Pneumoperitoneum following percutaneous endoscopic gastrostomy: A prospective study

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. The authors recently observed a patient who developed a benign pneumoperitoneum following PEG. Twenty-four patients were then prospectively studied after PEG to determine the incidence and significance of this finding. Nine patients (38%) developed radiologic pneumoperitoneum. Five patients (21%) had gross evidence of pneumoperitoneum, three patients had more subtle findings of small amounts of free air, and one patient had free air found by CT scan. No patient developed signs or symptoms of peritoneal inflammation. The authors conclude that pneumoperitoneum following PEG occurs frequently and that, in the absence of signs or symptoms of peritoneal inflammation, it is a benign finding which requires no further diagnostic or therapeutic intervention.     

Endoscopic holder-assisted percutaneous endoscopic gastrostomy placement: results of a prospective, randomized comparison study

BACKGROUND: We developed a new method of endoscope holder-assisted percutaneous endoscopic gastrostomy (PEG) placement requiring only a single physician. OBJECTIVE: This study compared the feasibility and safety of the new method with the conventional pull method of PEG performed by 2 physicians. DESIGN: Prospective, randomized comparison study. SETTING: Rural municipal hospital. PATIENTS: Eighty consecutive patients with dysphagia. INTERVENTIONS: Patients were randomized to receive PEG placement by a single physician using the endoscope holder (40 patients) or by 2 physicians using the conventional pull method (40 patients). MAIN OUTCOME MEASUREMENTS: The success rate, duration, and complications of both methods were scored. RESULTS: The success rate of PEG by either method was similar (98%) using the endoscope holder compared with 100% with the conventional method. The duration of both endoscopic procedures was also similar (12.9 +/- 2 and 11.5 +/- 2 minutes) (P = .43). No major complication occurred with either procedure. There was 1 death within 30 days (of aspiration pneumonia) 3 days after conventional PEG placement. LIMITATIONS: The number of patients evaluated is small. CONCLUSIONS: Endoscope holder-assisted PEG placement allows a single physician to perform all the important aspects of pull PEG placement under direct vision without assistance from another specially trained individual. The method appears to be as feasible and safe as the conventional pull method.     

Complications and early mortality in percutaneous endoscopic gastrostomy placement in lombardy: A multicenter prospective cohort study

BackgroundPercutaneous endoscopic gastrostomy (PEG) is the most common endoscopic procedure used to provide nutritional support.AimTo prospectively evaluate the mortality and complication incidences after PEG insertion or replacement.MethodsAll patients who underwent PEG insertion or replacement were included. Details on patient characteristics, ongoing therapies, comorbidities, and indication for PEG placement/replacement were collected, along with informed consent form signatures. Early and late (30-day) complications and mortality were assessed.Results950 patients (47.1% male) were enrolled in 25 centers in Lombardy, a region of Northern Italy. Patient mean age was 73 years. 69.5% of patients had ASA status 3 or 4. First PEG placement was performed in 594 patients. Complication and mortality incidences were 4.8% and 5.2%, respectively. The most frequent complication was infection (50%), followed by bleeding (32.1%), tube dislodgment (14.3%), and buried bumper syndrome (3.6%). At multivariable analysis, age (OR 1.08 per 1-year increase, 95% CI, 1.0–1.16, p = 0.010) and BMI (OR 0.86 per 1-point increase, 95% CI, 0.77−0.96, p = 0.014) were factors associated with mortality.PEG replacement was carried out in 356 patients. Thirty-day mortality was 1.8%, while complications occurred in 1.7% of patients.ConclusionsOur data confirm that PEG placement is a safe procedure. Mortality was not related to the procedure itself, confirming that careful patient selection is warranted.     

Survival after percutaneous endoscopic gastrostomy placement in older persons

BACKGROUND: The prolongation of life is an important consideration in the decision to initiate long-term tube feeding. This report critically synthesizes the evidence regarding the impact of percutaneous endoscopic gastrostomy (PEG) tube placement on survival in older persons. METHODS: A systematic search was conducted using MEDLINE from January 1980 until January 1999. Articles reporting survival data in older persons (mean or median age >65 years) after PEG tube placement were identified. The number and age of subjects, length of follow-up, setting, and survival data were extracted from all eligible studies. Mortality data at 1, 2, 6, and 12 months after PEG placement were quantitatively synthesized. Clinical characteristics associated with decreased survival among subjects with PEG tubes were identified. RESULTS: Five cohort studies compared survival in patients with and without feeding tubes in nursing homes, but none demonstrated a survival benefit. Another cohort study reported increased survival for tube-fed patients with amyotrophic lateral sclerosis. The pooled proportion of all subjects surviving after PEG placement was as follows: 1 month = 0.81 (95% confidence interval [CI], 0.74-0.88), 2 months = 0.70 (95% CI, 0.65-0.74), 6 months = 0.56 (95% CI, 0.20-0.92), and 12 months = 0.38 (95% CI, 0.26-0.49). Advanced age and malignancy were the factors most often reported to be associated with poorer survival among subjects with PEG tubes. CONCLUSIONS: The impact of PEG placement on survival is not known because the level of evidence is limited. PEG tubes may prolong life in selected populations. However, the majority of older patients selected for PEG placement will not survive 1 year after the procedure. Certain factors may identify those patients more likely to derive a survival benefit from long-term tube feeding. This information may offer some guidance to decision makers for whom prolongation of life is an important factor in the tube-feeding decision.     

Long-term outcome after placement of a percutaneous endoscopic gastrostomy tube

Aim:   To evaluate long-term survival and prognostic factors in patients who have undergone placement of a percutaneous endoscopic gastrostomy tube.
Methods:   A retrospective analysis of all patients without malignancy who underwent percutaneous endoscopic gastrostomy at Hanyu General Hospital during the period January 2001–December 2005.
Results:   A total of 198 patients (100 men, 98 women) were assessed. Median age was 78 years (range, 25–97 years). The primary diagnosis was a cerebrovascular disorder in 149 (75.3%) of the patients. Prior to placement, 120 (60.6%) had suffered pneumonia. Survival was 87.4% at 1 month, 67.8% at 3 months, 52.6% at 6 months, 38.1% at 1 year, 27.8% at 2 years and 22.3% at 3 years. Pneumonia was the most common cause of death during the follow-up period (91 of 140 patients, 65.0%). Cox's proportional hazards model showed independent predictors of mortality to be a low serum albumin concentration (≤2.9 g/dL) and history of pneumonia before the procedure.
Conclusions:   Mortality of patients who underwent percutaneous endoscopic gastrostomy appears to be high. In particular, the long-term prognosis was poor for patients with hypoalbuminemia, and this procedure is probably not preferred for patients with recurrent aspiration pneumonia.     

Risk factors for pneumonia after percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is currently a popular method of administering enteral feeding. Most of these patients are elderly, debilitated, and chronically ill. They are on a number of medications and have multiple diseases. With impaired consciousness and swallowing disability, these patients are prone to develop pneumonia. In order to identify possible risk factors, we followed 24 men who underwent PEG for the occurrence of pneumonia or until they died. We then analyzed the medical records of these patients for potential risk factors for pneumonia. The presence of esophagitis during PEG placement endoscopy and history of pneumonia prior to PEG were significant risk factors. Advanced age and cerebrovascular accident (CVA) tended to indicate a higher risk of pneumonia. Taking these risk factors into consideration may be beneficial in the management of such patients.     

Single endoscopist-performed percutaneous endoscopic gastrostomy tube placement

AIM: To investigate whether single endoscopist-performed percutaneous endoscopic gastrostomy (PEG) is safe and to compare the complications of PEG with those reported in the literature. METHODS: Patients who underwent PEG placement between June 2001 and August 2011 at the Baskent University Alanya Teaching and Research Center were evaluated retrospectively. Patients whose PEG was placed for the first time by a single endoscopist were enrolled in the study. PEG was performed using the pull method. All of the patients were evaluated for their indications for PEG, major and minor complications resulting from PEG, nutritional status, C-reactive protein (CRP) levels and the use of antibiotic treatment or antibiotic prophylaxis prior to PEG. Comorbidities, rates, time and reasons for mortality were also evaluated. The reasons for PEG removal and PEG duration were also investigated. RESULTS: Sixty-two patients underwent the PEG procedure for the first time during this study. Eight patients who underwent PEG placement by 2 endoscopists were not enrolled in the study. A total of 54 patients were investigated. The patients’ mean age was 69.9 years. The most common indication for PEG was cerebral infarct, which occurred in approximately two-thirds of the patients. The mean albumin level was 3.04 ± 0.7 g/dL, and 76.2% of the patients’ albumin levels were below the normal values. The mean CRP level was high in 90.6% of patients prior to the procedure. Approximately two-thirds of the patients received antibiotics for either prophylaxis or treatment for infections prior to the PEG procedure. Mortality was not related to the procedure in any of the patients. Buried bumper syndrome was the only major complication, and it occurred in the third year. In such case, the PEG was removed and a new PEG tube was placed via surgery. Eight patients (15.1%) experienced minor complications, 6 (11.1%) of which were wound infections. All wound infections except one recovered with antibiotic treatment. Two patients had bleeding from the P     

Patient outcomes related to percutaneous endoscopic gastrostomy placement

Although many aspects of percutaneous endoscopic gastrostomy (PEG) have been addressed in the literature, attention to psychologic and social outcomes of PEG has been limited. Our goal was to assess a range of physical, psychologic, and social outcomes related to PEG feeding. This study is a follow-up survey of patients undergoing PEG and/or their surrogates. Data were collected by semistructured interviews in two tertiary hospitals in Alberta, Canada. Measurements consisted of PEG status at 1-year follow-up, quality of life, impact on caregivers, and opinions about long-term support via PEG. We included 71 patients in the study. Of all 39% of patients died, 32% had the PEG still in place, and for 28% the PEG was removed at the end of the 1-year follow-up. The prognosis of the attending physician at the initial visit and the underlying disease were significantly related to the outcome (p < 0.05). After 1 year, 85% of all patients whose PEGs were still in place, were not working or studying or managing their own household in any capacity, 67% were not managing personal care, and 19% were feeling very ill. Fifty-two percent of the caregivers spent 15 hours or more per week visiting and caring for the patient. At the 1-year follow-up, all ten surviving patients who could be interviewed agreed they would have a PEG again. Seventy percent of the caregivers said that they would want the same decision to be made. Although a majority of patients and caregivers did not regret the decision to place a PEG, this did not necessarily mean enhanced quality of life. Developing strategies to select patients who will benefit from long-term nutritional support could improve patient outcomes.     

Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) tube placement is the preferred method for long-term enteral feeding of patients who are unable to take food by mouth. Despite the widespread acceptance of the procedure, no large-scale study of the long-term outcomes of patients receiving PEG tubes has been reported. The objective of this study was to determine the survival of patients in whom PEG tubes are placed. DESIGN: Retrospective cohort study using data obtained from two computerized databases. SETTING: Department of Veterans Affairs hospitals. PATIENTS: Seven thousand three hundred sixty-nine patients who received a PEG tube in fiscal years 1990 through 1992. RESULTS: For the 7,369 patients, the mean age was 68.1 years and 98.6% were men. PEG tubes were most commonly placed in patients with cerebrovascular disease (18.9%), other organic neurologic disease (28.6%), or head and neck cancer (15.7%). Although the complication rate of the procedure itself was low (4%), because of the severity of their underlying disease, 1,732 patients (23.5%) died during the hospitalization in which the PEG tube was placed. The median survival of the full cohort was 7.5 months. CONCLUSIONS: This study documents the widespread placement of PEG tubes in severely ill patients, half of whom are in the terminal phase of their illness. Further study is needed to determine whether these patients benefit from PEG tube placement in terms of their quality of life and survival. From the Department of Veterans Affairs Health Services Research and Development (HSR&D) Field Program, and the Department of Medicine, Baylor College of Medicine, Houston, Tex. Supported by the Department of Veterans Affairs Health Services Research and Development Houston Field Program. Presented at the 95th annual meeting of the American Gastroenterological Association, New Orleans, La., May 15–18, 1994.     

The safety and feasibility of percutaneous endoscopic gastrostomy placement

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) is now becoming increasingly popular. However, an increasing number of complications has also been reported. Regarding such complications, iatrogenic perforation of the colon is considered to be the most dangerous. METHODOLOGY: We routinely check the course of the colon using preoperative abdominal computed tomography with air injected into the stomach (pre-PEG CT), and thereafter the patients are classified into two groups, consisting of a Low-risk group and High-risk group, according to the locations of the stomach and colon. The patients in the High-risk group underwent PEG in combination with contrast radiography of the large intestine. We evaluated the safety and feasibility of PEG placement using a Pre-PEG CT and contrast radiography of the large intestine. RESULTS: A Pre-PEG CT showed a Low-risk type in 84.4% and a High-risk type in 15.6%. High-risk type patients underwent contrast radiography on the large intestine in conjunction with PEG. As a result, we were able to perform PEG safely with no iatrogenic perforation in any patients. CONCLUSIONS: A pre-PEG CT and contrast radiography of the large intestine combination with PEG are thus considered to be an effective modality for reducing the incidence of serious complications of PEG.     

Increased risk of peristomal wound infection after percutaneous endoscopic gastrostomy in patients with diabetes mellitus

Background. Results of prospective studies on the effect of prophylactic antibiotics before percutaneous endoscopic gastrostomy are conflicting. Factors for increased risk of peristomal wound infection have not been clearly identified.

Aim. To evaluate the incidence of complications of percutaneous endoscopic gastrostomy and to determine the predictors of wound infection.

Patients and Methods. Percutaneous endoscopic gastrostomy was performed on 134 patients in different disease groups between January 1996 and June 2000. Medical records were carefully reviewed for demographic data, indications for percutaneous endoscopic gastrostomy, use of prophylactic antibiotics, complications and comorbid conditions predisposing to wound infection.

Results. Of 134 patients, 22 (16.4%) developed complications after percutaneous endoscopic gastrostomy. Wound infection, the most common complication, occurred in 19 patients (14.2%) and Pseudomonas aeruginosa was the most frequently isolated microorganism. In univariate analysis, non-malignant disease and diabetes mellitus were significantly associated with peristomal wound infection after percutaneous endoscopic gastrostomy. In multivariate analysis, only diabetes mellitus was an independent risk factor for the development of peristomal wound infection after percutaneous endoscopic gastrostomy (p=0.035).

Conclusions. Patients with diabetes mellitus have a higher risk of peristomal wound infection after percutaneous endoscopic gastrostomy.