Gastrostomy: Past and Present Dr.Khayal Al Khayal

Gastrostomy: Past and PresentGastrostomy: Past and Present

Dr.Khayal Al Khayal

Overview: GastrostomyOverview: 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

Overview: GastrostomyOverview: 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

Overview: OutlineOverview: Outline

1. History of Gastrostomy1. Open temporary

2. Open permanent

3. Percutaneous endoscopic gastrostomy (PEG)

4. Percutaneous Radiologic Gastrostomy (PRG)

5. Laparoscopic Gastrostomy

2. Percutaneous endoscopic gastrostomy (PEG)1. Indications and contraindications

2. Complications

3. Ethics

4. PEG vs. open Gastrostomy

Overview: OutlineOverview: Outline

3. Laparoscopic Gastrostomy1. Results

2. Complications

3. Laparoscopic vs. PEG

4. Percutaneous Radiologic Gastrostomy1. Results

2. Complications

3. PRG vs. PEG

4. PRG vs. PEG vs. open gastrostomy

5. Conclusions

HistoryHistory• 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

HistoryHistory• 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

1891: Witzel Gastrostomy1891: 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

1894: Stamm Gastrostomy1894: 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

Early 1900s: Janeway GastrostomyEarly 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

Early 1900s: Beck-Jianu GastrostomyEarly 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

1939: Glassman’s Gastrostomy1939: 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

1980: Percutaneous Endoscopic Gastrostomy1980: 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

Percutaneous Endoscopic Gastrostomy (PEG)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

Percutaneous Endoscopic GastrostomyPercutaneous Endoscopic Gastrostomy

Identification of site for PEG Placement

Costal Margin


Infiltration and Skin Inscision


Insertion of Angiocatheter


Insertion of Guidewire


PEG pulled through abdominal wall

PEG in position with outer bolster


• “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


• “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

Percutaneous Endoscopic Gastro-JejeunostomyPercutaneous 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

1981: Radiological Percutaneous Gastrostomy1981: 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

Ho et al., Clin. Radiol. 56, 902-910, 2001

1990: Laparoscopic Gastrostomy1990: 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


Gastrostomy: IndicationsGastrostomy: 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

PEG: ContraindicationsPEG: ContraindicationsPercutaneous 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

PEG: ContraindicationsPEG: 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

PEG: IndicationsPEG: Indications

Percutaneous endoscopic gastrostomy Indications, success, complications, and mortality in 314 consecutive

patientsLarson DE et al., Gastroenterology 1987 Jul;93(1):48-52

Tracheoesophageal fistula (4)

Inflamatory Myopathy (3)

Short Bowel (3)

Gastric decompression (3)

Conective tissue disease (2)

Macroglossia (1)

Neurological Disorders (235)

Oropharyngeal disorders (42)

Anorexia/cachexia (11)

Aspiration (6)

Esophageal Cancer/stricture (4)

Indications

PEG: Success and FailurePEG: Success and Failure

Percutaneous endoscopic gastrostomy Indications, success, complications, and mortality in 314 consecutive

patientsLarson DE et al., Gastroenterology 1987 Jul;93(1):48-52

Not able to transilluminate (5)

Unable to pass scope (2)

Large diaphragmatic hernia (1)

Bilroth II (1)

Not able to dilate stricture (1)

Failures 5% (15)

Incidental gastric cancer (1)

Broken Gastrostomy tube (1)

Aspiration (1)

Laryngospasm (1)

Hematoma at gastrostomy site (1)

• 95% Technical Success

PEG: ComplicationsPEG: Complications

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

Minor Complications (13%)

•Wound Infections (18 patients)

•Tube dislodged (6 pateints)

•Ileus/Ogilvie’s (4 patients)

•Fever (3 patients)

•Aspiration (3 patients)

•Stomal Leak (2 patients)

•Anorexia (2 patients)

•Tube migration (1 patient)

•Hematoma (1 patient)

Major complication (3% )

•Death (3 pateints: Aspiration=2, laryngospasm=1)

•Gastric Perforation (4 patients)

•Gastric Bleed (2 patients)

•Hematoma (1 patient)

PEG: ComplicationsPEG: Complications

Incidence of Free Air after Percutaneous Endoscopic Gastrostomy

Dulabon

Gottfried

Pidala

Wojtowycz (CT)

Author Year # Patients Incidence Percentage

2002

1985

1992

1988

116

24

30

18

10

9

7

10

8.6%

37.5%

23.3%

55.5%

• Dulabon: two pateints had laparotomy for clinical peritonits (both Negative laparotomies)

• Gottfried: no patient required laparotomy

PEG: Rare ComplicationsPEG: 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

PEG: Rare ComplicationsSquamous 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

PEG: Rare ComplicationsPEG: 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

PEG: Long-Term OutcomePEG: 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)

PEG: Long-Term OutcomePEG: 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

PEG: EthicsPEG: Ethics

Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement.

Rabeneck L. et al., Lancet. 1997 Feb 15;349(9050):496-8.

Anorexia-Cachexia Syndrome

Permanent Vegetative State

Dysphagia withoutComplications

Dysphagia with complications

Do not offerPEG

Offer and RecommendAgainst PEG

Offer and recommend PEG

Discuss no PEG vs. Trial of PEG

Patient unable to make use of nutrients

Patient unable to experience any quality of life

Patient unequivocallyBenefits from PEG

Patient equivocallyBenefits from PEG and potential exists for loss of quality of life

No

No

No

Yes

Yes

Yes

Yes

PEG vs. Stamm GastrostomyPEG 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

PEG vs. Stamm GastrostomyPEG 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

Laparoscopic GastrostomyLaparoscopic Gastrostomy

Laparoscopic GastrostomyLaparoscopic Gastrostomy

First results of laparoscopic gastrostomyPeitgen 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%)

Laparoscopic and Open GastrostomyLaparoscopic 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

PEG and Laparoscopic GastrostomyPEG 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

Percutaneous Radiologic GastrostomyPercutaneous Radiologic Gastrostomy

Percutaneous Radiologic Gastrostomy (PRG)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

PEG and Radiologic GastrostomyPEG and Radiologic GastrostomyPercutaneous Radiologic and Endoscopic Gastrostomy: A 3 Year

Intstitutional Analysis of Procedure performanceWollman 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

PEG and Radiologic GastrostomyPEG and Radiologic Gastrostomy

Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the

literatureWollman 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

PEG and Radiologic GastrostomyPEG and Radiologic Gastrostomy

Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the

literatureWollman B et al., Radiology 1995 Dec;197(3):699-704

Major Complications Radiologic % PEG % Significance

Wound

Aspiration

Peritonitis

Other GI

Dislodged tube

Other

0.8

0.6

1.3

1.7

1.3

0.1

3.3

2.1

0.5

2.4

0.9

0.1

P<0.001

P<0.001

P<0.001

NS

NS

NS

5.9 9.3Total P<0.001

PEG and Radiologic GastrostomyPEG and Radiologic GastrostomyOutcomes 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)

ConclusionsConclusions• 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%


ConclusionsConclusions

• Laparoscopic Gastrostomy alternative to open gastrostomy in patients who are unsuitable for both PEG and PRG

• Minor Complications: 2-19%


Documents

Gastrostomy: Past and Present Dr.Khayal Al Khayal