Percutaneous gastrostomy in patients with a ventriculoperitoneal shunt: case series and review

Percutaneous gastrostomy in patients with a ventriculoperitoneal shunt: case series and review Robert Baird, MDCM, Robert Salasidis, MD, FRCS(C) Background: There are few data on the safety of PEG in patients with a ventriculoperitoneal shunt. Methods: Medical records for patients seen in 3 tertiary care, university-affiliated hospitals between January 1, 1991, and January 1, 1999, were reviewed. Observations: Six patients underwent PEG after ventriculoperitoneal shunt placement during the study period. There was no immediate complication. One patient died of pneumonia 2 months after PEG insertion. There was no instance of shunt malfunction, intra-abdominal complication, or wound infection in the study group. There was no long-term complication, with either the ventriculoperitoneal shunt or the PEG. Conclusions: Although the number of cases was small, PEG placement with prophylactic administration of antibiotics appears to be safe in patients with a pre-existing ventriculoperitoneal shunt.

It has become obvious during the last 25 years that nutritional support is integral to the care of the hospitalized patient, more so for the critically ill patient in the intensive care unit (ICU) setting. Choosing between enteral and parenteral nutrition often is one of the first decisions to be made in the ICU. There are many studies of the risks and benefits of such supplementation. The enteral route should be used whenever possible, because the tropic effects of luminal nutrition are substantial and disuse of the GI tract can lead to physiologic derangements, changes in the microflora, disruption of the mucosal barrier, and impaired immune function of the gut.1 Total parenteral nutrition is associated with several complications related to initial insertion of the delivery device (5.7%), as well as a long-term risk of infection (6.5%).2 There are 3 methods of placing a gastrostomy: surgical endoscopic, percutaneous radiologic, and percutaneous endoscopic. Each has different advantages and disadvantages. Since its introduction by Gauderer et al.3 in 1980, the PEG procedure has become well established and is used widely.

Received June 12, 2003. For revision September 19, 2003. Accepted December 17, 2003. Current affiliations: Department of General Surgery, McGill University Health Center, Montreal, Canada. Reprint requests: Robert Salasidis, MD, FRCS(C), 1628 Le Caron, Laval PQ, Canada H7V-3C5. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)00004-5 570

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Patients with hydrocephalus also may require placement of a cerebrospinal fluid (CSF) shunt to offset the major morbidity associated with this condition if untreated. The CSF shunt frequently is associated with complications, such as shunt obstruction, infection, and migration with or without erosion into nearby structures. Many of these occur at the abdominal site of a ventriculoperitoneal shunt (VPS), and this raises the question of whether concurrent use of a separate intra-abdominal catheter, such as a PEG, is safe and effective. Anecdotal reports of PEG placement in patients with a VPS appeared shortly after the advent of the procedure.4,5 Taylor et al.6 studied simultaneous PEG and VPS placement, and a small prospective study was performed of the safety of PEG placement in adult patients with a VPS.7 A more recent study examined radiologically guided percutaneous gastrostomy tube placement in children with a VPS.8 In total, however, the number of patients reported is small; 52 between the 3 studies. Our experience with PEG placements in patients with a VPS is described, and relevant publications are reviewed. PATIENTS AND METHODS Medical records of patients seen between January 1, 1991, and January 1, 1999, at 3 tertiary care, universityaffiliated teaching hospitals were reviewed to identify patients who underwent a PEG and placement of a VPS during the same hospitalization. Patient populations varied in the 3 hospitals, making it impossible to determine how many neurosurgical patients required a PEG during the study period. The following data were obtained for each patient: age, gender, indication for VPS, date of VPS, date of PEG, time to discharge, Glasgow Coma Scale at PEG insertion, and any in-hospital complication that occurred after PEG insertion. Only patients who underwent PEG placement after operation for VPS were included. Followup data were obtained by telephone for 3 patients who left the hospital with both a PEG and VPS in place. The requirement for informed consent was waived by the institutional review board of our university, because the design of the study was retrospective.

OBSERVATIONS Six patients (4 men, 2 women; mean age 55 [23] years) met inclusion criteria (Table 1). All underwent VPS for hydrocephalus because of hemorrhage, tumor, or a blocked pre-existing VPS. Half had a pre-existing tracheostomy, and one patient underwent subsequent creation of a tracheostomy. All shunts entered the abdomen at a point inferior to the right costal margin. Outcomes are shown in Table 2. PEG placement was performed 33 (28) days after VPS insertion. A general surgeon (R.S.) performed PEG placement in VOLUME 59, NO. 4, 2004

Percutaneous gastrostomy in patients with ventriculoperitoneal shunt

R Baird, R Salasidis

Table 1. Patients undergoing PEG after placement of a ventriculoperitoneal shunt Patient no. 1 2 3 4 5 6

Gender/age (y) M/50 M/82 M/25 F/78 M/59 F/36

Indication for VPS Hydrocephalus Hydrocephalus Hydrocephalus Hydrocephalus Hydrocephalus Hydrocephalus

(hemorrhage) (tumor) (hemorrhage) (hemorrhage) (blocked VPS) (post-operative bleed)

Presence of tracheostomy

VPS-PEG interval

GCS at PEG insertion

Yes Yes No No No Yes

34 85 4 26 32 14

8 15 7 13 10 9

Time to discharge (d) 80 60; died 274 55 24 66

VPS, Ventriculoperitoneal shunt; GCS, Glasgow Coma Scale.

5 cases, and one PEG was placed by a gastroenterologist. All PEG procedures were performed by using the pull method. The Glasgow Coma Scale (GCS) at the time of PEG placement was 10.3 (3.1), and the length of hospitalization was 93.2 (90.5) days after PEG insertion. Although the record is difficult to interpret in some cases, because of co-existing infections, an antibiotic (cefazolin, 1 gm) was definitely administered intravenously during the perioperative period in 5 patients. There was no immediate complication after PEG placement. One patient died from pneumonia and respiratory arrest 2 months after PEG placement, after being treated with several antibiotic regimens. It is unclear whether this patient died of aspiration pneumonia, although the GCS was 15 at the time of PEG insertion. One patient resumed eating, and the PEG was removed 54 days after insertion. One patient was lost to follow-up after hospital discharge. There was no shunt malfunction, no intraabdominal complication, and no wound infection in the study group. Because no infection occurred, based on clinical features (signs and symptoms), the need for a strict definition of infection (CSF culture or leukocyte count) is obviated. There has been no long-term complication in the 3 patients who still have a VPS and PEG, and no documentation that they were receiving antibiotics during follow-up (range 3-40 months). None has had a documented PEG tube change. DISCUSSION The concept of the open gastrostomy was developed during the early nineteenth century and was successfully performed in humans in 1876 by Verneuil. The most commonly used variation is that proposed by Stamm in 1894.9 This technique has been associated with several complications: wound infections, bleeding, skin erosions, anesthesia-related complications, and, occasionally, death. In a review of 1438 Stamm gastrostomies, Mamel10 noted a complication rate as high as 18.4%, with major and minor complication rates of, respectively, 9.8% and 8.7%. VOLUME 59, NO. 4, 2004

Table 2. Outcome for patients who had a PEG after placement of a ventriculoperitoneal shunt Patient no. 1 2 3 4 5 6

Complication

Outcome

Nil Pneumonia Nil Nil Nil Nil

Lost to follow-up Death Doing well at 40 mo PEG removed at 54 d Doing well at 14 mo Doing well at 3 mo

Gauderer et al.3 described the endoscopic placement of a feeding gastrostomy tube in 1980. This novel procedure could be performed with the patient under local anesthesia, with less operative time and without laparotomy. This procedure subsequently was shown to have fewer complications and cost significantly less than the traditional Stamm method.11,12 Complications of the PEG are mainly minor exit site infections and aspiration pneumonia. Cellulitis, other wound infections, gastric leakage causing peritoneal irritation, and tube dysfunction occur in approximately 10% of cases.12 Major complications that may require surgery, such as fistulas, intraperitoneal abscess, and tube migration, occur in 2% to 3% of cases.12 In cumulative studies, the mean procedure-related mortality rate ranges from 0.6% to 0.8%.12,13 Long-term mortality can be significantly higher, depending on underlying conditions. Pulmonary complications can occur, albeit no more frequently than with nasogastric feeding, and usually relate to an underlying swallowing disorder. Other less frequent complications include leakage of food at the gastrostomy site; tube withdrawal from the stomach, with possible peritonitis; and hemorrhage (usually minor). Towbin et al.14 described an antegrade technique for placement of gastrostomy tubes in children under fluoroscopy in 1998. Subsequently, several comparative studies examined the different gastrostomy tube placement techniques. Although there is consensus that surgical insertion generally should be reserved for patients undergoing a concurrent surgical GASTROINTESTINAL ENDOSCOPY

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Table 3. Summary of published data on infection related to gastrostomy placement in patients with ventriculoperitoneal shunt Investigator

Method

N

Antibiotic used

Baird et al. Percutaneous 6 Cefazolin (present study) Percutaneous 16 Yes Taylor et al.6 (unspecified) Graham et al.7 Percutaneous 15 Cefazolin Fluoroscopic 21 None Sane et al.8

Infection rate 0% 50% 0% 9%

procedure,15 publications in radiology journals tend to favor fluoroscopic placement,16,17 whereas, those in surgical journals support endoscopic placement.18 This issue remains unresolved and is influenced by institutional and individual expertise. The CSF shunt is a major achievement in neurosurgery because of the disabling morbidity and mortality associated with untreated hydrocephalus. However, it soon became evident that the CSF shunt is the neurosurgical procedure with the highest frequency of complications.19 Shunt obstruction is regarded as the most common source of shunt failure, there being 3 types based on site: proximal, valve-related, and distal. The most common is proximal obstruction (40%-50%), usually caused by growth of normal brain tissue into the lumen.20 Treatment is by removal and replacement. Valverelated obstructions are relatively rare and thought to correlate with high CSF protein, although there are few data to support this opinion. Distal shunt obstruction occurs principally in the following settings: (1) improper placement (preperitoneal), (2) low-grade infection with subsequent intra-abdominal loculation or pseudocyst formation, and (3) disconnection or migration of the catheter from peritoneum. Shunt infection is a relatively common complication (3%-29%) that can be devastating; the mortality rate is 30% to 40%.21 It is most frequent at the extremes of age and is categorized into internal and external infections. The former occurs when the shunt apparatus and the CSF within it become infected. Obstructive symptoms and fever are predominate clinical manifestations, although the clinical spectrum varies. External shunt infections occur along the subcutaneous tract around the shunt catheter. They manifest as fluid, induration, and tenderness along the shunt tract. These infections usually are caused by organisms of low virulence, Staphylococcus epidermis being the most common, followed by Staphylococcus aureus, gram-negative bacilli, and mixed infections.21 The majority of CSF shunt infections occur within the first month after 572

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shunt placement, suggesting that bacterial inoculation occurs at surgery. Many studies have attempted to find ways to decrease the shunt infection rate, but results are mixed. Abdominal complications of CSF shunts are rare. Erosion and perforation of virtually every structure near the shunt (stomach, gallbladder, small and large bowel, vagina, abdominal wall, pleural cavity) are reported.20 Clinical manifestations of such erosion vary. Often the erosion is found incidentally on imaging studies, probably because it is a slow, chronic process that may seal by development of a fibrous tissue layer. Removal and externalization of the catheter usually is mandated, possibly with laparotomy to repair any injured abdominal organ. Fluid may accumulate within the peritoneum and can form a loculated pseudocyst or generalized ascites. Pseudocysts most often arise in patients with low-grade shunt infections or those with adhesions from previous surgery.22 Many of the complications of VPS could preclude a PEG or raise a serious concern with respect to PEG placement. PEG placement in a patient with a loculated infection may increase the rate of wound complications. No patient in the present study had an intra-abdominal loculation or infection at the time of PEG placement. The rate of peritonitis after PEG placement at the 3 tertiary hospitals where this study was conducted is 0.9% (4/426). In all cases, peritonitis occurred in confused patients who pulled the gastrostomy tube out within 10 days of insertion. In a recent study, the rate of peritonitis was 1.9% (2/119).23 Nevertheless, it is acknowledged by us that the rate of peritonitis may be increased by the presence of a VPS. There are considerable published data to support the prophylactic administration of an antibiotic before PEG placement. This has been shown to reduce the frequency of infection after the procedure24,25 and also to be cost-effective.26 Although it is argued that indiscriminate administration of antibiotics as prophylactic measure promotes the selection of resistant organisms,27 the presence of a foreign body (e.g., VPS) makes this argument essentially inapplicable. Although there has been no experience by us with ventriculo-atrial shunts, it is our belief that the same argument applies and prophylactic antibiotics would be administered by us before that procedure as well. At present, there are no published data pertaining to this question. Also, the present study does not address the issue of whether antibiotics are required for PEG tube changes in patients with a VPS, either before or after maturation of the fistula. VOLUME 59, NO. 4, 2004

Percutaneous gastrostomy in patients with ventriculoperitoneal shunt

Taylor et al.6 (Table 3) studied simultaneous PEG and VPS placement in neurosurgical patients. All patients received an unspecified antibiotic prophylactically. Half of the patients received the PEG first; the other half had the VPS placed first. Of the 16 VPSs inserted in 13 patients, 8 became infected, which was defined as either a positive CSF culture or CSF leukocytosis. There was no difference in infection rate based on which procedure was performed first, but patients with tracheostomies had a higher rate of infection. Taylor et al.6 concluded that simultaneous placement of a VPS and PEG should be avoided. In their study, PEGs and VPSs were placed at the same time, in contrast to the present study in which a PEG was placed after the VPS. Our preference is that the PEG be established before placing the VPS, but these patients were not evaluated inasmuch as no difference was expected in VPS outcome, because the PEG site would have already been healed. This group represents a small minority of patients, because the need for a VPS usually is more urgent than for the PEG. As such, our patients had the VPS inserted first, with the PEG performed at a later date in the ICU. The only other study of PEG placement in adult patients with VPSs is that of Graham et al.7 In this prospective study of 15 patients, the indication for VPS was hydrocephalus in all cases. The PEG was performed at a mean of 16 days after VPS insertion, and antibiotics were administered prophylactically before the procedure in all patients. After PEG insertion, there was no wound or intra-abdominal complication at a mean follow-up of 8.6 months. Proximal shunt obstruction that necessitated shunt revision developed in one patient. Graham et al.7 concluded that PEG tubes could be place in patients with a VPS without undue concern for short- or longterm infectious or neurologic sequelae. Sane et al.8 assessed the safety of gastrostomy placement by using a fluoroscopically guided percutaneous antegrade technique in pediatric patients. The short-term complication rate was 9%; two patients had developed culture-positive (grampositive cocci) peritonitis by post-procedure day 6. Neither had been given antibiotics prophylactically. Given that data comparing PEG placement vs. radiologic gastrostomy technique remain equivocal, the complications noted by Sane et al.8 cannot be attributed to the technique but are likely because of the lack of antibiotic administration. PEG was found to be safe in the present retrospective study of 6 patients with VPS catheters. Although the potential complications associated with this combination are numerous, the only adverse outcome noted in the present study was pneumonia in one VOLUME 59, NO. 4, 2004

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patient. Although PEG placement in patients with a VPS probably is common, there are few data on this combination of procedures. Including the present series, there are now, irrespective of method or timing, only 58 patients reported who have had both a PEG and VPS. Until the results of larger clinical trials are available, it is our recommendation to proceed with a PEG in patients with a VPS when long-term enteral nutrition is required. Ideally, PEG should be performed several weeks after VPS placement, and patients should be given an antibiotic prophylactically to prevent infection with skin flora (e.g., cefazolin, 1 gm intravenously). REFERENCES 1. Greenfield LJ, Mulholland MW, Oldham KT, Zelenock GB, Lillemoe KD, Oldham K, editors. Surgery: scientific principles and practice. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1997. 2. Wolfe BM, Ryder MA, Nishikawa RA, Halsted CH, Schmidt BF. Complications of parenteral nutrition. Am J Surg 1986; 152:93-9. 3. Gauderer MW, Ponsky JL, Izant R. Gastrostomy without laparoscopy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5. 4. Cantor M, Miskovitz PF. Percutaneous endoscopic gastrostomy following ventriculoperitoneal shunting for intracranial pressure: preliminary report. Gastointest Endosc 1988;34:202-3. 5. Rahmin M, Roston A, Miskovitz PF. PEG placement in patients with ventriculoperitoneal shunts [letter]. Gastointest Endosc 1994;40:395. 6. Taylor AL, Carroll TA, Jakubowski J, O’Reilly G. Percutaneous endoscopic gastrostomy in patients with ventriculoperitoneal shunts. Br J Surg 2001;88:724-7. 7. Graham SM, Flowers JL, Scott TR, Lin F, Rigamonti D. Safety of percutaneous endoscopic gastrostomy in patients with a ventriculoperitoneal shunt. Neurosurgery 1993;32:932-4. 8. Sane SS, Towbin A, Bergey EA, Kaye RD, Fitz CR, Albright L, et al. Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts. Pediatr Radiol 1998;28:521-3. 9. Grant JP. Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy. Ann Surg 1988;207:598-603. 10. Mamel JJ. Percutaneous endoscopic gastrostomy. Nutr Clin Pract 1987;2:65-7. 11. Finocchiaro C, Galletti R, Rovera G, Ferrari A, Todros L, Vuolo A, et al. Percutaneous endoscopic gastrostomy: a longterm follow-up. Nutrition 1997;13:520-3. 12. Amann W, Mischinger HJ, Berger A, Rosanelli D, Schweiger W, Werkgartner G, et al. Percutaneous endoscopic gastrostomy (PEG). 8 years of clinical experience in 232 patients. Surg Endosc 1997;11:741-4. 13. Miller RE, Castelmain BN. Percutaneous endoscopic gastrostomy. Surg Endosc 1989;3:186-90. 14. Towbin R, Ball W, Bisset G. Percutaneous gastrojejunostomy in children; an antegrade approach. Radiology 1988;168:473-6. 15. Barkmeier J, Trerotola S, Weibke E, Sherman S, Harris V, Snidow J, et al. Percutaneous radiologic, surgical endoscopic and percutaneous endoscopic gastrostomy/gastrojejunostomy: comparative study and cost analysis. Cardiovasc Intervent Radiol 1998;21:324-8. 16. Wollman B, D’Agostino H. Percutaneous radiologic and endoscopic gastrostomy: a 3 year institutional analysis of procedure performance. AJR Am J Roentgenol 1997;169:1551-3. GASTROINTESTINAL ENDOSCOPY

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Diagnosis and staging of hepatocellular carcinoma

17. Hoffer E, Cosgrove J, Levin D, Herskowittz M, Sclafani S. Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: a prospective randomized comparison. J Vasc Interv Radiol 1999;10:413-20. 18. Cosentini E, Sautner T, Gnant M, Winkelbauer F, Teleky B, Jakesz R. Outcomes of surgical, percutaneous endoscopic and percutaneous radiologic gastrostomies. Arch Surg 1998;133: 1076-83. 19. Little JL, Rhouton AL Jr, Mellinger JF. Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children. Mayo Clin Proc 1972;47:396-401. 20. Blount JP, Campbell JA, Haines SJ. Complications in ventricular cerebrospinal shunting. Neurosurg Clin N Am 1993;4: 633-56. 21. O’Brien M, Parent A, Davis B. Management of ventricular shunt infections. Childs Brain 1979;5:304-9. 22. Hahn YS, Engelhard H, McLorne DG. Abdominal CSF pseudocyst. Clinical features and surgical management. Pediatr Neurosci 1985;12:75-9.

CASE REPORTS Diagnosis and staging of hepatocellular carcinoma by EUS-FNA of a portal vein thrombus Rebecca Lai, MD, Valerie Stephens, MD, Ricardo Bardales, MD

Portal vein thrombosis is a well-known but relatively rare complication of cirrhosis, with a prevalence that ranges from 1% to 5.7%.1 However, it is a much more frequent complication of hepatocellular carcinoma (HCC). Tumor invasion into the portal vein by direct venous extension or metastasis occurs in up to 70% of patients with HCC.1-3 Vascular invasion is a poor prognostic indicator and is a contraindication to surgery and liver transplantation. Thus, it is important to distinguish between benign and malignant portal vein thrombosis. Several case series describe the feasibility and safely of FNA of portal vein thrombus under transcutaneous US guidance.1-7 However, this technique is not used widely, perhaps because of technical difficulties, especially in accessing thrombus in the

Current affiliations: Division of Gastroenterology, Division of Pathology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota. Reprint requests: Rebecca Lai, MD, Division of Gastroenterology, Hennepin County Medical Center, 701 Park Ave. South, Minneapolis, MN 55415. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)00007-0 574

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23. Dulabon GR, Abrams JE, Rutherford EJ. The incidence and significance of free air after percutaneous endoscopic gastrostomy. Am Surg 2002;68:590-3. 24. Panigrahi H, Shreeve DR, Tan WC, Prudham R, Kaufman R. Role of antibiotic prophylaxis for wound infection in percutaneous endoscopic gastrostomy (PEG): result of a prospective double-blind randomized trial. J Hosp Infect 2002;50:312-5. 25. Dormann AJ, Wigginghaus B, Risius H, Kleimann F, Kloppenborg A, Rosemann J, et al. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): results from a prospective randomized multicenter trial. Z Gastroenterol 2000;38:229-34. 26. Kulling D, Sonnenberg A, Fried M, Bauerfeind P. Cost analysis of antibiotic prophylaxis for PEG. Gastrointest Endosc 2000;51:152-6. 27. Chaudhary KA, Smith OJ, Cuddy PG, Clarkston WK. PEG site infections: the emergence of methicillin resistant Staphylococcus aureus as a major pathogen. Am J Gastroenterol 2002;97:1713-6.

centrally located main portal vein. EUS provides a unique opportunity to image the portal vein in close proximity. As such, an EUS approach for FNA would be relatively simple. The first case of EUSFNA of a portal vein thrombus is reported here, in which the primary tumor was suspected but not apparent at transabdominal US. CASE REPORT A 78-year-old man with a 20-year history of excessive alcohol ingestion was hospitalized for evaluation of generalized weakness and abdominal pain. He was not known to have liver disease. Examination revealed no scleral icterus or sign of chronic liver disease. Examination of the abdomen revealed no enlarged organ or palpable mass. Laboratory test results were the following: aspartate aminotransferase, 88 U/L (normal: 5-40 U/L); alanine aminotransferase, 54 U/L (0-65 U/L); alkaline phosphatase, 514 U/L (40-134 U/L); and total bilirubin, 1.9 mg/dL (0-1.5 mg/dL). The serum albumin was 2.7 g/dL (3.5-5.3 g/ dL) and platelet count, 86,000/mm3 (130-400/mm3). All serologic tests for viral hepatitis were negative. An alpha fetoprotein level was not obtained. Transabdominal US demonstrated a heterogeneous liver with compression of the inferior vena cava, an apparent portal vein thrombosis, and splenomegaly. The patient was referred for EUS to rule out pancreatic cancer as a cause of the portal vein thrombosis. CT obtained in the interval initially was interpreted as showing a portal vein thrombosis and intrahepatic biliary dilatation, along with a possible soft tissue mass in the region of the head of the pancreas. EUS was performed with a linear-array echoendoscope (FG-3630; Pentax Precision Instruments, Orangeburg, N.Y.), with the patient under conscious sedation. No pancreatic mass was found. The liver was diffusely heterogeneous, but no discrete mass was seen. A filling defect was noted within the main portal vein, which not only occluded the lumen but expanded the vessel to VOLUME 59, NO. 4, 2004