Gastrointestinal interventons

Percutaneous gastroenterostomy

In patients who are in need of long-term nutritional therapy for swallowing disorders or tumor obstruction of the esophagus percutaneous placement of a feeding tube into the stomach or jejunum under fluoroscopic control is a low risk procedure. The main advantage over endoscopic gastrostomy is that the radiologic procedure is feasible even in patients with complete obstruction of the upper gastrointestinal tract. In contrast to a surgical approach percutaneous placement of a feeding tube is particularly useful for patients in poor physical condition.

Jejunal feeding may be accomplished via a percutaneous gastrostomy by manipulating the feeding tube into the jejunum. In patients after total gastrectomy or with extensive tumor infiltration of the stomach, the feeding tube can be placed directly into the jejunum.

Dilatation and stenting of oesophageal and enteric strictures

Since the early 80s guidewire guided balloon dilatation catheters have been used to treat enteric strictures under fluoroscopy. Although oesophageal lesions have been most frequently treated, symptomatic strictures in the pylorus, colon and stenosed surgical anastomoses also have been dilated. Using over the wire balloon techniques benign oesophageal strictures can be safely dilated with a lower risk of complication (perforation) compared to the bougienage method. Very tight stenoses can be negotiated using hydrophilic guidewires and angiographic catheters. For anastomotic strictures balloon dilation is often the only non-operative technique because the lesions cannot be reached by conventional bougies. Usually these anastomotic strictures respond very well to balloon dilation. In the oesophagus at sites of oesophagogastric, oesophagojejunal or esophagocolonic anastomoses, the same techniques are used as for primary oesophageal lesions.

For inoperable malignant tumors of the oesophagus or anastomotic recurrences after partial or total gastrectomy balloon dilation does not offer a durable palliation. Metallic endoprostheses, mainly of the self-expanding types or Nitinol stents, have been tried in an attempt to improve the results of dilation. Initial results have been quite encouraging although tumor in growth into the stent may occur quite rapidly. To

prevent tumor invasion into the stented area covered stents are currently being tested (Fig. 13).

Christoph Zollikofer