Gastroscope-assisted Trans-Trocar Gastrostomy and Abdominal Exploration

Summary

Here, we introduce a novel technique of gastrostomy, which integrates laparoscopic and gastroscopic techniques, offering a streamlined approach with reduced invasiveness, expedited recovery, and the capacity for abdominal exploration while minimizing the risk of adjacent organ injury.

Abstract

Advanced endoscopic technologies have revolutionized gastrointestinal surgical procedures, transitioning from open or laparoscopic methods to endoscopic interventions. Gastrostomy is a classic clinical technique for patients with swallowing impediments due to obstructions in the cardiac or esophageal regions and has evolved significantly with the establishment of percutaneous endoscopic gastrostomy (PEG). While PEG offers reduced trauma and swift recovery, it falls short of exploratory capabilities and risks damaging adjacent organs. Therefore, we developed an innovative approach-gastroscope-assisted trans-Trocar gastrostomy (GTTG), which not only takes full play to the advantages of PEG with less trauma and faster postoperative recovery but also takes into account the advantages of laparoscopic gastrostomy with a good exploration of the abdominal cavity. This technique is characterized by ease of operation, minimal trauma (including short operation time and no redundant incision), rapid recovery, the ability to explore the abdominal cavity, and avoidance of injury to adjacent organs, which is quite worthy of widespread promotion in clinical settings.

Introduction

Gastrostomy is the cornerstone of enteral nutrition for patients with organic or functional obstruction of the cardiac orifice or other organs¹. Percutaneous endoscopic gastrostomy (PEG) was first performed in 1979, and it is now a widely accepted and practiced approach². A PEG tube not only functions as a conduit for the administration of liquid nutritional supplements directly into the stomach but also holds utility in the realms of gastric decompression and the management of gastric volvulus, which offers a multifaceted approach to gastrointestinal care³. PEG is a minimally invasive approach compared with traditional open gastrostomy. Currently, two typical access types for PEGs have emerged, Pull-PEG and Push-PEG. Pull-PEG is the standard procedure used to help patients whose gastroscopic access to the stomach is difficult due to obstruction or stenosis. In Push-PEG, primary gastropexy is performed under disphanoscopy followed by the direct introduction of a balloon-fixed tube⁴. Although PEG is considered a safe procedure, several complications can occur, including bumper syndrome, bleeding, and tube dislodgement. Several studies have focused on finding solutions to these complications, but only a few have succeeded⁵.

Another disadvantage of traditional PEG is that, compared to traditional open or laparoscopic gastrostomy, peritoneal exploration is unreliable during PEG. Moreover, bleeding could not be completely avoided because the vessels on the surface of the stomach were invisible when performing Pull-PEG or Push-PEG, and the greater omentum was sometimes attached or damaged⁶. To address these shortcomings, we propose a hybrid approach that combines endoscopic and laparoscopic techniques and offers a clinically viable and widely applicable method.

Protocol

Ethical approval for the surgical procedure was granted by the ethics board at the First Affiliated Hospital, Sun Yat-Sen University. A 65-year-old male patient, presenting with a one-month history of dysphagia and a diagnosis of esophageal carcinoma with extensive lymph node metastases, was deemed a candidate for systemic therapy following multidisciplinary team discussions. Given the tumor-induced obstruction, gastrostomy was planned to facilitate enteral nutrition, and the patient provided informed consent before the procedure.

1. Surgical procedures

1. Place the patient in a supine position after general anesthesia post-tracheal intubation.
2. Use a povidone-iodine solution for routine disinfection.
   NOTE: The chief surgeon and an assistant are located on the left side of the patient.
3. Make a 1 cm incision at the predetermined site. The site is located 2 cm right to the left midclavicular line and 2-4 cm below the costal arch, which is the position for gastrostomy (Figure 1).
4. Insert a 12 mm Trocar and inject CO₂ gas to maintain an abdominal pressure of 12 mmHg.
5. Introduce a gastroscope into the abdominal cavity through the Trocar and explore the abdominal cavity.
6. Find the non-vascular zone of the anterior wall of the stomach for further gastrostomy.
7. Utilize rat tooth forceps to clamp the selected site and exteriorize it using the gastroscope and the trocar.
8. Fix the gastric well with a cured clamp to prevent retraction into the abdominal cavity.
9. Anchor the gastric well to the abdominal wall with four interrupted sutures using 2-0 absorbable sutures.
10. Execute a purse-string suture on the gastric wall with 2-0 absorbable sutures.
11. Open the stomach well using an electrotome, and insert a balloon-type gastrostomy tube into the gastric cavity.
12. Instill ~20 mL of normal saline (NS) into the balloon to secure the tube and tie up the tube again with the 2-0 absorbable sutures.
13. Administer 20-50 mL of NS into the tube to test its patency.
14. Fix the tube on the abdominal wall with 2-0 absorbable sutures.
15. Close the incision around the tube with interrupted sutures using 2-0 absorbable sutures (Figure 2).

2. Postoperative procedures

1. Send the patient back to the ward safely after resuscitation.
2. Administer 500 mL of glucose saline through the gastrostomy tube one day after the operation to maintain tubal patency.
3. Administer 250-500 mL of enteral nutrient solution through the gastrostomy tube 2 days after the operation.
4. Increase the volume of enteral nutrient to 1,500-2,000 mL per day gradually.

Results

The operation was completed within 50 min, with minimal intraoperative bleeding of <5 mL. Enteral nutrition was initiated one day postoperatively, with a gradual increase in volume. By the 4^th day, no additional parenteral nutrition was required. The patient and his family members were trained to perform enteral nutrition via a tube s for home care after discharge. Systemic antitumor therapy was commenced 3 days after the operation, and the patient was discharged 4 days later (Table 1). Du...

Discussion

Gastrostomy is a classic therapy for patients without the ability to undergo it because of the organic or functional obstruction of the digestive tract above the cardia. With the development of medicine, laparotomy and laparoscopy have gradually been replaced by PEG, which was first performed in 1979⁷. However, in cases of severe obstruction, endoscopy access may be impeded, prompting the development of Push-PEG and radiologic gastrostomy (RG) to address these challenges⁸

Materials

Name	Company	Catalog Number	Comments
2-0 absorbable suture	Ethicon	VCP345H
Curved forceps
Electric knife pen	Xinhai Hexing Science and technology (dalian) co.,LTD
Gastroscope	Olympics	GIF-H290Z
Percutaneous gastroscopy kit	CREATE MEDIC	PEG18
Rat tooth forceps	Micro-Tech(Nanjing)	MTN-GF-23
Scissors
Trocar	Surgaid Medical	12mm
Vessel forceps