Suture Anchor for Visceral Drainage

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Suture Anchor                                        for Visceral                           Drainage
Constantin             Cope1

      Recently,        interest      has increased         in devising     percutaneous              be necessary, it may easily be removed: The center suture is cut to
techniques         for inserting          tubes into the stomach           [1] and drains            release the retention device within the visceral lumen and a 5-French
into the gallbladder    [2] and other hollow viscera [3]. Because                                    plastic sheath is threaded over the untaped end suture back into the
                                                                                                     viscus (fig. 2D); when gentle traction is exerted on the end suture,
there is an inherent      risk of spillage of gastric juices, bile, or
                                                                                                     the crossbar will realign itself along the axis of the sheath lumen and
infected fluids into the abdominal        cavity because  of invagina-
                                                                                                     can then be easily withdrawn along with the sheath (fig. 2E).
tion [4] of the visceral wall during tract dilatation     or malinser-
tion of drains due to intraperitoneal coiling of guide wires [5],
safer methods    have been devised, including percutaneous
endoscopic    gastrostomy    [1 ], the Hawkins    accordion     system
[6], and air or balloon distension     of the stomach     [7]. None of
these techniques,                 however,      prevents      harmful    leakage      during
early drain exchanges  or intravisceral    catheter manipulations.
A new simple removable     retention    device is described    which
serves to firmly anchor the visceral wall against the parietal
wall for safer drain insertion.

Materials         and     Methods

    The device consists of a stainless-steel  cannula or rod 6-1 0 mm
long that is jacketed in a plastic or helical spring sheath (OD, 0.87
mm) and fitted with a center and an end suture. The part of the
suture that arises from the center of the anchoring device is armed
with a curved cutting needle. The purpose of the sheath is to provide
atraumatic floppy ends to the stiff crossbar (fig. 1).
    A 15-cm, 22-gauge fine needle over which is telescoped a 5-cm,
1 6-gauge plastic-sheathed   needle is used for puncture. Once the
distended viscus lumen is localized with the protruding fine needle,
the sheathed needle is advanced over it, and the sheath left in place.
The anchor device is aligned with the end suture trailing and pushed
through the plastic sheath with a 0.038-inch (0.96-mm) J guide wire
into the cavity         of the hollow       viscus   (fig. 2A). When     the center   suture
is pulled back with the sheath, the retention bar will align itself
perpendicularly  to the needle tract. On further traction the crossbar
will engage the visceral wall and eventually bring it into close approx-
imation to the body wall(fig. 2B). With the visceral wall firmly retracted
against the panetal wall, there is little chance of intraperitoneal
    The tension of the center thread is maintained by suturing it to the
skin, thus preventing              retraction   of the viscus.     The wire guide,        which
had previously been inserted into the cavity, can now be used to
further dilate the tract and insert a drain with impunity (fig. 2C). The
loose end suture is taped to the drain. A few days later, when the                                      Fig. 1 -Floppy-tip     spring-sheathed   suture anchor. Center   suture    with
drain tract has been established and the anchor device may no longer                                 needle is for retraction and fixation; end suture is for removal.

      Received December 14, 1984; accepted after revision August 28, 1985.
      1Department of Radiology, Temple University School of Medine,   Albert Einstein Medical Center, Northern                    Division, York and Tabor   Ads., Philadelphia,    PA
AJR     146:160-161,       January      1986 0361-.803X/85/1461-01600          American      Roentgen Ray Society
AJR:146,      January      1986                                    SUTURE         ANCHOR           FOR   VISCERAL             DRAINAGE                                                           161


    Fig. 2-A,   Suture anchor has been pushed through cannula
into viscus with J wire. Traction on center suture is beginning. B,
Further    traction     of center   suture   causes     approximation   of visceral
wall to abdominal wall. Plastic sheath has been removed. C,
Centerthread isfirst clamped and then sutured to skin to maintain
retractile tension. After dilatation of tract, large (12-French) drain
is inserted over guide wire without fear of visceral mnvagmnation.
0, Center suture has been severed, releasing crossbar within
viscus lumen. A 16-gauge plastic cannula is threaded over long
end suture into lumen. E, With increasing tension on end suture,
anchor will realign itself along axis of cannula and can easily be
pulled out with sheath.

                                                                                           D                                                           E

    I have safely used the suture anchor (provided      by J. Roberts of                                 obstructed  viscus [1 1 ], catheter                     manipulation        [1 2], endos-
Cook) as a preliminary step before inserting a 12-French loop drain                                      copy of gallbladder,  or chemical                       dissolution       of gallbladder
[8] in three percutaneous   gastrostomies    and two cholecystostomies                                   stones [13].
in five patients. Apposition of the anterior wall of the viscus to the                                       In my preliminary  experience     with the use of the suture-
parietal peritoneum secured by the suture anchor was further rein-
                                                                                                         anchoring   device, I have found it perfectly    safe to selectively
forced by gently pulling on the loop retention drain and maintaining
                                                                                                         intubate  the duodenum      immediately    after the percutaneous
that tension by attaching a Molnar disk to the drain at skin level.
There were no symptoms         of peritonitis or infection. The suture                                   gastrostomy            in order to place a feeding                 loop gastroduoden-
anchors were easily removed 1 week after positioning, and endo-                                          ostomy        tube     without      waiting       1-2   weeks       for a firm gastros-
scopic inspection with the Needlescope         (Dyonics) of the visceral                                 tomy tract to form.               Likewise,       in one patient         with a percuta-
lumen showed no residual inflammatory mucosal changes caused by                                          neous cholecystostomy        drain and a common-duct                               stone, it
the device. Although this technique takes advantage of using the                                         was possible to temporarily      remove the drain 2 days                          later and
same tract for both the suture anchor and the drain, it is also possible                                 catheterize  the cystic duct in an attempt      to entrap                       the stone
to insert additional anchors for better organ fixation through separate                                  in a basket and push it into the duodenum,          without                       incurring
punctures, but so far this has not been necessary. Loop gastroduo-                                       any biliary peritonitis. Further experience     is needed                        to further
denostomy feeding tubes (Cook) were exchanged at 3-month inter-
                                                                                                         explore the potential    wide usefulness    of the suture                       anchor.
vals, and cholecystostomy    loop drains were removed before surgery
a few weeks later.
Discussion                                                                                                1 . Ponsky          JL, Gauderer       MWL, Stellato TA. Percutaneous               endo-
                                                                                                               scoplc   gastrostomy:              review  of 150 cases. Arch                    Surg
   The purpose               of the suture            anchor     is to mobilize       atraumati-               1983;1 18:913-914
cally and tamponade                    internally       the wall of the stomach,               gall-      2.   Shaver RW, Hawkins IF Jr, Soong J. Percutaneous                        cholecystos-
bladder, bowel, and superficial  abscesses    against the abdom-                                               tomy.    AJR 1982;138:1133-1136
inal and chest wall, so that catheter   exchanges     and manipu-                                         3.   Bezreh     JS. Percutaneous          catheter drainage of closed-loop          small-
lations      may         be performed             without         intraperitoneal        leakage               bowel     obstruction.       MR    1983;141       :797-798
before and while inserting           a larger retention    drain. Although                                4.   Preshaw RM. A percutaneous method for inserting a feeding
                                                                                                               gastrostomy tube. SLug Gynecol Obstet 1981;152:659-661
percutaneous       intubation     of the gallbladder    and stomach     have
                                                                                                          5. Wills JS, Ogleby JR. Percutaneous                     gastrostomy:      further experi-
been performed         with little morbidity      so far in several series
                                                                                                               once.    Radiology         1985;154:71-74
[1 , 5, 6, 9], I believe that initial percutaneous        mobilization and                                6. Pearse DM, Hawkins IF Jr, Shaver A, Vogel S. Percutaneous
fixation      of a hollow           viscus by suture              anchoring       represents       a         cholecystostomy      in acute cholecystitis    and common duct ob-
good surgical principle    that should result in fewer instances                                             struction. Radiology    1984;i 52:365-367
of peritonitis, especially  in accidental  tube withdrawal     [2, 10]                                    7. vanSonnenberg      E, Cubberley DA, Brown LK, Wittich GR, Lyon
before the drain tract is well established,    drainage    of a tense                                        JW, Stanffer AE. Percutaneous        gastrostomy:   use of intragastric
162                                                                     COPE                                                      AJR:146,   January   1986

    balloon support. Radiology     1984;152:531-532                            1 1 . Phillips G, Bank 5, Kumari-Subaiya     S, Kurtz LM. Percutaneous
 8. Cope C. Improved anchoring of nephrostomy          catheters: loop               ultrasound-guided    puncture of the gallbladder (PUPG). Radiology
    technique. AJR 1980135:402-403                                                   1982;145:769-772
 9. McGahan JP, Walter JP. Diagnostic percutaneous         aspiration of       12. Mazzariello       AM. Residual biliary tract stones: non-operative
    the gallbladder. Radiology    1985;1 55: 61 9-622                                treatment of 570 patients. Ann Surg 1976;8:130-133
10. Strodel WE, Eckhauser FE, Lemmer JH, Knol JA, Dent TL.                     13. Allen MJ, Borody      TJ, Bugliosi TF, May GA, et al. Rapid dissolu-
    Endoscopic       percutaneous      gastrostomy.   Contemp        Surg            tion of gallstones by methyl tert-butyl ether. N EngI J Med
     1983;23: 17-23                                                                  1985;312:217-220