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SURGEON AT WORK

aparoscopic-Assisted Percutaneous Gastrostomyube Placement in the Initial Management ofesectable Esophageal and Gastroesophagealunction Carcinoma

ark Joseph, MD, Michael O Meyers, MD, FACS

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alnutrition and weight loss secondary to dysphagia areommon presenting symptoms in patients with resectablesophageal and gastroesophageal (GE) junction cancers.pwards of 80% of patients with esophageal cancer may bealnourished.1 Many of these patients will subsequently

ndergo neoadjuvant chemotherapy or chemoradiother-py, both of which may intensify the malnutrition causedy the inability to eat and may lead to treatment delays.2

espite nutritional supplementation, some of these pa-ients will require additional means of nutritional alimen-ation. Although esophageal stenting will alleviate symp-oms in some patients, a feeding tube will be needed inany.3 Evidence clearly indicates the use of enteral nutri-

ion to be effective in patients with dysphagia or thoseeceiving radiation to the head and neck, along with criti-ally ill patients with impaired gastric emptying.4 The ques-ion remains as to what type of enteral access to use ifatients cannot have adequate oral intake.In patients with esophageal or GE junction cancer, this

as traditionally been accomplished in one of two ways:ejunostomy or gastrostomy. Jejunostomy tube placementas the advantage of avoiding use of the stomach, whichill commonly be used to restore gastrointestinal continu-

ty at the time of definitive resection. However, it has mostommonly been performed as an open procedure becauseercutaneous and laparoscopic approaches to jejunostomy,lthough described, have not gained widespread accep-ance and may require more advanced technical skills.5,6 Asuch, this often requires an inpatient hospitalization afterube placement. In addition, jejunostomy tubes have aigher rate of complication than gastrostomy tubes, andatients may find them more difficult to manage.7 Gastros-omy has most commonly been accomplished via percuta-eous endoscopic (PEG) means and has the advantage of

isclosure Information: Nothing to disclose.

eceived May 2, 2010; Revised June 22, 2010; Accepted June 28, 2010.rom the Department of Surgery, University of North Carolina at Chapelill, Chapel Hill, NC.orrespondence address: Mark Joseph, MD, Department of Surgery, Univer-

ity of North Carolina School of Medicine, P1150 POB, 170 Manning Dr,

pB# 7213, Chapel Hill, NC 27599-7213. Email: mjoseph@unch.unc.edu

e212010 by the American College of Surgeons

ublished by Elsevier Inc.

eing performed in percutaneous fashion, commonlyvoiding general anesthetic and inpatient hospitalization.he downside of PEG is use of a portion of the stomach

hat will eventually be used for esophageal reconstruction.lthough some have reported the safe use of PEG in pa-

ients who eventually undergo esophagectomy, the poten-ial exists for disruption of the blood supply to the stomach,n which the future conduit will be dependent.8,9 In addi-ion, there is the potential for seeding of tumor cells alonghe gastrostomy tube tract when PEG is performed by tra-itional techniques.10,11 As such, gastrostomy has not beenidely embraced as an alternative to jejunostomy for pre-perative enteral nutrition in patients in whom a subse-uent esophagectomy is planned.

Laparoscopic gastrostomy tube placement provides theenefits of a minimally invasive approach that can often beccomplished on an outpatient basis with direct visualiza-ion of the stomach to avoid injury to the blood supply andotential conduit. This approach also allows placement of aastrostomy tube in patients with a lesion in the esophagushat precludes passage of an endoscope. Laparoscopic gas-rostomy tube placement has been described, but it doesequire laparoscopic skills that many surgeons may not beomfortable with. In contrast, laparoscopic-assisted percu-aneous gastrostomy tube placement achieves the sameenefit as laparoscopic gastrostomy without the need fordvanced technical skills.

ECHNIQUEnder general anesthesia, pneumoperitoneum is estab-

ished. Although this can be accomplished by severaleans, our preferred approach is via Veress needle in a left

ubcostal location. A 5-mm port is placed at the umbilicus,nd diagnostic laparoscopy is performed for accurate stag-ng to assure the absence of small volume liver or peritoneal

etastases that may escape detection on preoperative im-ging. Additional working ports are placed as needed toacilitate biopsy. If there are no other findings, the stomachan usually be exposed with postural maneuvers, althoughe have a low threshold for placing an additional 5-mm

ort if needed to mobilize omentum or retract the left

ISSN 1072-7515/10/$36.00doi:10.1016/j.jamcollsurg.2010.06.388

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e22 Joseph and Meyers Laparoscopic Placement of Gastrostomy Tube J Am Coll Surg

ateral segment of the liver. An upper endoscope can thene passed, if needed, through the oropharynx and advancedhrough the esophagus into the stomach under direct visu-lization. Once the stomach has been evaluated and dis-ended endoscopically, the gastroepiploic arcade can beeadily identified laparoscopically and an appropriate sitehosen for PEG placement in a location away from theessels. At this point, we prepare to access the stomachercutaneously. We favor using a laparoscopic PEG kit thatllows for placement of a gastrostomy tube via theeldinger technique and does not require pulling the tubehrough the oropharynx and esophagus (Ross Introducerastrostomy Kit with Brown/Mueller T-Fastener; Rossroducts Division, Abbott Laboratories).12

Although other PEG systems can be used in patientsho do not have significant obstruction of the esophagus

rom tumor at the discretion of the surgeon, we favor thisechnique in all patients to eliminate any risk, albeit small,f seeding the subcutaneous gastrostomy tube tract withumor cells.10,11 A site for the gastrostomy tube is chosenell away from the gastroepiploic arcade. We generallylace the tube in the body of the stomach in an area thatill be easy to close at the time of esophagectomy. We doot attempt to place the tube in a portion of the stomachhat will subsequently be resected. Once the stomach isistended, the initial maneuver is to place 3 or 4 Brown/ueller T-bar fasteners through the abdominal wall into

Abbreviations and Acronyms

GE � gastroesophagealLAPEG � laparoscopic-assisted percutaneous endoscopic

gastrostomyPEG � percutaneous endoscopic gastrostomy

Figure 1. Stomach suspended by Brown-Mueller fasteners.

he stomach that will be used to affix the stomach to thebdominal wall postprocedure and to provide tensionhen pushing against the stomach during the next steps of

he procedure13 (Fig. 1). Alternatively, a grasper through andditional laparoscopic port through the same incision cane used to stabilize the stomach (Fig. 2). The stomach ishen accessed percutaneously with an introducer needle,sing care to avoid the gastroepiploic arcade. The guide-ire is then threaded through the introducer needle ineldinger fashion and serial dilators are used to dilate theubcutaneous tract and gastric wall (Fig. 3). The PEGube is then passed into the stomach in the usual fashionsing the provided obturator to allow appropriate place-ent into the gastric lumen (Fig. 4). The retention bal-

oon can then be inflated and the pneumoperitoneumlowly evacuated to allow the stomach to be brought upo the abdominal wall. All of these steps are accom-

igure 2. Stomach stabilized with grasper prior to puncture whennsufflation is not used.

Figure 3. Dilation of gastrostomy tube tract.

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e23Vol. 211, No. 4, October 2010 Joseph and Meyers Laparoscopic Placement of Gastrostomy Tube

lished under direct visualization of the stomach via theaparoscope.

Although we prefer to use an endoscope in most patientso facilitate gastric distention, this technique can also besed in patients with obstructing or near-obstructing tu-ors that cannot be traversed endoscopically. One alterna-

ive is to pass a small gauge nasogastric tube into the stom-ch to distend it. If passage of either endoscope orasogastric tube is restricted, the gastrostomy tube can belaced without gastric distention by placing 1 or 2 addi-ional 5-mm laparoscopic port sites. Atraumatic laparo-copic graspers can then be used to tent the anterior gastricall so that the stomach can be accessed with the intro-ucer needle followed by the guidewire without fear oferforation of the posterior gastric wall. This procedureould also lend itself to a single incision laparoscopic site

echnique. Although we have not yet had occasion to per-orm this, based on our experience with other single inci-ion laparoscopic site procedures, we would add an addi-ional working port placed through the same incision offsetrom the camera port, which would allow completion ofhe procedure without need for another incision. Addition-lly, if there is any hesitation about the use of the T-barasteners to approximate the stomach to the abdominalall, or if they are unavailable, a Keefe needle can be used tolace 2 stay sutures through the abdominal wall and stom-ch in order to anchor the stomach to the abdominal wall.

Postoperatively, many patients can be discharged theame day or after an overnight stay, depending on perfor-ance status. The gastrostomy can be used within 24

ours. At the time of esophagectomy, the gastrostomy tubeite is taken down from the abdominal wall and closed primar-ly, as described by others.9 We prefer closing this in 2 layers,

igure 4. Placement of gastrostomy tube into stomach afterilation.

lthough some have simply stapled across this. When a circu- P

ar stapler is used to create the esophagogastric anastomosis,he gastrostomy site can also be used to place the staplerhrough instead of making a separate gastrotomy.

In conclusion, malnutrition in patients with esophagealancer can be a challenging problem, often making surgicalonsideration more difficult in patients who otherwiseould be candidates for esophageal resection; malnour-

shed patients have a higher incidence of complications andssociated morbidities.14 Although recent advances insophageal stenting have mitigated the need for feedingubes in some patients, many still require enteral supple-entation through either a jejunostomy or gastrostomy

ube. Both procedures can be performed via laparoscopic,pen, or percutaneous techniques. Jejunostomy tubesvoid potential injury to the stomach, which may later besed as a conduit, but they require more advanced skillshan are often available for percutaneous or laparoscopicpproaches, both of which are associated with higher com-lication rates than PEG placement.5,6,15

Gastrostomy tubes can usually be placed without theeed for advanced endoscopic, laparoscopic, or interven-ional radiology expertise. However, several pitfalls exist.

ost often, PEG tubes are placed using a “pull” tech-ique,16 which allows entry of the tube from within thetomach through the oropharynx to the abdominal wall.here are some concerns about the use of PEG in patientsith aerodigestive obstructing tumors. These include the

nability to pass the scope beyond the obstructing lesion, asell as tumor seeding of the feeding tube tract.10 PEG tubesave also been avoided because of the potential for injury tohe gastroepiploic artery, which makes the stomach unus-ble for possible future conduit.8 PEG placement can alsoe difficult in patients who have colon, small bowel, orubcutaneous fat transposed between the stomach and ab-ominal wall, which would potentially exclude safely en-ering into the stomach without injury to other structures.

Laparoscopic gastrostomy and laparoscopic-assisted PEGubes (LAPEG), however, have been shown to be safe alterna-ives to both open gastrostomy and PEG.17,18 The disadvan-ages of the laparoscopic gastrostomy approach has been theeed for general anesthesia and requirement of multiple portsnd advanced laparoscopic skills. Similarly, an open gastros-omy requires general anesthesia and has a higher morbidityhan the laparoscopic or PEG approach. However, open oraparoscopic approaches may still be necessary in patients whoave had earlier abdominal operations, previous placement oferitoneal dialysis or shunts, varices, or any process that mayake placement of PEG tubes challenging. LAPEG was first

escribed in 1993 and can be safely used in these situations.he morbidity of this technique is comparable to that of a

EG, and both have lower morbidity than an open gastrosto-

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e24 Joseph and Meyers Laparoscopic Placement of Gastrostomy Tube J Am Coll Surg

y.19 LAPEG has since evolved and can potentially be per-ormed with 1 port, low pressure insufflation, and without theeed for advanced laparoscopic skills. However, the techniquef LAPEG is not an option for the patient with upper aerodi-estive obstruction non-endoscopic techniques.

Our technique, laparoscopic-assisted percutaneous gas-rostomy, although similar in concept to the previouslyescribed LAPEG, has several distinguishing features andan be performed without the use of an endoscope andhrough a single incision. We prefer the “push” method asescribed earlier rather than the “pull” technique for tubelacement for the reasons described earlier.19 Although these of T-bar fasteners has been described before, ourethod differs in that it is performed with direct visualiza-

ion of the gastric wall.14,20 Terry and colleagues20 describedhe use of a push method withT-bar fasteners with use of anndoscope similar to a “pull” method, with the complica-ions still being the possibility of inadvertently perforatinghe colon or small bowel if proper transillumination is notchieved. Our technique has the benefits of visualization viaaparoscope and in patients with upper aerodigestive obstruc-ion that precludes passage of a scope or nasogastric tube, andt allows us to gain access into the stomach safely without aosterior wall perforation. Our method can be achieved with-ut the use of fluoroscopically placed tubes as is done in manyenters in patients with obstructing head and neck cancers.his technique can also be performed without an additional

ssistant and may be adapted to use a single incision tech-ique, even when additional ports are needed.Our experience with this technique should be described as

pilot experience because we have performed this in only aew patients who have subsequently gone on to esophagec-omy. It is now our preferred technique, however, for patientseeding enteral feeding access before esophagectomy. Despiteur limited experience, other authors have described favorableutcomes in larger series of patients in whom a gastrostomyube was used for enteral nutrition before esophagectomy.9

ith earlier literature supporting the long-term outcomes ofastrostomy placement for this purpose, but concerns remain-ng with regard to the technical aspects of tube placement, theescribed technique, which mitigates both of the primaryoncerns about percutaneously placed gastrostomy tubes, mayffer an alternative for appropriate patients who need feedingccess before esophagectomy.

uthor Contributionstudy conception and design: Joseph, Meyerscquisition of data: Joseph, Meyersnalysis and interpretation of data: Joseph, Meyersrafting of manuscript: Joseph, Meyers

ritical revision: Joseph, Meyers

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