Gastrostomía por minilaparotomía / PERCUTANEOUS GASTROSTOMY WITHOUT LAPAROTOMY

Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares. Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares.

Introduction: Percutaneous surgery is undoubtedly the preferred technique to perform a gastrostomy for enteral feeding. Despite its advantages, it requires expensive sets and a complex procedure, which are not always available in our locations. All this led us to look for a safe alternative, easy to manage at home, and economically viable in all cases that occur in our locations. Material and Method: This is a retrospective study that includes 18 patients treated between 2005 and 2008 using the technique of minimal laparotomy (3 cm) for left median below the costal ridge, detection of the ascending portion of the stomach, placement of a Foley tube No. 18 and fixation of the stomach to the wall during the closure of the incision. Results: No serious complications were observed in the patients included in this study, except for some peri-tube reflux dermatitis and a mucous membrane prolapse. Easy home management and good patient tolerance were also observed. Discussion: Although this procedure is not the first-line treatment of choice, it is a safe and low-cost technique, which allows the placement of a safe, low-cost enteral feeding route with similar results in areas with scarce economic means like ours.

[Fluoroscopic-guided primary single-step percutaneous gastrostomy: initial results using the Freka® GastroTube]. / Primäre einzeitige durchleuchtungsgesteuerte perkutane Gastrostomie (PG): Erste Ergebnisse mit dem Freka® GastroTube.

PURPOSE: To determine the practicability and outcome of fluoroscopic-guided primary one-step treatment of percutaneous gastrostomy (PG) with the system Freka® Gastro Tube (Fresenius Kabi, Germany). MATERIALS AND METHODS: In 39 patients (mean age 62.7 ± 12.0 years), primary PG was performed based on clinical indication from August 2009 to April 2010. The intervention was performed by an experienced radiologist under aseptic conditions by direct puncture with Freka® Gastro Tube under fluoroscopic guidance. The clinical data and outcome as well as any complications originated from the electronic archive of the University Medical Center Hamburg-Eppendorf. RESULTS: The intervention was technically successful in all 39 patients. Within the mean follow-up time of 155.3 ± 73.6 days, 29 patients (74.4 %) did not experience complications. 10 patients (25.6 %) had to be revised. Complications manifested after a mean of 135.6 ± 61.2 days and mainly corresponded to accidental dislocation (50 %). One patient had to be surgically revised under suspicion of a malpositioned tube and suspected intestinal perforation. Clinically relevant wound infections were not detected. The total costs per patient were 553.17 € for our single-step treatment (OPS 5 - 431.x) vs. 963.69 € (OPS 5 - 431.x and OPS 8 - 123.0) for the recommended two-step treatment. CONCLUSION: Fluoroscopic-guided primary single-step treatment with Freka® Gastro Tube system is feasible and not associated with an increased complication rate when compared to published literature applying a two-step treatment approach. Material costs as well as human and time resources could be significantly reduced using the single-step treatment.

Fundoplication and gastrostomy versus image-guided gastrojejunal tube for enteral feeding in neurologically impaired children with gastroesophageal reflux.

BACKGROUND: Neurologically impaired children with gastroesophageal reflux (GER) usually are treated with a fundoplication and gastrostomy (FG); however, this approach is associated with a high rate of complications and morbidity. The authors evaluated the image-guided gastrojejunal tube (GJ) as an alternative approach for this group of patients. METHODS: A retrospective review of 111 neurologically impaired patients with gastroesophageal reflux was performed. Patients underwent either FG (n = 63) or GJ (n = 48). All FGs were performed using an open technique by a pediatric surgeon, and all GJ tubes were placed by an interventional radiologist. RESULTS: The 2 groups were similar with respect to diagnosis, age, sex and indication for feeding tube. Patients in the GJ group were followed up for an average of 3.11 years, and those in the FG group for 5.71 years. The groups did not differ statistically with respect to most complications (bleeding, peritonitis, aspiration pneumonia, recurrent gastroesophageal reflux [GER], wound infection, failure to thrive, and death), subsequent GER related admissions, or cost. Children in the GJ group were more likely to continue taking antireflux medication after the procedure (P <.05). Also, there was a trend for GJ patients to have an increased incidence of bowel obstruction or intussusception (20.8% v 7.9%). Of the FG patients 36.5% experienced retching, and 12.7% experienced dysphagia. Eighty-five percent of patients in the GJ group experienced GJ tube-specific complications (breakage, blockage, dislodgment), and GJ tube manipulations were required an average of 1.68 times per year follow-up. Nine patients (14.3%) in the FG group had wrap failure, with 7 (11.1%) of these children requiring repeat fundoplication. In the GJ group, 8.3% of patients went on to require a fundoplication for persistent problems. A total of 14.5% of GJ patients had their tube removed by the end of the follow-up period because they no longer needed the tube for feeding. CONCLUSIONS: Image-guided gastrojejunal tubes are a reasonable alternative to fundoplication and gastrostomy for neurologically impaired children with GER. The majority can be inserted without general anesthesia. This technique failed in only 8.3% patients, and they subsequently required fundoplication. A total of 14.5% of GJ patients showed some spontaneous improvement and had their feeding tube removed. Each approach, however, still is associated with a significant complication rate. A randomized prospective study comparing these 2 approaches is needed.

Laparoscopic gastrostomy and jejunostomy: safety and cost with local vs general anesthesia.

BACKGROUND AND HYPOTHESIS: General anesthesia is used for laparoscopic enteral access because pneumoperitoneum requires relaxation of the abdominal muscles. We wanted to determine whether these procedures could be performed with similar results and cost under local anesthesia. DESIGN: Randomized controlled study with 30-day follow-up including a cost-benefit analysis. SETTING: University-affiliated hospitals. PATIENTS: Forty-eight patients (32 men, 16 women; mean age, 67 years) undergoing laparoscopic gastrostomies (n = 32) and jejunostomies (n = 16). INTERVENTION: Twenty-four patients underwent laparoscopic gastrostomy (n = 15) and jejunostomy (n = 9) under local anesthesia with intravenous conscious sedation and monitored anesthesia care. Twenty-four patients had general anesthesia. MAIN OUTCOME MEASURES: Conversion to general anesthesia, complications, and cost. RESULTS: Ten patients under local anesthesia had periods of deep sedation and 1 required conversion to general anesthesia. One patient under general anesthesia required conversion to open gastrostomy. No patients had intraoperative aspiration; however, 4 aspirated after the procedure. One patient died of myocardial infarction during the 30-day follow-up. We found no significant difference in the total mean cost and actual procedure time. The surgeon's fee accounted for 31% of the total cost. CONCLUSIONS: Some patients undergoing laparoscopic enteral access may require deep sedation and a rare patient may require general anesthesia. Clinical conditions and surgeon preference, therefore, should determine whether local anesthesia is suitable for laparoscopic gastrostomies and jejunostomies, and in what setting, since there is no difference in success rate or complications when compared with general anesthesia. Potential savings are possible from the operating room (26% of total cost) or anesthesiologist (12% of total cost) if these procedures are performed in an endoscopy suite without monitored anesthesia care.

Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature.

PURPOSE: To evaluate the effectiveness and safety of radiologic, percutaneous endoscopic (PEG), and surgical gastrostomy. MATERIALS AND METHODS: This project involved 5,752 patients (837 patients underwent radiologic gastrotomy; 4,194, PEG; and 721, surgical gastrostomy). Seventy-two (47 male, 25 female; age range, 12-94 years) underwent gastrostomy within 1 year in this series (radiologic gastrostomy, n = 33; PEG, n = 35; surgical gastrostomy, n = 4). A meta-analysis of 5,680 additional cases from literature published from 1980 to the present was also performed. RESULTS: Rates of successful tube placement were higher for radiologic gastrostomy than for PEG in our series and in the meta-analysis (99.2% vs 95.7%, P < .001). Major complications occurred less frequently after radiologic gastrostomy in our series and in the meta-analysis (5.9% vs 9.4% for PEG and 19.9% for surgery, P < .001). Thirty-day procedure-related mortality rates were highest for surgery (2.5% vs 0.3% for radiologic gastrostomy and 0.53% for PEG, P < .001). CONCLUSION: Radiologic gastrostomy is associated with a higher success rate than is PEG and less morbidity than either PEG or surgery.