A simple gastropexy for the loop-gastrostomy tube.

The percutaneous endoscopic gastrostomy has been in clinical use for more than three decades. A recent innovation, the loop-gastrostomy, is more suitable for developing countries because the tube cannot be dislodged and is easy to change. Gastropexy and gastrostomy are separate but related moieties. We describe a novel technique to add a gastropexy to the loop-gastrostomy, using it successfully in a man with permanent dysphagia. It involved creating a secondary loop at the mid-portion of the LOOPPEG(®) 3G tube with absorbable ligatures.

INTRODUCTION

The percutaneous endoscopic gastrostomy (PEG) has been in clinical use for more than thirty years now. A recent innovation, the loop-gastrostomy, makes the tube more secure and easier to change.[12] Thus it is more suitable for developing countries.

In the typical PEG, one end of the hollow tube is fitted with a dilator (for pull-through) while the other end has a mushroom- or dome-shaped retention disc. The loop-gastrostomy tube, however, has both ends fitted with dilators and the exit opening is at the midpoint [Figure 1a]. Insertion of the loop-gastrostomy tube is similar to the typical PEG except that two gastric punctures are needed and both ends are pulled-through simultaneously, after which the ends are locked together [Figure 1e].

Figure 1

Loop-gastrostomy with gastropexy (a) Formation of the secondary loop (b) Simultaneous pull-through of both ends of the loop-gastrostomy tube (c) Apposition of the stomach wall to abdominal wall using the secondary loop and lock (d) Matured track with fibrous adhesions between stomach and abdominal walls (e) After release of the secondary loop, only the standard loop-gastrostomy tube remains

Gastropexy, the apposition of the anterior stomach wall to the anterior abdominal wall, enhances the safety of a tube gastrostomy. It is typically achieved with suturing, T-fasteners, and a bumper-bolster combination in surgical, radiologic and endoscopic gastrostomies, respectively.[3-5] Fibrous adhesions between the stomach and abdominal wall will develop after a while and maintain the gastropexy.

Ideally the gastropexy for the loop-gastrostomy should be simple, effective and low-cost. We describe a novel technique which meets these criteria.

CASE REPORT

A 40-year-old man, had arrested hydrocephalus since childhood. Mentally retarded, he was cared for by his mother. He had been fed orally until aspiration pneumonia precipitated his admission into the hospital. As his swallowing reflex had deteriorated, to prevent recurrence of aspiration pneumonia, his doctor recommended tube-feeding. Unfortunately, naso-gastric intubation proved to be impossible; the tube kept coiling in the throat. Thus, a gastrostomy tube was necessary. The family gave written informed consent for the loop-gastrostomy instead of a standard PEG.

Pre-procedure fasting, initial gastroscopy, skin preparation, selection of puncture sites, etc. were performed in the usual manner. Only one modification was made: prior to pull-through insertion of the tube (LOOPPEG® 3G) a secondary loop was fashioned at the mid-portion with Vicryl® (polyglactin 910) 3/O ligatures, as illustrated in Figure 1a. Pulling the tube ends apposed the stomach wall to the abdominal wall [Figure 1b]. When doing so, care was taken to avoid strangulating the tissues. Then the lock was applied to the two ends as per the instructions of the manufacturer [Figure 1c].

The endoscopic view of the secondary loop in the stomach is shown in Figure 2.

Figure 2

Endoscopic view of the secondary loop in the stomach of the patient

The patient tolerated the procedure well. This was to be expected because only sedation and local anaesthesia were used, as is the case for most PEG insertions. Enteral feeds were started 24 hours after the procedure and increased gradually.

DISCUSSION

This case proves that a gastropexy can be added to the loop-gastrostomy via the tube. Fashioning the secondary loop was a simple matter because only two reef knots per ligature were needed.

In the acidic environment of the stomach, polyglactin 910 will last about 3 weeks, enough time for adhesions to form.[6] Upon degradation of the ligatures by hydrolysis, the secondary loop will be released, and the tube may be changed percutaneously without risk.[2] Release of the secondary loop is easily detected because the lock will be lifted off the skin [Figure 1e]. If non-absorbable ligatures are used, the loop-gastrostomy tube must be changed endoscopically.

It is plain to see that the secondary loop and lock are the counterparts of the bumper and bolster of the standard PEG. Clinical experience with the PEG allowed us to predict that the secondary loop and lock would be safe and effective. In that sense, this case is proof of the concept. We look forward to the publication of case series by other clinicians.