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.     

Experience with Percutaneous Endoscopic Gastrotomy in a Community Hospital

Percutaneous endoscopic gastrotomy (PEG) has become the procedure of choice for meeting long-term nutritional needs in chronically ill patients. To determine the complication and mortality rates in a community hospital, we performed a retrospective analysis of 224 patients having PEG placement over a 2-yr period. Our study indicates that the morbidity and mortality resulting from PEG placement in a community hospital should be similar to that reported from large university studies.     

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 Endoscopic and radiologic approaches have almost entirely superseded surgical placement.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.     

Pneumoperitoneum after Percutaneous Endoscopic Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is a safe and widely used technique to establish an enteral feeding route. It has eliminated much of the operative morbidity associated with gastrostomy placed by laparotomy. Although pneumoperitoneum can be seen after surgery and in association with certain endoscopic procedures, it has not been seen after percutaneous endoscopic gastrostomy. We describe a patient who developed a benign pneumoperitoneum after insertion of a percutaneous gastrostomy tube.     

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.     

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.     

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.     

Percutaneous Endoscopic Gastrostomy with Jejunal Extension: A New Technique

Percutaneous endoscopic gastrostomies (PEG) with jejunal extensions are placed in patients at risk for aspiration of gastric contents. Current methods used are difficult and often ineffective in preventing aspiration, and frequently result in substantial morbidity and mortality. In this study, a new method of jejunal extension from a PEG was evaluated with regard to efficacy and prevention of aspiration of gastric contents while providing adequate enteral nutrition. Twelve patients with recent aspiration pneumonitis underwent PEG placement with a jejunal extension by this new method. The technique was accomplished rapidly and without difficulty in an average time of 26.2 min (range 17-31 min). In all instances, the jejunal extension remained functional for the first 8 wk after placement, and there were no instances of aspiration of gastric contents while nutritional requirements were met. None of the patients died from complications of the procedure. The method described was effective in preventing aspiration of gastric contents, was easily performed, and was associated with minimal complications.     

Buried Bumper Syndrome as a Rare Complication of Percutaneous Endoscopic Gastrostomy

Abstract: Percutaneous Endoscopic Gastrostomy (PEG), which can be performed under local anesthesia and does not require laparotomy, has become an accepted means of providing long-term nutritional support for patients who cannot swallow. PEG can be successfully performed in 10–20 minutes with minimal invasion. Although the incidences are low, some complications with PEG have been reported. We describe herein a patient who developed an early complication of PEG in which the internal bumper became buried in the gastric wall. The buried bumper was immediately removed under local anesthesia, and a new PEG tube was successfully placed. There have also been reports of tube migration into the appears to result from excessive traction on the tube with subsequent ischemic necrosis of the gastric mucosa and pressure necrosis. Careful management of the tube is needed prevent this complication.     

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.