Percutaneous Endoscopic Gastrostomy

The development of an endoscopic procedure for the placement of a gastrostomy feeding tube has revived interest in the use of this technique for nutritional support. The medical literature has reported a considerable amount of experience which attests to its ease of placement and low incidence of complications associated with placement. The "push" and "pull" techniques both have been used effectively to establish access to the stomach. Innovations by numerous practitioners have helped reduce some of the minor complications associated with percutaneous endoscopic gastrostomy (PEG) placement. Serious complications from pulmonary aspiration and stomal infection remain important management issues after gastrostomy placement and initiation of feeding. The adequacy of nutritional support should be the final measure of successful PEG placement.     

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy

There are a variety of techniques for gastrostomy tube placement. Endoscopic and radiologic approaches have almost entirely superseded surgical placement. However, an aging population and significant advancements in modern healthcare have resulted in patients with increasingly complex medical issues or postsurgical anatomy. The rising prevalence of obesity has also created technical challenges for proceduralists of many specialties. When patients with these comorbidities develop the need for long-term enteral nutrition and feeding tube placement, standard approaches such as percutaneous endoscopic gastrostomy (PEG) by endoscopists and percutaneous image-guided gastrostomy (PIG) by interventional radiologists may be technically difficult or impossible. For these challenging situations, laparoscopic-assisted PEG (LAPEG) is an alternative option. LAPEG combines the advantages of PEG with direct intraperitoneal visualization, helping ensure a safe tube placement tract free of intervening organs or structures. In this review, we highlight some of the important factors of first-line gastrostomy techniques, with an emphasis on the utility and procedural technique of LAPEG when they are not feasible.     

A New Complication of Percutaneous Endoscopic Gastrostomy

Two cases of complications of percutaneous endoscopic gastrostomy are described that have not been reported previously. Each had misplacement of a gastrostomy tube in the intestine, one in the transverse colon resulting in profuse diarrhea and metabolic acidosis, and the other in the jejunum causing adhesions with subsequent small bowel obstruction. An explanation of these complications and suggestions for prevention are presented.     

Outcomes of Percutaneous Endoscopic Gastrostomy in Children

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe and minimally invasive surgical method for providing enteral access in children. In pediatrics, the indications for PEG placement frequently include malnutrition or failure to thrive, as well as oropharyngeal dysphagia, especially in children with neurological impairment (NI). The risk for postoperative complications is low. However, among children with NI, gastroesophageal reflux disease (GERD) may necessitate fundoplication prior to gastrostomy tube placement. Preoperative pH probe testing has not been shown to be an effective screening tool prior to PEG placement among patients with GERD. Laparoscopic gastrostomy tube insertion was introduced in pediatric patients in an attempt to decrease complications associated with PEG. Although outcomes were reported to be similar to or better than PEG alone, future comparative studies are needed to better define the optimal patient demographic for this technique.     

Percutaneous Endoscopic Gastrostomy: A Preferred Method of Feeding Tube Gastrostomy

Percutaneous endoscopic gastrostomy was attempted in 16 patients using local anesthesia and intravenous meperidine and diazepam sedation. The procedure was shown to be safe, easy to perform, and avoided the need for laparotomy. We suggest percutaneous endoscopic gastrostomy be the preferred route of alimentation in those patients requiring feeding gastrostomy.     

Effect of Antibiotic Prophylaxis in Percutaneous Endoscopic Gastrostomy

Thirty-three patients completed a prospective double-blind, randomized study to compare the effect of antibiotic prophylaxis or placebo on percutaneous endoscopic gastrostomy-associated wound infections. We define wound infection and arrive at an incidence of 29.4% in patients receiving Cefoxitin antibiotic prophylaxis and 31.2% in patients receiving placebo. Based on these results, we do not recommend antibiotic prophylaxis for percutaneous endoscopic gastrostomy tube placement.     

Rehabilitation of Neurogenic Dysphagia with Percutaneous Endoscopic Gastrostomy

Neurogenic oropharyngeal dysphagia is common in nursing home populations, and the risk of aspiration is sufficient to indicate the need for percutaneous endoscopid gastrostomy (PEG) feedings. Although intake provided through the PEG may meet the nutritional and hydration requirements for this group of patients, the risk of complication, e.g., aspiration of reflux, skin breakdown at the site of insertion, potential for infection, digestive difficulties, higher risk of rehospitalization, pneumonia, prolonged nursing home stay, and greater morbidity than for those without PEG tubes, may compromise the gains accrued from the ease of feeding. In an attempt to reduce these complications and return individuals to per orum (PO) diets, a program was developed to treat the dysphagia. Sixteen male nursing home patients were enrolled in a treatment program based on videofluoroscopic examination. Interventions included combinations of dietary consistency modifications, compensatory techniques, and direct swallow retraining. Results indicated such an approach reintroduced successful oral feeding in all patients, improved dietary consistency, resulted in a mean weight gain of 5.1 pounds, yielded a mean albumin increase of 0.5 g/dl, and allowed PEG tubes to be removed in 10 of the 16 patients. As a result of intervention, these findings suggest significant benefits in both quality of life issues and health care savings for this neurogenically based population.     

Risk Factors for Complications of Percutaneous Endoscopic Gastrostomy

Background

Percutaneous endoscopic gastrostomy (PEG) is a commonly performed procedure for patients with severe dysphagia leading to malnutrition. Improved knowledge of risk factors for PEG-related complications might decrease patient discomfort and healthcare costs.

Aim

The aim of the present study was to investigate factors associated with complications after PEG.

Methods

A retrospective review was performed for all patients referred for PEG placement from December 2002 to December 2012 in single-tertiary care center. PEG-related complications and risk factors were evaluated through chart reviews, endoscopic reports, and endoscopic and radiologic images.

Results

Among a total of 245 consecutive individuals (146 male, mean age 59.2 ± 12.6 years) enrolled, 43 major complications had developed. Multivariate analysis revealed that patients with an internal bolster of a PEG tube in the upper body of stomach were at significant risk for early [OR 6.127 (95 % CI 1.447–26.046)] and late complications [OR 6.710 (95 % CI 1.692–26.603)]. Abnormal leukocyte counts [OR 3.198 (95 % CI 1.174–8.716)], stroke as an indication for PEG [OR 3.047 (95 % CI 1.174–8.882)], and PEG tube placement by an inexperienced endoscopist [OR 3.401 (95 % CI 1.073–10.779)] were significantly associated with early complications.

Conclusions

A PEG tube should not be inserted into the upper body of stomach to reduce complication risk, and PEG procedures should be performed by skilled endoscopists to prevent early complications. An abnormal leukocyte count can be a predictor of early complication, and care is needed when PEG is performed for patients with stroke.     

Comparison of Percutaneous Endoscopic Gastrostomy with Surgical Gastrostomy at a Community Hospital

The results of percutaneous endoscopic gastrostomies in 100 patients in a community hospital were compared with those of surgically placed gastrostomies in 50 patients. The morbidity rate for the percutaneous endoscopic gastrostomy group was 4%, compared with 30% for the patients with surgically placed gastrostomies. The procedure-related mortality for percutaneous endoscopic gastrostomy was 1%, compared with 16% for surgically placed gastrostomies. Patients admitted to the hospital for percutaneous endoscopic gastrostomy stayed an average of 4 days compared with 10 days for the surgical patients; 14 patients had the percutaneous endoscopic gastrostomy performed as an outpatient procedure. There were no complications in this group, suggesting that percutaneous endoscopic gastrostomy can be safely performed as an outpatient. In this community hospital, percutaneous endoscopic gastrostomy was both substantially safer and far less expensive than surgically placed gastrostomy.     

Esophageal Biopsy Does Not Predict Clinical Outcome after Percutaneous Endoscopic Gastrostomy in Children

Clinically symptomatic gastroesophageal reflux may occur after percutaneous endoscopic gastrostomy (PEG). Preoperative evaluation for gastroesophageal reflux does not reliably predict those individuals who will develop reflux unresponsive to medical management after PEG. Esophageal histology at the time of PEG might be used to identify patients at risk for developing intractable gastroesophageal reflux. The study aim was to correlate the clinical outcome after PEG with esophageal histology at the time of PEG insertion. A retrospective review of 68 consecutive children who had an esophageal biopsy obtained at the time of PEG insertion was undertaken. Preoperative evaluation, esophageal histology, and clinical outcomes were compared. Preoperative gastroesophageal reflux was present in 23% of upper gastrointestinal series performed, in 10% of pH probe studies, and in 29% of reflux scans. Histology was normal in 57% of esophageal biopsies obtained at the time of PEG insertion. Symptomatic gastroesophageal reflux requiring antireflux surgery or conversion to gastrojejunostomy developed in 10% of patients after PEG placement. Only one of these patients had esophagitis on biopsy. In conclusion, preoperative esophageal histology does not reliably predict the development of symptomatic gastroesophageal reflux after PEG placement.     

Outcome of Rehabilitation and Swallowing Therapy after Percutaneous Endoscopic Gastrostomy in Dysphagia Patients

The objective of this study was to investigate the outcomes of rehabilitation (with swallowing therapy) after percutaneous endoscopic gastrostomy (PEG) in patients with neurogenic dysphagia. Forty-seven patients (29 males and 18 females) who were transferred to the rehabilitation ward of our hospital after receiving PEG tube placements during a 5-year period were enrolled in this study. Patients’ demographic data, comorbidities, nutritional statuses, and laboratory biomarkers before the PEG procedure were collected. Rehabilitation (with swallowing therapy) outcomes such as changes in Functional Independence Measure (FIM) and dysphagia grade (using Fujishima’s classification) were evaluated. Significant improvements in FIM scores and dysphagia grades after rehabilitation therapy were observed. Twenty-seven patients (57.4 %) were discharged with some oral intake and 10 patients (21.3%) were discharged PEG-free (defined as the PEG tube not being used or removed). Factors associated with being discharged with some oral intake were increase in FIM score (adjusted OR 1.10, 95 % CI 1.02–1.19) and higher baseline dysphagia grade (adjusted OR 1.88, 95 % CI 1.04–3.39). Factors associated with being discharged PEG-free were longer rehabilitation period (OR 1.03, 95 % CI 1.01–1.04), absence of respiratory disorders (OR 0.12, 95 % CI 0.03–0.35), and increase in FIM score (OR 1.17, 95 % CI 1.08–1.28). Changes in dysphagia grade were significantly correlated with changes in FIM score (r ² = 0.46, p < 0.0001), indicating that improvement of FIM scores through general rehabilitation therapy may play an important role in the treatment of dysphagia.     

Traction Removal of Percutaneous Endoscopic Gastrostomy Devices in Children

Background  

There are few published data on non-endoscopic removal of percutaneous endoscopic gastrostomy devices in children.     

Safety and Efficacy of Percutaneous Endoscopic Gastrostomy in Children

Objectives: To establish the safety and efficacy percutaneous endoscopic gastrostomy (PEG) placement for nutritional support in children. Methods: The charts of 70 children who underwent the procedure between 1989 and 1992 were reviewed. Three of the 70 had repeat PEG placement. Patients ranged in age from months to 24 yr, and included 28 females and 42 males. In all patients, the weights at the time of insertion the PEG, and in 64, weight after 6 months of nutritional support, were compared by Z-score, and the incidence of major and minor complications was determined. Results: Forty-five of 70 patients (70%) had improved nutritional status after initiation of PEG feedings, and in three (4%), the weight was maintained despite limited oral intake. Patients with congenital heart disease (86%) and cystic fibrosis (80%) derived the greatest benefit from the enteral feedings. Major complications were noted in 13 (19%) patients and minor complications in 16 (22%). Nine of 13 (70%) major complications and four of 116 (25%) minor complications occurred the 12 (17%) children with multi-system organ failure. The rate of major complication was significantly greater in children with multi-system organ failure than in patients ( p < 0.001) and their relative risk of complication was increased by a factor of 40. Conclusions: Our data indicate that PEG is a safe and effective modality for nutritional support in children without multi-system organ failure. Those with multi-system organ failure have an increased rate of complications and a poor response to nutritional support, suggesting that the risk of PEG may outweigh its benefit for this population.