Abdominal Imaging
ª Springer Science+Business Media, LLC 2008 Published online: 7 January 2009
Abdom Imaging (2010) 35:189–194 DOI: 10.1007/s00261-008-9496-1
Percutaneous radiologic gastrostomy: a modified Chiba-needle puncture technique with single gastropexy Ji Hoon Shin, Ho-Young Song, Tae-Hyung Kim, Kyung-Rae Kim, K. Eugene Choi, Jin Hyoung Kim Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
Abstract Background: To evaluate the feasibility, safety, and effectiveness of percutaneous radiologic gastrostomy (PRG) with a modified Chiba-needle puncture technique with the use of a single gastropexy in the same puncture tract. Methods: In 80 patients with dysphagia, the stomach was punctured with a 21-gauge Chiba-needle, which was exchanged for a 6-Fr Neff catheter. Eleven patients with a high-lying stomach and four patients with surgically altered gastric morphology were included. A Cope suture anchor was then deployed into stomach lumens through the Neff catheter to achieve gastropexy. Then, following serial dilation, a 14-Fr diameter locking loop catheter was inserted. Results: All 80 patients successfully underwent PRG. Only a single puncture attempt was required for 78 patients (98%) and two attempts for two patients each. The average procedure time was 5 min 38 s. Three patients (3.8%) had major complications such as hemorrhage, deep stomal infection, and worsening pneumoperitoneum requiring tube removal. Procedure-related mortality and 30-day mortality was 0% and 5%, respectively. Conclusions: PRG with the modified Chiba-needle puncture technique with use of single gastropexy in the same puncture tract was feasible, safe, and effective, especially in patients with high-lying or surgically altered stomachs. Key words: Enterostomy—Percutaneous gastrostomy—Gastropexy—High-lying stomach—Surgically altered stomach
Gastrostomy provides access for enteral nutrition in patients for whom oral intake is either impossible or unsafe, as well allows for palliative decompression in patients with proximal small bowel or gastric outlet obstructions. Traditionally, the stomach is punctured using a 15–18-gauge bevelled needle preloaded with a Cope suture anchor. The Cope suture anchor is then pushed into the stomach with a 0.035-inch guide wire or an Amplatz guide wire [1–7]. Puncture of the stomach with bevelled needles whose tips afford extensive cutting action can be associated with vascular injury [1]. There remains some controversy as to the number of Cope suture anchors that are sufficient. The number of anchoring devices for gastropexy varies from one through the same puncture tract to four placed in the form of a square around the tract [3, 6, 8–10]. Theoretically, the greater number of Cope suture anchor increases the fixating force for tube placement, but also increases the risk of bleeding or skin excoriations. To date, reports on gastrostomy using a 21- or 22-gauge Chiba-needle are limited [11, 12] and use of single gastropexy is also limited [3, 8]. The purpose of this study was therefore to evaluate the feasibility, safety, and effectiveness of percutaneous radiologic gastrostomy (PRG) with a modified Chiba-needle puncture technique with the use of single gastropexy in the same puncture tract.
Materials and methods Permission was granted by the Institutional Review Board of our hospital prior to the study; informed consent for the medical record review was waived.
Patients Correspondence to: Ji Hoon Shin; email:
[email protected]
From July 2006 to October 2007, percutaneous gastrostomy was attempted in 80 consecutive patients using the
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modified Chiba-needle technique and gastropexy. Fiftynine men and 21 women were included in this study (mean age: 63.2 years, range: 15–95 years). The majority of indications for gastrostomy were either the inability or difficulty in swallowing due to head and neck cancer (n = 26), neurodegenerative disease (n = 23), organic brain damage (n = 21), advanced oesophageal cancer (n = 4), or lung cancer with a bronchoesophageal fistula (n = 2). Miscellaneous indications (n = 4) included dysphagia or poor peroral intake secondary to upper gastrointestinal tract pathology (i.e., esophageal perforation, gastric cancer involving the cardia) or generalized poor medical condition (i.e., chronic obstructive pulmonary disease, aortic dissection). A high-lying stomach (i.e., stomach being positioned under the lower left rib cage) was observed in 11 patients. In three of these cases, percutaneous endoscopic gastrostomy (PEG) was attempted prior to PRG, but PEG failed because of inadequate transillumination of the anterior abdominal wall by the gastroscope light. Three patients had undergone subtotal gastrectomies, and a single case of esophagocologastrostomy was also included. The 80 patients were treated consecutively, and no qualified cases were excluded from the study. Informed consent for the procedures was obtained from all patients.
anchored to the abdominal wall, the puncture site was serially dilated over the 0.035-inch superstiff guide wire to allow placement of a 14-Fr diameter locking loop catheter (Cook).
Technique A nasogastric tube was used to inflate the stomach with approximately 300–400 mL of air. This increased stomach size made it an easier target for puncture and also brought the anterior stomach wall into contact with the anterior abdominal wall. Anteroposterior and lateral radiographs were then performed to ensure that the stomach lay in contact with the anterior abdominal wall with no interposing bowel and that the transverse colon had been deflected inferiorly. Our technique consists of a single puncture of the stomach, creating a single tract for both a Cope suture anchor and a guide wire over which serial dilation and tube insertion can be performed. Twenty milligrams of Buscopan was administered to inhibit bowel motility. Under fluoroscopic guidance, an appropriate puncture site was selected overlying the lower body of the stomach. After local anesthesia using 1% (w/v) lidocaine and a skin incision of approximately 5 mm in length, a 21-gauge Chiba-needle (Cook, Bloomington, IN) was advanced into the insufflated stomach toward the fundus. After confirming needle position by contrast injection, a 0.018-inch guide wire (Cook) was passed into the stomach (Fig. 1). The Chiba-needle was then exchanged for a 6-Fr Neff catheter (Cook). A Cope suture anchor (Cook) was then deployed into the stomach lumen through the Neff catheter using a 0.035-inch superstiff guide wire (Cook) for gastropexy. Once the stomach was
Follow-up and study endpoints Patients underwent a contrast study via the tube 1 day and 1 week after placement to confirm tube position and absence of leakage. Tube feeding was commenced once the initial follow-up contrast study demonstrated the absence of leakage or other complications related to tube placement. The external part of the suture string was cut at 1 week follow-up. We evaluated for the following: the technical success of the procedure, the number of puncture attempts with the 21-gauge Chiba-needle, the time length of the procedure, complications occurring within 30 days, procedure-related mortality, and the 30-day mortality. Technical success was defined as correct positioning of the feeding tube in the stomach, which was documented fluoroscopically with 5 mL of contrast medium injection at the end of the procedure. The procedure time was defined as the time between lidocaine skin infiltration and confirmation of the feeding catheter within the stomach by contrast injection. Major complications were defined as life-threatening complications or any complications that caused gastrostomy malfunction or required additional interventional procedures [1]. Minor complications were defined as those requiring only minimal medical management or local wound care [1].
Results All 80 patients successfully underwent PRG using the modified Chiba-needle technique and single gastropexy under fluoroscopic guidance (100% technical success). In all patients, the Chiba-needle was introduced slowly towards the stomach, and the anterior stomach wall was seen clearly as a ‘‘tenting’’ on anteroposterior radiographs (Fig. 1). When the tenting was seen, the needle was introduced more deeply and was seen piercing the anterior stomach wall. There were no problems related to the PRG procedures in 15 patients with high-lying stomachs or who had experienced previous gastric surgery (Fig. 2). A single puncture attempt was all that was required in 78 patients (98%); two attempts were needed in two patients. In these patients, the 0.035-inch superstiff guide wire was carelessly removed during serial dilation, but a second puncture into the stomach and the subsequent insertion of the feeding tube was successful in both the cases. The subsequent Neff catheter insertion using the 0.018-inch guide wire was successful in all the patients. In five patients, there was resistance to advancement of the
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Fig. 1. A A Chiba-needle is advanced into the gastric fundus. The pushed anterior stomach wall is seen as ‘‘tenting’’ (arrows). B After confirmation of the intragastric location of the Chibaneedle by contrast injection, a 0.018-inch guide wire (arrows) is passed through the Chibaneedle. C, D The Chiba-needle is exchanged for a Neff catheter (arrows) and a Cope suture anchor (arrowheads in D) is deployed into the stomach through the Neff catheter using a 0.035-inch superstiff guide wire. E, F The puncture site is serially dilated with a dilator (arrow in E) in order to place a 14-Fr diameter, locking loop catheter (arrows in F). The Cope suture anchor is seen (arrowheads).
Neff catheter into the stomach. In these patients, the dilator of the Neff catheter was first advanced, after which the Neff catheter with associated dilator was successfully advanced. In all patients, the Cope suture anchor was easily introduced through the Neff catheter into the stomach. Only a single Cope suture anchor was used for each patient. The average procedure time was 5 min 38 s (range 2 min 30 s–12 min 1 s).
Three patients (3.8%) had major complications. One patient with oropharynx cancer showed fresh blood drainage through the feeding tube with a resultant hemoglobin drop from 12.9 to 6.1 g/dL one day after the procedure and underwent transfusion with subsequent normalization of the hemoglobin level. Another patient developed a deep stomal infection 2 days after the procedure. This patient recovered uneventfully after antibiotic treatment, percutaneous drainage of the abdominal
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Fig. 2. Percutaneous radiologic gastrostomy in a patient with high-lying stomach. Percutaneous endoscopic gastrostomy was attempted four times but failed. A The stomach which was inflated with air is under the lower left rib cage. B A 14-Fr diameter, locking loop catheter is inserted successfully.
wall abscess, and tube removal. The remaining one patient showed worsening pneumoperitoneum and thus underwent tube removal 9 days after the procedure. Seven patients (8.8%) had minor complications. A pneumoperitoneum was noted after tube insertion in five patients; four patients were asymptomatic and the pneumoperitoneum resolved spontaneously. One patient showed symptoms of peritonitis (i.e., fever and abdominal pain); however, his symptoms improved with intravenous antibiotic treatment over 2 days and thus the complication was categorized as minor. One patient experienced inadvertent tube removal 16 days after the procedure and underwent tube replacement. In the remaining patient with subtotal gastrectomy, the procedure was uneventful with the tube tip directed into the gastric antrum due to the small size of the remnant stomach. One day follow-up contrast study showed the tip located in the distal esophagus, and gastrojejunostomy was subsequently performed to prevent possible aspiration during feeding. The procedure-related mortality was zero. The 30-day mortality was 5% (four patients) due to progression of underlying pneumonia (n = 2) or underlying malignancy (n = 2).
Discussion The results of our study demonstrate that PRG with the 21-gauge Chiba-needle puncture technique with use of single gastropexy in the same puncture tract was feasible, safe, and effective. We were able to achieve 100% technical success in the placement of a 14-Fr gastrostomy tube with an acceptable complication rate. For gastric puncture, a 16-gauge (1.2 mm) needle is usually used in PEG and a 17-gauge (1.1 mm) needle is most commonly employed for PRG. In our study, however, we used a 21-gauge Chiba-needle for gastric puncture. We found gastric puncture with a 21-gauge Chiba-needle to be very easy because tenting of the
stomach wall was clearly seen as the needle was gently advanced towards the fundus in all the patients. During advancement of the Chiba-needle, there was also less fear of vascular injury because of its smaller diameter. In addition, a single puncture attempt was successful in most patients in the present study (98%, 78/80). The second punctures performed on two patients were required only because the inserted guide wires were carelessly removed. We believe that gentle advance of the Chiba-needle until visualization of the gastric wall tenting contributed to the minimal number of the puncture attempts. In the present study, we used a 6-Fr Neff catheter through which a Cope suture anchor was inserted for gastropexy after exchange of the 21-gauge Chiba-needle for the 6-Fr Neff catheter. Neff catheter is very useful for exchanging a micro guide wire for a 0.035-inch guide wire and its use has been reported in the procedure of PRG [11, 12]. However, introduction of the Cope suture anchor through the Neff catheter for gastropexy has not been reported. A Cope suture anchor was introduced through the Neff catheter without any resistance. In the present study, only a single Cope suture anchor was used along the puncture tract, and minimization of puncture numbers with sufficient gastropexy effect was obtained during the procedure. The presence of the Cope suture anchor string and guide wire in the same puncture tract was not problematic during serial dilation and gastrostomy tube insertion in most cases. The superstiff guide wire was carelessly removed during serial dilation in two patients in the present study; however, this could be prevented with more precaution. In this study, the Cope suture anchor was sutured to the skin for 1 week to reduce the risk of tube dislodgement and gastric leakage. We believe that the temporary use of gastropexy contributed to the low incidence rates of peritonitis and tube dislodgement in our study. In support of this, higher rates of peritonitis (3%) and tube dislodgement (4%) were observed in the study of
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Watkinson et al. [11], who used a 22-gauge Chiba-needle to puncture the stomach and inserted 12-Fr gastrostomy tubes without the use of gastropexy. While, Lorentzen et al. [8] performed a simplified gastropexy technique with the use of a 17-gauge puncture needle mounted with a Cope suture anchor and release of the Cope suture anchor by cutting the external part of the suture string at the end of the 14-Fr balloon-retained gastrostomy tube insertion in a study based on 154 patients. They reported a low incidence (2.6%, four patients) of deep stomal infection (n = 2) and tube dislodgement (n = 2). Although they have reported only two cases of tube dislodgement, such cases were fatal and resulted in a change from simplified gastropexy into traditional gastropexy for 10 days [8]. High-lying stomach and surgically altered gastric morphology present technical challenges because the approaches for gastrostomy placement are angled rather than perpendicular to the abdominal wall, and only unfavorable puncture windows are available [8, 10]. Despite the high incidence (19%, 15/80 cases) of patients with high-lying stomachs or with surgically altered gastric morphology in our study, punctures were performed securely and reliably with the Chiba-needle. We were able to confirm tenting of the anterior abdominal wall and then advance the Chiba-needle gently under fluoroscopic guidance. In patients with subtotal gastrectomy, however, it is possible for the tube tip to be placed in the distal esophagus because of the small volume of the remnant stomach. Therefore, in patients with small remnant gastric volume, gastrojejunostomy or jejunostomy could be an option to minimize the risk of aspiration during feeding, as performed for one of our patients in the study. The average procedure time between lidocaine skin infiltration and confirmation of the feeding catheter within the stomach was less than 6 min in this study. Reports on gastrostomy procedure times are limited [1, 8]. Deutsch et al. [1] reported a mean of 7 min for simplified PRG without gastropexy. Considering that we performed gastropexy, our procedure time seems to be quite short. Compared with the 10–15 min reported procedure time in a series with gastrostomy with a single gastropexy using a 17-gauge puncture needle under ultrasonographic and fluoroscopic guidance [8], our procedure time is considerably shorter. The shorter procedure times in our study are likely due, at least in part, to the low number of gastric puncture attempts required, single gastropexy and the use of only fluoroscopic guidance. Gastric bleeding after PRG and PEG has been reported to occur at a frequency of 1%–3% [13–15], with gastric punctures made using a 16- or 17-gauge needle. Given the higher risk of hemorrhage associated with vascular injury resulting from use of a 16- or 17-gauge needle tip [1, 16], we used a 21-gauge Chiba-needle for
gastric puncture and encountered bleeding complication which resolved spontaneously after transfusion in one out of 80 patients (1.3%). This bleeding complication rate belonged to the lower range of the reported rates. In one similar study using 22-gauge Chiba-needle for gastric puncture without gastropexy in 100 cases of percutaneous gastrostomy and gastrojejunostomy, there were no hemorrhagic complications, suggesting the possibility of lower bleeding complications with the use of smaller needles [11]. We believe that, in the present study, the use of a 21-gauge Chiba-needle and a single gastropexy with minimal number of puncture attempts could contribute to the safety of the procedure with a minimization of hemorrhage risks although a comparison study is necessary to substantiate the lower bleeding complication of this study. The zero procedure-related mortality and 5% overall 30-day mortality rate could also reflect the safety of the procedure in the present study. In conclusion, PRG with the modified Chiba-needle puncture technique with use of a single gastropexy in the same puncture tract was feasible, safe, and effective, especially in patients with high-lying or surgically altered stomachs. This technique has advantages of minimization of the puncture numbers with short procedure time, sufficient gastropexy effect, and enhanced expectation of fewer complications. References 1. Deutsch LS, Kannegieter L, Vanson DT, Miller DP, Brandon JC (1992) Simplified percutaneous gastrostomy. Radiology 184:181– 183 2. Ho SG, Marchinkow LO, Legiehn GM, Munk PL, Lee MJ (2001) Radiological percutaneous gastrostomy. Clin Radiol 56:902–910 3. Coleman CC, Coons HG, Cope C, et al. (1990) Percutaneous enterostomy with the Cope suture anchor. Radiology 174:889–891 4. Given MF, Hanson JJ, Lee MJ (2005) Interventional radiology techniques for provision of enteral feeding. Cardiovasc Intervent Radiol 28:692–703 5. Silas AM, Pearce LF, Lestina LS, et al. (2005) Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: a comparison of indications, complications and outcomes in 370 patients. Eur J Radiol 56:84–90 6. Dewald CL, Hiette PO, Sewall LE, Fredenberg PG, Palestrant AM (1999) Percutaneous gastrostomy and gastrojejunostomy with gastropexy: experience in 701 procedures. Radiology 211:651–656 7. Given MF, Lyon SM, Lee MJ (2004) The role of the interventional radiologist in enteral alimentation. Eur Radiol 14:38–47 8. Lorentzen T, Nolsøe CP, Adamsen S (2007) Percutaneous radiologic gastrostomy with a simplified gastropexy technique under ultrasonographic and fluoroscopic guidance: experience in 154 patients. Acta Radiol 48:13–19 9. Thornton FJ, Fotheringham T, Haslam PJ, et al. (2002) Percutaneous radiologic gastrostomy with and without T-fastener gastropexy: a randomized comparison study. Cardiovasc Intervent Radiol 25:467–471 10. Thornton FJ, Fotheringham T, Alexander M, et al. (2002) Amyotrophic lateral sclerosis: enteral nutrition provision–endoscopic or radiologic gastrostomy? Radiology 224:713–717 11. Watkinson AF, Fache JS, Burhenne HJ (1995) Percutaneous gastrostomy and gastrojejunostomy experience in 100 cases. Eur Radiol 5:13–18 12. Stein EG, Cynamon J, Katzman MJ, et al. (2007) Percutaneous gastrostomy of the excluded gastric segment after Roux-en-Y gastric bypass surgery. J Vasc Interv Radiol 18:914–919
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