Prospective evaluation of Foley catheter as a replacement gastrostomy tube.

Percutaneous endoscopic gastrostomy provides a nonsurgical alternative to enteral feeding. However, the percutaneous endoscopic gastrostomy tube may deteriorate, malfunction, or be accidentally expelled from the stomach, requiring replacement. This prospective study was performed to evaluate the use of an all silicone Foley catheter (Foley) as a replacement feeding gastrostomy in 28 patients requiring replacement gastrostomy. A plastic ring and a retention disc were always placed over the Foley prior to replacement. Foley functioned well without replacement in 19 (68%) patients for a mean of 167 days. It needed to be replaced in nine (32%) patients due to malfunction after a mean of 138 days. Lack of migration of Foley was the most striking finding of our study, in contrast to case reports in the literature. These data suggest that Foley can be safely used as replacement gastrostomy tube. A randomized controlled trial comparing the Foley catheter as a replacement tube with other commercially available devices is needed.     

Radiological insertion of gastrostomy in patients in whom endoscopy was unsuccessful

INTRODUCTION: Endoscopy is the standard technique of percutaneous gastrostomy placement, but failure of placement may occur due to difficulty with intubation or previous abdominal surgery. A review of personal experience is made. PATIENTS AND METHODS: Between January 1997 and May 1998, 90 gastrostomy devices were successfully placed endoscopically in our unit. Endoscopic placement was unsuccessful in 3 patients and not attempted in a further 7 because of oro-pharyngeal obstruction. These 10 patients (6 male, 4 female, aged 51-84 years) had advanced neuro-degenerative disease or malignancy of the head and neck or oesophagus. All patients underwent radiological insertion of a gastrostomy tube by the 'push' method after insufflation of air into the stomach via a naso-gastric tube. RESULTS: Radiological insertion of gastrostomy device was successful in 9 out of 10 patients. Failure occurred in 1 patient due to inability to pass a naso-gastric tube and surgical gastrostomy was required. Pain at the gastrostomy site was the most common problem post-procedure and 4 patients still required analgesia on discharge. One patient developed a wound infection. There were no procedure-related deaths. The 30-day mortality due to all causes was 20%. Only 1 patient remained alive at 6 months. DISCUSSION: Availability of a radiologist trained in the placement of percutaneous gastrostomy allowed 99% of such devices to be placed percutaneously, even in those patients in whom endoscopy was not possible. However advanced underlying disease in this patient group results in a high mortality.     

Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension

BACKGROUND: Jejunostomy tubes can be placed endoscopically by means of percutaneous gastrostomy with jejunal extension (PEG-J) or by direct percutaneous jejunostomy. These 2 techniques were retrospectively compared in patients requiring long-term jejunal feeding. METHOD: An endoscopy database was used to identify all patients who underwent endoscopic jejunal feeding tube placement from January 1996 to May 2001. Patients with a history of upper GI surgery were excluded. There were 56 patients with a direct percutaneous jejunostomy and 49 with a percutaneous gastrostomy with jejunal extension. Patients in the direct percutaneous jejunostomy group received a 20F direct jejunostomy tube; a 20F PEG tube with a 9F jejunal extension was used in the percutaneous gastrostomy with jejunal extension group. Medical records for the period of 6 months after establishment of jejunal access were reviewed. Complications and need for further endoscopic intervention within this time frame were recorded. The duration of feeding tube patency (number of days from established jejunal access to first endoscopic reintervention) was compared for both groups. RESULTS: Feeding tube patency was significantly longer in patients who had a direct percutaneous jejunostomy compared with those with a percutaneous gastrostomy with jejunal extension. Within the 6-month period, 5 patients with a direct percutaneous jejunostomy required endoscopic reintervention for tube dysfunction compared with 19 patients who had a percutaneous gastrostomy with jejunal extension (p < 0.0001). CONCLUSIONS: For patients who require long-term jejunal feeding, a direct percutaneous jejunostomy with a 20F tube provides more stable jejunal access compared with a percutaneous gastrostomy with jejunal extension with a 9F extension and has a lower associated rate of endoscopic reintervention.     

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.     

Prospective Trial Evaluating Early Initiation of Feeding in Patients with Newly Placed One-Step Button Gastrostomy Devices

The purpose of this study was to prospectively assess the feasibility and safety of early feeding in patients with newly placed one-step button (OSB) gastrostomy devices. Twenty-five patients who underwent percutaneous endoscopic button gastrostomy placement were prospectively enrolled. The patients underwent radiographic assessment (Gastrografin gastrograms) 3 hr after gastrostomy placement. Contrast extravasation was not documented in any patient. Aside from one patient who aspirated the contrast solution after the radiologic study, all others (96%) were successfully fed on the day the gastrostomy buttons were placed. In this prospective study of patients with newly placed OSB gastrostomy devices, early initiation of feeding was feasible and safe. In a fashion similar to their tube-style counterparts, button gastrostomy devices provide adequate apposition between the stomach and abdominal wall immediately after their initial placement.     

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.     

Postgastrostomy tube deformity on upper GI series

Three cases are presented in which a focal concave deformity occurred along the greater curvature of the stomach on upper gastrointestinal (GI) series. These patients all had recent removal of a surgically placed gastrostomy tube from a similar location. This deformity appears to be related, at least in part, to invaginated gastric mucosa intentionally produced during surgical gastrostomy tube placement. This association and appearance should be noted as it may mimic other lesions.     

Percutaneous endoscopic gastro-duodenostomy: modified technique

OBJECTIVES: Percutaneous endoscopic gastro-jejunostomy is appropriate for patients with severe neurologic deficit to avoid repeated tube feeding-related aspiration. We describe a modified technique of endoscopic gastro-duodenostomy. PATIENTS AND METHODS: This technique was performed in 9 patients with severe neurologic deficit. No fluoroscopy was necessary. The gastrostomy button was pushed across the pylorus into the bulb; a nasogastric tube was then placed in the duodenum under endoscopic control and the button was drawn to the gastric wall. When the gastroduodenal tube migrated or was occluded, the button was placed in the bulb through the pylorus and maintained in this position for alimentation. RESULTS: Placement of the gastro-duodenostomy tube was successful without any complication in 100% of patients. The mean duration of the procedure was 15 min. The tube had to be removed for migration (N = 4) and occlusion (N = 5) after a mean period of 5.8 weeks (range: 2-10). During the follow-up period, no tube feeding-related aspiration was observed. CONCLUSION: This modified low-cost technique of endoscopic gastro-duodenostomy is simple and efficient.     

Percutaneous transgastric endoscopic tube ileostomy in a porcine survival model

AIM To introduce natural orifice transgastric endoscopic surgery(NOTES) tube ileostomy using pelvis-directed submucosal tunneling endoscopic gastrostomy and endoscopic tube ileostomy.METHODS Six live pigs(three each in the non-survival and survival groups) were used. A double-channeled therapeutic endoscope was introduced perorally into the stomach. A gastrostomy was made using a 2-cmtransversal mucosal incision following the creation of a 5-cm longitudinal pelvis-directed submucosal tunnel. The pneumoperitoneum was established via the endoscope. In the initial three operations of the series, a laparoscope was transumbilically inserted for guiding the tunnel direction, intraperitoneal spatial orientation and distal ileum identification. Endoscopic tube ileostomy was conducted by adopting an introducer method and using a Percutaneous Endoscopic Gastrostomy Catheter Kit equipped with the Loop Fixture. The distal tip of the 15 Fr catheter was placed toward the proximal limb of the ileum to optimize intestinal content drainage. Finally, the tunnel entrance of the gastrostomy was closed using nylon endoloops with the aid of a twin grasper. The gross and histopathological integrity of gastrostomy closure and the abdominal wall-ileum stoma tract formation were assessed 1 wk after the operation.RESULTS Transgastric endoscopic tube ileostomy was successful in all six pigs, without major bleeding. The mean operating time was 71 min(range: 60-110 min). There were no intraoperative complications or hemodynamic instability. The post-mortem, which was conducted 1-wk postoperatively, showed complete healing of the gastrostomy and adequate stoma tract formation of ileostomy.CONCLUSION Transgastric endoscopic tube ileostomy is technically feasible and reproducible in an animal model, and this technique is worthy of further improvement.     

Endoscopic Clips Prevent Displacement of Intestinal Feeding Tubes: A Long-Term Follow-Up Study

Background Displacement of jejunal feeding tubes is a major problem in enteral feeding. Although endoscopic clips have been used to prevent migration of the tube during placement, the long-term effect of the clips on tube displacement is unknown. Objectives The purpose of this study was to examine the long-term effect of endoscopic clips on preventing displacement of the jejunal feeding tube. Design A retrospective study. Setting A single tertiary medical center. Main outcome measurements The success rate of the procedure and the functional duration of the feeding tube. Results About 93% of patients had a percutaneous endoscopic gastrostomy jejunal (PEGJ) tube successfully placed with use of endoscopic clips. About 7% had tube migration and repeat procedures were successful. The mean functional duration of the tube was 55 days. Limitations Retrospective, single-center. Conclusions Use of endoscopic clips can prevent migration during placement of the feeding tube and can also reduce tube displacement in the long term.     

Aspiration after percutaneous gastrostomy. Assessment by Tc-99m labeling of the enteral feed

Aspiration pneumonia, a recognized complication of enteral feeding via a nasogastric tube, is considered uncommon with percutaneously placed gastrostomy tube feeding. We report aspiration pneumonia during enteral alimentation in a neurologically compromised but conscious patient. Aspiration continued despite changing the route of enteral feeding from nasogastric to percutaneous gastrostomy. Quantitative scintigraphic studies with Tc-99m-labeled enteral infusion demonstrated frequent episodes of gastroesophageal reflux and aspiration of gastric contents, which increased when the infusion rate was speeded up for nutritional replacement. Gastric retention also occurred at the higher infusion rate. Thus, percutaneous gastrostomy may not decrease the frequency of aspiration in patients at risk.     

Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients.

Presence of a nasogastric tube is a risk factor for the development of ventilator-associated pneumonia (VAP). Alternatively, gastrostomy can be used for administration of enteral feedings. To determine whether early performance of gastrostomy affects frequency of VAP, a randomised, controlled study was carried out in patients mechanically ventilated for stroke or head injury. In the gastrostomy group, patients underwent the procedure within 24 h of intubation. A nasogastric tube was inserted in controls. Individual subjects were studied for 3 weeks. In total, 20 subjects (mean age 48+/-15.2 yrs) were allocated to the gastrostomy group, and 21 to the control group (46.6+/-15.4 yrs). Of these groups, two (10%) and eight (38.1%) developed VAP, respectively. Four patients with gastrostomy and three controls did not complete the study (due to weaning from ventilatory support or death). After excluding these subjects, difference in VAP frequency persisted: two out of 16 subjects with gastrostomy had VAP (12.5%) versus eight out of 18 controls (44.4%). There were no differences in duration of hospitalisation or mortality between the two groups. In conclusion, in patients mechanically ventilated for stroke or head injury early gastrostomy is associated with a lower frequency of ventilator-associated pneumonia compared with a nasogastric tube.     

Ethical aspects of percutaneous endoscopic gastrostomy placement for artificial nutrition and hydratation

Of the many decisions that family members and physicians must make about medical care in patients with advanced disease and perceived poor quality of life, none is more heart-wrenching than the decision about artificial nutrition and hydratation. The endoscopist often is placed in a precarious position when percutaneous endoscopic gastrostomy tube placement is requested in such patients. Clinical decision-making between the patient, the family and the physician should be consistent with legal and ethical principles. The purpose of this article is to provide an evaluation of medical and ethical issues regarding the decision on placing a percutaneous endoscopic gastrostomy tube for various indications, as well as suggesting strategies to optimize the decision-making process.     

Tube feeding - who, how and when

Summary. The concept of enteral nutrition is well established for a long time. During the past twenty years different percutaneous tube feeding techniques have been established. The most popular method is the percutaneous endoscopic gastrostomy (PEG) which is applied as a pull-through technique in Germany. In some patients this approach is not successful and alternative techniques must be used (e. g. introducer method). In some patients nasal or percutaneous feeding tube have to be placed directly into the intestine. There are different systems available for this approach which have to be clearly indicated. As a second step after initiation of enteral nutrition therapy quality of life can be improved by implanting secondary systems (e. g. button gastrostomy).A standardized technique for inserting tubes is essential to have a successful long-term outcome in enteral nutrition and care after has to be integrated into the regimen. The aim of this article is to demonstrate different enteral nutrition tube techniques their indication, contraindication and long-term follow-up.     

Percutaneous endoscopic gastrostomy in cystic fibrosis: patient acceptance and effect of overnight tube feeding on nutritional status

BACKGROUND: Malnutrition remains a common problem in cystic fibrosis (CF) patients, despite pancreatic enzymes and hypercaloric diet advice. When oral supplementation fails, additional overnight gastrostomy tube-feeding is a therapeutic option. METHODS: In our centre gastrostomy tube feeding is proposed when weight for height drops below 85% despite intensive dietetic counselling. All the CF patients at our centre (n = 11) receiving gastrostomy tube feeding were evaluated for changes in nutritional status and pulmonary function. Complications of percutaneous endoscopic gastrostomy were inventarised and patients older than 7 years and all the parents were asked to fill in a questionnaire concerning subjective well-being with gastrostomy supplemental feeding. RESULTS: The patients received 40% of the recommended daily allowances (RDA) for energy by tube feeding. Total daily energy intake increased by 30%. Within 3 months this resulted in a significant improvement in nutritional status expressed as percentage of ideal weight for height or body mass index z-score. After 6 months a significant catch-up growth was detectable. Pulmonary function remained stable. The complications were local irritation (n = 4), night sweating (n = 1) and bed-wetting (n = 1). The gastrostomy was well accepted. CONCLUSION: Gastrostomy appears to be a good and safe way to improve nutritional status, growth and mood of the CF child. As decreased pulmonary function plays a crucial role in the growth of the CF child, full normalisation of growth pattern is not achieved despite catch-up. Gastrostomy tube feeding should perhaps be used earlier to optimalise growth.     

Percutaneous endoscopic gastrostomy: results of 115 cases

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy is one of the gastrostomy methods used for patients who are unable to take food orally. We aimed to present our results for percutaneous endoscopic gastrostomy. METHODOLOGY: One hundred and fifteen patients undergoing percutaneous endoscopic gastrostomy by pull technique were retrospectively evaluated in terms of indications, complications, durability of tube, and mortality. RESULTS: Of the 115 cases, 60 were males and 55 females with the median age of 67 (2-93) years. Indications for percutaneous endoscopic gastrostomy placement were cerebrovascular accident in 39, brain tumors in 24, subarachnoidal hemorrhage in 21, several neurologic disorders in 17, miscellaneous extracerebral tumors in 6, head injury in 5, hypoxic encephalopathy in 2, and iatrogenic in 1. The durability of the tube was a median of 242 (9-1988) days. The tube was removed in 16 patients and was changed in 11 patients with a median interval of 142.5 (35-427) and 133 (24-1251) days, respectively. Four wound infections, two buried bumper syndromes, and two aspiration pneumonias developed. Total follow-up was 114.1 patient-years with procedure-related mortality, 30-day mortality, and overall mortality of 0%, 3.5% (4/115), and 17.4% (20/115), respectively. The mortality rate was 45% for patients who had brain tumor and 11.6% for the remainder. CONCLUSIONS: Percutaneous endoscopic gastrostomy is a minimally invasive gastrostomy method with low morbidity and mortality rates, easy to follow-up, and easy to replace when clogged.     

Percutaneous endoscopic gastrostomy. Clinical care of PEG tubes in older adults

Percutaneous endoscopic gastrostomy (PEG) tube feeding is recommended by the American Gastroenterological Association as the preferred device to provide long-term enteral nutrition when oral intake is inadequate. Although PEG placement is a relatively common procedure--more than 200,000 are placed annually--it often presents a clinical dilemma for healthcare workers. This pragmatic discussion focuses on the comprehensive clinical care of PEG tubes from the initial discussion with the patient and the caregiver to place the tube to long-term management issues.     

Gastrostomy tube insertion in children: the Edmonton experience

BACKGROUND:

Although gastrostomy tube insertion – whether endoscopic or open – is generally safe, procedure-related complications have been reported.

OBJECTIVE:

To compare gastrostomy tube insertion-related complications between percutaneous endoscopic gastrostomy and open gastrostomy at a single pediatric centre.

METHODS:

The charts of children (younger than 17 years of age at the time of tube insertion) who underwent endoscopic or open gastrostomy tube insertion from January 2005 to December 2007 at the Stollery Children’s Hospital (Edmonton, Alberta) were examined.

RESULTS:

A total of 298 children underwent gastrostomy tube insertion over a period of three years. After excluding patients with incomplete charts, 160 children (91 boys, mean [± SD] age 3.18±4.73 years) were included. Eighty-five children (mean age 4.50±5.40 years) had their gastrostomy tube inserted endoscopically, while the remaining 75 (mean age 1.68±3.27 years; P<0.001) underwent an open procedure. The overall rate of major complications was 10.2% for the endoscopic technique and 8.6% for the open technique (P=0.1). Major infections were higher in the endoscopic technique group, while persistent gastrocutaneous fistulas after tube removal were more common in the open technique group.

CONCLUSION:

Although the rate of major complications was similar between the endoscopic and open tube insertion groups, major infections were more common among children who underwent endoscopic gastrostomy. The decision for gastrostomy tube insertion was primarily based on clinical background.     

Assessment of the percutaneous endoscopic gastrostomy feeding tube as part of an integrated approach to enteral feeding.

The insertion of percutaneous endoscopic gastrostomy has been well documented. The possible benefits for patient nutrition and nursing practice have, however, not been assessed. We report a study of enteral feeding by percutaneous endoscopic gastrostomy in 30 patients, the majority with a persistent vegetative state. All patients had previously been fed through a nasogastric tube using manual administration and a dietitian assessed protein calorie intake. Based upon body mass index (weight/height2), midarm circumference and triceps skinfold thickness, 20 (67%) were malnourished, with 10 patients having a body mass index less than 17 (severe malnutrition); attributed to high rates of both tube displacement and feed regurgitation. Patients were observed over six to 12 months after percutaneous endoscopic gastrostomy insertion combined with overnight continuous pump feeding. All patients attained a body mass index greater than 17, and 17 (56%) of the total number achieved the normal range with no change in protein-calorie intake (pre: 2110 kcal, post: 1880 kcal). Complications of percutaneous endoscopic gastrostomy in the study group included peritonitis (one), tube site infection (two) and displacement (two); all without serious sequelae. As part of an integrated approach percutaneous endoscopic gastrostomy proved a safe and efficient method of enteral feeding and justifies wider consideration in the United Kingdom.     

Endoscopic versus operative gastrostomy: final results of a prospective randomized trial

This study compared operative gastrostomy (OG) (by surgeons) with endoscopic gastrostomy (PEG) (by physicians) in a prospective randomized fashion to determine whether one technique was superior. PEG (Sachs-Vine) and OG (Stamm) were done using local anesthesia. Patients were assessed for complications, mortality, tube function, and cost. Groups were equally matched for indications and underlying disease. Fifty-seven had OG and 64 had attempted PEG. Complications occurred in 26% of OG patients and 9% died. Complications occurred in 25% of PEG patients and 12% died. Tube feeding was initiated in both groups within a mean of 29 (24 to 72) hours of the gastrostomy placement. OG cost $1675 and PEG $979 to perform. Twenty-one PEG patients required endoscopic tube change which raised their total cost to $1574. We conclude there is no difference between OG (using local anesthesia) and PEG with regard to morbidity, mortality, or tube function. The endoscopic technique does appear to have economic advantage.