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1
Department of Radiology, MC 2026, The University of Chicago Hospitals, 5841 S.
Maryland Ave., Chicago, IL 60637.
2
Racine Radiologist Group, 3803 Spring St., Rm. 208, Racine, WI 53405.
Received December 14, 2000;
accepted after revision January 30, 2001.
Address correspondence to B. Funaki.
Abstract
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MATERIALS AND METHODS. Between July 8, 1999, and August 4, 2000, 80 percutaneous gastrostomy catheters were placed in 80 patients in 80 attempts. Twenty-five 16-, 18-, or 20-French balloon-retained catheters and 55 20-French mushroom-retained catheters were inserted. Typically, the type of catheters placed was based on operator preference. However, balloon-retained tubes were preferred for use in patients with obstructive head and neck or esophageal malignancies, and mushroom-retained catheters were preferred for use in demented or combative patients. Follow-up was conducted through chart reviews and telephone interviews. The technical success, procedural complications, and catheter complications were recorded. Chi-square statistical analysis was performed.
RESULTS. Technical success was 100% (80/80 patients), and no procedural complications occured. In patients who received balloon-retained catheters, the major complication rate was 0%, the minor complication rate was 8% (2/25 patients), and the tube complication rate was 68% (17/25 patients). The following complications occurred: catheter dislodgment (n = 17), superficial cellulitis (n = 1), and bleeding gastric ulcer (n = 1). In patients who received mushroom-retained catheters, the major complication rate was 0%, the minor complication rate was 3.6% (2/55 patients), and the tube complication rate was 3.6% (2/55 patients). The following complications occurred: superficial cellulitis (n = 2), tube occlusion (n = 1), and peristomal tube leakage (n = 1). No significant differences in major or minor complications were found between the gastrostomy procedures. Balloon-retained catheters had a significantly higher rate of tube complications (p < 0.001).
CONCLUSION. Compared with balloon-retained catheters, mushroom-retained gastrostomy catheters are significantly more durable, more secure, and less prone to tube dysfunction. Mushroom-retained catheters should be the preferred type of gastrostomy catheter to place in patients whenever possible.
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Placement of Gastronomy Catheters
Before all procedures, patients who were coagulopathic (defined as having a
prothrombin coagulation time longer than 17 sec or an international normalized
ratio larger than 1.92) or thrombocytopenic (defined as having platelets less
than 150 x 103 mL) received blood products to correct deficiencies. All
patients received 1 g of IV ceftizoxime sodium for prophylaxis. 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 by noninvasive means. All patients received 1 mg of IV glucagon
approximately 5 min before gastric insufflation. Enteric contrast material to
opacify the colon was not routinely given, and sonography to localize the left
lobe of the liver was not routinely performed.
Balloon-Retained Catheter Placement
The patient's stomach was insufflated using either a nasogastric tube
(Salem sump tube; Sherwood Medical, St. Louis, MO) or a 5-French end-hole
catheter (MPA [multipurpose angled]; Cook, Bloomington, IN). 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) were placed around the intended catheter site. A 3- to 4-mm
incision was made in the center of the gastropexy fasteners, the stomach was
accessed through the incision, and the tract was serially dilated to accept a
peel-away sheath that was 6 French larger than the tube. A 16-, 18-, or
20-French single-use balloon-retained catheter was inserted through the sheath
into the stomach (Fig.
2A,2B).
Tube size to be used was chosen by the attending interventional radiologist.
The sheath then was removed, the balloon was inflated, and the catheter
secured to the patient. T-fasteners were released 2 weeks after tube
insertion.
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Mushroom-Retained Catheter Placement
We used the technique described by Szymski et al.
[8]. An upper endoscopy
bite-block (Endo Bite-Block; Encompas, 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
insufflated using either a nasogastric tube or a 5-French end-hole catheter.
After administering local anesthesia, we made an approximately 10- to 15-mm
incision in the skin at the site of gastric puncture. The stomach was
punctured through the incision, and a single gastropexy T-fastener (Cope;
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 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 in the gastrostomy set
was attached to the wire and pulled from the stomach out of the mouth (Fig.
3A,3B).
The gastropexy fastener was then cut, and a 20-French mushroom-retained
gastrostomy catheter was attached to the snare and pulled from the mouth into
the stomach. The catheter tube was lubricated (Surgilube; Fougera, Melville,
NY) and coated with povidone-iodine (Betadine ointment; Purdue Fredrick,
Norwalk, CT) to facilitate passage. The catheter was attached to a plastic
dilator that matched the tube diameter exactly, so that the puncture site was
enlarged as the tube was pulled from the mouth into the stomach.
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Follow-Up
The technical success, procedural complications, and catheter complications
were recorded. All relevant discharge summaries, outpatient notes, laboratory
reports, and imaging studies were reviewed. Attempts were made to contact by
telephone those patients who did not receive close clinical follow-up
(n = 17). Two patients were lost to follow-up. Major complications
were defined as procedural or tube complications that prolonged a patient's
hospital stay, required repeated hospitalizations of a patient, or resulted in
a patient's death. 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 balloon-retained catheters was 171.1 days
(range, 16-372 days). In patients who received mushroom-retained catheters,
mean follow-up was 149.4 days (range, 1-399 days). The chi-square test was
performed to assess statistical significance.
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In patients who received mushroom-retained catheters, the major complication rate was 0%, the minor complication rate was 3.6% (2/55 patients) and the tube complication rate was 3.6% (2/55 patients). The overall 30-day complication rate (including tube complications) was 1.8% (1/55 patients). The only minor complication we encountered was superficial cellulitis (n = 2), which was successfully treated with topical creams and oral antibiotics. Tube complications were tube occlusion (n = 1), and peristomal tube leakage (n = 1). The occluded tube was removed and did not need to be replaced because the patient was able to resume eating. Pericatheter leakage was treated with topical creams and local ostomy nursing care. The volume of tube feedings was also decreased. No mushroom-retained catheters were dislodged during this study period.
The 30-day mortality rate for the group who received balloon-retained catheters was 8% (2/25 patients), and the 30-day mortality rate for the group who received mushroom-retained catheters was 5.5% (3/55 patients). None of the deaths were related to gastrostomy placement. One balloon-retained catheter and one mushroom-retained catheter were removed during the study period in patients who were able to resume eating. As described previously, one balloon-retained catheter was removed in a patient with a bleeding duodenal ulcer, and one mushroom-retained catheter was removed because of tube obstruction. One mushroom-retained catheter was converted to a gastrojejunostomy catheter because of severe gastroesophageal reflux.
Chi-square statistical analysis revealed no significant differences in major or minor procedural complications between techniques. Tube complications were significantly higher in patients who received balloon-retained catheters (p < 0.001).
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Radiologic gastrostomy is typically performed by puncturing the stomach, performing serial dilation of the puncture site, and advancing either a pigtail- or balloon-retained catheter into the stomach over a guidewire. Smaller pigtail-retained catheters are inserted directly whereas large-bore balloon-retained tubes are inserted via a peel-away sheath or in tandem with a leading angioplasty balloon [10]. This technique is straightforward and clearly the method of choice for tube insertion in patients with obstructing head and neck or esophageal carcinomas.
A second technique gaining in popularity is oropharyngeal insertion of mushroom-retained catheters [7,8,9]. These tubes have traditionally been used primarily in endoscopic gastrostomy. In this technique, retrograde esophageal catheterization is performed after gastric puncture, and a guidewire is advanced from the stomach out through the mouth. A snare is then used to pull the mushroom-retained tube into the stomach (or alternatively, some types of tubes are placed over an exchange-length guidewire). These tubes are directly attached to a dilator that exactly matches the tube's diameter. Thus, the puncture site is dilated from inside the stomach outward as the tube is inserted. The advantage of this catheter is that its fixed retention mechanism cannot be unlocked or deflated.
Many studies have shown the safety and efficacy of percutaneous gastrostomy [1,2,3,4,5,6,7,8,9,10]. Wollman et al. [6] performed a meta-analysis comparing fluoroscopic, endoscopic, and surgical gastrostomy and concluded that fluoroscopic gastrostomy had the highest success rate with the lowest complication rate. However, in practical terms, differences among the techniques were small. In comparing the costs of the techniques, the costs of endoscopic and fluoroscopic gastrostomy are similar whereas the cost of surgical gastrostomy is significantly higher [11].
Relatively few studies have compared the performance of different catheters. Funaki et al. [12] compared large-bore mushroom-retained catheters to smaller pigtail-retained tubes and found that, although the two catheters had similar technical success and procedural complication rates, the long-term tube performance was significantly better with the mushroom-retained tubes. Pigtail-retained tubes were found to have a more than 20-fold increase in tube obstruction, leakage, and dislodgment when compared with mushroom-retained catheters. To our knowledge, our study is the first single-institution report to compare the performance of two large-bore catheters.
There were no major complications in our series related to either the procedure or indwelling gastrostomy catheters. The most common minor complication was superficial cellulitis that occurred in both groups with similar frequency and was successfully treated with peristomal skin care and topical antibiotics. Theoretically at least, patients who undergo oropharyngeal gastrostomy may be more susceptible to infection than if they had undergone traditional radiologic gastrostomy because the catheter is inserted through the mouth. To minimize the risk of cellulitis, our patients received prophylactic antibiotics, and the catheters were coated with antibacterial ointment before placement. In our study, no difference in the incidence of skin infection was found between two types of gastrostomy. One other study comparing oropharyngeal gastrostomy to pigtail gastrostomy also found no significant differences in the incidence of infection between techniques [12]. One patient who received a balloon-retained gastrostomy catheter developed a bleeding duodenal ulcer that was revealed at upper endoscopy. This complication is relatively unusual and may not have been related to tube placement.
As expected, both tubes provided excellent patency because of their larger diameters. There was only one instance of tube occlusion in the mushroom-retained catheter group (<2%). Overall, the mushroom-retention device appears to be more durable than a balloon. Tube dislodgment caused by either accidental balloon deflation or breakage occurred in 68% (17/25) of patients who received balloon-retained catheters. In three patients, two replacement procedures were required when their catheters broke twice during the follow-up period. Eight tubes were dislodged within 15 days of placement. Tube dislodgment in this early period may have devastating consequences because the tract from skin to stomach is not well established. Peritonitis caused by the leakage of gastric contents is the most feared complication. In our patients, we believe that the routine use of gastropexy fasteners both protected against spillage of gastric contents and facilitated tube replacement via the existing puncture site. Late tube dislodgment is usually only a minor inconvenience: most patients have well-developed subcutaneous tracts to the stomach after 2 weeks. In our experience, balloon-retained tubes needed to be replaced, on average, every 2 months. In contrast, none of the mushroom-retained catheters needed replacement. Thus, the balloon-retained catheters showed a rate of tube complications that is statistically significant—more than 15-fold higher than the mushroom-retained catheters.
The limitations of this study include its retrospective nature and placement biases. Specifically, the type of catheters placed depended on the preference of the operator, although balloon-retained tubes were the preferred choice for patients with obstructive head and neck or esophageal malignancies and mushroom-retained catheters were preferred for demented or combative patients. This bias reflects day-to-day practice and underscores the importance of understanding different methods of radiologic gastrostomy.
A single catheter design is not appropriate for all patients. Because mushroom—retained catheters are placed via the mouth, we do not attempt their placement in patients with high-grade obstruction of the mouth, throat, or esophagus caused by esophageal or head and neck cancer. It is important to note that mushroom-retained tubes can be successfully inserted in many patients with less-advanced head and neck malignancies if these cancers are not obstructive. In this series, mushroom-retained tubes were inserted in 62% (21/34) of patients with head and neck carcinomas.
In conclusion, we have found that oropharyngeal and direct methods of percutaneous fluoroscopic gastrostomy are equivalent in rates of technical success and procedural complications. Both balloon-retained and mushroom-retained large-bore catheters showed excellent patency rates. However, tube dislodgment presumably caused by balloon rupture or accidental deflation was a major drawback of the balloon-retained tubes that limited long-term durability. Therefore, unless a contraindication to oropharyngeal placement exists (such as obstructive esophageal or head and neck malignancy), we recommend insertion of mushroom-retained catheters, pending completion of a randomized trial.
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