Laparoscopic‐Assisted Percutaneous Endoscopic Gastrostomy

Background/Purpose: Percutaneous endoscopic gastrostomy (PEG) is a simplified catheter placement procedure for alimentation. Although the endoscopic approach to gastrostomy tube placement is a safe and well‐tolerated procedure in most patients, the PEG procedure is difficult in elderly patients disabled since childhood who have severe scoliosis and malpositioning of the stomach. We describe a simple and effective laparoscopic‐assisted PEG (LAPEG) technique that can be used for catheter placement in severely disabled patients. Methods: Thirteen severely disabled patients aged 14–57 years underwent gastrostomy tube placement with the LAPEG technique. After general anesthesia was achieved, an endoscope was placed into the stomach. Then, a 5‐mm camera port was inserted at the umbilicus, and a 3‐mm working port was inserted to identify and lift the optimal site for gastrostomy tube placement. After the 4‐point fixation of the stomach, the 20‐Fr gastrostomy tube was placed under endoscopic and laparoscopic observation. Results: All patients tolerated the procedure well, and there were no major complications. The procedure was successful, and all patients could feed via the tube. Conclusions: Elderly disabled patients who have been bedridden since childhood often have severe scoliosis and malpositioning of the stomach. Our LAPEG procedure is effective, well tolerated, and safe for gastrostomy tube placement in such elderly patients.     

Evaluation of Gastropexy and Stoma Tract Maturation Using a Novel Introducer Kit for Percutaneous Gastrostomy in a Porcine Model

Background: Fluoroscopic placement of percutaneous gastrostomy (PG) requires the use of T‐bar fasteners to affix the stomach to the anterior abdominal wall; the effect of T‐fasteners on stoma tract maturation is unknown. The authors studied PG stoma tract maturation, comparing PG + gastropexy with standard percutaneous endoscopic gastrostomy (PEG). Methods: Sixteen pigs underwent PG placement using a novel introducer kit. Three absorbable suture T‐fasteners were placed around the stoma site, and PG was placed using the Russell method. A standard PEG was then placed using the Ponsky pull method, allowing each animal to serve as its own control. Gross and histopathological integrity of stoma tract formation was assessed at 1–3 weeks. Results: At sacrifice, all PGs were intact with no evidence of infection, disruption, or significant leakage. Stoma tracts of all test and control sites were robust and histologically mature at all time points. Stoma tract diameters were also similar between test and control PGs (mean ± SEM: control 13.1 ± 0.7 mm, test 12.1 ± 0.4 mm; P = .2, n = 15). Histopathological evaluation demonstrated a generally comparable tissue response between test and control PGs, with slight decreases in fibrosis noted in test compared to control sites (P = .02, n = 15). Conclusions: Stoma tract maturation of PG with gastropexy provides similar results to standard PEG. Stoma tracts were mature at 1 week regardless of placement method. Placement and performance of PG using the new introducer kit with novel T‐fasteners and absorbable suture yields effective gastric anchoring and has similar ease of use as standard PEG placement.     

Fluoroscopy‐Guided Percutaneous Gastrostomy With Pull Technique for the Amyotrophic Lateral Sclerosis Patients With Very Low Vital Capacity

Background: The purpose of this study was to evaluate the safety and usefulness of fluoroscopy‐guided percutaneous gastrostomy (FPG) in patients with amyotrophic lateral sclerosis (ALS) using a large‐profile gastrostomy tube accompanied by the pull technique. This procedure was done without an accompanying endoscopy or gastropexy. Methods: Thirty‐six patients with ALS underwent FPG using a large‐profile gastrostomy tube accompanied by the pull technique. A 24 Fr pull‐type tube was inserted under fluoroscopic guidance into the mouth and pulled to the upper‐abdominal puncture site using a snare. The technical success rate, occurrence of complications, and clinical outcomes were evaluated. Results: The technical success rate was 100%. There were no procedure‐related mortalities or respiratory complications. The mean forced vital capacity of the patients was 732 mL (17.7% of the normal predicted value). During the procedure, 16 patients required ventilator support by nasal mask or tracheostomy. The tube indwelling period ranged from 1 to 24 months (average, 9.3). During this period, all the tubes were maintained in a proper position. In 18 patients, the tube was exchanged after 6 months without any problems. Conclusions: The FPG procedure using a 24 Fr tube and the pull technique shows a high rate of technical success. This procedure has a low risk for respiratory complications because endoscopic guidance is not needed. In addition, gastropexy is not required, which allows a large‐profile catheter to be inserted during a single procedure.     

Percutaneous Endoscopic Gastrostomy in the Open Abdomen Patient

Nutrition support of critically ill patients is an integral element to their multimodal care. We describe the placement of a percutaneous endoscopic gastrostomy (PEG) for long‐term enteral access in a patient with an open abdomen. To our knowledge, this is the third successfully reported case that demonstrates the viability of PEG in this uncommon population. In critically ill and malnourished surgical patients with contraindications for immediate abdominal closure, PEG should be strongly considered as a procedure for enteral feedings.     

Understanding Why Patients Die After Gastrostomy Tube Insertion: A Retrospective Analysis of Mortality

Objectives: To understand the causes of mortality of inpatients receiving a percutaneous endoscopic gastrostomy (PEG) tube compared with a survival curve predicted from a model proposed by Levine et al (2007). Design: A retrospective study of patients receiving a PEG over an 18‐month period. Setting: Royal United Hospital Bath, a district general hospital in the southwest of England. Patients: Fifty‐five cases, with 44 found eligible for inclusion. Interventions: A Levine score was calculated for this cohort. A survival curve after PEG was produced and compared with the Kaplan‐Meier curve predicted by the Levine model. Main Outcome Measures: Mortality over a period of 1 year. Results: The mortality at 1, 3, 6, and 12 months was 16%, 20%, 25%, and 28%, respectively. This matched the predicted death rate from the Levine model closely (Pearson's rank correlation coefficient = 0.96). Conclusions: The authors found that the mortality of patients receiving a PEG followed that predicted for a similar cohort of patients without PEGs in the Levine model. This suggests that the deaths observed were due to underlying comorbidities, can provide a baseline for mortality targets for PEG services, and is useful patient information regarding the risks and benefits of the procedure. The findings demonstrate that PEG does no harm and supports the accepted opinion that nutrition support is associated with a better outcome. Furthermore, they show that most deaths occur within the first month of placement and would support arguments for delaying placement until outcome from the underlying condition is more predictable.     

Pain and Anxiety Experienced by Patients Following Placement of a Percutaneous Endoscopic Gastrostomy

Background: Abdominal pain following percutaneous endoscopic gastrostomy (PEG) placement is a recognized complication. However, the prevalence and degree of severity of pain are poorly characterized. We assessed abdominal pain and anxiety levels associated with PEG placement in communicative and noncommunicative patients. Methods: A prospective questionnaire assessed patients' anxiety and abdominal pain 1 hour before, 1 hour after, and 24 hours after PEG placement using 11‐point Likert‐type scales. Patients were followed up until pain had resolved. Procedural data, analgesia requirements, and complications were recorded. For analysis, patients were divided into 2 groups: communicative (able to self‐assess) and noncommunicative (clinician assessed). Results: Seventy consecutive patients were assessed. Of the 49 self‐assessed patients, 11 (22%) reported immediate pain, 32 (65%) reported pain at 1 hour (24 mild, 5 moderate, 3 severe), and 40 (82%) reported pain at 24 hours. Pain most commonly lasted between 24 and 48 hours (25 patients). Of the 21 clinician‐assessed patients, only 1 was deemed to have pain, and this was at 24 hours. Four (6%) patients were admitted with pain. There was no relationship between preplacement anxiety scores and postplacement pain scores. Discussion: Abdominal pain after PEG placement pain is common but resolved by 48 hours in most patients. In patients able to communicate, clinicians scored pain lower compared with patients' scores. It is likely that pain is not identified in patients unable to communicate. Patients need to be better informed about the possibility of postprocedural pain and routinely offered access to appropriate analgesia.     

Percutaneous endoscopic gastrostomy complication rates and compliance with the American Society for Gastrointestinal Endoscopy guidelines for the management of antithrombotic therapy

Background: The American Society for Gastrointestinal Endoscopy (ASGE) has published recommendations in regards to anticoagulant (AC) and antiplatelet (AP) therapy management during endoscopic procedures. So far, no study has assessed either ASGE recommendation compliance during percutaneous endoscopic gastrostomy (PEG) placement or procedure‐associated complication rates as related to the observance of these recommendations. The aims of this study were to compare the incidence and type of complications during PEG placement in patients receiving or not receiving AC and/or AP therapy and to determine the compliance with ASGE's AC and AP management guidelines. Methods: Medical files of patients who underwent PEG placement from January 2004 to December 2008 were reviewed. Clinical and procedure‐related data were recorded. Patients were separated into 1 of 2 groups: patients under AP and/or AC therapy prior to PEG placement (n = 51) and a control group of patients (n = 40) not receiving any AP and/or AC treatment at least 6 months prior to the procedure. Results: A total of 91 patients (51 cases) were included. Groups were comparable in demographics and clinical characteristics. No differences in the frequency and type of complications were found between groups. ASGE's recommendations were not followed in any of these patients. Conclusions: Overall PEG placement complication rate was 13.7%. AP therapy may be safely discontinued closer to the time of endoscopic procedure than the time currently recommended by the ASGE guidelines.     

Unsedated percutaneous endoscopic gastrostomy insertion: a safe, effective, and well-tolerated method

Background: Percutaneous endoscopic gastrostomy (PEG) tube insertion is an uncomfortable procedure that has traditionally required sedation. In some patients, PEG tube insertion can be postponed or is not possible due to the risk of sedation. This article is a retrospective case series of 10 patients who have undergone unsedated peroral PEG tube insertion in the past 4 years at Stafford Hospital in the United Kingdom. Methods: Between 2006 and 2010, 10 patients who were identified by the nutrition team as needing a PEG tube underwent unsedated peroral PEG tube insertion. Patients were given pharyngeal anesthesia (lidocaine 1%), and the PEG tubes were inserted using the push‐pull technique and local anesthesia. The procedures were performed without complications. Results: Those patients who were able to respond stated they would be willing to have the procedure performed again using this method. It was acceptable to them and not as unpleasant as they had expected. Conclusions: This case series demonstrates that gastroenterology units without specialized equipment are able to safely insert PEGs in patients who are at increased risk for intravenous sedation.     

Inhibition of Gastroesophageal Reflux by Semi‐solid Nutrients in Patients With Percutaneous Endoscopic Gastrostomy

Background: Aspiration is one of the major complications after percutaneous endoscopic gastrostomy (PEG). The administration of semi‐solid nutrients by means of gastrostomy tube has recently been reported to be effective in preventing aspiration pneumonia. The effects of semi‐solid nutrients on gastroesophageal reflux, intragastric distribution, and gastric emptying were evaluated. Methods: Semi‐solid nutrients were prepared by liquid nutrients mixed with agar at the concentration of 0.5%. The distribution of the administered radiolabeled liquid and semi‐solid nutrients was monitored by a scintillation camera for 15 post‐PEG patients. The percentage of esophageal reflux, the distribution of the proximal and distal stomach, and the gastric emptying time were evaluated. Results: The percentage of gastroesophageal reflux was significantly decreased in semi‐solid nutrients (0.82 ± 1.27%) compared with liquid nutrients (3.75 ± 4.25%), whereas the gastric emptying time was not different. The distribution of semi‐solid nutrients was not different from liquid nutrients in the early phase, whereas higher retention of liquid nutrients in the proximal stomach was observed in the late phase. Conclusions: Gastroesophageal reflux was significantly inhibited by semi‐solid nutrients. One of the mechanisms of the inhibition is considered to be an improvement in the transition from the proximal to distal stomach in semi‐solid nutrients.     

Peritonitis after gastrostomy tube replacement: a case series and review of literature

Background: The placement of feeding gastrostomy (G) tubes through a percutaneous endoscopic gastrostomy (PEG) technique has become common because of its simplicity and safety. The majority of the serious complications are reported to occur within a few days of initial tube placement and happen in fewer than 3% of cases. Long‐term reported complications of this procedure include occlusion or breakage of the G‐tube, requiring reinsertion. This report describes the complication of intraperitoneal placement and the development of peritonitis after replacement of an established PEG tube and reviews the pertinent world literature. Methods: A retrospective review of cases of intraperitoneal insertion of replacement G‐tubes was done as well as a Medline search for cases of intraperitoneal insertion of replacement G‐tube or development of peritonitis after replacement tube insertion. Results: Three new cases of inadvertent intraperitoneal insertion of a replacement G‐tube in adult patients with mature tracts are reported. An additional 5 cases have been previously described in adults. Significant morbidity was associated with this complication, and 4 deaths were related to it. Methods used to determine whether the replacement G‐tube was intragastric were not uniform. Conclusions: There have been few reports of intraperitoneal insertion of replacement G‐tubes in patients with mature (>30 days) stoma sites. The cases presented in this report highlight for the clinician the importance of considering this complication, particularly if there are any difficulties with the reinsertion. Prospective studies are needed to determine the frequency of this complication and the optimal protocol for PEG replacement.     

Percutaneous Gastrostomy Tube Placement Using a Balloon Catheter in Patients With Head and Neck Cancer

Background: Patients with head and neck cancer frequently require gastrostomy feeding. The aim of this study was to evaluate the safety and feasibility of percutaneous radiologic gastrostomy with push‐type gastrostomy tubes using a rupture‐free balloon (RFB) catheter under computed tomography (CT) and fluoroscopic guidance in patients with head and neck cancer with swallowing disturbance or trismus. Methods: Percutaneous CT and fluoroscopic gastrostomy placement of push‐type gastrostomy tubes using a RFB catheter was performed in consecutive patients with head and neck cancer between April 2007 and July 2010. The technical success, procedure duration, and major or minor complications were evaluated. Results: Twenty‐one patients (14 men, 7 women; age range, 55–78 years; mean age, 69.3 years) underwent gastrostomy tube placement. The tumor location was the pharynx (n = 8), oral cavity (n = 7), and gingiva (n = 6). Gastrostomy was performed in 15 patients during treatment and 6 patients after treatment. Percutaneous radiologic gastrostomy was technically successful in all patients. The median procedure time was 35 ± 19 (interquartile range) minutes (range, 25–75). The average follow‐up time interval was 221 days (range, 10–920 days). No major complications related to the procedure were encountered. No tubes failed because of blockage, and neither tube dislodgement nor intraperitoneal leakage occurred during the follow‐up periods. Conclusion: Percutaneous CT and fluoroscopic‐guided gastrostomy with push‐type tubes using a RFB catheter is a relatively safe and effective means of gastric feeding, with high success and low complication rates in patients with head and neck cancer in whom endoscopy was not feasible.     

The Role of Pretreatment Percutaneous Endoscopic Gastrostomy in Facilitating Therapy of Head and Neck Cancer and Optimizing the Body Mass Index of the Obese Patient

Background: Chemoradiation of head and neck cancer induces severe dysphagia and malnutrition, which may lead to interruptions in therapy and reduction in its efficacy. Percutaneous endoscopic gastrostomy (PEG) feedings bypass the oropharynx, allowing administration of nutrients and medications into the stomach, thus preventing malnutrition, dehydration, and treatment interruption. Methods: Medical records of 161 patients treated for head and neck cancer who had PEGs placed prior to chemoradiation and 2 PEGs placed during chemoradiation were reviewed from the date of PEG placement throughout treatment and utilization. The objective was to determine the contribution of pretreatment PEGs to the therapy of patients with head and neck cancer and to optimize their body mass index. Results: Severe chemoradiation‐induced dysphagia developed in 160 patients (98%), necessitating PEG utilization for feeding and hydration. PEGs were used for a mean 251 ± 317 days. Significant complications related to PEG placement and utilization were infrequent. PEG feeding allowed chemoradiation to continue without interruption in 93% of patients. Individualized feeding regimens optimized body mass index in obese and overweight patients with a decline from 33.0 ± 3.4 to 28.4 ± 4.8 kg/m² (P < .001) and 27.3 ± 1.5 to 24.6 ± 2.7 kg/m² (P < .001), respectively. Radiation‐induced strictures developed in 12% of patients, requiring endoscopic dilatation. Conclusions: Enteral feeding through prechemoradiation‐placed PEGs is an effective and safe method for nutrition and hydration of patients with head and neck cancer undergoing chemoradiation. PEGs allowed chemoradiation to proceed with minimal interruptions despite severe dysphagia, which excluded oral intake for prolonged periods.     

Tract Disruption and External Displacement Following Gastrostomy Tube Exchange in Adults

Background: Anecdotal reports, mostly in children, indicate that disruption of the gastrostomy tract may occur during gastrostomy tube exchange and cause serious complications. The aim of our study was to determine the rate of tract disruption occurring in adults requiring long‐term enteral nutrition who had an original gastrostomy tube replaced and to evaluate factors contributing to this complication. Methods: We retrospectively reviewed the medical records of all patients who underwent replacement of their gastrostomy tube over a 3‐year period. Information was collected relating to patient demographics, underlying diagnosis, method of insertion and tube type used for initial gastrostomy tube and subsequent tube replacement, staff involved in tube replacement, patient nutritional status at the time of tube change, and the number of days from initial tube placement to replacement. For comparative purposes, the patients were divided into 2 groups: those with tract disruption and those without tract disruption. Results: A total of 182 tube changes in 108 adults were performed; 55 were initial tube changes. Four (7.3%) tract disruptions occurred, all with skin‐level replacement devices and only with the initial replacement of the original gastrostomy tube. There were no significant differences in patient demographics, principal diagnosis, method of insertion and tube type used for initial gastrostomy tube, staff involved in tube replacement, patient nutritional status at the time of tube change, or the number of days from initial tube placement to replacement. Conclusion: Tract disruption occurs infrequently during replacement of gastrostomy tubes and appears to be an issue primarily during the initial tube exchange when using a skin‐level device.     

Gastrostomy tube placement outcomes: comparison of surgical, endoscopic, and laparoscopic methods.

BACKGROUND: Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques now allow for less invasive placement of gastrostomy tubes. This study compared morbidities and feeding outcomes of these procedures with standard surgical (OPEN) insertion. METHODS: Gastrostomy tubes placed in the operating room by the PEG, LAP, and OPEN methods were compared for insertion times, tube insertion and maintenance complications, enteral feeding complications, and feeding start days. Patients with concomitant intra-abdominal procedures were excluded. Patients were followed for 6 days after tube placement. RESULTS: A total of 91 catheters (PEG = 23, LAP = 39, OPEN = 29) were inserted in the operating room for indications of ventilator-dependent respiratory failure (45), dysphagia (30), head and neck cancer (9), and decreased mental status (7). No patients were fed on the day of the procedure. Insertion times were significantly longer (p < .05) in the OPEN technique (68 minutes) vs LAP (48 minutes) and PEG (30 minutes). Insertion complications occurred in the LAP and PEG cohorts (3 failed LAP, 1 failed PEG), and maintenance complications were higher in the LAP group, including 1 episode each of cellulitis, bleeding, and serous drainage. Twenty enteral feeding complications in 17 patients occurred in all groups (9 in LAP vs 6 in PEG and 5 in OPEN), and included emesis (6), high residual (5), diarrhea (3), ileus (3), nausea (2), and pain after feeding (1). Overall complications were significantly lower in the PEG (7) and OPEN (5) groups compared with the LAP group (15). Feeding start day was significantly delayed in the OPEN technique (2.1 days vs 1.7 in PEG and 1.5 in LAP); however, no difference was found in days to goal among groups (4.4-4.8 days). CONCLUSIONS: PEG should be the procedure of choice for placement of gastrostomy tubes. If PEG is contraindicated, then OPEN technique may be best due to fewer complications, although insertion time is longer than the LAP technique.     

Percutaneous endoscopic gastrostomy feeding in haemodialysis out‐patients

Introduction Malnutrition is highly prevalent in haemodialysis (HD) patients and plays a major role in influencing outcome. Although use of home enteral feeding is expanding rapidly in the UK, it is a method of nutritional support which remains under‐utilized in HD out‐patients. We report our experience and outcomes in a series of eight cases. Methods Home gastrostomy feeding was initiated in eight malnourished HD out‐patients, administered either continuously overnight or as daily bolus feeds. Nutritional parameters were monitored weekly by the renal dietitian and included dry weight, upper‐arm anthropometry and serum albumin. The number and duration of hospitalizations during the period of feeding were recorded. Results After 3 months of feeding, median dry weight increased from 43.0 to 48.3 kg (P = 0.012), mid‐upper arm circumference increased from 20.2 to 24.8 cm (P = 0.018), triceps skinfold thickness increased from 7.3 to 11.3 mm (P = 0.046), mid‐upper arm muscle circumference increased from 17.7 to 19.8 cm (P = 0.027) and serum albumin increased from 29.5 to 36.5 g L^?1 (P = 0.011). Few complications were encountered and hospital admission rates were low. Conclusion Home gastrostomy feeding, with appropriate monitoring and support, is an effective method of improving and maintaining nutritional status in this vulnerable group.     

Safety techniques for percutaneous endoscopic gastrostomy tube placement in Pierre Robin Sequence

Pierre Robin Sequence (PRS) is a craniofacial anomaly characterized by a triad of micrognathia, glossoptosis, and cleft palate. Infants with PRS frequently have feeding problems that may require supplemental nutrition through a nasogastric or gastrostomy tube. Very few published studies have illustrated the most appropriate method for securing an enteral feeding route in this patient population. One case report described a major complication leading to death from airway compromise following percutaneous endoscopic gastrostomy (PEG) tube placement. The authors describe a case of an infant with PRS who underwent successful PEG tube placement without complications, and they highlight certain techniques to improve procedure success and patient safety.     

Gastrostomy feeding in advanced Huntington's disease

This case study reports the progress of a 41-year-old man with advanced Huntington's disease (HD) during a 12-week period when he was fed a high-energy regimen via percutaneous endoscopic gastrostomy (PEG). The regimen consisted of a low-protein, low-mineral, energy-dense (2 kcal mL^?1) carbohydrate polymer. Achieving weight gain with a 1.5 kcal mL^?1 feed and carbohydrate polymer had produced steady but slow results (52–56 kg – a rise of 4 kg in 15 months). It was concluded that a more energy-dense regimen would facilitate faster weight gain.     

Predictive factors of mortality after PEG insertion: guidance for clinical practice

Background: Percutaneous endoscopic gastrostomy (PEG) is considered the preferred route for long‐term enteral feeding. The aim of this study was to determine predictors of an increased mortality risk after PEG insertion. Methods: A retrospective study was conducted during a 13‐year period in the gastroenterology department of Erlangen University Hospital. The authors completed a questionnaire with details of demographic data, diagnosis, indication for PEG, type of tube, and cause of death. Patients were contacted regularly at scheduled appointments. Results: In total, 787 patients (574 male [72.9%]) underwent PEG placement by the pull technique. The main underlying disease was malignant (75.6%). By the end of the study period, 614 patients had died. The average survival time was 720 days. The 30‐, 60‐, 90‐day and 1‐, 3‐, and 5‐year mortality rates amounted to 6.5%, 9.8%, 13%, 32.1%, 59.3%, and 69.8%, respectively. Predictive factors of increased 30‐day mortality were higher age, lower body mass index (BMI), and the presence of diabetes mellitus. The presence of all 3 variables served as an indicator to detect high‐risk patients, with a sensitivity of 0.80 and a specificity of 0.64. Conclusion: Mortality predictors for patients after PEG insertion are higher age, lower BMI, and the presence of diabetes mellitus. To avoid unnecessary and dangerous examinations in high‐risk patients, the above‐mentioned predictive factors of mortality should be checked before PEG placement.     

Prophylactic percutaneous endoscopic gastrostomy tube placement in treatment of head and neck cancer: a comprehensive review and call for evidence-based medicine

Background: Patients with head and neck cancers (HNCs) are at increased risk of experiencing malnutrition, which is associated with poor outcomes. Advances in the treatment of HNCs have resulted in improved outcomes that are associated with severe toxic oral side effects, placing patients at an even greater risk of malnutrition. Prophylactic placement of percutaneous endoscopic gastrostomy (PEG) tubes before treatment may be beneficial in patients with HNC, especially those undergoing more intense treatment regimens. PEG tube placement, however, is not without risks. Methods: A comprehensive review of the literature was conducted. Results: Systematic evidence assessing both the benefits and harm associated with prophylactic PEG tube placement in patients undergoing treatment for HNC is weak, and benefits and harm have not been established. Conclusions: More research is necessary to inform physician behavior on whether prophylactic PEG tube placement is warranted in the treatment of HNC.