultrasound or CT) percutaneous interventional procedures, both diagnostic and therapeutic, thoraco-abdominal and musculoskeletal, as well as to review risk factors and the best practice recommendations. Prior to any interventional procedure, it is necessary to ascertain the absence of any abnormality in coagulation, to secure enough time to explain the procedure to the patient, and to adhere to strict sterile technique. Indeed, infections and hemorrhagic complications are the principal causes of mortality and morbidity for all procedures. Following lung biopsy, CT scan detects an immediate pneumothorax in 30% of patients. Major complications following percutaneous liver biopsy occur within 3 to 6 hours. Following a percutaneous drainage, complications occur in less than 10% of cases. Following a radiofrequency thermal ablation of malignant tumors, the mortality rate is low (0,5 to 1,4%), infection and hemorrhage are the most frequent complications. While rare, septic arthritis is the main complication that can follow musculoskeletal procedures and is a cause of medical malpractice lawsuits brought by patients.

De Novo Placement of Button Gastrostomy Catheters in an Adult Population: Experience in 53 Patients

PURPOSE

To investigate the feasibility of primary button gastrostomy insertion with the aid of T-fastener gastropexy.

MATERIALS AND METHODS

Fifty-three consecutive patients (33 men, 20 women; mean age, 63.4 years) referred for percutaneous radiologic gastrostomy (PRG) underwent primary button gastrostomy insertion over an 18-month period in two centers. Nine of the patients (17%) were referred after failed endoscopic gastrostomy and 44 (83%) were primarily referred for PRG. Indications for gastrostomy included esophageal/head and neck malignancy (n = 33) and neurologic disorders (n = 20). Gastropexy with three or four T-fasteners was performed in all patients and angioplasty balloon catheters (6 mm x 40 mm) were used to measure tract length and dilate the tract. An 18-F dilator was used for final tract dilation. Button gastrostomy catheters with retention balloons were inserted in all patients. Patient follow-up was performed by the department of dietetics, which contacted patients on a weekly basis.

RESULTS

Primary button gastrostomy insertion was successful in 52 of 53 patients (98%). The mean gastrostomy button catheter survival was 13.3 weeks (range, 1-28 weeks). No episodes of button occlusion occurred. Since the beginning of this study, 33 patients (63%) have had their gastrostomy buttons replaced. The reasons for button replacement include burst retention balloons (n = 27; 52%), dislodgment of the catheter (n = 4; 8%), and continuing pain/discomfort at the gastrostomy site (n = 2; 4%).

CONCLUSION

Button-type gastrostomy catheters can be placed de novo by interventional radiologists without the need for a mature tract, provided a T-fastener gastropexy is used. The balloon retention button devices are not compromised by occlusion but do tend to become dislodged.

National trends in gastrointestinal access procedures: an analysis of Medicare services provided by radiologists and other specialists

PURPOSE

To evaluate national trends in enteral access services by radiologists and other specialists.

MATERIALS AND METHODS

Medicare data from 1997 to 2000 were analyzed for trends in gastrointestinal access services. Current Procedural Terminology codes for gastrostomy placement and maintenance services were selected. Utilization was analyzed by physician specialty. Targeted service analysis was performed for interventional radiologists.

RESULTS

For sampled enteral access procedures, annual services to Medicare beneficiaries increased from 279,509 to 283,353 (+1.4%). These were most often performed by gastroenterologists (48.6%), surgeons (25.1%), radiologists (7.4%), and others (18.9%). Total procedures by radiologists increased 29.6% whereas procedures by gastroenterologists, surgeons, and other nonradiologists changed +6.9%, -4.9%, and -10.2%, respectively. For new gastrostomy accesses, radiologist volume increased 46.9% whereas gastroenterologist, surgeon, and other volumes changed +7.9%, -5.0%, and -21.5%, respectively. For maintenance services, radiologist volume increased 21.8% whereas gastroenterologist, surgeon, and other volumes changed +3.1%, -4.7%, and +7.9%, respectively. Analyzed for frequency, relative value, and physician time, enteral access services account for less than 1% of all services provided by interventional radiologists.

CONCLUSIONS

Although the number of gastrointestinal access services provided to Medicare beneficiaries has remained static, radiologists have experienced a marked relative increase in volume, particularly for new gastrostomy procedures. This increase is largely at the expense of surgeons and other nongastroenterologists. However, radiologists still provide only a small portion of gastrointestinal access services nationwide, and these services account for only a small portion of all procedures performed by interventionalists. Therefore, the potential for enteral access service growth in interventional radiology is high.

Percutaneous abscess drainage: use of related radiology services and associated economic impact on a radiology practice

PURPOSE

To evaluate the impact of percutaneous abscess drainage on the usage and professional value of subsequent services provided by a radiology practice.

MATERIALS AND METHODS

Percutaneous abscess drainage was selected as a marker interventional radiology procedure because of its pervasiveness and ease of identification of related services. Billing records were reviewed for 48 consecutive patients who underwent abscess drainage during a 9-month period. Current procedural terminology (CPT) codes for all radiology services during the subsequent 90 days were analyzed to identify those related to the initial drainage procedure. Professional relative value unit (RVU) impact was calculated.

RESULTS

Initial abscess drainage services were identified by 2.6 +/- 1.2 CPT codes, but patients underwent 13.4 +/- 10.7 related radiology services during the subsequent 90 days. The professional RVU impact of subsequent services was 64% higher than that of initial procedures: initial drainage services accounted for 11.5 +/- 5.1 RVUs and all subsequent related radiology services accounted for 18.9 +/- 16.8 RVUs (P =.0042). Of those, additional interventional radiology procedures amounted to 10.7 +/- 12.8 RVUs, diagnostic radiology services 4.7 +/- 4.6 RVUs, and evaluation and management services 3.5 +/- 2.9 RVUs.

CONCLUSION

Basic interventional radiology services may result in far more economic impact on radiology practices than initial direct procedure analyses suggest. For percutaneous abscess drainage, the professional RVU impact of subsequent services exceeds that of the initial procedure by 64%. Practices negotiating capitated contracts for interventional services need to consider the high value of such related services.

Percutaneous radiologic gastrostomy

Gastrostomy is a preferred method of nutrition in patients with impaired ability to eat. Although surgical gastrostomy is a well-established method and has been widely performed in the last century, beginning with early 1980s, percutaneous gastrostomy techniques, either endoscopic or radiologic, has widely gained acceptance. As percutaneous methods have been shown to be an effective, safe, easy to perform and low-cost techniques with low morbidity and mortality rates, nowadays percutaneous gastrostomy is the first method of choice in need of nutrition in patients with functioning gut. In this article authors review the technique of percutaneous radiologic gastrostomy, as well as indications, contraindications, variations of technique, ethical considerations, controversies and comparison with surgical and endoscopic methods.

Establishing radiological percutaneous gastrostomy with balloon-retained tubes as an alternative to endoscopic and surgical gastrostomy in patients with tumours of the head and neck or oesophagus

The purpose of this study was to report our experience introducing radiological percutaneous gastrostomy (RPG) catheters at a hospital where hitherto only endoscopic and surgical methods have been used. The feasibility, success, time requirements, and complications of RPG were prospectively evaluated during a 12-month period. 26 consecutive patients (median age 63 years, range 41-91 years) underwent gastropexy with T-fasteners followed by insertion of a 12-18 F balloon tube through a peel-away introducer and were followed-up clinically and radiologically. Success and complications occurring within 30 days were assessed. RPG was technically successful in all cases. Median procedure time was 34 min (range 20-90 min), median fluoroscopy time 6.9 min (range 2.3-30 min). 13 surgical gastrostomies were avoided. One minor complication (peristomal leakage) occurred in a patient with gastric reflux and atony. Another patient destroyed the balloon of his tube by injecting food into the balloon port, which led to tube dislocation and peritonitis. In conclusion, radiological gastrostomy can be quickly learned by radiologists and is readily accepted by clinicians. It is an alternative to surgical gastrostomy when percutaneous endoscopic gastrostomy is not feasible, but can also be used as the primary method instead of the endoscopic method.

Percutaneous radiological gastrostomy in patients with head and neck cancer

AIM

To evaluate the results of percutaneous radiological gastrostomy in patients with head and neck cancer.

PATIENTS AND METHODS

This was a retrospective study design. One hundred and eighteen patients with head and neck cancer were referred 130 times for gastrostomy tube placement between 1 April 1993 and 17 August 1998. Mean age was 60 years. All data were analysed by using the following parameters: success rate, complications and mortality. Complications were divided into major, minor (complication that needed only conservative treatment) and tube-related.

RESULTS

The success rate of percutaneous radiological gastrostomy was 97%. Major complications occurred in 6% of patients after gastrostomy tube placement. Minor complications occurred in 15% of patients. There was one tube-related complication. Procedure-related mortality occurred in one patient. The results of this study show no difference from those known from the literature for the percutaneous method and confirm that radiological gastrostomy has significantly lower rates of major complications than other methods of gastrostomy placement.

CONCLUSION

Percutaneous radiological gastrostomy tube placement is, in our opinion, an effective and reliable method for placing a feeding tube in patients with head and neck cancer.

Fluoroscopically guided percutaneous placement of large-bore gastrostomy and gastrojejunostomy tubes: review of 109 cases

PURPOSE

To evaluate our experience with percutaneous placement, management, and complications of large-bore (20-24 F) gastrostomy and gastrojejunostomy feeding tubes.

MATERIALS AND METHODS

A retrospective review was performed on 109 consecutive patients who underwent placement of percutaneous large-bore feeding tubes between January 1994 and May 1998. Data were collected with respect to underlying illness, technical success, number of replaced tubes, and immediate and late complications. No patient had a small-bore tube placed during this series.

RESULTS

A total of 109 cases were reviewed. Immediate follow-up within the first 2 weeks was available for all 109. Follow-up after 2 weeks was available for 61 (56%) patients. Tubes were placed in patients aged 15 to 94 years. Neurologic dysfunction from a variety of causes was the most common underlying illness and occurred in 52% of patients. There were nine (8.3%) immediate, treatable complications: three major and six minor. There was one procedure-related death (0.9%). Persistent fistula tracts following tube removal occurred in three patients (4.9%). Balloon rupture was the most common reason for tube exchange (40.7%).

CONCLUSION

Percutaneous large-bore gastrostomy and gastrojejunostomy tubes are safe to place and have technical success, morbidity, and mortality rates comparable to those of tubes placed surgically or endoscopically as well as small-bore tubes placed with fluoroscopic guidance.