Percutaneous drainage and feeding gastrostomies in 100 patients

Efficiency and Safety of Balloon-Assisted Gastrostomy

PURPOSE

To examine the safety and efficiency of balloon-assisted gastrostomy for insertion of large bore feeding tubes compared to conventional techniques using dilators.

MATERIALS AND METHODS

Retrospective review of all fluoroscopically guided percutaneous gastrostomy tube insertions between July 2017 and September 2019 was performed. Collected data points included patient demographics, initial pathology, type of gastrostomy tube (G tube) inserted [(Avanos standard balloon retained (Mic-G), or low-profile balloon retained (Mic-Key)], type of insertion technique (balloon-assisted or -nested dilator technique), fluoroscopy time, amount of sedation required, technical success, and complications. The focus of the study was method of tract dilatation - either balloon-assisted gastrostomy (BAG group) versus nested or sequential dilators (dilator group). Two hundred patients were included in this study; 100 patients were evaluated in each group.

RESULTS

There were no significant differences between the two groups. The overall rate of minor complications (grades 1 and 2, according to the CIRSE classification system) was higher in the dilator group (11%, compared to 7% in the BAG group) but did not reach statistical significance. Males were associated with lower risk of minor complications (OR 0.19, 95% CI (0.07, 0.53)), while age did not present a significant association. Patients in the BAG group received a significantly lower amount of fentanyl (p < 0.001) and midazolam (p < 0.001) than patients in the dilator group.

CONCLUSION

Balloon-assisted gastrostomy is a safe and effective technique for large bore gastrostomy placement. Patients required less sedation, allowing for faster recovery and discharge time in outpatients at our institution.

Percutaneous radiologic gastrostomy with single gastropexy: outcomes in 636 patients

OBJECTIVES

This study aimed to assess the technical success and overall complication rate of percutaneous radiologic gastrostomy (PRG) with single gastropexy using a separate tract from that used for tube placement.

METHODS

From January 2014 to December 2018, 636 patients (469 men, 167 women; mean age 66.8 years; age range, 22-98 years) underwent PRG using single gastropexy at a tertiary center. Preprocedural computed tomography (CT) was recommended if there were no data on the location of the stomach on previous CT. After a single anchor was applied, the PRG tube was inserted through a separate tract from that used for tube placement. The technical success rate and major and minor complications were retrospectively reviewed. The number of patients and percentages were used as descriptive statistics for evaluating the complication rate.

RESULTS

The technical success rate of PRG with single gastropexy was 99.2% (631/636). There were 32 complications among the 631 procedures. There were 19 (3.0%) major complications, including peritonitis (n = 7), migration (n = 5), infection (n=4), malposition (n = 2), and bleeding (n = 1). There were 13 (2.1%) minor complications, including local infection (n = 11), malfunction (n = 1), and pneumoperitoneum (n = 1). The overall complication rate within 30 days of PRG placement was 4.1% (26/631).

CONCLUSIONS

PRG with single gastropexy using a separate tract from that used for tube placement is technically feasible with a low complication rate.

KEY POINTS

• Percutaneous radiologic gastrostomy with single gastropexy using a separate tract from that used for tube placement is technically feasible. • Complications including peritonitis and bleeding were comparatively low with the conventional technique.

Percutaneous radiologic gastrostomy catheter placement without gastropexy: a co-axial balloon technique and evaluation of safety and efficacy

PURPOSE

The purpose of this study is to evaluate the short-term safety and efficacy of a co-axial angioplasty balloon technique for percutaneous radiologic gastrostomy catheter placement (PRG).

METHODS

A total of 65 percutaneous radiologic gastrostomy tube placements were performed with the co-axial angioplasty balloon technique from 10/1999 to 1/2014. This included 19 females and 46 males between the ages of 20-83. Without the use of T-fasteners for gastropexy, the gastrostomy tube was placed over a catheter-shaft angioplasty balloon as a co-axial system. The angioplasty balloon was used to sequentially approximate the stomach wall to the abdominal wall, dilate the tract, and was then used as a dilator to aid gastrostomy tube advancement into the gastric lumen. Technical success, complications, and dislodgements were evaluated by means of retrospective review of patient medical records and imaging.

RESULTS

There was no procedural failure in any of the 65 placements. 30-day follow-up was available for 56 patients. 7 patients died within 30 days; none of the deaths were recorded as procedure-related. There was 1 major complication (1.5%) consisting of a colocutaneous fistula. There were 4 minor complications (6.2%). There was no occurrence of bleeding or skin infection while using this technique.

CONCLUSIONS

PRG with the co-axial angioplasty-balloon technique is a safe and effective technique for gastrostomy placement.

Palliative venting gastrostomy in patients with malignant bowel obstruction and ascites

BACKGROUND

Fluoroscopic-guided placement of a percutaneous decompression gastrostomy tube (PDGT) is used to palliate patients with malignant bowel obstruction (MBO). We report our clinical experience in cases of MBO and ascites that were known to be technically difficult and at increased risk for complications after PDGT placement.

METHODS

Between October 2005 and April 2010, a total of 89 consecutive oncology patients with MBO and ascites underwent at least one attempt at PDGT placement. We retrospectively reviewed the electronic medical record to collect demographic details, procedure information, and morbidity and mortality data. Kaplan-Meier curves were used to calculate median survival after PDGT.

RESULTS

Ninety-three new gastrostomy encounters occurred in 89 patients. The primary and secondary technical success rates were 72 % (67 of 93) and 77.4 % (72 of 93), respectively. Inadequate gastric distention was the reason for failure in 84.6 % (22 of 26) of the cases in which the initial PDGT attempt was unsuccessful. For ascites management, 13 patients underwent paracentesis and 78 patients underwent placement of an intraperitoneal catheter. The overall complication rate in successful placements was 13.9 %, with a major complication rate of 9.7 %. After PDGT, the median overall survival rate was 28.5 days (95 % confidence interval 20-42).

CONCLUSIONS

PDGT is feasible in the majority of patients with MBO and ascites, although there is an inherent risk of major complications. An intraperitoneal catheter can be used to manage ascites to facilitate PDGT.

Percutaneous gastrostomy and gastrojejunostomy

Gastrostomy allows enteral nutrition to continue in patients who are unable to meet their caloric requirements orally. Though the indications for gastrostomy placement are varied, dysphagia secondary to a neurological condition is the most common. These catheters were initially placed surgically, but percutaneous endoscopic placement is now the routine in most centers. Interventional radiologists have been performing this procedure under fluoroscopic guidance for several years with encouraging results. Percutaneous radiological gastrostomy is reported to have a success rate comparable to that of the endoscopic method, with lower morbidity and mortality rates. A further benefit is that it may be performed in patients for whom the endoscopic method would be difficult or dangerous, such as those with head and neck malignancies. One of the main factors currently limiting the use of this procedure is the shortage of interventional radiology facilities and specialists.This article describes a technique for routine percutaneous radiological gastrostomy catheter placement and procedural variations for difficult cases. Indications and contraindications will be discussed, as will complication rates and how these compare with the traditional methods of gastrostomy tube placement.

Gastrostomy-to-gastrojejunostomy tube conversion: impact of the method of original gastrostomy tube placement

PURPOSE

To determine the outcome of gastrostomy tube-to-gastrojejunostomy tube conversion on the basis of the method of original gastrostomy tube placement.

MATERIALS AND METHODS

One hundred twenty-four patients (age range, 13-87 years; 72 male and 52 female patients) underwent conversion of a primarily placed gastrostomy tube to a gastrojejunostomy tube at the authors' institution between January 2000 and December 2008. The method of original gastrostomy tube placement was radiologic (n = 27), endoscopic (n = 75), laparoscopic (n = 2), or open surgery (n = 20). The method of placement was correlated with the success rates of gastrostomy-to-gastrojejunostomy tube conversion. Medical records and radiologic images were reviewed to determine the frequency of proximal migration of the jejunostomy tube into the stomach. Follow-up data were available for an average of 136 days after gastrostomy-to-gastrojejunostomy tube conversion (median, 63 days; range, 1-1,300 days).

RESULTS

Of 124 gastrostomy tube-to-gastrojejunostomy tube conversions, 109 (87.9%) were successfully performed. Procedural conversion failure occurred in one of the 27 radiologically inserted gastrostomy tubes (3.7%) compared to 14 of the 97 (14%) nonradiologically inserted gastrostomy tubes (P = .19), of which 12 were inserted endoscopically and two were inserted surgically. Of the 109 patients with successful tube conversion, jejunal tip malposition occurred at follow-up in 18 (16.5%). Of these, four patients developed aspiration pneumonia (22%), which contributed to patient death in two. The frequency of jejunal tip malposition was 3.8% (one of 26 patients) for radiologically placed gastrostomy tubes and 20% (17 of 83 patients) for nonradiologically placed gastrostomy tubes (P = .07). Combined, 32% of gastrostomy tubes placed nonradiologically resulted in either procedural failure or eventual jejunal tip malposition, compared to 7.4% of radiologically placed gastrostomy tubes (P = .01).

CONCLUSIONS

The frequency of procedural failure or eventual jejunal tip malposition with conversion of radiologically placed gastrostomy tubes to gastrojejunostomy tubes is significantly lower with radiologically placed gastrostomy tubes than with nonradiologically inserted gastrostomy tubes.

Single-Access Gastrostomy (SAG) Dispenses Endoscopy or Laparoscopy: A Simple Method Under Local Anesthesia

Objective. Gastrostomy for feeding or desobstructive purposes is often performed transendoscopically. However, as endoscopy specialists and instruments are not widely available in community hospitals in Brazil, an alternative method was developed at the authors’ institution. Surgical single-access gastrostomy (SAG), performed under local anesthesia and requiring no endoscopic guidance is described. Methods. The authors used the SAG technique on 19 patients eligible for gastrostomy, and the data were prospectively documented. After local anesthesia and a 1-cm incision, the gastric wall was localized under direct vision. Purse string sutures were placed to work as a fixed valve to rectus sheath. Results. SAG was feasible in all patients. Minor complications occurred in 3 patients. The mean operative time was 44.2 minutes, and the mean institution of gastrostomy feeding was 27.8 hours. Conclusion. SAG may dispense with the use of endoscopy and laparoscopy, providing a feasible, reproducible, and effective feeding gastrostomy in developing countries where alternative methods are not available.

EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube placement

BACKGROUND

Patients without adequate abdominal-wall transillumination are at a high risk of developing complications after PEG.

OBJECTIVE

We evaluated the feasibility and utility of EUS to guide PEG in patients lacking abdominal-wall transillumination.

DESIGN

Single-center case series.

SETTING

Tertiary-referral center.

PATIENTS

Six patients who lacked adequate abdominal-wall transillumination and 2 patients with a large laparotomy scar deemed to be at high risk of developing complications after PEG.

INTERVENTIONS

Patients underwent EUS-guided PEG and deployment of a standard enteral feeding tube.

MAIN OUTCOME MEASUREMENTS

Technical success and complication rates.

RESULTS

PEG was successful under EUS guidance in 5 of 8 patients. Causes of failure included an inadequate EUS window because of a prior Billroth 1 gastrectomy in one and suspected bowel interposition in 2 patients. There were no complications.

LIMITATIONS

A small number of patients, uncontrolled study, and short follow-up period.

CONCLUSIONS

This technique may facilitate deployment of PEG in patients who lack adequate abdominal-wall transillumination.

Gastrostomies in palliative care

OBJECTIVE

In palliative care, gastrostomies are used to provide nutritional support or to decompress the bowel. To evaluate what happened to the patients monitored at our palliative care unit (PCU) who underwent gastrostomy between October 1994 and January 2005, a retrospective audit was made.

METHOD

The charts of 154 patients were reviewed.

RESULTS

The most frequent reason why a patient underwent a gastrostomy was dysphagia due to head and neck and/or esophageal cancer. Only one patient underwent a drainage gastrostomy because of intestinal obstruction. Interventional radiology performed 96% of the gastrostomies. Early complications occurred in 53 patients (34%) who underwent the gastrostomy for feeding and the most common was local pain, usually mild. However, there was one death due to peritonitis, probably related with the procedure. Late complications also occurred in 53 patients and major complications occurred in 22 patients, the most common was extrusion. The median survival after the performance of the gastrostomy was 61 days (range 1 to 551 days). Nineteen patients (12%) survived 1 week or less, 28 (18%) between 8 and 30 days, 51 (33%) from 31 to 90 days, 53 (35%) 91 days or more, and one unknown. The patient who underwent a gastrostomy for bowel obstruction survived for only 7 days. One hundred and twenty-five patients (81%) died at the PCU, 26 (17%) at home, and four (3%) at other places.

Gastrostomia de incisão única como alternativa para o procedimento endoscópico

OBJETIVO: A gastrostomia, realizada para possibilitar acesso nutricional ou descompressão, é comumente realizada por via endoscópica, por radiologia intervencionista, e, mais raramente, por via cirúrgica através de videolaparoscopia ou incisão mediana supra-umbilical. Os métodos endoscópico e radiológico, apesar de estabelecidos em muitos centros, não constituem rotina em hospitais comunitários pela necessidade de pessoal qualificado e material descartável, sendo usualmente realizada a gastrostomia cirúrgica com incisão mediana e anestesia geral. A Gastrostomia de Incisão Única descrita neste trabalho é um novo método cirúrgico menos invasivo, que foi desenvolvido para ser realizado sob anestesia local, com uma única incisão e sem necessidade de equipamento especial. MÉTODO: Quinze pacientes elegíveis para gastrostomia por diferentes indicações foram operados sob anestesia local. Após incisão subcostal de 1cm sobre o músculo reto abdominal esquerdo, uma área de parede gástrica era localizada, com ajuda de azul de metileno injetado no estômago, e exteriorizada através da incisão. Duas suturas em bolsa eram realizadas e a sonda gástrica introduzida. O estômago era fixado à aponeurose, resultando em uma gastrostomia de incisão única, segura e bem fixada. Alimentação pôde ser iniciada através da gastrostomia em 24 a 48hs. RESULTADOS: Todos os pacientes foram submetidos à técnica com sucesso. Complicações menores ocorreram em três pacientes: um apresentou alargamento do estoma, necessitando de sutura local adicional, e em outro, ocorreu deiscência parcial de mucosa que foi tratada conservadoramente. Em um terceiro paciente, houve lesão iatrogênica de cólon transverso, que foi suturada sem intercorrências. O tempo operatório médio foi de 49,4 min, e a introdução de alimentação foi de 34,3 hs em média. Não houve falha na instituição de dieta com esta técnica, nem complicações maiores como fístula ou peritonite. CONCLUSÕES: Os resultados desta casuística inicial sugerem que a abordagem é efetiva em propiciar um acesso rápido e seguro para gastrostomia, com ferida única, dispensando o uso de suporte endoscópico e anestesia geral. Pode ser utilizado como opção ao método endoscópico em pacientes com obstrução neoplásica faríngea ou esofageana. Uma casuística mais expressiva, acompanhamento mais longo dos casos, e estudos prospectivos randomizados são necessários para estabelecer o papel desta nova técnica na rotina cirúrgica.

The role of the interventional radiologist in enteral alimentation

The provision of enteral nutrition through the placement of gastrostomy/gastrojejunostomy tubes is a well-established procedure. Traditionally, these catheters have been placed either surgically or endoscopically; however, over the past two decades interventional radiologists have increasingly performed these procedures successfully. The perceived advantages of this route lie in the reported lower morbidity and mortality rates. In addition, percutaneous radiologically guided (PRG) catheters may be placed in certain subgroups of patients in whom it would be technically difficult or impossible by other routes, e.g., patients with head and neck or oesophageal tumours. The aim of this review is to describe the techniques of radiologically placed gastrostomy/gastrojejunostomy, discuss its indications and contraindications, describe any associated potential complications and compare PRG results with the more established techniques of open surgical and endoscopic placement. We also describe some recent procedural and catheter modifications.

Endoscopic palliation and nutritional support in advanced gastric cancer

Most of the patients with advanced gastric cancer have incurable disease at presentation and require palliative treatment to reduce symptoms as vomiting, nausea and inability to eat. Treatment options are palliative surgery and endoscopic techniques. Insertion of self-expanding metal stents is nowadays a well-established method of treating biliary and esophageal strictures and is also effective in gastric tumors. The indication and application technique are described in this review. In addition, enteral nutrition is indicated if the gastrointestinal tract functions but swallowing or mastication is compromised by disease or if it is needed to pass an obstructed area, especially in gastric tumor patients. This article reviews the enteral nutrition techniques and their clinical value for patients with advanced gastric cancer.

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.

PEG with introducer or pull method: a prospective randomized comparison

BACKGROUND

PEG by the conventional pull method has the potential drawback of being associated with a higher frequency of wound infection, presumably caused by contamination of the gastrostomy catheter as it passes through the oral cavity. This study investigated the occurrence of peristomal wound infection after PEG placement by using the pull and introducer techniques.

METHODS

Between September 1999 and May 2002, consecutive patients with dysphagia for whom PEG was recommended were enrolled in the study and randomly assigned to two groups: PEG with the introducer method (Group I) or PEG with the pull method (Group II). The peristomal area of each patient was evaluated on a daily basis for one week after PEG. Erythema and exudate were scored on a scale from 0 to 4 and induration on a scale of 0 to 3. Criteria for infection were a maximum combined score of 8 or higher, or the presence of microscopic and microbiologic evidence of suppurating exudate. In each group, the endoscope was passed once during the procedure, and an antibiotic (piperacillin) was given prophylactically. All procedures were performed by one investigator with the assistance of another physician.

RESULTS

Of the 60 patients enrolled, 30 were assigned to each group. PEG was successful in all patients. One patient was excluded from each group because of death (Group I, stroke; Group II, myocardial infarction) within one week of the procedure. Therefore, 58 patients, 29 in each group, were evaluated. There was no significant difference between the groups in terms of clinical parameters (age, gender, disease, performance score, mode of previous feeding, and recent antibiotic exposure). The occurrence of peristomal infection within one week of PEG was lower in Group I (introducer method) (0 vs. 9; p = 0.00094). The mean daily combined scores in Group I were significantly lower than those in Group II. Median of maximum parameter scores in Group I were significantly lower than those in Group II. There were no procedure-related mortalities or clinically significant wound infections that required surgical intervention.

CONCLUSIONS

The risk of peristomal wound infection after PEG is lower with the introducer method compared with the pull method.

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.

Percutaneous fluoroscopic guided gastrostomy: 6 Years experience in Jeddah, Saudi Arabia

Purpose: To assess the local experience with the percutaneous fluoroscopic gastrostomy (PG) with regard to indications, outcome, limitations and complications of the procedure.

Method: Retrospective analysis of 33 patients in whom PG was requested and performed over a period of 6 years.

Results: All 33 patients had successful catheter placement. Six patients had their catheters advanced to the jejunum (transgastric jejunostomy). Two patients had PG after failed endoscopic gastrostomy (EG). No major complications were encountered within the first 30 days. Minor complications were noted in seven patients (21%). Three patients (9%) had local infection at the stoma. The other four patients (12%) had catheter occlusion (use-related complications) that required catheter change. Longterm follow-up in eight patients showed a pericatheter leak at the stoma in three patients that was managed by change and step-up in the feeding catheter; French size. There was no 30-day mortality.

Conclusion: The results indicate that PG is a safe and effective method for enteral feeding. It is useful for short and long-term feeding. Failed EG can be considered an indication for PG.

Enteral nutrition access devices

During the past decade a concerted effort has been made to use enteral nutrition instead of parenteral nutrition for hospitalized patients. Enteral nutrition has major advantages over parenteral nutrition in terms of cost and fewer serious complications. A clinician interested in initiating enteral nutrition may be limited by a lack of familiarity with the variety of options for enteral access and the difficulty of choosing among them. This paper reviews the different enteral access routes and devices available to the clinician.

Percutaneous gastrostomy and gastrojejunostomy with gastropexy: experience in 701 procedures

PURPOSE

To evaluate the safety and efficacy of fluoroscopically directed percutaneous gastrostomy and gastrojejunostomy catheter placement with gastropexy.

MATERIALS AND METHODS

The authors retrospectively reviewed the charts from 643 patients referred for fluoroscopically directed percutaneous gastrostomy or gastrojejunostomy during a 9 1/2-year period. In 615 patients, placement was attempted with use of three T-fastener gastropexy devices followed by percutaneous gastric puncture. Placement of a 14-F gastrostomy or gastrojejunostomy catheter was then accomplished with the Seldinger technique.

RESULTS

A catheter could not be placed in 28 patients (4.4%) owing to overlying viscera or prior gastric surgery. In the remaining patients, 701 procedures, including revisions, were performed, including 643 gastrojejunostomies (92%) and 58 gastrostomies (8.3%). The success rate for catheter placement was 100%. Revision was necessary in 83 instances in 64 patients (13.5%). Forty-six (55%) of these were attributed to tube dislodgment, but only two repeat gastric punctures were necessary secondary to tract disruption. There were three major complications (0.5%) and 29 minor complications (5.3%). No complications were attributed directly to gastropexy. Thirty-day follow-up data were available for 393 patients (64%), and 14-day follow-up data were available for 550 (89%). The 30-day mortality rate was 5.8% (23 of 393 patients); none of the deaths were related to the procedure.

CONCLUSION

Fluoroscopically directed percutaneous placement of gastrostomy and gastrojejunostomy catheters with routine gastropexy is a safe procedure. Catheter revision was necessary in 13% of patients and was usually secondary to tube dislodgment, with tract disruption an unusual complication.

Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: a prospective, randomized comparison

PURPOSE

To compare the efficacy of radiologic guided placement of percutaneous gastrojejunostomy (PGJ) and percutaneous endoscopic gastrostomy (PEG).

MATERIALS AND METHODS

Patients were randomized to PGJ (n = 66) or PEG (n = 69). Indications for gastrostomy were need for prolonged enteral nutrition (97%) or gastrointestinal decompression (3%), with etiologies of neurologic impairment (81%), head and neck neoplasm (12%), bowel obstruction (3%), or other (4%). Mean follow-up was 202 days and 30-day follow-up was obtained for 85% of patients.

RESULTS

PEG was successful in 63 of 69 (91%) patients, while PGJ established access in all of 66 attempts (100%) (P = .014). Average procedural time was 53 minutes for PGJ and 24 minutes for PEG (P = .001). At 30-day follow-up, there were 33 and 45 complications in the PGJ and PEG groups, respectively. This difference was due to the greater incidence of pneumonia in the PEG group (P = .013). Long-term tube-related complications occurred with 17 PGJs and four PEGs (P = .007). The PGJ cost more than PEG, but this advantage was offset by the cost of complications.

CONCLUSION

PGJ had higher success rate and fewer complications, due to a lower incidence of pneumonia. PEG took less time to perform, cost less, and required less tube maintenance.

Performing radiologic gastrostomy or gastrojejunostomy in patients with malignant ascites

OBJECTIVE

We describe our protocol for performing decompression radiologic gastrostomy and gastrojejunostomy in patients with ascites and small-bowel obstruction. We also assess the technical success rate, the complications, and the morbidity and mortality in 45 patients who underwent radiologic gastrostomy.

MATERIALS AND METHODS

Forty-five consecutive patients with ascites associated with metastatic ovarian cancer underwent a radiologic gastrostomy or gastrojejunostomy with gastropexy. Six patients underwent gastrostomy, and 39 patients underwent gastrojejunostomy. Locking catheters were placed using the Seldinger technique after gastropexy in all patients. Paracentesis was performed before gastrostomy or gastrojejunostomy. Additional serial paracenteses were performed after the procedure when reaccumulation of ascites close to the site of gastropexy was detected on follow-up sonography.

RESULTS

Forty-five procedures were attempted. The technical success rate was 97.8%. The complication rate was 15.6%. Three major complications (6.7%) and four minor complications (8.9%) occurred. One procedure-related death (2.2%) occurred 16 days after gastrojejunostomy.

CONCLUSION

Radiologic gastrostomy and gastrojejunostomy can be performed safely in patients with ascites if the patients undergo paracentesis first and if the reaccumulation of ascites is prevented after tube placement. In patients with ascites, gastropexy plays an important role in preventing pericatheter leakage. Ascites and peritoneal carcinomatosis should not be considered contraindications for radiologic gastrostomy or gastrojejunostomy.

Radiologic percutaneous gastrostomy: results in 56 patients with head and neck cancer

OBJECTIVE

The establishment of a direct enteral feeding route is critical in the overall treatment of many patients with head and neck cancer. Use of radiologic percutaneous gastrostomy (RPG), the newest technique for gaining enteral access, has not been studied in such patients extensively. This study evaluated the indications, technique, success rate, and complications associated with RPG in patients with head and neck cancer.

STUDY DESIGN

Retrospective.

METHODS

A comprehensive chart review was undertaken of 56 patients with head and neck cancer treated at a tertiary care institution who had undergone successful or attempted RPG at some point during their treatment course.

RESULTS

Most study patients had advanced oropharyngeal squamous cell carcinoma. The most frequent indications for RPG were dysphagia/aspiration following tumor resection (n = 26) and dysphagia following completion of single- or combined-modality therapy (n = 22). The success rate of attempted RPGs was 98.2%. The overall complication rate for RPG was 12.7% (10.9% minor and 1.8% major).

CONCLUSIONS

RPG is a valuable tool for establishing enteral nutrition in patients with head and neck cancer. Advantages of RPG include high success rate despite obstructing lesions, low complication rate, time efficiency and scheduling ease compared with intraoperative percutaneous gastrostomy (PEG) by a second team, no reported tumor seeding of the tube site, and the fact that postoperative RPG allows for more accurate selection of patients who require a gastrostomy tube.

Gastrostomy tube infections in a community hospital

BACKGROUND

Percutaneous gastric feeding tubes are becoming increasingly more common to provide nutrition in debilitated patients, while they decrease the risk of aspiration associated with nasogastric tubes.

METHODS

We reviewed infectious complications of 372 feeding gastrostomy tubes placed in a small urban community hospital over a recent period.

RESULTS

In our study there was an infection rate of 4.8%. Four serious infections occurred: two cases of peritonitis and two deep abscesses, but there were no infectious deaths. The most common infecting organisms were staphylococci, gram negative bacteria, and yeast. Most infections required treatment with parenteral antibiotics, prolonging hospitalization. Two of 17 infected tubes required removal.

CONCLUSION

Percutaneous gastrostomy tubes can produce life threatening infections and deserve serious attention by ICPs in hospitals, long-term care facilities, and home care services. These tubes should only be inserted if they extend meaningful life in patients. Protocols are needed for the care of gastrostomy tubes, and infections must be treated as early and as aggressively as possible to avoid serious consequences.

Gastric wall dissection as a complication of percutaneous gastrostomy

A percutaneous gastrostomy (PG) was complicated by gastric wall dissection and partial tube malposition. It occurred after tangential puncture along the greater curvature of the stomach which was performed in order to avoid an enlarged left lobe of the liver. To prevent this complication we recommend not using hydrophilic guidewires during PG.

Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results

PURPOSE

To evaluate fluoroscopically guided percutaneous feeding tube placement in pediatric patients.

MATERIALS AND METHODS

Sixty-one procedures were performed. Periprocedural care protocol was changed after patient nine. Forty-eight-hour and 30-day outcomes were assessed.

RESULTS

Almost 97% of procedures were successful. The 48-hour major and minor complication rates were 1.9% and 9.6%, respectively, after the initial nine procedures. Risk factors for early complications were the use of the initial care protocol (P < .01) and patient weight below the 50th percentile (P < .05). Major and minor 30-day complication rates were 8.3% and 12.0%, respectively. Risk factors for delayed complications were placement of a gastrojejunostomy tube rather than a gastrostomy tube (P < .05) and immunosuppression (P < .05).

CONCLUSION

Percutaneous feeding tubes can be placed in children with a high rate of technical success. Optimal results require attention to periprocedural care. Morbidity is common during the first month of tube use.

Decision-making for enteral feeding administration: the why behind where and how

Enteral nutrition has become the preferred route of nutrient administration. Because of vigorous attempts to deliver nutrient enterally in expanded patient groups, many different locations for enteral access have been advocated along with a variety of methods related to rate and pattern of delivery. Because all modes of delivery are not compatible with all sites of access and both need to be tailored to specific subsets of patients, confusion can develop regarding where and how enteral nutrients are best delivered and why. In an era when such a high priority has been placed on feeding through the enteral route, a review of the methods and rationale behind the ever-expanding choices of enteral access is timely.

Enteral access

The enteral route is the preferred method of nutrition support in patients with functional gastrointestinal tracts. Many techniques for obtaining enteral access are available, and the decision regarding which one to use depends on several issues, including anticipated duration of support, aspiration risk, and local expertise. Using laparotomy, laparoscopy, fluoroscopy, or endoscopy, tubes can be placed into the stomach, the duodenum, and the jejunum. Nasogastric and nasoenteric tubes are useful for short-term supplementation; however, patients needing support for more than 6 weeks may be better served with a more permanent tube. In this review, specific methods for obtaining enteral access are discussed along with their advantages and disadvantages.

Fluoroscopically guided percutaneous gastrostomy: tube function and malfunction

We describe our experience with fluoroscopically guided percutaneous gastrostomy, assessing in particular the functional performance of inserted tubes. We also examine the ability of radiological investigations to detect intraperitoneal gastrostomy leakage after the procedure. A functioning gastrostomy tube was established and maintained for as long as was required in 34 (89.5%) of 38 patients referred during a 21-month period. This necessitated further gastrostomy tube placements in 13 patients. On average, inserted gastrostomy tubes functioned for 10.75 weeks and during the review period a total of 34 malfunctioning tubes required replacement or removal. This was most commonly due to tube dislodgement, blockage, or intraperitoneal leakage. We found increasing pneumoperitoneum on sequential postprocedure erect chest films a reliable sign in the diagnosis of the latter complication. In conclusion, while we have been disappointed with aspects of individual tube function, our satisfactory overall functional success rate indicates that percutaneous gastrostomy is an effective method for establishing and maintaining enteral feeding. We also propose a protocol for the management of suspected intraperitoneal leakage based on the findings on postprocedure erect chest films.

Implantation metastasis following percutaneous endoscopic gastrostomy

Since it was first described, the original percutaneous endoscopic gastrostomy (PEG) technique has proved to be a valuable adjunct in patients with head and neck tumours. This procedure is being increasingly utilized in the face of swallowing impairment related to head and neck carcinoma. Although generally well tolerated, it may be associated with complications. In this report, we document tumour implantation at the percutaneous endoscopic gastric site and review the report cases. It appears that implantation metastasis does alter prognosis.

Percutaneous gastrostomy and gastrojejunostomy after gastric surgery

The authors reviewed their experience with percutaneous gastrostomy and gastrojejunostomy in 30 consecutive patients who had undergone prior gastric surgery consisting of either partial resections (n = 24) or alteration of normal gastric anatomy (n = 6). Parameters evaluated included indications for the procedure, procedural modifications, type of prior gastric surgery, major and minor procedural complications, tube efficacy, and follow-up data. Gastrostomy tubes were placed in 27 patients for enteral feeding and in three for decompression. The success rate (100%), as well as the prevalence of major (0%) and minor (23%) morbidity--transient fever, skin infection, and high gastric residuals--were similar to those reported in patients who had not undergone prior gastric surgery. Thirty-day mortality was 13% (four patients); no deaths were related to the gastrostomy tube placement. Minor procedural modifications such as an extra-long needle, a peel-away sheath, or additional rotational fluoroscopy were necessary in 18 patients (60%). Knowledge of the postsurgical gastric anatomy is crucial in this subset of patients. Prior gastric surgery is no longer a contraindication to percutaneous gastrostomy or gastrojejunostomy tube placement.

Percutaneous radiologic gastrostomy

Percutaneous radiologic gastrostomy is comparable to endoscopic gastrotomy in its simplicity, high success rate and lack of complications. Furthermore, it compares favourably with endoscopic gastrostomy in significant aspects such as a lower incidence of wound infection, reduced risk of aspiration and ease of conversion to jejunal placement. There are also fewer contraindications to radiologic placement and the cost is likely to be less than for endoscopic gastrostomy. Since the emergence of percutaneous endoscopic gastrostomy, clinicians have been re-evaluating the role of the gastrostomy in managing patients requiring nutritional support or gastrointestinal decompression. Percutaneous radiologic gastrostomy is an eminently suitable alternative to endoscopic or surgical gastrostomy.

Malignant small bowel obstruction and ascites: not a contraindication to percutaneous gastrostomy

Percutaneous gastrostomy (PG) with gastropexy was performed for relief of malignant small bowel obstruction in 12 patients with extensive ascites. Abdominal paracentesis was performed before PG in nine patients and after PG in one patient. Gastrostomy catheters were inserted without complication in all patients. Clinical follow up revealed that pericatheter leakage of ascitic fluid and skin excoriation occurred only in the three patients who did not have paracentesis performed before PG. No dislodgement of gastrostomy catheters occurred but mild peritonitis was noted in one patient. Our experience suggests that although in the past extensive ascites was a relative contraindication for PG, these patients can now be successfully treated with a combination of ultrasound-guided paracentesis to reduce pericatheter leakage of ascitic fluid, and gastropexy to prevent catheter dislodgement.