GASTROI NTESTI NAL ENDOSCOPY Editor
CHARLES J. L1GHTDALE, MD Address all editorial correspondence to the Editor Memorial Sloan-Kettering Cancer Center 1275 York Ave., Box 67 New York, New York 10021 212-794-5006 fax 212-639-2766 Associate Editors
STEPHEN E. SILVIS, MD JEROME D. WAYE, MD ROBERT C. KURTZ, MD Managing Editor
REINA L1GHTDALE Editorial Assistant
PALMIRA GALL Associate Editor For Abstracts
JAMES S. BARTHEL, MD Editors Emeritus
WILLIAM S. HAUBRICH, MD BERNARD M. SCHUMAN Editorial Board
PAUL A. KANTROWITZ, MD, Chairman STANLEY B. BENJAMIN, MD LAWRENCE BRANDT, MD PETER B. COTTON, MD ROBERT S. FISHER, MD DENNIS M. JENSEN, MD PATRICE A. MICHALETZ, MD ROBERT W. SUMMERS, MD WILLIAM A. WEBB, MD WILFRED M. WEINSTEIN, MD International Editors
MEINHARD CLASSEN, MD Munich, Germany
MICHEL CREMER, MD Brussels, Belgium
L10NELLO GANDOLFI, MD Bologna, Italy
MOISES GELRUD, MD Caracas, Venezuela
KEIICHI KAWAI, MD Kyoto, Japan
ZDENEK MARATKA, MD Prague, Czechoslovakia
PAUL ROZEN, MD Tel-Aviv, Israel
GUIDO TYTGAT, MD Amsterdam, The Netherlands
CHRISTOPHER WILLIAMS, MD London, England
628
Editorials
Safety first, simplicity second In the last decade there has been a marked increase in utilization of long-term enteral feeding in a variety of clinical conditions. The Oley Foundation estimated that in 1989 about 130,000 patients across the United States received long-term enteral nutrition outside hospitals (38% in private homes and 62% in nursing homes).l The increase in the utilization of enteral feedings can be mainly attributed to three developments: (1) the availability of a wide variety of commercial enteral feeding solutions at a relatively low cost; (2) the development of an ingenious endoscopic method for placement of gastrostomy tubes;2 and (3) the demonstration that enteral feeding can be used safely and effectively in the home by the patient (or with assistance from a family member). With the increase in survival and numbers of patients receiving long-term enteral nutrition, issues of quality of life, comfort, ~nd aesthetics have become central. This is particularly true in patients who require prolonged enteral feeding but who are otherwise leading active lives. This category includes patients with head and neck cancer, cured of their disease but left with severe dysphagia as a complication,3 patients with total or subtotal gastrectomy who require supplemental enteral feedings, a variety of patients with neurological disorders, and others. In these patients the skin level gastrostomy offers significant advantages of comfort and convenience compared with the tube gastrostomy. The skin level gastrostomy (SLG) is placed after a mature gastrocutaneous fistula is formed by the tube gastrostomy. The insertion of the SLG into the gastrointestinal tract is done by stretching the mushroom head ofthe device over a metal trochar which is pushed through the mature fistula, thus introducing the mushroom head into the stomach in the case of a gastrostomy4-6 or into the jejunum in the case of a jejunostomy.3,6 A number of technical questions regarding this procedure have not been resolved: What is the shortest safe period required for the gastrocutaneous fistula to form so that the insertion of the SLG does not result in a separation of the stomach from the abdominal wall? How should the length of the gastrocutaneous fistula be measured so that an appropriate length SLG can be chosen? Should an upper gastrointestinal endoscopy be performed to verify that the mushroom head of the SLG is appropriately placed in the stomach or jejunum and did not become lodged in the fistula or in the abdominal cavity? GASTROINTESTINAL ENDOSCOPY
In this issue of the Journal, McQuaid and Little 7 report the tragic death of two patients as a direct result of placement of the Bard® button gastrostomies. In both cases, the deaths occurred because of lack of recognition that the blind insertion of the device resulted in misplacement of the intragastric portion outside the stomach. Since the buttons are placed primarily for comfort and aesthetics, the associated risk must be low and the procedure has to be safe. The temptation to make the procedure simple and easy must be tempered by the recognition that potential serious complications do exist. The device is pushed blindly with a metal stylet into the abdominal cavity and, therefore, it is possible to go astray, injure abdominal organs, or misplace the tip of the button. Because the technique is relatively new and clinical experience is limited, it is imperative to take all precautions to ensure the patient's safety. Primarily, this relates to performing an upper gastrointestinal endoscopy as a part of the procedure of placement of the button. The endoscopy serves a few purposes: (1) Removal of the intragastric portion of the original gastrostomy tube. Simply cutting this portion and letting it travel through the gastrointestinal tract may be hazardous. Complications with intestinal obstruction have been reported with such a practice. (2) Air insufflation into the stomach. Distention of the stomach creates resistance to the force pushing the button, thus facilitating the passage of the button through the gastrocutaneous fistula. Distention of the organ into which the button is placed can also prevent injury or perforation of the wall opposite to the site of insertion. This is particularly important when the button is placed in the jejunum which has a very short diameter. (3) Facilitation of the measurement of the length of the fistula under direct visualization. (4) Most importantly, visualizing the mushroom head of the button in the stomach or jejunum. Until now, the issue of whether an upper gastrointestinal endoscopy should be performed has been controversial, with some advocating no endoscopy,8 some advocating endoscopy only in certain patients, 9 and others advocating it in all patients. 6 The report by McQuaid and Little 7 underscores the importance of ascertaining the appropriate placement of the button. It is impossible to do so without direct visualization by endoscopy (or indirectly by a radiographic study). Injection of fluid through the button does not help in ensuring appropriate placement, since fluid can flow into the peritoneal cavity as easily as into the stomach. Auscultation of the flow of air injected through the button can also be misleading since air flowing through a fistula into the peritoneal cavity can also be heard through the stethoscope. With regard to measurement of the fistula for determination of the appropriate length of the SLG to
VOLUME 38, NO.5, 1992
be used, the measuring device currently included in the Bard kit is not useful and can be misleading. The bent tip of the device can be caught at any point in the fistula tract and create an impression that it traveled the whole length of the fistula. It is easy and safe to determine the length of the fistula by putting a mark on the tube gastrostomy at the point at which it exits the abdominal wall. Alternatively, with the endoscope in the stomach, a probe can be inserted through the fistula and a determination can be made when the tip enters the stomach, thus giving a measure of the length of the fistula. It is advisable to use a device about 1 cm longer than the fistula to prevent pressure on the gastric mucosa and skin and also to allow for thickening of the abdominal wall which occurs in malnourished patients following a period of feeding. In adults, the minimum length SLG should not be below 2.4 cm. The technique used for the placement of the original gastrostomy tube has important implications for the placement of an SLG. The stomach needs to be pulled and approximated to the abdominal wall. This will create a short fistula and prevent the formation of a fibrous tract between the abdominal wall and the stomach. The longer the tract, the greater are the chances for the tip of the insertion trochar to go astray and injure abdominal organs when an SLG is placed. The skin level gastrostomy is an important device which contributes to the well being, comfort, and selfimage of the patient who requires long-term enteral feeding. Experience to date indicates that with the appropriate precautions, the device can be placed safely and offer important long-term benefits. Moshe Shike, MD New York, New York
REFERENCES 1. Oasis Annual Report 1988. Albany, NY: Oley Foundation, 1990.
2. Gauderer MWL, Ponsky JL, Izart RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5. 3. Shike M, Berner YM, Gerdes H. Percutaneous endoscopic gastrostomy and jejunostomy for long term enteral feeding in patients with cancer of the head and neck. Otolary Head Neck Surg 1989;101:549-54. 4. Gauderer MWL, Olsen MM, Stellato T A. Feeding gastrostomy button: Experience and recommendations. J Pediatr Surg 1988;23:24-8.
5. Foutch PG, Talbert GA, Gaines JA, Sanowski RA. The gastrostomy button: a prospective assessment of safety, success and spectrum of use. Gastrointest Endosc 1989;35:41-4. 6. Shike M, Wallach C, Gerdes H. Skin level gastrostomies and jejunostomies for long-term enteral feeding. J Parenter Enteral Nutr 1989;13:648-50. 7. McQuaid KR, Little TE. Two fatal complications related to gastrostomy "button" placement. Gastrointest Endosc 1992;38:601-3.
8. Gauderer MWL, Stellato TA. Gastrostomy button: why complicate an office procedure? Gastrointest Endosc 1989;35:4689.
9. Foutch PG, Sanowski RA. Response. Gastrointest Endosc 1989;35:469.
629
CHARLES J. L1GHTDALE, MD Address all editorial correspondence to the Editor Memorial Sloan-Kettering Cancer Center 1275 York Ave., Box 67 New York, New York 10021 212-794-5006 fax 212-639-2766 Associate Editors
STEPHEN E. SILVIS, MD JEROME D. WAYE, MD ROBERT C. KURTZ, MD Managing Editor
REINA L1GHTDALE Editorial Assistant
PALMIRA GALL Associate Editor For Abstracts
JAMES S. BARTHEL, MD Editors Emeritus
WILLIAM S. HAUBRICH, MD BERNARD M. SCHUMAN Editorial Board
PAUL A. KANTROWITZ, MD, Chairman STANLEY B. BENJAMIN, MD LAWRENCE BRANDT, MD PETER B. COTTON, MD ROBERT S. FISHER, MD DENNIS M. JENSEN, MD PATRICE A. MICHALETZ, MD ROBERT W. SUMMERS, MD WILLIAM A. WEBB, MD WILFRED M. WEINSTEIN, MD International Editors
MEINHARD CLASSEN, MD Munich, Germany
MICHEL CREMER, MD Brussels, Belgium
L10NELLO GANDOLFI, MD Bologna, Italy
MOISES GELRUD, MD Caracas, Venezuela
KEIICHI KAWAI, MD Kyoto, Japan
ZDENEK MARATKA, MD Prague, Czechoslovakia
PAUL ROZEN, MD Tel-Aviv, Israel
GUIDO TYTGAT, MD Amsterdam, The Netherlands
CHRISTOPHER WILLIAMS, MD London, England
628
Editorials
Safety first, simplicity second In the last decade there has been a marked increase in utilization of long-term enteral feeding in a variety of clinical conditions. The Oley Foundation estimated that in 1989 about 130,000 patients across the United States received long-term enteral nutrition outside hospitals (38% in private homes and 62% in nursing homes).l The increase in the utilization of enteral feedings can be mainly attributed to three developments: (1) the availability of a wide variety of commercial enteral feeding solutions at a relatively low cost; (2) the development of an ingenious endoscopic method for placement of gastrostomy tubes;2 and (3) the demonstration that enteral feeding can be used safely and effectively in the home by the patient (or with assistance from a family member). With the increase in survival and numbers of patients receiving long-term enteral nutrition, issues of quality of life, comfort, ~nd aesthetics have become central. This is particularly true in patients who require prolonged enteral feeding but who are otherwise leading active lives. This category includes patients with head and neck cancer, cured of their disease but left with severe dysphagia as a complication,3 patients with total or subtotal gastrectomy who require supplemental enteral feedings, a variety of patients with neurological disorders, and others. In these patients the skin level gastrostomy offers significant advantages of comfort and convenience compared with the tube gastrostomy. The skin level gastrostomy (SLG) is placed after a mature gastrocutaneous fistula is formed by the tube gastrostomy. The insertion of the SLG into the gastrointestinal tract is done by stretching the mushroom head ofthe device over a metal trochar which is pushed through the mature fistula, thus introducing the mushroom head into the stomach in the case of a gastrostomy4-6 or into the jejunum in the case of a jejunostomy.3,6 A number of technical questions regarding this procedure have not been resolved: What is the shortest safe period required for the gastrocutaneous fistula to form so that the insertion of the SLG does not result in a separation of the stomach from the abdominal wall? How should the length of the gastrocutaneous fistula be measured so that an appropriate length SLG can be chosen? Should an upper gastrointestinal endoscopy be performed to verify that the mushroom head of the SLG is appropriately placed in the stomach or jejunum and did not become lodged in the fistula or in the abdominal cavity? GASTROINTESTINAL ENDOSCOPY
In this issue of the Journal, McQuaid and Little 7 report the tragic death of two patients as a direct result of placement of the Bard® button gastrostomies. In both cases, the deaths occurred because of lack of recognition that the blind insertion of the device resulted in misplacement of the intragastric portion outside the stomach. Since the buttons are placed primarily for comfort and aesthetics, the associated risk must be low and the procedure has to be safe. The temptation to make the procedure simple and easy must be tempered by the recognition that potential serious complications do exist. The device is pushed blindly with a metal stylet into the abdominal cavity and, therefore, it is possible to go astray, injure abdominal organs, or misplace the tip of the button. Because the technique is relatively new and clinical experience is limited, it is imperative to take all precautions to ensure the patient's safety. Primarily, this relates to performing an upper gastrointestinal endoscopy as a part of the procedure of placement of the button. The endoscopy serves a few purposes: (1) Removal of the intragastric portion of the original gastrostomy tube. Simply cutting this portion and letting it travel through the gastrointestinal tract may be hazardous. Complications with intestinal obstruction have been reported with such a practice. (2) Air insufflation into the stomach. Distention of the stomach creates resistance to the force pushing the button, thus facilitating the passage of the button through the gastrocutaneous fistula. Distention of the organ into which the button is placed can also prevent injury or perforation of the wall opposite to the site of insertion. This is particularly important when the button is placed in the jejunum which has a very short diameter. (3) Facilitation of the measurement of the length of the fistula under direct visualization. (4) Most importantly, visualizing the mushroom head of the button in the stomach or jejunum. Until now, the issue of whether an upper gastrointestinal endoscopy should be performed has been controversial, with some advocating no endoscopy,8 some advocating endoscopy only in certain patients, 9 and others advocating it in all patients. 6 The report by McQuaid and Little 7 underscores the importance of ascertaining the appropriate placement of the button. It is impossible to do so without direct visualization by endoscopy (or indirectly by a radiographic study). Injection of fluid through the button does not help in ensuring appropriate placement, since fluid can flow into the peritoneal cavity as easily as into the stomach. Auscultation of the flow of air injected through the button can also be misleading since air flowing through a fistula into the peritoneal cavity can also be heard through the stethoscope. With regard to measurement of the fistula for determination of the appropriate length of the SLG to
VOLUME 38, NO.5, 1992
be used, the measuring device currently included in the Bard kit is not useful and can be misleading. The bent tip of the device can be caught at any point in the fistula tract and create an impression that it traveled the whole length of the fistula. It is easy and safe to determine the length of the fistula by putting a mark on the tube gastrostomy at the point at which it exits the abdominal wall. Alternatively, with the endoscope in the stomach, a probe can be inserted through the fistula and a determination can be made when the tip enters the stomach, thus giving a measure of the length of the fistula. It is advisable to use a device about 1 cm longer than the fistula to prevent pressure on the gastric mucosa and skin and also to allow for thickening of the abdominal wall which occurs in malnourished patients following a period of feeding. In adults, the minimum length SLG should not be below 2.4 cm. The technique used for the placement of the original gastrostomy tube has important implications for the placement of an SLG. The stomach needs to be pulled and approximated to the abdominal wall. This will create a short fistula and prevent the formation of a fibrous tract between the abdominal wall and the stomach. The longer the tract, the greater are the chances for the tip of the insertion trochar to go astray and injure abdominal organs when an SLG is placed. The skin level gastrostomy is an important device which contributes to the well being, comfort, and selfimage of the patient who requires long-term enteral feeding. Experience to date indicates that with the appropriate precautions, the device can be placed safely and offer important long-term benefits. Moshe Shike, MD New York, New York
REFERENCES 1. Oasis Annual Report 1988. Albany, NY: Oley Foundation, 1990.
2. Gauderer MWL, Ponsky JL, Izart RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5. 3. Shike M, Berner YM, Gerdes H. Percutaneous endoscopic gastrostomy and jejunostomy for long term enteral feeding in patients with cancer of the head and neck. Otolary Head Neck Surg 1989;101:549-54. 4. Gauderer MWL, Olsen MM, Stellato T A. Feeding gastrostomy button: Experience and recommendations. J Pediatr Surg 1988;23:24-8.
5. Foutch PG, Talbert GA, Gaines JA, Sanowski RA. The gastrostomy button: a prospective assessment of safety, success and spectrum of use. Gastrointest Endosc 1989;35:41-4. 6. Shike M, Wallach C, Gerdes H. Skin level gastrostomies and jejunostomies for long-term enteral feeding. J Parenter Enteral Nutr 1989;13:648-50. 7. McQuaid KR, Little TE. Two fatal complications related to gastrostomy "button" placement. Gastrointest Endosc 1992;38:601-3.
8. Gauderer MWL, Stellato TA. Gastrostomy button: why complicate an office procedure? Gastrointest Endosc 1989;35:4689.
9. Foutch PG, Sanowski RA. Response. Gastrointest Endosc 1989;35:469.
629
