A Novel Method of Punctured Miller-Abbott Tube Placement Using a Guidewire Under Fluoroscopic Guidance

Transcription

1 Vascular and Interventional Radiology Original Research Park et al. Placement of Miller-Abbott Tube With Guidewire Vascular and Interventional Radiology Original Research Jung-Hoon Park 1 Ho-Young Song Sung Hee Min Ye Jin Lee Min Song Eun Young Kim Park JH, Song HY, Min SH, Lee YJ, Song M, Kim EY Keywords: ileus, Miller-Abbott tube, small-bowel obstruction DOI: /AJR Received April 26, 2011; accepted after revision July 21, All authors: Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea. Address correspondence to H. Y. Song (hysong@amc.seoul.kr). WEB This is a Web exclusive article. AJR 2012; 198:W274 W X/12/1983 W274 American Roentgen Ray Society A Novel Method of Punctured Miller-Abbott Tube Placement Using a Guidewire Under Fluoroscopic Guidance OBJECTIVE. The purpose of this article is to evaluate the usefulness of a new technique for placing Miller-Abbott tubes in patients with small-bowel obstruction. SUBJECTS AND METHODS. The Miller-Abbott tube was placed in 10 patients by use of the conventional method (group A) and in 11 patients with a punctured Miller-Abbott tube with the use of guidewire (group B). Technical success was defined as insertion of the tube into the duodenum beyond the pylorus of the stomach in group A and into the jejunum beyond the Treitz ligament in group B. Clinical success was defined as intestinal decompression and relief of obstructive symptoms. We evaluate the correlations between the cause of obstruction and the end results. RESULTS. The success rate of the tube placement was 40% (4/10) in group A and 100% (11/11) in group B. Clinical success of tube placement was achieved in five of 10 patients (50.0%) in group A and in nine of 11 patients (81.8%) in group B. Carcinomatosis was associated with significantly decreased clinical success rates in both groups (p = in group A; p = in group B). The mean (± SD) procedure time for placement of the Miller-Abbott tube was 35.8 ± 8.13 minutes in group A and 15.3 ± 5.93 minutes in group B, with a statistically significant difference (p < 0.001). CONCLUSION. The new technique of placing a punctured Miller-Abbott tube with the use of a guidewire enables the tube to pass through the pylorus and the Treitz ligament while significantly reducing the procedure time, with no clinical disadvantages caused by the puncture site. S mall-bowel obstruction due to mechanical bowel blockage or paralytic ileus can lead to progressively worsening abdominal pain, in cases of simple obstruction, or even fatality, in cases of strangulated obstruction. Previous studies have shown that the placement of a Miller-Abbott tube can be a safe and effective conservative treatment option for decompressing these obstructions [1 3] and that clinical improvement can be significantly increased and mortality highly reduced [4, 5]. However, placement of a Miller-Abbott tube into the target site has often proven to be difficult, especially when the obstruction is located in the jejunum. Although several techniques, such as placing mercury in the balloon portion of the tube or incorporating a wire stylet in the tube, have been attempted to improve the technical success rate of tube placement through the pylorus [1, 4, 6, 7], the success rate of tube placement still remains unsatisfactory [1]. Recently, several studies have reported that an endoscopy-guided technique allowed the tube to pass easily through the pylorus and reduced the total procedure time [8 11]. However, by its very nature, it evoked anxiety, a feeling of vulnerability, and discomfort for the patients [10, 12]. Furthermore, without the use of a guidewire, although the pylorus was able to be passed, it remained difficult to pass further beyond the Treitz ligament [11]. Since 2004, we have adopted the use of Miller-Abbott tubes in patients referred for tube placement by changing the patients body position under fluoroscopic guidance for conservative treatment of small-bowel obstruction. However, as described in other studies, this method resulted in low technical success rates because of the difficulty of passing through the pylorus and the Treitz ligament. To overcome these limitations, we have devised a new technique by which a punctured Miller-Abbott tube could be easily and quickly glided over a guidewire and W274 AJR:198, March 2012

2 Placement of Miller-Abbott Tube With Guidewire in conjunction placed past the pylorus and Treitz ligament under fluoroscopic guidance. The goal of this pilot study was to evaluate the usefulness of this new technique of Miller-Abbott tube placement in patients with small-bowel obstruction. Subjects and Methods Patients This prospective study was approved by our institutional review board, and informed consent for Miller-Abbott tube placement was obtained for each patient. From July 2004 to January 2010, a total of 21 Miller-Abbott tubes were placed in 21 patients with small-bowel obstruction. The patients were divided into two groups according to the technique used to place the Miller-Abbott tube. In group A, 10 Miller-Abbott tubes were placed in 10 patients using conventional methods of insertion without the use of a guidewire from July 2004 to July 2009; in group B, 11 Miller- Abbott tubes were placed in 11 patients using a modified punctured Miller-Abbott tube with the use of a guidewire, starting from August 2009 when we first devised the new technique. The inclusion criterion for Miller-Abbott tube placement was documented small-bowel obstructions. The exclusion criteria were (1) clinical evidence of bowel perforation or peritonitis (2) and previous esophageal or gastroduodenal obstructions. The characteristics of the two patient populations are summarized in Table 1. There was no statistically significant difference in mean age or sex between groups A and B. Miller-Abbott Tube Placement Techniques In group A, after application of a topical nasal anesthesia, a long conventional (> 3 m) doublechannel intestinal Miller-Abbott tube (Song-Lim Gastric Catheter, Fuji Systems), consisting of one lumen for suction and the other lumen connected to an inflatable balloon [13, 14], was inserted through the patient s nasal cavity. When the distal part of the tube reached the gastric pylorus, we repeatedly repositioned the patient s body under fluoroscopic guidance in order for the Miller-Abbott tube to pass through the pylorus, as has been described in previous studies [9 11]. In group B, before tube placement, the suction lumen of a standard Miller-Abbott tube was punctured using a 16-gauge angiocatheter (BD Angiocath Plus, Becton Dickinson Korea) along with a central needle cm from the distal tip of the tube. The central needle was then removed while the angiocatheter was left in place, allowing the guidewire to be later passed in and out through the angiocatheter easily (Fig. 1). The puncture site of the tube was determined to be cm from TABLE 1: Characteristics of 21 Patients With Small-Bowel Obstruction Characteristic Group A (n = 10) Group B (n = 11) p Age (y), mean ± SD (range) 53.1 ± 17.1 (32 78) 64.8 ± 14.9 (39 89) Sex Male 3 (30.0) 5 (45.5) Female 7 (70.0) 6 (54.5) Type of obstruction Adhesion (postoperative) 5 (50.0) 7 (63.6) Carcinomatosis (peritoneal seeding) 3 (30.0) 4 (36.4) Paralytic obstruction 1 (10.0) 0 (0.0) Unknown 1 (10.0) 0 (0.0) Symptom Repeated vomiting 5 4 Abdominal pain 8 9 No gas out 3 3 L-tube present 8 (80.0) 9 (81.8) Note Except where noted otherwise, data are no. (%) of patients. the distal tip because it was the optimal location to reduce the friction between tube and guidewire while providing sufficient stiffness to the tube. Then, after application of a topical anesthesia to the nasal cavity using an aerosol spray, a 260-cm hydrophilic exchange guidewire (Radifocus M, Terumo) was carefully passed through the nasal cavity into the gastrointestinal tract under fluoroscopic guidance. When the guidewire was not able to pass through the jejunum, we used a coil catheter (Phycon, S&G Biotech) to negotiate the guidewire beyond the jejunum without difficulty [15]. After the guidewire was placed in the jejunum, the punctured Miller-Abbott tube was passed over the wire from the distal tip of the Miller-Abbott tube through the nasal cavity. After the tube was passed approximately cm over the guidewire, the guidewire was manipulated out through the angiocatheter, which was held in place at the tube s puncture site just outside of the nasal cavity. After the guidewire was manipulated out through the puncture site, the angiocatheter was removed. From that moment, the Miller-Abbott tube and the guidewire were inserted together until the distal tip of the Miller-Abbott tube reached the jejunum. At the time the distal tip of the Miller-Abbott tube was placed in the jejunum, the puncture site was located in the stomach. Finally, the guidewire was removed through the puncture site, and the balloon at the distal tip of the second lumen was inflated with diluted water soluble contrast medium. After final placement, the Miller-Abbott tube was fixed to the patient s face with tape. Thereafter, a tubogram was performed with 50 ml of a contrast medium (iohexol; Omnipaque 3000, GE Healthcare) to evaluate the location and patency of the Miller-Abbott tube (Fig. 2). Follow-Up Study and Evaluation of Outcome All patients underwent radiography immediately after tube placement to verify the location of the tube. Thereafter, follow-up radiography was performed every 24 hours to evaluate further movement of the tip of the Miller-Abbott tube and improvement of bowel obstruction. We investigated the efficacy of this new technique compared with the conventional method in terms of the technical success rate, total procedure time, clinical improvement, and complications. Technical success was defined as insertion of the tube into the jejunum beyond the Treitz ligament. The total procedure time was calculated from Miller-Abbott tube insertion to final placement of the Miller-Abbott tube for group A, and from guidewire insertion to final placement of the Miller-Abbott tube for group B. Clinical improvement was defined as intestinal decompression and relief of the obstructive symptoms, according to clinical assessment and radiographic observation. The Fisher exact test was used to evaluate the correlations between cause of obstruction and end results (clinical and technical success rates). Statistical Analysis The statistical significance of parametric data was determined using Student t test, and that of nonparametric data was determined using the chi-square or Fisher exact test. A two-sided p value less than 0.05 was considered to indicate statistical significance. All statistical analysis was performed using the SPSS software package (version 17, SPSS). AJR:198, March 2012 W275

3 Park et al. Results Technical success rates of tube insertion were 40% (4/10) in group A and 100% (11/11) in group B (p < 0.001). In group A, the tubes of four patients were not able to be manipulated past the pylorus because of the extreme angulation of the stomach, and the tubes of two patients were not able to be passed beyond the Treitz ligament because of the anatomic structure of the duodenum. The mean (± SD) procedure time for the placement of the Miller-Abbott tube was 35.8 ± 8.13 minutes in group A and 15.3 ± 5.93 minutes in group B, with a statistically significant difference (p < 0.001). Clinical success of tube placement was achieved in five of 10 patients (50.0%) in group A and nine of 11 patients (81.8%) in group B (p = 0.023). Carcinomatosis was associated with significantly decreased clinical success rate in both groups (p = in group A; p = in group B). There was no significant difference of correlations between cause of obstruction and technical success rate (Table 2). The mean duration of tube placement was 8.33 ± 4.80 days in group A and 9.09 ± 5.07 days in group B. The mean amount of daily tube drainage was ± ml in group A and ± ml in group B (Table 3). A Fig. 1 Procedure for puncturing Miller-Abbott tube. A, Miller-Abbott tube. B, Miller-Abbott tube punctured by central needle and 16-gauge angiocatheter, and removal of central needle afterward. C, Wire passing through tube, puncture site, and angiocatheter. D, Punctured Miller-Abbott tube with guidewire. There were no statistically significant differences between the two groups. No complications relevant to the procedure, including clinically significant epistaxis, were encountered in either of the groups. Discussion The traditional treatment for small-bowel obstruction was originally based on surgery [16, 17]. As nonsurgical procedures developed to provide a curative management beyond a temporary symptomatic control, however, the focus of care switched from predominantly operative management to long intestinal tube decompression with fluid resuscitation. Except for the absolute indications for surgery, such as existence of the traditional signs of strangulation, long intestinal tube placement has been frequently used to treat small-bowel obstruction. The downsides to this approach were a higher proportion of missed strangulation obstructions, a greater need for small-bowel resections, and prolonged durations of stay [16, 17]. The placement of a long intestinal tube has long been used for the purpose of bowel decompression in patients with small-bowel obstruction [10 12, 18, 19]. However, it has also long proved difficult to pass the tube C through the pylorus, resulting in low technical success rates and a relatively long procedure time [1, 7, 10, 11]. The first major step in overcoming these limitations came in 1976, when Meissner and Weissenhofer [20] first introduced the technique of Miller-Abbott tube placement under endoscopic guidance. This technique provided much improvement to the reported success rates and the procedure time; however, without the use of a guidewire, it continued to remain difficult to pass the tube further through the Treitz ligament. Furthermore, because of the length of the tube and friction between the tube and the guidewire, the guidewire easily became uncontrollable during placement, leading to additional problems [11]. A more recent method for Miller-Abbott tube insertion with the use of a guidewire under endoscopic guidance, referred to as the ropeway method, has been reported to help insert the Miller-Abbott tube all the way into the jejunum [11]. In the ropeway method [11], after endoscopic placement, a guidewire was advanced through the working channel of the endoscope and was left in place while the endoscope was removed. Then the guidewire was passed through the tip hole of the long B D W276 AJR:198, March 2012

4 Placement of Miller-Abbott Tube With Guidewire A Fig year-old woman with postoperative adhesion. Tubograms show insertion of punctured Miller-Abbott tube with guidewire. A, Insertion of guidewire into proximal jejunum. B, Miller-Abbott tube passing over wire. C, Punctured Miller-Abbott tube located in proximal jejunum. TABLE 2: Results of Chi-Square of Fisher Exact Test for Evaluation of Correlations Between Cause of Obstruction and End Results Group A (n = 10) Group B (n = 11) Clinical Success (50%) Technical Success (40%) Clinical Success (81.8%) Technical Success (100%) Cause of Obstruction No. of Patients p No. of Patients p No. of Patients p No. of Patients p Adhesion (postoperative) NA 7 NA Carcinomatosis (peritoneal seeding) NA Paralytic obstruction NA NA NA NA Unknown NA NA NA NA Note NA = not applicable. TABLE 3: Technical Success Rate, Procedure Time, and Clinical Improvement in Both Groups of Patients Parameter Group A (n = 10) Group B (n = 11) p Technical success, no. (%) of patients 4 (40.0) 11 (100.0) < Procedure time (min) 35.8 ± 8.13 (26 47) 15.3 ± 5.93 (9 27) < Duration of tube placement (d) 8.33 ± 4.80 (3 15) 9.09 ± 5.07 (2 18) Amount of daily drainage (ml) ± ( ) ± ( ) Clinical improvement, no. (%) of patients 5 (50.0) 9 (81.8) Note Except where noted otherwise, data are mean ± SD (range). B tube to the most distal side hole (4 cm from the tip), with another splinting guidewire inserted close to the tip of the tube and inserted into the patient for placement. This method, according to their study, did help place the tube beyond the jejunum but was overly complicated and caused discomfort to the patient because of the necessity for an endoscopic insertion. In the current study, we have designed and assessed a new method of Miller-Abbott tube insertion that may overcome the problems associated with the conventional technique, and the results thus far have been highly successful. The technical success rate of this new technique, defined as placement of the Miller-Abbott tube into the jejunum (100%) was shown to be much better than the success rate in the conventional group (40.0%; p < 0.001) or the success rate of an endoscopic-guided technique reported in the literature (92 95%) [6, 11]. In addition, the mean total procedure time was significantly shorter with our new method (15.3 ± 5.93 minutes; n = 11) than with the conventional method (35.8 ± 8.13 minutes; n = 10). It is also shorter than the procedural time of long intestinal tube placement under endoscopic guidance ( minutes) reported in earlier studies [6, 11, 21 23]. One of the more distinct advantages of our tube insertion technique is the ability to place a Miller-Abbott tube into the jejunum with relative ease, compared with that under endoscopic guidance and with that of conventional insertion techniques. It also reduces the chance of complications from an endoscopy-guided technique and simplifies the procedure by obviating endoscope insertion, which has been reported to be quite uncomfortable for patients. C AJR:198, March 2012 W277

5 Park et al. In our study, the indication for the Miller- Abbott tube placement was small-bowel mechanical or paralytic ileus and small-bowel obstructions. However, the results of statistical analysis showed that carcinomatosis was associated with significantly decreased clinical success rates in both groups (p = in group A; p = in group B). This finding might be explained by the fact that peritoneal carcinomatosis has the theoretic risk of multifocal small-bowel obstructions and that the long intestinal tube is not effective for small-bowel decompression for this type of obstruction. For this reason, carcinomatosis was considered a relative contraindication to the placement of a long intestinal tube. The one major concern in designing our modification to the Miller-Abbott tube was that we made the puncture site cm from the distal tip, which is in the pathway through which the guidewire passes. There was a possibility that this could have affected the amount of drainage able to be performed, thus affecting the clinical improvement of our patients. However, in our study, the mean amount of daily drainage was ml in group A and ml (range, ml) in group B (p = 0.513). There was no evidence of significant decrease in the drainage amount (Table 3). However, the rate of clinical improvement was higher in group B than in group A. This difference was caused by the differences in procedure time and in the position of the distal tip of the Miller-Abbott tube. Thus, the size of the puncture site was too small to influence the efficacy of the drainage. In summary, the newly developed tube placement technique using a punctured Miller-Abbott tube has several potential advantages over the conventional tube placement technique. First, it is easy to place the punctured tube under fluoroscopic guidance with the use of a guidewire, allowing the tube to pass through the pylorus and Treitz ligament while significantly reducing the procedure time. Second, there are no complications that could have occurred had an endoscope been used while still allowing placement of the Miller- Abbott tube into the jejunum with a 100% technical success rate. Thus, for patients with a contraindication for the use of an endoscope, this technique can become especially useful. The current study was limited by the small number of patients. A larger-scale prospective study needs to follow. In conclusion, this new technique of placing a punctured Miller-Abbott tube with the use of a guidewire enables the tube to pass through the pylorus and Treitz ligament while significantly reducing the procedure time, with no clinical disadvantages caused by puncturing the tube. We believe that this technique has advantages for patients with small-bowel obstructions. Moreover, a shorter procedure time and a lower failure rate will yield less radiation exposure to both patients and operators. We, therefore, expect that this method will become widely used in the future. References 1. Smith BC. Experience with the Miller-Abbott tube. Ann Surg 1949; 130: Smith BC, Beuren FT. Acute ileus. Ann Surg 1943; 117: Abbott WO, Johnston CG. A non-surgical method of treating, localizing and diagnosing the nature of obstructive lesions. Surg Gynecol Obset 1938; 66: Loe RH, Tuohy CE Jr. Technic and indications for Miller-Abbott tube intubation: rapid method of introduction. Am J Surg 1959; 98: Leigh OC Jr, Nelson JA, Swenson PC. The Miller- Abbott tube as adjunct to surgery of small intestinal obstruction. Ann Surg 1940; 111: Ishizuka M, Nagata H, Takagi K, et al. Transnasal fine gastrointestinal fiberscope-guided long tube insertion for patient with small bowel obstruction. 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