Percutaneous endoscopic gastrostomy (PEG) is now the most common
method of enteral nutrition in patients who require long-term tube feeding
[1]. Endoscopic retrograde cholangiopancreatography
(ERCP) distresses bedridden patients and puts them at risk of aspiration
pneumonia [2]. To avoid such risk, we tried
transgastrostomic ERCP and related procedures in four cases.
A bedridden woman patient developed choledocholithiasis and
cholangitis; she was unable to lie prone because of a fracture of the right
upper limb and contracture deformity. First we tried a transgastrostomic
examination using a direct-viewing endoscope (GIF-XQ240; Olympus, Tokyo,
Japan). Although we could observe the ampulla of Vater, we could not cannulate
into the common bile duct (CBD) ([Fig. 1 a, b]). Next we cannulated using
an oblique-viewing endoscope (GIF-XK240; Olympus) transgastrostomically; a
cholangiogram showed a stone in the distal CBD ([Fig. 1 c, d]). However, it was
difficult to insert the devices for lithotomy. To observe and cannulate the
ampulla, the angle between the duodenal second portion and antrum (between the
tip and main shaft of the endoscope) is sharper in a transgastrostomic approach
than when using the usual oral route. Thus a side-viewing duodenoscope is
needed for lithotomy. To enlarge the PEG stoma (from 8 mm) and insert a
duodenoscope (JF-260V; diameter 12.6 mm; Olympus), we used a dilator
followed by additional gastropexy. Stones were extracted successfully ([Fig. 1 e, f]) after an endoscopic
sphincterotomy.
Fig. 1 a In a direct-viewing
endoscope, the angle is very acute; b only observation
of the ampulla of Vater is possible. c Using an
oblique-viewing endoscope, a cholangiogram was obtained. d The degree of bend with an oblique-viewing endoscope,
however, is so acute that the devices for lithotomy cannot be inserted into the
ampulla. e After dilation of the percutaneous endoscopic
gastrostomy (PEG) stoma, a side-viewing duodenoscope was used.
f The bile duct stone was extracted completely using the
side-viewing duodenoscope.
We also treated three patients with bile duct cancer with endoscopic
biliary stenting via this transgastrostomic approach.
Many patients who have undergone PEG are bedridden and find it
difficult to lie prone because of their diseases. Furthermore, ERCP via the
oral cavity may distress these patients and may put them at risk of aspiration
pneumonia as a complication of the pharyngeal local anesthesia. Thus a
transgastrostomic endoscope has several advantages over conventional methods
[3]
[4]. Transgastrostomic ERCP may
be recommended in patients having gastrostomy.
Endoscopy_UCTN_Code_TTT_1AR_2AK
