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graded I or II (without main duct injury) are treated conservatively. Main pancreatic
duct (MPD) injury is the most important nding on the CT scan and operation is
often the choice, although associated with high morbidity and mortality. Pancreatic
injury can be associated with other abdominal lesions rendering conservative treatment less likely, notably after penetrating trauma. Despite the dearth of solid evidence, non-operative management (NOM) is increasing in this eld [5].
NOM in moderate and severe PI (grades III, IV, and V) has a success rate of 30%
however with a high rate of subsequent pseudocysts, ranging from 65% to 74%
[12]. Nevertheless these are mostly benign troubles amenable to minimally invasive
interventions, particularly endoscopic drainage. After ERCP pancreatic stent insertion could be a successful strategy for grade III PI.
L. S. Coelho et al.
Main Duct Disruption
There is still not consensus on whether NOM is a legitimate approach for
MPD. However, if delayed presentation with a well-walled pseudocyst is detected,
MPD might benet from minimally invasive treatment nominally endoscopic cystogastrostomy. To this aim various models of stents contribute to keep the transmural
drainage open till the cyst is reabsorbed.
Pancreatic Necrosis andAbscess
Acute pancreatitis is deemed as the most common cause, after gallbladder colic, of
serious upper abdominal pain in clinical practice and although the vast majority of
cases are mild and self-limited, up to 10% are associated with extensive pancreatic
necrosis, which means high morbidity and prolonged hospital stay. In the relatively
recent past it could carry a mortality rate of 30%, and even 70% with associated
infection.
Pancreatic necrosis may present as an acute necrotic collection (ANC), usually
seen in the rst 4 weeks and often extending into surrounding fat and retroperitoneal
tissues, or walled-off necrosis (WON) which is a more mature, encapsulated pancreatic mass seen 4 weeks or more after the onset of pancreatitis. In both circumstances infection of the necrotic tissue is possible, eventually encompassing
anaerobic bacteria [13].
Early laparotomy, debridement and drainage of infected pancreatic necrosis
(IPN) was the established approach during many years, yet burdened by major complications (34–95%) and death (11–39%). Recent experience [14] demonstrates that
non-operative treatment of IPN is the best alternative. In a series of 31 patients eight
were treated with antibiotics only (25.8%), and the remaining ones were handled by
drainage procedures (endoscopic and percutaneous). Surgical necrosectomy was
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necessary in only four patients (12.9%) because of treatment failure. Total mortality
was 3.2% (01 death only).
The PANTER trial challenged open necrosectomy versus a less invasive approach
named “step-up”, in which minimally invasive procedures can be escalated or reemployed for draining IPN.Such encompassed percutaneous drainage, endoscopic
transgastric drainage, and minimally invasive retroperitoneal necrosectomy, generally employed in this sequence.
467
Percutaneous Drainage
Currently this represents indeed the rst line of treatment for IPN achieving 25–60%
resolution of infection, with a high level of evidence (1A) [13]. Endoscopic transgastric drainage or necrosectomy and video-assisted retroperitoneal debridement
are other alternatives, when required. Open surgery should be employed when those
less invasive options fail as this approach relates to less new-onset organ failures,
although it is more aggressive and may require more interventions.
In cases of disconnected duct syndrome with walled-off necrosis surgical transgastric necrosectomy may be also feasible, with morbidity and mortality around
38% and 2%, respectively [13].
Nonsurgical Pneumoperitoneum
Spontaneous nonlaparoscopy-related pneumoperitoneum indicates hollow viscus
perforation and conventionally demands emergent surgical exploration. However, in
5% to 15% of cases it is not associated to perforation and may be conservatively
managed.
Common andInfrequent Conditions
Early post-operative pneumoperitoneum can of course be detected after 60% of
open surgeries and 25% of laparoscopic procedures. Around two-thirds of the ndings will resolve within 2 days and 97% after 5 days. On CT scan free peritoneal air
may be recognized for somewhat longer, in about 50% of the cases after 6 days. A
decreasing volume without worrisome clinical or peritoneal signs indicates a
benign course.
Peritoneal dialysis can be associated with asymptomatic pneumoperitoneum
(10–33% of the patients) [14]. Pneumatosis cystoides intestinalis is a rather rare
cause of nonsurgical pneumoperitoneum. This condition is characterized by
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multiple intramural cysts lled with gas that may eventually rupture leading to
pneumoperitoneum. Only in exceptional circumstances will intervention be
required.
The lungs and thoracic structures may also be a source of nonsurgical pneumoperitoneum as occasionally occurs during prolonged mechanical ventilation with
pneumothorax or pneumomediastinum. Risk factors include high airway pressures,
noncompliant lungs, obstructive airway disease, and acute respiratory distress syndrome. Pneumoperitoneum in this setting, in the absence of peritoneal signs, could
lead to unnecessary imaging investigation and even laparotomy [14].
Although unusually air may enter the peritoneal cavity from the genital tract
through the uterus and uterine tubes. Tubal insufation during an hysterosalpingogram is an obvious mechanism; however, other local manipulations including sexual intercourse could be possible causes. Spontaneous resolution is the rule [14].
Only in circumstances of signicant pain or rebound tenderness, fever, elevated
white blood cell count, or other signs of peritoneal inammation should additional
work be provided.
L. S. Coelho et al.
Case Report
As previously alluded to, non-operative treatment of infected pancreatic necrosis is
the preferred approach nowadays. Especially when percutaneous or endoscopic
catheter drainage of the septic focus is feasible, and material can be collected for
bacteriologic prole and targeted antibiotic therapy. More than three decades ago
interventional radiology and endoscopy were not as available and effective in this
condition as nowadays. Mortality with strictly conservative therapy was prohibitive,
therefore nearly all services advocated urgent open drainage. A patient seen by one
of the authors [15] was a profoundly religious man admitted to an academic hospital.
The involved microbes could not be identied as initial blood cultures were negative, and minimally invasive access to the focus was not available at that time.
However, the individual was clinically septic with fever, high white blood cell
count, upper abdominal distention and pain, and gas bubbles were identied during
the imaging exploration of the pancreatic area, along with extensive retroperitoneal
necrosis. As the case was being prepared for operative handling the patient adamantly refused surgical consent. In his opinion either his faith would save him, or
otherwise he would peacefully accept that his time of dying has arrived. As he
offered no alternative intravenous nutrients and high doses of antibiotics were prescribed, and the medical team crossed ngers hoping for the best. “After the second
week the patient rapidly started to improve, to the point that he could be discharged
home without operation” [15]. To the best of our knowledge, it was the rst report
of full regression with medical management only.
Not surprisingly the article was subsequently criticized, not only on account of
lack of bacteriologic conrmation, but because the concept of non-operative recovery after such an ominous infection was unconscionable at that time. Only about a
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469
decade later did that pathway start to become mainstream and now of course it’s
commonplace, provided minimally invasive drainage is also accomplished.
We agree that our rst plan had not been medical care either, as in the 1980s and
1990s of last century minimally invasive approaches were mostly a distant horizon,
and even well-equipped surgical intensive care units (SICUs) were not easy to come
by. Only today can one be condent that a critically ill subject will be well monitored when admitted to a SICU.Should conservative therapy fail and unexpected
deterioration occur, the surgeon will still be able to change course and provide the
required operation.
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W, Baiocchi GL, Catena F, Ansaloni L.The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC
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G, Torricelli P. Non-surgical management of blunt splenic trauma: a comparative analysis
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M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di
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L. S. Coelho et al.
Part VII
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Bedside and Adjunct Procedures
Chapter 28
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Percutaneous Ultrasound-Guided
Gastrostomy Placement
SamuelB.Fordyce, RooshiK.Parikh, andStephenP.Reis
Introduction
Surgical techniques for gastrostomy tubes were rst developed in the 1800s, with
most of the test subjects perishing due to infection prior to the advent of antibiotics.
Fast forward to 1969, two surgeons, Dr. Jeffery Ponsky and Dr. Michael Gauderer,
devised and performed the rst percutaneous endoscopic gastrostomy tube placement [1]. Other minimally invasive techniques, such as uoroscopic and ultrasoundguided techniques, were subsequently developed. Today, approximately 250,000
gastrostomy tubes are placed annually in the United States alone [2]. With our everaging population and medical capabilities allowing patients to live longer lives, gastrostomy tubes are becoming a vital part of the treatment algorithm, particularly for
critically ill patients. The most recently developed technique, ultrasound-guided
gastrostomy tube placement, has become a widely adopted technique that holds
specic advantages. Apart from surgical approaches for gastrostomy tube placement, open or laparoscopic routes, minimally invasive techniques (endoscopic, uoroscopic, and ultrasound) are widely preferred, secondary to their low complication
risk and lack of general anesthesia; however, they still require special equipment,
trained practitioners, and dedicated endoscopic/uoroscopic suites.
On the other hand, percutaneous ultrasound-guided gastrostomy tube placement
has been shown to be effective and safe as a bedside option, using readily available
S. B. Fordyce (*) · S. P. Reis
Department of Interventional Radiology, Columbia University Irving Medical Center,
New York, NY, USA
e-mail: saf9141@nyp.org; sr3321@cumc.columbia.edu
R. K. Parikh
City University of NewYork School of Medicine, New York, NY, USA
e-mail: rparikh000@citymail.cuny.edu
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_28
473© The Author(s), under exclusive license to Springer Nature
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S. B. Fordyce et al.
technology, thereby reducing complications and inconveniences such as transportation of patients [2]. Depending on the specic patient and medical reasoning behind
placing a gastrostomy tube, all of the techniques mentioned below have their advantages and disadvantages.
Indications
The main indication for gastrostomy tube placement is the need for supplemental
nutrition secondary to insufcient oral intake, contraindication to oral intake through
the mouth or gastric decompression; however, there are nuances that need to be
carefully considered prior to gastrostomy tube placement [3]. Assuming patients
have acceptable baseline nutritional status, they can tolerate up to 10 days of partial
fasting prior to signicant protein catabolism [3]. On the other hand, patients with
chronic illnesses that previously inhibited their oral intake abilities may require the
initiation of nutritional support sooner.
Enteral feedings options are most commonly split between nasoenteric and gastroenteric techniques. Typically, nasoenteric options, namely nasogastric tubes, are
reserved for short-term enteric supplementation of acutely ill patients, such as
immediately postoperatively. Nasogastric tubes have their advantages: they areeasily placed and arefairly low risk. As mentioned above, acutely ill patients or patients
expected to make a full recovery can benet from short-term enteral supplementation and gastric decompression without the need for an invasive procedure; however, there are several disadvantages. Nasoenteric alternatives can be associated
with skin irritation, gastroesophageal reux, bleeding, and ulceration, especially
with use greater than 2 weeks [3, 4]. Gastrostomy tube placement forgoes many of
these complications; however, the procedure itself is more invasive and can lead to
complications. One cited reason for gastrostomy tube placement over nasoenteric
techniques is the possible reduction of aspiration risk [5, 6].
Patients at a moderate to high risk of malnourishment requiring nutritional support greater than 30days should consider placement of a gastrostomy tube [3, 7]. A
wide variety of conditions/diagnosis are referred for gastrostomy tube placement
(Table28.1); it is important to carefully assess an individual patient’s needs, including preferences, diagnosis, goals, and life expectancy. Quality of life should remain
a priority.
Table 28.1 Referral diagnosis for gastrostomy tube placement
Neurological disorders Malignancy
Congenital or acquired
neurological
disordersinterfering
with ability to ingest
food
Head and neck,
esophagus,
upper abdomen,
brain
Congenital and
neonatal Miscellaneous
Cystic brosis, low
birth weight,
congenital heart
disorders
Trauma including traumatic
brain injury, burns
especially involving face,
dysphagia, other digestive
aberrations, palliative care
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Aspiration Pneumonia
Aspiration pneumonia is the most commonly cited cause of mortality in patients with
nasogastric or gastrostomy tubes [6, 8, 9]. Originally, one of the main presumed
advantages of gastrostomy over nasogastric tubes was decreased events of aspiration
pneumonia. Purely from an anatomical and technical perspective, this assumption
makes sense. Nasogastric tubes extend from the patient’s nares, through the gastroesophageal sphincter and into the stomach. This keeps the gastroesophageal sphincter partially open, thereby increasing the likelihood of aspiration, especially in
chronically ill patients with impaired normal functions. Gastrostomy tubes forgo the
need to keep the gastroesophageal sphincter open, which prevents aspiration.
Contrary to anatomical logic, past studies and meta-analyses have been unable to
elicit statistically signicant differences for incidences of aspiration pneumoniabetween nasoenteric and gastroenteric techniques [10]. On the other hand, dysphagia secondary to stroke, gastrostomy tube placement reduced the risk of aspiration
by almost ve times, compared to nasogastric tube placement [11]. Regardless of
such results, it is well known that both increase the risk compared to patients without
either, and it shouldbe considered in the decision-making process [12].
Dementia
Most experts agree that the incidence and prevalence of dementia will proportionally increase with a continuously aging population [13]. A majority of these patients,
more than 90%, have dysphagia or other oral intake problems, leading to the placement of long-term enteral feeding options, like gastrostomy tubes, which are considered a prognostic indicator of mortality within a 6-month time period [14].
Patients with dementia who undergo a gastrostomy tube placement have a mortality
rate of up to 54% after 1 month and 90% after 1 year [15]. For these reasons, quality
of life and improvement in mortality should be of paramount importance [8].
Periprocedural Care andPatient Preparation
Pre-Procedural Care
It’s important to conduct a comprehensive physical exam prior to any gastrostomy
procedure to ensure certain modalities are not precluded. The oropharynx needs to
be evaluated for anatomical variants, congenital anomalies, and facial fractures,
which would increase the risk for an endoscopic approach [16]. The endoscopic
route with partially obstructing head and neck malignancies is contraindicated and
infeasible. Certain conditions may increase procedural complexity, for example,
obesity, ascites, and neurological disorders. Any prior imaging and/or obtaining
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S. B. Fordyce et al.
Table 28.2
placement techniques
Technique PUG PRG PEG
Advantages
Disadvantages
Comparison of the advantages and disadvantages of the various gastrostomy tube
– Performed at
bedside
– Shorter ICU and
hospital length of
stay
– Cost savings
– No radiation
exposure
– Longer procedure
length
– Inadequate
gastropexy with
larger patients
– Shorter procedure
length
– Better visualization
of gastric insufation
– No cross-
contamination of oral
ora
– Radiation exposure
– Requirement of a
uoroscopy suite
– Shorter procedure
time
– Possible at bedside
– No radiation
exposure
– Inadequate
transillumination in
obese patients
– No direct
visualization of
intercepting bowel or
liver
– Risk of gastrostomy
tract tumor seeding
further imaging is advised if you suspect or know of altered anatomy from prior
surgery [16, 17]. The delineation of hepatic and colonic anatomy can be a priority
as well. Certain patients may warrant pre-procedural ultrasound to delineate the
liver edge in order to ensure it isn’t accidentally punctured (Table28.2).
Typically, patients are required to be nothing by mouth (NPO) or nothing per
nasogastric tube for 6–8h prior to the procedure, mainly due to aspiration risk secondary to anesthesia, whether that is moderate or general anesthesia. Additionally,
most policies require patients to ingest oral contrast (Barium) 12–24h prior to the
procedure to elucidate colonic anatomy, particularly the transverse colon.
Alternatively, patients may be given pre-procedural rectal contrast instead of oral
contrast to ensure the transverse colon is clear of the potential needle path.
Antibiotic Prophylaxis
As a “clean-contaminated” procedure, antibiotic prophylaxis has long been standard of practice, as it reduces periprocedural infections, particularly peristomal
infections [18]. The guidelines dictating appropriate antibiotic prophylaxis are varied and technique specic. According to the Society of Interventional Radiology
(SIR), Standards of Practice Committee (SPC), and American Society for
Gastrointestinal Endoscopy (ASGE), 1g of cefazolin is recommended for the “pull”
uoroscopic and endoscopic-guided techniques, since traversing the oropharynx or
nasopharynx is thought to seed bacteria within the stomach and skin tunnel. Special
considerations should be considered for patients with head and neck cancer with
potential bacterial overgrowth from an obstructing malignancy. Per SIR guidelines,
second generation cephalosporins should be used for prophylaxis followed by an
oral course of a rst generation of cephalosporins [18] (Table 28.3). There is
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