Percutaneous transesophageal gastric catheter removal and follow up: A case series

Abstract

Percutaneous transesophageal gastric catheter (PTEG) placement is an alternative technique for gastric decompression in patients who require long-term venting with contraindication(s) to traditional gastrostomy access (percutaneous, endoscopic, or surgical), such as primary or metastatic gastric cancer, refractory ascites, or altered anatomy. Despite growing evidence supporting PTEG’s efficacy and safety especially for palliative care, literature on catheter removal, and follow-up is sparse. We present 4 cases of PTEG catheter removal in patients with malignant bowel obstruction (MBO) and contraindications to radiologic percutaneous gastrostomy (PG). Each case involved successful PTEG placement, followed by removal once symptoms resolved. Follow-up periods varied, with no reported complications postremoval and a median follow-up time of 599 (139-725) days. PTEG provides a viable alternative for patients requiring gastric decompression who are not candidates for PG. This case series demonstrates the safety and feasibility of PTEG catheter removal, even within the limitations of the sample size. This case series demonstrates that PTEG catheter removal after symptomatic relief of malignant bowel obstruction is safe. Further research is needed to better understand the long-term outcomes and to confirm these preliminary findings.

Introduction

Percutaneous gastrostomy (PG) is a common technique used for bowel decompression and enteral feeding [1]. Patients with cancer of the stomach (primary or metastatic), refractory large volume ascites, altered anatomy, or overlaying peritoneal carcinomatosis have contraindication to the placement of PG. These patients are at risk for complications from access, such as poor healing, peritonitis, bleeding, and potentially tumor seeding [2,3]. Percutaneous transesophageal gastric catheter (PTEG) placement is an alternative technique for gastric decompression that can be utilized in patients who require long-term venting and have these contraindications to PG. Recent reports by Aramaki et al. [4] showed that PTEG was superior to nasogastric tubes (NGT) in symptom improvement and quality of life [4]. While there is increasing evidence for the use of PTEG catheter, the removal and follow-up is nearly absent from the literature. Herein we discuss the procedural technique of PTEG placement and present 4 patients who underwent PTEG catheter removal and report their follow-up.

Procedural technique

Placement

All procedures were performed with sonographic and fluoroscopic guidance by a primary interventionalist who maintained sterility and an assistant who performed nonsterile maneuvers. Preprocedural gastric decompression was achieved by oral or NGT placement. Patients received general anesthesia with endotracheal intubation in the supine position. The patient was prepped and draped bilaterally from the mandible to mid thorax. One operator removed the NGT over a guidewire and advanced a deflated generic dilatation balloon over the guidewire to be positioned in the cervical esophagus. The ballon was filled with dilute iodinated contrast and was aligned above the sternal notch with fluoroscopic and sonographic guidance. The other operator sonographically evaluated the anterior triangle of the neck to plan the access needle path. If critical structures obstructed the path, hydrodissection was performed to improve access through the tissue planes. Sonography was used to advance an 22-18-gauge needle through the anterior neck and then into the esophagus until the dilatation balloon was punctured. This allowed advancement of a guidewire into the punctured balloon and confirm positioning within the esophagus. The balloon containing the guidewire was advanced distally into the stomach. Once in the stomach the wire was retracted from the balloon, positioned in the stomach and the balloon was removed. Over the guidewire dilatations were performed and a single lumen pigtail catheter (Cook Medical, Bloomington, IN) was advanced from the neck entry site along the esophagus, and then into the stomach. The size of the catheter ranged from 8 to 14 French, while length varied from 45 cm 120 cm. The catheter was sutured to the patient’s neck and final position confirmed with contrast administration and fluoroscopy (Fig. 1A-D).

Fig. 1.

(A) Transverse sonographic image of the left neck shows the cervical esophagus (arrowheads) with the inflated balloon in the lumen (B). The space between the thyroid gland (T) and common carotid artery (C) is narrow. J = internal jugular vein. (B) Transverse sonographic image performed after hydrodissection, ample space was created between the thyroid gland and the common carotid artery (double arrow), facilitating access to the cervical esophagus. (C) Radiograph of the cervicothoracic junction shows the use of 2 dilatation balloons to displace the esophagus, enabling percutaneous access. The sonographically placed puncture needle (arrow) is shown before it pierced the balloon. (D) Radiograph of the upper abdomen demonstrates the pigtail catheter terminating in the stomach with contrast lining the gastric lumen (arrows).

Removal was performed at bedside under no fluoroscopic guidance and with a sterile approach. Fixing sutures at the neck were cut. The catheter was transected to unlock the distal pigtail. The catheter was then withdrawn through the mature tract with gentle external traction and sterile dressing was applied over the skin entry site. Patients were taken to the recovery bay to ensure an oral diet could be tolerated prior to discharge, when applicable.

Case presentations

Case 1

A 64-year-old male with a known history of stage IV metastatic colorectal cancer, currently on palliative chemotherapy, presented to the ED with abdominal pain and vomiting from malignant bowel obstruction (MBO). CT demonstrated diffuse small bowel dilation with large volume ascites and diffuse peritoneal carcinomatosis, findings which preclude PG placement (Fig. 2A and B). NGT decompression alleviated the patient’s symptoms, and it was elected to perform a PTEG tube placement, which the patient underwent without complication. Due to lack of use for more than 3 weeks, the catheter was removed 140 days after discharge. The patient re-presented to the ED 352 days after catheter removal with similar features of MBO symptoms and recurrence of ascites secondary to progression of their primary disease. The patient reported no issues following removal of the original PTEG and was tolerating PO intake in the interim. A second PTEG procedure was performed successfully without complication at the same site of the previously removed catheter. The patient was lost to follow-up 95 days after discharge.

Fig. 2.

(A) Axial CT of the abdomen demonstrates areas of irregular thickening of the stomach wall (arrowhead) and malignant ascites (white arrows). These findings preclude percutaneous gastrostomy tube placement. (B) Axial CT of the abdomen of the same patient demonstrates diffuse small bowel dilation measuring up to 7 cm with diffuse peritoneal implants (not seen).

Case 2

A 21-year-old female with a history of ulcerative colitis, metastatic appendiceal adenocarcinoma, peritoneal carcinomatosis and malignant ascites presented to the ED with symptoms of MBO. CT revealed a 7 cm infiltrative mass at the ileocecal junction, invasion to the anterior abdominal wall with possible fistulization, and diffuse peritoneal soft tissue involvement (Fig. 3A and B). At this point, the patient and family refused palliative surgery, and she was initiated on chemotherapy. She received an NGT for decompression and 3 days later was referred for a PTEG catheter placement. One week later, she underwent right hemicolectomy with posterior abdominal wall resection. The PTEG catheter was removed 45 days after placement as it was no longer needed. The patient died 23 months after PTEG removal from their underlying condition, and no complications were reported during that period.

Fig. 3.

(A) Axial CT of the abdomen reveals a 7 cm ileocecal mass (yellow arrow), with local invasion into the posterior right rectus muscle and a thin tract extending to the skin (arrowhead). There are multiple distended small bowel loops, indicative of malignant bowel obstruction (MBO). (B) Axial CT of the pelvis demonstrates a 2 cm peritoneal soft tissue mass consistent with carcinomatosis.

Case 3

A 44-year-old female with a history of BRCA1 mutation, high-grade serous carcinoma of primary peritoneal origin, presented to the ED with abdominal pain with distention, nausea and vomiting. CT of the abdomen and pelvis revealed extensive omental caking, and peritoneal carcinomatosis (Fig. 4A-C). CT also revealed diffuse dilated bowel loops consistent with MBO. A NGT was placed and a PTEG procedure was performed 12 days later without complication. Neoadjuvant chemotherapy was initiated and 2 months later she no longer experienced signs and symptoms of MBO. The catheter was removed 70 days after placement with no complications reported. An upper GI series with small bowel follow through was performed 13 days after the catheter removal showed normal passage of contrast across the cervicothoracic segments of the esophagus without evidence of extraluminal contrast. She underwent surgical debulking of the primary tumor, omentectomy and HIPEC after the neoadjuvant chemotherapy with no complications and is being followed up 22 months after catheter removal.

Fig. 4.

(A) Axial view of a contrast enhanced CT of the abdomen demonstrates fluid filling the proximal stomach (double arrow). A 7 cm fluid collection (arrow) adjacent to the stomach is seen causing anterior displacement. (B) Axial view of the abdomen shows the distal stomach (white arrows) is decompressed due to mass effect by the dilated bowel loops. (C) Axial view at this level demonstrates thickening and enhancement of the peritoneum consistent with carcinomatosis.

Case 4

A 66-year-old female patient with a history of colorectal cancer and underwent abdominoperineal resection 2 years earlier, presented to the ED with symptoms of recurrent episodes of nausea and vomiting that was occurring over the prior month. CT revealed multiple dilated small bowel loops consistent with MBO. Surgery was deferred due to her poor baseline functional status and the patient elected to undergo percutaneous enteral access of which a PTEG procedure was performed due to absence of anatomic window (Fig. 5A and B). The patient was discharged after resolution of her MBO and the PTEG catheter was removed after 189 days when it was no longer required. The patient expired 139 days after catheter removal from their underlying condition.

Fig. 5.

(A) A noncontrast enhanced axial CT of the abdomen shows decompressed stomach with nasogastric tube (white arrows) within the lumen, and poor window for safe access due to overlying bowel and colon. (B) A noncontrast enhanced axial CT at the level of the distal stomach shows no safe subcostal window for placement of percutaneous gastrostomy tube within the stomach (arrow).

Discussion

Palliative gastric decompression in the setting of MBO is indicated and greatly helps alleviate symptoms [5]. When ascites, altered anatomy, or gastric cancer is present, PG is contraindicated and long-term NGT placement can be discomforting and distressing. The outcomes of PTEG catheter removal have not been reported in the literature secondary to its most common indication being terminal malignant disease.

In this case series, 4 patients with contraindications to PG underwent PTEG placement and subsequent removal after resolution of their MBO symptoms. Contraindications for PG placement were peritoneal carcinomatosis (n = 3) and no anatomic window (n = 1) (Fig. 1, Fig. 2, Fig. 3). PTEG tube placement was successful in all 4 patients, and the median catheter life was 105 days (45-189). Catheter removal was performed at the bedside, and no immediate complications were reported. The median follow-up time after catheter removal was 599.5 days (139-725). One patient underwent follow-up imaging to confirm MBO resolution after the removal procedure and no abnormality in the esophagus was detected.

Oishi et al. [6] mentioned catheter removal in passing in their retrospective study of 115 patients who underwent PTEG procedure [6]. However, the number of patients who underwent removal was not declared and it was only stated that the scar was “fairly small” after removal at an undisclosed time of follow-up. In this small cohort, complications such as dysphagia, infection, poor tract healing or bleeding were not reported after catheter removal. Additionally, 1 patient required another PTEG procedure 352 days after removal of his primary catheter, and the second placement was performed with no complications on the same side of the neck and juxtaposed to the prior site.

There are several limitations in this study which include a relatively small sample size and the retrospective design. Additionally, no standardized imaging follow-up was set up to evaluate the esophagus and patients received imaging according to the clinical presentation and the treating physician’s decision (Table 1).

Table 1.

Clinical, imaging findings, and follow-up of patients who received percutaneous transesophageal gastric catheter.

Patient	Age/sex	Primary malignancy	Contraindications to PG placement	PTEG duration (d)	Follow-up after PTEG removal (mo)
1	64/M	Colorectal cancer	Diffuse ascites and extensive peritoneal carcinomatosis	140a	15a
2	21/F	Appendiceal adenocarcinoma	Malignant ascites, peritoneal carcinomatosis, and abdominal wall invasion	45	23
3	44/F	High-grade serous carcinoma of primary peritoneal origin	Extensive peritoneal carcinomatosis	70	22
4	66/F	Colorectal cancer	Poor anatomic window	189	5

PG, percutaneous gastric catheter; PTEG, percutaneous transesophageal gastric catheter.

^aSecond PTEG catheter was placed after 352 days. Follow-up is calculated from primary catheter removal.

Conclusion

In this small retrospective case series, bedside PTEG catheter removal was feasible and was not associated with clinically evident access-site complications during available follow-up.

Ethics approval

As the case report contains information of the retrospective period, we obtained exempt for ethical approval from the Institutional ethical committee. This study was approved by the Mayo Clinic IRB with a waiver of HIPAA authorization in accordance with applied regulations.

Patient consent

Informed written consent for publication was obtained or waived by all participants in this study.