- Email: [email protected]
T-Fastener Gastropexy and Percutaneous Gastrostomy Under CT-Fluoroscopic Guidance in a Patient with Partial Gastrectomy
S.C. Chan, et al
CASE REPORT
T-Fastener Gastropexy and Percutaneous Gastrostomy Under CT-Fluoroscopic Guidance in a Patient with Partial Gastrectomy Siu-Cheung Chan, Sheung-Fat Ko,1 Shu-Hang Ng, Yun-Chung Cheung, Joseph Tung-Chieh Chang,2 Chun-Ta Liao,3 Hung-Ming Wong,4 Kar-Wai Lui* The real-time images of computed tomography (CT)-fluoroscopy provide an excellent means of guidance for percutaneous interventions. We describe the performance of T-fastener gastropexy and percutaneous gastrostomy under CT-fluoroscopic guidance in a 59-year-old woman who had received total pharyngolaryngectomy for hypopharyngeal cancer and partial gastrectomy with Billroth II anastomosis for bleeding gastric ulcer 10 years before this operation. The previous gastric operation altered the gastrointestinal anatomy and made conventional fluoroscopic-guided percutaneous gastrostomy extremely difficult and risky. The T-fastener gastropexy and percutaneous gastrostomy were accomplished smoothly in a single session using CT-fluoroscopic guidance. This modified method of percutaneous gastrostomy may be useful in patients with anatomic distortion due to previous gastric surgery. [J Formos Med Assoc 2006;105(2):168–171] Key Words: anatomic distortion, computed tomography, fluoroscopy, percutaneous gastrostomy
Radiologic percutaneous gastrostomy has been established as a safe and effective technique for creating a route for enteral feeding.1–5 However, there are several potential problems in performing percutaneous gastrostomy under conventional fluoroscopic guidance in a patient with previous partial gastrectomy, including small and elevated gastric remnant, and overlying transverse colon and left lobe of the liver. Unlike conventional computed tomography (CT), multi-detector CT scan with high-speed array processors allows real-time image reconstruction and display of CT images. CT fluoroscopy offers real-time monitoring of the procedure. It plays an important role when percutaneous interventional procedures cannot be guided adequately by other imaging techniques such as conventional fluoroscopy.6 It is possible to scan
and view the procedure continuously, allowing real-time assessment of the T-fasteners, Seldinger needle, puncture direction and route, hydrophilic guide wire and deployment of the gastrostomy catheter. In problematic situations, CT fluoroscopy may be a safe and practical alternative for treating patients with distorted anatomy. We describe the successful performance of percutaneous gastrostomy using T-fastener gastropexy under CTfluoroscopic guidance in a patient with partial gastrectomy.
Case Report A 59-year-old woman underwent total pharyngolaryngectomy due to hypopharyngeal cancer and
©2006 Elsevier & Formosan Medical Association Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Linkou Medical Center and Keelung Hospital, 1Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, and Departments of 2Radiotherapy, 3Oto-Rhino-Laryngology and 4Oncology, Chang Gung Memorial Hospital, Linkou Medical Center, Tao Yuan, Taiwan, R.O.C. Received: January 17, 2005 Revised: March 24, 2005 Accepted: April 12, 2005
168
*Correspondence to: Dr. Kar-Wai Lui, Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsing Street, Tao Yuan, Taiwan, R.O.C. E-mail: [email protected]
J Formos Med Assoc | 2006 • Vol 105 • No 2
CT-fluoroscopic guidance percutaneous gastrostomy
needed enteral feeding access due to postoperative deglutition disorders. She had a history of gastric ulcer with bleeding, and had undergone subtotal gastrectomy and Billroth II anastomosis prior to this admission > 10 years previously. She had also received cholecystectomy, choledochoduodenostomy, and choledocholithotomy due to gallstones and intrahepatic-duct stones 15 years previously. The percutaneous gastrostomy procedure began with insertion of a 5-F angiographic catheter through the nose into the gastric remnant. Thereafter, a preliminary radiograph was taken during inflation of air via the angiocatheter. Small size of the gastric remnant with poor gaseous distension due to rapid escape of the inflated air into the efferent loop was noted. Furthermore, the gastric remnant was highly seated in the subcostal location, making direct percutaneous gastric puncture hazardous (Figure A). Owing to the great difficulty in performing conventional fluoroscopicallyguided percutaneous gastrostomy, percutaneous gastrostomy under CT-fluoroscopic guidance was planned. The scanner used was a four-detector row CT (Somatom Volume Zoom, Siemens, Erlangen, Germany) with fast half-second gantry-rotation time. Its high-speed array processors allow realtime image reconstruction (delay time, < 1.3 seconds; up to 6 image frames/second). A dosereduction function (HandCareTM) was available to switch off radiation from 10 to 2 o’clock clockwise to reduce patient and operator exposure to radiation. A ceiling-mounted monitor placed beside the CT gantry allowed viewing of real-time image frames during the procedure. Foot pedals alongside the CT table were used to control CT fluoroscopy and to adjust the CT table’s position and height. The CT table could be moved in and out of the gantry during CT fluoroscopy by using a joystick anchored to the CT table. The exposure parameters were 120 kV and 50–130 mAs, with a collimation of 7 mm thickness. The image quality from CT fluoroscopy was considered adequate when the target organ, T-fastener and Seldinger needles could be well visualized. The expected puncture site in the left upper abJ Formos Med Assoc | 2006 • Vol 105 • No 2
dominal wall overlying the gastric remnant was localized using the CT images. A puncture site in the left intercostal space was carefully determined to avoid inadvertent puncture of the left lobe of the liver and the left lower lobe of the lung. Under CT-fluoroscopic guidance, we used the introducer needle preloaded with the T-fastener (Brown/ Mueller T-fastener set; Medi-tech/Boston Scientific, Watertown, MA, USA) to pierce the anterior wall of the gastric remnant and then to perform the gastropexy. The second T-fastener was placed about 2 cm laterally from the first in order to tightly anchor the anterior gastric remnant to the abdominal wall (Figures B and C). An 18-gauge, 10-cm Seldinger needle (Cook Inc, Bloomington, IN, USA) was directly inserted via the center part of the skin between the gastropexy fasteners into the gastric remnant, and a 0.035-inch Terumo hydrophilic guide wire (Terumo, Tokyo, Japan) was exchanged with the Seldinger needle. After gradual dilation of the tract, a 12-F pigtail gastrostomy catheter (Medi-tech/Boston Scientific) was inserted into the remnant stomach (Figures D–F). At the end of the procedure, 10 mL of water-soluble contrast medium was injected via the feed port of the gastrostomy catheter. Clear opacification of the remnant stomach was noted, indicating a successful procedure. No complications, either major (peritonitis, hemorrhage necessitating emergency exploratory laparotomy, or external catheter leak necessitating catheter removal) or minor (catheter malfunction requiring catheter exchange or superficial stomal infection), were observed during the 48 hours after the procedure. A formula diet was started. The patient had no complications during 90 days of postoperative follow-up.
Discussion Conventional fluoroscopic guidance for percutaneous gastrostomy is recognized as a safe and effective technique for creating an access for enteral feeding in patients with deglutition disorders,1–5 with high success rates (95–100%), few complica169
S.C. Chan, et al
A
B
C
D
E
F
Figure. (A) A 5-F angiographic catheter was used as a nasogastric tube for air inflation of the small gastric remnant. (B) The first T-fastener was punctured via the selected site in the left anterior abdominal wall into the gastric remnant under CT-fluoroscopic guidance. (C) The second T-fastener was positioned 2–2.5 cm lateral from the first. (D) A 0.035-inch hydrophilic guide wire was inserted through the 18-G puncture needle into the gastric remnant under CT-fluoroscopic guidance. (E) A 12-F pigtail gastrostomy catheter was inserted into the gastric remnant. (F) A small amount of watersoluble contrast medium was injected via the pigtail gastrostomy catheter into the gastric remnant to confirm correct placement of the catheter within the stomach after the procedure.
tions (1.2–9%) and low mortality (0.8%).7 However, gastric surgery may lead to anatomic distortion, which poses a great difficulty to the performance of percutaneous gastrostomy. The anatomic problems of gastric remnants, including small volume, high position, poor distension, are hazardous for conventional percutaneous gastrostomy under fluoroscopic guidance. The application of CT as a guiding tool for percutaneous gastrostomy in patients with small gastric remnant after partial gastrectomy has been described, but none of the reported cases were completed in a single session. Sanchez et al reported gastric puncture or T-fastener placement under conventional CT guidance, while the subsequent steps, such as guide wire and gastrostomy-catheter insertion, were completed under conventional fluoroscopic guidance in the fluoroscopic suite. 7 Kanazawa et al used conventional CT to guide initial gastric puncture and to confirm guide wire status within the gastric remnant; thereafter, the patients were moved to the fluoroscopic suite for completion of the pro8 cedure. 170
With the advent of CT fluoroscopy that allows continuous real-time display, interventional procedures under CT-fluoroscopic guidance for drainage or biopsy of lesions that are difficult to access 6,9–11 have been reported with great success. However, CT-fluoroscopic guidance for percutaneous gastrostomy with a large-bore (12-F) catheter in a single session has not been previously reported. This case suggests the usefulness of CT fluoroscopy in performing percutaneous gastrostomy in patients with distorted gastric anatomy. Unlike conventional CT, the dose-reduction function of CT fluoroscopy allows radiation from the 10 to 2 o’clock position to be switched off to reduce operator hand exposure. With a minimal time delay, the insertion of T-fasteners, guide wire and gastrostomy catheter can be continuously viewed on the ceiling-mounted CT monitor, helping to avoid inadvertent injury to adjacent visceral organs and to ensure the patient’s safety throughout the procedure. Although CT-fluoroscopic guidance for percutaneous gastrostomy seems to be unnecessary as J Formos Med Assoc | 2006 • Vol 105 • No 2
CT-fluoroscopic guidance percutaneous gastrostomy
a routine, it may be clinically feasible for patients with distorted gastric anatomy or small gastric remnant after surgery to facilitate safe performance of the whole procedure in a single session.
References 1. Wollman B, D’Agostino HB. Percutaneous radiologic and endoscopic gastrostomy: a 3-year institutional analysis of procedure performance. AJR Am J Roentgenol 1997;169: 1551–3. 2. Halkier BK, Ho CS, Yee CAN. Percutaneous feeding gastrostomy with the Seldinger technique: review of 252 patients. Radiology 1989;171:359–62. 3. Saini S, Mueller PR, Gaa J, et al. Percutaneous gastrostomy with gastrostomy: experience in 125 patients. AJR Am J Roentgenol 1990;154:1003–6. 4. Bell SD, Carmody EA, Yeung EY, et al. Percutaneous gastrostomy and gastrojejunostomy: additional experience in 519 procedures. Radiology 1995;194:817–20.
J Formos Med Assoc | 2006 • Vol 105 • No 2
5. de Baere T, Chapot R, Kuoch V, et al. Percutaneous gastrostomy with fluoroscopic guidance: single-center experience in 500 consecutive cancer patients. Radiology 1999;210: 651–4. 6. Daly B, Krebs TL, Wong-You-Cheong JJ, et al. Percutaneous abdominal and pelvic interventional procedures using CT fluoroscopy guidance. AJR Am J Roentgenol 1999;173: 637–44. 7. Sanchez RB, vanSonnenberg E, D’Agostino HB, et al. CT guidance for percutaneous gastrostomy and gastroenterostomy. Radiology 1992;184:201–5. 8. Kanazawa S, Naomoto Y, Hiraki Y, et al. Percutaneous feeding gastrostomy in patients with a partial gastrectomy: transhepatic approach with CT guidance. Abdom Imaging 1995;20:302–6. 9. Katada K, Anno H, Kago S, et al. Initial trial with CT fluoroscopy. Radiology 1994;190(P):662. [Abstract] 10. Katada K, Anno H, Ogura Y, et al. Early clinical experience with real-time CT fluoroscopy. Radiology 1994;193(P): 339. [Abstract] 11. Silverman SG, Tuncali K, Adams DF, et al. CT fluoroscopyguided abdominal interventions: techniques, results, and radiation exposure. Radiology 1999;212:673–81.
171
CASE REPORT
T-Fastener Gastropexy and Percutaneous Gastrostomy Under CT-Fluoroscopic Guidance in a Patient with Partial Gastrectomy Siu-Cheung Chan, Sheung-Fat Ko,1 Shu-Hang Ng, Yun-Chung Cheung, Joseph Tung-Chieh Chang,2 Chun-Ta Liao,3 Hung-Ming Wong,4 Kar-Wai Lui* The real-time images of computed tomography (CT)-fluoroscopy provide an excellent means of guidance for percutaneous interventions. We describe the performance of T-fastener gastropexy and percutaneous gastrostomy under CT-fluoroscopic guidance in a 59-year-old woman who had received total pharyngolaryngectomy for hypopharyngeal cancer and partial gastrectomy with Billroth II anastomosis for bleeding gastric ulcer 10 years before this operation. The previous gastric operation altered the gastrointestinal anatomy and made conventional fluoroscopic-guided percutaneous gastrostomy extremely difficult and risky. The T-fastener gastropexy and percutaneous gastrostomy were accomplished smoothly in a single session using CT-fluoroscopic guidance. This modified method of percutaneous gastrostomy may be useful in patients with anatomic distortion due to previous gastric surgery. [J Formos Med Assoc 2006;105(2):168–171] Key Words: anatomic distortion, computed tomography, fluoroscopy, percutaneous gastrostomy
Radiologic percutaneous gastrostomy has been established as a safe and effective technique for creating a route for enteral feeding.1–5 However, there are several potential problems in performing percutaneous gastrostomy under conventional fluoroscopic guidance in a patient with previous partial gastrectomy, including small and elevated gastric remnant, and overlying transverse colon and left lobe of the liver. Unlike conventional computed tomography (CT), multi-detector CT scan with high-speed array processors allows real-time image reconstruction and display of CT images. CT fluoroscopy offers real-time monitoring of the procedure. It plays an important role when percutaneous interventional procedures cannot be guided adequately by other imaging techniques such as conventional fluoroscopy.6 It is possible to scan
and view the procedure continuously, allowing real-time assessment of the T-fasteners, Seldinger needle, puncture direction and route, hydrophilic guide wire and deployment of the gastrostomy catheter. In problematic situations, CT fluoroscopy may be a safe and practical alternative for treating patients with distorted anatomy. We describe the successful performance of percutaneous gastrostomy using T-fastener gastropexy under CTfluoroscopic guidance in a patient with partial gastrectomy.
Case Report A 59-year-old woman underwent total pharyngolaryngectomy due to hypopharyngeal cancer and
©2006 Elsevier & Formosan Medical Association Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Linkou Medical Center and Keelung Hospital, 1Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, and Departments of 2Radiotherapy, 3Oto-Rhino-Laryngology and 4Oncology, Chang Gung Memorial Hospital, Linkou Medical Center, Tao Yuan, Taiwan, R.O.C. Received: January 17, 2005 Revised: March 24, 2005 Accepted: April 12, 2005
168
*Correspondence to: Dr. Kar-Wai Lui, Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsing Street, Tao Yuan, Taiwan, R.O.C. E-mail: [email protected]
J Formos Med Assoc | 2006 • Vol 105 • No 2
CT-fluoroscopic guidance percutaneous gastrostomy
needed enteral feeding access due to postoperative deglutition disorders. She had a history of gastric ulcer with bleeding, and had undergone subtotal gastrectomy and Billroth II anastomosis prior to this admission > 10 years previously. She had also received cholecystectomy, choledochoduodenostomy, and choledocholithotomy due to gallstones and intrahepatic-duct stones 15 years previously. The percutaneous gastrostomy procedure began with insertion of a 5-F angiographic catheter through the nose into the gastric remnant. Thereafter, a preliminary radiograph was taken during inflation of air via the angiocatheter. Small size of the gastric remnant with poor gaseous distension due to rapid escape of the inflated air into the efferent loop was noted. Furthermore, the gastric remnant was highly seated in the subcostal location, making direct percutaneous gastric puncture hazardous (Figure A). Owing to the great difficulty in performing conventional fluoroscopicallyguided percutaneous gastrostomy, percutaneous gastrostomy under CT-fluoroscopic guidance was planned. The scanner used was a four-detector row CT (Somatom Volume Zoom, Siemens, Erlangen, Germany) with fast half-second gantry-rotation time. Its high-speed array processors allow realtime image reconstruction (delay time, < 1.3 seconds; up to 6 image frames/second). A dosereduction function (HandCareTM) was available to switch off radiation from 10 to 2 o’clock clockwise to reduce patient and operator exposure to radiation. A ceiling-mounted monitor placed beside the CT gantry allowed viewing of real-time image frames during the procedure. Foot pedals alongside the CT table were used to control CT fluoroscopy and to adjust the CT table’s position and height. The CT table could be moved in and out of the gantry during CT fluoroscopy by using a joystick anchored to the CT table. The exposure parameters were 120 kV and 50–130 mAs, with a collimation of 7 mm thickness. The image quality from CT fluoroscopy was considered adequate when the target organ, T-fastener and Seldinger needles could be well visualized. The expected puncture site in the left upper abJ Formos Med Assoc | 2006 • Vol 105 • No 2
dominal wall overlying the gastric remnant was localized using the CT images. A puncture site in the left intercostal space was carefully determined to avoid inadvertent puncture of the left lobe of the liver and the left lower lobe of the lung. Under CT-fluoroscopic guidance, we used the introducer needle preloaded with the T-fastener (Brown/ Mueller T-fastener set; Medi-tech/Boston Scientific, Watertown, MA, USA) to pierce the anterior wall of the gastric remnant and then to perform the gastropexy. The second T-fastener was placed about 2 cm laterally from the first in order to tightly anchor the anterior gastric remnant to the abdominal wall (Figures B and C). An 18-gauge, 10-cm Seldinger needle (Cook Inc, Bloomington, IN, USA) was directly inserted via the center part of the skin between the gastropexy fasteners into the gastric remnant, and a 0.035-inch Terumo hydrophilic guide wire (Terumo, Tokyo, Japan) was exchanged with the Seldinger needle. After gradual dilation of the tract, a 12-F pigtail gastrostomy catheter (Medi-tech/Boston Scientific) was inserted into the remnant stomach (Figures D–F). At the end of the procedure, 10 mL of water-soluble contrast medium was injected via the feed port of the gastrostomy catheter. Clear opacification of the remnant stomach was noted, indicating a successful procedure. No complications, either major (peritonitis, hemorrhage necessitating emergency exploratory laparotomy, or external catheter leak necessitating catheter removal) or minor (catheter malfunction requiring catheter exchange or superficial stomal infection), were observed during the 48 hours after the procedure. A formula diet was started. The patient had no complications during 90 days of postoperative follow-up.
Discussion Conventional fluoroscopic guidance for percutaneous gastrostomy is recognized as a safe and effective technique for creating an access for enteral feeding in patients with deglutition disorders,1–5 with high success rates (95–100%), few complica169
S.C. Chan, et al
A
B
C
D
E
F
Figure. (A) A 5-F angiographic catheter was used as a nasogastric tube for air inflation of the small gastric remnant. (B) The first T-fastener was punctured via the selected site in the left anterior abdominal wall into the gastric remnant under CT-fluoroscopic guidance. (C) The second T-fastener was positioned 2–2.5 cm lateral from the first. (D) A 0.035-inch hydrophilic guide wire was inserted through the 18-G puncture needle into the gastric remnant under CT-fluoroscopic guidance. (E) A 12-F pigtail gastrostomy catheter was inserted into the gastric remnant. (F) A small amount of watersoluble contrast medium was injected via the pigtail gastrostomy catheter into the gastric remnant to confirm correct placement of the catheter within the stomach after the procedure.
tions (1.2–9%) and low mortality (0.8%).7 However, gastric surgery may lead to anatomic distortion, which poses a great difficulty to the performance of percutaneous gastrostomy. The anatomic problems of gastric remnants, including small volume, high position, poor distension, are hazardous for conventional percutaneous gastrostomy under fluoroscopic guidance. The application of CT as a guiding tool for percutaneous gastrostomy in patients with small gastric remnant after partial gastrectomy has been described, but none of the reported cases were completed in a single session. Sanchez et al reported gastric puncture or T-fastener placement under conventional CT guidance, while the subsequent steps, such as guide wire and gastrostomy-catheter insertion, were completed under conventional fluoroscopic guidance in the fluoroscopic suite. 7 Kanazawa et al used conventional CT to guide initial gastric puncture and to confirm guide wire status within the gastric remnant; thereafter, the patients were moved to the fluoroscopic suite for completion of the pro8 cedure. 170
With the advent of CT fluoroscopy that allows continuous real-time display, interventional procedures under CT-fluoroscopic guidance for drainage or biopsy of lesions that are difficult to access 6,9–11 have been reported with great success. However, CT-fluoroscopic guidance for percutaneous gastrostomy with a large-bore (12-F) catheter in a single session has not been previously reported. This case suggests the usefulness of CT fluoroscopy in performing percutaneous gastrostomy in patients with distorted gastric anatomy. Unlike conventional CT, the dose-reduction function of CT fluoroscopy allows radiation from the 10 to 2 o’clock position to be switched off to reduce operator hand exposure. With a minimal time delay, the insertion of T-fasteners, guide wire and gastrostomy catheter can be continuously viewed on the ceiling-mounted CT monitor, helping to avoid inadvertent injury to adjacent visceral organs and to ensure the patient’s safety throughout the procedure. Although CT-fluoroscopic guidance for percutaneous gastrostomy seems to be unnecessary as J Formos Med Assoc | 2006 • Vol 105 • No 2
CT-fluoroscopic guidance percutaneous gastrostomy
a routine, it may be clinically feasible for patients with distorted gastric anatomy or small gastric remnant after surgery to facilitate safe performance of the whole procedure in a single session.
References 1. Wollman B, D’Agostino HB. Percutaneous radiologic and endoscopic gastrostomy: a 3-year institutional analysis of procedure performance. AJR Am J Roentgenol 1997;169: 1551–3. 2. Halkier BK, Ho CS, Yee CAN. Percutaneous feeding gastrostomy with the Seldinger technique: review of 252 patients. Radiology 1989;171:359–62. 3. Saini S, Mueller PR, Gaa J, et al. Percutaneous gastrostomy with gastrostomy: experience in 125 patients. AJR Am J Roentgenol 1990;154:1003–6. 4. Bell SD, Carmody EA, Yeung EY, et al. Percutaneous gastrostomy and gastrojejunostomy: additional experience in 519 procedures. Radiology 1995;194:817–20.
J Formos Med Assoc | 2006 • Vol 105 • No 2
5. de Baere T, Chapot R, Kuoch V, et al. Percutaneous gastrostomy with fluoroscopic guidance: single-center experience in 500 consecutive cancer patients. Radiology 1999;210: 651–4. 6. Daly B, Krebs TL, Wong-You-Cheong JJ, et al. Percutaneous abdominal and pelvic interventional procedures using CT fluoroscopy guidance. AJR Am J Roentgenol 1999;173: 637–44. 7. Sanchez RB, vanSonnenberg E, D’Agostino HB, et al. CT guidance for percutaneous gastrostomy and gastroenterostomy. Radiology 1992;184:201–5. 8. Kanazawa S, Naomoto Y, Hiraki Y, et al. Percutaneous feeding gastrostomy in patients with a partial gastrectomy: transhepatic approach with CT guidance. Abdom Imaging 1995;20:302–6. 9. Katada K, Anno H, Kago S, et al. Initial trial with CT fluoroscopy. Radiology 1994;190(P):662. [Abstract] 10. Katada K, Anno H, Ogura Y, et al. Early clinical experience with real-time CT fluoroscopy. Radiology 1994;193(P): 339. [Abstract] 11. Silverman SG, Tuncali K, Adams DF, et al. CT fluoroscopyguided abdominal interventions: techniques, results, and radiation exposure. Radiology 1999;212:673–81.
171