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1 Department of Radiology, UMDNJ-Robert Wood Johnson Medical School, PO Box 19,
Medical Education Bldg., Rm. 404, New Brunswick, NJ 08903-0019.
2 Department of Radiology, Jersey Shore Medical Center, 1945 State Rte. 33,
Neptune, NJ 07754-0397.
3 Department of Radiology, Saint Peter's University Hospital, 254 Easton Ave.,
New Brunswick, NJ 08901.
Received August 25, 2003;
accepted after revision April 23, 2004.
Address correspondence to J. L. Nosher.
Abstract
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MATERIALS AND METHODS. Eight patients with morbid obesity and
Roux-en-Y gastric bypass underwent percutaneous radiologic gastrostomy for
postoperative decompression of the bypassed stomach. Four patients underwent
gastrostomy on the fourth day after surgery: two in the early postoperative
period (
30 days after surgery) and two in the late postoperative period
(6, 11 months after the procedure). Procedures were performed using
combinations of fluoroscopic, CT, and sonographic guidance. T-tacks and a
variety of locking pigtail drainage catheters were placed in seven
patients.
RESULTS. Gastrostomy placement was technically successful in all patients. Seven of eight patients experienced resolution of symptoms. Gastrostomy catheters were in place for a mean of 31 days. Two complications occurred. Periprocedural peritonitis in one patient with underlying small-bowel obstruction required surgical intervention. One wound infection was treated with antibiotics and local wound care. No catheters became dislodged or obstructed. Four patients treated during the early postoperative period had resolution of symptoms after tube placement and recovered uneventfully. Three of four patients presenting during the intermediate or late postoperative periods had temporary resolution of symptoms, but all eventually required surgical intervention.
CONCLUSION. In the absence of complete small-bowel obstruction, percutaneous radiologic gastrostomy provides safe and effective decompression of the excluded gastric remnant after Roux-en-Y gastric bypass. Gastrostomy tube placement after the early postoperative period is temporizing, with surgical intervention eventually required.
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Two patients presented shortly after discharge from the hospital (11, 29 days after surgery) with nausea, vomiting, and significant dilatation of the bypassed stomach. One of these patients (patient 5) had a mechanical obstruction of the afferent loop and the bypassed stomach. The second patient (patient 6) presented with fever and abdominal pain. This patient had erosion of the gastric staple line by a Jackson-Pratt drain that was seen 15 days after surgery. She subsequently developed a fistula from the gastric pouch to the excluded stomach. The erosion was operatively repaired. Seven days later, the patient presented with upper gastrointestinal bleeding. Blood had accumulated in the bypassed stomach, causing symptoms of abdominal pain and nausea.
Two patients presented during the late postprocedural period. One patient (patient 7) presented 6 months after laparoscopic Roux-en-Y gastric bypass with partial small-bowel obstruction and underwent gastrostomy for decompression of the distended bypassed stomach. The last patient (patient 8) presented 11 months after Roux-en-Y gastric bypass with afferent loop obstruction and distention of the bypassed stomach.
Guidance for percutaneous radiologic gastrostomy catheter placement was provided by fluoroscopy, CT, CT and fluoroscopy, or sonography and fluoroscopy. Fluoroscopy was used if the distended bypassed stomach was air-filled. CT guidance was used if the bypassed stomach was fluid- or blood-filled and not identified fluoroscopically. Sonography was used to delineate the border of the left lobe of the liver. Gastropexy, when performed, was accomplished with the use of T-tacks (Cope Gastrointestinal Suture Anchor Set, Cook). All procedures were performed by one of four interventional radiologists with experience in percutaneous gastrostomy catheter placement.
The procedure consisted of two fluoroscopically or CT-guided punctures of the distended air-filled stomach to facilitate placement of T-tacks for apposition of the stomach to the anterior abdominal wall. A third puncture was made into the stomach between the T-tacks using a 20-gauge Hinck needle (Cook). Through this needle, a 0.018-inch guidewire was advanced into the stomach. The coaxial catheter of the Accustik II Introducer System (Boston Scientific) was advanced into the stomach over the 0.018-inch guidewire. A 0.035-inch guidewire provided with the system was placed through the Accustick catheter. The gastric puncture site and tract were dilated to an 8- to 14-French diameter for placement of a catheter for decompression of the excluded stomach. After gastrostomy catheter placement, nonionic contrast material was injected through the catheter to confirm catheter placement within the gastric lumen. Gastrostomy catheters were secured in place using a Molnar disk (Cook).
Using combined CT and fluoroscopic guidance, we inserted a 20-gauge Hinck needle into the lumen of the stomach under CT guidance. Through this needle, an 0.018-inch guidewire was advanced into the stomach. The patient was then transported to the angiographic suite for completion of the procedure as previously described. With CT guidance alone, the technique was identical to that using fluoroscopic guidance alone, with each step monitored by obtaining multiple CT slices through the stomach. Gastrostomy tubes were chosen at the discretion of the operator and included a variety of self-retaining catheters.
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Seven of the eight patients experienced resolution of gastric distention and associated symptoms of nausea and vomiting. The mean time to resolution of symptoms was 40 hr (range, 24–96 hr).
Two complications resulted from gastrostomy tube placement. One patient required early operative intervention for peritonitis caused by leakage around the catheter in conjunction with acute small-bowel obstruction. One day after placement of a gastrostomy tube, the patient developed peritoneal signs with fever and elevation of the WBC. This patient was taken to the operating room for revision of the small-bowel anastomosis (jejunojejunostomy) 2 days after gastrostomy tube placement. One patient developed a wound infection at the T-tacks insertion site approximately 2 weeks after gastrostomy tube placement. The infection was successfully treated with local wound care, antibiotics, and removal of the suture holding the T-tacks in place.
With respect to the two patients presenting during the late postoperative period, the patient presenting 6 months after Roux-en-Y gastric bypass with small-bowel obstruction experienced resolution of symptoms after percutaneous radiologic gastrostomy. The gastrostomy tube was then removed without complication. Three months later, the signs and symptoms recurred, necessitating surgery for mechanical obstruction with lysis of adhesions. The second patient, presenting 11 months after Roux-en-Y gastric bypass with afferent loop obstruction, also experienced initial resolution of symptoms after gastrostomy tube drainage. However, symptoms recurred several days later, and during exploratory laparotomy, dense adhesions and a tight stricture at the enteroenterostomy were discovered. The enteroenterostomy was revised, and the gastrostomy tube was removed.
Gastrostomy tubes remained in place for a mean of 31 days (range, 13–71 days). Gastrostomy tubes were removed in asymptomatic patients 10 days or more after placement and immediately after outpatient evaluation by the referring bariatric surgeon. All gastrostomy tubes were removed electively in an outpatient setting without complication. One tube remains in place at the present time. There were no instances of tube dislodgment, obstruction, or malfunction. On routine gastrointestinal examination after gastrostomy placement, surgical anastomoses were shown to be intact in all seven patients evaluated.
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Complications after Roux-en-Y gastric bypass are common, occurring in 25% or more of patients [1]. One of the more serious of these complications is anastomotic leak, reported in 0.5–20% of patients [1, 2]. The many potential causes of anastomotic leak include technical errors during surgery. Disruption of the staple line may also occur from distention of the excluded gastric remnant. Some surgeons routinely place gastrostomy tubes in the excluded gastric remnant at the time of Roux-en-Y gastric bypass to decompress the gastric remnant and provide a means to investigate the excluded stomach and duodenum in the postoperative period [2]. Other investigators argue that tube gastrostomy is unnecessary because it adds to the operative risk and is subsequently used in only 2% of patients [3].
Roux-en-Y gastric bypass, by the nature of its anatomic reconfiguration, precludes passage of a nasogastric tube to decompress the excluded stomach. The 100- to 150-cm Roux-en-Y limb in combination with the pancreaticobiliary limb and duodenum exceed the working length of most endoscopes needed for PEG. An alternative to routine surgical gastrostomy is percutaneous radiologic gastrostomy, which is performed only when gastrostomy becomes indicated. We were requested to place decompressive gastrostomies to treat eight patients in whom dilatation of the excluded stomach and duodenum developed after Roux-en-Y gastric bypass. Distention of the excluded stomach produced symptoms of nausea and vomiting and was believed by the bariatric surgeons, in some cases, to threaten disruption of a recently placed surgical suture line. To our knowledge, no previous reports have established the safety and efficacy of percutaneous gastrostomy for postoperative decompression of the excluded stomach in patients after Roux-en-Y gastric bypass surgery for morbid obesity.
Percutaneous gastrostomy was first described in 1983, shortly after the development of techniques for PEG. Since then, percutaneous radiologic gastrostomy has been shown to be a safe and effective method for providing enteral nutrition and secondarily for decompression of the stomach [4]. It provides an alternative to surgical and endoscopic gastrostomy [5].
Studies comparing percutaneous radiologic gastrostomy with PEG report higher technical success and similar or fewer procedural complications in percutaneous radiologic gastrostomy than in PEG [4]. However, long-term complications in percutaneous radiologic gastrostomy are more common than in PEG. The late complications of percutaneous radiologic gastrostomy are predominantly tube-related, including tube obstruction, kinking, and dislodgement. Tube-related complications reflect the characteristics of tubes placed for percutaneous radiologic gastrostomy. Catheters placed for percutaneous radiologic gastrostomy are most frequently 8- to 16-French with lengths up to 35 cm. The internal diameter of the 12-French Wills Oglesby catheter is approximately 2 mm compared with 4.5 mm for a 20-French bumper or mushroom-retaining catheter used for PEG. The combination of small internal diameter and the resistance created by 35-cm catheters used for percutaneous radiologic gastrostomy increases the probability of occlusion when compared with catheters used for PEG [6]. Catheters used for percutaneous radiologic gastrostomy are self-retaining with a locking pigtail configuration compared with a broad-based mushroom or bumper used for PEG. As a result, catheters used for percutaneous radiologic gastrostomy have a greater propensity for dislodgement than catheters placed for PEG [7]. Recently, techniques have been described for placement of the larger-bore mushroom or bumper catheters at the time of percutaneous radiologic gastrostomy [6, 8].
Percutaneous access to the excluded stomach after Roux-en-Y gastric bypass has been previously described for evaluation of gastrointestinal hemorrhage. This can be accomplished by sonographic or CT-guided puncture of the excluded stomach with a Chiba needle and injection of water-soluble contrast material for examination of the upper gastrointestinal tract [9]. Alternatively, percutaneous radiologic gastrostomy can provide access for the introduction of contrast material or endoscopic evaluation [10].
Percutaneous radiologic gastrostomy in morbidly obese patients presents technical challenges related to body habitus. To our knowledge, no information is available in the literature on placement of percutaneous radiologic gastrostomy tubes in patients after bariatric surgery. Access was successfully accomplished in all patients using fluoroscopic or CT guidance. Distention of the excluded stomach created an easy target for percutaneous puncture. CT guidance alone was chosen when the patient was already in the CT suite for evaluation of an underlying cause for nausea and vomiting or if the stomach was distended by fluid or blood that was not identifiable on fluoroscopy. In one case, CT was performed to clarify the relationship of the colon to the stomach, which was not readily apparent on fluoroscopy. In this case, CT was used to puncture the stomach for placement of a 0.018-inch guidewire, after which the patient was transferred to a fluoroscopy room for completion of the procedure. The decision about completion of the procedure using fluoroscopy or CT was primarily left to operator preference.
Preliminary access in our patients was accomplished with a 13-cm-length 20-gauge Hinck needle and a 19-cm-length Accustick II Introducer System, which provided sufficient purchase within the bypassed stomach for placement of a stiff 0.035-inch guidewire included in the Accustick system. The Hinck needle was preferred for access because it is stiffer than the needle provided with the Accustick II introducer system and less likely to undergo deflection when advanced into the patient. With sufficient guidewire purchase in the stomach, dilators and gastrostomy catheters were easily introduced despite the long distance between the skin and the bypassed stomach. Percutaneous access may have been facilitated by gastropexy with T-tacks, reducing the tendency of the stomach to tent and become displaced from the anterior abdominal wall as the dilators and gastrostomy tube were advanced. None of our patients was in the superobese category (body mass index, > 50 kg/m2), which might require longer needle length for access to the stomach.
Because all the patients treated had gastric distention with ileus or obstruction as the indication for the gastrostomy, concern about the potential for leakage from the gastrostomy site and peritonitis led to placement of T-tacks in most patients (seven of eight) at the discretion of the interventional radiologist performing the procedure. No compelling evidence supported the routine use of T-tacks for percutaneous gastrostomy. Studies have shown that traction on the stomach can lead to skin ischemia, development of a patulous gastrocutaneous tract resulting in leakage around the tube, gastric erosion at the traction site, and hemorrhage. The use of T-tacks may increase the incidence of superficial soft-tissue infection at the insertion site when the T-tacks are left in place for more than 2 weeks, as occurred in one of our patients. Proponents of T-tack placement claim that rapid tract maturation occurs, resulting in fewer instances of tube dislodgement and easy replacement of the tube through the mature tract should the gastrostomy tube become dislodged. Furthermore, they claim that the risk of peritonitis is reduced [11, 12]. One instance of postprocedural peritonitis occurred in our series in a patient in whom T-tacks were placed. The one patient who did not have T-tacks placed did not have leakage from the gastrostomy site. We, therefore, cannot state that the T-tacks contributed to the safety of percutaneous radiologic gastrostomy in obese patients with distention of the excluded stomach.
Catheter dislodgement and tube occlusion are common complications of percutaneous radiologic gastrostomy performed using small-diameter catheters with self-locking mechanisms [4, 6, 11–13]. We were concerned about the added potential for catheter dislodgement because of the excessive soft tissue and laxity of the soft tissues in the abdominal wall of these patients. Catheter dislodgement was not a problem in spite of the body habitus of these patients. T-tacks may have contributed to the stabilization of the stomach and provided additional help in preventing dislodgement. Most of our gastrostomy tubes were in place for very short periods, which may have reduced both catheter dislodgement and tube occlusion. Because our catheters were placed primarily for drainage and decompression, they were of smaller diameters than the gastrostomy catheters traditionally placed for alimentation. The catheters of 8–16 French performed equally well in draining primarily air and enteric contents from the distended stomach.
No patient experienced disruption of the surgical staple lines after decompressive gastrostomy. Surgery was averted in patients who presented with gastric distention in the immediate postoperative period. In patients who developed intestinal obstruction, the decompressive gastrostomy provided short-term relief of symptoms because surgical revision of the small-bowel anastomosis was ultimately necessary.
One patient treated at our institution in 1997 was not included in this series because hospital records were destroyed or lost. This 31-year-old morbidly obese woman was treated for intestinal obstruction during the early postoperative period with percutaneous radiologic gastrostomy because she refused insertion of a nasogastric tube. She developed an acute leak and peritonitis around the gastrostomy site that required emergency surgery. This case emphasizes the difference between acute intestinal obstruction and ileus with gastric dilatation in terms of potential complications from percutaneous gastrostomy and the ultimate need for surgical correction in patients with intestinal obstruction.
Our experience shows the effectiveness of percutaneous gastrostomy for decompressing the excluded gastric remnant in patients undergoing Roux-en-Y gastric bypass. Percutaneous gastrostomy eliminates the need for prophylactic placement of a surgical gastrostomy in anticipation of its requirement in the postoperative period. In patients who develop intestinal obstruction during the late postoperative period, placement of a gastrostomy catheter may occasionally temporize the underlying problem, allowing the patient to be stabilized before surgical revision. However, peritonitis secondary to leakage around the tube is a risk in patients with complete bowel obstruction.
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