Both percutaneous radiologic and endoscopic placement of gastrostomy tubes (G-tubes) and J-tubes for decompression and feeding provide an acceptable alternative to the uncomfortable presence of nasogastric tubes, and eliminate the need for operative procedures (6, 11). Insertion of PEG involves a standard upper endoscopy with conscious sedation. After endoscopic examination of the stomach and duodenum to exclude significant ulcerations, the anterior gastric body

or antrum is transilluminated and the gastric body is fully insufflated. Using the endoscopic light source, a suitable area on the anterior abdominal wall is identified and the suitability of the site for a percutaneous tract is confirmed by gentle external compression at the potential entry site. These maneuvers allow for the determination of a safe site with the absence of any intervening viscera or major blood vessels. With some exceptions, dependent on the type of G-tube to be inserted and operator preference, a needle or trocar is passed into the gastric lumen and a guidewire is then threaded through the hollow needle and retrieved endoscopically. The guidewire is then pulled up to the patient’s oropharynx and the G-tube is passed over the wire into the stomach and out of the anterior abdominal wall. Firm traction is applied to ensure passage of the internal bolster through the esophagus and to allow a traction seal and apposition of the gastric and abdominal walls to minimize leakage of gastric contents or feedings.

Recently, endoscopic ultrasound (EUS) has been used as an adjunct to aid in the endoscopic placement of G-tubes when the transillumination and indentation are not optimal (12). The advantage of this technique is that it may be performed in formerly complicated situations, including previously operated abdomens and in partial gastrectomy patients. The use of EUS imaging significantly improves visualization of the bowel and gastric viscera, which might otherwise be impeded by the formation of adhesions, presence of taut peritoneum or ascites, or diffuse intra-abdominal metastases. As a result, risks of inadvertent perforation of bowel, other organs, and metastatic foci are minimized. Studies show promising results over conventional procedures in facilitating ease of insertion and decreasing morbidity associated with the procedure (5).

Esophageal stents may be unsuccessful for palliation of patients with malignant dysphagia or in the management of tracheoesophageal (TE) fistulae. In some cases, the stent placement appears to be successful but the patient continues to have poor intake and may require enteral access. Placing a percutaneous gastrostomy was thought to be problematic in the setting of an esophageal stent but a small case series reviewed the success in eight patients (13). A PEG was placed in all nine patients but stent migration into the stomach was noted in one of the nine patients. This was managed endoscopically. Larger studies are needed to safety of this approach.

Radiologic gastrostomy is performed using fluoroscopic guidance under local anesthetic, with conscious sedation if needed. If swallowing function is intact and there is no GI obstruction, the patient is given oral contrast the night before to opacify the transverse colon and splenic flexure the next day. A nasogastric tube is placed and the stomach insufflated with air. Ultrasound (US) is used to mark the left lobe of the liver if it crosses over the stomach. The anterior wall of the stomach is then punctured through the abdominal wall under fluoroscopy, avoiding both the colon and the liver. Aspiration of air and injection of contrast confirm that the needle tip is within the stomach. One or more “T-anchors” are placed for gastropexy, then the puncture tract is dilated over a guidewire and the tube placed. In patients with aspiration risk, the pylorus is crossed and a gastrojejunostomy catheter is placed with the tip beyond the ligament of Treitz. Single- or double-lumen catheters are available, with the second lumen allowing decompression of the stomach as well as jejunal feeding. The catheter is left to external drainage for 24 hours, and the patient is monitored for peritoneal signs. If the tube is to be used for feeding, an enteral cap is placed and feeds begun with water or dextrose solution at 30 mL per hour, which is advanced as tolerated. Peritoneal leakage, procedure-induced ileus, or bowel dysmotility may limit advancement of feeds.

Technical difficulties encountered during insertion tend to be relatively low, ranging from 4–8% (5, 7, 11, 14, 15). The inability to implant G-tubes has been attributed to tumor invasion of anterior gastric wall, anatomical anomalies, and massive ascites (11, 16, 17). Overall, such difficulties seem to be noted more frequently with endoscopic placement than for radiologic guidance (9). Complication rates for both procedures vary from study to study, and must be cautiously interpreted in view of different methods of placement, operator experience, and diversity of patients. Procedure-related deaths, typically defined as mortality within 30 days of the procedure, have been reported (9). However, mortality rates within 30 days of the procedure may reflect consequences of the underlying disease and the overall poor status of the patients rather than direct consequence of the procedure. Significant risks for complications include urinary tract infection, previous aspiration, and age >75 years (18).

Intestinal (colonic) perforation, peritonitis, and gastric hemorrhage are among the most serious complications. Isolated occurrences of mechanical intra-abdominal seeding of tumor (19) and stomal seeding (20) have been reported. Although the diameter of the lumen might be expected to increase adverse effects, Cannizzaro et al. found no appreciable differences in symptomatic relief and placement-related
complications between patients who received 15- and 20-French lumen catheters (5). Prophylactic use of preprocedure and postprocedure antibiotic administration has been used to reduce the incidence of infection. The data are not clear, but it appears that the preprocedure use of antibiotics reduces the postprocedure incidence of tube site cellulitis and fasciitis. Meticulous cleansing of the tube site with an iodine prep or antibacterial soap and application of a sterile gauze dressing minimizes early wound infections. Once the sutures are removed (if used) and the subcutaneous tract has sealed (in approximately 3 weeks), no additional care to the site is generally required.

Radiologic and endoscopic placements of jejunostomies are valuable techniques associated with low risks while avoiding the need for surgery. Tubes can be placed into the jejunum indirectly through a gastric puncture site, such as a double-lumen gastrojejunostomy tube or a J-tube threaded through a G-tube (17, 21). Alternatively, direct endoscopic jejunostomy is placed using methods similar to PEG placement with good success rates, low complication rates, and high patient satisfaction (22, 23). The tubes are inserted distal to the ligament of Treitz under conscious sedation. The advantage of this technique is the relative stability of the direct J-tube placement in comparison with a J-tube threaded through a G-tube. In a study that compared the complications and the need for intervention with direct percutaneous endoscopic jejunostomy (D-PEJ) and percutaneous endoscopic gastrostomy with jejunostomy extension (PEG-J) revealed that 5 (13.5%) of 37 patients in the D-PEJ group required endoscopic reintervention compared with 19 (55.9%) of 34 patients in PEG-J group over a 6-month period (23). Eight of those 19 patients required the J-tube extension to be replaced at a mean of 33 days. Insertion of percutaneous jejunostomy catheters are more easily accomplished when a J-tube has previously been present because the small bowel is adherent to the abdominal wall, creating a secure tract. The bowel loop can be punctured under fluoroscopic or endoscopic guidance, the tract dilated, and a new tube placed. The absence of a well-established access site makes the initial percutaneous procedure technically more difficult because of bowel mobility. In these circumstances, a gastrojejunostomy catheter may be needed. Magnetic technology, which allows for transient fixation of otherwise mobile bowel segments against the anterior abdominal wall, may allow for easier endoscopic placement of J-tubes. This has been studied in a swine model, and holds promise for direct endoscopic enteral tube placement using minimally invasive techniques (24).

Several factors must be taken into account to select the best method and site of GI tube insertion. Both radiologic and endoscopic methods have similar procedural success rates, 30-day mortality rates, and types of complications (9, 17). Local expertise and patient factors should be considered in selecting the appropriate method of placement. For instance, in patients with severe pharyngeal or esophageal strictures that prevent the passage of an endoscope, radiologic guidance may be preferred (17). It is also preferred to have radiologic placement in those who have old tracks that have healed. In other patients, who need visual investigation of the upper GI tract, endoscopic guidance is favored.

Other factors are considered in selecting the appropriate site of GI tube placement (gastric vs. jejunal). Feeding gastrostomies are preferred over jejunostomies for patients who may require skilled nursing placement, as J-tubes tend to fall out and clog more, frequently requiring more follow-up interventions. Venting gastrostomies are indicated for patients with high upper intestinal or gastric outlet obstructions, whereas venting jejunostomies are more effective for decompression of intestinal obstructions that are more distal. Patients at risk for aspiration through emesis, as opposed to oropharyngeal dysphagia, are better candidates for jejunostomy feeding tubes. Through the use of a dual-lumen gastrojejunostomy tube, an artificial GI bypass can be constructed with a venting gastrostomy above the obstruction, enabling enteral feedings through a jejunostomy below the obstruction (25). Recently developed endoscopic techniques may mature allowing for endoscopic creation of gastrojejunostomies.

Lumen size appears to be more of an issue for patients who require intermittent or continuous decompression and wish to ingest soft food and fluids. Modifications in the contour of the tube and outflow portion, rather than lumen size, seem to be most critical in maximizing the flow of GI secretions mixed with semisolid foods and liquids (14). It is necessary to ensure that the tube selected for any patient is appropriate for its intended purpose. Some tubes now have one-way valves, which decrease the likelihood of patients expelling gastric contents if the end seal is loose, but these tubes are not suitable for gastric decompression. Most tubes are now designed in such a manner that they may be removed through firm traction and do not require repeat surgery or endoscopic procedure solely for removal. Replacement button devices and stomal tubes are available.

Above all, patient and family acceptance, motivation, and ability to care for the tube or administer feedings are critically important in the successful management of GI intubation. Patients and families are instructed to do the following:

The tube can be anchored to the abdomen with special securing devices. Arrangements for home health care are coordinated if patients are immediately discharged to home after tube placement, require nutritional support (enteral or total parenteral) or fluid replacement, or need additional teaching after hospitalization. This is necessary to assure proper monitoring as feeds are initiated and advanced, as well as to assist the patient and family with wound care and help them select an appropriate drainage container and operate suction devices for venting tubes.

Costs associated with the procedure must also be considered. Endoscopically and radiologically placed tubes can avoid the use of the operating room and general anesthesia, and their attendant costs and risks. Charges for PEG placement have been assessed around $2400 and radiologic placement at $4500 (9). Estimated reimbursement for professional fees remains similar, and for inpatients, the hospital reimbursement for the procedure is generally embedded into the fixed rate established for the diagnostic category.

Esophageal endoprosthetic intubation is used to treat esophageal compression from locally advanced esophageal, mediastinal, or tracheobronchial malignancies, as well as strictures that may have resulted from prior radiotherapy. Endoprostheses (stents) also allow for the palliation and occlusion of TE fistula, permitting oral intake. The insertion of an artificial tube restores patency of the esophagus and can provide relief from dysphagia, pain, and the inability to swallow or effectively clear oral secretions.

Relative contraindications for the placement of esophageal stents include extensive circumferential tumor growth that occludes the lumen and interferes with passage of a guidewire and dilators, necrotic lesions that may hemorrhage, friable tissues that increase the chance for perforation, anticipated discomfort associated with the presence of the stent, and lack of patient acceptance or compliance with dietary modifications and follow-up care. The stents may leave a patient with a persistent globus sensation if placed within 2 cm of the upper esophageal sphincter. The placement of a stent into a fibrotic (post-therapy) stricture or one resistant to dilatation may result in mediastinal pain, as the pressure exerted by the stent in its attempt to deploy continues until full expansion.

A variety of rigid and metal self-expandable stents are available as endoprosthetic devices. Selection of stents is dependent on several factors, including life expectancy, pattern of tumor growth (e.g., location, orientation of tumor invasion, extent of invasion, size), anticipated complications, and desired treatment outcomes (Table 53.3). Rigid stents have been manufactured from several materials, including polyvinyl tubing, silicone with metal reinforcements (Wilson-Cook, Wilson-Cook, Inc., Winston-Salem, NC), radiopaque silicone with metal reinforcements (Atkinson tube, Key-Med, Inc., Essex, UK). Promising results have been reported using cuffed rigid stents in managing life-threatening sequelae associated with TE fistulas (26, 27). Patients with TE fistulas tend to be poor surgical candidates because of respiratory distress, malnutrition, and debilitation from advanced stages of cancer. Mortality rates as high as 36% have been documented with attempts to surgically repair this type of fistula; however, peroral intubation using a cuffed rigid stent to seal off the fistula has reduced mortality to 24% (26). Expandable cuffs attached to rigid endoprostheses have been successful in occluding fistulas with less patient discomfort and reduced hospitalization compared to surgery, and without the risk of pressure necrosis (27).

The introduction of metal self-expanding esophageal stents, patterned after biliary and vascular stents, has minimized problems associated with the rigid polymeric stents and their fixed lumen diameters. Although self-expanding metal stents are approximately 10 times more expensive, their advantages of larger lumen size, ease of insertion, decreased complication rates, and greater success with more stenotic lesions often outweigh any cost expenditures. All of the metal stents share an ability to be placed into a narrow lumen on a small-bore delivery device and then allowed to expand once in correct anatomical position. Technical success rates for deployment are reported to be >95%, with significant improvement in dysphagia and tolerability of oral intake (28, 29, 30, 31). A variety of self-expanding metallic stents are available that differ in design, elasticity, and resistance to angulation (32). Knowledge of their physical properties and tumor characteristics/anatomy can help in selecting the appropriate stent for a particular patient.

Some metallic self-expanding stents are covered with a polymeric sheet to inhibit tumor ingrowth and to facilitate occlusion of TE fistula tracts and have become the preferred design for most indications in the esophagus (31, 33). A prospective, randomized study was performed to compare three covered metal stents: Gianturco-Z stent (Wilson-Cook, Bjaeverskov, Denmark), Flamingo Wallstent (Bulach, Switzerland), and Ultraflex stent (Microvasive Endoscopy/Boston Scientific, Natick, MA) (34). The study demonstrated that there were no differences in the technical success in placement, relief of dysphagia, mortality at 30 days and median survival among the three stents. There was a higher complication rate (36%) with the Gianturco-Z stent compared to the two other stents, but this result was not statistically significant (p = .23).

Antireflux stents have been developed to decrease reflux symptoms after placement for tumors near the gastroesophageal junction. Patients who have a stent placed across the gastroesophageal junction experience severe reflux, and this can result in aspiration pneumonia. Newer stents have been developed that have an artificial sleeve or valve to prevent reflux. Small studies have shown that these revised stents decrease reflux episodes (35, 36).

Unlike rigid stents that can be taken out, metal self-expanding tubes are virtually impossible to remove short of an open surgical procedure, due to the expandable nature of the device and the design which favors an inflammatory tissue response which, while it decreases migration, causes difficulty with removal. One of the newer stents on the market is the Polyflex stent which is a silicone covered nonmetallic stent. Its major advantage is that it can be removed. The Polyflex stent (Boston Scientific, Natick, MA) is made of Trevira monofilaments with a silicone coat. The stent has a smooth inner surface and it a high expansive force. This stent was first introduced for the treatment of benign esophageal strictures but the indications are expanding to include patients with a malignant stricture who are undergoing chemoradiotherapy. Palliative radiation is effective in 60–80% of patients but it takes up to 4–6 weeks to see the improvement with dysphagia. Placement of a removable stent in this patient
group is beneficial for reducing complications and related reintervention as demonstrated by Shin et al. (37).

In initial reports, Castamanga et al. showed a technical success rate of 75% of patients with inoperable esophageal strictures (38). In 4 of the 16 patients the stent placement was unsuccessful. In three of those patients, the delivery system could not be advanced across the stricture and in the one patient the stent did not open. In another similar study, the success rate was 100%. The disadvantages of the Polyflex stent include the bulky delivery system therefore resulting in the possible need for dilation and the resultant higher rate of stent migration (39).

Perforation, stent migration, pain, and hemorrhage are among the most common complications of esophageal stents. Perforation is the most serious complication and occurs with a frequency of approximately 6–8% with the rigid endoprostheses (40, 41). The rate of perforation is <3% with the metallic self-expandable stents (28, 29, 30, 31, 42). Perforation may occur as a result of the endoscopy, esophageal dilatation, or the endoprosthetic placement itself. Factors associated with a higher incidence of perforation include prior radiotherapy and surgical intervention, sharp angulation from tortuous tumor involvement, and preexisting kyphoscoliosis. In most cases, perforations are identified at the time of stent placement by careful endoscopic inspection of the esophagus and pharynx, the physical examination findings of subcutaneous emphysema or crepitation of air, and radiographic detection of extraluminal air in the chest and neck areas. The exact location of a leak can be detected by the use of water-soluble contrast media.

Perforation always carries a risk for accompanying mediastinitis. Once identified, the use of acid-suppressive agents and intravenous antibiotics are the mainstays of therapy; the stent itself may seal off the site of the perforation. Consideration for the placement of an additional endoprosthetic or surgical repair may need to be entertained for open communicating tracts.

Stent migration and dislodgement may complicate metallic stent placement in up to 5% of patients (31). Some stents are designed to decrease migration (30), but further studies ascertaining their effectiveness for this complication are needed. Barium studies postprocedure documents location and function of the stent, and provides a baseline should migration be suspected in the future. Tumor ingrowth occludes stents in approximately 10–60% of cases, depending on the type of endoprosthesis used, the indication, and its length, and occurs a mean of 7 weeks postprocedure (28, 31).

Bleeding related to expandable metallic stent placement occurs in <5% of cases (29, 31). This is often insignificant, but more serious hemorrhage requiring transfusions has been reported (29). Aspiration may occur either during the placement of the endoprosthetic or subsequently, due to reflux of gastric contents. It is important to instruct patients that they should not lie supine or prone after placement; this is especially critical when the endoprosthetic bridges the gastroesophageal junction. A persistent globus sensation may occur if the stent is placed in the proximal esophagus, usually within 2 cm of the upper esophageal sphincter. Mediastinal pain may occur in 5–15% of patients, most often in those with preexisting pain or extraesophageal tumors (28, 31, 42).