Absorbable fixation straps for laparoscopic gastropexy in dogs.

OBJECTIVE: To evaluate the feasibility and efficacy of laparoscopic absorbable fixation straps (AFS) for laparoscopic gastropexy in dogs. STUDY DESIGN: Cadaveric and prospective clinical study. ANIMALS: Five dog cadavers for the cadaveric study; 12 dogs for the clinical study. METHODS: The pyloric antrum was affixed to the abdominal wall laparoscopically by applying a series of straps. The cadaveric study assessed potential challenges during the procedure and stomach mucosal penetration. For the clinical study, the total duration of surgery, time to complete the gastropexy, and the number of straps used were recorded. Ultrasound evidence of adhesion, complications, and weight were monitored at 7, 30, and 90 days after surgery. Owner satisfaction was evaluated at the 6-month follow-up. RESULTS: The total duration of surgery was 25.8 minutes (range, 19-39; SD, 6.7), and the time to complete the gastropexy was 10.1 minutes (range, 7-19; SD, 3.9). The linear regression analysis revealed an inverse correlation between the time to complete the gastropexy and the order of the surgeries (r2  = 0.75, P < .05). No complications were recorded. Ultrasound examination was used to confirm gastropexy at all follow-ups. CONCLUSION: Laparoscopic gastropexy with AFS was performed in both cadavers and clinical animals with minimal complications. Persistent adhesion was demonstrated during ultrasound evaluations and in one postmortem evaluation. CLINICAL SIGNIFICANCE: This novel laparoscopic technique can be employed safely, effectively, and reasonably quickly, and the learning curve is expected to be relatively short.

Percutaneous Ultrasound Gastrostomy: First-in-Human Experience with the PUMA-G System.

Percutaneous ultrasound gastrostomy (PUG) technique was developed to allow for gastrostomy tube insertion to be performed solely under ultrasound guidance without need for fluoroscopy or endoscopy. This report discusses the new device, proposed PUG technique, and the first-in-human experience. Five patients had PUG tube insertion performed as part of a Health Canada approved investigational study. All procedures were successful with no complications within 30 days postprocedure. Mean total procedure time was 50 ± 13 minutes. Two of 5 procedures required temporary fluoroscopy use to localize the orogastric balloon position within the stomach to achieve magnetic gastropexy.

Guided Transabdominal U-Stitches Gastropexy: A Simplified Technique for Secure Laparoscopic Gastrostomy Tube Insertion.

Introduction: Insecure gastropexy, gastric mucosa overgrowth, granulation tissue formation, and a nonhealing gastrostomy are unwanted consequences encountered in the current minimally invasive gastrostomy tube (GT) placement techniques. Aiming to overcome these problems we have developed a simplified laparoscopic-assisted GT insertion (LAG) procedure using guided transabdominal U-stitches (GTU) gastropexy. Materials and Methods: We retrospectively reviewed all LAG cases performed in our institute using the GTU technique. In brief, a curved clamp is inserted intragastrically through the laparoscopic port and guides a needle across the abdominal and gastric walls to exit, then re-enter back, through the port in an out-in-out fashion creating multiple spaced transabdominal U-stitches that are tied over pledgets. Results: Between March 2008 and January 2015, 31 cases had LAG attempted using GTU. Two cases were converted to open procedures for non-LAG-related reasons. The median age of the remaining 29 cases was 37 (range, 0.3-154.9) months. Of those patients, 20 had fundoplication (LAG-Fundo), whereas the remaining 9 had LAG-only. The mean operative times for LAG-Fundo and LAG-only were 148 ± 57.5 minutes and 41 ± 12.4 minutes, respectively. During a median follow-up of 21 (range, 4-81) months we did not encounter any procedure-related mortality, intraabdominal leaks, or bowel injuries. One patient required redo gastropexy due to unplanned early U-stitch removal, and 7 cases had transient external GT leak, granuloma formation, and/or skin infection. Conclusions: GTU can achieve a simple and secure LAG, avoiding the catastrophic complications of intraabdominal leak without the need of special instruments or enlarging the port's wound. Using a smaller wound and intraabdominally placed mucosa helps in minimizing the risk of wound infection and external leak. Transient complications are expected during the earlier phase of the learning curve.

Modified tube gastropexy using a mushroom-tipped silicone catheter for management of gastric dilatation-volvulus in dogs.

OBJECTIVES: To report the short- and long-term complications and clinical outcomes of a cohort of dogs managed for gastric dilatation-volvulus using a modified right-sided tube gastropexy technique. MATERIALS AND METHODS: Retrospective case series. RESULTS: Of 31 dogs treated, 29 (93·5%) had an excellent short-term outcome, and gastric dilatation-volvulus did not recur in any dog. Twenty-six dogs (84%) were initially fed via the gastrostomy tube postoperatively; three (9·7%) suffered a major complication including septic peritonitis (n=1), and premature tube removal (n=2). Fourteen dogs (45·1%) had minor complications including mild, self-limiting discharge from the stoma site in 13. CLINICAL SIGNIFICANCE: Modified tube gastropexy using a mushroom-tipped silicone catheter is an effective and safe surgical method for the management of gastric dilatation-volvulus. The gastrostomy tube allowed early enteral feeding and easy administration of medications, including gastroprotectants.

Safety and Short-Term Complication Rates Using Single-Puncture T-Fastener Gastropexy.

PURPOSE: To report a single operator's experience using a modified single-puncture gastrostomy technique deploying up to three nonabsorbable gastropexy anchors. MATERIALS AND METHODS: A retrospective review of 69 consecutive patients undergoing gastrostomy, gastrojejunostomy, or jejunostomy tube insertion between March 2012 and January 2014 was performed. Technical success and 30-day local, major, and minor complication rates were assessed according to the Society of Interventional Radiology (SIR) Standards of Practice for Gastrointestinal Access. Procedure time was also recorded. RESULTS: Primary technical success of the procedure was 98.6% (68/69). In one patient, the procedure was aborted because the stomach could not be safely accessed. Major complications occurred in one of 69 (1.4%) patients, minor complications occurred in 10 of 69 (13%) patients, and local complications occurred in three of 69 (4.3%) patients. Local complications consisted of redness and mild tenderness at the enteric access site. Mean procedure time was 5 minutes (range, 3.1-36 min). CONCLUSIONS: Single-puncture, multianchor gastrostomy is a feasible technique for radiologically guided enteric access tube insertion with technical success and complication rates similar to conventional gastrostomy techniques. This technique could be considered when expeditious performance of a procedure is required.

Comparison of Two Laparoscopic Techniques for Gastropexy in Children.

BACKGROUND: Laparoscopic gastrostomy is a widely used interventional procedure in pediatric surgery. We report comparative data for two endosurgical methods for the fixation of the stomach against the abdominal wall, using the U-stitches technique and the Saf-T-Pexy® (Halyard Health Inc., Alpharetta, GA) system. MATERIALS AND METHODS: Within the period from January 2012 to June 2014 we performed 24 operations involving laparoscopic placement of a gastrostomy tube using U-stitches (Group I) and 24 operations using the Saf-T-Pexy system (Group II). The two groups of patients were compared in terms of demographics and intraoperative and postoperative results. RESULTS: No statistical difference (P > .05) was found while comparing the patients' demographics and intra- and postoperative results. The mean duration of the surgical procedure in Group I was 23.75 minutes; in contrast, the mean duration of surgery in Group II was 22.71 minutes (P > .05). The time to first feeding (9.96 hours versus 10.63 hours) and time to full enteral feeding (23.13 hours versus 24.5 hours) were consistent for patients from both groups (P > .05). A similar postoperative duration of stay was recorded for the patients from the comparison groups (7.25 days versus 7.21 days; P > .05). Statistical analysis of the two groups demonstrated a significant difference in the parameters of minor postoperative complications (41.67% versus 8.33%; P < .05). CONCLUSIONS: Use of the Saf-T-Pexy system is a simple and efficient method for gastropexy involving placement of gastrostomy tubes that significantly reduces the number of postoperative complications.

Biomechanical Analysis of Laparoscopic Incisional Gastropexy With Intracorporeal Suturing Using Knotless Polyglyconate.

OBJECTIVE: To evaluate load to failure of laparoscopic incisional gastropexy performed with intracorporeal suturing using knotless polyglyconate (KP). STUDY DESIGN: Cadaveric study. ANIMALS: Canine cadavers (n = 12). METHODS: Laparoscopic incisional gastropexy using 2 strands of KP was performed in 6 canine cadavers and by an open approach in 6 cadavers. Length of the gastropexy, number of suture bites on each side of the gastropexy, and number of inadvertent full thickness gastric suture bites were recorded. Load to failure was measured. RESULTS: There was no significant difference in mean (±SD) gastropexy load to failure for the open (46.3 ± 19.6 N) and laparoscopic (69.0 ± 26.0 N) approaches (P = .123). No significant differences between laparoscopic and open approaches were detected for mean stomach (3.1 ± 0.1 cm; 3.0 ± 0.2 cm; P = .353) or abdominal wall (3.1 ± 0.2 cm; 3.0 ± 0.2 cm; P = .553) incision lengths. There was no significant difference between groups for number of suture bites medially (P = .448) or laterally (P = .363). There were 3 instances of a single gastric intraluminal suture for the laparoscopic group and none for the open approach (P = .023). CONCLUSION: Incisional gastropexy performed with laparoscopic intracorporeal suturing and KP has a load to failure that is comparable with an open method. Load to failure was similar to reported values for open incisional gastropexy with knotless glycomer 631.

T-fastener migration after percutaneous gastropexy for transgastric enteral tube insertion.

BACKGROUND/AIMS: To determine the prevalence and time-course of t-fastener migration after gastropexy deployment. METHODS: We reviewed our procedural database for all percutaneous gastrostomy and gastrojejunostomy tube insertions performed over a 14-month period using a widely accepted t-fastener kit for gastropexy (Kimberly-Clark). Of 201 patients, 71 (41 males, 30 females; mean age, 56 years) underwent subsequent abdominal computed tomography (CT) imaging. The location and associated findings of each t-fastener were retrospectively recorded for each CT scan performed after the tube insertion. RESULTS: A total of 153 t-fasteners were deployed during 71 procedures with subsequent CT follow-up. In the short term (within 4 weeks after deployment), 5.1% of the t-fasteners had detached and were no longer present; 59.5% were intraluminal or within the gastric wall; and 35.5% were within the anterior abdominal wall musculature or subcutaneous. In the long term (>3 months), 48.6% of the t-fasteners had detached and were no longer present, 25.0% were intraluminal or within the gastric wall, and 26.4% were within the anterior abdominal wall musculature or subcutaneous. No t-fastener-related complications, such as abscesses, fluid collections, or fistulae, were identified. CONCLUSIONS: Following gastropexy for percutaneous transgastric feeding tube placement, t-fastener migration into the abdominal wall frequently occurred soon after the tube insertion. Therefore, recent t-fastener deployment does not guarantee an intact gastropexy.

Evaluation of two novel self-anchoring barbed sutures in a prophylactic laparoscopic gastropexy compared with intracorporeal tied knots.

OBJECTIVE: To compare laparoscopic gastropexy using 2 self-anchoring barbed sutures to gastropexy using laparoscopically tied intracorporeal knots. STUDY DESIGN: Prospective, randomized controlled, clinical trial. ANIMALS: Dogs (n = 30) weighing >16 kg. METHODS: Dogs were randomly assigned to 1 of 3 laparoscopic gastropexy groups: group 1 (controls), intracorporeal 2-0 polydioxanone sutures (PDSII, Ethicon); group 2, barbed suture (0 Quill™ PDO; Angiotech); and group 3, barbed suture (2-0 V-Loc™ 180; Covidien). Gastropexy suturing time (GST) and total surgery time (TST) were recorded for each dog. Complications were recorded. Each dog was examined by ultrasound (1, 3, and 6 months postoperatively) to ensure persistence of the gastropexy. One dog each in group 2 and group 3 had 2nd look laparoscopy to evaluate the gastropexy. RESULTS: All gastropexies were intact at 6 months. Mean GST was significantly longer for group 1 (36 minutes; range, 25-46 minutes) than for groups 2 (20 minutes; range, 16-37 minutes) and 3 (19 minutes; range, 15-30 minutes; P < .05), which were not significantly different from each other. Likewise TSTs for groups 2 and 3 were significantly shorter than for group 1 (P < .05). CONCLUSION: Barbed sutures (Quill™ and V-Loc™) allowed for effective intracorporeal laparoscopic suturing of an incisional gastropexy without tying intracorporeal knots.

Disc-retained tubes for radiologically inserted gastrostomy (RIG): not up to the job?

AIM: To assess the insertion procedure and performance of disc-retained gastrostomy tubes, recording complications and accidental displacements by prospective audit, and to determine whether primary placement of the tube off-licence was feasible. MATERIALS AND METHODS: Disc-retained 12 F single-lumen Monarch gastrostomy tubes (Enteral UK, Selby, UK) were inserted by three gastrointestinal interventional radiologists in a supra-regional cancer centre. The 12 F tubes required a 20 F peel-away sheath with four-point gastropexy fixation and were placed under conscious sedation, using electrocardiogram (EEG) bispectral index monitoring. Follow-up was performed in an in-house gastrostomy drop-in clinic at 1 week and 1 month, supplemented with weekly telephone follow-up. Patients also had open access to the gastrostomy drop-in clinic for immediate advice and complication management. RESULTS: Eighteen patients underwent primary insertion of a Monarch gastrostomy tube over 5 months. A total of 6/18 (33%) tubes displaced; 4/18 (22%) completely, 2/18 (11%) occult into the peritoneum. Four of 18 (22%) patients developed infection at the stoma site. Due to the unexpectedly poor performance of the tube, the study was terminated early. CONCLUSION: Initial experience with the Monarch disc-retained gastrostomy tube demonstrates it unsuitable for primary placement with current protocols. In view of the potentially serious complications, the Medicines and Healthcare Products Regulatory Agency (MHRA) has been informed. A request has been made to the distributer to reassess the tube design and/or review the procedure promoted for primary placement.

Prospective evaluation of absorbable gastropexy anchor indwelling time in 33 patients.

PURPOSE: To evaluate the time to absorbable suture gastropexy anchor release and gastropexy-related complications in patients receiving percutaneous image-guided transabdominal gastrostomy or gastrojejunostomy tube placement. MATERIALS AND METHODS: Thirty-three consecutive patients (16 women; mean age, 63.5 y; range, 25-92 y) undergoing fluoroscopically guided (n = 32) or computed tomography-guided (n = 1) percutaneous transabdominal gastrostomy (n = 26) or gastrojejunostomy (n = 7) were prospectively enrolled in a single-center study. Each patient had three synthetic absorbable suture T-fasteners inserted and were followed until all gastropexy button-locks released naturally, were cut by a health care provider, or were lost to follow-up. Patients or caregivers were contacted weekly to determine timing of gastropexy button-lock release and assess for postprocedural complications. RESULTS: All three T-fastener button-type suture locks released naturally in 14 of 33 patients (42.4%) at a median of 29.5 days (mean, 26.7 d; range, 8-40 d). One or more T-fastener sutures were cut in 10 of 33 patients (30.3%), and nine patients (27.3%) were lost to follow-up. Accounting for patient censorship, T-fasteners in all 33 patients remained intact for a median of 35 days. Local infections developed in three patients (9%) on days 22, 25, and 34. CONCLUSIONS: Relative to nonabsorbable gastropexy sutures, absorbable suture gastropexy anchors offer the potential to reduce complications associated with long gastropexy indwelling times. However, absorbable gastropexy anchor buttons usually remain intact for longer than 3 weeks after insertion. A postprocedural plan for gastropexy inspection and removal within 3 weeks should continue to be emphasized to avoid local complications, even for absorbable suture kits.

Subcutaneous T-fastener gastropexy: a new technique.

OBJECTIVE: T-fastener gastropexy is a step in percutaneous radiologic gastrostomy in which the stomach is fastened to the abdominal wall. Minor complications of gastropexy are often related to the prolonged presence of T-fastener sutures. We describe a new technique for gastropexy using absorbable sutures placed subcutaneously, as opposed to the standard percutaneous approach. CONCLUSION: Subcutaneous gastropexy is safe, obviates follow-up suture removal, and eliminates complications associated with cutaneous sutures.

Biomechanical comparison of glycomer 631 and glycomer 631 knotless for use in canine incisional gastropexy.

OBJECTIVE: To compare the load to failure of incisional gastropexy performed with standard glycomer 631 (G) and with knotless glycomer 631 (GV) in ex vivo model of gastropexy. STUDY DESIGN: Cadaveric study. SAMPLE POPULATION: Cadaveric canine stomach and body wall (n = 24). METHODS: Specimens were divided into 4 groups based on suture type (G, GV) and size (3 metric, 2 metric). An incisional gastropexy was performed on all samples, and load to failure evaluated. RESULTS: Gastropexy with GV had significantly higher load to failure than gastropexy performed with G (P = .0006). Suture size had no significant effect on maximum load to failure (P = .36). The interaction between size of the suture and suture materials had a significant effect on the load to failure of the gastropexy (P = .0474). Knotless glycomer 631, 3 metric had significantly greater load to failure than G 3 metric (P = .0016) and G 2 metric (P = .0107). CONCLUSION: A knotless suture appears to have comparable, if not greater load to failure than a standard suture of similar composition when used in canine incisional gastropexy in an acute ex vivo model.

A biomechanical study of laparoscopic 4S-modified Roeder and Weston knot strength in 3-0 polyglactin 910 and 3-0 polydioxanone.

OBJECTIVE: To (1) evaluate biomechanical strength of 4 different laparoscopic knots using 2 suture types, and (2) evaluate carotid artery ligature bursting pressure of 2 knots using a single suture type. STUDY DESIGN: Biomechanical materials testing. SAMPLE POPULATION: Suture material (3-0 polydioxanone, 3-0 polyglactin 910). METHODS: Four knot types were tested: 4S-modified Roeder (4SMR) Weston plus 3 square throws (W3S); Weston plus 3 granny throws (W3G); and a 4 square throw knot as a control (control); 24 specimens of each knot type were tied with 3-0 polyglactin 910 and 24 of 3 knot types (4SMR, W3S, control) were tied with 3-0 polydioxanone. Suture loop constructs were tested to 3 mm displacement failure and ultimate failure. Carotid artery ligation bursting pressure was tested using 10 samples each of 4SMR and W3S knots with 3-0 polyglactin 910. RESULTS: The W3S, W3G, and controls were similar. The 4SMR was similar to W3S using 3-0 PDS but the 4SMR had lower load to failure and greater elongation than the Weston using 3-0 polyglactin 910. The 4SMR had a higher slippage rate with 3-0 polyglactin 910. All ligatures withstood supraphysiologic pressures. CONCLUSIONS: Surgeons using 3-0 polyglactin 910 should consider using the Weston knot with added throws during laparoscopic procedures.

Gastropexy using the Carter-Thomason device in lieu of T-fasteners in a critically ill, severely obese patient: an innovative technique.

A gastropexy with T-fasteners can maintain gastric apposition to the abdominal wall before a mature gastrocutaneous fistula. In patients at high risk for inadvertently removing their percutaneous endoscopic gastrostomy tube, or those in whom early, unintentional removal and subsequent laparotomy would be catastrophic, the T-fasteners can act as a safety mechanism. We present a case of an obese patient, for whom a surgical gastrostomy was not practical, and the T-fastener system had inadequate length to traverse the abdominal wall. Innovatively a fascial closure device was used in a similar fashion to create an equivalent gastropexy. Obesity frequently complicates surgical and critical care, providing additional technical challenges. We must continue to be creative and innovatively utilize current equipment to deliver more effective and safer care for this unique patient population.

CT fluoroscopy-guided percutaneous gastrostomy with loop gastropexy and peel-away sheath trocar technique in 31 amyotrophic lateral sclerosis patients.

BACKGROUND: In amyotrophic lateral sclerosis (ALS) patients with respiratory impairment and/or advanced disease, performing even mild sedation - as is usually necessary for percutaneous endoscopic gastrostomy (PEG) placements - is fraught with risk. These patients are often referred to Interventional Radiology for alternative percutaneous gastrostomy tube placement options. PURPOSE: To report our experience with CT fluoroscopy-guided percutaneous gastrostomy with a novel loop gastropexy and peel-away sheath trocar technique in ALS patients as an alternative to endoscopic techniques. MATERIAL AND METHODS: A consecutive series of 31 amyotrophic lateral sclerosis patients in whom endoscopic gastrostomy was considered too dangerous or impossible to perform underwent CT-guided percutaneous gastropexy and gastrostomy and prospective follow-up. All procedures were performed with a 15 FR Freka® Pexact gastrostomy kit, a 16-row CT scanner (Aquilion 16) and single shot CT fluoroscopy mode. RESULTS: The procedure was performed successfully in 30 of 31 patients (20 men, 11 women; median age 60 years, range 38-80 years). In the remaining case the stomach was punctured under CT fluoroscopy and CO2 insufflation was initiated thereafter, leading to successful gastrostomy without prior gastropexy and without further adverse events during follow-up. Two patients reported unproblematic exchange of a balloon tube due to skin irritations with no further adverse events. One patient reported accidental displacement of an exchanged new balloon tube in domestic environment due to balloon leakage: A new balloon tube was easily re-inserted in a hospital the same day. No serious adverse events such as peritonitis, persistent local bleeding, systemic blood loss, or any local infection requiring surgical intervention were observed. Until August 11, 2011 follow-up resulted in 7473 cumulative gastrostomy-days from the date of first placement. CONCLUSION: Initial results suggest that the described technique under CT guidance is feasible and safe and may especially be advantageous in cases where endoscopic gastrostomy and sedation are contraindicated.