EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube placement

EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube placement

NEW METHODS: Clinical Endoscopy EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube placement Dalton M. Chaves, MD, PhD, Atul Kum...

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NEW METHODS: Clinical Endoscopy

EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube placement Dalton M. Chaves, MD, PhD, Atul Kumar, MD, Marcos E. Lera, MD, Fauze Maluf, MD, PhD, Everson L. Artifon, MD, PhD, Eduardo G. Moura, MD, Bhawna Halwan, MD, MS, Shinichi Ishioka, MD, PhD, Paulo Sakai, MD Sa˜o Paulo, Brazil

Background: Patients without adequate abdominal-wall transillumination are at a high risk of developing complications after PEG. Objective: We evaluated the feasibility and utility of EUS to guide PEG in patients lacking abdominal-wall transillumination. Design: Single-center case series. Setting: Tertiary-referral center. Patients: Six patients who lacked adequate abdominal-wall transillumination and 2 patients with a large laparotomy scar deemed to be at high risk of developing complications after PEG. Interventions: Patients underwent EUS-guided PEG and deployment of a standard enteral feeding tube. Main Outcome Measurements: Technical success and complication rates. Results: PEG was successful under EUS guidance in 5 of 8 patients. Causes of failure included an inadequate EUS window because of a prior Billroth 1 gastrectomy in one and suspected bowel interposition in 2 patients. There were no complications. Limitations: A small number of patients, uncontrolled study, and short follow-up period. Conclusions: This technique may facilitate deployment of PEG in patients who lack adequate abdominal-wall transillumination.

Since the first report of PEG in 1980, it has become the preferred mode for placement of enteral feeding tubes in patients requiring prolonged enteral feeding.1 Complication rates after PEG, which vary from 3% to 19%, are often related to the blind nature of the procedure.2,3 Patients with a history of laparotomy or those lacking abdominalwall transillumination at endoscopy are at a high risk of gastrocolic fistula, which is the most worrisome complication of the PEG procedure. In patients without adequate abdominal-wall transillumination, US, or CT-guided gastrostomy has been reported to prevent complications.4,5 We evaluated whether EUS could be used to guide PEG in patients at high risk of developing complications, eg, those

Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$34.00 doi:10.1016/j.gie.2008.06.062

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in whom adequate abdominal-wall transillumination is lacking, or in those with prior gastric resection and/or large laparotomy.

PATIENTS AND METHODS The study was conducted in the endoscopy unit of the Clinicas Hospital of Sa˜o Paulo University where about 250 PEG procedures are performed each year. Approval from the institutional review board was obtained before the start of the study. The study was performed in compliance with good clinical practices and institutional human investigations committee guidelines. Eligible patients for the trial included those who had failed conventional approaches because of a lack of abdominal-wall transillumination or those with previous major abdominal surgeries and deemed to be at high risk of developing PEG-related www.giejournal.org

Chaves et al

complications. Patient data, including demographics, indications, success rates, and complications after the procedure, were collected. Patients either returned for a follow-up visit or a follow-up telephone call was made at the end of 1 week and 1 month after the procedure.

EUS-guided percutaneous endoscopic gastrostomy

Capsule summary What is already known on this topic d

EUS-directed PEG technique

Patients in whom adequate abdominal-wall transillumination cannot be achieved are at a high risk of complications after PEG.

What this study adds to our knowledge

All patients received Cefotaxime or amoxicillin as prophylaxis prior to the procedure. Patients were sedated with midazolam, fentanyl, and propofol titrated to patient comfort. Endoscopy was performed using an endoscope (GIF Q140; Olympus America Corp, Melville, NY) and EUS using an echoendoscope (GF-UCT-160; Olympus). With the patient in the supine position, the linear echoendoscope was passed into the stomach and the probe was placed over the anterior gastric wall to identify the anterior abdominal wall (Fig. 1). The abdominal wall was identified as a thick hypoechoic muscle layer and a thin hyperechoic aponeurotic layer. The skin was identified as a very thin echogenic layer superficial to the underlying subcutaneous hyperechoic layer of variable thickness, which depended on the build of the patient. The intestinal loop was identified as a hollow structure with variable fluid in the lumen, surrounded by intestinal lumen, which comprised 3 to 4 layers of consecutive hyperechoic and hypoechoic layers. Any interposition of bowel and blood vessels between the stomach and the abdominal-wall skin was carefully assessed by using Doppler imaging (Fig. 2A). Finger indentation of the abdominal was visualized by EUS to identify an adequate site and also to facilitate delineation of layers of the abdominal wall (Fig. 2B). A 22-gauge FNA cytology needle, (Cook Endoscopy, Winston-Salem, NC) was then passed from the gastric lumen and out through the anterior abdominal wall, under real-time EUS guidance. A 3-mm to 4-mm puncture was made alongside the protruding needle in the anterior abdominal wall (Fig. 3B). A trocar was inserted over the needle into the gastric lumen (Fig. 3C). The needle was withdrawn into the echoendoscope, and the standard pull-type gastrostomy kit was deployed by using standard techniques to place an enteral feeding tube.

RESULTS A total of 8 patients, 4 women and 4 men, were invited, and all agreed to undergo PEG under EUS guidance (Table 1). The median age was 65.5 years (range 15-76 years). Indications for PEG included enteral feeding in 7 and decompression for intestinal pseudoobstruction in 1 patient. In 6 patients, a previous PEG attempt had been aborted because of a lack of adequate abdominal-wall transillumination. Two other patients were not considered for conventional PEG because of a history of prior large laparotomy (Table 1). These patients were deemed to be www.giejournal.org

d

By using linear EUS guidance, PEG was successful in 5 of 8 patients; in the 3 patients in whom the procedure was unsuccessful, abdominal-wall transillumination was inadequate.

at high risk of PEG-related complications because of a complicated postoperative course and severe abdominal scarring. EUS-assisted PEG was successful in 5 of 8 patients. Of 3 patients in whom the EUS-guided PEG was unsuccessful, all lacked adequate abdominal-wall transillumination. One patient had prior Billroth 1 gastrectomy, and the only access point that could be identified was in between the left ribs, an inadequate location for PEG access. In a second patient with prior intestinal pseudoobstruction and a large median laparotomy, an adherent bowel loop made it impossible to find a suitable window for access to the gastric cavity. In a third patient, a prior attempt to deploy an enteral feeding tube (by using the pull PEG technique) 3 months earlier had resulted in a gastrocolic fistula. There were no complications after EUS-directed PEG deployment. The time for PEG placement from the time of endoscope insertion to PEG deployment varied from approximately 30 to 60 minutes.

DISCUSSION PEG may be unsuccessful in 4% to 5% of patients requiring enteral feeding tube placement. The most common reasons for failure include absence of abdominal-wall transillumination and esophageal stenosis.6-8 Contraindications to PEG placement include coagulopathy, interposition of organs, blood vessels, peritoneal carcinomatosis, voluminous ascites, peritonitis, anorexia nervosa, severe psychosis, and limited life expectancy.9 Other contraindications to PEG include prior laparotomy, morbid obesity, partial gastrectomy, and esophageal strictures. Abdominal-wall transillumination allows the identification of an adequate window in the abdominal wall for deployment of PEG. Without adequate abdominal-wall transillumination (such as in patients with prior abdominal surgeries, peritoneal infection, hepatosplenomegaly, ascites, interposition of the bowel, and obesity), the risk of the complications, such as percutaneous or gastrocolic fistula may be high. Volume 68, No. 6 : 2008 GASTROINTESTINAL ENDOSCOPY 1169

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Figure 2. A, Doppler image of a vessel between the probe and the anterior abdominal wall. B, EUS image, demonstrating finger indentation of the anterior abdominal wall to identify the puncture site.

In CT-guided PEG, where the stomach is insufflated by using a nasogastric tube, the failure and complication rates are comparable with the conventional PEG technique.10,11 CT-guided gastrostomy may be performed in conjunction with endoscopy5,12; however, such procedures are logistically cumbersome. Recently, Schlottmann et al4 reported

PEG deployment by using transcutaneous US to guide access to the stomach cavity, which may also be logistically challenging. The EUS-guided technique allows a single operator with EUS experience to successfully complete the procedure. Panzer et al,13 in 1995, were the first to use a radial EUS to assist the PEG-tube placement in a patient who was morbidly obese and in whom abdominal transillumination could not be adequately performed. However, when using a radial EUS, the needle cannot be passed into the stomach in real time, and the PEG procedure has to be completed in a blind fashion, which may potentially be risky. Using linear EUS guidance, a needle can be safely inserted through the abdominal wall under US visualization in real time. A PEG can then be deployed by using standard techniques. When used in patients who lack abdominal-wall transillumination, this technique may prevent complications. Longer needles may be required to obtain percutaneous gastric access under EUS guidance in patients who are morbidly obese. Bender14 and Minocha et al15 have previously published a technique of endoscopically placing a PEG tube in conjunction with surgical tunneling through the subcutaneous layer in patients who are obese. In our series, none of the patients were morbidly obese; however, it is likely that EUS may be

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Figure 1. Schematic of echoendoscope along the anterior gastric wall.

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EUS-guided percutaneous endoscopic gastrostomy

Figure 3. A, A schematic of the puncture site and the insertion of trocar. B, Trocar is inserted over the EUS needle.

TABLE 1. Patient characteristics and outcomes Patient no.

Sex

Age (y)

1

F

65

Stroke

Prior colectomy

2

F

76

Dementia

3

M

15

4

F

5

Indication

Condition

Complication

Success

Left supraumbilical

None

Yes

No transillumination

Left infraumbilical

None

Yes

Head trauma

Splenectomy

Right supraumbilical

None

Yes

77

Achalasia

No translumination

Left supraumbilical

None

Yes

M

67

Pharyngeal tumor

Billroth I and no transillumination



None

No

6

M

35

Head trauma

No transillumination



None

No

7

M

66

Stroke

Gastrocolic fistula and no transillumination

None

Yes

8

F

24

Intestinal pseudoobstruction

Prior laparotomy and no transillumination

None

No

challenging in the obese patient because subcutaneous fat is poorly echogenic. In summary, we demonstrate that EUS may guide deployment of PEG in patients lacking satisfactory abdominal-wall transillumination. Our experience may have to be validated by other endosonographers, and new accessories may have to be developed to facilitate this technique.

DISCLOSURE The authors report that there are no disclosures relevant to this publication. www.giejournal.org

PEG site

Left infraumbilical –

REFERENCES 1. Gauderer MWL, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a cutaneous endoscopic technique. J Pediatr Surg 1980;15: 872-5. 2. Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy. A non-operative technique for feeding gastrostomy. Gastrointest Endosc 1981;27:9-11. 3. Marin OE, Glassman MS, Schoen BT, et al. Safety and efficacy of percutaneous endoscopic gastrostomy in children. Am J Gastroenterol 1994;89:357-61. 4. Schlottmann K, Klebl F, Wiest R, et al. Ultrasound-guided percutaneous endoscopic gastrostomy in patients with negative diaphanoscopy. Endoscopy 2007;39:686-91. 5. Vogt W, Messmann H, Lock G, et al. CT-guided PEG gastrostomy in patients with unsuccessful endoscopic transillumination. Gastrointest Endosc 1996;43:138-40.

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EUS-guided percutaneous endoscopic gastrostomy 6. 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. 7. Luetzow AM, Chaffoo RA, Young H. Percutaneous gastrostomy: the Stanford experience. Laryngoscope 1988;98:1035-9. 8. Miller RE, Castlemain B, Lacqua FJ, et al. Percutaneous endoscopic gastrostomy. Results in 316 patients and review of literature. Surg Endosc 1989;3:186-90. 9. Loser C, Aschl G, Hebuterne X, et al. ESPEN guidelines on artificial enteral nutrition-percutaneous endoscopic gastrostomy (PEG): an adjuvant technique in patients with abdominal varices. Dig Liver Dis 2005;37:709-12. 10. Halkier BK, Ho CS, Yee AC. Percutaneous feeding gastrostomy with Seldinger technique: review of 252 patients. Radiology 1989;171: 359-62. 11. O’Keeffe FN, Carrasco CH, Charnsangavej C, et al. Percutaneous drainage and feeding gastrostomies in 100 patients. Radiology 1989;172: 341-3. 12. Sanchez RB, van Sonnenberg E, D’Agostino HB, et al. CT guidance for percutaneous gastrostomy and gastroenterostomy. Radiology 1992;184:201-5.

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13. Panzer S, Harris M, Berg W, et al. Endoscopic ultrasound in the placement of a percutaneous endoscopic gastrostomy tube in the nontransilluminated abdominal wall. Gastrointest Endosc 1995;42:88-90. 14. Bender JS. Percutaneous endoscopic gastrostomy tube placement in the morbidly obese [letter]. Gastrointest Endosc 1992;38:97-8. 15. Minocha A, Chotiprasidhi P, Elmajian DA. PEG using a preexisting abdominal surgical incision in an obese patient with situs inversus. Gastrointest Endosc 1999;50:128.

Received April 3, 2008. Accepted June 27, 2008. Current affiliations: Department of Gastrointestinal Endoscopy (D.M.C., M.E.L., F.M., E.L.A.A., E.G.H.M., S.I., P.S.), University of Sa˜o Paulo School of Medicine, Sa˜o Paulo, Brazil, Department of Gastroenterology and Hepatology (A.K.), Stony Brook University, Stony Brook, Department of Gastroenterology and Hepatology (B.H.), SUNY-Downstate University Medical Center, Brooklyn, New York, USA. Reprint requests: Atul Kumar, MD, Department of Gastroenterology and Hepatology, Stony Brook University, Stony Brook, NY 11794.

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