Modified catheter for percutaneous gastrojejunostomy

A catheter for gastrojejunostomy was modified to include a Cope-loop retention device in the proximal part of the catheter and multiple side holes in the distal part. The modification was made to prevent catheter dislodgment, which can lead to infusion of feeding solution into the peritoneum. The catheter has been used successfully in 71 patients, and only minor complications have been reported.     

X线引导下经皮胃造瘘术和鼻-胃营养管置入术的疗效比较

目的 探讨X线引导下经皮胃造瘘术和鼻-胃营养管置入术的临床疗效和安全性.方法 回顾性分析67例吞咽困难患者,其中喉癌14例,食管-纵隔瘘18例,颈段食管癌35例.22例行X线引导下经皮胃造瘘术,45例行X线引导下鼻-胃营养管置入术.结果 所有患者均成功实施介入治疗,技术成功率为100％.术后8d、1个月两组患者的血清白蛋白、前白蛋白和淋巴细胞计数较术前明显升高(P＜0.05).术后1、3个月两组患者的体重及生活质量较术前明显提升(P＜0.05).术后1个月胃造瘘组的血清白蛋白和生活质量明显高于鼻-胃营养管置入组(P＜0.05).术后两组的总并发症发生率差异无统计学意义(P＞0.05).胃造瘘组的治疗费用为鼻-胃营养管置入组的2.6倍.结论 X线引导下经皮胃造瘘术和营养管置入术均可改善患者的营养状况,且安全、有效,胃造瘘术的临床疗效优于营养管置入术,但费用较昂贵.     

Enteric feeding with gastric decompression: management with separate gastric accesses

OBJECTIVE: Our purpose is to describe our experience with combined enteral feeding and gastric decompression or drainage in debilitated patients with persistent gastroesophageal reflux using two separate catheters. CONCLUSION: The placement of two percutaneous catheters through separate skin sites is a feasible and successful approach to providing enteral feeding and gastric decompression or drainage in debilitated patients with persistent gastroesophageal reflux and aspiration pneumonia.     

Infracolic percutaneous gastrojejunostomy: Technical note

The authors describe and discuss the safe percutaneous placement of an infracolic gastrojejunostomy catheter in a burn patient with no other access route for nutritional support.     

Chronic intestinal obstruction: value of percutaneous gastrostomy tube placement

Percutaneous gastrostomy tubes were placed in six patients for treatment of nausea and vomiting associated with chronic intestinal obstruction. There were no complications related to the tubes, and in all patient, symptoms were relieved. For the patient, the advantages of gastrostomy over nasogastric drainage include improved comfort, increased mobility, and a decreased risk of pulmonary aspiration. Percutaneous gastrostomy is a safe procedure and provides excellent palliation for intractable nausea and vomiting in patients with chronic intestinal obstruction.     

Fluoroscopy-guided jejunal extension tube placement through existing gastrostomy tubes: analysis of 391 procedures

PURPOSE

We aimed to evaluate the safety and efficacy of fluoroscopically placed jejunal extension tubes (J-arm) in patients with existing gastrostomy tubes.

METHODS

We conducted a retrospective review of 391 J-arm placements performed in 174 patients. Indications for jejunal nutrition were aspiration risk (35%), pancreatitis (17%), gastroparesis (13%), gastric outlet obstruction (12%), and other (23%). Technical success, complications, malfunctions, and patency were assessed. Percutaneous gastrostomy (PEG) tube location, J-arm course, and fluoroscopy time were correlated with success/failure. Failure was defined as inability to exit the stomach. Procedure-related complications were defined as adverse events related to tube placement occurring within seven days. Tube malfunctions and aspiration events were recorded and assessed.

RESULTS

Technical success was achieved in 91.9% (95% CI, 86.7%–95.2%) of new tubes versus 94.2% (95% CI, 86.7%–95.2%) of replacements (P = 0.373). Periprocedural complications occurred in three patients (0.8%). Malfunctions occurred in 197 patients (50%). Median tube patency was 103 days (95% CI, 71–134 days). No association was found between successful J-arm placement and gastric PEG tube position (P = 0.677), indication for jejunal nutrition (P = 0.349), J-arm trajectory in the stomach and incidence of malfunction (P = 0.365), risk of tube migration and PEG tube position (P = 0.173), or J-arm length (P = 0.987). A fluoroscopy time of 21.3 min was identified as a threshold for failure. Malfunctions occurred more often in tubes replaced after 90 days than in tubes replaced before 90 days (P < 0.001). A total of 42 aspiration events occurred (OR 6.4, P < 0.001, compared with nonmalfunctioning tubes).

CONCLUSION

Fluoroscopy-guided J-arm placement is safe for patients requiring jejunal nutrition. Tubes indwelling for longer than 90 days have higher rates of malfunction and aspiration.Since enteral nutrition is the preferred method of nourishment for all patients with adequate intestinal length and function, a variety of access methods to the gastrointestinal tract has been developed (1). Endoscopy-guided percutaneous gastrostomy (PEG) tubes are commonly placed in patients in whom oral intake is contraindicated. However, a PEG tube may not be preferred in mechanically ventilated or critically ill patients due to risk of aspiration; in these, administration of the nutrients directly into the jejunum through a nasojejunal tube or a percutaneously placed jejunostomy tube is recommended so that the stomach is bypassed and the risk for aspiration is decreased (2). Other indications for direct administration of nutrients into the jejunum include malfunction of the swallowing mechanism, gastric outlet obstruction, gastroparesis, pancreatitis, and the presence of esophageal fistulas or enteric foregut leaks (3–8).Jejunal feeding tubes can be placed via the nasogastric route, but are not tolerated in the long-term as they can have irritating effects on the nostrils, nasopharynx, and esophagus, and predispose the patient to reflux (9). Hence, a wide variety of other methods for placing jejunal tubes are available, including surgical, fluoroscopy-guided, and endoscopy-guided placement (5). The conversion of an already existing PEG tube into percutaneous endoscopic gastrojejunostomy (PEGJ) tube is also available (10, 11). Another method is placement of a jejunal extension tube (J-arm) through a PEG tube; this is most commonly done endoscopically, usually at the same time that the gastrostomy tube is placed, and known as the gastrojejunostomy tube (12). However, endoscopic advancement of jejunal extension tube through a PEG tube can be difficult, particularly when the operator has no access to fluoroscopy to determine its exact position within the bowel (11). Furthermore, the need for jejunal tube feeds can become apparent only after placement of the PEG tube, at which point the patient may return to the endoscopic suite or to the fluoroscopic suite for jejunal extension tube placement.At our institution, placement of a J-arm through an existing PEG tube by the radiologist under fluoroscopic guidance followed by affixation of the tube to the existing PEG tube has been a routine procedure for almost 10 years. The method does not involve removal of the PEG tube, and omits the use of endoscopy, which makes conscious sedation unnecessary and avoids the complications related to endoscopic placement. The purpose of our study was to establish the safety and efficacy of jejunal extension tube placement utilizing only fluoroscopic guidance.     

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.     

Stomal metastases complicating percutaneous endoscopic gastrostomy: CT findings and the argument for radiologic tube placement

OBJECTIVE: This article describes the CT appearance of metastatic implantation at the percutaneous endoscopic gastrostomy (PEG) tract in patients with malignancy of the upper aerodigestive tract. Cumulative data from previous case reports are also considered for insight into causes of metastasis and the implications for gastrostomy placement in these patients. CONCLUSION: CT showed lobulated soft tissue involving the entire abdominal wall PEG tract in all proven cases. CT is an effective method for evaluation because the tumor burden lies predominately in the abdominal wall and not at the entry or exit site. The stomal implant is often the only site of metastatic disease at presentation. In general, CT findings of mildly increased soft tissue along the PEG tract are nonspecific, but a lobulated mass is highly suspicious for tumor implantation, especially if the one-sided thickness exceeds 1 cm. The preponderance of evidence from the existing literature points to direct tumor implantation during endoscopic placement as the likely cause (rather than hematogenous spread). This conclusion would support the alternative of radiologic tube placement in these patients.     

X线透视下经鼻十二指肠营养管的置入及临床应用

目的探讨X线透视下十二指肠营养管的置入及其临床应用价值。方法从2003年6月3日至2007年8月17日,59例患者在X线透视下行经鼻十二指肠营养管置入,置管成功后营养管末端位于十二指肠空肠连接部。结果59例患者中首次成功放置空肠营养管57例,成功率96.6%,2例患者因明显胃扩张首次置管失败后在充分胃肠减压后置管成功。置管时间为3.9～68.6 min,平均17.8 min。置管中及置管后未发生严重并发症。结论X线透视下经鼻十二指肠营养管置入是一种安全、经济、有效的肠内营养途径,因而具有广泛的临床应用价值。     

DSA影像监视下鼻肠营养管置入的技术与技巧

目的 回顾性分析总结DSA影像监视下放置鼻肠营养管建立肠内营养的技术.方法 441例患者置入鼻肠营养管.鼻、叫部喷雾麻醉后,存DSA影像监视下,经导丝引导导管依次经鼻、咽、食管、胃、幽门、十二指肠各部使导管头端位于水平部,置换入加硬导丝沿加硬导丝送入鼻肠营养管并将其头端送至屈氏韧带以下20～30 cm.结果 全部病例平均在5 min内成功放置肠道营养管,营养管位置满意,无一例出现并发症.结论 应用DSA影像监视能够快速、简便、安全的放置鼻肠营养管,成功率高,患者无痛苦,值得临床推广应用.     

Gastroduodenal stent placement versus surgical gastrojejunostomy for the palliation of gastric outlet obstructions in patients with unresectable gastric cancer: a propensity score-matched analysis

Objectives

To compare the outcomes between stent placement and surgical gastrojejunostomy (GJ) for the palliation of gastric outlet obstruction (GOO) in patients with unresectable gastric cancer.

Methods

A retrospective study was performed in a single university hospital in 224 patients with GOO, and who were treated either by stent placement (n?=?124) or surgical GJ (n?=?100). The outcomes were assessed with reference to the following variables with the use of propensity-score matching: success rates; complications; dysphagia scores, albumin, and body mass index; survival; symptom-free duration; and hospitalization.

Results

We identified a well-balanced cohort of 74 pairs of patients, matched on the basis of propensity score. The dysphagia score 7 days after treatment was significantly better in the stent group (P?<?0.001). Albumin level 1 month after treatment was significantly lower in the stent group (P?<?0.001). Symptom-free duration and hospitalization were significantly longer in the surgery group (P?=?0.002, P?<?0.001, respectively). The recurrence rate was significantly higher in the stent group (P?=?0.032).

Conclusions

Stent placement can provide faster symptom relief and shorter hospitalization, while surgical GJ can provide longer symptom-free duration, less recurrent obstruction symptoms and better nutritional status.

Key Points

? The two methods are equally effective in palliating gastric outlet obstruction symptoms ? The stent group showed rapid and efficient palliation of symptoms ? Recurrent symptoms were more frequent in the stent group ? Surgical gastrojejunostomy provides a longer symptom-free duration and better nutritional status

     

Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach

Twenty-five percutaneous gastrostomies and nine percutaneous gastrojejunostomies were performed in 24 children aged 4 months to 22 years. Indications for percutaneous gastrostomy included severe injury to the central nervous system (nine patients), malignancy (seven patients), failure to thrive (four patients), degenerative central nervous system disease (one patient), and miscellaneous conditions (three patients). All procedures were performed under local anesthesia and sedation. An antegrade approach is described for percutaneous gastrostomy and percutaneous gastrojejunostomy placement. No major complication occurred, and only three skin infections have been encountered. The children were evaluated and followed up by a nutritional support team. Early experience with percutaneous gastrostomy and percutaneous gastrojejunostomy in the pediatric population suggests that the technique is safe and applicable to children of all ages and sizes. In particular, the antegrade approach appears to be an acceptable solution for enteric alimentation.     

Fluoroscopically guided nasoenteric feeding tube placement: results of a 1-year study

Nasoenteric tube feeding is a widely used alternative to parenteral intravenous nutritional support or gastrostomy tube placement. Unmonitored tube passage may result in complications and delays the beginning of tube feedings. The authors studied the results of 882 fluoroscopically guided feeding tube placements in 448 patients in 1 year to determine rates of success and complications, as well as the long-term outcome of this population of patients. Seven hundred sixty-four attempts (86.6%) were successful in positioning the tube distal to the third portion of the duodenum. Four major complications (three fatal arrhythmias and one tracheobronchial injury) were encountered. Only seven patients (2%) experienced aspiration events that were due to positioning of the tube in the distal duodenum. Seventy-seven percent of patients required either one or two tubes; the average "tube life" was 7.8 days. Most repositionings were required because of patient noncompliance or inappropriate administration of solid medications. Fluoroscopically guided nasoenteric tube passage is safe, easily performed, and highly successful, and has resulted in widespread clinical acceptance in our institution.