Percutaneous Radiologic Gastrostomy Using the One-Anchor Technique in Patients after Partial Gastrectomy

Objective

The purpose of our study was to assess the feasibility of performing percutaneous radiologic gastrostomy (PRG) in patients who had undergone partial gastrectomy and to evaluate factors associated with technical success.

Materials and Methods

Nineteen patients after partial gastrectomy, who were referred for PRG between April 2006 and April 2012, were retrospectively analyzed. The remnant stomach was punctured using a 21-gauge Chiba-needle. A single anchor was used for the gastropexy and a 12-Fr or 14-Fr gastrostomy tube was inserted. Data were collected regarding the technical success, procedure time, and presence of any complications. Univariable analyses were performed to determine the factors related to the technical success.

Results

Percutaneous radiologic gastrostomy was technically successful in 10 patients (53%), while a failed attempt and failure without an attempt were observed in 5 (26%) and 4 (21%) patients, respectively. Percutaneous radiologic jejunostomy was successfully performed in 9 patients who experienced technical failure. In the 10 successful PRG cases, the mean procedure time was 6.35 minutes. Major complications occurred in 2 patients, tube passage through the liver and pneumoperitonum in one and severe hemorrhage in the other. The technical success rate was higher in patients with Billroth I gastrectomy (100%, 6/6) than in patients with Billroth II gastrectomy (31%, 4/13) (p = 0.011).

Conclusion

Percutaneous radiologic gastrostomy can be successfully performed using the one-anchor technique in approximately half of the patients after partial gastrectomy.     

Incidence and Management of Bleeding Complications Following Percutaneous Radiologic Gastrostomy

Objective

Upper gastrointestinal (GI) bleeding is a serious complication that sometimes occurs after percutaneous radiologic gastrostomy (PRG). We evaluated the incidence of bleeding complications after a PRG and its management including transcatheter arterial embolization (TAE).

Materials and Methods

We retrospectively reviewed 574 patients who underwent PRG in our institution between 2000 and 2010. Eight patients (1.4%) had symptoms or signs of upper GI bleeding after PRG.

Results

The initial presentation was hematemesis (n = 3), melena (n = 2), hematochezia (n = 2) and bloody drainage through the gastrostomy tube (n = 1). The time interval between PRG placement and detection of bleeding ranged from immediately after to 3 days later (mean: 28 hours). The mean decrease in hemoglobin concentration was 3.69 g/dL (range, 0.9 to 6.8 g/dL). In three patients, bleeding was controlled by transfusion (n = 2) or compression of the gastrostomy site (n = 1). The remaining five patients underwent an angiography because bleeding could not be controlled by transfusion only. In one patient, the bleeding focus was not evident on angiography or endoscopy, and wedge resection including the tube insertion site was performed for hemostasis. The other four patients underwent prophylactic (n = 1) or therapeutic (n = 3) TAEs. In three patients, successful hemostasis was achieved by TAE, whereas the remaining one patient underwent exploration due to persistent bleeding despite TAE.

Conclusion

We observed an incidence of upper GI bleeding complicating the PRG of 1.4%. TAE following conservative management appears to be safe and effective for hemostasis.     

Value of Antibiotic Prophylaxis for Percutaneous Gastrostomy: A Double-Blind Randomized Trial

Purpose

To compare peristomal infection rates following percutaneous gastrostomy (PG) after a single dose of prophylactic antibiotics versus placebo and evaluate rates of peristomal infection in patients receiving concurrent antibiotics.

Single-Step Method for Pull-Type Gastrostomy Tube Placement

Single-step pull-type gastrostomy tube (PGT) placement is a method involving gastric puncture with a curved 18-gauge trocar needle allowing retrograde cannulation of the gastroesophageal junction without use of a sheath or snare. This retrospective review of 102 patients who underwent single-step PGT placement demonstrated 91% success in advancing the wire up the esophagus using only the curved trocar. Successful placement of a gastrostomy tube was 100%. Two major and 2 minor complications occurred within 30 days, all unrelated to the single-step technique. Mean fluoroscopy time for all patients was 5.1 min (range, 1.5–19.2 min). Single-step PGT placement is an effective, safe, fast, and equipment-sparing method for gastrostomy placement.     

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

Objective

We 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 Methods

Fourteen 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.

Results

We achieved successfully percutaneous gastrostomy using the modified technique in all patients without any major or minor complications after the procedure.

Conclusion

A 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.     

Early Initiation of Enteral Feeding in Cancer Patients after Outpatient Percutaneous Fluoroscopy-Guided Gastrostomy Catheter Placement

PurposeTo report the results of early enteral feeding in patients with cancer after outpatient placement of a percutaneous fluoroscopy-guided gastrostomy (PFG).Materials and MethodsFrom January 2008 through December 2008, 121 consecutive patients with cancer underwent outpatient placement of a PFG for nutrition. Of these patients, 118 patients met criteria for early feeding, and 113 were successfully fed early (after at least 3 hours). Of the patients fed early, 5 had insufficient follow-up for further analysis leaving 108 patients for outcomes analysis. After placement of the PFG, patients were put on low-wall suction via the PFG for 1 hour followed by feeding via the PFG at least 3 hours after placement. Follow-up evaluation was done the next business day. The medical records were reviewed for 30-day outcomes of early feeding, technical aspects of the procedures, and complications.ResultsAfter placement of the PFG, 98% (118 of 121) of patients met criteria for early feeding, and 93% (113 of 121) of patients were successfully fed early. The median time between the end of the procedure and initiation of feeding was 4 hours (interquartile range, 3.7–4.4 h). The 30-day minor complication rate was 14% (15 of 108), and the 30-day major complication rate was 1% (1 of 108). No complications were directly attributable to early feeding.ConclusionsEarly initiation of tube feedings after outpatient placement of a PFG was well tolerated in patients with cancer and carried comparable risks to previously reported results using traditional delayed feeding protocols. Early feeding provided patients with prompt enteral nutrition and eliminated the need for routine hospital admission after the procedure.     

Postpyloric Balloon Occlusion to Increase Technical Success during Pediatric Percutaneous Gastrostomy/Gastrojejunostomy Tube Placement

Gastric distension through insufflation is a key step in creating a safe percutaneous window during gastrostomy/gastrojejunostomy (G/GJ) placement; however, poor or incomplete gastric distention can occur, despite the use of glucagon, and lead to rapid egress of air from the stomach into the duodenum. This report describes the adjunctive technique using postpyloric balloon occlusion in 29 patients to maximize gastric insufflation during G/GJ tube placement after failure of conventional methods. Balloon occlusion was successful in salvaging 23 of 29 (79.3%) of G/GJ tube placements without any complications.     

Regional Anesthesia as an Alternative to Moderate Sedation for Perioperative Pain Control for Percutaneous Gastrostomy Tube Placement

Percutaneous gastrostomy tube placement is typically performed under moderate sedation. However, some patients are not ideal candidates for moderate sedation because of respiratory compromise, difficult airways, or other factors. The purpose of this study was to evaluate regional anesthesia as an alternative to moderate sedation. A retrospective review of patients who underwent percutaneous gastrostomy tube placement between March 2014 and September 2020 was performed. Data on patient demographics, anesthesia type, pain scores, and opiate usage were collected. A total of 189 patients were included in the study; 35 (18.5%) received regional anesthesia and 154 received moderate sedation. Patients in the regional anesthesia group tolerated the procedure well, with lower mean immediate postprocedural and maximal pain scores of 0.7 vs 2.2 (P = .011) and 4.3 vs 6.5 (P = .003), respectively. Regional anesthesia is effective at controlling perioperative pain and is an alternative with a low complication rate for patients who cannot tolerate moderate sedation.     

经皮胃造瘘术治疗肌萎缩侧索硬化症吞咽困难51例

目的 评价X线下经皮胃造瘘术(PRG)在51例肌萎缩侧索硬化症(ALS)吞咽困难患者中的临床应用,评估PRG对肺功能不全ALS患者的安全性及营养状况的改善作用.方法 回顾性分析51例行PRG手术的ALS患者.记录手术成功率,观察术后并发症情况.术后对患者进行定期随访,记录患者长期并发症及术后1、3、6个月病死率,评估术后营养状况的改变.结果 为51例ALS患者行PRG手术,手术成功率100％.7例患者(13.7％)出现轻微并发症,出现1例(2.0％)大出血严重并发症,术后未发现患者呼吸功能受损情况.术后1、3个月无患者死亡,术后6个月死亡3例(6.8％,3/44).术后1个月31例患者体重增加超过1 kg,平均BMI从术前18.60±2.14增加到19.27±1.81(术后1个月)、19.17±1.93(术后3个月)和18.89±2.33(术后6个月).结论 PRG无需胃镜和麻醉,降低了肺功能差的ALS患者的经皮胃造瘘术的误吸窒息风险,提高了手术成功率和安全性,是保证肺功能不全ALS患者足够的能量摄入、改善患者营养状况的有效手段之一.     

Percutaneous Gastrostomy Compared with Esophageal Stent Placement for the Treatment of Esophageal Cancer with Dysphagia

PurposeTo compare the outcomes of self-expandable metal stent placement and percutaneous gastrostomy (PG) for the treatment of patients with esophageal cancer (EC) and dysphagia.Materials and MethodsThis retrospective observational study consisted of 113 patients with EC and dysphagia who underwent either stent placement (n = 47) or PG (n = 66) at a single center between June 2014 and June 2018.ResultsThere were 63 men and 50 women, with a mean age of 76.5 years (standard deviation 4.9 years). The 2 groups had similar baseline characteristics, except that the PG group had a higher percentage of patients with cervical EC (22.7% vs 2.1%, P < .001). The PG group had better maintenance of nutritional status in terms of reduction in serum albumin level (P = .039) and weight loss (P = .041). Compared with the stent group, the PG group demonstrated a lower incidence of local severe pain (0% vs 21.3%, P < .001) and lower incidence of dislodgment of device (1.5% vs 19.1%, P = .002). The PG group demonstrated longer overall survival compared with the stent group for Stages II and III (201 vs 185 days, P = .034) and Stage IV (122 vs 86 days, P = .001).ConclusionsCompared with stent insertion, PG is associated with better maintenance of nutritional status, fewer complications, and better survival. Thus, PG may be the preferred choice for treating malnutrition in patients with EC and dysphagia.     

Percutaneous Ultrasound Gastrostomy: First-in-Human Experience with the PUMA-G System

Percutaneous ultrasound gastrostomy (PUG) technique was developed to allow for gastrostomy tube insertion to be performed solely under ultrasound guidance without need for fluoroscopy or endoscopy. This report discusses the new device, proposed PUG technique, and the first-in-human experience. Five patients had PUG tube insertion performed as part of a Health Canada approved investigational study. All procedures were successful with no complications within 30 days postprocedure. Mean total procedure time was 50 ± 13 minutes. Two of 5 procedures required temporary fluoroscopy use to localize the orogastric balloon position within the stomach to achieve magnetic gastropexy.     

Percutaneous radiologic gastrostomy with a simplified gastropexy technique under ultrasonographic and fluoroscopic guidance: experience in 154 patients

Purpose: To evaluate the effectiveness and safety of percutaneous radiologic gastrostomy (PRG) under ultrasonographic (US) and fluoroscopic guidance using a simplified gastropexy technique.

Material and Methods: One hundred and fifty-four (154) patients (mean age 73, range 22-93 years) were referred for PRG. Indication for PRG was neurologic disease, head/neck cancer, and other disease in 73%, 15%, and 12%, respectively. Initially, the stomach was filled with 300-500 cm³ of tap water via a nasogastric tube. The fluid-filled stomach was punctured under US guidance. A guidewire and a single T-fastener were introduced. Under fluoroscopic guidance, the tract was dilated over the guidewire until a 16F dilator with a peel-away sheath could be introduced. During dilatation, the external suture string to the T-fastener was held tight to fixate the gastric wall. A 14F balloon-retained gastrostomy tube was introduced and inflated. The T-fastener was then released, and the gastrostomy tube was retracted gently to affix the gastric wall to the abdominal wall (tube gastropexy). Technical success was assured by aspiration of gastric fluid and fluoroscopically by injection of a water-soluble contrast medium.

Results: The primary technical success rate was 98%. At 30-day follow-up, 3.2% had major complications and 14% minor complications. Three patients (1.9%) died of complications related to the procedure. Thirteen cases (8%) of simple tube displacement without other complications occurred.

Conclusion: PRG guided by US and fluoroscopy is a relatively safe technique with a high success rate, provided the stomach can be properly distended with fluid. However, tube gastropexy alone does not seem to protect against early dislodgement.     

CT-Guided Percutaneous Drainage of Pneumoperitoneum Presenting as Acute Abdomen

PurposeTo evaluate the feasibility and effectiveness of computed tomography (CT)-guided percutaneous drainage (PD) in patients with iatrogenic pneumoperitoneum presenting as acute abdomen.Materials and MethodsIn this retrospective, single-center cohort study, 16 consecutive patients (9 males, 7 females; median age, 67.5 [51–85] years) undergoing PD for managing acute abdomen caused by iatrogenic pneumoperitoneum between 2013 and 2019 were analyzed. Inclusion criteria were clinical signs of acute abdomen that was unresponsive to conservative management and pneumoperitoneum due to an iatrogenic cause after PD, observed using CT imaging. Volumetry of pneumoperitoneum was performed using computer-aided image segmentation. To evaluate the clinical outcome, the paired t-test was performed to analyze the course of pain intensity on the numerical pain rating scale (NPRS, 0–10). Patient records were reviewed to determine PD-related adverse events and median drain duration.ResultsThe median pneumoperitoneum volume was 891.1 (127.7–3,677.0) mL. All PD procedures were successfully performed, with symptom relief and immediate abdominal decompression (mean segmental volume reduction, 79.8% ± 13.5). Acute abdomen symptoms were resolved, with significant improvement in pain intensity between the day of the PD procedure and the first day after the procdure (mean NPRS scores, 3.3 ± 1.9 vs 0.8 ± 1.0; P < .001). The median drain duration was 2 (1–3) days. No PD-associated adverse events were observed. After PD, 14 patients required only conservative management, whereas 2 patients with anastomotic leakage required additional surgery as they showed signs of persisting sepsis and generalized peritonitis.ConclusionsPD is a safe and suitable procedure for the management of symptoms in patients with iatrogenic pneumoperitoneum presenting as acute abdomen.     

X线引导下鼻空肠管置入及临床应用

目的 探讨X线透视下鼻空肠管的置人及其临床应用价值.方法 89例因疾病限制不能经口进食而生命体征相对平稳的危重病患者,鼻空肠管经一侧鼻孔插入,在X线引导下将鼻空肠管插至十二指肠曲氏韧带附近或更远处的小肠.结果 全部病例鼻空肠管均顺利通过幽门插入预定位置,平均置管时间为14.5 min(7～55 min).置管中及置管后未发生严重并发症.经鼻空肠管滴(注)入营养液,促进了患者消化道功能恢复,改善了机体的营养状况,效果满意.结论 X线引导下经鼻鼻空肠管置入是一种安全、经济、有效的肠内给养途径,因而具有广泛的临床应用价值.     

Endovascular Treatment of Persistent Epistaxis due to Pseudoaneurysm Formation of the Ophthalmic Artery Secondary to Nasogastric Tube

We present the case of a 60-year-old man with persistent epistaxis for 20 days that had started 2 weeks after removal of a nasogastric tube placed for an abdominal operation. There was no pathologic finding at selective facial and internal maxillary artery injections. An injury to the ethmoidal branches of the ophthalmic arteries or other arterial origins of bleeding was suspected. The internal carotid artery angiography revealed a pseudoaneurysm of an anterior ethmoidal branch of the left ophthalmic artery. The pseudoaneurysm was occluded with NBCA-histoacryl (25%) injection.     

Replacement of Mushroom Cage Gastrostomy Tube Using a Modified Technique to Allow Percutaneous Replacement with an Endoscopic Tube in Patients with Amyotrophic Lateral Sclerosis

Radiologic inserted gastrostomy (RIG) is the preferred method in our institution for enteral feeding in amyotrophic lateral sclerosis (ALS). Skin-level primary-placed mushroom cage gastrostomy tubes become tight with weight gain. We describe a minimally invasive radiologic technique for replacing mushroom gastrostomy tubes with endoscopic mushroom cage tubes in ALS. All patients with ALS who underwent replacement of a RIG tube were included. Patients were selected for a modified replacement when the tube length of the primary placed RIG tube was insufficient to allow like-for-like replacement. Replacement was performed under local anesthetic and fluoroscopic guidance according to a preset technique, with modification of an endoscopic mushroom cage gastrostomy tube to allow percutaneous placement. Assessment of the success, safety, and durability of the modified technique was undertaken. Over a 60-month period, 104 primary placement mushroom cage tubes in ALS were performed. A total of 20 (19.2%) of 104 patients had a replacement tube positioned, 10 (9.6%) of 104 with the modified technique (male n = 4, female n = 6, mean age 65.5 years, range 48–85 years). All tubes were successfully replaced using this modified technique, with two minor complications (superficial wound infection and minor hemorrhage). The mean length of time of tube durability was 158.5 days (range 6–471 days), with all but one patient dying with a functional tube in place. We have devised a modification to allow percutaneous replacement of mushroom cage gastrostomy feeding tubes with minimal compromise to ALS patients. This technique allows tube replacement under local anesthetic, without the need for sedation, an important consideration in ALS.     

CT-Guided Placement of a Drainage Catheter Within a Pelvic Abscess Using a Transsacral Approach

A 66-year-old man underwent CT-guided drainage catheter placement within a pelvic abscess with a diameter of 46 mm. We performed the drainage by a transsacral approach because it was considered the safest and most feasible approach. An 8G bone marrow biopsy needle was used to penetrate the sacrum to create a path for subsequent drainage catheter insertion. After withdrawal of the biopsy needle, a 6 Fr catheter was advanced into the abscess cavity through the path using the Seldinger technique. Except for bearable pain, no procedure-related complications occurred. Twenty-nine days after the placement, the catheter was withdrawn safely and the abscess cavity had shrunk remarkably.