Assessment of safety and feasibility of a new technical variant of gastropexy for percutaneous endoscopic gastrostomy: an experience with 435 cases
© Campoli et al; licensee BioMed Central Ltd. 2009
Received: 19 January 2009
Accepted: 26 June 2009
Published: 26 June 2009
Percutaneous Endoscopic Gastrostomy (PEG) performed through the Introducer Technique is associated with lower risk of surgical infection when compared to the Pull Technique. Its use is less widespread as the fixation of the stomach to the abdominal wall is a stage of the procedure that is difficult to be performed. We present a new technical variant of gastropexy which is fast and easy to be performed. The aim of this study was to evaluate the safety and feasibility of a new technical variant of gastropexy in patients submitted to gastrostomy performed through the Introducer Technique.
All the patients submitted to PEG through the Introducer Technique were evaluated using a new technical variant of gastropexy, which consists of two parallel stitches of trasfixation sutures involving the abdominal wall and the gastric wall, performed with a long curved needle.
Prophylactic antibiotics were not used. Demographic aspects, initial diagnosis, indication, sedation doses, morbidity and surgical mortality were all analyzed.
Four hundred and thirty-five consecutive PEGs performed between June 2004 and May 2007 were studied. Nearly all the cases consisted of patients presenting malignant neoplasia, 79.5% of which sited in the head and neck. The main indication of PEG was dysphagia, found in 346 patients (79.5%). There were 12 complications (2.8%) in 11 patients, from which only one patient had peristomal infection (0.2%). There was one death related to the procedure.
Gastropexy with the technical variant described here is easy to be performed and was feasible and safe in the present study. PEG performed by the Introducer Technique with this type of gastropexy was associated with low rates of wound infection even without the use of prophylactic antibiotics.
Percutaneous Endoscopic Gastrostomy (PEG), described in 1980 [1, 2], has replaced Conventional Surgical Gastrostomy as it has proved to be more advantageous. Its use, therefore, has grown rapidly in daily clinical practice .
Several technical variants have been described for performing PEG, with the one proposed by Gauderer et al  topping the list in the majority of centers. Known as the Pull Technique, it is easy to be performed and quite safe. Through this technique, the gastric tube (G-tube) is pulled through the mouth and the esophagus, which results in an increased risk of peristomal infection [4, 5], despite the routine use of antibiotic prophylaxis, as is the risk of tumoral implantation in the surgical wound in patients presenting malignant tumors .
There is a technical variant, named the Introducer Technique, in which the G-tube is introduced by means of percutaneous punction in an attempt to avoid its passage through the mouth. It can be performed under radiological  or endoscopic [2, 8–13] guidance and also offers the great advantage of low risk of peristomal infection, which renders the use of prophylactic antibiotics unnecessary [7, 8, 14]. This technique is also associated with low risk of tumor wound implantation . A lower risk of infection and lower risk of tumor implantation has motivated several authors to use the Introducer Technique instead of using the Pull Technique for PEG [4, 6, 8, 15, 16].
The Introducer Technique almost always involves a stage in which the stomach is fixated to the abdominal wall (gastropexy). For such fixation, T-fasteners [7, 16, 17], Fogarty catheters  or stitches [2, 5, 8–11, 14, 19, 20] can be used. The use of stitches was first described by Hashiba in 1980 . In 1999, Kiser et al  reported gastropexy performed with two straight needles, a method used by us until June 2004 . Several authors [5, 9, 11, 14, 20] have recently described the use of a device that also contains two straight needles for the easier performance of gastropexy.
We have recently published a successful series of 142 cases  of PEGs with an Introducer Technique variant which employs stitches with straight needles in order to fixate the anterior gastric wall to the abdominal wall, followed by the introduction of a G-tube by means of a percutaneous punction.
The present study describes a new technical variant of gastropexy which uses a long curved needle. It aims to investigate the feasibility and safety of the procedure.
We studied all patients referred to perform PEG in a tertiary cancer hospital between June 2004 and May 2007.
Exclusion criteria comprised patients with Body Mass Index (BMI) ≥ 30 kg/m2, those on whom PEG was performed without gastropexy once the stomach was adequately fixated to the abdominal wall as well as those on whom PEG could not be performed.
Almost all the procedures were performed in the endoscopy room, with patients under conscious sedation and monitored by a pulse oximeter. Supplementary oxygen was used when necessary. Olympus GIF-V video gastroscope and Olympus CV-100 video processor were used (Olympus America Inc., Melville, New York, USA). All the procedures were performed by three authors specialized in digestive endoscopy and with experience in interventional endoscopic techniques.
Endoscopic dilation was attempted when stenosis was present and whenever possible performed with Eder-Puestow dilators. Prophylactic antibiotics were not used. All the patients were fed through the G-tube on the same day of the procedure.
An informed consent was obtained from all patients and this study was approved by the Ethical Institutional Review Board.
Gastric tube introduction technique
Abdominal Wall Path
Gastric Tube Introduction
A G-tube (16 Fr) was introduced through the sheath (Figure 3c) and the balloon was inflated (Figure 3d). The sheath was removed and disconnected from the G-tube through the longitudinal fenestration (Figure 3d).
Additional file 1: New technical variant of gastropexy for percutaneous endoscopic gastrostomy. Video containing the described procedure. (MPG 17 MB)
The patients received daily dry dressing and the gastropexy stitches were removed between postoperative days 10 and 12. The G-tube removal or changing was performed whenever needed. Wound infection evaluation was provided in all cases.
The feasibility of the procedure was evaluated through the percentage of success in the performance of gastropexy among the cases included in the study.
To evaluate the safety of the method the complications were classified into two categories: minor and major complications. Minor complications were the ones which occurred during the procedure and were solved with no need of additional intervention. The major complications needed additional interventions or added risk to the patients. The safety was also evaluated by procedure related mortality.
Exclusion criteria from the present study of 44 patients referred to the Endoscopy Unit to perform PEG*.
BMI** ≥ 30 kg/m 2
PEGs suture-free technique
PEGs could not be performed
Non dilatable stenosis
Neoplasias affecting stomach
Gastric ulcer perforation
Patients with ascites
Respiratory failure associated to supine position
Clinical features and morbimortality of 435 patients submitted to PEG* with curved needle.
In four patients the procedure had to be performed under general anesthesia in the surgery room. In the other patients the PEG was performed in the endoscopy room and the conscious sedation was obtained with doses of midazolam ranging from 0 to 13 mg with a median of 4 mg (interquartile range, 3–5) associated or not with doses between 0 and 130 mg with a median of 40 mg (interquartile range, 30–50) of meperidine.
In 37 patients peptic ulcer was diagnosed (gastric or duodenal). Successful endoscopic dilation was performed in 24 patients. Nine patients were diagnosed as having a second synchronous neoplasia during the performance of PEG. Four patients had tracheoesophageal fistula. Two patients had previous partial gastrectomy.
Among the 471 patients included, gastropexy was not performed in 36 of them through the method described in this study as the curved needles were unable to reach the gastric cavity due to excessively thick abdominal walls. In this group of patients, gastropexy was performed with two straight needles.
The remaining four hundred and thirty five suture-based PEGs were performed with the new curved-needle method described, representing a success index of 92.4% (Figure 4).
Among the 435 patients in whom gastropexy was performed with a curved needle, morbidity consisted of 12 events (2.8%) in 11 patients. Minor complications occurred in 7 patients and consisted of four cases of gastric wall bleeding which were observed during the procedure and controlled with local measures and three cases of respiratory failure controlled with the habitual measures of ventilatory assistance and the use of naloxone or flumazenil.
Five major complications occurred in four patients. Section of the gastric wall caused by the thread of the first stitch occurred in one patient and resulted in pneumoperitoneum. Laparotomy was necessary to conclude the gastrostomy. The second patient started with abdominal pain on the postoperative period and a large pneumoperitoneum was identified. This patient underwent surgery with no other findings. The third patient evolved with a gastro-cutaneous fistula closed after changing the G-tube for a Dobbhoff tube. The fourth patient presented wound infection (0.2%) on the first postoperative week. This patient received oral antibiotic with good outcome and resolution of the infection. This same patient developed wound leakage on postoperative day 50 due to severe malnutrition and cancer cachexia and died. There were one procedure-related death (0.2%), as described above.
This study presents a high success rate of a simple and safe technical variant of the gastropexy during PEG, in patients with malignant diseases. Moreover, in this study this procedure was associated with a low surgical infection rate.
Published series of PEGs by the Introducer Technique
Russell TR 
Hashiba K 
Kadota T 
Robertson FM 
Tucker AT 
Maetani I 
Dormann AJ 
Saito M 
Campoli PMO 
Toyama Y 
Foster JM 
Shastri YM 
Shastri YM 
Horiuchi A 
The cases presented here were performed using this Introducer Technique, and even without using the prophylactic antibiotics, the peristomal infection rate was as low as 0.2%.
There are few studies comparing Pull Technique and Introducer Technique.
Three non-randomized studies with a small number of cases have compared the Pull Technique with the Introducer Technique. Deitel et al  reported that the Introducer Technique was not associated with peristomal infection, whereas Tucker et al  concluded that the risk of complications was significantly lower with this technique. The third study published recently showed that the Introducer Technique was associated with lower risk of peristomal infection, lower risk of aspiration pneumonia and lower postoperative hospital stay .
Two studies that compared the two techniques through a prospective and randomized trials were lead by Maetani et al  and Horiuchi et al . They found that the risk of peristomal infection was lower when the Introducer Technique was used.
In the present study major and minor complications occurred in a small number of cases with few repercussions for patients, yielding a morbidity rate of 2.8% and an acceptable mortality rate of 0.2%. We have a historical control group  in which gastropexy was performed with two straight needles in 142 patients and the morbidity rate was 9.1% and the mortality was 0.7%. Most authors use device with two straight needles upon the performance of gastropexy [5, 9, 11, 14, 20] and described a morbidity ranging from 0 to 6.7% and a mortality rate varied from 0 to 2.9%. The results of our study support the premise that gastropexy performed with curved needles is a safe procedure. Gastropexy as presented here is a more simple option which is easy to perform and uses surgical suture material routinely available in the surgical room.
The technical variant presented here is also feasible because a high success index was obtained (92.4%). The majority of failure procedures were due to not reaching the gastric cavity with the curved needles, and these situations were solved with the use of straight needles as described in other study .
One limitation of the present study is that feasibility and safety were not evaluated in relation to a control group in which gastropexy would be performed with two straight needles. Another limitation is that the population studied was almost entirely composed of patients with malignant neoplasias and BMI < 30 kg/m2 and the validity of the method in populations with neurological diseases and different BMI profiles needs to be evaluated. Another disadvantage of this new technical variant of gastropexy is that it can only be used in patients evaluated by endoscopy.
The new gastropexy technical variant presented in this study has proven to be feasible and safe. This technique yielded low rates of peristomal infection and made unnecessary the use of prophylactic antibiotics.
List of abbreviations
Percutaneous Endoscopic Gastrostomy
Body Mass Index.
- Gauderer MW, Ponsky JL, Izant RJ: Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980, 15 (6): 872-875. 10.1016/S0022-3468(80)80296-X.View ArticlePubMed
- Hashiba K: [Technic for opening a gastrostomy under endoscopic control and manipulation]. Rev Paul Med. 1980, 95 (1–2): 37-38.PubMed
- Gauderer MW: Percutaneous endoscopic gastrostomy and the evolution of contemporary long-term enteral access. Clin Nutr. 2002, 21 (2): 103-110. 10.1054/clnu.2001.0533.View ArticlePubMed
- Maetani I, Tada T, Ukita T, Inoue H, Sakai Y, Yoshikawa M: PEG with introducer or pull method: a prospective randomized comparison. Gastrointest Endosc. 2003, 57 (7): 837-841. 10.1016/S0016-5107(03)70017-0.View ArticlePubMed
- Horiuchi A, Nakayama Y, Tanaka N, Fujii H, Kajiyama M: Prospective randomized trial comparing the direct method using a 24 Fr bumper-button-type device with the pull method for percutaneous endoscopic gastrostomy. Endoscopy. 2008, 40 (9): 722-726. 10.1055/s-2008-1077490.View ArticlePubMed
- Cappell MS: Risk factors and risk reduction of malignant seeding of the percutaneous endoscopic gastrostomy track from pharyngoesophageal malignancy: a review of all 44 known reported cases. Am J Gastroenterol. 2007, 102 (6): 1307-1311. 10.1111/j.1572-0241.2007.01227.x.View ArticlePubMed
- Dinkel HP, Beer KT, Zbaren P, Triller J: Establishing radiological percutaneous gastrostomy with balloon-retained tubes as an alternative to endoscopic and surgical gastrostomy in patients with tumours of the head and neck or oesophagus. Br J Radiol. 2002, 75 (892): 371-377.View ArticlePubMed
- Campoli PMO, Ejima FH, Cardoso DMM, Barros AP, Souza Fo PP, Freitas MAF, Castro FCF, Barreto PAQ, Mota OM: [Percutaneous endoscopic gastrostomy performed using the suture and percutaneous puncture technique]. GED – Gastroenterologia Endoscopia Digestiva. 2007, 26 (4): 109-113. Current url: http://www.fbg.org.br/medicos/associado/conteudo_cientifico/revistas/ged/_revistas/gedv26n4-109-113.pdf
- Dormann AJ, Wejda B, Kahl S, Huchzermeyer H, Ebert MP, Malfertheiner P: Long-term results with a new introducer method with gastropexy for percutaneous endoscopic gastrostomy. Am J Gastroenterol. 2006, 101 (6): 1229-1234. 10.1111/j.1572-0241.2006.00541.x.View ArticlePubMed
- Kiser AC, Inglis G, Nakayama DK: Primary percutaneous endoscopic button gastrostomy: a modification of the "push" technique. J Am Coll Surg. 1999, 188 (6): 704-706. 10.1016/S1072-7515(99)00036-8.View ArticlePubMed
- Saito M, Muto M, Yano T, Kojima T, Minashi K, Ohtsu A, Yoshida S: Gastropexy Reduces Severe Adverse Events After Percutaneous Endoscopic Gastrostomy (PEG). Gastrointest Endosc. 2007, 65 (5): AB163-10.1016/j.gie.2007.03.257.
- Russell TR, Brotman M, Norris F: Percutaneous gastrostomy. A new simplified and cost-effective technique. Am J Surg. 1984, 148 (1): 132-137. 10.1016/0002-9610(84)90300-3.View ArticlePubMed
- Kadota T, Nakagawa K, Taguchi J, Ono H, Hiraide H, Tamakuma S, Ueno F: A simplified percutaneous endoscopic gastrostomy using the trocar introducer technique with peel-away sheath. Surg Gynecol Obstet. 1991, 173 (6): 490-494.PubMed
- Shastri YM, Hoepffner N, Tessmer A, Ackermann H, Schroeder O, Stein J: New introducer PEG gastropexy does not require prophylactic antibiotics: multicenter prospective randomized double-blind placebo-controlled study. Gastrointest Endosc. 2008, 67 (4): 620-628. 10.1016/j.gie.2007.10.044.View ArticlePubMed
- Cruz I, Mamel JJ, Brady PG, Cass-Garcia M: Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head and neck cancer. Gastrointest Endosc. 2005, 62 (5): 708-711. 10.1016/j.gie.2005.06.041. quiz 752, 753View ArticlePubMed
- Tucker AT, Gourin CG, Ghegan MD, Porubsky ES, Martindale RG, Terris DJ: 'Push' versus 'pull' percutaneous endoscopic gastrostomy tube placement in patients with advanced head and neck cancer. Laryngoscope. 2003, 113 (11): 1898-1902. 10.1097/00005537-200311000-00007.View ArticlePubMed
- Foster JM, Filocamo P, Nava H, Schiff M, Hicks W, Rigual N, Smith J, Loree T, Gibbs JF: The introducer technique is the optimal method for placing percutaneous endoscopic gastrostomy tubes in head and neck cancer patients. Surg Endosc. 2007, 21 (6): 897-901. 10.1007/s00464-006-9068-9.View ArticlePubMed
- Robertson FM, Crombleholme TM, Latchaw LA, Jacir NN: Modification of the "push" technique for percutaneous endoscopic gastrostomy in infants and children. J Am Coll Surg. 1996, 182 (3): 215-218.PubMed
- Hashiba K: Endoscopic gastrostomy. Endoscopy. 1987, 1 (Suppl 1): 23-24. 10.1055/s-2007-1018304.View Article
- Toyama Y, Usuba T, Son K, Yoshida S, Miyake R, Ito R, Tsuboi K, Kashiwagi H, Tajiri H, Yanaga K: Successful new method of extracorporeal percutaneous endoscopic gastrostomy (E-PEG). Surg Endosc. 2007, 21 (11): 2034-2038. 10.1007/s00464-007-9270-4.View ArticlePubMed
- Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA, Galandiuk S: Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther. 2007, 25 (6): 647-656.View ArticlePubMed
- Lipp A, Lusardi G: Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy. Cochrane Database Syst Rev. 2006, CD005571-4
- Deitel M, Bendago M, Spratt EH, Burul CJ, To TB: Percutaneous endoscopic gastrostomy by the "pull" and "introducer" methods. Can J Surg. 1988, 31 (2): 102-104.PubMed
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/9/48/prepub
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