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Randomized study of two radiologically guided percutaneous gastrostomy insertion techniques
JVIR
’
Scientific Session
Sunday
3:57 PM
Abstract No. 70
Percutaneous cholecystostomy drain placement: clinical outcomes in 195 patients E.C. Bendel, A.B. Crush, H. Bjarnason; Mayo Clinic Rochester, Rochester, MN Purpose: To better define the expected clinical course of patients undergoing cholecystostomy drain placement at a single institution. Materials and Methods: 195 consecutive patients undergoing cholecystostomy drain placements between January 1, 2010 and February 22, 2013 were retrospectively reviewed. Patients included 69 (35%) females and 126 (65%) males with an average age of 69 years and a distribution from 19-106. The rate of cholecystectomy was measured as well as the mortality, culture results, and length of tube dwell time. Complication rates were also assessed. Results: 181/195 patients had follow-up documentation. Of these, 61 (31.3%) died with the drain in place, 66 (33.8%) did undergo cholecystectomy, and 51 (26.2%) of the drains were removed without further intervention. Three patients (1.5%) still had the drain in place at time of the review. Time from
S37
placement to cholecystectomy was 109 days on average. Death occurred on average at 78 days, and the average time to drain removal was 99 days. Positive cultures were found in 95 (48.7%) patients, 90 (46.2%) patients had negative cultures, and 10 (5.2%) were either not sent for culture or results were unavailable. Overall, there were 24 complications (12.3%). Complications included drain dislodgement (10.8%), bleeding (1.5%), and inadequate placement (1%). 5 patients (2.6%) became septic, requiring ICU monitoring. Of the 3 patients that bled, two had a negative angiogram and one was transfused. Conclusion: Procedural outcomes are important for preprocedural counseling and for managing patient expectations. At our institution, 6 weeks is the often-quoted expected duration to have a cholecystostomy drain in place. In reality, this study demonstrates the actual length of time to be longer (14-15 weeks). Additionally, having a cholecystostomy drain can be a source of significant morbidity and mortality, with approximately 1/3 of patients dying with the drain in place and 1/3 of patients receiving definitive surgery.
4:06 PM
Abstract No. 71
Randomized study of two radiologically guided percutaneous gastrostomy insertion techniques O.A. Bernstein1, J. Campbell1, J. Ringash2, C. Ho1, K. Tan1; 1Vascular and Interventional Radiology, University of Toronto, Toronto, ON, Canada; 2Radiation Oncology, The Princess Margaret Hospital, Toronto, ON, Canada Purpose: To prospectively compare two radiologically guided gastrostomy techniques: insertion of the large-bore 20F mushroom-retained catheters via the “pull” or per-oral technique versus the smaller-bore 14F cope loop catheter via the “push” through the abdominal wall technique. This is the first randomized study seeking to answer this question. Materials and Methods: Sixty patients undergoing radiation therapy for head and neck cancer were recruited and randomized to undergo gastrostomy insertion by either the “push” or “pull” technique. Forty-seven patients completed the sixmonth follow-up. There was no significant difference in patient demographics between the groups (push: 86% male, mean age 58 yrs; pull: 89% male, mean age 58 yrs). The level of pain experienced was measured by recording the patients’ pain scores (0-10) at the end of the procedure and at one hour, two hours, three hours, one day, two days, three days and weekly for six weeks post-procedure. The intra-procedural doses of fentanyl and midazolam and 24-hour post-procedural IV morphine doses were compared. The technical success, complication rate (using SIR classification) and gastrostomy related quality of life (QOL) using the FACT-EF questionnaire were compared between the two groups. Results: 98% of the gastrostomy insertions were technically successful with a 2% major complication rate (tube misplacement within the peritoneal cavity). Patients in the “pull” group required significantly higher doses of midazolam and Fentanyl intra-procedurally (mean 1.2 mg and 67 mcg in the push group versus 1.9 mg and 105 mcg in the pull group, Po0.001). However, the post-procedure pain scores and morphine doses were not significantly different between the two groups. QOL at one and six weeks and complication rates were not significantly different between the groups.
SUNDAY: Scientific Sessions
Purpose: Patients with extensive metastatic hepatic tumor burden may be questionable candidates for percutaneous transhepatic biliary drainage (PBD) insertion due to concern for traversing tumor, a presumed dismal prognosis, compromised hepatic function as a contributor to hyperbilirubinemia, and multifocality of biliary ductal obstruction. The purpose of this study was to analyze outcomes of percutaneous biliary drainage (PBD) catheters in patients with advanced hepatic metastatic disease. Materials and Methods: Retrospective review of our procedural database was performed to identify patients undergoing PBD catheter insertion for the indication of hyperbilirubinemia and imaging-confirmed biliary dilation in the setting of severe multifocal hepatic metastatic disease (greater than 20% volume replacement) over a 7.5 year period. A total of 44 patients (24 males, mean age 57.4 years, range 34-80 years) were included for analysis. Periprocedural cross-sectional imaging was used to assess hepatic metastatic disease burden and location of PBD catheters. Complications, serum alkaline phosphatase (AP), and total bilirubin (TB) values were also investigated. Results: PBD insertion was performed in 44 patients with severe hepatic metastatic disease burden. Colorectal (n¼16) and pancreatic metastases (n¼9) were most common. The serum total bilirubin decreased by at least 10% in 68% of patients. Of these patients, the mean decrease in bilirubin levels was 4.5⫾2.7mg/dL (42%⫾20%). Only 6% demonstrated normalization of bilirubin levels (less than 2 mg/dL). The median survival was 29 days (95% CI 15-43 days). Of 14 patients with a post-PBD insertion CT scan, in 11 patients (79%), the PBD traversed tumoral tissue prior to entering the biliary tree. Two patients required blood transfusions due to periprocedural blood loss without need for additional interventions. One patient re-presented with persistent pericatheter leakage. Conclusion: While the majority of patients demonstrated decreased serum bilirubin levels, normalization was rare and prognosis is dismal. PBD catheter traversal of hepatic tumors demonstrated a low incidence of significant hemorrhage or pericatheter leakage.
’
S38
’
Sunday
Scientific Session
Conclusion: Radiologically guided gastrostomy insertion, performed by either technique, has a high technical success rate and low major complication rate. Although patients undergoing peroral “pull” gastrostomy insertion required higher intra-procedural conscious sedation doses, post-procedural pain scores and QOL did not significantly differ between the groups.
SUNDAY: Scientific Sessions
4:15 PM
Abstract No. 72
Push technique for radiologic gastrostomy tube placement: a large cohort study on primary patency and replacement rates R. Sheth, A. Kambadakone, S. Ganguli, P. Mueller; Massachusetts General Hospital, Boston, MA Purpose: To evaluate the primary patency and replacement rates for percutaneous gastrostomy tubes placed using the push technique and T-fastener gastropexy in high-risk patients. Materials and Methods: A retrospective analysis of all primary percutaneous gastrostomy tube (G-tube) placements and replacement procedures between 2010 - 2013 was conducted. Our institutional standard protocol for G-tube placements includes gastropexy with T-type fasteners and deployment of either a 14Fr Cope-type catheter (Cook Medical, Bloomington, IL) or a balloon-retained catheter (MIC-KEY; Kimberly-Clark, Dallas, TX). The electronic medical records and imaging studies in these patients were evaluated for type of sedation, procedure success rate, complications and number of re-interventions. Results: Between 2010 - 2013, a total of 1006 primary gastrostomy catheters were placed in 984 patients (57:43 M: F, mean age: 63 yrs). General anesthesia for sedation was required in 61% (611/1006). G-tube indications included enteral nutrition (67%, 670/1006) and venting (33%, 336/1006). Patients with head and neck cancer (49%, 334/670) formed the plurality for feeding G-tubes followed by patients with amyotrophic lateral sclerosis (33%, 222/670). Complication rate from primary placement was 6.6% (65/984). A total of 713 G-tube replacement procedures were performed in 446 patients which included 418 (58%) “rescue procedures” in 261 patients due to catheter malfunction including catheter occlusion, inadvertent catheter removal, or catheter fracture. Most patients (67%, 177/261) only underwent one “rescue” procedure, with most (90%) “rescues” occurring within 45 days of primary placement. Almost all “rescue” procedures were performed through the pre-existing gastrocutaneous tract (98%, 411/418), with only 2.6% (7/261) of patients requiring repeat primary puncture due to closure of the skin tract. Conclusion: Replacement rates for tube malfunction are high in high-risk patients requiring anesthesia support for gastrostomy tube placement. The use of T-fastener gastropexy may facilitate successful rescue/replacement through the pre-existing gastrocutaneous tract, supporting its routine use in high-risk patients.
4:24 PM
Abstract No. 73
Retrograde gastrojejunostomy tube tip malposition within the stomach: outcomes of various strategies of reinsertion M.D. Malinzak, M.S. Hodavance, M. Miller, Jr, T.P. Smith, C.Y. Kim; Vascular & Interventional Radiology, Duke University Medical Center, Durham, NC
’
JVIR
Purpose: Gastrojejunostomy (GJ) tube insertion is typically performed in lieu of gastrostomy tube insertion when postpyloric feeding is indicated. Unfortunately, retrograde migration of the GJ tube tip back into the stomach is a known complication that can result in occult intragastric feeding. The purpose of this study is to assess and compare outcomes of 3 different types of interventions performed on malpositioned GJ tubes. Materials and Methods: The medical records of patients who underwent conventional GJ tube insertion under fluoroscopic guidance were reviewed for any subsequent episodes of retrograde migration of the GJ tip into the stomach. Only the first malposition event was included for analysis. Patients with less than one month of follow-up data were excluded. Three different interventions were analyzed: 1) GJ tube exchange for a correctly positioned conventional GJ tube (18 Fr MIC GJ tube 45cm length); 2) exchange for a correctly positioned weighted-tip 58cm length tube, which has a more flexible and longer jejunal component than the conventional type; 3) insertion of a new conventional GJ tube at a new site with a more optimal tract angle. Freedom-from-malposition intervals were calculated with the Kaplan-Meier method and compared with the logrank test. Results: Analysis was performed on 48 patients who underwent GJ tube exchange for a conventional GJ tube, 17 patients who underwent GJ tube exchange for a weighted-tip extralength GJ tube, and 9 who underwent GJ insertion at a more optimal site and angle. At 1 month, the percentage of GJ tubes that became re-malpositioned was 71%, 59%, and 67% respectively. Freedom-from-malposition intervals were not significantly different between groups, at a median of 73, 26, and 14 days, respectively (p¼0.73). Conclusion: Radiologically inserted GJ tubes that presented with subsequent tip malposition into the stomach demonstrated poor outcomes with a high risk for recurrent malposition, regardless of the method of correction. Therefore, if intragastric feeding is unacceptable, gastrojejunal feeding access should be abandoned after initial GJ malposition event. If post-pyloric feeding is needed, a jejunostomy tube may be the optimal solution.
4:33 PM
Abstract No. 74
The impact of PleurX catheters for ascites and peritoneal carcinomatosis on patient rehospitalizations C. Qu, M. Xing, K.M. McCluskey, E. Santos, H.S. Kim; Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pittsburgh, PA Purpose: To assess patients’ outcomes, complications and impact on rehospitalizations in patients with malignant ascites treated with PleurX catheters. Materials and Methods: Patients with peritoneal carcinomatosis and malignant ascites treated with PleurX drain placement between 2011 and 2014 were studied. Overall survival from time of ascites and catheter placement were stratified by primary cancer and analyzed using Kaplan-Meier method. Complications were graded using Common Terminology Criteria for Adverse Events v3.0 (CTCAE) and differences between pre- and post-catheter ascites-specific hospitalizations and ED visits were compared using para t-tests.
’
Scientific Session
Sunday
3:57 PM
Abstract No. 70
Percutaneous cholecystostomy drain placement: clinical outcomes in 195 patients E.C. Bendel, A.B. Crush, H. Bjarnason; Mayo Clinic Rochester, Rochester, MN Purpose: To better define the expected clinical course of patients undergoing cholecystostomy drain placement at a single institution. Materials and Methods: 195 consecutive patients undergoing cholecystostomy drain placements between January 1, 2010 and February 22, 2013 were retrospectively reviewed. Patients included 69 (35%) females and 126 (65%) males with an average age of 69 years and a distribution from 19-106. The rate of cholecystectomy was measured as well as the mortality, culture results, and length of tube dwell time. Complication rates were also assessed. Results: 181/195 patients had follow-up documentation. Of these, 61 (31.3%) died with the drain in place, 66 (33.8%) did undergo cholecystectomy, and 51 (26.2%) of the drains were removed without further intervention. Three patients (1.5%) still had the drain in place at time of the review. Time from
S37
placement to cholecystectomy was 109 days on average. Death occurred on average at 78 days, and the average time to drain removal was 99 days. Positive cultures were found in 95 (48.7%) patients, 90 (46.2%) patients had negative cultures, and 10 (5.2%) were either not sent for culture or results were unavailable. Overall, there were 24 complications (12.3%). Complications included drain dislodgement (10.8%), bleeding (1.5%), and inadequate placement (1%). 5 patients (2.6%) became septic, requiring ICU monitoring. Of the 3 patients that bled, two had a negative angiogram and one was transfused. Conclusion: Procedural outcomes are important for preprocedural counseling and for managing patient expectations. At our institution, 6 weeks is the often-quoted expected duration to have a cholecystostomy drain in place. In reality, this study demonstrates the actual length of time to be longer (14-15 weeks). Additionally, having a cholecystostomy drain can be a source of significant morbidity and mortality, with approximately 1/3 of patients dying with the drain in place and 1/3 of patients receiving definitive surgery.
4:06 PM
Abstract No. 71
Randomized study of two radiologically guided percutaneous gastrostomy insertion techniques O.A. Bernstein1, J. Campbell1, J. Ringash2, C. Ho1, K. Tan1; 1Vascular and Interventional Radiology, University of Toronto, Toronto, ON, Canada; 2Radiation Oncology, The Princess Margaret Hospital, Toronto, ON, Canada Purpose: To prospectively compare two radiologically guided gastrostomy techniques: insertion of the large-bore 20F mushroom-retained catheters via the “pull” or per-oral technique versus the smaller-bore 14F cope loop catheter via the “push” through the abdominal wall technique. This is the first randomized study seeking to answer this question. Materials and Methods: Sixty patients undergoing radiation therapy for head and neck cancer were recruited and randomized to undergo gastrostomy insertion by either the “push” or “pull” technique. Forty-seven patients completed the sixmonth follow-up. There was no significant difference in patient demographics between the groups (push: 86% male, mean age 58 yrs; pull: 89% male, mean age 58 yrs). The level of pain experienced was measured by recording the patients’ pain scores (0-10) at the end of the procedure and at one hour, two hours, three hours, one day, two days, three days and weekly for six weeks post-procedure. The intra-procedural doses of fentanyl and midazolam and 24-hour post-procedural IV morphine doses were compared. The technical success, complication rate (using SIR classification) and gastrostomy related quality of life (QOL) using the FACT-EF questionnaire were compared between the two groups. Results: 98% of the gastrostomy insertions were technically successful with a 2% major complication rate (tube misplacement within the peritoneal cavity). Patients in the “pull” group required significantly higher doses of midazolam and Fentanyl intra-procedurally (mean 1.2 mg and 67 mcg in the push group versus 1.9 mg and 105 mcg in the pull group, Po0.001). However, the post-procedure pain scores and morphine doses were not significantly different between the two groups. QOL at one and six weeks and complication rates were not significantly different between the groups.
SUNDAY: Scientific Sessions
Purpose: Patients with extensive metastatic hepatic tumor burden may be questionable candidates for percutaneous transhepatic biliary drainage (PBD) insertion due to concern for traversing tumor, a presumed dismal prognosis, compromised hepatic function as a contributor to hyperbilirubinemia, and multifocality of biliary ductal obstruction. The purpose of this study was to analyze outcomes of percutaneous biliary drainage (PBD) catheters in patients with advanced hepatic metastatic disease. Materials and Methods: Retrospective review of our procedural database was performed to identify patients undergoing PBD catheter insertion for the indication of hyperbilirubinemia and imaging-confirmed biliary dilation in the setting of severe multifocal hepatic metastatic disease (greater than 20% volume replacement) over a 7.5 year period. A total of 44 patients (24 males, mean age 57.4 years, range 34-80 years) were included for analysis. Periprocedural cross-sectional imaging was used to assess hepatic metastatic disease burden and location of PBD catheters. Complications, serum alkaline phosphatase (AP), and total bilirubin (TB) values were also investigated. Results: PBD insertion was performed in 44 patients with severe hepatic metastatic disease burden. Colorectal (n¼16) and pancreatic metastases (n¼9) were most common. The serum total bilirubin decreased by at least 10% in 68% of patients. Of these patients, the mean decrease in bilirubin levels was 4.5⫾2.7mg/dL (42%⫾20%). Only 6% demonstrated normalization of bilirubin levels (less than 2 mg/dL). The median survival was 29 days (95% CI 15-43 days). Of 14 patients with a post-PBD insertion CT scan, in 11 patients (79%), the PBD traversed tumoral tissue prior to entering the biliary tree. Two patients required blood transfusions due to periprocedural blood loss without need for additional interventions. One patient re-presented with persistent pericatheter leakage. Conclusion: While the majority of patients demonstrated decreased serum bilirubin levels, normalization was rare and prognosis is dismal. PBD catheter traversal of hepatic tumors demonstrated a low incidence of significant hemorrhage or pericatheter leakage.
’
S38
’
Sunday
Scientific Session
Conclusion: Radiologically guided gastrostomy insertion, performed by either technique, has a high technical success rate and low major complication rate. Although patients undergoing peroral “pull” gastrostomy insertion required higher intra-procedural conscious sedation doses, post-procedural pain scores and QOL did not significantly differ between the groups.
SUNDAY: Scientific Sessions
4:15 PM
Abstract No. 72
Push technique for radiologic gastrostomy tube placement: a large cohort study on primary patency and replacement rates R. Sheth, A. Kambadakone, S. Ganguli, P. Mueller; Massachusetts General Hospital, Boston, MA Purpose: To evaluate the primary patency and replacement rates for percutaneous gastrostomy tubes placed using the push technique and T-fastener gastropexy in high-risk patients. Materials and Methods: A retrospective analysis of all primary percutaneous gastrostomy tube (G-tube) placements and replacement procedures between 2010 - 2013 was conducted. Our institutional standard protocol for G-tube placements includes gastropexy with T-type fasteners and deployment of either a 14Fr Cope-type catheter (Cook Medical, Bloomington, IL) or a balloon-retained catheter (MIC-KEY; Kimberly-Clark, Dallas, TX). The electronic medical records and imaging studies in these patients were evaluated for type of sedation, procedure success rate, complications and number of re-interventions. Results: Between 2010 - 2013, a total of 1006 primary gastrostomy catheters were placed in 984 patients (57:43 M: F, mean age: 63 yrs). General anesthesia for sedation was required in 61% (611/1006). G-tube indications included enteral nutrition (67%, 670/1006) and venting (33%, 336/1006). Patients with head and neck cancer (49%, 334/670) formed the plurality for feeding G-tubes followed by patients with amyotrophic lateral sclerosis (33%, 222/670). Complication rate from primary placement was 6.6% (65/984). A total of 713 G-tube replacement procedures were performed in 446 patients which included 418 (58%) “rescue procedures” in 261 patients due to catheter malfunction including catheter occlusion, inadvertent catheter removal, or catheter fracture. Most patients (67%, 177/261) only underwent one “rescue” procedure, with most (90%) “rescues” occurring within 45 days of primary placement. Almost all “rescue” procedures were performed through the pre-existing gastrocutaneous tract (98%, 411/418), with only 2.6% (7/261) of patients requiring repeat primary puncture due to closure of the skin tract. Conclusion: Replacement rates for tube malfunction are high in high-risk patients requiring anesthesia support for gastrostomy tube placement. The use of T-fastener gastropexy may facilitate successful rescue/replacement through the pre-existing gastrocutaneous tract, supporting its routine use in high-risk patients.
4:24 PM
Abstract No. 73
Retrograde gastrojejunostomy tube tip malposition within the stomach: outcomes of various strategies of reinsertion M.D. Malinzak, M.S. Hodavance, M. Miller, Jr, T.P. Smith, C.Y. Kim; Vascular & Interventional Radiology, Duke University Medical Center, Durham, NC
’
JVIR
Purpose: Gastrojejunostomy (GJ) tube insertion is typically performed in lieu of gastrostomy tube insertion when postpyloric feeding is indicated. Unfortunately, retrograde migration of the GJ tube tip back into the stomach is a known complication that can result in occult intragastric feeding. The purpose of this study is to assess and compare outcomes of 3 different types of interventions performed on malpositioned GJ tubes. Materials and Methods: The medical records of patients who underwent conventional GJ tube insertion under fluoroscopic guidance were reviewed for any subsequent episodes of retrograde migration of the GJ tip into the stomach. Only the first malposition event was included for analysis. Patients with less than one month of follow-up data were excluded. Three different interventions were analyzed: 1) GJ tube exchange for a correctly positioned conventional GJ tube (18 Fr MIC GJ tube 45cm length); 2) exchange for a correctly positioned weighted-tip 58cm length tube, which has a more flexible and longer jejunal component than the conventional type; 3) insertion of a new conventional GJ tube at a new site with a more optimal tract angle. Freedom-from-malposition intervals were calculated with the Kaplan-Meier method and compared with the logrank test. Results: Analysis was performed on 48 patients who underwent GJ tube exchange for a conventional GJ tube, 17 patients who underwent GJ tube exchange for a weighted-tip extralength GJ tube, and 9 who underwent GJ insertion at a more optimal site and angle. At 1 month, the percentage of GJ tubes that became re-malpositioned was 71%, 59%, and 67% respectively. Freedom-from-malposition intervals were not significantly different between groups, at a median of 73, 26, and 14 days, respectively (p¼0.73). Conclusion: Radiologically inserted GJ tubes that presented with subsequent tip malposition into the stomach demonstrated poor outcomes with a high risk for recurrent malposition, regardless of the method of correction. Therefore, if intragastric feeding is unacceptable, gastrojejunal feeding access should be abandoned after initial GJ malposition event. If post-pyloric feeding is needed, a jejunostomy tube may be the optimal solution.
4:33 PM
Abstract No. 74
The impact of PleurX catheters for ascites and peritoneal carcinomatosis on patient rehospitalizations C. Qu, M. Xing, K.M. McCluskey, E. Santos, H.S. Kim; Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pittsburgh, PA Purpose: To assess patients’ outcomes, complications and impact on rehospitalizations in patients with malignant ascites treated with PleurX catheters. Materials and Methods: Patients with peritoneal carcinomatosis and malignant ascites treated with PleurX drain placement between 2011 and 2014 were studied. Overall survival from time of ascites and catheter placement were stratified by primary cancer and analyzed using Kaplan-Meier method. Complications were graded using Common Terminology Criteria for Adverse Events v3.0 (CTCAE) and differences between pre- and post-catheter ascites-specific hospitalizations and ED visits were compared using para t-tests.