Double-tubing Percutaneous Trans-esophageal Gastro-tubing As a Brand New Technique for Treatment of Postoperative Complications

Hideto Oishi, MD, PhD¹, Takeshi Ishita, MD¹, Masayuki Ishii, MD¹, Takayuki Iino, MD¹, Takuya Saito, MD¹, Hidekazu Kuramochi, MD, PhD¹, Shunsuke Onizawa, MD, PhD¹, Eiichi Hirai, MD, PhD¹, Mie Hamano, MD, PhD¹, Tsutomu Nakamura, MD, PhD¹, Tatsuo Araida, MD, PhD¹, Shingo Kameoka, MD, PhD². ¹Div of Gastroenterological Surgery, Dept of Surgery, Yachiyo Med Ctr, Tokyo Women’s Med Univ, ²Dept of Surgery 2, Tokyo Women’s Med Univ

Objective of the Technique

In 1994, we devised percutaneous trans-esophageal gastro-tubing (PTEG) as an alternative to percutaneous endoscopic gastrostomy (PEG). Because this PTEG procedure, which we now refer to as standard PTEG, is a non-endoscopic surgical procedure, it was understood as a minimally invasive procedure that could be used for seriously ill patients who could not undergo the PEG procedure. We have performed this standard PTEG procedure in 207 patients. Beginning in 2003, we began developing an advanced PTEG procedure for endoscopists. We refer to this procedure as endoscopy-assisted PTEG (EA-PTEG), and we have performed EA-PTEG in 90 patients. In total, we have performed PTEG procedures in 297 patients: 176 (59.3%) for enteral nutrition and 121 (40.7%) for gastrointestinal decompression. We have found PTEG placement to be very effective for gastrointestinal decompression and for enteral nutrition. In 15 patients (5.1%), we used it for treatment of postoperative complications. We have now devised double-tubing PTEG as a brand new technique for treatment of postoperative complications.

Methods and Procedures

We first create a cervical esophagostomy according to the standard PTEG procedure. We then insert the tip of a drainage tube through the opening and place it at the site of anastomotic leakage for gastrointestinal decompression. Next, we insert a guidewire into the patient's esophagus through the side of the drainage tube, and we dilate the esophagostomy using a dilator with a sheath. We insert the tip of a feeding tube through the sheath and place it in the distal bowel away from the site of leakage. This tube is used for enteral nutrition.

Preliminary Results

Among the 15 patients with postoperative complications, we used the double-tubing PTEG technique for simultaneous enteral nutrition and gastrointestinal decompression in 5 patients (1.7% of our PTEG patients). All 5 patients recovered without reoperation and without any other complications.

Conclusions/Expectations

Ideally, reoperation is to be avoided in patients, and long-term nasogastric feeding can be problematic. The PTEG procedure is a nonvascular intervention technique that is performed in two main steps: esophagostomy by ultrasound guidance and tube placement by fluoroscopic guidance. PTEG placement avoids reoperation and frees patients from the discomfort of a nasogastric tube. With the double-tubing PTEG technique, two tubes can be used at the same time very effectively for gastrointestinal decompression and enteral nutrition.

Thus far, we have found our double-tubing PTEG technique not only effective for treating postoperative complications but also safe, easy, and minimally invasive. The technique holds promise as a general treatment strategy for postoperative complications in patients who have undergone gastrectomy.