Keywords
Roux-en-Y - percutaneous decompression - gastrostomy
Roux-en-Y gastric bypass (RYGB) has been shown to result in durable weight loss in
morbidly obese patients.[1] This procedure creates a small gastric pouch that restricts food consumption. RYGB
also limits the extent of nutrient absorption, as it excludes the gastric body, antrum,
duodenum, and proximal jejunum.[1]
[2] The excluded stomach remains in continuity distally with the remaining gastrointestinal
tract via the afferent pancreaticobiliary limb of reconstruction, which is anastomosed
distally to form a side-to-side jejunojejunostomy. Complications following RYGB are
common and can include postoperative ileus, late distal small bowel obstruction (SBO),
or mechanical obstruction at the jejunojejunal anastomosis (defined here as afferent
loop obstruction [ALO]).[3]
[4] These complications in particular can lead to distention of the excluded portion
of stomach and even lead to risk of perforation. Traditionally, treatment for distal
SBO includes nasogastric tube placement for decompression and bowel rest, versus immediate
surgical exploration for patients who appear septic, unstable, or peritonitic on abdominal
examination. Specifically for patients with ALO, dilation of the stenotic anastomosis
site with single-balloon enteroscopy can be performed as the first-line therapy in
addition to decompression.[5] However, the anatomic reconfiguration established by RYGB often precludes antegrade
access to the bypassed stomach and bowel, including placement of a nasogastric tube
for decompression.[2]
[4] In such cases, image-guided percutaneous gastrostomy may be performed to decompress
the dilated remnant stomach. The incidence of remnant stomach distention in RYGB patients
is not clear. One prospective study of 246 RYGB patients reported a 7.3% rate of postoperative
intestinal obstruction, with 3 cases secondary to jejunojejunostomy stricture (1.2%).[6]
Successful computed tomography (CT)–guided percutaneous gastrostomy for decompression
of the distended excluded segment after bariatric surgery has been previously described
in small case series reports by Stein et al and Nosher et al, but there has not been
any literature describing decompression gastrostomy after bariatric surgery using
only fluoroscopy and ultrasound (US) guidance.[2]
[4] The avoidance of CT and use of US and limited fluoroscopy guidance instead may help
reduce radiation exposure in these patients. Additionally, Nosher et al describe using
a combination of CT, fluoroscopy, and US guidance in several of the cases in the study,
potentially reducing efficiency by relying on so many modalities during a single procedure.
Last, percutaneous gastrostomy for decompression in this subset of patients may be
a safe and feasible alternative to surgery that mitigates the risks of morbidity and
mortality associated with open surgical decompression. In this series, we describe
our experience with 10 consecutive cases of percutaneous gastrostomy placement for
decompression of the excluded gastric remnant, using only US and fluoroscopic guidance.
The purpose of this article is to evaluate the feasibility and safety of percutaneous
gastrostomy for decompression of the excluded stomach in patients status post RYGB.
Materials and Methods
This study was designed as an institutional review board (IRB)–approved (IRB #201806190)
retrospective case series. Departmental records from a prospectively maintained database
were reviewed to identify cases of percutaneous gastrostomy performed between January
2001 and August 2017. Inclusion criteria were as follows: (1) The patient underwent
prior RYGB, (2) the target for tube placement was the excluded gastric remnant, and
(3) the indication for procedure was ileus, distal bowel obstruction, or ALO with
dilation of the excluded segment requiring decompression. Prior to their inpatient
referral to interventional radiology for treatment, patients were typically diagnosed
by their primary medical teams using a combination of clinical symptoms indicative
of obstruction (nausea, vomiting, bloated, distended abdomen, absent signs of bowel
function) and ancillary CT imaging that would reveal dilation of the excluded gastric
lumen, often along with a transition point (for SBO) or stenosis at the anastomotic
site (for ALO). Eight interventional radiologists at our institution with an average
of 15 years of operator experience were involved with managing the procedures in this
cohort. Technical success was defined as successful placement of a gastrostomy catheter
in the bypassed portion of stomach. The follow-up period was defined as the time point
from initial catheter placement until the date of chart review. To establish clinical
success post-procedure, patient charts were retrospectively interrogated for documentation
of clinical resolution of obstructive symptoms within the follow-up period. Additional
follow-up outcomes included time point of catheter removal and any treatment-related
adverse events at any point post-procedure within the follow-up period.
Informed consent to undergo percutaneous gastrostomy was obtained from all patients
prior to each procedure following a discussion of risks, benefits, and alternatives.
Preprocedurally, relevant laboratory parameters and available imaging were reviewed
([Fig. 1A]). All procedures were performed under moderation sedation. The skin over the stomach
was sterilely prepped, draped, and infiltrated with 1% lidocaine. The upper abdomen
was carefully examined both with fluoroscopy and US ([Fig. 1B]). The decision to perform gastropexy was left to the discretion of the individual
practitioners in a case-by-case basis, and gastropexy sutures were used for two of
the patients in this cohort. In patients who underwent gastropexy, two T-fasteners
were placed into the anterior wall of the distal gastric remnant under US guidance
and sutured to the skin. US and fluoroscopy modalities were used to identify a safe
access target on the excluded stomach. In all cases, there were gas and fluid within
the excluded stomach lumen. Fluoroscopy was used to identify the target viscera given
the partially air-filled lumen. US was primarily used to visualize a point along the
gastric wall that would be accessible without damaging adjacent structures such as
organs or blood vessels. Using US and fluoroscopy guidance, the targeted distended
stomach was accessed with a 19-gauge single-wall needle ([Fig. 1C]). In each case, the specific approach with US versus fluoroscopy guidance for needle
access to the excluded stomach was left to the discretion of the provider, and in
this series, all providers used a combination of both techniques to ensure safe access.
Contrast was injected to confirm needle placement into the gastric remnant. A 0.035-in
Bentson guidewire (Cook Medical) was advanced into the stomach through the needle
and coiled within the stomach cavity. The tract was serially dilated over the guidewire
to the appropriate diameter based on catheter size. A locking pigtail 14F multipurpose
drainage catheter (Cook Medical) was advanced over the wire into the stomach, and
contrast was injected through the catheter to confirm appropriate positioning within
the excluded stomach ([Fig. 2]). The catheter was secured to the skin using 0 silk suture and connected to gravity
drainage or bulb suction. Patients were monitored for 24 hours following tube placement
for signs of peritonitis or other immediate complications. If gastropexy sutures were
placed, they were subsequently removed after 7 days.
Fig. 1 A 64-year-old man with history of RYGB in 2003 who presented in 2016 with abdominal
pain. CT scan revealed obstruction of the afferent limb along with a massively dilated
excluded gastric remnant in the coronal view (white arrows) (A). The patient was brought to interventional radiology for decompression of the gastric
remnant. The upper abdomen was carefully examined both with fluoroscopy and ultrasound,
and the targeted stomach was noted to be massively dilated under fluoroscopy (white
arrows) (B). Two gastropexy sutures were placed, and then the targeted distended stomach was
accessed with a 19 gauge single-wall needle (white arrow) (C).
Fig. 2 A 67-year-old woman with recurrent SBO status post RYGB many years prior. Final fluoroscopic
image with contrast injection via the 14F catheter demonstrates the gastrostomy to
be within the excluded gastric remnant.
Results
Ten consecutive patients underwent percutaneous gastrostomy catheter placement for
decompression of the excluded bypass remnant. In this study cohort, patients presented
with signs of distension or obstruction at minimum 1 year after their initial RYGB
surgery. This cohort was predominantly female 9/10 (90%), with an average age of 54
± 14 years (range: 28–70). Median follow-up was 35.2 months after initial catheter
placement (range: 0.6–115). Technical success rate for decompressive gastrostomy placement
into the gastric remnant was 100% using US and fluoroscopy ([Table 1]). In 2 of the 10 patients, a 12F catheter was placed. In seven cases, a 14F catheter
was initially placed, although in one of these cases, the catheter was upsized to
18F due to poor function. In one case, a 16F catheter was used. Two of the 10 patients
had gastropexy sutures placed during the procedure. All patients ultimately demonstrated
improvement in gastric remnant distention and resolved clinical symptoms following
catheter placement. In four patients, tubes were removed after 8 weeks, and patients
demonstrated complete symptom resolution over that period. In four patients, catheter
placement resulted in clinical resolution of symptoms but was not removed until they
underwent definitive surgical revision of their jejunojejunal anastomotic site or
surgical lysis of adhesions as necessary for SBO. In two patients, the catheters remained
in place long term, with transfer to hospice due to multiple other comorbidities.
Table 1
Procedural data for patients who received US/fluoroscopy–guided percutaneous gastrostomy
into a dilated excluded gastric segment after RYGB
|
Case
|
Age (y)
|
Sex
|
Indication
|
Catheter size (F)
|
Gastropexy
|
Complications
|
|
Abbreviations: ALO, afferent limb obstruction; F, female; M, male; RVGB, Roux–en–Y
gastric bypass; SBO, small bowel obstruction; US, ultrasound.
|
|
1
|
67
|
F
|
SBO
|
14
|
Yes
|
None
|
|
2
|
64
|
M
|
ALO
|
14
|
No
|
None
|
|
3
|
47
|
F
|
SBO
|
12
|
No
|
None
|
|
4
|
49
|
F
|
SBO
|
18
|
Yes
|
Poor output; leaking
|
|
5
|
63
|
F
|
ALO
|
14
|
No
|
None
|
|
6
|
55
|
F
|
ALO
|
14
|
No
|
None
|
|
7
|
70
|
F
|
ALO
|
12
|
No
|
None
|
|
8
|
28
|
F
|
SBO
|
14
|
No
|
None
|
|
9
|
36
|
F
|
SBO
|
16
|
No
|
Poor output; leaking
|
|
10
|
63
|
F
|
SBO
|
14
|
No
|
None
|
Two patients in this cohort developed complications: one major that required rehospitalization
and one minor that required catheter exchange. One patient developed recurrent distal
SBO and dilation of the excluded remnant stomach after initial catheter placement
(14F), and the catheter had to be upsized to 18F 8 days later. This patient had complete
resolution of clinical SBO symptoms over the course of several days. They were ultimately
transferred to hospice due to multiple medical comorbidities, and the gastrostomy
tube remained in place long term for feeding. The second complication was in a patient
who had pericatheter leakage around their 16F tube that necessitated exchange 4 days
later to another 16F catheter. Following exchange, the catheter functioned appropriately.
This patient's tube remained in place for several weeks with successful decompression
and symptomatic improvement. Subsequently, the patient underwent surgical removal
of tube at the time of their anastomotic revision.
Discussion
Distention and dilation of the excluded gastric remnant is a known complication of
RYGB surgery, which clinically manifests as ileus or SBO.[3]
[4] As aforementioned, the traditional approach to treating distal SBO includes conservative
supportive measures, including nasogastric tube placement, bowel rest, and intravenous
fluid administration, versus immediate surgical exploration for patients who appear
septic, unstable, or peritonitic on abdominal examination with concern for perforation.
Specifically for patients with ALO, dilation of the stenotic jejunojejunal anastomosis
site with single-balloon enteroscopy in addition to decompression is considered the
first-line treatment for anastomotic strictures.[5] However, due to the anatomic changes in patients status post RYGB surgery, antegrade
access to the excluded stomach with nasogastric tube is often precluded, and alternative
approaches must be used to access and decompress the excluded stomach. Placement of
gastrostomy tubes in the excluded stomach at the time of gastric bypass surgery as
a prophylactic measure against distension has been described.[7] However, later studies demonstrated that routine gastrostomy at the time of gastric
bypass does not improve clinical outcomes and is beneficial only in the subset of
patients considered at high risk for developing obstruction or anastomotic leak.[8] Additionally, these prophylactic gastrostomy tubes were typically removed after
several weeks, when the risk of acute distension was lower. In our study population,
most patients presented with signs of distension or obstruction at minimum 1 year
after their initial gastric bypass surgery, rather than within a few weeks. Other
techniques have been suggested to address risk of distension in this patient population,
including the placement of radiopaque markers at the anatomical site of gastrostomy
insertion, which is thought to facilitate future catheter placement if required.[6]
This study findings concur with two previously published retrospective case series
reports endorsing the feasibility of gastrostomy catheter placement for decompression
into the excluded stomach after RYGB.[2]
[4] In a 2007 retrospective case series, Stein et al reported on the use of CT guidance
alone to place gastrostomy catheters in 10 patients.[2] They reported technical success rate of 100%, stating that even with only 3 patients
having clear access windows, gastrostomy catheters were successfully placed under
CT guidance in all 10 patients. One patient in the study by Stein et al had a technical
complication reported: During initial access, it became evident that the gastric wall
rather than the lumen was entered and was dissected during air insufflation. The procedure
was aborted and reattempted a few days later after injected air could be resorbed,
with successful catheter placement into the gastric lumen upon second attempt. Another
retrospective study, by Nosher et al, reported on the use of a combination of CT,
US, and fluoroscopy guidance to place gastrostomy catheters in a series of eight patients.[4] In their study, multiple cases were started in CT and then transferred to fluoroscopy
for final catheter placement. They also reported a technical success rate of 100%
for percutaneous gastrostomy placement. In their series, seven of eight patients experienced
clinical resolution of symptoms following catheter placement. They reported two complications,
including one patient with periprocedural peritonitis with underlying SBO who ultimately
required surgical intervention, and one wound infection treated with antibiotics and
local wound care. In our study, US and fluoroscopy were the only modalities used for
catheter placement, with a 100% technical and clinical success rate.
Overall it appears that the evidence supporting use of gastropexy in routine percutaneous
gastrostomy is inconclusive. Opponents of T-fasteners assert that their use may induce
tension on the gastric wall, which could lead to ischemia, necrosis, and subsequent
leakage around the tube.[9] However, advocates of T-tack usage maintain that tract maturation may occur more
rapidly with gastropexy and consequently reduce the risk of peritonitis.[10] Nosher et al describe the placement of gastropexy sutures in seven of eight cases
in their previously mentioned report.[4] They contend that there was concern for potential leakage from the gastrostomy because
all patients had gastric distention with the ileus or obstruction and thus predominantly
used T-fasteners. In their study, one of the seven patients who underwent gastropexy
during the procedure subsequently developed peritonitis. In our study, use of gastropexy
was left to the practitioner's discretion, and in this cohort, gastropexy sutures
were used in 2 of 10 patients. One of these two patients later presented with leakage
at the catheter entry site requiring subsequent upsizing, which led to resolution
of the leakage. Consistent with our institutional practice, we do not have strong
recommendations for or against the use of T-fasteners in this subset of patients and
believe it should be left to the operator's discretion.
Inherently this study is limited by its small sample size and its design as a retrospective
case series. Because of the low incidence of this disease process, which is restrained
to the RYGB population, large prospective cohort studies and randomized controlled
trials would be extremely difficult to carry out. Despite such limitations, we maintain
with cautious optimism that fluoroscopic- and US-guided decompressive gastrostomy
is a reasonable approach for this subset of patients. Our rate of successful decompression
is corroborated by high rates of technical success described in the limited published
data.[2]
[4] The existing literature affirms that effective image-guided percutaneous gastrostomy
eliminates the need for prophylactic placement of a surgical gastrostomy at the time
of gastric bypass surgery to prevent gastric distension as a complication.[4]
[8] Additionally, we assert based on our own technique that percutaneous gastrostomy
of the excluded remnant stomach can be performed efficaciously without requiring or
relying on previously placed radiopaque markers.
While traditional percutaneous gastrostomy tubes in non-RYGB patients can typically
be performed with fluoroscopy alone, using insufflation of air into the stomach via
nasogastric tube and subsequent visualization of the target viscera on fluoroscopy,
antegrade access to the excluded stomach is often precluded due to post-surgical anatomic
changes in RYGB, and a nasogastric tube cannot be placed. Therefore, multiple imaging
modalities are often required to aid visualization and avoid complications such as
injury to the bowel, blood vessels, and other surrounding organs. In this study cohort,
all cases involved gastric lumens that were distended with both air and fluid. There
was heavy reliance on the use of US to identify and avoid important adjacent structures
such as bowel or blood vessels along the gastric wall. Fluoroscopy was primarily used
to identify our target viscera using air already within the lumen of the excluded
stomach. We concede that access of the excluded stomach is considerably more difficult
when the distended stomach is not partially air-filled and thus requires careful sonographic
evaluation. However, if there is no appropriate visualization, we advocate for the
use of CT guidance if a safe access window cannot be appreciated using US and/or fluoroscopy.
Complications following RYGB are common and can include postoperative ileus, late
distal SBO, or mechanical obstruction at the jejunojejunal anastomosis. These complications
in particular can lead to distention of the excluded portion of stomach that remains
in continuity distally with the remaining gastrointestinal tract. Traditional image-guided
approaches to percutaneous gastrostomy with fluoroscopy alone are difficult due to
poor visualization of the excluded stomach using a single imaging modality. Whereas
earlier studies have reported the feasibility of using CT guidance alone or a combination
of CT with fluoroscopy and US guidance in this subset of patients, there are no reports
prior to this study describing the use of fluoroscopy and US alone to guide percutaneous
gastrostomy in patients status post RYGB. When appropriate visualization with these
two imaging modalities can be achieved in this setting, the avoidance of CT may help
reduce radiation exposure in these patients. Our retrospective analysis in this case
series indicates that fluoroscopic- and US-guided percutaneous gastrostomy is a safe,
effective, and feasible approach to treating dilation of the excluded gastric remnant
in RYGB patients.
