Solved on SIR Connect: Gastropexy suture/disc follow-up after primary gastrostomy/gastrojejunostomy placement

This column summarizes patient cases posted to SIR Connect (SIR’s popular online member community), the responses from other SIR members and how that feedback helped the original poster. To see how SIR’s online community can help you, visit SIR Connect at connect.sirweb.org.

Original post, lightly edited for flow: bit.ly/2XkdRpR

Our IR section is having a discussion regarding follow-up of patients who have had primary gastrostomy/gastrojejunostomy catheter placements using button-type gastropexy sutures. The buttons are supposed to fall off on their own over the period of a few weeks, but there are reports that these buttons can stay on the skin surface for longer than 3–4 weeks.

In practices where you use these gastropexy sutures, what are your practices for follow-up for these patients (if any), and why?

What challenges have you faced in following up on gastrostomy/GJ catheters placed in patients with gastropexy sutures?

A fair percentage of patients who have gastrostomy/GJ catheters placed by our service have socioeconomic or logistical issues that make follow-up difficult, sometimes requiring an inordinate amount of coordination, time, effort and cost.

Prior to development of our outpatient clinic at my former practice, follow-up was essentially dependent on the performing physician, which was prone to interoperator variability.

Patients have variable levels of care at home or in nursing facilities, which creates variability in how the catheters are maintained as well as in the threshold for calling our team with potential issues such as excessive leakage, signs of infection or ulceration.

What specifically prompted you to reach out regarding this case/topic?

After moving to my new job, I noticed that my practice of bringing these patients back for follow-up did not align with the existing practice, developed with the notion that the gastropexy sutures we use absorb and the discs fall off spontaneously without complication.

With the emergence of the SARS-CoV-2 pandemic, additional discretionary measures are being implemented, causing us to scrutinize every outpatient visit.

After discussing management of enteral access patients, it became clear to me that there was variation in follow-up, gastropexy suture type and method of placement among the 18 IRs in the group.

My post was meant to garner information from other groups regarding their practices and to assess what evidence they have used to guide their practice.

What post or posts were most valuable to you and why?

Peter Bream, MD, FSIR, shared his personal experiences, which, like mine, spanned a relatively long timeframe and multiple practice settings and, in addition, provided peer-reviewed literature and unpublished internal data as a basis for his comments and decision-making.

Will you, or have you, changed your practice patterns based on responses from SIR Connect?

Based on some of the feedback and literature we received from the SIR Connect forum, and discussion within our IR section, we are creating a standardized management approach to enteral access patients.

Additional commentary

Percutaneous radiologic gastrostomy (PRG) tube placement offers safe, effective and minimally invasive long-term nutritional support in various disorders that disrupt normal oral intake.1–4 Gastropexy fixation has been widely employed since the 1980s5 to prevent stomach movement during tube insertion, promote tract maturation and mitigate the risk of complications such as peritoneal leaks and disolodgement.6–9 The aftercare of patients who have received PRG placement with absorbable gastropexy sutures poses questions regarding suture lifespan. The original post described follow-up protocol for gastropexy suture removal in primary PRG patients.

A randomized comparison study of PRG with and without T-fastener gastropexy demonstrated 10% incidence of serious complications without gastropexy.9 Given the variable behavior of absorbable gastropexy sutures to retain themselves or slough off on their own in the gastrointestinal tract, time to tract maturation, and potential for local complications, many IRs recommend follow-up within 2–3 weeks post-procedure to ensure correct use of gastrostomy tube and the presence of buttons on the skin.7,8,10 A recent retrospective study reported that immediate removal of T-fasteners demonstrated no statistically significant difference in major or minor complication rates when compared with delayed 2-week removal (major, 2% vs. 1.4%; minor, 7.9% vs 6.8%).11 Similarly, Foster et al. (2009) reported that T-fastener removal at 2 days resulted in no major and only 14% minor complications which resolved with removal.10

A prospective study on absorbable gastropexy anchors mentions that the manufacturer manual outlines a suture absorption timeframe well before 90–110 days.7,12 Absorbable gastropexy anchors have been shown to remain in place for at least three weeks after insertion and may not fully absorb, leading to complications such as site pain, infection or T-fastener migration.7,11,13

As pointed out by the original poster and members of SIR Connect, there are often logistical difficulties with respect to ease of access to health care and social determinants that inhibit the ability of many patients to follow up at a later time period (within 2–4 weeks). PRG placement technique, gastropexy suture type and follow-up protocol (respondents on SIR Connect generally follow up before 6 weeks) also differ by physician and institution. Many respondents on SIR Connect have observed the fact that T-fasteners do not necessarily fall off on their own in a timely fashion. This may highlight a potential role for early T-fastener removal in these patient populations, especially with the variable data we currently have on absorbable gastropexy suture self-release.

References

  1. Shin, Ji Hoon, et al. Percutaneous gastrostomy, percutaneous gastrojejunostomy, jejunostomy, and cecostomy. Handbook of Interventional Radiologic Procedures. 2016:478–488.
  2. Covarrubias, Diego Antonio, et al. Radiologic percutaneous gastrostomy: Review of potential complications and approach to managing the unexpected outcome. AJR. 2013;200(4):921–31.
  3. Shin, Ji Hoon, and Auh-Whan Park. Updates on percutaneous radiologic gastrostomy/gastrojejunostomy and jejunostomy. Gut and Liver. 2010;4(Supp 1):S25–31.
  4. Laasch, HU, and DF Martin. Radiologic gastrostomy. Endoscopy. 2007;39(3):247–55.
  5. Brown, AS, et al. Controlled percutaneous gastrostomy: Nylon T-fastener for fixation of the anterior gastric wall. Radiology. 1986;158(2):543–45.
  6. Black, Michelle T, et al. Subcutaneous T-fastener gastropexy: A new technique. AJR. 2013;200(5):1157–80.
  7. Durack, Jeremy C., et al. Prospective evaluation of absorbable gastropexy anchor indwelling time in 33 patients. J Vasc Interv Radiol. 2013:24(9):1377–80.
  8. Milovanovic, Lazar, et al. Safety and short-term complication rates using single-puncture T-fastener gastropexy. J Vasc Interv Radiol. 2016;27(6):898–904.
  9. Thornton, FJ, et al. Percutaneous radiologic gastrostomy with and without T-fastener gastropexy: A randomized comparison study. Cardiovasc Intervent Radiol. 2002;25(6):467–71.
  10. Foster, A, et al. Removal of T-fasteners 2 days after gastrostomy is feasible. Cardiovasc Intervent Radiol. 2009;32(2):317–19.
  1. Sanogo, Mamadou L., et al. Removal of T-fasteners immediately after percutaneous gastrostomy tube placement: Experience in 488 patients. AJR. 2018;211(5):1144–1147.
  2. MIC-Key, G. Introducer Kit [instructions for use]. Kimberly-Clark, Irving, TX; 2007.
  3. Sydnor, Ryan H, et al. T-fastener migration after percutaneous gastropexy for transgastric enteral tube insertion. Gut and Liver. 2014;8(5):495–499.