Sa1551 Endoscopic Sutured Gastropexy, a Novel Technique for Performing a Secure Gastrostomy

CASE STUDIES

Endoscopic sutured gastropexy: a novel technique for performing a secure gastrostomy (with videos) Rajeev Attam, MD,1 Mustafa A. Arain, MD,1 Daniel B. Leslie, MD,2 Mustafa A. Tiewala, MD,3 Thomas Leventhal, MD,1 Martin L. Freeman, MD,1 Sayeed Ikramuddin, MD2,* Minneapolis, Minnesota, USA

Percutaneous endoscopic gastrostomy (PEG) involves access to the stomach by a percutaneous needle puncture under endoscopic guidance followed by placement of a gastric tube.1 The stomach wall is loosely anchored to the anterior abdominal wall by the balloon or internal bumper of the gastric tube, with healing of the tract by inflammatory response and secondary intention. This technique allows a pathway for leakage of intra-abdominal contents such as fluid in patients with ascites or dehiscence of the stomach from the anterior abdominal wall when the tube is inadvertently dislodged or when an endoscopic procedure is performed within a few weeks of placement of a gastrostomy tube.2,3 The result is often peritonitis with free leakage of gastric contents and the need for urgent surgery.4-6 Although T-fasteners are widely used by interventional radiologists, few gastroenterologists are familiar with their placement, and the T-fastener leaves a metallic foreign body in the gastric wall, with an external retention device,7,8 which has the capacity to become infected or cause skin maceration. We describe an endoscopic technique that secures the stomach to the anterior abdominal wall with full-thickness sutures.

review board exemption for chart review was obtained. Gastropexy was performed in patients at risk of adverse events at the time of conventional PEG tube placement or to secure prior PEG tube placement. Informed consent was obtained after a detailed discussion of risks and alternatives, including PEG tube placement by other means. Ten patients had PEG tube placement by sutured gastropexy, of which 7 were male. Age ranged from 15 to 80 years. Four patients had been admitted with severe necrotizing pancreatitis, needed long-term enteral feeding with a gastro-jejunal tube, and required endoscopic procedures such as cystgastrostomy and necrosectomy. Three patients had cirrhotic ascites and needed gastrostomy tube placement. One patient with ascites who underwent conventional PEG tube placement without sutured gastropexy later developed leakage of ascites fluid and underwent rescue sutured gastropexy. Three other patients were chosen for sutured gastropexy because they were at risk of poor healing because of severe malnutrition from Crohn’s disease, chronic pancreatitis, and severe gastroparesis and were expected to undergo endoscopic procedures.

PATIENTS AND METHODS All patients who underwent sutured gastropexy between July 2010 and August 2012 were evaluated. Internal Abbreviation: PEG, percutaneous endoscopic gastrostomy. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. *All authors contributed equally to the article. Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.02.014 Received October 9, 2013. Accepted February 10, 2014. Current affiliations: Division of Gastroenterology (1); Division of Minimally Invasive and Bariatric Surgery, University of Minnesota, Minneapolis (2); Division of Gastroenterology, Hennepin County Medical Center, Minneapolis, Minnesota, USA (3). Reprint requests: Rajeev Attam, MD, 406 E. Harvard St, SE, Mail Code MMC 36, Minneapolis, MN 55405.

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PROCEDURE Procedures were performed in the operating room with patients under general anesthesia in the supine position. Patients received routine prophylactic intravenous antibiotics. The procedures were performed by a team of 2 gastroenterologists or 1 gastroenterologist and a surgeon.

Gastrostomy tube placement An adult endoscope (Olympus Endoscopy, Center Valley, Pa) was used to perform upper endoscopic examinations and to choose appropriate spots for gastrostomy by using standard techniques of transillumination and oneto-one finger indentation. After an appropriate site was identified, the skin on the abdomen was cleaned and prepped in the usual manner. An 18F to 24F gastrostomy tube was inserted by the PEG pull technique. Volume 79, No. 6 : 2014 GASTROINTESTINAL ENDOSCOPY 1011

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Placement of full-thickness sutures After placement of a gastrostomy tube by conventional pull technique, the gastric wall was secured to the anterior abdominal wall with 4-sided, full-thickness sutures. A laparoscopic suture passing device (14 gauge outer diameter; Progressive Medical Corporation, Fenton, Mo) (Fig. 1) loaded with 0-Vicryl absorbable suture (Ethicon Endosurgery, Cincinnati, OH), was advanced across the abdominal wall and into the gastric lumen on one side of the PEG (Fig. 2). In some cases, a small stab incision was made before puncturing the abdominal wall with the suture passing devices. The suture was visualized within the gastric lumen by the endoscopist and released. A rat-tooth or biopsy forceps (Olympus) passed through the endoscope was used to grab the suture, and the suture passing device was opened, releasing the suture, and then withdrawn (Fig. 3). The device was then reinserted into the gastric lumen through the same skin incision but at a different angle, and, entering the gastric lumen approximately 10 mm from the previously placed suture, the suture was grasped and the device withdrawn (Fig. 4). The suture was tied extracorporeally, thereby placing a transmural, full-thickness suture. This process was repeated 3 more times, thereby placing a full-thickness suture on 4 sides around the PEG tube, effectively creating a 4-quadrant gastropexy (Fig. 5). A modified version of this technique involved placement of 4 full-thickness sutures around the spot chosen for gastrostomy followed by placement of the PEG tube between the sutures. The modified technique avoids obstruction of the endoscopic view by the PEG tube bumper as the suture passing device is passed into the stomach.

Figure 1. Loading a suture onto a laparoscopic, suture-passing needle.

PEG tube placement was first described by Gauderer et al1 in 1980 as a safe alternative to gastrostomy with

laparotomy. The procedure has been used widely to provide nutrition to patients incapable of oral feeding. PEG has been found to be safer and more cost effective as compared with surgical gastrostomy.9 The presence of ascites has been a relative contraindication to endoscopic gastrostomy. Leakage from the gastrostomy occurs in up to one-fourth of patients with ascites, especially when the ascites is caused by cirrhosis.10 Furthermore, the presence of a significant volume of ascites leads to poor apposition of the stomach to the anterior abdominal wall and the potential for leakage of gastric contents and subsequent peritonitis.11 Although the risk of adverse events may have decreased with the use of T-fasteners in patients with malignant ascites, it has been reported as often as 16%.12 Endoscopic sutured gastropexy may minimize the risk of fluid leakage and peritonitis because 4-sided, fullthickness sutures are placed, securing the gastric wall to the anterior abdominal wall. In contrast to T-fasteners, the current technique uses full-thickness absorbable sutures, thus providing secure apposition of the gastric and abdominal walls but leaving no permanent foreign object or device. Inadvertent PEG tube removal occurs in up to 4.4% of patients.13,14 Although the PEG tract begins to mature approximately 7 to 10 days after PEG tube placement, in malnourished patients this process can take longer. In the event that a PEG tube is dislodged while the gastrostomy is still immature, the stomach may separate from the anterior abdominal wall, resulting in free perforation. A prolonged endoscopic procedure such as ERCP can place traction on the gastric wall and potentially pull the stomach away from the abdominal wall, thereby causing free perforation. Traditionally, endoscopic procedures such as ERCP have been avoided in patients with fresh gastrostomies.3 Our series includes 4 patients who presented with severe necrotizing pancreatitis and needed enteral feeding for a period of weeks. These patients also needed potentially prolonged procedures such as ERCP, endoscopic cystgastrostomy, and endoscopic transluminal necrosectomy. A secured gastrostomy provided access for nutrition and

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RESULTS Ten patients underwent endoscopic sutured gastropexy over a period of 2 years. The procedure was successfully performed in all patients. There were no intraprocedural adverse events. One patient developed localized erythema and presumed infection at the suture site a week later and needed treatment with oral antibiotics. Patients with cirrhotic ascites requiring sutured gastrostomy did well without any evidence of fluid leakage around the gastrostomy site. Patients who needed endoscopic procedures soon after sutured gastropexy tolerated procedures such as ERCP and direct endoscopic transluminal necrosectomy well, without any radiologic or clinical evidence of gastric wall separation. In 3 patients, ERCP was performed at the time of sutured gastropexy, without any evidence of separation of the gastric wall from the anterior abdominal wall.

DISCUSSION

Attam et al

Endoscopic sutured gastropexy

Figure 2. A, The needle, loaded with suture, is advanced into the gastric lumen. B, The suture is released and grabbed by a forceps.

Figure 3. A, The needle is inserted into the gastric lumen at a different angle. B, The suture is recaptured.

Figure 4. Percutaneous needle puncture between 4-quadrant sutures (A) to place a gastrostomy tube (B). C, External view of gastrostomy with small stab incisions.

ensured that invasive endoscopic procedures could be performed with reduced risk of dissection or dehiscence of the gastrostomy tract. In our review of medical literature, we did not find any other published series of patients who have undergone 4-sided, endoscopic-guided, sutured gastropexy by using readily available surgical equipment. In 2005, Wejda et al15 had described a technique of PEG tube placement in 4 patients with ascites in which sutures were placed www.giejournal.org

by using a double-lumen gastropexy device. Two of these patients had ascites at the time of PEG placement, whereas the other 2 developed ascites after PEG tube placement and underwent suture placement. The double-lumen gastropexy device used in that series (Cliny 15 CH PEG set; AP Nenno, Marl, Germany) is not readily available in the United States. In the current series, all equipment used is readily available in operating rooms and is used routinely for Volume 79, No. 6 : 2014 GASTROINTESTINAL ENDOSCOPY 1013

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Figure 5. Schematic overview of the procedure. A, Cross-sectional pathway for 1 full-thickness gastropexy suture. B, Schematic shows mapping of skin incisions and fascial pathways. Large circle (O), percutaneous endoscopic gastrostomy; short line (-), stab incisions; diamond (A), fascial and gastric pathways.

1. Gauderer MW, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5. 2. Choi EK, Chiorean MV, Cote GA, et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013;27:2894-9. 3. Sanders GB, Alzikafi F. Trauma causing separation of gastric wall and peritoneum in healed gastrostomy. Am Surg 1976;42:579-80. 4. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes: a comprehensive clinical review. J Gastrointest Liver Dis 2007;16:407-18. 5. Taheri MR, Singh H, Duerksen DR. Peritonitis after gastrostomy tube replacement: a case series and review of literature. JPEN 2011;35:56-60.

6. Baltz JG, Argo CK, Al-Osaimi AM, et al. Mortality after percutaneous endoscopic gastrostomy in patients with cirrhosis: a case series. Gastrointest Endosc 2010;72:1072-5. 7. Ryan JM, Hahn PF, Boland GW, et al. Percutaneous gastrostomy with T-fastener gastropexy: results of 316 consecutive procedures. Radiology 1997;203:496-500. 8. Timratana P, El-Hayek K, Shimizu H, et al. Percutaneous endoscopic gastrostomy (PEG) with T-fasteners obviates the need for emergent replacement after early tube dislodgement. Surg Endosc 2012;26: 3541-7. 9. Bankhead RR, Fisher CA, Rolandelli RH. Gastrostomy tube placement outcomes: comparison of surgical, endoscopic, and laparoscopic methods. Nutrit Clin 2005;20:607-12. 10. O'Keeffe F, Carrasco CH, Charnsangavej C, et al. Percutaneous drainage and feeding gastrostomies in 100 patients. Radiology 1989;172:341-3. 11. DiLorenzo J, Dalton B, Miskovitz P. Percutaneous endoscopic gastrostomy. What are the benefits, what are the risks? Postgrad Med 1992;91:277-81. 12. Ryan JM, Hahn PF, Mueller PR. Performing radiologic gastrostomy or gastrojejunostomy in patients with malignant ascites. AJR Am J Roentgenol 1998;171:1003-6. 13. Dwyer KM, Watts DD, Thurber JS, et al. Percutaneous endoscopic gastrostomy: the preferred method of elective feeding tube placement in trauma patients. J Trauma 2002;52:26-32. 14. Larson DE, Burton DD, Schroeder KW, et al. Percutaneous endoscopic gastrostomy: indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987;93:48-52. 15. Wejda BU, Deppe H, Huchzermeyer H, et al. PEG placement in patients with ascites: a new approach. Gastrointest Endosc 2005;61: 178-80.

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laparoscopic surgical procedures. The procedure does not need surgical expertise and can be performed by a gastroenterologist trained in PEG insertion. We consider sutured gastropexy in all patients with ascites who need PEG tube placement for the purposes of nutritional supplementation or gastric decompression (such as patients with malignant ascites and bowel obstruction). We also consider sutured gastropexy in patients who are risk for early tube dislodgement, those with poor would healing, and in patients who are expected to undergo endoscopic procedures such as ERCP after PEG tube placement with insufficient time for gastrostomy to mature. REFERENCES