Gastrostomy Clinical Trial
Official title:
Percutaneous Radiologic Gastrostomy With and Without Gastropexy: A Prospective Comparison
Percutaneous (through the skin) radiologic (x-ray guided) gastrostomy (to the stomach) (PRG)
is a common procedure performed to help provide supplemental nutrition for those for who have
difficulty swallowing their food. This population typically includes patients receiving
radiation therapy for cancers of the mouth or throat, patients who have had a stroke or other
neurologic disorders. It involves making a small incision in the skin on the belly to insert
a feeding tube directly into the stomach. PRG has been well established as a safe and
effective procedure for many years now. Although known to be safe, there is still debate
regarding the best way to perform the procedure. Some doctors believe it is necessary to
stitch the stomach wall against the wall of the belly before inserting the tube, this is
called gastropexy. They argue that this decreases the risk of the tube being positioned
incorrectly and prevents leakage of stomach content in the first few weeks after the
procedure. Other doctors feel that these risks are very small and this step is not required
as it can cause the patient more pain in the days following the procedure since the stomach
is fixed against the body wall and cannot move naturally. To this day, the procedure is
performed safely both ways, depending on the hospital.
The purpose of this research study is to compare these two methods and determine if one
technique gives better results, meaning less pain and fewer complications for patients.
When percutaneous radiological gastrostomy (PRG) first emerged as an alternative method to
surgical or endoscopic techniques, gastropexy was considered an essential step. This consists
of using sutures and "T-fasteners" to fix the anterior gastric wall to the anterior abdominal
wall and many variations are described in the literature. It was postulated that this step is
necessary to avoid tube misplacement and peritonitis caused by early leakage of gastric
content around the site of tube insertion. It is still considered imperative in some groups
of patients at high risk of gastric leakage (i.e. patients with ascites, steroid treatment,
and/or severe malnourishment). However, in other patients its use has become subject of
debate.
Experiments with animal models have shown no evidence of gastric leakage following insertion
of a 14 French tube, even when the tube is subsequently removed and the defect left
unrepaired. Furthermore, several groups have had success without the use of gastropexy and
some have described complications caused by performing this step such as peristomal
infection, increased post-procedural pain, persistent leakage, and gastrocutaneous fistulas.
Other large series of patients who underwent gastrostomy with gastropexy did not experience
gastropexy-related complications, further complicating the matter. To date, the guidelines
for transabdominal gastrostomy published by the Society of Interventional Radiology (SIR) and
American Gastroenterological Association (AGA) acknowledge both techniques but have no
official recommendation on the use of gastropexy reflecting the lack of clear evidence
regarding advantage with or without its use.
The investigators hypothesize that the use of gastropexy for PRG does not significantly
decrease complications.
The investigators also hypothesize that the use of gastropexy is associated with increased
post procedural pain.
At the investigators' institution (University Health Network) PRG without gastropexy is
regularly performed first-line for gastrostomy. There is a high volume of requests for PRG
and thus establishing which method is superior will help to reduce the number of
complications and revisions. In doing so, the investigators hope to be able to establish an
optimal evidence-based protocol for PRG for future patients as well as improving patient
safety and satisfaction.
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