Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_999_Библиотеки_им_академика_М_И_Перельмана
.pdf
28 Percutaneous Ultrasound-Guided Gastrostomy Placement
https://t.me/med1917
477
conicting data concerning antibiotic prophylaxis for “push” techniques and an
absence of SIR guidelines [18, 23, 24].
Ultrasound-Guided Placement
Even though there is no consensus, the technique requires traversal of the mouth,
increasing the potential of bacterial seeding and the likelihood of periprocedural
infections [24]. Therefore antibiotic prophylaxis should be a consideration.
Management ofAnticoagulation
According to the SPC, gastrostomy tube placement is considered a “high bleeding
risk” procedure, with greater than 1.5% rate of major bleeding [25, 26]. Prothrombin
time (PR)/ international normalized ratio (INR) and platelets should be routinely
checked and corrected if less than 1.5 and 50,000, respectively [25] (Table28.3).
Per ASGE, warfarin and clopidogrel should be stopped at least 5 and 7 days prior to
the procedure, respectively [19]. Patients requiring interim anticoagulation can be
given aspirin or low molecular weight heparin; however, they should be held the day
of the procedure. Similar guidelines are prescribed by SIR; however, they suggest
withholding clopidogrel for 5 days instead of 7 [19].
Anti-Platelet Therapies
These are becoming a widely prescribed class of drugs in patients with cardiovascular disease and strokes. Requiring patients to stop taking these vital drugs prior to
percutaneous or radiologically placed gastrostomy tubes is no longer routine practice, with retrospective analysis showing no increased risk of bleeding complications while taking single or dual anti-platelet therapy [27]. As most of the societal
guidelines are 5–10 years old, they don’t reect the most up-to-date practices.
Regardless of societal guidelines, pre-procedural laboratory values should be conrmed prior to placement.
Table 28.3 Societal guidelines and practices for gastrostomy tube placement
American Gastroenterology
Association (AGA) and others
American Society of Parental and
Enteral Nutrition and others
Cardiovascular and Interventional
Radiological Society of Europe
(CIRSE)
Society of Interventional
Radiology—Updated Review
2011
jvir.org/article/S1051- 0443(11)00850-5/
[19]
fulltext#secd29348500e1435
2013
saxinstitute.org.au/wp- content/uploads/
[20]
Gastrostomy- guidelines- a- rapid- review.pdf
2016
pubmed.ncbi.nlm.nih.gov/27184363/
[21]
2020
jvir.org/article/S1051- 0443(21)00326-2/fulltext
[22]
478
https://t.me/med1917
S. B. Fordyce et al.
Post-Procedural Care
Immediately after gastrostomy tube placement, it is important to assess for acute
(within 24h) complications, like bleeding, aspiration perforation, pneumoperitoneum, and developing peritonitis [16]. Typically, providers will begin with a slow
infusion of sterile water on the day of insertion followed by the initiation of trickle
feeds to be advanced as tolerated by the patient. Historically, providers have waited
24h prior to the initiation of feeds through the newly placed gastrostomy tubes.
Multiple past and ongoing retrospective and prospective trials have shown the safety
and feasibility of early feeding, 4h after the placement of an uncomplicated gastrostomy tube [28]; however, these are primarily focused on endoscopic approaches.
Even though extrapolations have been made to transabdominal techniques, like
ultrasound and uoroscopic-guided techniques, there is limited clinical research
supporting the current practices. Additionally, no formal guidelines exist for optimal post-procedural feeding time.
Gastronomy Placement Options
Ultrasound-Guided Gastrostomy
Ultrasound has been previously used in tandem with traditional percutaneous endoscopically guided (PEG) and percutaneous radiologic guided (PRG) procedures to
enhance visualization and/or reduce radiation exposure/dose [29, 30]. Ultrasound
has also been proven useful at the bedside to replace damaged or dislodged gastrostomy tubes through the pre-existing stoma [31]. While there are older reports of a
retrograde percutaneous ultrasound-guided (PUG) procedure in both adult and
pediatric populations [30, 32, 33], anterograde PUG is a recently established technique with a wide array of applications.
Contraindications
Any electronic implants, such as a pacemaker, may interfere and/or be disrupted
using strong magnets [34]. Suboptimal stomach position such as high under the ribs
require uoroscopic visualization using insufation [2, 24]. A pre-procedure ultrasound measurement spanning from anterior gastric wall to skin greater than 4.5cm
may make needle puncture difcult or infeasible [24, 35]. Additionally, inability to
pass two enteric tubes into the patient secondary to nasopharyngeal or oropharyngeal obstruction is a contraindication [24].
28 Percutaneous Ultrasound-Guided Gastrostomy Placement
https://t.me/med1917
479
Procedure
The oral cavity and oropharynx should be anesthetized with topical spray and the
patient should be moderately sedated. If not already present, a nasogastric tube
should then be inserted for insufation of the stomach. Prior to the procedure, it is
important to establish known landmarks, most importantly the stomach and the left
hepatic lobe. First, the Point-of-care Ultrasound Magnetically Aligned Gastrostomy
kit (PUMA-G System; CoapTech, Baltimore MD, USA) orogastric tube (OGT)
should be inserted through the mouth and into the stomach. The PUMA-G orogastric tube contains an inatable balloon with an internal magnetic component to
allow for temporary gastropexy of the stomach.
Next, the PUMA-G external handheld magnet should be placed over the epigastrium to attract the internal magnet and the anterior gastric wall toward the abdominal surface, in order to achieve a temporary magnetic gastropexy. Optionally, a
gauss meter can be used to locate the internal magnet to ensure appropriate coaptation and plan optimal needle entry. Following coaptation of the internal and external
magnets, the orogastric balloon should be inated with 20–30 ml of saline.
Methylene blue can be added to the saline to act as a visual cue for needle entry into
the balloon. Using ultrasound, the orogastric balloon should be placed in the eld of
view. Prior to needle puncture, it’s important to ensure the proposed needle track
does not traverse interposed loops of bowel, particularly the transverse colon, or the
left lobe of the liver. If necessary, the external magnet can be utilized to move the
balloon to a more suitable location.
Local anesthetic should be injected into the skin and along the proposed gastrostomy tract. Under direct ultrasound guidance, an 18-gauge needle should be
advanced through the anterior abdominal wall and into the uid-lled orogastric
balloon. To avoid tenting of the gastric wall, the needle should be advanced with a
short jab into the stomach lumen rather than slowly pushed in. Aspiration of colored
sterile saline ensures correct placement of the needle inside the orogastric balloon
within the stomach. The PUMA-G pigtail guidewire should be passed through the
needle into the orogastric balloon and the orogastric balloon should be deated to
entrap the guidewire. At this point, the orogastric tube and trapped guidewire should
be pulled back through the mouth leaving the guidewire running continuously from
the mouth through the newly made gastrostomy and out of the anterior abdominal
wall (Figs.28.1 and 28.2).
The guidewire should be cut from the orogastric balloon, and a 20-French gastrostomy tube should be pushed over the guidewire through a small dermatotomy
into the stomach. Once the gastrostomy tube is in correct position, the guidewire
should be removed. If desired, contrast can be injected through the gastrostomy tube
and a portable X-ray image can be used to conrm correct placement [2, 24, 35, 36].
480
https://t.me/med1917
Fig. 28.1 Transverse ultrasound image depicting the OGT ballon with the stomach. Permission of
usage granted by CoapTech, Baltimore MD 21230
S. B. Fordyce et al.
Advantages
The biggest advantage of PUG placement is the ability to perform this procedure at
the bedside without the constraint of an available endoscopic tower or uoroscopy
suite. This allows for earlier gastrostomy tubeplacement in the intensive care unit
(ICU), and in the case of seriously ill candidates in general. PUG is performed on
average of 4 days earlier than PEG or PRG[34]. PUG is associated with shorter
lengths of hospitalstay; approximately 5 less days in the ICU and 10 less days in the
hospital [34]. PUG is also associated with cost saving of over $25,000 per patient
[34]. Concomitant percutaneous dilatation tracheostomy can be successfully performed alongwith PUG [37]. Additionally, PUG eliminates radiation dose/exposure to the patient and real-time ultrasound visualization can prevent injury to
surrounding organs/tissue.
Disadvantages
PUG has a longer procedure time, around 40–50min, whereas PEG and PRG procedures last 30–40min [2, 36, 38]; however, procedure time diminishes with experi-
ence. Magnetic gastropexy and subsequent ultrasound visualization is difcult in
larger, morbidly obese patients and necessitates uoroscopic visualization using
gastric insufation. Ultrasound visualization is also a challenge with difcult anatomy including a higher set stomach.
28 Percutaneous Ultrasound-Guided Gastrostomy Placement
https://t.me/med1917
481
Fig. 28.2 Outlining the four major steps for gastrostomy tube placement using the PUMA-G
system. Permission of usage granted by CoapTech, Baltimore MD 21230
Image 1: The PUMA-G: The orogastric route is employed to position the catheter in the
stomach. An external magnet is applied on the abdominal wall to attract the balloon, thus
simultaneously carrying forward the anterior gastric wall and creating a temporary
gastropexy
Image 2: Using ultrasound, theupper abdominal anatomy is reviewed and a tract for needle
and guidewire insertion is selected
Image 3: The pigtail guidewire is ensnared by the balloon catheter and both are removed
together through the mouth
Image 4: A small abdominal skin incision is made, and the gastrostomy tube is introduced
into the stomach by means of the existing guidewire
Complications
Access/stomal site infection is the most reported complication of PUG.Mild aspiration, abdominal wall abscess, and bleeding are also noted [2, 38]. Overall, complications from PUG overlap with complications seen in all other gastrostomy tube
placement procedures. Aspiration, bleeding, and ulceration are known to occur in
about 1% of all gastrostomy tube placements [16]. Injury to surrounding structures
including colon and liver can be avoided by proper pre-procedure visualization.
482
https://t.me/med1917
Finally, in patients with head and neck cancer, transoral gastrostomy has a risk of
tumor seeding within the tract and thus a transabdominal approached is preferred [16].
S. B. Fordyce et al.
Endoscopic Gastrostomy Tube Placement
The rst feasible and readily available alternative to surgically placed gastrostomy
tubes was an endoscopic approach developed by two surgeons, Dr. Jeffery Ponsky
and Dr. Michael Gauderer, in 1969 [1]. With the advent of advanced endoscopic
equipment, it became possible to transilluminate the stomach and “directly” visualize the stomach for a percutaneous approach. Over the years, a variety of different
techniques have become available, including the “pull,” “push over a wire,” and
“introducer” techniques [16].
Contraindications
Prior abdominal surgery, more specically a partial or total gastrectomy, and the
potential of interposed organs or anatomical variation are the most signicant
technique- specic contraindications [3]. Additionally, obstructive oropharyngeal
processes, like head and neck malignancies, oropharyngeal stenosis, Zenkers diverticulum or facial fractures, prevent proper passage of the endoscope and are considered contraindications [39]. Other absolute contraindications that are shared among
all the non-surgical gastrostomy tube placement techniques are severe ascites, peritonitis, peritoneal carcinomatosis, and coagulation derangement. Compared to
radiologically placed gastrostomy tubes, a patient’s weight is not considered a
contraindication.
Procedure
All methods start with an upper endoscopy to transilluminate the stomach so that a
suitable percutaneous entry track can be chosen. Using a catheter and needle, an
incision is made in the anterior abdominal wall followed by a small gastrostomy.
For the “pull” technique, a string with a metal wire loop is advanced through the
needle and snared using the endoscope. Once the string is snared, the endoscope is
removed along with the string through the patient’s mouth creating a continuous
track from the patient’s mouth through the stomach and out the newly made gastrostomy. The gastrostomy tube is attached to the wire loop and pulled through the
mouth and esophagus into the stomach and out of the anterior abdominal wall and
secured in place. For the “push over a wire” technique, the general steps are similar;
however, instead of using a piece of string to pull the gastrostomy tube, a wire is
28 Percutaneous Ultrasound-Guided Gastrostomy Placement
https://t.me/med1917
483
used as a track to push a gastrostomy tube from the patients mouth into position in
the newly made gastrostomy [16]. The “pull” and “push over a wire” techniques are
similar and only differ in the nal step of physically placing the gastrostomy tube
within the stomach [16].
The “introducer” technique avoids oropharyngeal contamination of the gastrostomy tube prior to placement. This could avoid seeding of bacteria and cancer cells
for certain patient populations, such as those withhead and neck malignancies. Like
the “pull” and “push over wire” techniques, an endoscope is used to transilluminate
the stomach, enabling the placement of a needle/trocar system into the stomach. A
wire is placed into the stomach and ensnared using the endoscope to secure the
newly made gastrostomy. T-bar fasteners, more frequently used in the uoroscopicguided gastrostomy techniques, are used to provide preliminary gastropexy of the
stomach to the anterior abdominal wall. Once the tract is serially dilated to the
appropriate size, the gastrostomy tube can be passed over the wire and secured
in place.
Advantages
The biggest advantage of PEG compared to PRG placementtechniques is direct
visualization of the stomach and needle tract. Compared to the PRG techniques,
PEG gives the practitioner the ability to conrm the needle is intraluminal within
the stomach, but also that an appropriate location has been chosen for the gastrostomy tube tract.
Disadvantages
The most signicant disadvantage of an endoscopic approach is the specialized
equipment, including the endoscope and the endoscopic tower, along with the need
for a specialized practitioner trained in the use of an endoscope.
Complications
Similar general complications could occur such as bleeding, aspiration pneumonia,
and internal organ injury, with the likelihood of any of them being very low. For
example, reported major bleeding events range from 0.2% to 2.5% [40]. Overall,
complication rates of PEG compared to PRG are comparable at 0–8% and 1.4–5.6%,
respectively [39]. Minor differences are seen in a subset of categories. For example,
PEG has increased rates of minor post-procedural infections (8–15%) [41]. Tumor
seeding is considered a rare complication exclusive to “pull” techniques in circumstances such as esophageal cancer [42].
484
https://t.me/med1917
S. B. Fordyce et al.
Fluoroscopic-Guided Gastrostomy Placement
Originally devised in 1981 with the advancement of real-time imaging modalities,
PRGtube placement is generally considered to be the gold standard non-surgical
technique [43]. Compared to the other gastrostomy tube techniques, PRG is considered the least invasive with the lowest complication rate [43].
Contraindications
Like the ultrasound-guided technique, the most signicant contraindication to PRG
is an unsafe needle tract, for example, secondary to interposed bowel loops.
Additionally, portal hypertension and the presence of varices increase the risk of the
procedure, particularly in a non-surgical setting where there are limited opportunities to control potential bleeding [44]. Other similarly important contraindications
are inability for patients to tolerate insufation, anatomical variance specically
with positioning of the stomach, and prior surgical history with possible adhesions
and anatomical distortions, leading to a hostile intrabdominal environment preventing safe needle passage or appropriate gastropexy. There are a handful of relative
contraindications that don’t necessarily preclude patients from receiving gastrostomy tubes but require additional consideration and planning. For example, ascites,
altered oropharyngeal anatomy, and obesity [16].
Procedure
Techniques can similarly be divided into the “push” and “pull” type techniques. The
initial step for both requires an indwelling nasogastric tube to insufate the stomach
with air, approximately 500–1000ml. The “pull” technique was originally adopted
from endoscopic procedures, gaining access to the stomach via an internal-external
approach. Firstly, an 18G needle is used to puncture the stomach and veried with
the aspiration of the injected air, or administration of contrast to elucidate the rugal
folds. Ideally, the stomach is punctured centrally, in the lower one-third, to avoid the
gastroepiploic arteries [43]. Once correct positioning is conrmed, the needle is
exchanged over a wire and the placement of a sheath, usually 5-Fr, creates a denitive entry point for the rest of the procedure. Depending the patient’s anatomy and
procedure difculty, a catheter and wire are advanced into the esophagus and out of
the patients oropharynx [43]. If there is difculty in gaining access to the patient’s
esophagus or advancing the catheter/wire, an option is to use a loop snare, advance
it anterograde through the oropharynx and esophagus, and snare the wire within the
stomach. Depending on institutional policy and the practitioner’s comfort, the
hydrophilic wire is exchanged for a stiffer wire, attached to theexternal end of the
gastrostomy tube, and pulled from the patient’smouth out of the newly made gastrostomy [43].
28 Percutaneous Ultrasound-Guided Gastrostomy Placement
https://t.me/med1917
485
Compared to “pull” technique, the “push” technique inserts the gastrostomy tube
without the need to traverse the patient’s esophagus and oropharynx [43]. Exactly
like the “pull” technique, access to the stomach is gained through a 17G needle;
however, it is preloaded with an anchor. The anchors are specialized T-bar fasteners
(Cope Gastrointestinal Suture Anchor Set; Cook, Bloomington IN, USA) [43].
Depending on institutional and provider practices, a minimum of three fasteners are
placed with an optional fourth. By suturing the fasteners tight, a gastropexy is
formed. Once secure, the gastric wall is punctured and a gastrostomy tube is pushed
into the stomach after appropriate serial dilation of the tract using a peel away
sheath [43].
Advantages
Of all the non-surgical gastrostomy tube techniques, PRG has the highest success
rate, close to 100% [44]. It is also deemed the least invasive. Risk of tumor cell
seeding is eliminated, bypassing postsurgical or obstructed nasopharynx/oropharynx, and surrounding structures are identied in real time during the procedure [45].
Disadvantages
Ionizing radiation occurs and specialized equipment is mandatory. Comparable to
endoscopic techniques, a specialized practitioner with the appropriate expertise and
skill is required.
Complications
Reportedly PRG has the lowest rate, in the range of 0–6%, compared to up to 9.4%
and 19.9% for endoscopic and surgical approaches, respectively [39, 46].
References
1. Strong AT, Ponsky JL.Following the light: a history of the percutaneous endoscopic gastrostomy tube. 2017.
2. Reis SP, et al. Percutaneous ultrasound guided gastrostomy tube placement: a prospective
cohort trial. J Intensive Care Med. 2022;37:641–6.
3. Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT.Percutaneous
endoscopic gastrostomy: indications, technique, complications and management. World J
Gastroenterol. 2014;20:7739–51.
4. Mekhail TM, etal. Enteral nutrition during the treatment of head and neck carcinoma: is
a percutaneous endoscopic gastrostomy tube preferable to a nasogastric tube? Cancer.
2001;91:1785–90.
486
https://t.me/med1917
5. Long-term use of percutaneous endoscopic gastrostomies: a survey of duration of use and level
of maintenance. Internet. J Gastroenterol. 2006;4:4.
6. Preventing aspiration pneumonia in older people: do we have the ‘know-how’? HKMJ https://
www.hkmj.org/abstracts/v20n5/421.htm; 2015.
7. Vudayagiri L, Hoilat GJ, Gemma R.Percutaneous endoscopic gastrostomy tube. In: StatPearls.
StatPearls Publishing; 2022.
8. Parrish, C.R., Plonk Jr., W.M. Nutrition issues in gastroenterology, series #29.
9. Vergis EN, Brennen C, Wagener M, Muder RR.Pneumonia in long-term care: a prospective
case-control study of risk factors and impact on survival. Arch Intern Med. 2001;161:2378–81.
10. Gomes CA Jr, etal. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding
for adults with swallowing disturbances. Cochrane Database Syst Rev. 2015;2015:CD008096.
11. Ikenaga Y, Kusunoki T, Yamaguchi H. Percutaneous endoscopic gastrostomy reduces aspiration pneumonia rate in stroke patients with enteral feeding in convalescent rehabilitation
wards. Prog Rehabil Med. 2021;6:20210031.
12. Lin T-H, Yang C-W, Chang W-K.Evaluation of oropharyngeal dysphagia in older patients for
risk stratication of pneumonia. Front Immunol. 2022;12
13. Nichols E, etal. Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: an analysis for the global burden of disease study 2019. Lancet Public Health.
2022;7:e105–25.
14. Mitchell SL, etal. The clinical course of advanced dementia. N Engl J Med. 2009;361:1529–38.
15. Sanders DS, etal. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse
outcome in patients with dementia. Am J Gastroenterol. 2000;95:1472–5.
16. Rajan A, Wangrattanapranee P, Kessler J, Kidambi TD, Tabibian JH. Gastrostomy tubes:
fundamentals, periprocedural considerations, and best practices. World J Gastrointest Surg.
2022;14:286–303.
17. Boeykens K, Duysburgh I.Prevention and management of major complications in percutaneous endoscopic gastrostomy. BMJ Open Gastroenterol. 2021;8:e000628.
18. Venkatesan AM, etal. Practice guideline for adult antibiotic prophylaxis during vascular and
interventional radiology procedures. J Vasc Interv Radiol. 2010;21:1611–30.
19. Itkin M, et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral
nutrition and decompression from the Society of Interventional Radiology and American
Gastroenterological Association (AGA) institute, with endorsement by Canadian interventional radiological association (CIRA) and cardiovascular and interventional radiological
Society of Europe (CIRSE). J Vasc Interv Radiol. 2011;22:1089–106.
20. Collins K, Gaffney L, Tan J, Roberts S, Nyulasi I.Gastrostomy guidelines: a rapid review.
21. Sutcliffe J, etal. CIRSE standards of practice guidelines on gastrostomy. Cardiovasc Intervent
Radiol. 2016;39:973–87.
22. Crowley JJ, Cahill AM.Society of interventional radiology guidelines and statements division
2020 year-end document review. J Vasc Interv Radiol. 2021;32(918):e1–918.e4.
23. Khashab MA, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc.
2015;81:81–9.
24. Accorsi F, etal. Percutaneous ultrasound gastrostomy (PUG): rst prospective clinical trial.
Abdom Radiol. 2021;46:5377–85.
25. Patel IJ, etal. Society of Interventional Radiology Consensus Guidelines for the Periprocedural
Management of Thrombotic and Bleeding Risk in patients undergoing percutaneous imageguided interventions—part II: recommendations: endorsed by the Canadian Association for
Interventional Radiology and the cardiovascular and interventional radiological Society of
Europe. J Vasc Interv Radiol. 2019;30:1168–84.
26. Baron TH, Kamath PS, McBane RD.Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med. 2013;368:2113–24.
S. B. Fordyce et al.
Соседние файлы в папке Библиотека им академика М.И. Перельмана