Percutaneous Gastrostomy Technique Research Articles

Enteric Access: IR Perspective

AbstractGastrostomy tube placement may be needed for nutritional support, as in the setting of neurogenic dysphagia or head and neck malignancy, or for gastric decompression, as in the setting of malignant small bowel obstruction. Additionally, gastrojejunostomy or direct jejunostomy tubes may be needed in the setting of gastric outlet obstruction among other indications. Surgical, endoscopic, and percutaneous approaches are all well-described with generally similar outcomes. In this article, the standard radiologic percutaneous gastrostomy technique is reviewed including both the “push” and “pull” methods. Then, the special indications and techniques of advanced percutaneous enteral access such as percutaneous transesophageal gastrostomy and direct jejunostomy are discussed with examples shown.

What the radiologist should know about the role of percutaneous gastrostomy: a pictorial essay.

The image-guided gastrostomy techniques, as transoral and transabdominal, can be performed when there is a failure of the endoscopic procedure or in some specific clinical scenarios. This pictorial essay intends to show the percutaneous gastrostomy techniques, indications, technical approaches, post-procedure care, and complications.

Percutaneous endoscopic gastrostomy versus percutaneous radiological gastrostomy for swallowing disturbances.

Gastrostomy has been established as the standard procedure for administering long-term enteral nutrition in individuals with swallowing disturbances. Percutaneous gastrostomy is a less-invasive approach than open surgical gastrostomy, and can be accomplished via endoscopy (percutaneous endoscopic gastrostomy or PEG) or sonographic or fluoroscopic guidance (percutaneous radiological gastrostomy or PRG). Both techniques have different limitations, advantages, and contraindications. In order to determine the optimal technique for long-term nutritional supplementation many studies have been conducted to compare the outcomes of these two techniques; however, it remains unclear as to which method is superior to the other with respect to both efficacy and safety. To compare the safety and efficacy of PEG and PRG in the treatment of individuals with swallowing disturbances. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, January 2016); MEDLINE (1946 to 22 January 2016); EMBASE (1980 to 22 January 2016); the reference lists of identified articles; databases of ongoing trials, including the Chinese Cochrane Centre Controlled Trials Register; and PubMed. We applied no language restrictions. Randomised controlled trials (RCTs) comparing PEG with PRG in individuals with swallowing disturbances, regardless of the underlying disease. Two authors independently evaluated the search results and assessed the quality of the studies. Data analyses could not be performed as no RCTs were identified for inclusion in this review. We identified no RCTs comparing PEG and PRG for percutaneous gastrostomy in individuals with swallowing disturbances. The large body of evidence in this field comes from retrospective and non-randomised controlled studies and case series. Based on this evidence, both PEG and PRG can be safely performed in selected individuals, although both are associated with major and minor complications. A definitive RCT has yet to be conducted to identify the preferred percutaneous gastrostomy technique. Both PEG and PRG are effective for long-term enteral nutritional support in selected individuals, though current evidence is insufficient to recommend one technique over the other. Choice of technique should be based on indications and contraindications, operator experience and the facilities available. Large-scale RCTs are required to compare the two techniques and to determine the optimal approach for percutaneous gastrostomy.

Comparison of “Pull” and “Introducer” Techniques for Placement of PEG Tubes

Introduction: Patients require placement of endoscopic percutaneous gastrostomy (PEG) tube for a number of indications and develop numerous complications as a result of PEG tube placement. There are several techniques for placement of PEG tube including the “pull” method where a guidewire is used to pull the PEG tube through the mouth and the “introducer” technique where gastric anchors are used to allow direct insertion of the tube through the abdominal wall. Comparisons of these two techniques however are limited. Methods: Endoscopic records were reviewed for PEG tube placements from 2011 through 2014 at a single academic medical center to identify appropriate patients for comparison. The technique used for placement was identified and patients were placed into 2 groups. Group 1 was the “pull” PEG procedures and group 2 was the “introducer” PEG procedures. Individual patient characteristics were collected, including the following: age at the time of tube placement, gender, and indication for tube placement. In addition, the electronic medical records were reviewed for each patient to identify any tube related complications that occurred following the initial procedure. Information regarding tube replacement/exchange for each patient was also collected. Results: A total of 75 patients were identified, 50 in group 1 and 25 in group 2. The patients in group 1 were 52% male (26/50) with an average age of 68 years old (+/-12 years). The patients in group 2 were 72% male (18/25) with an average age of 63 years old (+/- 11 years). See Table 1 for the top four indications by PEG tube technique. See Table 2 for the top four complications by PEG tube technique.Table 1: Indications by PEG Tube TechniqueTable 2: Complications by PEG Tube TechniqueConclusion: “Pull” PEGs were placed more often in ALS patients than “introducer” PEGs. “introducer” These patients were more likely to have dysphagia. PEGs were placed more often in Head & Neck cancer patients than “pull” PEGs. Weight loss was more common in this group of patients. Abdominal pain occurred more frequently with the “pull” PEG technique whereas drainage was higher with the “introducer” PEG technique.

CT-Guided Percutaneous Radiologic Gastrostomy for Patients with Head and Neck Cancer: A Retrospective Evaluation in 177 Patients.

The purpose of this study was to assess the technical success rate and adverse events (AEs) associated with computed tomography (CT)-guided percutaneous gastrostomy for patients with head and neck cancer (HNC). This retrospective study included patients with HNC who had undergone CT-guided percutaneous gastrostomy between February 2007 and December 2013. Information regarding the patients' backgrounds, CT-guided percutaneous gastrostomy techniques, technical success rate, and AEs were obtained from the medical records. In all patients, the stomach was punctured under CT fluoroscopy with a Funada gastropexy device. During the study period, 177 patients underwent CT-guided percutaneous gastrostomy. The most common tumor location was the oral cavity, followed by the pharynx and maxilla. The indication for CT-guided percutaneous gastrostomy were tumor obstruction in 78 patients, postoperative dysphagia in 55 patients, radiation edema in 43 patients, and cerebral infarction in 1 patient. The technical success rate was 97.7%. The overall mean procedure time was 25.3min. Major AEs occurred in seven patients (4.0%), including bleeding (n=4), colonic injury (n=1), gastric tear (n=1), and aspiration pneumonia (n=1). Minor AEs occurred in 15 patients (8.5%), which included peristomal leakage (n=6), irritation (n=4), inadvertent removal (n=2), peristomal hemorrhage (n=1), peristomal infection (n=1), and wound granulation (n=1). The mean follow-up period was 111days (range 1-1106days). Our study suggests that CT-guided gastrostomy may be suitable in patients with HNC.

Give 'em 3 liters of hyperal.

Give 'em 3 liters of hyperal.

Modified Radiology-Guided Percutaneous Gastrostomy (MRPG) for Patients with Complete Obstruction of the Upper Digestive Tract and Who are without Endoscopic or Nasogastric Access

ObjectiveWe wanted to report on our experience with modified radiology-guided percutaneous gastrostomy (MRPG) without endoscopic or nasogastric access for treating patients with complete obstruction of the upper digestive tract.Materials and MethodsFourteen oncology patients (13 had hypopharyngeal cancer and 1 had upper esophageal cancer) with complete obstruction of the upper digestive tract were recruited. Conventional percutaneous endoscopic gastrostomy (PEG) and radiologic (fluoroscopy-guided) percutaneous gastrostomy (RPG) were not feasible in all the patients. An MRPG technique (with a combination of ultrasound, an air enema and fluoroscopic guidance) was performed in these patients.ResultsWe achieved successfully percutaneous gastrostomy using the modified technique in all patients without any major or minor complications after the procedure.ConclusionA modified radiology-guided percutaneous gastrostomy technique can be safely performed in patients who failed to receive conventional PEG or RPG due to the absence of nasogastric access in the completely obstructed upper digestive tract.

Gastrostomie tubulisée cœlioscopique : une solution avantageuse pour une nutrition entérale autonome

Introduction. – Laparoscopic gastrostomy according to Janeway (LGJ) is an alternative to percutaneous gastrostomy techniques. Methods. – A series of 10 LGJ is reported. The laparoscopic technique involves an isoperistaltic tube of 6–7 cm of length and 10–12 mm of diameter is created by 2 applications of linear stapling and cutting device. The tube is led out, opened and fixed to the fascial and cutaneous planes and a Foley catheter is inserted. Results. – Mean operation time was 35 minutes. There was no complication. The LGJ was indicated in 9 patients with tumour of the pharynx and 1 patient with encephalopathy. Conclusion. – The main drawback of the LGJ is the need of general anaesthesia. The main advantage is the creation by minimal invasive surgery of a permanent gastrostomy equipped with a removable catheter easily changeable by non specialized health professionals, and even by the patient himself.

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.

Nonendoscopic antegrade percutaneous gastrostomy: the effect of preplacement gastric insufflation on tube position and intra-abdominal anatomy.

Nonendoscopic tube gastrostomy was performed on 47 anesthetized dogs using the technique of Fulton and Dennis with or without gastric insufflation prior to tube placement. Immediately after tube placement, dogs were euthanized and postmortem examinations performed. When gastric insufflation was not performed (group I), gastrostomy tubes penetrated the visceral surface of the stomach in 25% of dogs. The deep leaf of the omentum was interposed between stomach and body wall in the majority of these dogs, exposing other intra-abdominal organs to potential injury. Additionally, displacement and tethering of the spleen cranial to the gastrostomy site were observed in 33% of dogs in group I. Similar results were obtained when preplacement gastric insufflation was performed after the orogastric tube was inserted sufficiently far to displace the stomach laterally against the body wall (group II). In contrast, consistent positioning of gastrostomy tubes through the parietal surface of the stomach was achieved when the stomach was insufflated prior to lateralizing the left abdominal wall with the gastric end of the orogastric tube (group III). It was concluded that the blind percutaneous gastrostomy technique is made safer by insufflating the stomach immediately prior to pushing the gastric wall laterally into contact with the parietal peritoneum.

Percutaneous Gastronomy and Jejunostomy: Lessons from the First Decade

Percutaneous gastrostomies and jejunostomies have increasingly been used for long term enteral feeding in patients with functioning gastrointestinal tracts but who are unable, for a variety of reasons, to use the standard oropharyngeal route. Since these devices can be placed without the use of general anesthesia, the morbidity and mortality generally are less than for placement of a surgical gastrostomy. A permanent gastrostomy tube is easy to manage in most patients who require prolonged tube feeding. There are four basic types of percutaneous gastrostomy techniques; three employ an endoscope and one uses only radiographic or ultrasonic guidance. All gastrostomy tubes may be convened to feeding jejunostomies if the clinical situation warrants. Jejunal feeding tubes are prone to many technical problems and do not always solve the problems of gastric dysfunction and reflux that make gastrostomy tubes less desireable. Percutaneous endoscopic gastrostomics are technically simple to perform and have become the main method for access to the gastrointestinal tract in many patients. If judiciously used, the percutaneous enterostomy offers many benefits over a nasogastric tube for long term enteral feeding.

Fine-needle endoscopic percutaneous gastrostomy.

A procedure for percutaneous endoscopic gastrostomy is described. Under direct endoscopic control, the surgeon introduces, percutaneously, into the inflated stomach a 9 French Foley catheter through a special needle, which may then be opened for removal. After positioning, the terminal balloon of the Foley is inflated with 7-8 ml of air and the catheter is placed under slight traction to appose the gastric and abdominal walls. Such a method has been used in 5 patients with cancer of the cardia requiring enteral feeding prior to surgery. No complications due to the positioning of the gastrostomy catheter have been observed. We believe that this simple, reliable and inexpensive method constitutes an improvement on the previously described endoscopic percutaneous gastrostomy techniques.

Percutaneous gastrostomy for jejunal feeding.

A simple percutaneous gastrostomy technique for jejunal feeding which requires no general anesthesia or gastroscopy is described. This may replace the feeding jejunostomy as a means of providing total enteral nutrition to patients with severe and disabling esophageal or gastric dysfunction.