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Laparoscopic-assisted percutaneous endoscopic gastrostomy in two patients who failed percutaneous endoscopic gastrostomy
ABBASSI, Ziad, et al.
Abstract
Percutaneous endoscopic gastrostomy (PEG) is a common procedure to obtain a feeding tube. However, this technique might imply several difficulties and complications. The inability to transilluminate the abdominal wall may occur frequently, especially in obese or multi-operated patients. With the emergence of minimally invasive surgery, laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) might provide a safe and efficient alternative.
ABBASSI, Ziad, et al . Laparoscopic-assisted percutaneous endoscopic gastrostomy in two patients who failed percutaneous endoscopic gastrostomy. International Journal of Surgery Case Reports , 2015, vol. 13, p. 40-42
DOI : 10.1016/j.ijscr.2015.06.002 PMID : 26101053
Available at:
http://archive-ouverte.unige.ch/unige:73834
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CASE REPORT – OPEN ACCESS
InternationalJournalofSurgeryCaseReports13(2015)40–42
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International Journal of Surgery Case Reports
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Laparoscopic-assisted percutaneous endoscopic gastrostomy in two patients who failed percutaneous endoscopic gastrostomy
Ziad Abbassi
a,∗, Surennaidoo P. Naiken
a, Nicolas C. Buchs
a, Wojciech Staszewicz
a, Emiliano Giostra
b, Philippe Morel
aaClinicforVisceralandTransplantationSurgery,DepartmentsofSurgery,UniversityHospitalofGeneva,Geneva,Switzerland
bDivisionofGastroenterology,UniversityHospitalofGeneva,Geneva,Switzerland
a r t i c l e i n f o
Articlehistory:
Received23May2015
Receivedinrevisedform29May2015 Accepted1June2015
Availableonline6June2015
Keywords:
Gastroscopy Gastrostomy PEG Laparoscopy
a b s t r a c t
INTRODUCTION:Percutaneousendoscopicgastrostomy(PEG)isacommonproceduretoobtainafeeding tube.However,thistechniquemightimplyseveraldifficultiesandcomplications.Theinabilitytotransil- luminatetheabdominalwallmayoccurfrequently,especiallyinobeseormulti-operatedpatients.With theemergenceofminimallyinvasivesurgery,laparoscopic-assistedpercutaneousendoscopicgastros- tomy(LAPEG)mightprovideasafeandefficientalternative.
PRESENTATIONOFCASES:WereportherebytwocasesofpatientshavingundergoneLAPEGinourinsti- tution.ConventionalPEGsweredeemedimpossiblebecauseoftheabsenceoftransilluminationand motivatedasurgicalapproach.
TwoobesepatientswithaBodyMassIndex(BMI)of31and45kg/m2respectivelypresentedneuro- logicalcondition(strokeandParkinson’sdisease)requiringafeedingtube.WhileaPEGwasunsuccessful (impossibilitytotransilluminate),aLAPEGwasattempted.Theprocedureandtherecoverywereunevent- ful.
DISCUSSION:Therearedifferenttechniquesforgastrostomytubeplacement:opengastrostomy,PEGand radiologicprocedure.ThePEGisassociatedwithasignificantriskofbowelperforation.
LAPEGseemstobeaninterestingoptioninordertoavoidanopengastrostomyinpatientsinwhom aPEGcannotbeperformed.Thisisespeciallytrueinobesepatients,whereatransilluminationcannot beperformed.Itoffersanendoscopicviewofthestomachsimultaneouslytothelaparoscopicapproach thatallowsapotentialdecreaseofmajorcomplications.
CONCLUSION:Whiletheliteraturereportsmainlypediatriccases,wepresenthereintwosuccessfulLAPEG inadultobesepatients.IncaseofimpossibilitytoperformPEG,thistechniqueallows asafedirect visualizationofthestomachandotheradjacentorgans.
©2015TheAuthors.PublishedbyElsevierLtd.onbehalfofSurgicalAssociatesLtd.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Gastrostomycanbeanecessityinavarietyofclinicalsituations eitherfornutrition orfor gastrointestinaldischarge [1].Indeed, thereare multipleindications for gastrostomy whethertempo- raryordefinitive,incaseofswallowingdisorders,poornutritional statusrequiringlong-termnutritionalsupport,orchronicintesti- nalobstructionnecessitatingdischarge[2,3].Inthesesituations, themostfrequentindications arepalliativeforexampleincase ofobstructivetumorsoftheheadandthebodyofthepancreas,
∗ Corresponding authorat: Clinicfor Visceraland TransplantationSurgery, DepartementofSurgery,UniversityHospitalofGeneva,RueGabrielle-Perret-Gentil 41211Geneva,Switzerland.Fax:+41223727689.
E-mailaddress:Ziad.abbassi@hcuge.ch(Z.Abbassi).
laryngealcancers,cerebralvascularaccidents,cranialtraumas,and neurodegenerativesyndromes[4].
Therearetwomajortechniques:opengastrostomy(OG)and minimally invasive gastrostomy, which includes: percutaneous endoscopicgastrostomy(PEG),percutaneousfluoroscopic-guided gastrostomy [5] and more recently laparoscopic gastrostomy andlaparoscopic-assisted percutaneousendoscopicgastrostomy (LAPEG)(Fig.1).
With the increasing acceptance of minimally invasive tech- nique,asubstantialdecreaseofOGwasobserved.Asaconsequence, thecomplicationrateassociatedtolaparotomywasreducedaswell (pain,abscesses,hematoma,eviscerationorincisionalhernia)[6].
TheLAPEGisarelativelyrecentoptionandwasfirstdescribedin 1993byRaafetal.[7].Whilemajorityofreportsofthistechnique concernspediatricpatients[2],LAPEGmightbeaninterestingalter- nativeinpatientsinwhomaPEGcouldnotbeperformedsafely (difficultytotransilluminate,riskofintestinalinterposition).
http://dx.doi.org/10.1016/j.ijscr.2015.06.002
2210-2612/©2015TheAuthors.PublishedbyElsevierLtd.onbehalfofSurgicalAssociatesLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
CASE REPORT – OPEN ACCESS
Z.Abbassietal./InternationalJournalofSurgeryCaseReports13(2015)40–42 41
Fig.1.ThesetusedfortheLAPEG,consist:alancet,aguidewire(17Fr),thegastros- tomycatheter(14Fr/17cm)andaneedleguidewithadilatator(17Fr).
WedescribehereinatechniqueofLAPEGin2caseswithdif- ferentprimarypathologiesandunsuccessfulattemptofPEGasthe firstintention.
2. Presentationofcasesandtechnique 2.1. Caseone
Our first case was a 83-year old male patient presenting a cerebral vascular accident with major swallowing disorder.
TheendoscopicteamattemptedaPEGwhounfortunatelyfailed becauseoftheabsenceoftransilluminationoftheabdominalwall.
Ofnotethepatient’sBodyMassIndex(BMI)was31kg/m2. 2.2. Casetwo
Oursecondpatientwasa66-yearoldfemalepatient,withapast medicalhistorysignificantforaParkinson’disease.ThePEGwas indicatedforacontinuouspumpofMadopar®.Unfortunately,PEG insertionfailed(absenceoftransillumination).Ofnote,thepatient’s BMIwas45kg/m2.Inthesetwosituations,wedecidedtoperform aLAPEG.
2.3. Technique
Patientswere undergeneral anesthesia, indorsal decubitus.
Thefirst12mmopticalportwasinsertedbytheopentechnique, throughtheumbilicus(Fig.2).The stomachwasvisualizedand positionedcorrectlyforPEGinsertion(Fig.3A).Thegastroenterolo- gistproceededtothegastroscopysimultaneouslywithinsufflation ofthestomach.Theabdominalinsufflationpressurewasdecreased from15mmHgto10mmHg.Aneedlewasinsertedattheentry pointforthePEG(Fig.3B)(RusselGastrostomySet:C-GAST-1700- RFS).Aguidewirewasplacedthroughtheneedle(Fig.4A)anda dilatorwasplacedovertheguidewiretocreateatractwideenough forthegastrostomytube(Fig.4B).Theplacementofthegastros- tomywascheckedbylaparoscopyandendoscopy(Fig.4C).
Theoperativetimewas35and42min,respectively.Therewas no intra-operative complication. The postoperative course was uneventful.Thelengthofstaywas1and2days,respectively.
3. Discussion
Therearedifferenttechniquesforgastrostomytubeplacement:
opengastrostomy,PEGandradiologicprocedure.ThePEGisasso- ciatedwithasignificantriskofbowelperforation.However,the mainreasonofafailureoftheprocedureisaninadequatetransil- luminationthroughtheabdominalwall.Moreover,therearealso manyotherfactorsthatcouldlimitPEGinsertionsuchasanatomic
Fig.2.A12-mmumbilicaltrocarisplacedforthelaparoscope.Afterhavingstomach repair,weperformanabdominalincisionoppositetheilluminatingsite.
variationssecondarytogastricsurgery,adhesionsfromprevious abdominalsurgery,orseverescoliosis[8].
While not completely new, LAPEG seemsto bean interest- ingoptioninorder toavoidanopengastrostomyinpatientsin whomaPEGcannotbeperformed.Thisisespeciallytrueinobese patients,whereatransilluminationcannotbeperformed.Thistech- niqueallowsviewingtheperitonealcavityandthestomach;firstly torecognizetheidealgastrostomysiteandtoavoida potential intestinalperforation;secondlytoguaranteeagoodplacementof thegastrostomytubeinthestomachlumen[9].Severalauthors havecomparedtheLAPEGwiththeotherpercutaneoustechniques [3,5,6].Whilethecomplicationrateissimilar,thesuccessrateis higherbyfluoroguidanceorlaparoscopic-assistedtechniquesthan endoscopy[10].WhiletheLAPEGproceduretakesalongeropera- tivetime,thesafetyseemstobehigherthanthePEGtechnique.
Ontheotherhand,itisimportanttospecifythatthecontraindi- cation for PEGremains relevant duringa LAPEG.These include notablystenosisoftheoesophagus,totalorsubtotalgastrectomy, coagulationdisorders,andsevererespiratoryfailure.TheLAPEG respectthemainadvantagesofthePEG,alowmorbidityprocedure forgastrostomytubeplacement.
OneofthemaindisadvantagesoftheLAPEGisitscosts,which remainshigherthantheotherprocedures[4].Finallythereisno studycomparingthevarious minimallyinvasive approachesfor surgicalgastrostomy.However,recently,Frankenetal.described theirexperiencewithlaparoscopicgastrostomy(LAG)inchildren.
Theyshowedasignificantrateofmajorcomplications(2%)includ- ingdeath,postoperativedehiscenceofstomachwall,intraoperative bleedings,perforationofadjacentorgans,acuteintestinalobstruc- tion,volvulusandomentalherniation[11].Ontheotherhand,while requiringtwodifferentteams,LAPEGmightbenotonlyfasterbut alsosaferthantheLAG.Indeed,itoffersanendoscopicviewofthe stomachsimultaneouslytothelaparoscopicapproachthatallows apotentialdecreaseofthiskindofcomplications[4].
CASE REPORT – OPEN ACCESS
42 Z.Abbassietal./InternationalJournalofSurgeryCaseReports13(2015)40–42
Fig.3.A.Insuflationofthestomachthroughtheendoscope.
B.Directvisualizationoftheneedleintothestomachafterarepairofthegoodlocalizationbytransillumination.
Fig.4.A.Theguidewireisplacedthroughtheneedleandadilatorisplacedovertheguidewire.
B.Theguidewireallowscreatingatractwideenoughforthegastrostomytube.
C.Finalresult.
4. Conclusion
LAPEGisatpresentconsideredasaminimallyinvasivealter- nativetotheclassicpercutaneoustechniques.It mightbesafer thanthePEGbydirectvisualizationoftheinsideandtheoutside ofthestomach.Andincasesoffailureoftransillumination,LAPEG mightbeaninterestingoptionbyminimizingtheriskofintestinal injury.Finally,LAPEGmightbeafasterandeasierprocedurethan laparoscopicgastrostomy,andshouldbeconsideredforselected cases.
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