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Original Report |
1 Department of Radiology, Division of Abdominal Imaging and Intervention,
Massachusetts General Hospital, Boston, MA 02114-9657.
2 Department of Radiology, Harvard Medical School, White 270, 55 Fruit St.,
Boston, MA 02114-9657.
Received September 8, 2003;
accepted after revision February 2, 2004.
Address correspondence to P. R. Mueller.
Abstract
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CONCLUSION. The placement of two percutaneous catheters through separate skin sites is a feasible and successful approach to providing enteral feeding and gastric decompression or drainage in debilitated patients with persistent gastroesophageal reflux and aspiration pneumonia.
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For most patients, gastrostomy provides a straightforward solution to long-term enteral nutrition. Gastrostomy can be placed surgically, endoscopically, or percutaneously using imaging guidance to provide an easily maintained route for administration of any of numerous tube feeding formulae. In general, gastrostomy tubes are easier and less time-consuming to place than gastrojejunostomy tubes and are simpler to replace when clogged or dislodged. On occasion, however, gastrostomy feeding tubes may be associated with pulmonary aspiration as a result of gastroesophageal reflux [4]. Most gastrostomy tubes can be converted to gastrojejunostomy tubes, which significantly diminishes the risk of gastroesophageal reflux and aspiration [4–8]. However, a small subgroup of patients remain who have a gastrojejunostomy tube in place but still have persistent problems of gastroesophageal reflux. These patients require simultaneous gastric decompression and jejunal delivery of tube feeding formula, and their treatment is more complicated. In these patients, neither a gastrostomy alone nor a gastrojejunostomy catheter alone is sufficient to solve the problem of providing enteral nutrition safely and successfully. Two traditional approaches are taken to solve this apparently straightforward, yet clinically complicated, problem. The first solution is the placement of a multilumen catheter with one lumen open to the stomach for drainage and the second lumen distal to the ligament of Treitz for feeding [4]. The second solution is to place two catheters through the same skin incision site with one catheter tip in the stomach and the second catheter tip distal to the ligament of Treitz [9].
In our experience, both of these approaches have proven unsatisfactory because in the former case reflux continues and in the latter case considerable gastric leakage may be seen around the skin incision.
We propose a third approach: placement of two single-lumen 14-French catheters through separate punctures, with one directed into the jejunum and the second one directed to the fundus of the stomach. In a select patient population this technique is feasible, successful, and ultimately improves patient care. The purpose of this article is to report our experience with this technique.
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Of 459 patients, 339 had gastrostomy and 120 had a primary gastrojejunostomy at the time of their initial procedure. The choice of catheter, gastrostomy, or gastrojejunostomy was influenced by the preference of the referring clinical service and was based on their assessment of each patient's risk of aspiration. Of the 339 patients who initially received gastrostomy tubes, 78 (23%) required conversion to gastrojejunostomy because of persistent gastroesophageal reflux of tube feedings. Thus, between the initial placement and subsequent conversion, 198 patients had gastrojejunostomy catheters placed for enteral feeding.
Of these 198 patients, 40 patients returned to the department for placement of a second tube. The second tube was required because aspiration was noted in these patients despite the fact that the feeding tube was at or beyond the ligament of Treitz. Twenty-seven patients had initial gastrostomy converted to a gastrojejunostomy, and 13 patients had initial gastrojejunostomy. All 40 patients underwent a second percutaneous procedure for creation of a separate transgastric access so that one tube could be left in the jejunum for feeding and a second tube positioned in the gastric fundus for drainage of gastric secretions. This cohort of 40 patients from the 459 patients (8.7%) serves as the basis for this study.
Clinical Evaluation
In the 40 patients who ended up with two separate transgastric tubes, the
indication for gastrojejunostomy tube placement was enteral feeding. Gastric
drainage was required in 34 of 40 patients because of clinical evidence of
increased gastric residual volume during feeding or aspiration pneumonia.
Increased gastric residual volume was ascertained by nurses who noted that a
high percentage of the volume of the patients' enteric feed was easily
returned on catheter aspiration. Aspiration pneumonia was confirmed by
clinical symptoms (diagnosed by the referring physician), and imaging evidence
of aspiration pneumonitis on CT or chest radiography.
The remaining six of the 40 patients had increased secretions and poor gastric drainage as a result of direct tumor involvement of the distal stomach or proximal duodenum. Three of these six patients had pancreatic cancer, two had metastatic cholangiocarcinoma, and one had gallbladder cancer.
All the patients were debilitated, and all 40 had radiologic evidence, either by chest radiograph (n = 34) or CT scan (n = 30), of aspiration pneumonia before the placement of the second catheter. In some patients, both CT and chest radiography were performed. Ten patients had serious head injury after trauma, four patients had neurologic disorders, four patients had recent head and neck surgery, and three patients were recovering from severe burns. Nineteen patients were recovering from recent major abdominal surgery including aneurysm rupture, necrotizing pancreatitis, and extensive resection for malignant disease. Eight of the nine patients younger than 60 years old requiring two catheters had either a neurologic disorder or a history of trauma. One patient younger than 60 years had cancer. All patients were bedridden and were usually positioned in a supine or semisupine position.
Nine (22.5%) of the 40 patients had undergone anatomy-altering surgery of the upper gastrointestinal tract before placement of the gastrostomy or gastrojejunostomy catheter (Fig. 1). These surgeries included a Whipple procedure (n = 5), a partial gastrectomy and vagotomy, duodenal resection, duodenal and jejunal bypass, and a gastrojejunostomy (n = 1, each). Assessment of successful outcome was made by a combination of documentation of catheter tip position and lack of clinical or radiologic evidence of aspiration pneumonia.
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Gastrostomy and Gastrojejunostomy Tube Placement
The technique for placing gastrostomy and transgastric jejunal feeding
tubes has been well described elsewhere
[10,
11]. All gastrostomy and
gastrojejunostomy feeding tubes were placed under fluoroscopy using conscious
sedation according to standard protocol. The patient was given 300–400
mL of barium per nasogastric tube the night before and made nothing by mouth.
The patient was given conscious sedation during the procedure. The transverse
colon was identified by the barium given the night before. The left lobe of
the liver was identified using sonography before the procedure. Air was
introduced into the stomach through the nasogastric tube. Three or four
retention sutures were placed in the mid transverse portion of the stomach. A
puncture was then made in the center of a triangle or square either toward the
antrum of the stomach or toward the fundus. If a primary gastrojejunostomy was
planned, the initial puncture was directed toward the antrum. The puncture was
made with a thin-wall 18-gauge needle. A 0.035-inch guidewire was inserted
into the stomach or into the proximal jejunum to the ligament of Treitz. A
14-French gastrostomy or gastrojejunostomy catheter with a locking pigtail
(Cook) was then positioned either in the stomach or proximal jejunum. The
technique for placement of the second catheter did not always require barium
administration before the procedure to opacify the colon or sonographic
location of the liver. In all patients, the stomach was already
"adhered" to the abdominal wall from a previous gastrostomy.
Despite this fact, retention sutures were used in all patients. Air
insufflation to distend the stomach was performed through the primary tube. If
the location of the colon was questioned, an enema was performed at the time
of the procedure.
In the 40 patients who had a second catheter placed, the entrance position of the second catheter was determined by the location of the entrance position of the first catheter. If the first catheter had been placed in the transverse portion of the antrum, this first catheter was used as a gastrojejunostomy tube and the second catheter position was chosen more proximal and could then be directed toward the fundus. If the original catheter had been positioned toward the fundus, the entrance point of the second catheter was more distal so that it could be directed toward the antrum.
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In this subgroup of patients requiring enteral feeding and gastric drainage or decompression, two approaches are traditionally taken. One strategy has been to use a dual-lumen catheter with one lumen open to the stomach and a second lumen distal to the ligament of Treitz. Such catheters have several disadvantages. The first is that large-bore catheters are required (20- to 24-French) [4]. In addition, the internal lumen of each of the tubes is relatively small. The feeding lumen is usually approximately 9-French, and the draining lumen is approximately 6-French. Their small size makes these catheters prone to clogging and malfunction, which has been acknowledged by proponents of dual-lumen single catheters [4]. More importantly, such catheters do not permit ideal placement of the gastrostomy catheter opening. Many of the patients who require these catheters are debilitated and spend a large percentage of their time in the recumbent position. As a result, the gastric secretions pool in the gastric fundus. Because these dual-lumen tubes serve a dual purpose of both feeding and draining, the gastric drainage opening in these tubes cannot consistently be directed to lie in the fundus, so such patients remain susceptible to the risk of gastroesophageal reflux with subsequent aspiration pneumonia.
The alternative approach to dealing with the problem is to place separate gastrostomy and gastrojejunostomy tubes in the patient via a solitary puncture site. We found this process unsatisfactory for two reasons. First, as with the single dual-lumen catheter, optimal placement of the gastrostomy tube is not always possible because it requires different angulations of the two tubes, which may sometimes be difficult to achieve through one access site. The draining gastrostomy tube needs significant cephalad angulation to direct the tip into the gastric fundus, and the gastrojejunostomy tube requires an initial caudal angulation for optimal passage through the duodenum. In addition, the placement of two round catheters through one puncture site promotes pericatheter leakage of gastric contents caused by the geometry of the side-by-side tubes with subsequent skin breakdown caused by autodigestion from gastric contents.
We have found that inserting a separate tube works effectively with few complications. We are unaware of any other report describing this technique.
Percutaneous placement of a decompression or drainage gastrostomy tube and feeding gastrojejunostomy tubes through separate percutaneous access sites allows optimal placement of the catheter tips with maximal success for both feeding and decompression or drainage without the complications associated with the smaller lumens of the dual-lumen catheters.
In conclusion, debilitated patients requiring both enteral feeding and gastric decompression or drainage present a treatment challenge. The two traditional methods of dealing with this problem have definite disadvantages. We propose a new approach with which we have had success.
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