1. Gastrostomy: Past and Present
Dr.Khayal Al Khayal

2. Overview: Gastrostomy
The delivery of health care has changed over the past two decades
More aggressive approach to the placement of tube gastrostomies
Earlier return to home
Transfer to chronic care facility
Obvious benefits of enteral feeding over parenteral nutrition

3. Overview: Gastrostomy
Open surgical gastrostomies have been supplanted by closed procedures
These procedures are generally safe and effective
Complications are frequent
Surgeon must be aware of both the options for enteral access and complications related to tube gastrostomies

4. Overview: Outline History of Gastrostomy Open temporary Open permanent
Percutaneous endoscopic gastrostomy (PEG)
Percutaneous Radiologic Gastrostomy (PRG)
Laparoscopic Gastrostomy
Indications and contraindications
Complications
Ethics
PEG vs. open Gastrostomy

5. Overview: Outline Laparoscopic Gastrostomy
Results
Complications
Laparoscopic vs. PEG
Percutaneous Radiologic Gastrostomy
PRG vs. PEG
PRG vs. PEG vs. open gastrostomy
Conclusions

6. History 1837: Egeberg first to suggest gastrostomy
1849: Sedillot of Strausbourg, performed first gastrostomy in human patient
patient died ten days later of peritonitis
1869: Maury was the first American to perform a gastrostomy this patient died as well
1870: Nine reported cases of gastrostomy in the literature
All the patients died
Usually of peritonitis

7. History 1876: Verneuil performed first successful gastrostomy
oppossed visceral and parietal surfaces with silver wire
used for feeding
problems with leakage of gastric juice
1880: L.L. Staton first succesful gastrostomy in America
8 yr old boy with a lye stricture of the esophagus
opposed visceral and parietal surfaces
patient chewed food and ejected it into feeding tube
Patient reportedly lived fifteen years

8. 1891: Witzel Gastrostomy
Pursestring suture is placed in anterior stomach
Incision is made in the stomach
Tube is passed for 5cm and pursestring secured
Additional sutures are placed to imbricate the gastric wall
Stomach is then secured to the abdominal wall

9. 1894: Stamm Gastrostomy Anterior wall of mid-stomach
Separate incision in abdominal wall for exit of gastrostomy
Pursestring suture is placed followed by incision into the stomach
Feeding tube then inserted into stomach and pursestring secured
Second pursestring placed to invaginate the first pursestring
Stomach is then secured to the abdominal wall

10. Early 1900s: Janeway Gastrostomy
Mucosa lined permanent gastrostomy
flap of stomach 5-6 cm in width is made
Flap is then made into a tube by approximating the edges
A feeding tube is then advanced into stomach
the tube is then brought out through abdominal wall
mucosa sutured to the abdominal skin

11. Early 1900s: Beck-Jianu Gastrostomy
Permanent mucosa lined
Long gastric tube fashioned from the greater curve
based on the left gastroepiploic a.
Gastrocolic ligament and gastrosplenic omentum divided
stomach is divided longitudinally and sutured
Tube is then exteriorized and mucosa is secured to skin
Can use GI stapling device

12. 1939: Glassman’s Gastrostomy
Mucosa lined
leakage of gastric juice prevented by formation of coned shape diverticulum
anterior wall of stomach grasped with Babcock clamp
pulled up into cone shape
pursestring suture placed around base
second and third pursestring are placed above
Lambert sutures are then placed to create circular valve

13. 1980: Percutaneous Endoscopic Gastrostomy
Gauderer and Ponsky (J. Ped. Surg., 15:872, 1980)
Gastrostomy without laparotomy
“Pull Technique”
pre-procedure antibiotic prophylaxis
Intravenous sedation and local anesthesia
Gastroscopy is performed and the stomach insufflated with air and transilluminated
Site for placement selected and a small 5-8mm incision is made
Intravenous catheter is quickly introduced through abdominal and gastric walls and needle removed

14. Percutaneous Endoscopic Gastrostomy (PEG)
“Pull Technique”
Guidewire grasped with snare
Snare, guidewire and gastroscope pulled through mouth
Commercially available PEG tube is then attached to guidewire
PEG pulled retrograde through mouth, esophagus, stomach, stomach wall and abdominal wall
Gastroscope re-inserted to confirm positioning of PEG
Tension is applied to the PEG to ensure gentle approximation of stomach and abdominal wall
Outer bolster then applied to secure position

15. Percutaneous Endoscopic Gastrostomy
Costal Margin
Identification of site for PEG Placement

16. Percutaneous Endoscopic Gastrostomy
Infiltration and Skin Inscision

17. Percutaneous Endoscopic Gastrostomy
Insertion of Angiocatheter

18. Percutaneous Endoscopic Gastrostomy
Insertion of Guidewire

19. Percutaneous Endoscopic Gastrostomy
PEG pulled through abdominal wall
PEG in position with outer bolster

20. Percutaneous Endoscopic Gastrostomy
“Push Technique” (Sacks et al., Inves Rad 1983: 18: )
Guidewire pulled through the mouth and gastrostomy tube loaded onto the wire
Gastrostomy tube pushed into stomach
Once seen emerging from anterior abdominal wall, tube is grasped and pulled into position
Gastroscope re-inserted to confirm position

21. Percutaneous Endoscopic Gastrostomy
“Introducer Technique” (Russel et al., AM J Surg 1984;148: )
Endoscopist is observer
Puncture is performed as usual
Guidewire inserted
Introducer with outer sheath is then passed over wire into gastic lumen
Foley then passed through sheath
Sheath then peeled away
Traction placed on balloon and secured

22. Percutaneous Endoscopic Gastro-Jejeunostomy
Gastric feedings may be inappropriate:
Gastric Atony
Gastroesophageal reflux
PEG can be modified to provide jejunal feeding
Guidewire is passed through previous PEG and advanced to duodenum
Feeding tube is then advanced over wire into dudenum

23. 1981: Radiological Percutaneous Gastrostomy
Percutaneous gastrostomy for jejunal feeding. Pershaw RM. Surg Gyne Obstet ;152:
U/S performed to ensure liver not over puncture site
Stomach is distended with CO2 via NG
Stomach punctured with needle
Gastropexy to anchor stomach wall to abdominal wall
Guidewire passed into stomach and dilated to 16 Fr
Catheter then advanced over guidewire into stomach and confirmed with contrast
Ho et al., Clin. Radiol. 56, , 2001

24. 1990: Laparoscopic Gastrostomy
Edleman and Unger (Surg Gyne Obstet 173: 401, 1991)
Local or general anesthesia
CO2 insufflation
5mm umbilical port and mid epigastric ports
Stomach is grasped and a site selected below left costal margin
7 cm 18 guage needle catheter is guided into the stomach
a J-wire fed into stomach
Dilators are passed over the wire
16 Fr peel away sheath finally placed and balloon feeding tube fed into stomach

25. Percutaneous Endoscopic Gastrostomy

26. Gastrostomy: Indications
Health Sciences Centre
: 104 PEGs
: 109 PEGs
Patients who have an intact, functional gastrointestinal tract but are unable to consume sufficient calories to meet metabolic needs.
neurologic conditions associated with impaired swallowing
neoplasms of the oropharynx, larynx and esophagus.
facial trauma
supplemental feedings in patients with miscellaneous catabolic conditions
Gastric decompression

27. PEG: Contraindications
Percutaneous endoscopic gastrostomy: indications, limitations, techniques, and results. Ponsky et al. World J Surg Mar-Apr;13(2):
Absolute:
Inability to bring the anterior gastric wall in apposition to the anterior abdominal wall
prior subtotal gastrectomy
ascites
marked hepatomegaly
Careful evaluation to determine if stomach can reach abdominal wall
Intestinal obstruction

28. PEG: Contraindications
Percutaneous endoscopic gastrostomy: indications, limitations, techniques, and results. Ponsky et al. World J Surg Mar-Apr;13(2):
Relative:
Obesity
proximal small bowel fistula
neoplastic and infiltrative diseases of the gastric wall
obstructing esophageal lesions

29. PEG: Indications
Percutaneous endoscopic gastrostomy Indications, success, complications, and mortality in 314 consecutive patients Larson DE et al., Gastroenterology 1987 Jul;93(1):48-52
Indications
Tracheoesophageal fistula (4)
Inflamatory Myopathy (3)
Short Bowel (3)
Gastric decompression (3)
Conective tissue disease (2)
Macroglossia (1)
Neurological Disorders (235)
Oropharyngeal disorders (42)
Anorexia/cachexia (11)
Aspiration (6)
Esophageal Cancer/stricture (4)

30. PEG: Success and Failure
Percutaneous endoscopic gastrostomy Indications, success, complications, and mortality in 314 consecutive patients Larson DE et al., Gastroenterology 1987 Jul;93(1):48-52
95% Technical Success
Failures 5% (15)
Not able to transilluminate (5)
Unable to pass scope (2)
Large diaphragmatic hernia (1)
Bilroth II (1)
Not able to dilate stricture (1)
Incidental gastric cancer (1)
Broken Gastrostomy tube (1)
Aspiration (1)
Laryngospasm (1)
Hematoma at gastrostomy site (1)

31. Larson DE et al., Gastroenterology 1987 Jul;93(1):48-52
PEG: Complications
Larson DE et al., Gastroenterology 1987 Jul;93(1):48-52
Minor Complications (13%)
Wound Infections (18 patients)
Tube dislodged (6 pateints)
Ileus/Ogilvie’s (4 patients)
Fever (3 patients)
Aspiration (3 patients)
Stomal Leak (2 patients)
Anorexia (2 patients)
Tube migration (1 patient)
Hematoma (1 patient)
Major complication (3% )
Death (3 pateints: Aspiration=2, laryngospasm=1)
Gastric Perforation (4 patients)
Gastric Bleed (2 patients)
Hematoma (1 patient)

32. Incidence of Free Air after Percutaneous Endoscopic Gastrostomy
PEG: Complications
Incidence of Free Air after Percutaneous Endoscopic Gastrostomy
Author
Year
# Patients
Incidence
Percentage
Dulabon
2002
116 10
8.6%
Gottfried
1985 24 9
37.5%
Pidala
1992 30 7
23.3%
Wojtowycz (CT)
1988 18 10
55.5%
Dulabon: two pateints had laparotomy for clinical peritonits
(both Negative laparotomies)
Gottfried: no patient required laparotomy

33. PEG: Rare Complications
Colocutaneous fistula
(Yamazaki et al., Surg Endosc 1999;13: )
Approx. 11 cases in literature
Penetration of transverse colon at tube placement
Excessive tension of tube and tube migration
5 of 11 cases previous abdominal surgery
8 of 11 cases presented >6 weeks post placement
Peritonitis requires surgery
However, can be treated with tube removal
Fistula usually closes spontaneously

34. PEG: Rare Complications
Squamous cell carcinoma at PEG site (Ananth and Amin Br J Oral Max Surg 2002;40: )
Head and Neck Cancer is a common indication for PEG
18 Cases in the literature
All used “pull method”
No cases reported using the “introducer method”
Implantation vs. hematogenous vs. local spread
11 cases had other metastatic disease, 7 no other mets

35. PEG: Rare Complications
Squamous cell carcinoma at PEG site (Ananth and Amin Br J Oral Max Surg 2002;40: )
Local trauma at gastrosotmy placement may predispose to hematogenous and lymphatic spread
Perhaps best to place tube after resection/debulking of tumour
Biopsy suspicious granulation tissue around PEG site

36. PEG: Long-Term Outcome
Long-term survival in patients undergoing percutaneous endoscopic gastrostomy and jejunostomy
Wolfson HC wt al., Am J Gastroenterol 1990 Sep;85(9):1120-2
Retrospective Review: 191 patients
64% Benign disease
53% benign mechanical obstruction or disordered swallowing
11% inability to maintain eneteral nutrition
36% Cancer
12% local disease
24% systemic disease
Patients followed for a mean of 275 days (median 114 days)

37. PEG: Long-Term Outcome
Long-term survival in patients undergoing percutaneous endoscopic gastrostomy and jejunostomy
Wolfson HC wt al., Am J Gastroenterol 1990 Sep;85(9):1120-2
Patients followed for a mean of 275 days (median 114 days)
Total mortality: 60% (115 patients)
Median time to expiration: 164 days
21% (40 patients) died within 30 days (no procedure deaths)
21% (40 patients) had their tube removed after recovery
16% benign disease, 5% cancer
Overall, high cummulative mortality
Benefits are limited if projected early mortality
Benefit in facilitating patient discharge from hospital to other long term care facilities

38. PEG: Ethics
Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Rabeneck L. et al., Lancet Feb 15;349(9050):496-8.
Anorexia-Cachexia
Syndrome
Yes
Do not offer
PEG
Patient unable
to make use of nutrients No
Patient unable to
experience
any quality of life
Offer and
Recommend
Against PEG
Permanent
Vegetative State
Yes No
Dysphagia without
Complications
Yes
Patient unequivocally
Benefits from PEG
Offer and recommend
PEG No
Patient equivocally
Benefits from PEG
and potential exists for loss
of quality of life
Yes
Discuss no PEG vs.
Trial of PEG
Dysphagia with
complications

39. PEG vs. Stamm Gastrostomy
Endoscopic vs. operative gastrostomy final results of a prospective randomized trial
Steigmann, Silas et al., Gastrointest Endosc Jan-Feb; 36(1):
57 patients Stamm gastrostomy, 64 patients PEG
Groups equally matched for underlying disease
100% (57 of 57) success for Stamm
95% (61 of 64) success for PEG, 2 had successful Stamm
4 PEG patients had migration of tube through stomach
3 PEG patients had bleeding requiring transfusion
Complications similar (26% vs 25%)
Costs: Stamm $1675 vs PEG $979

40. PEG vs. Stamm Gastrostomy
Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy Grant JP. Ann Surg May;207(5):
Retrospective: 125 PEG and 88 Stamm
Less total operating time: PEG 38 min vs. Stamm 96 min
Complications: PEG 8.8% (4% major) vs. Stamm 23.9% (10% major)
only one PEG patient required laparotomy
PEG associated with $1000 less cost

41. Laparoscopic Gastrostomy

42. Laparoscopic Gastrostomy
First results of laparoscopic gastrostomy
Peitgen K et al., Surg Endosc Jun;11(6):
Retrospective review of 42 laparoscopic gastrostomies
Locally advanced oropharyngeal cancer and esophageal cancers
Operative time: 38 minutes
Procedure could be performed in all patients
Procedure related mortality: 0%
Major complications: 2/42 (4.7%)
Gastric perforations due to grasping forcep
Laparotomy after falsely interpreted contrast radiograph
Minor complications: 4/42 (9.4%)

43. Laparoscopic and Open Gastrostomy
Laparoscopic Gastrostomy: A safe method for obtaining enteral access
Murayama KM et al., J Surg Res Jan;58(1):
Retrospective review
Patients who could not undergo gastroscopy
32 patients laparoscopic and 37 open gastrostomy
General anesthesia in 94% of laparoscopic and 73% of open gastrostomies
Major complications: 6% of laparoscopic and 11% of open gastrostomy
Operative time: Laparoscopic 38 min vs. 62 min
No difference in mortality
Safe alternative for patients that cannot under go PEG

44. PEG and Laparoscopic Gastrostomy
Laparoscopic gastrostomy versus percutaneous endoscopic gastrostomy
Edelman DS, Arroyo PJ, Unger SW. Surg Endosc 1994 Jan;8(1):47-9
Retrospective review
17 patients PEG and 14 patients laparoscopic gastrostomy
Laparoscopic procedures performed for inablilty to perform gastroscopy
No difference in complications
one death in laparoscopic group due to tube dislodgement and intraperitoneal feeding

45. Percutaneous Radiologic Gastrostomy

46. Percutaneous Radiologic Gastrostomy (PRG)
Percutaneous gastrostomy in patients who fail or are unsuitable for endoscopic gastrostomy. Thornton FJ et al., Cardiovasc Intervent Radiol. Jul-Aug;23(4):
42 patients unsuitable for PEG
Unable to perform gastroscopy (15)
Subopitmal transillumination (22)
Advanced cardiorespiratory disease (5)
Technical success in 41/42 (98%)
CT guidance required in 4 cases
3 intercostal and 6 under the costal margin tube placement
3 major complications:
Intraperitoneal tube placement
Bleeding requiring transfusion
Severe gastrostomy site infection

47. PEG and Radiologic Gastrostomy
Percutaneous Radiologic and Endoscopic Gastrostomy: A 3 Year Intstitutional Analysis of Procedure performance
Wollman B and D’Agostino HB. AJR 1997 Dec;169:
Retrospective Review:
68 Percutaneous radiologic gastrostomies
114 Endoscopic gastrostomies
Success rate: 100% for PRG and 95% PEG
PRG performed in 4/6 patients that failed PEG
Incidental findings in 30% of PEG patients
66% no action taken
the remaining had biopsy and/or medications (esophagitis, stricture, Barrett’s, gastritis, ulcer)
No difference in procedure related mortality or complications

48. PEG and Radiologic Gastrostomy
Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature Wollman B et al., Radiology 1995 Dec;197(3):
837 patients radiologic gastrostomy, 4194 underwent PEG, open gastrostomy
Successful tube placement higher for radiologic vs PEG (99.2% vs. 95.7% p<0.001)
No difference in procedure related mortality

49. PEG and Radiologic Gastrostomy
Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature Wollman B et al., Radiology 1995 Dec;197(3):
Major Complications
Radiologic %
PEG %
Significance
Wound
Aspiration
Peritonitis
Other GI
Dislodged tube
Other
0.8
0.6
1.3
1.7
0.1
3.3
2.1
0.5
2.4
0.9
0.1
P<0.001 NS
Total
5.9
9.3
P<0.001

50. PEG and Radiologic Gastrostomy
Outcomes of surgical, percutaneous endoscopic, and percutaneous radiologic gastrostomies Cosentini EP, Arch Surg 1998 Oct;133(10):
Retrospective Review:
14 patients surgical gastrostomy
24 patients PEG
44 Percutaneous radiological gastrastomy
1 procedure related death in the radiological group (aspiration followed by multiorgan failure)
No difference in minor and major complications complications
3 patients in radiological group needed early laparotomy for tube dislodgement (2 patients) and tear off of T-bolster (1 patient)
10% lower tube function rate in radiological group (16F vs. 22F)

51. Conclusions
Percutaneous Endoscopic Gastrostomy is the most common means of establishing eneteral nutrition
Can be performed at the bedside
Minor Complications: 2-36%
Major Complications: 0-17%
Percutaneous Radiological Gastrostomy is a reasonable alternative to PEG and may be the procedure of choice when PEG fails
More difficulty in maintaining tube patency
Minor Complications: %
Major Complications: 0-11%

52. Conclusions
Laparoscopic Gastrostomy alternative to open gastrostomy in patients who are unsuitable for both PEG and PRG
Minor Complications: 2-19%
Major Complications: 0-6%