Clinical Radiology (1999) 54, 462-464

A Simplified Method of Gastropexy for Transgastric Enterostomy

D. J. S A D L E R , R. R. G R A Y , C. B. SO, J. C. S A L I K E N

Department of Diagnostic Imaging, Foothills Hospital, 1403-29 Street N.W., Calgary, Alberta T2N 2T9, Canada

Received: 2 October 1998 Revised: 8 February 1999 Accepted: 11 February 1999

Radiological placement of gastrostomy tubes was first described in 1983. Percutaneous gastropexy to facilitate gastrostomy placement was reported in 1986. Debate has continued to this day regarding the necessity of gastric fixation. We describe our technique of a simplified gastropexy to facilitate transgastric enterostomy and advocate its more widespread use. Sadler, D. J. et al. (1999). Clinical Radiology 54, 462-464.

Key words: gastropexy, enterostomy, gastrostomy, gastrojejunostomy.

Fluoroscopically guided percutaneous gastrostomy (FGPG) using a Seldinger technique was described by several radiolo- gists in 198311-3]. In 1986 Brown et al. [4] described a percntaneous method of gastropexy using T-fasteners. They describe the intra-gastric placement of four T-fasteners, one at each corner of a 5 cm square, which could be pulled back to appose the anterior gastric wall to the anterior abdominal wall. A percutaneous gastrostomy is then performed at the centre of the square necessitating a fifth gastric puncture. At the time of the procedure obliteration of the peritoneal space at the gastro- storey site facilitates passage of dilators and catheters by preventing the stomach wall from moving away as these devices are introduced. Moreover, by holding anterior wall of stomach and abdominal wall in approximation they are felt to promote the formation of adhesions. Whether gastropexy is necessary, however, remains controversial with many authors promoting FGPG both with and without gastric fixation [4-11]. We describe our simplified gastropexy technique, based on the method described by Coleman et al. [7] and advocate its more widespread use.

METHODS AND RESULTS

Both sonography and fluoroscopy are used pre-procedure to ensure there is no colonic or hepatic interposition between the anterior abdominal wall and the chosen puncture site in the stomach. Ideally this is at the junction of the body and antrum equidistant from the lesser and greater curves to minimize the

Correspondence to: Dr David J. Sadler, Department of Clinical Radiology, Ninewells Hospital and Medical School, Dundee DD1 9SY, U.K.

0009-9260/99/070462+03 $12.00/0

possibility of vascular injury. If possible an access site lateral to rectus abdominus will avoid the epigastric vessels and avoiding the costal margin improves patient comfort. Local anaesthetic is administered to all layers of the abdominal wall. Sedation is not routinely required. Glucagon may be helpful to ensure gastric stasis but it should be borne in mind that the lack of peristalsis may make placement of a gastrojejunostomy more difficult. Gastric distension is achieved using a nasogastric (NG) tube. Occasionally an NG tube will not pass and gastric access can be obtained using a steerable vascular catheter wire combination. A 17-gauge introducer needle preloaded with a Cope gastrointestinal anchor suture (Cook, Bloomington, ID.) is used to puncture the stomach. Indentation of the gastric wall by the needle prior to puncture is observed on fluoroscopy followed by a distinct 'give'. Injection of contrast medium or aspiration of air are unnecessary if both the above are noted. The T-fastener is deployed in the usual manner by advancing the supplied guide wire. The puncture needle is withdrawn and the guidewire and anchor suture left in place. The suture is then secured to the protective plastic cover that comes with the scalpel (Fig. 1). This is achieved by cutting two small slots on opposite sides of the mid-point of the scalpel cover using the scalpel blade. By wrapping the suture around the scalpel cover in the slots the suture 'locks' and controlled tension on the gastropexy is obtained (Fig. 2). Importantly the tension on the T-fastener is automatically maintained allowing the operator and assistant to concentrate on the enterostomy placement. A small dilator is then passed over the indwelling guidewire which can be removed and replaced by a heavy duty 0.038inch 120cm gnidewire (for gastrostomy) or 180cm wire (for gastrojejunostomy). Serial dilatation and catheter placement then proceed as usual (Fig. 3). Controlled counter traction prevents movement of the stomach during device

© 1999 The Royal College of Radiologists

GASTROPEXY FOR TRANSGASTRIC ENTEROSTOMY 463

ten,led Tlacll

Scalpel blade'cover with T-fastener suture

Fig. 1 - Illustration of gastropexy site with single T-fastener. The end of the suture is wrapped around a plastic scalpel blade cover. This is facilitated by cutting slots on either side and readily provides hands free controlled counter traction to allow tract dilatation and tube placement. Post-place- ment the tension on the fastener can be eased by unwinding the suture once or twice.

introduction but once the feeding tube is in place the tension can be eased by simply unwinding the suture once or twice. A further advantage is there are no sutures actually placed in the skin to cause irritation. The suture to the plastic sheath is cut at 7-10 days.

We have used this technique on 30 patients in the past year to place either 14F gastrostomy or 12F gastrojejunostomy tubes. The only procedure related complication was abdominal pain secondary to pneumoperitoneum in two patients. This required intravenous analgesia but settled within hours in both patients with no sequelae.

DISCUSSION

Since the introduction of T-fasteners there has been con- tinued debate as to whether or not gastric fixation is needed for percutaneous gastrostomy/gastrojejunostomy. Authors in favour of T-fasteners use the following arguments: fixation of the gastric wall prevents stomach movement away from dila- tors and the catheter, the peritoneal space is obliterated pre- venting leakage of gastric content, and adhesions to the

Fig. 2. - Suture of T-fastener demonstrated wrapped around scalpel blade cover providing counter traction allowing passage of a 13F dilator.

Fig. 3 - Single T-fastener (arrowhead) gastropexy site with 0.038 inch wire coiled in stomach over which has been passed a 13F dilator. Note tip of nasogastric tube in stomach.

abdominal wall form more quickly creating a gastrocutaneous rather than a gastroperitoneal track [4-7]. Additionally, they postulate reduction of risk of subsequent displacement of the feeding tube into the peritoneal space as this space is partially obliterated at the gastrostomy site. Furthermore Saini et al. [6] postulate that gastropexy reduces the risk of haemorrhage as the approximated gastric and abdominal walls afford a degree of tamponade.

This is countered by Deutsch et al. [8] who argue that the additional four 18-gange needle punctures required for the gastropexy described by Brown [4] and Saini [6] constitutes a greater risk of haemorrhage than a single puncture unsupported gastrostomy. Bell et al. [9] similarly contend that gastropexy is unnecessary. Other groups, Ho's in particular, [10] argue that gastric leakage does not occur even after 18F holes are made in the stomach. A contrary view is that leakage always occurs and may help form adhesions.

We agree with Ho that gastropexy is not routinely needed for gastrojejunostomy [11]. However, because of the simplified technique we employ we have a low threshold for performing a gastropexy, particularly in cachectic patients whose healing powers are limited, and in patients with ascites. The latter is a situation in which the adhesions which normally form between the peritoneal surfaces will not occur unless these surfaces are approximated and the ascites displaced.

For gastrostomy many of the available catheters, however, are quite blunt due to a large end-hole and require the use of sheaths larger than the catheter to allow their insertion. In this group we use T-fasteners without scientific proof of their usefulness, but it seems helpful in preventing buckling of the

464 CLINICAL RADIOLOGY

wire in the peritoneal space and greatly facilitates tract dilation, placement of the peel-away sheath and subsequent gastrostomy placement.

There are three major reasons why T-fasteners are not used routinely. First, the cost of the procedure is increased, as the cost of the T-fasteners is added to other costs. Second, the location of major gastric vessels is unknown and, unless sonographic Doppler imaging is used, unknowable. Increased numbers of punctures (to place fasteners and the guidewire) increase the risk of hitting a major vessel by accident, and, therefore, create a theoretical risk of increasing the risk of significant haemorrhage. Third, the pressure of the T-fasteners on the anterior gastric wall may result in gastric wall trauma or ischaemic change, a mechanism postulated to increase the rate of haemorrhage in endoscopic gastrostomies [12].

Our method reduces the number of gastric punctures to the minimum of one, thereby minimizing the bleeding risk. In addition, the T4astener is taut during dilation and catheter placement to provide counter traction, but then relaxed post procedure to reduce the risk of ischaemia in the gastric wall, whilst still maintaining apposition.

The costs of our method have not been addressed. However, the second T-fastener which comes with the set can be used for a second patient (via a new 17-gauge needle), thereby reducing the cost of T-fastener use. The fastener can be deployed by a standard wire as the needle on the end of the suture is redundant with our technique and can be removed.

The same technique is applicable to primary jejunostomy where T-fasteners are also helpful [13]. We believe this simple technique takes full advantage of the benefits of gastropexy,

while reducing the theoretical/real risks and decreasing the cost.

REFERENCES

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