Mini-laparoscopically guided percutaneous gastrostomy and jejunostomy

Percutaneous Endoscopic Gastrostomy in Children: An Update to the ESPGHAN Position Paper

BACKGROUND

The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position paper from 2015 on percutaneous endoscopic gastrostomy (PEG) required updating in the light of recent clinical knowledge and data published in medical journals since 2014.

METHODS

A systematic review of medical literature from 2014 to 2020 was carried out. Consensus on the content of the manuscript, including recommendations, was achieved by the authors through electronic and virtual means. The expert opinion of the authors is also expressed in the manuscript when there was a lack of good scientific evidence regarding PEGs in children in the literature.

RESULTS

The authors recommend that the indication for a PEG be individualized, and that the decision for PEG insertion is arrived at by a multidisciplinary team (MDT) having considered all appropriate circumstances. Well timed enteral nutrition is optimal to treat faltering growth to avoid complications of malnutrition and body composition. Timing, device choice and method of insertion is dependent on the local expertise and after due consideration with the MDT and family. Major complications such as inadvertent bowel perforation should be avoided by attention to good technique and by ensuring the appropriate experience of the operating team. Feeding can be initiated as early as 3 hours after tube placement in a stable child with iso-osmolar feeds of standard polymeric formula. Low-profile devices can be inserted initially using the single-stage procedure or after 2-3 months by replacing a standard PEG tube, in those requiring longer-term feeding. Having had a period of non-use and reliance upon oral intake for growth and weight gain-typically 8-12 weeks-a PEG may then safely be removed after due consultation. In the event of non-closure of the fistula the most successful method for closing it, to date, has been a surgical procedure, but the Over-The-Scope-Clip (OTSC) has recently been used with considerable success in this scenario.

CONCLUSIONS

A multidisciplinary approach is mandatory for the best possible treatment of children with PEGs. Morbidity and mortality are minimized through team decisions on indications for insertion, adequate planning and preparation before the procedure, subsequent monitoring of patients, timing of the change to low-profile devices, management of any complications, and optimal timing of removal of the PEG.

Totally laparoscopic feeding jejunostomy - a technique modification

In oncological patients with upper gastrointestinal tract tumours, dysphagia and cachexy necessitate gastrostomy or jejunostomy as the only options of enteral access for long-term feeding. In this article the authors describe a modified technique of laparoscopic feeding jejunostomy applied during the staging laparoscopy. A 48-year-old male patient with gastroesophageal junction tumour and a 68-year-old male patient with oesophageal tumour were operated on using the described technique. Exploratory laparoscopy was performed. Then the feeding jejunostomy was made using a Cystofix^® TUR catheter. The jejunum was fixed to the abdominal wall with four 2.0 Novafil™ transabdominal stitches. Two additional sutures were placed caudally about 4 cm and 8 cm from the jejunostomy, aiming at prevention of jejunal torsion. Total operating time was 45 min. There was no blood loss. There were no intraoperative complications. The only adverse event was one jejunostomy wound infection that responded well to oral antibiotics. There were no mortalities. The described technique has most of the benefits of laparoscopic feeding jejunostomy with some steps added from the open operation making the procedure easier to perform as part of a staging operation with a relatively short additional operating time. The proposed transabdominal stitches make the technique easier to apply. Two additional ‘anti-torsion sutures’ prevent postoperative volvulus. Use of the Cystofix catheter allows easy introduction of the catheter into the peritoneal cavity and the jejunal lumen, providing a good seal at the same time. Further studies on larger groups of patients are required to assess long-term outcomes of the proposed modified technique.

Laparoscopic-assisted percutaneous endoscopic gastrostomy tube placement

In those cases where a PEG tube cannot be placed safely, a laparoscopic-assisted technique may be a viable option to complete the procedure.

Background:

Percutaneous endoscopic gastrostomy (PEG) is the most common way of placing a feeding tube. Sometimes PEG cannot be used to safely place a feeding tube, most commonly secondary to an inability to transilluminate the abdominal wall. Whereas open gastrostomy was previously necessary in such cases, laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) is a viable option and is reviewed here.

Methods:

All patients referred for surgical feeding tube placement after unsuccessful PEG were considered for LAPEG. A diagnostic laparoscopy was performed to identify the reason for the failed PEG attempt. Additional ports were placed as needed for the retraction of organs and lysis of adhesions. The stomach was visualized, and the PEG was placed.

Results:

Eight patients who underwent an unsuccessful PEG were taken to the operating room for LAPEG. All patients had successful LAPEG placement. No postoperative complications occurred. The most common reason identified for failed PEG attempt was adhesions followed by overlying organs. Average OR time was 32 minutes.

Conclusion:

When conventional PEG placement is not possible, LAPEG placement should be considered as a time efficient, minimally invasive alternative to open gastrostomy.

Endoscopic identification of the jejunum facilitates minimally invasive jejunostomy tube insertion in selected cases

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG), direct percutaneous endoscopic jejunostomy, and laparoscopic feeding tube insertion are established techniques for placing a feeding tube. However, these techniques may be difficult or contraindicated after previous gastric or upper abdominal surgery.

METHODS

A total of 10 patients underwent minimally invasive jejunostomy tube insertion via endoscopic identification of the jejunum. The indications for the procedure were dysphagia, poor nutritional status, prolonged intensive care unit (ICU) admission, and gastroparesis. Eight of the patients had undergone previous upper abdominal surgeries and were rejected for either PEG or direct percutaneous jejunostomy. With the patients under general anesthesia, esophagogastroduodenoscopy was performed. The jejunum was identified and intubated. A small abdominal incision (1 in.) was made. The proximal jejunum was identified easily by the light and digital palpation of the endoscope. The jejunum was delivered in the wound, and the jejunostomy tube was inserted using Witzel's technique. The wound was closed.

RESULTS

All the patients tolerated the procedure well. The mean time for the procedure was 29 +/- 13 min. There was no mortality related to the procedure and no complications. Jejunal feeding started on the first postoperative day.

CONCLUSION

The use of intraoperative endoscopy facilitated identification of the jejunum. Easy, safe, and quick, the procedure saved the patient a formal laparotomy and extensive manipulation.

The multidisciplinary management of gastrointestinal cancer. Multimodal treatment of gastric cancer

Although radical surgical R0 resections are the basis of cure for gastric cancer, surgery alone only provides long-term survival in 20-30% of patients with advanced-stage disease. Thus, in Western and European countries, advanced gastric cancer has a high risk of recurrence and metachronous metastases. Very recently, multimodal strategies combining different neoadjuvant and/or adjuvant protocols have improved the prognosis of gastric cancer when combined with surgery with curative intent. As used in palliative regimens, the combination of cisplatin with intravenous or oral fluoropyrimidines has been the integral component of such (neo)adjuvant strategies. However, the cytotoxic agents docetaxel, oxaliplatin and irinotecan and new targeted biologicals such as cetuximab, bevacizumab or panitumumab are currently under investigation, with or without irradiation, in multimodal treatment regimens. These studies may further increase R0 resection rates, and prolong disease-free and overall survival times in the treatment of advanced gastric cancer. This article reviews the most relevant literature on multimodal treatment of gastric cancer, and discusses future strategies to improve locoregional failures.

Mediastinal carcinosis involving the esophagus in breast cancer: the "breast-esophagus" syndrome: report on 25 cases and guidelines for diagnosis and treatment

INTRODUCTION

Breast metastases of mucosal/submucosal layers of the esophagus are extremely rare: esophageal involvement is usually part of a mediastinal carcinosis.

AIM

We report the largest series to date of 25 cases of metastatic esophageal involvement from breast cancer, discussing both diagnostic techniques and treatment options.

MATERIALS AND METHODS

Twenty-five female patients with a history of breast cancer referred for secondary esophageal involvement (1980-2006) were studied.

RESULTS

All patients presented with worsening dysphagia. Twenty-four had undergone surgery for breast cancer a median of 10 years earlier: 1 had received chemoradiotherapy, and 17 had adjuvant radiotherapy/telecobalt therapy following breast surgery. Endoscopic biopsy/cytology were negative for cancer in 17 of 19 patients; in 9 patients, the diagnosis was made with thoracoscopy/laparoscopy. Immunohistochemical staining was done in 10 patients (ER and/or PrR positive). Fifteen patients presented with distant metastatic involvement. Therapy was directed toward dysphagia relief, mostly with endoscopic dilations/prostheses. Complications (4 perforations) occurred only in those 15 patients who had endoscopic dilations/prostheses. Fifteen patients had cytoreductive therapy. Nine of 25 patients are still alive. The median overall survival was 7 months; 1-, 3-, and 5-year survival rates were 44%, 16%, and 8%, respectively.

CONCLUSIONS

A "breast-esophagus" syndrome can be defined: it is often diagnosed only after excluding other diseases or after relief of dysphagia with adequate therapy. The presence of distant metastases helps the diagnosis of esophageal involvement from mediastinal carcinosis, while diagnosis is a problem in case of mediastinal/pleural disease only: in this case, exploratory thoracoscopy is mandatory for a final diagnosis. Given the high related risk of perforation from endoscopic procedures (dilations/prostheses), the treatments of choice are currently hormone therapy or chemotherapy/radiotherapy.

[Surgical access routes in enteral nutrition]

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last < or = 6 weeks, nasoenteral tubes are the best option. In NE > or = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 +/- 21.9 days, and 72 double lumen nasojejunal tubes.

Endoscopic approaches to enteral nutritional support

Enteral is preferred to parenteral nutritional support for acute and chronic diseases because it is more physiological and associated with fewer infection complications. Nasal tube feedings are generally used for 30 days or less and percutaneous access for the longer-term. Feeding by naso-gastric tubes is appropriate for most critically ill patients. However, trans-pyloric feeding is indicated for those with regurgitation and aspiration of gastric feeds. Deep naso-jejunal tube feeding is appropriate for patients with severe acute pancreatitis. There are several methods for endoscopic placement of naso-enteric tubes. Percutaneous endoscopic gastrostomy is used for most persons requiring long-term support. Long-term jejunal feeding is most often used for persons with chronic aspiration of gastric feeds, chronic pancreatitis intolerant to eating, or persons in need of concomitant gastric decompression. Percutaneous endoscopic gastrostomy with a jejunal tube extension is fraught with tube dysfunction and dislocation. Direct percutaneous endoscopic jejunostomy tubes may be more robust, but are less commonly performed.

Laparoscopic-assisted jejunostomy

BACKGROUND

Feeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients.

METHODS

Since January 2002, seven patients (age range, 5-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using two 10-mm trocars. The technique consists of identifying the first jejunal loop, grasping it 20-30 cm away from the Treitz ligament with fenestrated atraumatic forceps, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct positions of the intestinal loop and feeding tube were evaluated via laparoscopy.

RESULTS

Surgery lasted 40 min on average, the laparoscopic portion only 5 min. There were no perioperative complications; hospital stay was 3 or 4 days for all patients. At the longest follow-up (18 months), all patients had experienced a significant weight gain, with a high level of parental satisfaction. One patient died 1 year after the procedure of unknown causes. All the others are well, without complications or problems, and their parents are extremely satisfied with the improved quality of life of their children.

CONCLUSIONS

Laparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. This procedure solves these patients' feeding problems even if the reflux is not completely eliminated. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. This technique is extremely safe because the surgeon is able to verify, at the end of procedure, the status of the jejunostomy from outside and inside the abdominal cavity. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure.

(Neo)adjuvant strategies of advanced gastric carcinoma: time for a change?

Despite surgical R0 resections, patients with gastric cancer stage UICC II-III have a high risk of recurrence and metachronic metastases. Preliminary evidence exists that adjuvant chemotherapy or neoadjuvant chemo(radio)therapy protocols may improve the prognosis of these patients undergoing surgery of gastric cancer with curative intention. As for palliative regimens, 5-fluorouracil and cisplatin are integral components of such (neo)adjuvant strategies. Upcoming cytostatic agents, i.e. irinotecan, docetaxel, oxaliplatin, and oral fluoropyridines are currently under investigation in new multimodality treatment regimens and may further increase R0 resection rates and may prolong disease-free and overall survival in the treatment of advanced localized gastric cancer.