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1
Department of Radiology, The University of Chicago Hospitals, MC 2026, 5841 S.
Maryland Ave., Chicago, IL 60637.
2
Racine Radiologist Group, 3803 Spring St., Rm. 208, Racine, WI 53405.
Received November 10, 1999;
accepted after revision January 6, 2000.
Presented at the annual meeting of the American Roentgen Ray Society,
Washington, DC, May 2000.
Abstract
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SUBJECTS AND METHODS. Between January 1, 1998, and August 10, 1999, 127 percutaneous gastrostomy catheters were placed in 128 patients in 128 attempts. Seventy-five 12- or 14-French pigtail-retained catheters and fifty-two 20-French mushroom-retained catheters were inserted. Catheters were generally placed on the basis of operator preference except pigtail-retained tubes were preferentially placed in patients with head and neck or esophageal malignancies and mushroom-retained catheters were preferentially placed in neurologically compromised or combative patients. The technical success, procedural complications, and catheter complications were recorded. Statistical analysis was performed.
RESULTS. Ninety-nine percent (127/128) of the procedures were successful, and there were no procedural complications. One catheter was not placed because the colon intervened between the abdominal wall and stomach. In patients who received pigtail-retained catheters, the major complication rate was 3% (2/75), the minor complication rate was 8% (6/75), and the tube complication rate was 36% (27/75). The following complications were seen: tube occlusion (n = 12), inadvertent catheter removal (n = 8), peristomal tube leakage (n = 7), superficial cellulitis (n = 4), aspiration pneumonia (n = 2), and T-fastener cellulitis (n = 2). In patients who received mushroom-retained catheters, the major complication rate was 0%, the minor complication rate was 2% (1/52), and the tube complication rate was 2% (1/52). Complications were superficial cellulitis (n = 1) and partial catheter fracture (n = 1). There were no significant differences in major and minor complications between procedures. Pigtail-retained catheters had a significantly higher rate of tube complications (p < 0.001)
CONCLUSION. Compared with pigtail-retained catheters, mushroom-retained gastrostomy catheters are more durable and secure and are less prone to tube dysfunction. These catheters should be preferentially placed when possible.
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Gastrostomy Placement
Before all procedures, patients who were coagulopathic (a prothrombin time
of >17 sec or an international normalized ratio of >1.92) or
thrombocytopenic (platelets, <150 x 103 µL) received
blood products to correct deficiencies. All patients received 1 g of IV
ceftizoxime sodium prophylactically. IV midazolam (Versed; Roche
Pharmaceuticals, Nutley, NJ) and fentanyl citrate (Sublimaze; Abbott
Laboratories, North Chicago, IL) were given for sedation and analgesia. Oxygen
saturation, blood pressure, and heart rate and rhythm were monitored in all
patients using noninvasive means. All patients received 1 mg of IV glucagon
approximately 5 min before gastric insufflation. Enteric contrast material was
not routinely given to opacify the colon, and sonography was not used to
localize the left lobe of the liver.
Pigtail-Retained Catheter Placement
The stomach was inflated using either a nasogastric tube or a 5-French
end-hole catheter. The midbody of the stomach was punctured using fluoroscopic
guidance after subcutaneous administration of local anesthesia. Two or three
gastropexy T-fasteners (Cope gastrointestinal suture anchor set, Cook; or
Brown/Mueller T-fastener set, Boston Scientific, Natick, MA) were placed
around the intended catheter site. A small incision (3-4 mm) was made in the
center of the gastropexy fasteners, the stomach was accessed through the
incision, and the tract was serially dilated to accept either a 12-or
14-French pigtail-retained gastrostomy catheter (Wills-Oglesby percutaneous
gastrostomy catheter or Mallinckrodt gastrostomy catheter; Cook). To avoid the
risk of duodenal perforation, Wills-Oglesby gastrostomy catheters were
preferentially oriented toward the gastric fundus
[10]. Tubes were secured to
the skin with sutures and not used for feeding for 24 hr. Sutures and
gastropexy fasteners were cut after 2 weeks.
Mushroom-Retained Catheter Placement
An upper endoscopy bite-block (Endo Bite-Block; Encompas Unlimited, St.
Petersburg, FL) was placed and lidocaine (Xylocaine 10%; Astra, Westborough,
MA) oral spray was sprayed onto the posterior wall of the oropharynx to reduce
the gag reflex. The stomach was inflated using either a nasogastric tube or a
5-French end-hole catheter. After the administration of local anesthesia, an
approximately 10- to 15-mm incision was made in the skin at the site of
gastric puncture. The stomach was punctured through the incision and a single
gastropexy T-fastener (Cope gastrointestinal suture anchor set; Cook) was
placed. A 200-cm guidewire (Rosen; Cook) was advanced through the needle
toward the gastroesophageal junction. If the guidewire did not immediately
enter the esophagus, either a 5-French end-hole catheter (MPA [multipurpose
angled]; Cook) or a 10-French sheath (Braun, Bethlehem, PA) was used to direct
the guidewire into the esophagus and out of the mouth. A snare included with
the gastrostomy kit was attached to the wire and pulled from the stomach out
of the mouth. The gastropexy fastener was then cut, and a 20-French
mushroom-retained gastrostomy catheter (removable pull-PEG; Medical
Innovations) was attached to the snare and pulled from the mouth into the
stomach. Note that the catheter was attached to a plastic dilator exactly
matching the tube diameter, which enlarges the puncture site as the tube is
pulled from mouth to stomach. The tube was lubricated (Surgilube; Fougera,
Melville, NY) and coated with povidoneiodine (Betadine ointment; Purdue
Fredrick, Norwalk, CT) to facilitate passage.
Follow-Up
All patients were followed up. The technical success, procedural
complications, and catheter complications were recorded. All relevant
discharge summaries, laboratory reports, and imaging studies were reviewed. In
patients who did not receive close clinical follow-up (n = 15),
attempts were made to contact either the patients themselves or their
caregivers by telephone. Major complications were defined as procedural or
tube complications that prolonged hospital stay or required repeated
hospitalization. Minor complications were defined as self-limiting events.
Tube complications included dislodgment, obstruction refractory to flushing
and guidewire recanalization, pericatheter leakage, and fracture. Mean
follow-up in patients who received pigtail-retained tubes was 90.9 days
(range, 1-420 days), and in patients who received mushroom-retained catheters,
mean follow-up was 95.8 days (range, 2-441 days). Five patients were lost to
follow-up. The chi-square test was performed to assess statistical
significance.
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The 30-day mortality rate for the group receiving mushroom-retained catheters was 13% (7/52), and the 30-day mortality rate for the group receiving pigtail-retained catheters was 9% (7/75). None of the deaths were related to gastrostomy placement. One mushroom-retained catheter and 19 pigtail-retained catheters were removed during the study period in patients who were able to resume eating. Tube removal was uneventful in all patients. Four pigtail-retained and two mushroom-retained tubes were converted to gastrojejunostomy catheters because of gastroesophageal reflux.
There were no significant differences in major or minor procedural complications between techniques. Tube complications were significantly higher in patients receiving pigtail-retained catheters (p < 0.001).
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Fluoroscopic placement of mushroom-retained catheters was first described in children [14]. In this technique, either a loop snare or basket is advanced from the mouth into the stomach. The stomach is punctured, and using fluoroscopic guidance, a guidewire is advanced into the snare or basket and pulled from the stomach into the oropharynx. The gastrostomy tube is then pulled into the stomach from the mouth. Szymski et al. [8] described a slightly different technique for placement of mushroom-retained gastrostomy catheters in adults. In this technique, rather than using a loop snare or basket to facilitate esophageal catheterization, the esophagus is retrogradely catheterized using either a sheath or an end-hole catheter from the gastric puncture site. Because, with rare exceptions, retrograde esophageal catheterization is technically trivial in adults, this method is quicker and less costly than the method described in children. The use of a generous skin incision is important when placing large-bore mushroom-retained catheters: Because the tube is placed via the oropharynx and is, by definition, contaminated during placement, a larger incision allows the wound to drain and heal without skin tension. Anecdotal reports have also implicated necrotizing fasciitis with the use of an inadequate skin incision [8, 15, 16]. Fluoroscopic peroral placement of gastrostomy catheters may be gaining in popularity. In addition to earlier reports, Clark et al. [9] recently reported further experience in adults using an endoscopic over-the-wire mushroom-retained catheter rather than a pull-type tube.
An analysis of the gastrostomy catheters reveals characteristics responsible for differential performance. Patency is generally a function of catheter resistance, which is determined by catheter length and diameter. The 12-French Wills-Oglesby pigtail-retained catheters have an inner diameter of approximately 2 mm and are 35 cm in length (side-holes are positioned 24 cm from the access port). The mushroom-retained catheters used in this series have an inner diameter of approximately 4.5 mm and are generally 6 cm in length when deployed. Thus, in terms of diameter and resistance by Poiseuille's law, pigtail-retained catheters have an approximately 100-fold greater resistance than mushroom-retained catheters. In this series, 16% (12/75) of the pigtail-retained catheters became occluded during follow-up compared with none of the mushroom-retained catheters.
The retaining mechanism of a gastrostomy catheter determines stability. The retaining mechanism of a pigtail-retained catheter is solely dependent on the thread that locks the loop. In the acidic gastric environment, this thread can break or slip. Alternatively, this mechanism can be accidentally unlocked by the patient or caregiver. In contrast, the retaining mechanism of the mushroom-retained catheter is fixed. Eleven percent (8/75) of the pigtail-retained catheters were dislodged versus 0% of the mushroom-retained catheters. Dislodgment of mushroom-retained catheters did not occur despite the fact that mushroom-retained catheters were preferentially placed in demented, combative patients who were prone to tube dislodgment.
Pericatheter leakage is a minor problem that usually responds to stomal care. In general, if all other conditions are equal, small-caliber catheters should leak less because of a smaller outer tube circumference. However, in our experience, peristomal leakage was less common with the larger mushroom-retained catheters. Nine percent (7/75) of patients with pigtail-retained catheters were treated for leakage versus none of the patients with mushroom-retained catheters. Because the dilator of a mushroom-retained gastrostomy catheter exactly matches the diameter of the tube, leakage is minimized. Leakage is further limited because the gastric wall is closely apposed to the abdominal wall because the gastrostomy catheter is pulled into the stomach. In contrast, although the gastric wall is held by T-fasteners, the stomach is pushed away from the abdominal wall during pigtail-retained catheter insertion, which may occasionally slightly increase the diameter of the gastric puncture site and predispose to leakage. The pigtail-retained catheters used in our study were composed of material that is rigid and less pliable than the soft rubber mushroom-retained catheters; this factor may also play a role in tract enlargement leading to leakage.
In a larger radiologic series, skin infection after gastrostomy reportedly occurred in 1.6-4.4% of patients [1,2,3,4,5]. These figures are somewhat problematic because the definition of skin infection is not uniform and infection can range from mild local erythema to subcutaneous abscess formation and severe tissue loss. In our series, no major infections occurred (i.e., all infections were superficial cellulitis consisting of erythema and heat) with either catheter type and there were no instances of peritonitis. The incidence of infection in endoscopic gastrostomy tends to be higher than that in radiologic gastrostomy presumably because the catheter is placed via the oropharynx in the former technique. However, in this series, the incidence of superficial cellulitis was higher in patients with pigtail-retained catheters than in those with mushroom-retained tubes (8% [6/75] versus 2% [1/52]). In several patients with pigtail-retained gastrostomy tubes, pericatheter leakage of acidic gastric contents led to skin ulceration and contributed to the subsequent self-limited infection. In two patients, infection of the gastropexy T-fasteners occurred. Both patients had missed follow-up appointments 2 weeks after gastrostomy and the fasteners had been in place for between 1 and 2 months. Although the routine use of gastropexy is controversial, in our experience T-fasteners are helpful both during and after insertion of pigtail-retained gastrostomy tubes. During the procedure, they help prevent the gastric wall from retracting from the abdominal wall and therefore ease tube insertion. After the procedure, they help to prevent spillage of gastric contents and development of peritonitis in the event of early catheter dislodgment. In contrast, although we use a single T-fastener during placement of mushroom-retained gastrostomy catheters, this fastener is released before final catheter deployment.
One weakness of this study concerns the patient selection bias. Because the gastrostomy placement via the oropharynx is inappropriate in patients with high-grade esophageal obstruction, pigtail-retained catheters were inserted in most patients with head and neck or esophageal cancer. In contrast, mushroom-retained tubes were placed in most patients with strokes or who were neurologically compromised or combative. Other types of gastrostomy catheters are available. The most popular alternative to the pigtail-retained tube is the balloon-retained catheter. This catheter does not require peroral placement, and large-bore varieties are less susceptible to obstruction than smaller pigtail-retained tubes. However, these catheters also have significant disadvantages. First, antegrade insertion of this large catheter may be quite difficult in some patients. Some researchers have even advocated tract dilatation using angioplasty balloon catheters [17]. Second, the tube is placed via a peelaway sheath that is 3- to 4-French larger than the outer diameter of the tube. In our experience, leakage of gastric contents around the tube, leading to skin irritation and superficial cellulitis, occurs more commonly with these tubes than with other types of gastrostomy catheters. Third and most significant, the balloon-retaining device is prone to breakage and accidental deflation, which often leads to tube dislodgment. We have even seen incidents in which the balloon port has inadvertently been "fed." Overall, our experience agrees with those of others and shows that there is no single gastrostomy catheter that is appropriate for all patients. Rather, radiologists must be familiar with the strengths and weaknesses of different tubes and their methods of placement. In this manner, radiologists can provide a comprehensive gastrostomy service and effectively compete with other specialties.
In summary, we have found no significant differences in procedural morbidity and mortality between the conventional and oropharyngeal methods of radiologic gastrostomy. However, mushroom-retained catheters inserted via the mouth appear inherently superior to pigtail-retained catheters because of their larger inner lumens and better retention mechanism. An added disadvantage of pigtail-retained catheters is gastropexy, which is unnecessary with mushroom-retained catheters. The reported increased rate of infection associated with oropharyngeal placement was not seen in our study. Therefore, we recommend placement of mushroom-retained catheters in all patients requiring gastrostomy except in those with high-grade obstruction of the esophagus due to head and neck or esophageal malignancies.
Acknowledgments
We thank Charles Metz for assistance with statistical calculations.
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