cations and mortality in 314 consecutive patients. Gastroenterology 1987;93:48-52. 4. Ruge J, Vasquez RM. An analysis of the advantages of Stamm and percutaneous endoscopic gastrostomy. Surg, Gynecol Obstet 1986;162:13-6. 5. Miller RE, Kummer BA, Tiszenkel HI, Kotler DP. Percutaneous endoscopic gastrostomy: procedure of choice. Am J Surg 1986;204:543-5. 6. Kozarek RA, Ball TJ, Ryan JA Jr. When push comes to shove: a comparison between two methods of percutaneous endoscopic gastrostomy. Am J Gastroenterol 1986;81:642-6.
Stabilizing sutures for percutaneous endoscopic gastrostomy B. H. Gerald Rogers, MD Mitchell V. Kaminski, Jr., MD Jerry All, RN
Percutaneous endoscopic gastrostomy (PEG) as described by Gauderer et aLl is a widely used technique for establishing a feeding gastrostomy. Although it is a benign procedure in most, some patients have developed complications because of the tenuous apposition of the gastric serosa to the parietal peritoneum. We describe a method of placing two U-shaped through and through sutures alongside the gastrostomy tube which prevents separation of the parietal surfaces and retards contamination of the peritoneal cavity. TECHNIQUE
Using the technique of Ponsky and Gauderer,2 a percutaneous endoscopic gastrostomy tube is placed. Before positioning the external rubber bumper, two stabilizing sutures are added. A 14 gauge, 21,4-inch catheter placement unit is inserted about 1 cm from the feeding tube and passed through the abdominal and gastric walls parallel to the feeding tube (Jelco, Critikon, Tampa, Fla.). The needle is removed, leaving the plastic catheter in place (Fig. 1). A 2 silk suture is passed through the catheter and grasped with the biopsy forceps (Fig. 2). The plastic catheter is withdrawn, leaving
the silk suture in place. A second puncture site is chosen 1 cm away from the feeding tube and opposite the first puncture site. This second puncture site must be a little lateral to the feeding tube so when the suture is tied, it clears the tube. The reassembled catheter unit is reinserted as before and the needle is retracted. A sterile "bare" polypectomy snare wire is fed through the plastic catheter. The loose end of the suture being held by the biopsy forceps is momentarily dropped. The biopsy forceps are then passed through the open snare loop and the loose end of the suture again captured (Fig. 3). The suture is pulled through the snare loop and released from the biopsy forceps. The snare loop is then withdrawn through the plastic catheter, dragging the Received June 15, 1988. For revision August 2, 1988. Accepted October 4, 1988. From the Ravenswood Hospital, Chicago, Illinois. Reprint requests: B. H. Gerald Rogers, MD, 406 Lake Point Tower, 505 N. Lake Shore Drive, Chicago, Illinois 60611-3493. VOLUME 35, NO.3, 1989
7. Hogan RB, DeMarco DC, Kent Hamilton J, Walker CO, Polter DE. Percutaneous endoscopic gastrostomy-to push or pull: a prospective randomized trial. Gastrointest Endosc 1986;32:2538. 8. Alberti-Flor JJ, Wright G, Arevalo P, Vaughan S, Delozier J, Dewey Dunn G. Percutaneous endoscopic placement of large (24 French) gastrostomy feeding tubes. Am J Gastroenterol 1986;81:222-3. 9. Jonas SK, Neimark S, Panwalker AP. Effect of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J GastroenteroI1985;80:438-41.
loose end of the suture with it. The first through and through suture has now been completed and can be tied (Fig. 4). A second through and through suture is placed opposite the first utilizing the same technique and then tied (Fig. 5). The external rubber bumper is now positioned and sutured in place. Tube feedings are not started until the following day. The stabilizing sutures are removed after 12 to 14 days. RESULTS
We have used the stabilizing sutures in four patients. Placement of the sutures adds 15 to 20 min to the performance of PEG. No complications were noted in placing the sutures. In the fourth case, the presence of stabilizing sutures may have averted a complication. This patient was a debilitated and confused 78-yearold woman who pulled out her gastrostomy tube 6 days after placement. The stabilizing sutures helped prevent separation of stomach from the abdominal wall. A Foley catheter was inserted through the stabilized gastrostomy and feedings were resumed without complication. DISCUSSION
The technique of PEG has been widely accepted as the preferred method for establishing a gastrostomy.I,3-5 Although this method is generally considered to be safe, complications have occurred. 6 - 10 One of the most serious complications is separation of the stomach from the abdominal wall with resulting contamination of the peritoneal cavity. This is most likely to happen in the first few postgastrostomy days when the wound is fresh. It is unlikely to happen after about 11 days when maturing collagen binds the gastric wall to the abdominal wall. Gastrostomy site separation requiring surgical intervention has been described. 3 Larson et al. 5 reported two cases of gastrostomy site separation that were due to migration of the gastrostomy tube through the gastric wall during the first 48 hours. The stabilizing sutures were designed to be used with the PEG method of Gauderer et al. 1 This method utilized a 16 French rubber mushroom catheter with a 16 French rubber crossbar. Some of the advantages of this small, soft device include its ability to be pulled atraumatically through the esophagus, its usefulness in infants as young as 4 months old, and its ease of 241
Figure 1. A 14 gauge plastic catheter has been placed alongside the gastrostomy tube.
Figure 3. The plastic catheter has been withdrawn, leaving the suture in place. The plastic catheter has been reinserted and a bare snare wire passed through it. The biopsy forceps is being used to pUll the silk suture into the snare loop (see text for details).
Figure 2. A 2 silk suture has been passed through the catheter and grasped with the biopsy forceps. extraction through the mature stoma when it comes time for its removal. The major disadvantage of this device is the ease with which it can become dislodged. Dislodgement when the stoma is immature can have disastrous consequences. Equipment manufacturers have responded to this need by producing gastrostomy tubes which have larger and firmer retention devices. l l These newer gastrostomy tubes greatly decrease the chances for accidental early pull-out and therefore greatly reduce the need for stabilizing sutures. Unfortunately, these refined tubes with their reinforced retention devices have their own disadvantages. During passage of the rigid retainer there is more trauma to the hypopharynx, cricopharyngeus, and gastroesophageal junction. Obviously, these refined tubes are designed for adults and are not usable in small children and infants. In order to remove them, repeat gastrostomy and retrograde extraction is necessary. The more rigid the retaining devices used, the more likelihood there is of producing pressure necrosis of tissue squeezed between them. 12 When using the newer tubes, the endoscopist must make the difficult 242
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Figure 4. This shows the first suture about to be tied. The ascending limb of the suture was drawn through the plastic catheter by means of the snare loop. The plastic catheter was then withdrawn, leaving the suture in place. top
Figure 5. Asecond U-shaped through and through stabilizing suture has been placed opposite the first utilizing the same technique as for the first. A top view is shown in the insert. GASTROINTESTINAL ENDOSCOPY
judgment in regard to how much pressure to apply, knowing full well that applying too much is just as hazardous as applying too little. When utilizing stabilizing sutures, the risk of producing pressure necrosis is almost nil because the retaining device can be applied loosely. The push technique of PEG as described by Russell et al. I3 and others 14 is the preferred method in a patient with a partly obstructed esophagus. This method involves placing a Foley-type catheter through the abdominal wall and into the stomach with endoscopic monitoring. Retention of the gastrostomy tube is dependent upon a soft inflatable balloon. Partial dislodgement with intraperitoneal feeding and intra-abdominal abscess formation has occurred using this technique. I5 It appears that stabilizing sutures as described herein are indicated when using this technique and should be placed before the balloon is expanded. A method of preventing gastrostomy separation by placing four stabilizing sutures was first described by Hashiba et aUG They described a technique in which a specially designed notched needle was used to complete the second limb of the stabilizing suture. At last report they have used their technique successfully in 56 patients. I7 Our technique is basically the same except only two sutures are placed. More important, all equipment used in our technique should be readily available in all gastrointestinal endoscopy and surgical suites. We hope to make PEG safer by this refinement of the technique. REFERENCES 1. Gauderer MWL, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr
Wire-guided brush cytology: a new endoscopic method for diagnosis of bile duct cancer P. G. Foutch, DO, FACP J. R. Harlan, MD D. Kerr, MD R. A. Sanowski, MD, FACP
Malignant strictures of the bile duct can be difficult to distinguish from benign conditions. Results of ERCP are suggestive but usually not diagnostic. DeReceived July 18, 1988. For revision August 29, 1988. Accepted i September 19, 1988. From the Departments of Gastroenterology ana Pathology, Carl T. Hayden Veterans Administration Medical Center, Phoenix, Arizona. Reprint requests: P. Gregory Foutch, DO, Carl T. Hayden Veterans Administration Medical Center, 7th Street and Indian School Road, Phoenix, Arizona 85012. VOLUME 35, NO.3, 1989
Surg 1980;15:872-5. 2. Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 1981;27:9-11. 3. Ponsky JL, Gauderer MWL, Stellato TA. Percutaneous endoscopic gastrostomy. Arch Surg 1983;118:913-4. 4. Foutch PG, Haynes WC, Bellapravalu S, Sanowski RA. Percutaneous endoscopic gastrostomy (PEG): a new procedure comes of age. J Clin Gastroenterol 1986;8:10-5. 5. Larson DE, Burton DO, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications and mortality in 314 consecutive patients. Gastroenterology 1987;93:48-52. 6. Greif JM, RaglandJJ, Ochsner MG, Riding R. Fatal necrotizing fasciitis complicating percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:292-3. 7. Cave DR, Robinson WR, Brotschi EA. Necrotizing fasciitis following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:294-6. 8. Bronner MH. Percutaneous endoscopic gastrostomy and crepitus. Gastrointest Endosc 1987;33:270-1. 9. Schnall HA, Falkenstein DB, Raicht RF. Persistent pneumoperitoneum after percutaneous endoscopic gastrostomy. Gastrointest Endosc 1987;33:248-50. 10. Ciocon JO, Silverstone FA, Graver LM, Foley CJ. Tube feedings in elderly patients. Indications, benefits, and complications. Arch Intern Med 1988;148:429-33. 11. Solomon SM, Kirby OF. Percutaneous endoscopic gastrostomy: a matter of choice. Endosc Rev 1988;3:36-45. 12. Foutch PG, Woods CA, Talbert GA, Sanowski RA. A critical analysis of the Sacks-Vine gastrostomy tube: a review of 120 consecutive procedures. Am J GastroenteroI1988;83:812-5. 13. Russell TR, Brotman M, Norris F. Percutaneous gastrostomy: a new simplified and cost effective technique. Am J Surg 1984;148:132-7. 14. Negri G, Cosentino F, Spino GP. Fine-needle endoscopic percutaneous gastrostomy. Endoscopy 1984;16:223-5. 15. Kozarek RA, Ball TJ, Ryan JA Jr. When push comes to shove: a comparison between two methods of percutaneous endoscopic gastrostomy. Am J Gastroenterol 1986;81:642-6. 16. Hashiba K, Fabbri CE, Cappellanes CA, Branco PO, Birolini 0, Oliveira MR. Endoscopic percutaneous gastrostomy without laparotomy. Endoscopy 1984;16:219-22. 17. Hashiba K. Endoscopic gastrostomy. Endoscopy 1987;19:23-4.
tection of metastases or a localized mass lesion by computed tomography (CT) is incriminating but these findings are frequently absent and percutaneous needle aspiration of bile duct strictures is extremely difficult when a mass is not present. 1. 2 Because of their location most cholangiocarcinomas are unresectable and palliative measures are indicated. 3.4 Endoscopic decompression is effective treatment for obstructive jaundice and some studies show enhanced survival for patients managed with radiation and chemotherapy.5-8 However, tumor-directed therapy is inappropriate in the absence of a tissue diagnosis. We have fashioned a cytology brush which can be pushed over a guide wire and precisely placed into tight strictures encountered during ERCP. Our data show that bile duct cancer can be reliably diagnosed by this method and thus specific antitumor treatment can be recommended with assurance. 243