CT fluoroscopy guided percutaneous gastrostomy or jejunostomy without (CT-PG/PJ) or with simultaneous endoscopy (CT-PEG/PEJ) in otherwise untreatable patients. Surg Endosc. 2013;27:1186-1195. [PMID: 23232989 DOI: 10.1007/s00464-012-2574-z]

Palliative Percutaneous Gastrostomy Decompression Methods for Small-Bowel Obstruction in Advanced Gastrointestinal Cancer

BACKGROUND

Malignant bowel obstruction (MBO) is a common and distressing complication in advanced gastrointestinal cancers, significantly impacting patients' quality of life. When conservative management fails, palliative decompression is essential to relieve symptoms such as nausea, vomiting, and abdominal distension. Venting gastrostomy is the most established method; however, anatomical challenges may necessitate alternative percutaneous approaches.

OBJECTIVE

This narrative review aims to provide a comprehensive overview of percutaneous gastrostomy techniques for palliative gastrointestinal decompression, including percutaneous endoscopic gastrostomy (PEG), interdisciplinary imaging-guided percutaneous or transhepatic gastrostomy, and percutaneous transesophageal gastrostomy (PTEG).

METHODS

A literature review was conducted to evaluate the indications, techniques, efficacy, and complications associated with these procedures. The role of a multidisciplinary approach, incorporating radiologic, endoscopic, and palliative care expertise, was also explored.

RESULTS

PEG remains the gold standard for venting gastrostomy, achieving symptom relief in up to 92% of cases, with a low complication rate. However, interdisciplinary imaging-guided percutaneous or transhepatic gastrostomy offers a viable alternative for patients with surgically altered anatomy or difficult percutaneous access. PTEG, a newer technique, has demonstrated high technical success and symptom improvement, particularly in patients with extensive peritoneal carcinomatosis or massive ascites, where transabdominal approaches are not feasible.

CONCLUSIONS

Palliative percutaneous decompression provides effective symptom relief in advanced gastrointestinal cancer. The choice of technique should be individualized based on patient anatomy, clinical condition, and resource availability. A multidisciplinary approach remains crucial in tailoring decompression strategies to improve the quality of life in end-stage malignancies.

A comparative analysis of transhepatic cardia-gastric fundus puncture vs. gastric body puncture for insufflation for CT-guided percutaneous gastrostomy

OBJECTIVES

To evaluate the safety and efficacy of transhepatic cardia-gastric fundus puncture (TCFP) for insufflation for CT-guided percutaneous gastrostomy (CPG).

METHODS

The clinical data of 38 patients who underwent TCFP for insufflation and 161 patients who underwent percutaneous gastric body for insufflation at a single center were retrospectively analyzed. The operative time, success rate, complication rate, overall procedure time, and incidence of complications within 3 months were collected.

RESULTS

The success rate of insufflation was 100%, and no serious complications occurred during percutaneous gastric insufflation. The average time for insufflation via TCFP was 9.60 ± 6.62 min, and that via gastric body puncture was 8.71 ± 71.8 min, with no significant difference between the two (p = 0.485). The overall duration of gastrostomy in the TCFP group was 32.16 ± 10.27 min and 33.94 ± 13.82 min in the gastric body group, with no significant difference (p = 0.456). The incidence of submucosal air spread was 0% in the TCFP group and 9.9% in the gastric body group, with significant difference (p = 0.045). The complication rates following insufflation via TCFP and via gastric body puncture were 18.4% and 21.7%, respectively, with no significant difference between the two groups (p = 0.652). The perioperative pain score was 2 after insufflation via TCFP and via gastric body puncture, with no significant difference (p = 0.119). The overall mortality rate was 0 in the first postoperative month, with a 3-month mortality rate of 5% (10/199). The surviving patients showed a significant increase in weight from 51.81 ± 8.52 kg to 52.52 ± 9.39 kg at 3 months postoperatively (p = 0.009).

CONCLUSIONS

TCFP for insufflation is safe and effective, with a 100% success rate and no increased risk of complications. The choice of procedure should be based on the patient's specific condition and the physician's experience.

Therapeutic Role of Subcutaneous Access Loop Created Adjunct to Hepaticojejunostomy for Management of Bile Duct Injury

BACKGROUND

Roux-en-Y hepaticojejunostomy (RYHJ) is usually required for major bile duct injury (BDI) as a definitive treatment. Hepaticojejunostomy anastomotic stricture (HJAS) is the most feared long-term complication following RYHJ. The ideal management of HJAS remains undefined. The provision of permanent endoscopic access to the bilio-enteric anastomotic site can make endoscopic management of HJAS feasible and attractive option. In this cohort study, we aimed to evaluate short- and long-term outcomes of subcutaneous access loop created adjunct to RYHJ (RYHJ-SA) for management of BDI and its usefulness for endoscopic management of anastomotic stricture if occurred.

MATERIALS AND METHODS

This is a prospective study including patients who were diagnosed with iatrogenic BDI and underwent hepaticojejunostomy with subcutaneous access loop between September 2017 and September 2019.

RESULTS

This study included a total number of 21 patients whom ages ranged between 18 and 68 years. During follow-up, three cases had HJAS. One patient had the access loop in subcutaneous position. Endoscopy was done but failed to dilate the stricture. The other 2 patients had the access loop in subfascial position. Endoscopy of them failed to enter the access loop due to failure of fluoroscopy to identify the access loop. The three cases underwent redo-hepaticojejunostomy. Parajejunal (parastomal) hernia occurs in 2 patients in whom the access loop was fixed subcutaneous position.

CONCLUSION

In conclusion, modified RYHJ with subcutaneous access loop (RYHJ-SA) is associated with reduced quality of life and patient satisfaction. Moreover, its role in endoscopic management of HJAS after biliary reconstruction for major BDI is limited.

CT Fluoroscopy-Guided Percutaneous Gastrostomy in the Palliative Management of Advanced and Relapsed Ovarian Cancer: The Charité Experiences and a Review of the Literature

Peritoneal carcinomatosis-associated malignant bowel obstruction is a common feature that merits more attention in advanced and recurrent ovarian cancer. Decompressive gastrostomy is one of the most preferred methods to palliate distressing symptoms and maintain patients' quality of life. We retrospectively identified 31 patients with ovarian cancer-associated MBO, who underwent decompressive CT fluoroscopy-guided percutaneous gastrostomy (CT-PG) between September 2015 and April 2023 at our institution. A systematic literature review was conducted for CT-guided gastrostomy in ovarian cancer. Prior to CT-PG, 27 (87%) patients underwent unsuccessful attempts at endoscopic gastrostomy or surgery due to bowel obstruction; a total of 55% had received ≥3 lines of chemotherapy. CT-PG could be successfully inserted in 25 of 31 (81%) patients without grade 4-5 complications. CT-PG insertion was feasible in 76% of patients with previous unsuccessful attempts of endoscopic gastrostomy. A total of 80% of patients with a successful insertion had considerable symptom relief and could tolerate fluid intake. Mean survival after the procedure was 44.4 days. Chemotherapy could be administered in 7 of 25 (28%) patients following the CT-PG insertion. CT-guided percutaneous gastrostomy is a safe procedure that effectively manages intractable symptoms of bowel obstruction in ovarian cancer. This minimally invasive technique should be emphasised as a routine instrument within the palliative management of MBO.

Safety and Efficacy of CT-Guided Central Venous Catheter Gastric Insufflation in Percutaneous Gastrostomy

Gastric insufflation for computed tomography (CT)-guided percutaneous gastrostomy is currently performed via a nasogastric tube or a Chiba needle. However, nasogastric tube placement requires patient pharynx and esophagus, and Chiba needle use is associated with an increased risk of organ damage and prolonged operation time. Herein, we introduce a new method of gastric insufflation via a central venous catheter and explore its safety and efficacy by retrospective analysis of the clinical data of patients who underwent percutaneous gastrostomy using this method in our hospital from April 2021 to March 2022. The extracted data included the following: success rate, operation time, gastric insufflation time, radiation dose, postoperative pain score, and complications. We also compared the preoperative levels of several nutritional indicators (body mass index, hemoglobin, albumin, creatinine, and blood urea nitrogen) with those obtained 1 month postoperatively. A total of 12 patients underwent percutaneous gastrostomy under CT guidance using central venous catheter gastric insufflation. The surgery and gastric insufflation success rates were 100% both. The average operation time, gastric insufflation time, and effective radiation dose were 24.08 ± 5.25 min, 5.08 ± 2.50 min, and 14.16 ± 3.63 mSv, respectively. Based on the World Health Organization scale for pain assessment, five patients reported no postoperative pain and seven patients had mild pain. There were no serious complications, such as stoma infection, peritonitis, gastrointestinal perforation and bleeding, or embedding syndrome. All evaluated nutritional indicators showed improvement at 1 month postoperatively, with statistically significant differences compared to the preoperative values (p < 0.05 for all). In conclusion, CT-guided percutaneous gastrostomy with central venous catheter gastric insufflation is a safe, effective, and feasible minimally invasive treatment.

Endoscopy in the CT Scanner: a Multidisciplinary Approach to Difficult Cases

Endoscopic interventions have been made safer with the use of fluoroscopy. This technique has limitations in patients with challenging anatomy. The combined use of endoscopy and CT fluoroscopy provides the added precision necessary to accomplish difficult interventions. In this video, we present two cases where endoscopy and CT fluoroscopy were used concurrently. While other publications have demonstrated the use of CT guidance to perform endoscopic interventions, this video also demonstrates the reverse-how endoscopic guidance can be used to make a CT-guided procedure possible. This video demonstrates the enhanced patient care possible when a multidisciplinary approach between interventional radiologists and surgeons is followed.

CT-guided gastrostomy tube placement-a single center case series

PURPOSE

The role of computed tomography (CT)-guided gastrostomy tube placement is still evolving. It is a valuable alternative to guide gastrostomy tube placement in a few selected patients, who are not candidates for the established endoscopy- or fluoroscopy-guided gastrostomy tube placement. Our objective was to describe our institutional experience placing gastrostomy tubes using CT guidance and to conduct a review of literature for similar studies to provide the best current evidence on success rates and complications.

METHODS

We identified gastrostomy tubes placed under CT guidance at our institution using a comprehensive case log. We also identified studies in the literature, through a systematic search of PubMed. In both the local and literature analyses, we recorded success and complication rates.

RESULTS

A total of 31 patients underwent 33 attempted CT-guided gastrostomy tube placements at our institution, with 32 successful procedures yielding a success rate of 97%. The overall rate of successful gastrostomy tube placement using CT-guidance was 94.9% (634/668), as reported in the existing literature.

CONCLUSION

CT-guidance is an effective method for gastrostomy tube placement and may play an important role in patients for whom endoscopic or fluoroscopic gastrostomy tube placement is not feasible.

Outcomes following percutaneous endoscopic gastrostomy versus fluoroscopic procedures in the Medicare population

Background

In the United States, few high-quality manuscripts have directly compared the complication profiles of percutaneous endoscopic versus fluoroscopic gastrostomy. Thus, it is our goal to compare these 2 common procedures to better understand their efficacy and complication profiles.

Materials and Methods

A retrospective analysis of patient records from Medicare parts A/B from 2007 to 2012 was used to identify percutaneous fluoroscopic gastrostomy and percutaneous endoscopic gastrostomy procedures. Patient demographics were stratified by age, sex, comorbidities, and complications.

Results

A total of 258,641 patients were found to have either percutaneous fluoroscopic gastrostomy (26,477, 10.2%) or percutaneous endoscopic gastrostomy (232,164, 89.8%). Percutaneous fluoroscopic gastrostomy experienced greater rates for all complications queried. Multivariate analysis revealed that the percutaneous fluoroscopic gastrostomy cohort had statistically significant increased odds for short-term complications, such as ileus (odds ratio 1.4, 95% confidence interval 1.22–1.54), mechanical (odds ratio 2.4, 95% confidence interval 2.28–2.58), wound infection (odds ratio 1.4, 95% confidence interval 1.24–1.52), persistent fistula after tube removal (odds ratio 1.9, 95% confidence interval 1.78–2.12), and other complications (odds ratio 2.2, 95% confidence interval 2.03–2.37), and long-term complications, including abdominal wall pain (odds ratio 1.4, 95% confidence interval 1.33–1.44), wound infection (odds ratio 1.1, 95% confidence interval 1.01–1.15), and persistent fistula after tube removal (odds ratio 1.8, 95% confidence interval 1.72–1.87).

Conclusion

Gastrostomy tubes are more frequently being placed via percutaneous endoscopic and fluoroscopic methods. This study suggests that those undergoing fluoroscopic placement have higher odds of developing short- and long-term postoperative complications.

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Fluoroscopic g-tubes have higher odds of developing short- and long-term complications.

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Fluoroscopy has higher odds for abdominal wall pain and mechanical complications.

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Hyperlipidemia, smoking, and hypertension are risk factors for abdominal wall pain.

Percutaneous CT fluoroscopy-guided core biopsy of pancreatic lesions: technical and clinical outcome of 104 procedures during a 10-year period

Background In unclear pancreatic lesions, a tissue sample can confirm or exclude the suspected diagnosis and help to provide an optimal treatment strategy to each patient. To date only one small study reported on the outcome of computed tomography (CT) fluoroscopy-guided biopsies of the pancreas. Purpose To evaluate technical success and diagnostic rate of all CT fluoroscopy-guided core biopsies of the pancreas performed in a single university center during a 10-year period. Material and Methods In this retrospective study we included all patients who underwent a CT fluoroscopy-guided biopsy of a pancreatic mass at our comprehensive cancer center between 2005 and 2014. All interventions were performed under local anesthesia on a 16-row or 128-row CT scanner. Technical success and diagnostic rates as well as complications and effective patient radiation dose were analyzed. Results One hundred and one patients (54 women; mean age, 63.9 ± 12.6 years) underwent a total of 104 CT fluoroscopy-guided biopsies of the pancreas. Ninety-eight of 104 interventions (94.2%) could be performed with technical success and at least one tissue sample could be obtained. In 88 of these 98 samples, a definitive pathological diagnosis, consistent with clinical success could be achieved (89.8%). Overall 19 minor and three major complications occurred during the intra- or 30-day post-interventional period and all other interventions could be performed without complications; there was no death attributable to the intervention. Conclusion CT fluoroscopy-guided biopsy of pancreatic lesions is an effective procedure characterized by a low major complication and a high diagnostic rate.

Computed Tomography-Guided Percutaneous Gastrostomy/Jejunostomy for Feeding and Decompression

BACKGROUND

An effective method for long-term enteral feeding or stomach decompression is the use of a percutaneous gastrostomy (PEG) or sometimes jejunostomy (PEJ). Under certain circumstances (eg, inadequate transillumination), endoscopic placement of PEG/PEJ tubes is impossible. In these cases, computed tomography (CT)-guided PEG/PEJ may represent an alternative technique. In this study, we evaluate indications, results, and complications of CT-guided PEG/PEJ.

MATERIALS AND METHODS

A total of 102 consecutive referred patients were enrolled in the study. Patients came to the endoscopy unit of our department to undergo a CT-guided PEG/PEJ for long-term intragastric/intrajejunal feeding (n = 57) or decompression (n = 45). The majority (n = 98) received a pull-through PEG/PEJ with simultaneous gastroscopy/jejunoscopy. Dose length product and the effective dose for every patient were calculated.

RESULTS

PEG/PEJ tube placement was successful in 87.3% (89 of 102). Feeding PEG/PEJ tube placement was successfully completed in 91.2% (52 of 57); decompressive PEG/PEJ tube placement was likewise successfully completed in 82.2% (37 of 45). No procedure-related mortality was observed. Minor complications (eg, tube dysfunction, local bleeding, minimal leakage, local skin infection) were observed in 13 patients. The complication rate was similar between the feeding and decompression groups ( P = .9).

CONCLUSIONS

CT-guided PEG/PEJ is a feasible and safe method with a low procedure-related morbidity rate for patients where endoscopic placement via transillumination is not successful. Thus, the procedure is an attractive alternative to surgical tube placement. Long-term complications, mainly tube disturbances, can be treated easily.

Usefulness of computed tomography with air insufflation of the stomach prior to percutaneous endoscopic gastrostomy procedure

We examined the results of computed tomography (CT) with and without air insufflation of the stomach prior to performing percutaneous endoscopic gastrostomy (PEG). We retrospectively analyzed 366 patients who underwent PEG. CT images obtained with and without air insufflation were examined for the presence or absence of contact between the gastric anterior wall and abdominal wall. PEG outcome based on CT findings was also examined. CT with and without air insufflation was performed in 272 and 94 patients, respectively. Contact between the gastric anterior wall and abdominal wall was shown in 254 (93.4%) with and 45 (47.9%) without air insufflation, all of whom underwent a successful PEG procedure. In patients without contact between the gastric anterior wall and abdominal wall, PEG was not successful in 3 of 49 (6.1%) examined by CT without and 6 of 18 (33.3%) examined with air insufflation (p = 0.004). Values for diagnostic accuracy for contact between the gastric anterior wall and abdominal wall shown by CT with and without air insufflation in successful PEG cases were 0.96 and 0.51, respectively. In conclusion, CT with air insufflation more often revealed contact between the gastric anterior wall and abdominal wall as compared to CT without air insufflation, which may help to predict PEG procedure success.

Percutaneous endoscopic gastrostomy versus percutaneous radiological gastrostomy for swallowing disturbances

BACKGROUND

Gastrostomy has been established as the standard procedure for administering long-term enteral nutrition in individuals with swallowing disturbances. Percutaneous gastrostomy is a less-invasive approach than open surgical gastrostomy, and can be accomplished via endoscopy (percutaneous endoscopic gastrostomy or PEG) or sonographic or fluoroscopic guidance (percutaneous radiological gastrostomy or PRG). Both techniques have different limitations, advantages, and contraindications. In order to determine the optimal technique for long-term nutritional supplementation many studies have been conducted to compare the outcomes of these two techniques; however, it remains unclear as to which method is superior to the other with respect to both efficacy and safety.

OBJECTIVES

To compare the safety and efficacy of PEG and PRG in the treatment of individuals with swallowing disturbances.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, January 2016); MEDLINE (1946 to 22 January 2016); EMBASE (1980 to 22 January 2016); the reference lists of identified articles; databases of ongoing trials, including the Chinese Cochrane Centre Controlled Trials Register; and PubMed. We applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing PEG with PRG in individuals with swallowing disturbances, regardless of the underlying disease.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the search results and assessed the quality of the studies. Data analyses could not be performed as no RCTs were identified for inclusion in this review.

MAIN RESULTS

We identified no RCTs comparing PEG and PRG for percutaneous gastrostomy in individuals with swallowing disturbances. The large body of evidence in this field comes from retrospective and non-randomised controlled studies and case series. Based on this evidence, both PEG and PRG can be safely performed in selected individuals, although both are associated with major and minor complications. A definitive RCT has yet to be conducted to identify the preferred percutaneous gastrostomy technique.

AUTHORS' CONCLUSIONS

Both PEG and PRG are effective for long-term enteral nutritional support in selected individuals, though current evidence is insufficient to recommend one technique over the other. Choice of technique should be based on indications and contraindications, operator experience and the facilities available. Large-scale RCTs are required to compare the two techniques and to determine the optimal approach for percutaneous gastrostomy.

Palliative percutaneous endoscopic gastrostomy placement for gastrointestinal cancer: Roles, goals, and complications

Percutaneous endoscopic gastrostomy tube placement is an invaluable tool in clinical practice that has an important role in the palliative care of patients with gastrointestinal cancer. While there is no extensive data regarding the use of this procedure in patients with gastrointestinal malignancy, inferences can be made from the available information derived from studies of similar or mixed populations. Percutaneous endoscopic gastrostomy tubes can be used to provide enteral nutrition for terminal malignancies of the upper gastrointestinal tract as well as for decompression of malignant obstructions. The rates of successful placement for cancer patients with either of these indications are high, similar to those in mixed populations. There is no conclusive evidence that the procedure will help patients reach nutritional goals for those needing alimental supplementation. However, it is effective at relieving symptoms caused by malignant obstruction. A high American Society of Anesthesiologist physical status score and an advanced tumor stage have been shown to be independent predictors of poor outcomes following placement in cancer patients. This suggests the potential for similar outcomes in the palliative care of patients with advanced stage gastrointestinal cancer who may be in relatively poor physiologic condition. However, this potential should not preclude its use in patients with terminal gastrointestinal cancer considering the high rate of successful tube placement, the possible benefits and the ultimate goal of comfort in palliative care.

Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy

AIM: To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy (PEG) could be a valuable option for patients with complicated anatomy.

METHODS: A retrospective analysis of twelve patients (seven females, five males; six children, six young adults; mean age 19.2 years) with cerebral palsy, spastic quadriparesis, severe kyphoscoliosis and interposed organs and who required enteral nutrition (EN) due to starvation was performed. For all patients, standard PEG placement was impossible due to distorted anatomy. All the patients qualified for the laparoscopy-assisted PEG procedure.

RESULTS: In all twelve patients, the laparoscopy-assisted PEG was successful, and EN was introduced four to six hours after the PEG placement. There were no complications in the perioperative period, either technical or metabolic. All the patients were discharged from the hospital and were then effectively fed using bolus methods.

CONCLUSION: Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.