Laparoscopic gastrostomy and jejunostomy

BACKGROUND: The percutaneous/endoscopic gastrostomy (PEG) has rapidly replaced the surgical gastrostomy as the preferred route for enteral access. In patients who are not candidates for a PEG, we prefer a laparoscopic gastrostomy to an open gastrostomy. Similarly, in patients who require a surgical jejunostomy, we prefer a laparoscopic approach. Minimally invasive techniques have several advantages over the standard open surgery. The purpose of this article is to review the indications, various techniques, and outcomes of laparoscopic gastrostomy and jejunostomy tubes. DATA SOURCES: Medline search from 1959-2002. CONCLUSIONS: The PEG remains the procedure of choice for placement of a gastrostomy. Laparoscopic gastrostomy is an excellent choice for patients who are not candidates for a PEG. Similarly, laparoscopic jejunostomy is an excellent choice for patients who require enteral access, but have contraindications to a gastrostomy tube. Placement of laparoscopic gastrostomy andjejunostomy tubes can be safely performed, and the success and complication rates of these procedures compare favorably with those of the corresponding open surgical procedure. Laparotomy is rarely needed to place enteral feeding tubes. Cost analysis has shown that laparoscopic procedures are similar to open procedures.     

Surgical technique. Intracorporeal laparoscopic-guided feeding jejunostomy.

Laparoscopic feeding jejunostomy is a safe and reproducible method of establishing enteral feeding in patients in whom percutaneous endoscopic gastrostomy is contraindicated. Current technology enables the jejunostomy to be achieved within the peritoneal cavity, without retrieval of the small bowel through the abdominal wall. This quick and simple technique is described.     

Percutaneous laparoscopic assisted gastrostomy (PLAG)—a new technique for cases of pharyngoesophageal obstruction

Purpose  

Percutaneous endoscopic gastrostomy (PEG) is the preferable method to provide enteral nutrition for a longer time period. Safe placement of a PEG tube requires passage of the esophagus and transillumination of the stomach through the abdominal wall. Surgical placement of a PEG tube has been shown to be feasible although the local complication rate ranges above the endoscopic procedure. We are presenting a new technique (percutaneous laparoscopically assisted gastrostomy, PLAG) to provide enteral access for patients with pharyngoesophageal obstruction not suitable for PEG placement.     

Laparoscopic feeding jejunostomy: also a simple technique

Summary Placement of feeding tubes is a common procedure for general surgeons. While the advent of percutaneous endoscopic gastrostomy has changed and improved surgical practice, this technique is contraindicated in many circumstances. In some patients placement of feeding tubes in the stomach may be contraindicated due to the risks of aspiration, gastric paresis, or gastric dysmotility. We describe a technique of laparoscopic jejunostomy tube placement which is easy and effective. It is noteworthy that this method may be used in patients who have had previous abdominal operations, and it has the added advantage of a direct peritoneal view of the viscera. We suggest that qualified laparoscopic surgeons learn the technique of laparoscopic jejunostomy.     

Laparoscopic gastrostomy

Although percutaneous endoscopic gastrostomy (PEG) has become a common technique for the placement of gastrostomy tubes, gastrostomy can be performed via the laparoscopic approach with minimal trauma or by using a percutaneous gastrostomy kit. In this report, we describe two procedures for laparoscopic gastrostomy using standard instruments. Standard laparoscopic techniques are used to create a pneumoperitoneum. In the first method, three transparieto-transgastric U stitches are placed to surround the site selected for the gastrostomy. A Foley catheter is inserted through the abdominal and gastric opening, then tied to the stomach with a pursestring suture. Traction on the balloon catheter brings the stomach to the anterior abdominal wall, where the three U stitches can be tied. In the second method, a 9-cm vascularized isoperistaltic gastric tube is made on the greater curvature using an endoscopic linear cutter and preserving the gastro-omental vessels. This gastric tube is then brought out through the anterior abdominal wall via a trocar orifice, opened, and fixed to the skin as for standard ostomy. Laparoscopic gastrostomy is a straightforward procedure that reduces postoperative pain and ileus. It obviates the need for a laparotomy while creating an adequate gastrostomy. Postoperative recovery is prompt, with rapid return of intestinal function and early discharge from the hospital. It not only represents an alternative to PEG when this route is not suitable or after failure of the procedure, but can also be widely used for patients as a first choice.     

Laparoscopic-assisted percutaneous endoscopic gastrostomy in children and adolescents.

OBJECTIVE: Pediatric gastric access for long-term enteral feeding may be performed via a laparotomy, laparoscopy, or a percutaneous approach. In children and adolescents, laparoscopic-assisted gastrostomy may be difficult due to a thick abdominal wall. Therefore, if the abdominal wall is estimated to be >2 cm on physical examination, or in children in whom a percutaneous endoscopic gastrostomy was unsuccessfully attempted by a gastroenterologist, we routinely perform a laparoscopic-assisted percutaneous endoscopic gastrostomy. METHODS: From January 1998 through February 2003, we retrospectively reviewed 15 cases of a laparoscopic-assisted percutaneous endoscopic gastrostomy. Instruments used to perform this technique are a percutaneous endoscopic gastrostomy kit, an Olympus flexible endoscope, and one 5-mm STEP port placed through an infraumbilical incision for a 5-mm, 30-degree scope. RESULTS: Age range was 2 years to 20 years (mean, 10). Operative time ranged from 20 minutes to 45 minutes. When a concurrent laparoscopic Nissen fundoplication was performed (n = 6), the percutaneous endoscopic gastrostomy was placed after completion of the Nissen fundoplication. No intraoperative complications occurred, and all tubes were successfully placed. Feeds were instituted the following day and advanced to goal. To date, no postoperative complications have occurred, and revision has not been necessary. CONCLUSIONS: Laparoscopic-assisted percutaneous endoscopic gastrostomy in children and adolescents is safe and effective. Utilizing laparoscopy permits evaluation of the peritoneum and lysis of adhesions, if necessary. Moreover, laparoscopy provides excellent exposure for accurate placement of the PEG, while avoiding injury to other organs.     

Laparoscopic Witzel gastrostomy—a reappraised technique

Background Laparoscopic gastrostomy is the best alternative for long-term enteral feeding when percutaneous endoscopic gastrostomy is not possible. The aim of the present study was to determine the feasibility, complications, adequacy of feeding support, and tolerability of laparoscopic Witzel gastrostomy (LWG) in head and neck cancer patients. The initial results and the results of extended follow-up were evaluated. Methods A consecutive series of 48 patients with stenotic head and neck or esophageal cancer were referred for laparoscopic gastrostomy. The patients consisted of 42 men and 6 women aged 36 to 82 years (mean, 54 years). After laparoscopic placement of a Foley catheter of 16 F into the stomach, a seromuscular tunnel 4 cm in length is created, embedding the catheter by interrupted sutures. Three stay sutures for gastropexy are fixed and tied on the abdominal skin at the end of the procedure. The mean duration of the procedure was 62.4 ± 11 min (52–124 min). Results Laparoscopic Witzel gastrostomy could be performed successfully in all patients with aerodigestive cancer. None of the laparoscopic gastrostomy tube placement procedures was converted to an open surgery, and none of the 48 patients in this series died as a result of the laparoscopic procedure. All LWG complications (11%) were minor, consisting of superficial wound infections, balloon rupture, and chronic granulation. No major complications were encountered. The mean usage time of gastrostomy was 6.3 ± 5.3 months. Conclusions Current techniques of LWG could be an alternative to percutaneous endoscopic gastrostomy (PEG) for long-term enteral access, because it has proved to be safe and reproducible with relatively few complications.     

Percutaneous approaches to enteral alimentation

Feeding gastrostomy and jejunostomy provide effective access for long-term enteral nutrition. Traditional operative techniques for the performance of these procedures requires laparotomy and often, general anesthesia. This report describes our experience with two relatively new methods, percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy. Results of percutaneous gastrostomy and jejunostomy to date in 323 cases include a morbidity of 5.9 percent and a 0.3 percent operative mortality. Percutaneous endoscopic gastrostomy and jejunostomy should become the procedures of choice for the establishment of enteral access in patients requiring long-term enteral alimentation.     

Concomitant placement of percutaneous endoscopic gastrostomy and jejunostomy

Summary Percutaneous endoscopic gastrostomies have gained wide use for long-term enteral nutrition. However, gastroesophageal reflux and aspiration pneumonia have occurred following this procedure. Initial enthusiasm concerning the ability of intrajejunal feeding to negate the risk of aspiration has been challenged by some reports. In this report, a new method is described for concomitant placement of endoscopic gastrostomy and feeding jejunostomy wherein the tip of the feeding jejunostomy is placed at least 40 cm distal to the pylorus while the gastrostomy tube is used for drainage. Twenty critically ill patients underwent the procedure utilizing general or local anesthesia. Sixty-day followup showed one uneventful episode of pulmonary aspiration (5%) after retrograde migration of the jejunal tube into the duodenum. All but two patients (90%) tolerated their tube feedings well. This technique can be easily performed with accurate placement of the PEJ tube distal to the pylorus and is associated with minimal risk of aspiration.     

A reproducible, safe jejunostomy replacement technique by a percutaneous endoscopic method

Patients undergoing esophagogastrectomy for cancer often benefit from postoperative nutritional support and an operative jejunostomy is frequently placed at the time of surgery. If the original tube has been removed, replacement of this jejunostomy previously required repeat laparotomy. Described here is the technique of direct percutaneous endoscopic jejunostomy placement (PEJ) used in two such patients following esophagogastrectomy. This PEJ placement technique using a #16-Fr, Pezzer-type Ponsky tube is an easy, reproducible method for the replacement of an operative jejunostomy tube. The fibrosed tract between the abdominal wall and jejunum allows the safe performance of the procedure if one endoscopically identifies the site of operative insertion.     

Laparoscopic-guided feeding jejunostomy

Summary Access for long-term enteral nutrition has long been the job of the surgeon. While percutaneous endoscopic gastrostomy has revolutionized the way we provide gastric feedings, jejunal access usually requires laparotomy. We have developed a technique for placing a laparoscopic guided jejunostomy. Twenty-three patients have undergone this procedure without complication. We believe this technique will be a valuable addition to the surgeon's options for obtaining enteral access.     

Laparoscopic feeding jejunostomy technique as part of staging laparoscopy

Placement of a feeding jejunostomy tube is indicated for patients who need enteral access but where a gastrostomy is not feasible. This paper presents the technique and results of laparoscopic placement of feeding jejunostomy tubes in patients presenting with esophagogastric cancer. From December 2002 to February 2004, patients diagnosed with esophagogastric cancer with a potentially resectable lesion underwent staging laparoscopy. Laparoscopic feeding jejunostomy was performed on patients who were potential candidates for chemotherapy with palliative intent or neoadjuvant treatment prior to resection surgery. Surgical technique, recovery of bowel function, commencement of feeding jejunostomy, total time tube was in situ, and perioperative complications were analyzed. Of the 22 patients who underwent staging laparoscopy, a feeding jejunostomy tube was placed in 18. The remaining 4 patients were deemed to have advanced disease precluding any therapeutic options and underwent placement of esophageal stents. Feeding tubes remained in situ for a median time period of 76 days. Fourteen patients required enteral support and tubes were used for a median of 30 days. Complications from tube placement included 2 cases of wound infections, 1 of minor leak and 1 tube dislodgment. Patients were followed up for a median time of 112 days. Findings from current series suggest that placement of a feeding jejunostomy tube at the time of staging laparoscopy is a safe and reliable means of providing and maintaining nutrition for patients presenting with esophagogastric cancers.     

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

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

Current management of endoscopic feeding tube dysfunction

Surgically placed gastrostomy and jejunostomy feeding tubes allow administration of enteral nutrition for patients who are unable to swallow safely. Several endoscopic techniques have been used for tube placement. Endoscopically placed feeding tubes provide access to the gastrointestinal tract, but only when patent. Use of the approaches presented permits optimal feeding tube care and prolongs tube patency. Table 1 summarizes the recommendations for preventing and restoring patency to feeding tubes. Received: 22 July 1998/Accepted: 13 October 1998     

Laparoscopic-assisted gastric button placement: a valuable alternative for a percutaneous endoscopic gastrostomy (PEG)

A percutaneous endoscopic gastrostomy remains the first choice when oral feeding is difficult. In some patients however an endoscopic placement of a gastrostomy tube is not possible. As an alternative, a laparoscopic-assisted insertion of a gastric button was performed to provide enteral feeding in seven patients. Enteral feeding could be resumed within one or two days after the procedure and no complications were encountered. This minimal invasive technique has certain advantages over a surgical gastrostomy by laparotomy. Therefore, a laparoscopically inserted gastric button should be considered a valuable alternative if percutaneous endoscopic gastrostomy is no longer possible.     

经皮内镜下胃造口、空肠造口及十二指肠造口120例临床分析

目的　探讨经皮内镜下胃造口、空肠造口及十二指肠造口的技术操作及适应证。方法2 0 0 1年 5月— 2 0 0 4年 4月间 ,共行 12 0例经皮内镜下胃肠造口 ,其中 75例经皮内镜下胃造口 (PEG) ,4 2例经皮内镜下空肠造口 (PEJ) ,2例经皮内镜下十二指肠造口 (PED) ,1例直接法经皮内镜下空肠造口(DPEJ)。操作均采用经典经腹壁拉出法技术。结果　采用上述方法共行长期肠内营养 88例 ;胃肠减压 2 5例 ;肠内营养联合胆汁回输 5例 ;围手术期应用PEG 2例 ,术前行胃肠减压 ,术后行长期肠内营养。PEG操作时间平均 (9± 4 )min ,PEJ平均 (17± 6 )min ,DPEJ为 2 0min ,2例PED分别为 10和 12min。技术成功率 98 4 % (12 0 / 12 2 )。严重并发症发生率为 0 8% (1/ 12 0 ) ,轻微并发症发生率为 7 5 %(9/ 12 0 )。结论　经皮内镜下胃肠造口操作简便、有效 ,并发症少。     

Laparoscopic-Assisted Gastric Button Placement: a Valuable Alternative for a Percutaneous Endoscopic Gastrostomy (PEG)

A percutaneous endoscopic gastrostomy remains the first choice when oral feeding is difficult. In some patients however an endoscopic placement of a gastrostomy tube is not possible. As an alternative, a laparoscopic-assisted insertion of a gastric button was performed to provide enteral feeding in seven patients. Enteral feeding could be resumed within one or two days after the procedure and no complications were encountered. This minimal invasive technique has certain advantages over a surgical gastrostomy by laparotomy. Therefore, a laparoscopically inserted gastric button should be considered a valuable alternative if percutaneous endoscopic gastrostomy is no longer possible.     

三孔法完全腹腔镜胃/空肠造瘘术

目的：总结三孔法完全腹腔镜胃/空肠造瘘术的初步经验。方法：回顾分析2007年10月至2009年11月采用三孔法行完全腹腔镜胃/空肠造瘘术放置永久性胃/空肠造瘘管10例的临床资料,其中晚期食管癌1例,晚期贲门癌2例,晚期胃癌7例,均完全或几乎不能经口进食,行三孔法完全腹腔镜胃造瘘术3例,三孔法完全腹腔镜空肠造瘘术7例。结果：本组手术均获成功,无中转开放,手术时间45~110min,平均60min,术中出血5~15ml,平均8.5ml,术后住院5~11d,平均7.2d。术后均无并发症发生,造瘘管均顺利开放并维持正常肠内营养。结论：三孔法完全腹腔镜胃/空肠造瘘术放置胃/空肠造瘘管具有患者创伤小、康复快、启用造瘘管早等特点,临床效果满意,值得推广。     

SLiC technique

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) has been an invaluable method for obtaining long-term enteral access and represents one of the first forays in the field of minimally invasive surgery. However, the traditional "pull" method for PEG tube placement continues to have some disadvantages, especially in patients with near-obstructive head and neck cancers. METHODS: We describe a new "SLiC" technique for establishing percutaneous gastrostomy using a radially expandable trocar. RESULTS: This technique is initially developed and refined on a porcine model and then successfully implemented on five human patients. CONCLUSION: The SLiC technique can be done safely and efficiently with a pediatric-sized gastroscope and avoids the need for radiation from fluoroscopy. It is a good alternative for obtaining enteral access in patients who would otherwise not be well suited for a traditional PEG tube.