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Percutaneous transesophageal gastrotubing: alternative tube nutrition for a patient with a ventriculoperitoneal shunt
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Surgical Neurology 72 (2009) 278 – 280 www.surgicalneurology-online.com
Infection
Percutaneous transesophageal gastrotubing: alternative tube nutrition for a patient with a ventriculoperitoneal shunt Tetsuya Yamamoto, MD, PhDa,b,⁎, Takao Enomoto, MD, PhDb , Akira Matsumura, MD, PhDa a
Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba City, Ibaraki 305-8575, Japan b Department of Neurosurgery, Tsukuba Central Hospital, Ushiku City, Ibaraki 300-1211, Japan Received 5 January 2008; accepted 10 April 2008
Abstract
Background: We report a patient who underwent percutaneous transesophageal gastrotubing (PTEG), that is, nonsurgical esophagostomy under ultrasonographic control, as an alternative to percutaneous endoscopic gastrostomy (PEG). Case Description: The PTEG was placed for shunt protection from inadvertent infection in a 29-year-old male patient in whom a ventriculoperitoneal (VP) shunt had previously been inserted. During the 3-year follow-up period, no complications associated with PTEG were experienced. Conclusion: Percutaneous transesophageal gastrotubing is a good alternative to PEG in a patient with a VP shunt. Further investigation concerning the risk of infection related to PTEG and PEG in VP shunt patients is needed. © 2009 Elsevier Inc. All rights reserved.
Keywords:
Nutrition; Percutaneous transesophageal gastrotubing; Ventriculoperitoneal shunt
1. Introduction Percutaneous transesophageal gastrotubing, that is, nonsurgical esophagostomy under US control, has been reported as an alternative to percutaneous endoscopic gastrostomy, nasogastric tubing, and surgical gastrostomy [3,4,6]. Percutaneous transesophageal gastrotubing has been reported to be safer and to have less severe and less frequent complications than PEG [6]. In this article, we report a PTEG placement for shunt protection from inadvertent infection; the PTEG was used as an alternative to PEG in a patient in whom a VP shunt had previously been inserted. 2. Case report A 29-year-old male was referred to our hospital for possible rehabilitation. The patient had developed epileptic seizures at 12 years of age. Later, an arteriovenous Abbreviations: PEG, percutaneous endoscopic gastrostomy; PTEG, percutaneous transesophageal gastrotubing; RFB, rupture-free balloon; US, ultrasonographic; VP, ventriculoperitoneal. ⁎ Corresponding author. Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki 305-8575, Japan. Tel.: +81 29 853 3220; fax: +81 29 853 3214. 0090-3019/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2008.04.029
malformation was identified in the right motor subcortex. For anatomical reasons, radical operation was postponed until the patient was 26 years old and developed an intracerebral hemorrhage with a secondary intraventricular tamponade leading to hydrocephalus. Emergency rescue surgery was performed followed by several operations, including VP shunting, after which the patient was fed by nasogastric tube until the present admission for physical and swallowing rehabilitation. The nasal tubing, which irritated the patient's nostrils and nasopharyngeal mucosa, became more uncomfortable to him as his level of consciousness improved. Diversion of the abdominal catheter to the atrium or pleural cavity was discussed as a possible method of preventing an inadvertent shunt infection but, taking the abdominal surgeon's opinion into account, we decided to adopt PTEG. The PTEG (Sumitomo Bakelite Co Ltd, Tokyo, Japan) procedure is carried out as follows. First, a straight guidewire is introduced into the esophagus via the nasal cavity, and an RFB catheter is inserted along it. Extracorporeal US is applied to the neck to observe the cervical organs, and the RFB is placed between the thyroid gland and the carotid artery. Under fluorescent and US guidance, the RFB is punctured percutaneously through the side neck, through
T. Yamamoto et al. / Surgical Neurology 72 (2009) 278–280
Fig. 1. Schematic illustration of PTEG, showing a feeding tube that does not approach the gastrointestinal system through the peritoneal cavity.
which an angle-type guidewire is introduced into the balloon. The guidewires and the balloon catheter are pushed down into the stomach and the wire and catheter introduced via the nostril are withdrawn, leaving the angle-type wire in place. A 16F dilator with a peel-away sheath is then inserted into the esophagus over the guidewire. Finally, a placement tube is inserted into the stomach along the wire through the sheath. The PTEG procedure is completed by peeling off the sheath and retrieving the wire (Fig. 1). A more detailed description is given in the article by Oishi et al [6]. In the present case, the patient's postoperative course was uneventful. He soon started to utter very simple words and even phrases, and transoral intake was further encouraged after the nasal tubing was removed. The PTEG tube is replaced every 4 weeks if necessary. Placement of the tube is very easy once the skin roll is established. In the present case, our patient's tube will be removed when his transoral intake becomes sufficient. 3. Discussion The PEG placement in a patient with poor neurologic status has been generally accepted [2]. Even in a patient with a preexisting VP shunt, previous reports indicate only a low incidence of shunt infection after PEG [1,2,5,7-9]. Graham et al [2] experienced no wound or intraabdominal complications in a series of 15 adult patients who underwent PEG
279
placement after a minimum of 1 week after a VP shunting operation; all patients in this series received periprocedural prophylactic antibiotics. However, some complications have been reported, including extrusion of the peritoneal catheter, peritoneal infection, and shunt malfunction [1,2,4,9]. Taylor et al [8] report an increased risk of infection, requiring shunt revision, with simultaneous placement of a PEG and a VP shunt, especially when tracheostomy has been performed. Sane et al [7] report 2 cases of peritonitis with subsequent shunt infection in 23 children who underwent PEG insertion at least 1 month after VP shunt insertion, showing a greater risk of infection by PEG in child patients with a VP shunt. Percutaneous transesophageal gastrotubing is an emergent technique of inserting a feeding tube without approaching the gastrointestinal system through the peritoneal cavity. In theory, therefore, it presents no risk of intraperitoneal infection associated with the PTEG procedure, even in a patient who has already undergone VP shunt insertion. In a report on 115 PTEGs for difficult cases by Oishi et al [6], no major complications were encountered, whereas wound infection, stomal leakage, tube obstruction, unrecovered tube migration, and minor bleeding occurred in 23.5%. In most cases (14/17) with wound infection and stomal leakage, the complication was related to gastric drainage rather than to tube feeding. Taking all of these factors into consideration, PTEG is a viable alternative to PEG in patients with a VP shunt. Further investigation is required on the risk of infection related to PTEG and PEG in patients with a VP shunt.
References [1] Chan Y, Datta NN, Chan KY, Rehman SU, Poon CY, Kwok JC. Extrusion of the peritoneal catheter of a VP shunt system through a gastrostomy wound. Surg Neurol 2003;60(1):68-9. [2] 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. [3] Inoue M, Uchida K, Kawamoto A, Okugawa Y, Otake K, Miki C, Kusunoki M. Percutaneous transesophageal gastrostomy (PTEG) placement in an infant. J Pediatr Gastroenterol Nutr 2007;45:363-5. [4] Mackey R, Chand B, Oishi H, Kameoka S, Ponsky JL. Percutaneous transesophageal gastrostomy tube for decompression of malignant obstruction: report of the first case and our series in the US. J Am Coll Surg 2005;201:695-700. [5] Nabika S, Oki S, Sumida M, Isobe N, Kanou Y, Watanabe Y. Analysis of risk factors, for infection in coplacement of percutaneous endoscopic gastrostomy and ventriculospinal shunt. Neurol Med Chir (Tokyo) 2006;46:226-30. [6] Oishi H, Shindo H, Shirotani N, Kameoka S. A nonsurgical technique to create an esophagostomy for difficult cases of percutaneous endoscopic gastrostomy. Surg Endosc 2003;17:1224-7. [7] Sane SS, Towbin A, Bergey EA, Kaye RD, Fitz CR, Albright L, Towbin RB. Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts. Pediatr Radiol 1998;28:521-3. [8] Taylor AL, Carroll TA, Jakubowski J, O'Reilly G. Percutaneous endoscopic gastrostomy in patients with ventricle peritoneal shunts. Br J Surgery 2001;88:724-7. [9] Valletta E, Angelini G, Castagnini A, Fontana E, Piccoli R, Ulmi D. Percutaneous endoscopic gastrostomy in children with ventriculoperitoneal shunt. Pediatr Med Chir 2003;25:360-3.
Surgical Neurology 72 (2009) 278 – 280 www.surgicalneurology-online.com
Infection
Percutaneous transesophageal gastrotubing: alternative tube nutrition for a patient with a ventriculoperitoneal shunt Tetsuya Yamamoto, MD, PhDa,b,⁎, Takao Enomoto, MD, PhDb , Akira Matsumura, MD, PhDa a
Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba City, Ibaraki 305-8575, Japan b Department of Neurosurgery, Tsukuba Central Hospital, Ushiku City, Ibaraki 300-1211, Japan Received 5 January 2008; accepted 10 April 2008
Abstract
Background: We report a patient who underwent percutaneous transesophageal gastrotubing (PTEG), that is, nonsurgical esophagostomy under ultrasonographic control, as an alternative to percutaneous endoscopic gastrostomy (PEG). Case Description: The PTEG was placed for shunt protection from inadvertent infection in a 29-year-old male patient in whom a ventriculoperitoneal (VP) shunt had previously been inserted. During the 3-year follow-up period, no complications associated with PTEG were experienced. Conclusion: Percutaneous transesophageal gastrotubing is a good alternative to PEG in a patient with a VP shunt. Further investigation concerning the risk of infection related to PTEG and PEG in VP shunt patients is needed. © 2009 Elsevier Inc. All rights reserved.
Keywords:
Nutrition; Percutaneous transesophageal gastrotubing; Ventriculoperitoneal shunt
1. Introduction Percutaneous transesophageal gastrotubing, that is, nonsurgical esophagostomy under US control, has been reported as an alternative to percutaneous endoscopic gastrostomy, nasogastric tubing, and surgical gastrostomy [3,4,6]. Percutaneous transesophageal gastrotubing has been reported to be safer and to have less severe and less frequent complications than PEG [6]. In this article, we report a PTEG placement for shunt protection from inadvertent infection; the PTEG was used as an alternative to PEG in a patient in whom a VP shunt had previously been inserted. 2. Case report A 29-year-old male was referred to our hospital for possible rehabilitation. The patient had developed epileptic seizures at 12 years of age. Later, an arteriovenous Abbreviations: PEG, percutaneous endoscopic gastrostomy; PTEG, percutaneous transesophageal gastrotubing; RFB, rupture-free balloon; US, ultrasonographic; VP, ventriculoperitoneal. ⁎ Corresponding author. Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki 305-8575, Japan. Tel.: +81 29 853 3220; fax: +81 29 853 3214. 0090-3019/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2008.04.029
malformation was identified in the right motor subcortex. For anatomical reasons, radical operation was postponed until the patient was 26 years old and developed an intracerebral hemorrhage with a secondary intraventricular tamponade leading to hydrocephalus. Emergency rescue surgery was performed followed by several operations, including VP shunting, after which the patient was fed by nasogastric tube until the present admission for physical and swallowing rehabilitation. The nasal tubing, which irritated the patient's nostrils and nasopharyngeal mucosa, became more uncomfortable to him as his level of consciousness improved. Diversion of the abdominal catheter to the atrium or pleural cavity was discussed as a possible method of preventing an inadvertent shunt infection but, taking the abdominal surgeon's opinion into account, we decided to adopt PTEG. The PTEG (Sumitomo Bakelite Co Ltd, Tokyo, Japan) procedure is carried out as follows. First, a straight guidewire is introduced into the esophagus via the nasal cavity, and an RFB catheter is inserted along it. Extracorporeal US is applied to the neck to observe the cervical organs, and the RFB is placed between the thyroid gland and the carotid artery. Under fluorescent and US guidance, the RFB is punctured percutaneously through the side neck, through
T. Yamamoto et al. / Surgical Neurology 72 (2009) 278–280
Fig. 1. Schematic illustration of PTEG, showing a feeding tube that does not approach the gastrointestinal system through the peritoneal cavity.
which an angle-type guidewire is introduced into the balloon. The guidewires and the balloon catheter are pushed down into the stomach and the wire and catheter introduced via the nostril are withdrawn, leaving the angle-type wire in place. A 16F dilator with a peel-away sheath is then inserted into the esophagus over the guidewire. Finally, a placement tube is inserted into the stomach along the wire through the sheath. The PTEG procedure is completed by peeling off the sheath and retrieving the wire (Fig. 1). A more detailed description is given in the article by Oishi et al [6]. In the present case, the patient's postoperative course was uneventful. He soon started to utter very simple words and even phrases, and transoral intake was further encouraged after the nasal tubing was removed. The PTEG tube is replaced every 4 weeks if necessary. Placement of the tube is very easy once the skin roll is established. In the present case, our patient's tube will be removed when his transoral intake becomes sufficient. 3. Discussion The PEG placement in a patient with poor neurologic status has been generally accepted [2]. Even in a patient with a preexisting VP shunt, previous reports indicate only a low incidence of shunt infection after PEG [1,2,5,7-9]. Graham et al [2] experienced no wound or intraabdominal complications in a series of 15 adult patients who underwent PEG
279
placement after a minimum of 1 week after a VP shunting operation; all patients in this series received periprocedural prophylactic antibiotics. However, some complications have been reported, including extrusion of the peritoneal catheter, peritoneal infection, and shunt malfunction [1,2,4,9]. Taylor et al [8] report an increased risk of infection, requiring shunt revision, with simultaneous placement of a PEG and a VP shunt, especially when tracheostomy has been performed. Sane et al [7] report 2 cases of peritonitis with subsequent shunt infection in 23 children who underwent PEG insertion at least 1 month after VP shunt insertion, showing a greater risk of infection by PEG in child patients with a VP shunt. Percutaneous transesophageal gastrotubing is an emergent technique of inserting a feeding tube without approaching the gastrointestinal system through the peritoneal cavity. In theory, therefore, it presents no risk of intraperitoneal infection associated with the PTEG procedure, even in a patient who has already undergone VP shunt insertion. In a report on 115 PTEGs for difficult cases by Oishi et al [6], no major complications were encountered, whereas wound infection, stomal leakage, tube obstruction, unrecovered tube migration, and minor bleeding occurred in 23.5%. In most cases (14/17) with wound infection and stomal leakage, the complication was related to gastric drainage rather than to tube feeding. Taking all of these factors into consideration, PTEG is a viable alternative to PEG in patients with a VP shunt. Further investigation is required on the risk of infection related to PTEG and PEG in patients with a VP shunt.
References [1] Chan Y, Datta NN, Chan KY, Rehman SU, Poon CY, Kwok JC. Extrusion of the peritoneal catheter of a VP shunt system through a gastrostomy wound. Surg Neurol 2003;60(1):68-9. [2] 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. [3] Inoue M, Uchida K, Kawamoto A, Okugawa Y, Otake K, Miki C, Kusunoki M. Percutaneous transesophageal gastrostomy (PTEG) placement in an infant. J Pediatr Gastroenterol Nutr 2007;45:363-5. [4] Mackey R, Chand B, Oishi H, Kameoka S, Ponsky JL. Percutaneous transesophageal gastrostomy tube for decompression of malignant obstruction: report of the first case and our series in the US. J Am Coll Surg 2005;201:695-700. [5] Nabika S, Oki S, Sumida M, Isobe N, Kanou Y, Watanabe Y. Analysis of risk factors, for infection in coplacement of percutaneous endoscopic gastrostomy and ventriculospinal shunt. Neurol Med Chir (Tokyo) 2006;46:226-30. [6] Oishi H, Shindo H, Shirotani N, Kameoka S. A nonsurgical technique to create an esophagostomy for difficult cases of percutaneous endoscopic gastrostomy. Surg Endosc 2003;17:1224-7. [7] Sane SS, Towbin A, Bergey EA, Kaye RD, Fitz CR, Albright L, Towbin RB. Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts. Pediatr Radiol 1998;28:521-3. [8] Taylor AL, Carroll TA, Jakubowski J, O'Reilly G. Percutaneous endoscopic gastrostomy in patients with ventricle peritoneal shunts. Br J Surgery 2001;88:724-7. [9] Valletta E, Angelini G, Castagnini A, Fontana E, Piccoli R, Ulmi D. Percutaneous endoscopic gastrostomy in children with ventriculoperitoneal shunt. Pediatr Med Chir 2003;25:360-3.