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Gastrostomy: Past and Present

Overview: Gastrostomy. The delivery of health care has changed over the past two decadesMore aggressive approach to the placement of tube gastrostomies Earlier return to homeTransfer to chronic care facilityObvious benefits of enteral feeding over parenteral nutrition. Overview: Gastrostomy

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Gastrostomy: Past and Present

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    1. Gastrostomy: Past and Present Dr.Khayal Al Khayal

    2. Overview: Gastrostomy The delivery of health care has changed over the past two decades More aggressive approach to the placement of tube gastrostomies Earlier return to home Transfer to chronic care facility Obvious benefits of enteral feeding over parenteral nutrition

    3. Overview: Gastrostomy Open surgical gastrostomies have been supplanted by closed procedures These procedures are generally safe and effective Complications are frequent Surgeon must be aware of both the options for enteral access and complications related to tube gastrostomies

    4. Overview: Outline History of Gastrostomy Open temporary Open permanent Percutaneous endoscopic gastrostomy (PEG) Percutaneous Radiologic Gastrostomy (PRG) Laparoscopic Gastrostomy Percutaneous endoscopic gastrostomy (PEG) Indications and contraindications Complications Ethics PEG vs. open Gastrostomy

    5. Overview: Outline Laparoscopic Gastrostomy Results Complications Laparoscopic vs. PEG Percutaneous Radiologic Gastrostomy Results Complications PRG vs. PEG PRG vs. PEG vs. open gastrostomy Conclusions

    6. History 1837: Egeberg first to suggest gastrostomy 1849: Sedillot of Strausbourg, performed first gastrostomy in human patient patient died ten days later of peritonitis 1869: Maury was the first American to perform a gastrostomy this patient died as well 1870: Nine reported cases of gastrostomy in the literature All the patients died Usually of peritonitis

    7. History 1876: Verneuil performed first successful gastrostomy oppossed visceral and parietal surfaces with silver wire used for feeding problems with leakage of gastric juice 1880: L.L. Staton first succesful gastrostomy in America 8 yr old boy with a lye stricture of the esophagus opposed visceral and parietal surfaces patient chewed food and ejected it into feeding tube Patient reportedly lived fifteen years

    8. 1891: Witzel Gastrostomy Pursestring suture is placed in anterior stomach Incision is made in the stomach Tube is passed for 5cm and pursestring secured Additional sutures are placed to imbricate the gastric wall Stomach is then secured to the abdominal wall

    9. 1894: Stamm Gastrostomy Anterior wall of mid-stomach Separate incision in abdominal wall for exit of gastrostomy Pursestring suture is placed followed by incision into the stomach Feeding tube then inserted into stomach and pursestring secured Second pursestring placed to invaginate the first pursestring Stomach is then secured to the abdominal wall

    10. Early 1900s: Janeway Gastrostomy Mucosa lined permanent gastrostomy flap of stomach 5-6 cm in width is made Flap is then made into a tube by approximating the edges A feeding tube is then advanced into stomach the tube is then brought out through abdominal wall mucosa sutured to the abdominal skin

    11. Early 1900s: Beck-Jianu Gastrostomy Permanent mucosa lined Long gastric tube fashioned from the greater curve based on the left gastroepiploic a. Gastrocolic ligament and gastrosplenic omentum divided stomach is divided longitudinally and sutured Tube is then exteriorized and mucosa is secured to skin Can use GI stapling device

    12. 1939: Glassman’s Gastrostomy Mucosa lined leakage of gastric juice prevented by formation of coned shape diverticulum anterior wall of stomach grasped with Babcock clamp pulled up into cone shape pursestring suture placed around base second and third pursestring are placed above Lambert sutures are then placed to create circular valve

    13. 1980: Percutaneous Endoscopic Gastrostomy Gauderer and Ponsky (J. Ped. Surg., 15:872, 1980) Gastrostomy without laparotomy “Pull Technique” pre-procedure antibiotic prophylaxis Intravenous sedation and local anesthesia Gastroscopy is performed and the stomach insufflated with air and transilluminated Site for placement selected and a small 5-8mm incision is made Intravenous catheter is quickly introduced through abdominal and gastric walls and needle removed

    14. Percutaneous Endoscopic Gastrostomy (PEG) “Pull Technique” Guidewire grasped with snare Snare, guidewire and gastroscope pulled through mouth Commercially available PEG tube is then attached to guidewire PEG pulled retrograde through mouth, esophagus, stomach, stomach wall and abdominal wall Gastroscope re-inserted to confirm positioning of PEG Tension is applied to the PEG to ensure gentle approximation of stomach and abdominal wall Outer bolster then applied to secure position

    15. Percutaneous Endoscopic Gastrostomy

    16. Percutaneous Endoscopic Gastrostomy

    17. Percutaneous Endoscopic Gastrostomy

    18. Percutaneous Endoscopic Gastrostomy

    19. Percutaneous Endoscopic Gastrostomy

    20. Percutaneous Endoscopic Gastrostomy “Push Technique” (Sacks et al., Inves Rad 1983: 18:485-487) Guidewire pulled through the mouth and gastrostomy tube loaded onto the wire Gastrostomy tube pushed into stomach Once seen emerging from anterior abdominal wall, tube is grasped and pulled into position Gastroscope re-inserted to confirm position

    21. Percutaneous Endoscopic Gastrostomy “Introducer Technique” (Russel et al., AM J Surg 1984;148: 132-137) Endoscopist is observer Puncture is performed as usual Guidewire inserted Introducer with outer sheath is then passed over wire into gastic lumen Foley then passed through sheath Sheath then peeled away Traction placed on balloon and secured

    22. Percutaneous Endoscopic Gastro-Jejeunostomy Gastric feedings may be inappropriate: Gastric Atony Gastroesophageal reflux PEG can be modified to provide jejunal feeding Guidewire is passed through previous PEG and advanced to duodenum Feeding tube is then advanced over wire into dudenum

    23. 1981: Radiological Percutaneous Gastrostomy Percutaneous gastrostomy for jejunal feeding. Pershaw RM. Surg Gyne Obstet 1981;152:659-660 U/S performed to ensure liver not over puncture site Stomach is distended with CO2 via NG Stomach punctured with needle Gastropexy to anchor stomach wall to abdominal wall Guidewire passed into stomach and dilated to 16 Fr Catheter then advanced over guidewire into stomach and confirmed with contrast

    24. 1990: Laparoscopic Gastrostomy Edleman and Unger (Surg Gyne Obstet 173: 401, 1991) Local or general anesthesia CO2 insufflation 5mm umbilical port and mid epigastric ports Stomach is grasped and a site selected below left costal margin 7 cm 18 guage needle catheter is guided into the stomach a J-wire fed into stomach Dilators are passed over the wire 16 Fr peel away sheath finally placed and balloon feeding tube fed into stomach

    25. Percutaneous Endoscopic Gastrostomy

    26. Gastrostomy: Indications Health Sciences Centre 2000-2001: 104 PEGs 2001-2002: 109 PEGs Patients who have an intact, functional gastrointestinal tract but are unable to consume sufficient calories to meet metabolic needs. neurologic conditions associated with impaired swallowing neoplasms of the oropharynx, larynx and esophagus. facial trauma supplemental feedings in patients with miscellaneous catabolic conditions Gastric decompression

    27. PEG: Contraindications Percutaneous endoscopic gastrostomy: indications, limitations, techniques, and results. Ponsky et al. World J Surg. 1989 Mar-Apr;13(2):165-70. Absolute: Inability to bring the anterior gastric wall in apposition to the anterior abdominal wall prior subtotal gastrectomy ascites marked hepatomegaly Careful evaluation to determine if stomach can reach abdominal wall Intestinal obstruction

    28. PEG: Contraindications Percutaneous endoscopic gastrostomy: indications, limitations, techniques, and results. Ponsky et al. World J Surg. 1989 Mar-Apr;13(2):165-70. Relative: Obesity proximal small bowel fistula neoplastic and infiltrative diseases of the gastric wall obstructing esophageal lesions

    29. PEG: Indications Percutaneous endoscopic gastrostomy Indications, success, complications, and mortality in 314 consecutive patients Larson DE et al., Gastroenterology 1987 Jul;93(1):48-52

    30. PEG: Success and Failure Percutaneous endoscopic gastrostomy Indications, success, complications, and mortality in 314 consecutive patients Larson DE et al., Gastroenterology 1987 Jul;93(1):48-52

    31. PEG: Complications Larson DE et al., Gastroenterology 1987 Jul;93(1):48-52

    32. PEG: Complications

    33. PEG: Rare Complications Colocutaneous fistula (Yamazaki et al., Surg Endosc 1999;13:280-282) Approx. 11 cases in literature Penetration of transverse colon at tube placement Excessive tension of tube and tube migration 5 of 11 cases previous abdominal surgery 8 of 11 cases presented >6 weeks post placement Peritonitis requires surgery However, can be treated with tube removal Fistula usually closes spontaneously

    34. PEG: Rare Complications Squamous cell carcinoma at PEG site (Ananth and Amin Br J Oral Max Surg 2002;40:125-130) Head and Neck Cancer is a common indication for PEG 18 Cases in the literature All used “pull method” No cases reported using the “introducer method” Implantation vs. hematogenous vs. local spread 11 cases had other metastatic disease, 7 no other mets

    35. PEG: Rare Complications Squamous cell carcinoma at PEG site (Ananth and Amin Br J Oral Max Surg 2002;40:125-130) Local trauma at gastrosotmy placement may predispose to hematogenous and lymphatic spread Perhaps best to place tube after resection/debulking of tumour Biopsy suspicious granulation tissue around PEG site

    36. PEG: Long-Term Outcome Long-term survival in patients undergoing percutaneous endoscopic gastrostomy and jejunostomy Wolfson HC wt al., Am J Gastroenterol 1990 Sep;85(9):1120-2 Retrospective Review: 191 patients 64% Benign disease 53% benign mechanical obstruction or disordered swallowing 11% inability to maintain eneteral nutrition 36% Cancer 12% local disease 24% systemic disease Patients followed for a mean of 275 days (median 114 days)

    37. PEG: Long-Term Outcome Long-term survival in patients undergoing percutaneous endoscopic gastrostomy and jejunostomy Wolfson HC wt al., Am J Gastroenterol 1990 Sep;85(9):1120-2 Patients followed for a mean of 275 days (median 114 days) Total mortality: 60% (115 patients) Median time to expiration: 164 days 21% (40 patients) died within 30 days (no procedure deaths) 21% (40 patients) had their tube removed after recovery 16% benign disease, 5% cancer Overall, high cummulative mortality Benefits are limited if projected early mortality Benefit in facilitating patient discharge from hospital to other long term care facilities

    38. PEG: Ethics Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Rabeneck L. et al., Lancet. 1997 Feb 15;349(9050):496-8.

    39. PEG vs. Stamm Gastrostomy Endoscopic vs. operative gastrostomy final results of a prospective randomized trial Steigmann, Silas et al., Gastrointest Endosc Jan-Feb; 36(1):1-5 1990 57 patients Stamm gastrostomy, 64 patients PEG Groups equally matched for underlying disease 100% (57 of 57) success for Stamm 95% (61 of 64) success for PEG, 2 had successful Stamm 4 PEG patients had migration of tube through stomach 3 PEG patients had bleeding requiring transfusion Complications similar (26% vs 25%) Costs: Stamm $1675 vs PEG $979

    40. PEG vs. Stamm Gastrostomy Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy Grant JP. Ann Surg May;207(5):598-603 1988 Retrospective: 125 PEG and 88 Stamm Less total operating time: PEG 38 min vs. Stamm 96 min Complications: PEG 8.8% (4% major) vs. Stamm 23.9% (10% major) only one PEG patient required laparotomy PEG associated with $1000 less cost

    41. Laparoscopic Gastrostomy

    42. Laparoscopic Gastrostomy First results of laparoscopic gastrostomy Peitgen K et al., Surg Endosc Jun;11(6):658-62 1997 Retrospective review of 42 laparoscopic gastrostomies Locally advanced oropharyngeal cancer and esophageal cancers Operative time: 38 minutes Procedure could be performed in all patients Procedure related mortality: 0% Major complications: 2/42 (4.7%) Gastric perforations due to grasping forcep Laparotomy after falsely interpreted contrast radiograph Minor complications: 4/42 (9.4%)

    43. Laparoscopic and Open Gastrostomy Laparoscopic Gastrostomy: A safe method for obtaining enteral access Murayama KM et al., J Surg Res Jan;58(1):1-5 1995 Retrospective review Patients who could not undergo gastroscopy 32 patients laparoscopic and 37 open gastrostomy General anesthesia in 94% of laparoscopic and 73% of open gastrostomies Major complications: 6% of laparoscopic and 11% of open gastrostomy Operative time: Laparoscopic 38 min vs. 62 min No difference in mortality Safe alternative for patients that cannot under go PEG

    44. PEG and Laparoscopic Gastrostomy Laparoscopic gastrostomy versus percutaneous endoscopic gastrostomy Edelman DS, Arroyo PJ, Unger SW. Surg Endosc 1994 Jan;8(1):47-9 Retrospective review 17 patients PEG and 14 patients laparoscopic gastrostomy Laparoscopic procedures performed for inablilty to perform gastroscopy No difference in complications one death in laparoscopic group due to tube dislodgement and intraperitoneal feeding

    45. Percutaneous Radiologic Gastrostomy

    46. Percutaneous Radiologic Gastrostomy (PRG) Percutaneous gastrostomy in patients who fail or are unsuitable for endoscopic gastrostomy. Thornton FJ et al., Cardiovasc Intervent Radiol. Jul-Aug;23(4):279-84. 2000 42 patients unsuitable for PEG Unable to perform gastroscopy (15) Subopitmal transillumination (22) Advanced cardiorespiratory disease (5) Technical success in 41/42 (98%) CT guidance required in 4 cases 3 intercostal and 6 under the costal margin tube placement 3 major complications: Intraperitoneal tube placement Bleeding requiring transfusion Severe gastrostomy site infection

    47. PEG and Radiologic Gastrostomy Percutaneous Radiologic and Endoscopic Gastrostomy: A 3 Year Intstitutional Analysis of Procedure performance Wollman B and D’Agostino HB. AJR 1997 Dec;169:1551-1553 Retrospective Review: 68 Percutaneous radiologic gastrostomies 114 Endoscopic gastrostomies Success rate: 100% for PRG and 95% PEG PRG performed in 4/6 patients that failed PEG Incidental findings in 30% of PEG patients 66% no action taken the remaining had biopsy and/or medications (esophagitis, stricture, Barrett’s, gastritis, ulcer) No difference in procedure related mortality or complications

    48. PEG and Radiologic Gastrostomy Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature Wollman B et al., Radiology 1995 Dec;197(3):699-704 837 patients radiologic gastrostomy, 4194 underwent PEG, 721 open gastrostomy Successful tube placement higher for radiologic vs PEG (99.2% vs. 95.7% p<0.001) No difference in procedure related mortality

    49. PEG and Radiologic Gastrostomy Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature Wollman B et al., Radiology 1995 Dec;197(3):699-704

    50. PEG and Radiologic Gastrostomy Outcomes of surgical, percutaneous endoscopic, and percutaneous radiologic gastrostomies Cosentini EP, Arch Surg 1998 Oct;133(10):1076-83 Retrospective Review: 14 patients surgical gastrostomy 24 patients PEG 44 Percutaneous radiological gastrastomy 1 procedure related death in the radiological group (aspiration followed by multiorgan failure) No difference in minor and major complications complications 3 patients in radiological group needed early laparotomy for tube dislodgement (2 patients) and tear off of T-bolster (1 patient) 10% lower tube function rate in radiological group (16F vs. 22F)

    51. Conclusions Percutaneous Endoscopic Gastrostomy is the most common means of establishing eneteral nutrition Can be performed at the bedside Minor Complications: 2-36% Major Complications: 0-17% Percutaneous Radiological Gastrostomy is a reasonable alternative to PEG and may be the procedure of choice when PEG fails More difficulty in maintaining tube patency Minor Complications: 2.9-33% Major Complications: 0-11%

    52. Conclusions Laparoscopic Gastrostomy alternative to open gastrostomy in patients who are unsuitable for both PEG and PRG Minor Complications: 2-19% Major Complications: 0-6%

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