Introduction Standard inside-out PEG insertion is not always technically possible or safe especially when there is narrowing of the oesophagus or pharynx with head-and-neck or oesophageal cancers. There is also concern about tumour seeding with inside-out technique. Similarly, in some patients it is not possible to pass the standard gastroscope through to upper GI tract. Gastropexy is an alternative technique which allows insertion of a gastrostomy tube with outside-in technique and can be performed using slimmer scopes. Gastropexy has been routinely performed in our unit for some time and therefore we aimed to review the experience of Gastropexy insertion in our unit.
Methods Gastropexy placement in our unit is based upon a previously described technique using Kimberly Clark MIC introducer kit. A standard endoscopy is performed by the oral or nasal route, a site identified and the stomach secured against the anterior abdominal wall with 3 pre-loaded T-toggles which can be fastened with a locking disc. A tract is formed using a single serial dilator passed over a guidewire and a 14F balloon gastrostomy inserted through the dilator and secured. The outer sheath of the dilator will then be peeled out. All patients receive pre-procedural prophylactic antibiotics. A retrospective review of all gastropexy procedures between June 2009 and November 2012 was carried out. Patient demographics, indication, sedation requirements and complication rates were recorded.
Results 45 procedures were carried out on 42 patients (28 males, median age 63 years range 56 – 84) with a technical success rate of 95.7% for placement. Indication for placement was head-and-neck cancer (n = 34), oesophageal stricture/cancer (n = 9) and neurological (n = 2). 17% of procedures were performed under general anaesthesia as part of another surgical procedure with the remainder having conscious sedation (mean doses midazolam 3.8mg and pethidine 17.8mg). 58% of procedures were performed using a nasal/neonatal endoscope. Of these, 62% cases had head-and-neck cancer, 31% had oesophageal cancer/stricture. One patient had a minor gastric fluid leak and one patient developed a pneumoperitoneum both of which were managed conservatively. At 7 days, 1/45 (2.2%) had a site infection and 1/45 (2.2%) had died whereas at 28 days, 5/45 (11.1%) had a site infection and 4/45 (8.8%) had died. Mortality at 1 year was 48%, with median survival of 5 months. The primary pathology in all the patients who died was head and neck or oesophageal cancer. None of the deaths were procedure related.
Conclusion Gastropexy is a suitable alternative in patients with difficult access and can be inserted with high success rate and low complication rates. Ideally, a randomised trial comparing gastropexy and radiological gastrostomy insertion should be undertaken.
Disclosure of Interest None Declared.
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