First results of laparoscopic gastrostomy

Comparison of laparoscopic versus open approach to gastrostomy tubes

BACKGROUND AND OBJECTIVES

Gastrostomy tube insertion for enteral access may be performed through laparotomy (open) or through the laparoscopic approach. This study's purpose is to compare outcomes of these different approaches.

METHODS

A retrospective chart review of all patients (age >18 years) who underwent insertion of a gastrostomy tube as a single elective procedure between 2004 and 2012 was performed. Primary end points included postoperative overall and tube-related morbidity, tube revision rates, and operative time.

RESULTS

During the study period, 71 patients had a gastrostomy tube inserted via either the open (n 46) or the laparoscopic (n 25) approach. Preoperative variables including age, gender, body mass index, albumin, and American Society of Anesthesiologists score were statistically comparable between groups. There was no difference in rates of previous upper abdominal surgery (24% vs 26%, P = .590) or gastric surgery (12% vs 13%, P = .720) in the laparoscopic and open groups, respectively. Previous percutaneous endoscopic gastrostomy tube insertion rates were higher in the laparoscopic group (32% vs 6.5%, P = .005). Operative time was significantly longer in the laparoscopic group (76.8 ± 7 vs 55.8 ± 3, P = .003) but was not affected by previous abdominal surgery or higher body mass index. Overall morbidity, tube-related morbidity, and tube revision rates were similar between groups. However, there was a trend toward increased major complication rates in the open group (6.5% vs 0%, P = .190).

CONCLUSION

Laparoscopic gastrostomy tube insertion is safe and feasible, even in patients who have had prior upper abdominal surgery. Patients with a prolonged prognosis, obesity, and intact neurologic capacity may benefit the most from this approach.

Laparoscopic Witzel gastrostomy—a reappraised technique

BACKGROUND

Laparoscopic gastrostomy is the best alternative for long-term enteral feeding when percutaneous endoscopic gastrostomy is not possible. The aim of the present study was to determine the feasibility, complications, adequacy of feeding support, and tolerability of laparoscopic Witzel gastrostomy (LWG) in head and neck cancer patients. The initial results and the results of extended follow-up were evaluated.

METHODS

A consecutive series of 48 patients with stenotic head and neck or esophageal cancer were referred for laparoscopic gastrostomy. The patients consisted of 42 men and 6 women aged 36 to 82 years (mean, 54 years). After laparoscopic placement of a Foley catheter of 16 F into the stomach, a seromuscular tunnel 4 cm in length is created, embedding the catheter by interrupted sutures. Three stay sutures for gastropexy are fixed and tied on the abdominal skin at the end of the procedure. The mean duration of the procedure was 62.4 +/- 11 min (52-124 min).

RESULTS

Laparoscopic Witzel gastrostomy could be performed successfully in all patients with aerodigestive cancer. None of the laparoscopic gastrostomy tube placement procedures was converted to an open surgery, and none of the 48 patients in this series died as a result of the laparoscopic procedure. All LWG complications (11%) were minor, consisting of superficial wound infections, balloon rupture, and chronic granulation. No major complications were encountered. The mean usage time of gastrostomy was 6.3 +/- 5.3 months.

CONCLUSIONS

Current techniques of LWG could be an alternative to percutaneous endoscopic gastrostomy (PEG) for long-term enteral access, because it has proved to be safe and reproducible with relatively few complications.

Spread of a pharyngeal cancer to the abdominal wall after percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy is frequently used in patients with head and neck cancer to establish enteral access for feeding. Spread of head and neck cancer to the gastrostomy site is a rare but increasingly reported complication after percutaneous endoscopic placement. We report the 13th such case in the literature, occurring in a 51-year-old black man with squamous cell carcinoma of the hypopharynx. The mode of tumor spread to the gastrostomy site remains debatable. Evidence exists for hematogenous dissemination and direct implantation. We think percutaneous endoscopic techniques for enteral access in this patient population are contraindicated, and we advocate a laparoscopic approach for gastrostomy placement.

Laparoscopic gastrostomy: results of 121 patients over 7 years

Laparoscopic gastrostomy was introduced in various technical variants 7 years ago. However, larger series and long-term results of these new methods are still lacking. In a prospective study, laparoscopic gastrostomies were performed by two institutions in 121 patients (88 men, 33 women; mean age, 58.3 +/- 11.16 years [range, 24-82]) with esophageal stenosis in locally advanced hypopharyngeal or oropharyngeal carcinoma, incurable esophageal carcinoma, and cerebral dysphagia. Operating time was 40 +/- 22 (range, 10-160) minutes. Procedure-related mortality was 0%, early mortality was 1.6%, the overall intraoperative complication rate was 7.4%, and the early complication rate was 9.9%. During a cumulative usage time of 1086.2 months, the complication rate in 1000 usage days was 0.8, and the stoma infection rate was 0.65. Laparoscopic gastrostomy is a reliable method for safe and economic establishment of enteral nutrition, even in patients for whom long-term nutrition by gastrostomy is expected.

Staging laparoscopy in the management of intra-abdominal malignancies

BACKGROUND

Laparoscopy in the evaluation of intra-abdominal malignancies has become a debated issue. Proponents have claimed that it increases resectability rates, whereas opponents suggest that many patients require laparotomy regardless of the laparoscopic findings. The purpose of this study was to compare outcomes in patients undergoing staging laparoscopy versus those who were managed by initial exploratory laparotomy.

METHODS

The medical records of all patients during an 18-month period who underwent surgical evaluation for upper gastrointestinal or hepatobiliary malignancies were reviewed. Forty-eight patients underwent staging laparoscopy (SL) initially; 80 patients underwent initial exploratory laparotomy (EL). Data obtained included type of cancer, laparoscopic findings, laparoscopic determination of resectability, laparoscopic procedures, open determination of resectability, open procedures, and length of stay (LOS). Statistical analysis was done by using Fisher exact test or the Mann-Whitney U test.

RESULTS

The malignancies of 75% of patients were deemed resectable by SL. Of these, 77.8% were resected. This compares to 56.3% resectability rate in the EL group (P = .025). SL findings in patients with unresectable malignancies were carcinomatosis (75%), liver metastasis (33.3%), and direct invasion (16.7%). In the 8 false-negative SLs, 75% were unresectable as a result of vascular invasion and 25% for other reasons. Findings in the EL group whose malignancies were unresectable were carcinomatosis (34.3%), direct invasion (22.6%), liver metastasis (42.9%), and vascular invasion only (17.1%). Therefore 82.9% of patients in the EL group could have been determined to have unresectable malignancy by SL. In the EL group 22.5% of the laparotomies were nontherapeutic, whereas 4.2% of patients in the SL group underwent nontherapeutic laparotomy. Average LOS for unresectable patients in the SL group was 0.5 days, with 75% discharged the same day of operation. This compares to 10.9 days in the EL group (P < .00001) and 7.6 days in the nontherapeutic EL group (P < .00001).

CONCLUSIONS

SL increases the resectability rate, decreases the nontherapeutic laparotomy rate, and decreases LOS in patients with unresectable disease. SL is poor at detecting unresectability as a result of vascular invasion only, but this accounts for less than one-fifth of patients. Laparoscopic sonography and palliation may further decrease the need for EL.