Endoscopically Assisted Transcervical Esophago-Gastrostomy Tube Placement for Non-operative Intestinal Obstruction: An Alternative to PEG Placement

Asif Talukder, MD, Karen Draper, MD, Carsten Schroeder, MD, PhD. Augusta University

INTRODUCTION: Surgical gastrostomy, gastrojejunostomy, and percutaneous endoscopic gastrostomy (PEG) have been used palliatively for bowel decompression and feeding in patients with carcinomatosis. However, there are circumstances that make these methods contraindicated. Percutaneous transcervical esophago-gastrostomy tube placement has been reported as an alternative in such cases but previously reported techniques involve the use of specialized kits requiring rupture-free balloons (which are unavailable in the United States), fluoroscopy, and ultrasound.We present a hybrid technique for the placement of a cervical gastrostomy tube using endoscopic guidance, commonly available equipment, and techniques familiar to most surgeons.

METHODS AND PROCEDURES: With the patient under general anesthesia, an esophagogastroduodenoscope is introduced and the esophagus, stomach, and duodenum are inspected. The endoscope is then withdrawn to 20-30 cm from the incisors and kept in place. A four cm incision is made in the inferior left neck anterior to the sternocleidomastoid muscle. Dissection is carried down to the cervical esophagus taking care to retract the carotid sheath posteriorly. Under palpation, the scope is withdrawn above the level of dissection and trans-illumination of the esophageal wall is performed (Fig. 1A). A Seldinger needle is used to introduce a guidewire into the esophagus under endoscopic guidance (Fig. 1B). A 16-Fr dilator and sheath are placed using the guide wire (Fig. 1C). A 14-Fr silicone nasogastric tube is introduced through the sheath into the stomach. Placement is confirmed endoscopically (Fig. 1E). The tube is secured to the skin and the incision is closed.

RESULTS: This endoscopically assisted transcervical esophago-gastrostomy tube placement (EATEG) was effective in achieving palliation of intestinal obstruction in our patients. Our first patient experienced return of obstructive symptoms six weeks after placement due to the gastric tube refluxing and kinking in the esophagus. This resolved spontaneously. In the second patient, obstructive symptoms and dysphagia resolved with systemic chemotherapy and the EATEG was removed two months after placement.

CONCLUSION: In the long-term setting, a cervical exit point for a gastrostomy tube is more tolerable for patients and more socially acceptable compared to a naso-gastric tube. Unlike previously reported techniques, our hybrid method uses widely available materials and familiar methods to place EATEG safely and effectively. Placement by endoscopic assistance keeps dissection in the neck to a minimum.