Percutaneous gastrostomy placement by intervention radiology: Techniques and outcome

Mini ECIRS with BotX: our single-case experience

Minimally invasive endoscopic combined intrarenal surgery has become the gold standard procedure for the treatment of large kidney stones. However, one of the most important critical success factors is the level of precision during renal accession, which requires a long learning curve. Robot-assisted fluoroscopy-guided renal access has been developed to address this difficulty. We report here the case of a 63-year-old woman presenting with a very large renal calculus whose treatment was successful using a robot-assisted fluoroscopy-guided minimally invasive endoscopic combined intrarenal surgery with suction sheath. The entire stone was cleared, and the patient recovered well with an absence of adverse events.

Complications of Percutaneous Radiologic Gastrostomy Among Patients in a Tertiary Care Hospital in Riyadh, Saudi Arabia

BACKGROUND

Percutaneous radiologic gastrostomy (PRG) is the method of choice for patients incapable of ingesting nutrition orally. The complications related to PRG are classified into major and minor complications. This article presents the prevalence of major and minor complications of PRG among adult patients admitted to King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia between 2017 and 2018.

METHODS

This was a retrospective cross-sectional study, which included adult patients who underwent a new PRG intubation between 2017 and 2018 in KAMC in Riyadh, Saudi Arabia. The variables reviewed were the demographics, comorbidities, indications of tube insertion, major and minor complications, and mortality rates.

RESULTS

A total of 105 patients who underwent PRG were covered in this study with a mean age of 69.2 + 20.4 years. The most common indications were neurogenic pharyngeal dysphagia (31%) and dementia (29%). Most of the complications reported were minor (40%) and major complications were found in 2%. The percentage of patients with both minor and major complications was 37%. The patients who had no complications made up 21%. Major skin complication was reported in 19 patients (18%), while leakage was the most occurring minor complication found in 49 patients (47%). The 30-day mortality was observed in five patients (5%) and one-year mortality was observed in 21 patients (20%), and none of them were related to the PRG tube.

CONCLUSION

This study found that the PRG procedure had low rates of complications in KAMC. The majority were minor complications, and the mortality rate was low with none being related to the tube itself. So PRG may be considered to be a relatively safe procedure.

Outcomes and Complications of Radiological Gastrostomy vs. Percutaneous Endoscopic Gastrostomy for Enteral Feeding: An Updated Systematic Review and Meta-Analysis

Background

Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) are commonly utilized to establish access to enteral nutrition. However, data comparing the outcomes of PEG vs. PRG are conflicting. Therefore, we aimed to conduct an updated systemic review and meta-analysis comparing PRG and PEG outcomes.

Methods

Medline, Embase, and Cochrane library databases were searched until February 24, 2023. Primary outcomes included 30-day mortality, tube leakage, tube dislodgement, perforation, and peritonitis. Secondary outcomes included bleeding, infectious complications, and aspiration pneumonia. All analyses were conducted using Comprehensive Meta-Analysis Software.

Results

The initial search revealed 872 studies. Of these, 43 of these studies met our inclusion criteria and were included in the final meta-analysis. Of 471,208 total patients, 194,399 received PRG and 276,809 received PEG. PRG was associated with higher odds of 30-day mortality when compared to PEG (odds ratio (OR): 1.205, 95% confidence interval (CI): 1.015 - 1.430, I² = 55%). In addition, tube leakage and tube dislodgement were higher in the PRG group than in PEG (OR: 2.231, 95% CI: 1.184 - 4.2 and OR: 2.602, 95% CI: 1.911 - 3.541, respectively). Perforation, peritonitis, bleeding, and infectious complications were higher with PRG than PEG.

Conclusion

PEG is associated with lower 30-day mortality, tube leakage, and tube dislodgement rates than PRG.

Severe Gastrointestinal Bleeding Following Gastrostomy Tube Replacement: A Case of an Unusual Presentation of Enterocutaneous Fistula

Gastrostomy tubes are widely used and provide an alternative route of enteral feeding when oral intake is not feasible. Previously, a surgical laparotomy was required for its placement, but percutaneous endoscopic gastrostomy and fluoroscopy-guided percutaneous radiological gastrostomy (PRG) techniques have widely replaced the surgical approach given their less invasive nature. Although the complications that might follow these procedures are usually minor, more severe complications can rarely occur. We describe a unique case of severe gastrointestinal bleeding in a patient who underwent PRG tube exchange reflecting an acute complication following an asymptomatic misplaced permanent gastrostomy tube.

Percutaneous Transgastric Duodenal Stenting and Gastrostomy Repair Using a Vascular Closure Device: Proof of Concept in a Porcine Model

Introduction. Gastroduodenal stenting is efficacious and safe in both benign and malignant foregut diseases. Transgastric duodenal stenting has been described and however requires a gastrostomy tube to remain in situ for 4 to 6 weeks post-procedure which can lead to complications. We present a technique for immediate gastric repair using a suture-mediated vascular closure device, without the need for a gastrostomy tube in porcine models. Methods. Percutaneous access into the stomach was achieved using fluoroscopy. Two or 3 Perclose Proglide devices were pre-deployed. The tract was dilated and a wire advanced into the distal duodenum. A 15.5 cm covered enteric stent was delivered through the gastrostomy, deployed and position confirmed. The gastrostomy was closed using Perclose Proglide sutures. Necropsy leak pressure measurement was performed to assess integrity of gastrostomy closure in the porcine models. Results. Two (n = 8) or 3 (n = 2) Perclose Proglide devices were deployed in ten porcine models, with 1 misfire (4.5%). Percutaneous transgastric access and stent delivery was successful in all porcine models. Mean leak pressure in the animals with adequately deployed devices was 219 mmHg (range 172 mmHg-270 mmHg). Conclusion. This study demonstrates percutaneous transgastric duodenal stenting with immediate gastric repair using suture-mediated vascular closure devices is a feasible procedure.

Dysphagia among geriatric trauma patients: A population-based study

Objective

To determine the significance of dysphagia on clinical outcomes of geriatric trauma patients.

Methods

This is a retrospective population-based study of geriatric trauma patients 65 years and older utilizing the Florida Agency for Health Care Administration dataset from 2010 to 2019. Patients with pre-admission dysphagia were excluded. Multivariable regression was used to create statistical adjustments. Primary outcomes included mortality and the development of dysphagia. Secondary outcomes included length of stay and complications. Subgroup analyses included patients with dementia, patients who received transgastric feeding tubes (GFTs) or tracheostomies, and speech language therapy consultation.

Results

A total of 52,946 geriatric patients developed dysphagia after admission during a 9-year period out of 1,150,438 geriatric trauma admissions. In general, patients who developed dysphagia had increased mortality, length of stay, and complications. When adjusted for traumatic brain and cervical spine injuries, the addition of mechanical ventilation decreased the mortality odds. This was also observed in the subset of patients with dysphagia who had GFTs placed. Of the three primary risk factors for dysphagia investigated, mechanical ventilation was the most strongly associated with later development of dysphagia and mortality.

Conclusion

The geriatric trauma population is vulnerable to dysphagia with a large number associated with traumatic brain injury, cervical spine injury, and polytraumatic injuries that lead to mechanical ventilation. Earlier intubation/mechanical ventilation in association with GFTs was found to be associated with decreased inpatient hospital mortality. Tracheostomy placement was shown to be an independent risk factor for the development of dysphagia. The utilization of speech language therapy was found to be inconsistently utilized.

Percutaneous Endoscopic Gastrostomy Feeding in Children with Cerebral Palsy

AIM

The prevalence of congenital cerebral palsy (CP) worldwide ranges from 0.15 to 0.4%. CP causes several gastrointestinal complications that inhibit normal eating behavior. This single-center observational study aimed to determine the tolerability and benefits of percutaneous endoscopic gastrostomy (PEG) in pediatric CP patients with malnutrition.

MATERIALS AND METHODS

The study included 41 pediatric CP patients with malnutrition. All patient data were retrospectively obtained from Bakırköy Dr. Sadi Konuk Research and Training Hospital, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Istanbul, Turkey. In addition to baseline measurements of weight, height, triceps skinfold thickness, 1,25-hydroxyvitamin D3, folate, iron, zinc, vitamin B12, hemoglobin, and mean corpuscular volume, data analyzed included follow-up measurements recorded at 3 and 6 months of PEG (standard polymeric enteral supplementation as 1.0 kcal mL^-1).

RESULTS

There was significant improvement in both height, weight, and triceps skinfold thickness in all patients at 3 and 6 months of PEG (p < 0.05). In terms of blood parameters, there was not significant improvement, except that the number of patients with a low hemoglobin count significantly decreased at 3 and 6 months of (p = 0.022). Moreover, the number of patients with vomiting after PEG also significantly decreased at 3 and 6 months of (p = 0.004).

CONCLUSION

PEG significantly improves malnutrition in pediatric CP patients and does not cause any major complications. Based on these findings, we think PEG is a beneficial and cost-effective intervention with a high rate of tolerability in pediatric CP patients with malnutrition.

The effects of total enteral nutrition via nasal feeding and percutaneous radiologic gastrostomy in patients with dysphagia following a cerebral infarction

OBJECTIVE

To explore the effects of total enteral nutrition (TEN) via nasal feeding and percutaneous radiologic gastrostomy (PRG) on the nutritional status, quality of life, and prognosis in long-term bedridden patients with dysphagia after cerebral infarction.

METHODS

One hundred and sixty long-term bedridden patients with dysphagia after cerebral infarction were randomly divided into a control group (CG, n=80) and an observation group (OG, n=80). The CG was administered TEN via nasal feeding, and the OG was administered TEN via PRG. The two groups' results were compared.

RESULTS

The Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) scores in the OG were lower than the corresponding scores in the CG at 3 and 6 months after the TEN (P < 0.05). The OG had a higher proportion of high compliance, but a lower proportion of both moderate and low compliance than the CG (P < 0.05). The total incidence of TEN intolerance was 8.75% in the OG, lower than the 20.00% in the CG (P < 0.05). The AST, ALB, ALT, TBIL, Scr, and BUN levels showed no significant differences between the OG and the CG at 3 and 6 months after the TEN (P > 0.05). The IgM, IgG, IgA, hemoglobin, total protein, albumin, and transferrin levels showed no significant differences between the OG and the CG at 3 and 6 months after the TEN (P > 0.05). The incidence of catheterization complications was 20.00% in the OG, higher than the 8.75% in the CG (P < 0.05). The OG had higher SF-36 scores than the CG at 6 months after the TEN (P < 0.05).

CONCLUSION

Both nasal feeding and TEN via PRG can effectively improve patients' nutritional status, enhance their immune function, and improve their liver and renal function, but TEN after PRG is more effective at reducing intolerance and promoting quality of life in long-term bedridden patients with dysphagia after cerebral infarction. However, TEN after PRG will also increase the occurrence of recent complications, complications that should get additional clinical attention.

A method for percutaneous radiologic gastrostomy tube placement without sedation as a bridge to lung transplantation

Gastrostomy tube placement is an appropriate option for long-term nutritional support for patients who cannot tolerate oral intake. Common indications for a gastrostomy tube include head and neck tumors and neurological disorders. Several methods for gastrostomy tube insertion exist (eg, surgical, endoscopic, and radiologic) that require sedation or general anesthesia, which can pose risks of cardiopulmonary compromise and postsurgical pulmonary complications. Unlike other methods, our practice uses a percutaneous balloon-assisted gastrostomy tube insertion method for which we can perform without sedation. We report a case of a percutaneous radiologic gastrostomy procedure for a patient with end stage lung disease as a bridge to lung transplantation, who is not a candidate for sedation and is high-risk for general anesthesia. Through enteral feeds administered through the successfully placed gastrostomy tube, the patient showed steady improvement in weight gain over the course of several months before approval for listing by the lung transplant selection committee. Our case highlights how gastrostomy tube placement can be safely performed in patients who are not sedation candidates using the minimally invasive balloon-assisted gastrostomy tube insertion method and local anesthetic.

Abdominal and pelvic radiographs of medical devices and materials-Part 1: gastrointestinal and vascular devices and materials

When compared with chest radiographs, medical devices of the abdomen and pelvis are less frequently seen. However, with recent advances in technology the interpreting radiologists are seeing more medical objects on these radiographs. The identification of these devices and materials are crucial for not only enabling the radiologist to understand the underlying background pathology but also for evaluating any related complications. An online survey of literature showed our review article to be the most detailed. In this first part of our two-part series, we discuss about the various gastrointestinal and vascular devices and materials seen on abdominal and pelvic radiographs.

Button Gastrostomy Tubes for Pediatric Patients: A Tertiary Care Center Experience

Results

Out of 34 patients who underwent gastrostomy tube insertion, 30 patients had their long tube replaced by a button gastrostomy. Majority were males (N = 18, 60%). Prolonged nasogastric tube feeding was the main indication of referral (N = 17, 56%) followed by feed intolerance (N = 6, 17%) and gastroesophageal reflux disease (N = 5, 16%). The main underlying diseases at referral were neurological impairment (N = 19, 63%) and metabolic disorders (N = 4, 13%). There was no significant difference between patients with neurological disorders and other diseases in terms of gender, nationality, or age. Laparotomy with gastrostomy is the main approach used (N = 18, 60%). No reported complications of button tubes in 50% of the patients (N = 15).

Conclusions

Prolonged nasogastric tube feeding is the main indication of referral for gastrostomy tube insertion. Neurological disorders are the main diagnosis for the cases operated upon. Laparotomy with gastrostomy is the procedure of choice at our center. Majority of patients had no reported complications of button tube replacement. These children are likely to benefit from the button tube with fewer complications.

Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG)—Single-Center Experience and Outcome

Background Gastrointestinal route is considered for feeding in subjects who are unable to swallow, either as a temporary or permanent option. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode for long-term enteral nutrition. The aim was to study the outcome of protocol-based PEG placement in a tertiary medical center.

Materials and Methods All the patients who underwent PEG placement between January 2017 and December 2019 were included in the retrospective study. Study variables were entered into a uniform structured proforma. The procedure was done by two people using Ponsky-Gauderer pull-technique. Fluoroscopy guidance was considered for placement in special situations. Post-procedure, all the patients were regularly followed as per protocol to evaluate for adverse events.

Results One hundred and eighteen patients with placement of PEG were included in the study. The mean age of the patients was 49.6 ± 7 years with 67.8% males. The most common indication of PEG was inability to swallow associated with head injury (43, 36.4%), followed by carcinoma esophagus (35, 29.8%) and stroke (24, 20.3%). Fluoroscopy was useful in 38 (32%) for PEG site identification. Tube dislodgement (16, 13.5%) and aspiration pneumonia (20, 16.9%) were the common adverse events. Age more than 60 years and dysphagia in neurologic disorders accounted for more than 60% of adverse events. Forty-nine (42%) of the PEG patients expired due to either primary illness or due to sepsis after a median time of 139 days (range: 32–288 days). There was no difference in the survival in patients with or without PEG-related complications (p = 0. 74).

Conclusions Fluoroscopy assistance helps in accurate PEG placement in one third. Age > 60 years and dysphagia in neurologic disorders were independent risk factors associated with PEG tube complications.

Complications of percutaneous gastrostomy and gastrojejunostomy tubes in children

Percutaneous feeding tubes are generally considered a safe option for enteral feeding and are widely used in children who require long-term nutritional support. However, complications are not infrequent and can range from bothersome to life-threatening. Radiologists should be familiar with the imaging appearances of potential complications for optimal patient care. In this review, we discuss radiologic appearances of common complications and less frequent but serious complications related to percutaneous feeding tubes. Additionally, as fluoroscopic feeding tube evaluation is often requested as the initial imaging study, we also discuss the fluoroscopic appearances of some uncommon complications.