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Departments of 1 Diagnostic Radiology, 2 Radiation Oncology and 3 Otolaryngology, Head and Neck Surgery, University of Bern, Inselspital, Freiburgstrasse, CH 3010 Bern, Switzerland
Correspondence: Dr H-P Dinkel, Institut für Diagnostische Radiologie, Inselspital Bern, University of Bern, CH 3010 Bern, Switzerland
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Abstract |
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 Top Abstract IntroductionMaterials and methodsResultsDiscussionReferences |
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Introduction |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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Materials and methods |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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Patients
Within a 12-month period, 26 consecutive patients with stenotic head and neck (n=17) or oesophageal cancer (n=9) were referred for radiological gastrostomy by the departments of radiation oncology and head and neck surgery. All patients were scheduled to undergo radiotherapy or combined radiochemotherapy. 22 patients were male and 4 were female. The median age was 63 years (range 41–91 years). Four patients had undergone previous Billroth II (BII) type gastric resection. In 8 (31%) of the 26 patients, endoscopic insertion of a gastrostomy tube had failed owing to an obstructing stenosis (n=6) or unsuccessful transillumination (n=2). In seven further patients endoscopy was judged to be impossible and PEG was not attempted. Seven (27%) patients who had recently undergone head and neck surgery were referred because the irphysicians thought radiological gastrostomy would be less invasive. The four (15%) remaining patients underwent RPG because their referring physicians would have had to wait too long for PEG. During the initial phase of the study period, most patients had failed PEG procedures prior to RPG. With growing experience with the "new" method, referring physicians increasingly requested RPG in patients in whom they suspected PEG might fail. The choice of gastrostomy method was made by the referring clinician in all cases, after consultation with interventional radiologists and gastroenterologists.
19 (73%) of the 26 patients had special risk factors (some had more than one such factor). These included: liver cirrhosis, n=5; ascites, n=1; alcoholism, n=12; organic brain syndrome, n=2; thrombocytopenia, n=5; obesity, n=3; aspiration and hypersalivation, n=9; and gastric surgery, n=4.
Technique
All patients fasted from midnight prior to the insertion and received 0.5 mg of atropine subcutaneously, and 20–30 ml of lidocaine for local anaesthesia. Sedatives and 5–10 mg of morphine were administered as required. Prophylactic antibiotics were not given. Patients had to have an INR of 1.8 or less and platelets exceeding 50 000 µl-1. In the 18 patients without indwelling nasogastric tube, the oesophagus was intubated under fluoroscopic guidance using a 5 F multipurpose or cobra catheter (Cook, Bloomington, MA) and a stiff 0.035 inch Terumo hydrophilic guidewire (Terumo, Tokyo, Japan). After administration of 40 mg butylscopolamine (Buscopan®; Boeringer Ingelheim, Ingelheim, Germany) the stomach was fully inflated with 500–1000 ml room air and punctured in the lower corpus portion with an 18 G needle. The correct needle position was checked by air aspiration and contrast injection. The T-fastener mounted in the needle was then pushed into the stomach (Figure 1a, b
) (Cope gastrointestinal suture anchor set; Cook, Bloomington, MA). The needle was withdrawn and the T-fastener retracted and sutured to the abdominal wall. In this way, gastropexy was performed with 2–4 T-fasteners. A small incision was made between the sutures, through which the stomach was punctured again, a guide wire advanced and, after dilation and insertion of a peel-away sheath (Cook, Bloomington, MA) (Figure 1c), the balloon gastrostomy tube (Balloon Replacement Tube, PEG-BRT; Cook, Bloomington, MA) inserted (Figure 1d). The peel-away introducer, which had to be 4 F larger than the nominal diameter of the gastrostomy tube, was then peeled off and the gastrostomy balloon blocked (Figure 1e, f). CT or ultrasound were not used for guidance in any of the cases. In 12 patients a 12 F gastrostomy tube was inserted, in 8 patients a 14 F gastrostomy tube was inserted, and in 6 patients an 18 F gastrostomy tube was inserted.
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Complications were defined in a standard manner. Minor complications were defined as abdominal pain with or without peritoneal tenderness, wound discharge, wound infection, fever, peristomal leakage, gastroparesis, simple dislocation, tract disruption without peritonitis, delayed catheter dislocation or catheter fracture.
Major complications were defined as haemorrhage requiring blood transfusion or other intervention, peritonitis, aspiration, cardiac failure, anaphylaxis and collapse, or other states necessitating surgery or intensive care.
Patients files were examined for any tube-related problems or repeat procedures within or beyond the 30-day limit. Patients and physicians were specifically instructed to contact one of the two interventional radiologists involved regarding any problem potentially associated with the implantation or use of the gastrostomy tubes.
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Results |
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Time requirements
In the 18 patients (69%) without an indwelling nasogastric tube, the oesophagus was catheterized with a 5 F catheter in a median time of 3 min (range 0.5–40 min). The median time required for gastropexy was 15 min (range 8–45 min) and that for subsequent gastrostomy tube insertion was 12 min (range 8–45 min). The median total procedure time was 34 min (range 20–90 min). Fluoroscopy took 6.9 min on average (range 2.3–30 min).
Complications
One major complication occurred in a patient with a T4 N2b oro- and hypopharyngeal carcinoma with pharyngeal leakage after pharyngolaryngectomy and a pectoralis flap. The patient successfully underwent RPG. Fluoroscopic examination the next day demonstrated that the tube was in the correct position and the retention balloon was intact. On the third day the patient began to complain of abdominal pain after use of the feeding tube, which was used until it fell out the following morning. In retrospect, it became clear that the patient had injected an excessive amount of nutritional fluid into the balloon port, which exploded the balloon and led to displacement of the tube with peritoneal spillage of feeding fluid. The patient had to undergo laparotomy for control of peritonitis caused by dislodging of the tube before the tube tract had become mature. The patient is free of abdominal symptoms after 12-month follow-up.
One minor complication occurred in a patient undergoing gastrostomy for control of mediastinitis caused by the perforation of a necrotic oesophageal cancer and oesophagobronchial fistula. The patient had undergone BII type gastric resection years before and was not deemed to be suitable for PEG by the gastroenterologists owing to a huge mediastinal tumour perforation. He had a successful gastrostomy as judged radiologically. The patient had paralytic ileus and developed a peristomal skin infection with peristomal leakage owing to reflux of bilious stomach contents. The complication was managed by insertion of an 18 F Foley catheter for drainage, insertion of a 9 F jejunal catheter for feeding, and antibiotics. After 1 week the infection had completely resolved and the jejunal catheter was withdrawn; the wound closed rapidly and gastrostomy was used without further problems.
The rate of major and minor complications was 3.9% each; there were no deaths. No bleeding was recorded although several of our patients had alcoholic liver disease and associated thrombocytopenia.
Follow up and secondary interventions
All patients underwent contrast examination the day after insertion. All but one patient were followed up radiographically for at least 30 days. The median clinical follow-up was 7.5 months (range 1–12 months). Five catheters were removed 6–26 weeks after conclusion of radiotherapy. Twenty catheters are still in place.
There were six (24%) repeat procudures after the 30-day period, caused by clogged tubes (n=5) or by delayed balloon rupture (n=1). All were dealt with by simple tube exchange (usually for an 18 F tube) under fluoroscopy, without complications.
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Discussion |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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The total procedure time fell from approximately 60 min in the first patients to 20 min in the last, clearly reflecting a learning curve. The method can be adopted quickly by a skilled interventional radiologist. Fluoroscopic times as low as 3 min were achieved even in difficult cases, thereby minimizing radiation exposure for both patient and interventional radiologist. All gastrostomies in this series were correctly positioned.
As part of internal quality assurance, we re-examined patients by fluoroscopy on two occasions. This naturally added to fluoroscopic time and costs, but is not needed routinely and was discontinued after RPG had become successfully established.
Complications
Minor complications comprise abdominal pain, peritoneal tenderness, wound discharge, wound infection, peristomal leakage, gastroparesis, simple dislocation, tract disruption without peritonitis, delayed catheter dislocation or catheter fracture. The reported rate of minor complications varies between 0.7% and 12% [9–15]. Major complications may include haemorrhage, peritonitis, aspiration, cardiac failure, anaphylaxis and apoplexy. Bleeding is uncommon (0.2%) [9] and, if present, mostly minor and self-limiting. Severe aspiration seems to be extremely rare in RPG (0.2%) [9]. The most serious complication is peritonitis caused by early tube displacement with peritoneal spillage. The rate of major complications in RPG varies between 0.5% and 6% [9–14]. Procedure-related 30-day mortality has been reported between 0% [13] and 0.9% [14] for RPG, which compares favourably with PEG (0–3%) [2–6] and especially with surgical gastrostomy (3–16%) [16, 17]. In our series, the rate of minor and major complications was 3.9% each, again comparing favourably with the literature.
Tube design
To our knowledge this is the first study in which radiological gastrostomy with balloon-type catheters has been evaluated prospectively. Most other authors have used pigtail loop catheters [9–13, 18]. Mildenberger et al [18] reported 10% of patients in whom pigtail loop catheters had to be repositioned on the day following insertion, whereas no initial incorrect positioning in any patient treated with balloon gastrostomy was observed in this study. The case of a patient bursting the catheter retention balloon early taught us to discourage patients from using the tubes themselves in the first week, before the tract was mature. As with any gastrostomy tube, if abdominal pain occurs, both nursing personnel and patients must immediately discontinue feeding and the position of the tube must be checked fluoroscopically. Foley type balloon catheters have been used routinely in surgical gastrostomy with good results. Whereas early displacement seems to be rare for balloon-retained tubes, late displacement owing to balloon rupture is not uncommon but can be managed by simple tube exchange [14].
Comparison of RPG with surgical gastrostomy and PEG
Barkmeier et al [19] found a significantly higher technical success rate in RPG compared with PEG. Likewise, in this study a RPG technical success rate of 100% was achieved, even in a series of patients in many of whom PEG had either failed or was not likely to be possible. In a meta-analysis by Wollman and D'Agostino [8] the technical success rate of RPG (99.2%) was significantly (p<0.001) higher than that of PEG (95.7%), while the major complication rate was significantly higher in PEG (9.4%) compared with RPG (5.9%). In their study, gastrostomy had the highest rate of major complications (19.9%) and a significantly higher procedure-related mortality rate (2.5%) than both endoscopic (0.5%) and radiological procedures (0.3%) [8]. The risk of life-threatening aspiration was four times lower in RPG compared with PEG [8], although differences possibly reflect institutional bias towards the use of a particular method in different patient categories. The rate of peritonitis was higher in RPG (1.3%) than in PEG (0.5%) [8]. In a recently published study on RPG with gastrostomy, however, the rate of peritonitis was only 0.3% [13]. The small but definite risk of tumour seeding in head and neck or oesophageal tumour patients undergoing PEG is minimized by RPG because the gastrostomy does not transverse the tumour [20]. The major complication rate seems to be lower for RPG (0.5–7%) than PEG (3–20%) [2–5, 8–14]. Wollman and D'Agostino reported significantly (p<0.001) fewer major complications in radiological gastrostomy (5.9%) than in either PEG (9.4%) or surgical gastrostomy (19.9%) [8].
Whereas rates reported for minor complications vary between 14% and 43% for surgical gastrostomy [8, 10, 14, 21] and between 6% and 43% for PEG [6, 8, 14, 21], the ranges for RPG vary between 0.7% and 12% [10, 14]. Peristomal infection is the most common complication of PEG and has been reported in up to 30% of cases. The site infection rate in RPG is lower than in PEG and prophylactic antibiotics are not essential [20, 22]. Our minor and major complication rates of 3.9% for each thus compare favourably with those reported in the literature.
Evaluation of the different published series has to be performed with caution as most studies are retrospective, patients' underlying conditions are difficult to compare and the definitions of success and complications differ. Unfortunately, there are not randomized-controlled studies comparing endoscopic and radiological methods. However, there is little doubt that both PEG and RPG are more efficient and less invasive than surgical gastrostomy.
Avoiding surgery and general anaesthesia is an important benefit of RPG. Many of the patients in this study would have required surgical gastrostomy prior to the introduction of RPG.
Conclusion
PEG is as a well-established procedure with excellent results and low overall complication rates and is well-suited for most feeding purposes. However, RPG has several intrinsic advantages in patients with malignancies of the aerodigestive tract. In these, RPG is a valuable adjunct to provide enteral nutrition when PEG is not feasible. Thus, RPG reduces the frequency of surgical procedures and lowers the proportion of patients who have to receive long-term parenteral treatment that is both expensive and not physiological.
Interventional radiologists may become familiar with RPG quickly and achieve excellent results. The use of balloon-retained feeding catheters for radiological gastrostomy is safe and feasible. When introducing RPG, close cooperation with gastroenterologists, nurses and dietary assistants is important. The experience described here confirms the value of radiological percutaneous gastrostomy as an alternative to surgical gastrostomy and PEG in patients for whom traditional methods are not suitable.
Received for publication June 25, 2001. Revision received September 11, 2001. Accepted for publication October 18, 2001.
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