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Gastrostomy: Past and Present
Dr.Khayal Al Khayal
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
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
Overview: Outline
1. History of Gastrostomy
1.
2.
3.
4.
5.
Open temporary
Open permanent
Percutaneous endoscopic gastrostomy (PEG)
Percutaneous Radiologic Gastrostomy (PRG)
Laparoscopic Gastrostomy
2. Percutaneous endoscopic gastrostomy (PEG)
1.
2.
3.
4.
Indications and contraindications
Complications
Ethics
PEG vs. open Gastrostomy
Overview: Outline
3.
Laparoscopic Gastrostomy
1.
2.
3.
4.
Results
Complications
Laparoscopic vs. PEG
Percutaneous Radiologic Gastrostomy
1.
2.
3.
4.
Results
Complications
PRG vs. PEG
PRG vs. PEG vs. open gastrostomy
5. Conclusions
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
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
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
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
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
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
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
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
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 Gastrostomy
Costal Margin
Identification of site for PEG Placement
Percutaneous Endoscopic Gastrostomy
Infiltration and Skin Inscision
Percutaneous Endoscopic Gastrostomy
Insertion of Angiocatheter
Percutaneous Endoscopic Gastrostomy
Insertion of Guidewire
Percutaneous Endoscopic Gastrostomy
PEG pulled through abdominal wall
PEG in position with outer bolster
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
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
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
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
Ho et al., Clin. Radiol. 56, 902-910, 2001
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
Percutaneous Endoscopic Gastrostomy
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
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
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
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
Indications
Neurological Disorders (235)
Tracheoesophageal fistula (4)
Oropharyngeal disorders (42)
Inflamatory Myopathy (3)
Anorexia/cachexia (11)
Aspiration (6)
Esophageal Cancer/stricture (4)
Short Bowel (3)
Gastric decompression (3)
Conective tissue disease (2)
Macroglossia (1)
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
• 95% Technical Success
Failures 5% (15)
Not able to transilluminate (5)
Incidental gastric cancer (1)
Unable to pass scope (2)
Broken Gastrostomy tube (1)
Large diaphragmatic hernia (1)
Aspiration (1)
Bilroth II (1)
Laryngospasm (1)
Not able to dilate stricture (1)
Hematoma at gastrostomy site (1)
PEG: 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: Complications
Incidence of Free Air after Percutaneous Endoscopic Gastrostomy
Author
Year
# Patients
Incidence
Dulabon
2002
116
10
8.6%
Gottfried
1985
24
9
37.5%
Pidala
1992
30
7
23.3%
Wojtowycz (CT)
1988
18
10
55.5%
Percentage
• Dulabon: two pateints had laparotomy for clinical peritonits
(both Negative laparotomies)
• Gottfried: no patient required laparotomy
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
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
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
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)
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
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.
Anorexia-Cachexia
Syndrome
Yes
Do not offer
PEG
Patient unable
to make use of nutrients
Yes
Offer and
Recommend
Against PEG
Patient unable to
experience
any quality of life
Yes
Offer and recommend
PEG
Patient unequivocally
Benefits from PEG
No
Permanent
Vegetative State
No
Dysphagia without
Complications
No
Dysphagia with
complications
Yes
Discuss no PEG vs.
Trial of PEG
Patient equivocally
Benefits from PEG
and potential exists for loss
of quality of life
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
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
Laparoscopic Gastrostomy
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%)
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
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
Percutaneous Radiologic Gastrostomy
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 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
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
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
Major Complications
Radiologic %
PEG %
Significance
Wound
0.8
3.3
P<0.001
Aspiration
0.6
2.1
P<0.001
Peritonitis
1.3
0.5
P<0.001
Other GI
1.7
2.4
NS
Dislodged tube
1.3
0.9
NS
Other
0.1
0.1
NS
Total
5.9
9.3
P<0.001
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)
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%
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%