Gastrostomy - Seeing Beyond the Endoscope

With great interest, I read the article on unsedated transnasal gastrostomy placement by Vitale et al. [1]. Head and neck tumors prohibiting conventional oral endoscopy frequently pose a problem to the endoscopist. Described alternatives range from adventurous techniques to place the endoscope into the stomach rather than do without it [2], to surgery [3], while minimally invasive nonendoscopic techniques are often ignored.

Radiologically inserted gastrostomy (RIG) is easily performed under local anesthesia alone and allows placing of balloon-replacements as well as of low-profile gastrostomy tubes (button gastrostomies) [4] [5] [6]. Where endoscopy has failed or is contraindicated, peroral image-guided gastrostomy (PIG) has an extremely high success rate and allows placement of large, bumper-retained push-gastrostomies [7] [8].

Unfortunately the article does not address the risk of tumor seeding into the stoma site. This is of little clinical relevance in incurable patients undergoing palliative gastrostomy insertion, but is important for patients awaiting curative procedures. This rare, but well-reported complication [9] [10] [11] [12] can be entirely avoided by percutaneous insertion using the RIG technique. Radiologists have been very ingenious in adapting endoscopic devices for fluoroscopic use; maybe better cooperation between the two specialties would allow endoscopists to profit from their radiological colleagues’ experience. If a small endoscope can be passed transnasally into the stomach, a gastrostomy tube can then be placed directly through the skin using a RIG technique, without having to pass through the pharynx and esophagus.

We use true ‘conscious’ sedation for all our patients undergoing peroral placement of push percutaneous endoscopic gastrostomies (push-PEGs) as passage through the oropharynx is uncomfortable, particularly in the presence of tumor. It would appear that passage of a bumper through the nose must be even more uncomfortable. Patients’ comments on their experience of this approach would be interesting.

References

• 1 Vitale M A, Villotti G, D’Alba L. et al . Unsedated transnasal percutaneous endoscopic gastrostomy placement in selected patients.  Endoscopy. 2005;  37 48-51
• 2 Taller A, Horvath E, Ilias L. et al . Technical modifications for improving the success rate of PEG tube placement in patients with head and neck cancer.  Gastrointest Endosc. 2001;  54 633-636
• 3 Raakow R, Hintze R, Schmidt S. et al . The laparoscopic Janeway gastrostomy. An alternative technique when percutaneous endoscopic gastrostomy is impractical.  Endoscopy. 2001;  33 610-613
• 4 Lyon S M, Haslam P J, Duke D M. et al . De novo placement of button gastrostomy catheters in an adult population: experience in 53 patients.  J Vasc Interv Radiol. 2003;  14 1283-1289
• 5 Given M F, Lyon S M, Lee M J. The role of the interventional radiologist in enteral alimentation.  Eur Radiol. 2004;  14 38-47
• 6 Chio A, Galletti R, Finocchiaro C. et al . Percutaneous radiological gastrostomy: a safe and effective method of nutritional tube placement in advanced ALS.  J Neurol Neurosurg Psychiatry. 2004;  75 645-647
• 7 Funaki B, Peirce R, Lorenz J. et al . Comparison of balloon- and mushroom-retained large-bore gastrostomy catheters.  AJR Am J Roentgenol. 2001;  177 359-362
• 8 Laasch H U, Wilbraham L, Bullen K. et al . Gastrostomy insertion: comparing the options - PEG, RIG or PIG?.  Clin Radiol. 2003;  58 398-405
• 9 Laccourreye O, Chabardes E, Merite-Drancy A. et al . Implantation metastasis following percutaneous endoscopic gastrostomy.  J Laryngol Otol. 1993;  107 946-949
• 10 Lin H S, Ibrahim H Z, Kheng J W. et al . Percutaneous endoscopic gastrostomy: strategies for prevention and management of complications.  Laryngoscope. 2001;  111 1847-1852
• 11 Sinclair J J, Scolapio J S, Stark M E, Hinder R A. Metastasis of head and neck carcinoma to the site of percutaneous endoscopic gastrostomy: case report and literature review.  JPEN J Parenter Enteral Nutr. 2001;  25 282-285
• 12 Wacke W, Hecker U, Woenckhaus C, Lerch M M. Percutaneous endoscopic gastrostomy site metastasis in a patient with esophageal cancer.  Endoscopy. 2004;  36 472