CT fluoroscopy-guided percutaneous gastrostomy with loop gastropexy and peel-away sheath trocar technique in 31 amyotrophic lateral sclerosis patients

Abstract

Background In amyotrophic lateral sclerosis (ALS) patients with respiratory impairment and/or advanced disease, performing even mild sedation – as is usually necessary for percutaneous endoscopic gastrostomy (PEG) placements – is fraught with risk. These patients are often referred to Interventional Radiology for alternative percutaneous gastrostomy tube placement options. Purpose To report our experience with CT fluoroscopy-guided percutaneous gastrostomy with a novel loop gastropexy and peel-away sheath trocar technique in ALS patients as an alternative to endoscopic techniques. Material and Methods A consecutive series of 31 amyotrophic lateral sclerosis patients in whom endoscopic gastrostomy was considered too dangerous or impossible to perform underwent CT-guided percutaneous gastropexy and gastrostomy and prospective follow-up. All procedures were performed with a 15 FR Freka® Pexact gastrostomy kit, a 16-row CT scanner (Aquilion 16) and single shot CT fluoroscopy mode. Results The procedure was performed successfully in 30 of 31 patients (20 men, 11 women; median age 60 years, range 38–80 years). In the remaining case the stomach was punctured under CT fluoroscopy and CO2 insufflation was initiated thereafter, leading to successful gastrostomy without prior gastropexy and without further adverse events during follow-up. Two patients reported unproblematic exchange of a balloon tube due to skin irritations with no further adverse events. One patient reported accidental displacement of an exchanged new balloon tube in domestic environment due to balloon leakage: A new balloon tube was easily re-inserted in a hospital the same day. No serious adverse events such as peritonitis, persistent local bleeding, systemic blood loss, or any local infection requiring surgical intervention were observed. Until August 11, 2011 follow-up resulted in 7473 cumulative gastrostomy-days from the date of first placement. Conclusion Initial results suggest that the described technique under CT guidance is feasible and safe and may especially be advantageous in cases where endoscopic gastrostomy and sedation are contraindicated.