Laparoscopically assisted antegrade percutaneous endoscopic gastrostomy

We describe a new technique named laparoscopically assisted antegrade percutaneous endoscopic gastrostomy (PEG), whereby a PEG tube is placed in the stomach with the aid of laparoscopy. The procedure is simple and avoids injury to adjacent organs that may occur with a standard PEG tube placement.     

Gastroenteric fistula complicating percutaneous endoscopic gastrostomy

Background

Gastroenteric fistula occurs in 2% to 3% of patients undergoing percutaneous endoscopic gastrostomy (PEG). The authors identified 12 children with this major complication.

Methods

A retrospective case note review was performed.

Results

Over a 5-year period, the complication rate for gastroenteric fistula was 3.5% (12 of 343 procedures). Presentation ranged from 1 day to 25 months post-PEG insertion. Eight patients presented with acute intestinal obstruction. The gastroenteric fistulous tract involved the posterior wall of the stomach in all cases. The plain abdominal x-ray was useful in establishing the diagnosis of the gastroenteric fistula.

Conclusions

Patients with gastroenteric fistula as a complication of PEG insertion can remain asymptomatic for prolonged periods. It often is difficult to make the diagnosis. A plain abdominal x-ray is a useful diagnostic modality.     

Laparoscopically monitored percutaneous endoscopic gastrostomy (PEG) in children: a safer procedure

Background Percutaneous endoscopic gastrostomy (PEG) has now become the preferred technique for facilitating enteral nutrition in children with inadequate caloric intake. Because many problems related to PEG insertion have recently been reported, we were motivated to reassess this established technique. We have therefore added a new step—laparoscopic monitoring—to the classic PEG procedure.Methods Fifteen children who required PEG during the previous year were studied. Their ages ranged from 2 months to 18 years. Six children were < 1 year old at the time of operation. In 11 patients, the PEG was performed at the end of a laparoscopic Nissen fundoplication. In the others, it was done as a single procedure.Results In all 15 children, the PEG was performed safely and quickly, without complications.Conclusion The addition of laparoscopic monitoring to the classic PEG procedure introduced by Gauderer et al. changes the first and last parts of the procedure from an almost blind undertaking to a well-controlled and safer procedure.     

Ethical challenges of percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is a widely used procedure for patients who cannot swallow. Athough it is mostly performed for valid indications, its use in terminally ill patients is questionable. In this study, more than 30% of patients died in hospital after PEG placement and 16% died less than 30 days after placement. Strict guidelines and oversight or PEG placement are recommended. Presented as poster #216 at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the International Pediatric Endosurgery Group meeting 14 March 2003     

A simplified technique for percutaneous endoscopic gastrostomy

Summary Percutaneous endoscopic gastrostomy (PEG) is the preferred method of establishing long-term enteral access for feeding. Many patients requiring PEG are elderly and at risk for complications. Expeditious placement of the gastrostomy tube will minimize complications, but distorted esophageal anatomy can significantly lengthen the procedure. Some endoscopists abandon conventional repeat gastroscopy in difficult cases to accelerate the procedure. The authors describe a reliable method for quick reinsertion of the endoscope which shortens time required for PEG, and may reduce complications.     

Successful new method of extracorporeal percutaneous endoscopic gastrostomy (E-PEG)

Background Although percutaneous endoscopic gastrostomy (PEG) has become popular for patients with swallowing disorders as a nutrition support or a decompressant of gastrointestine, perioperative complications associated with PEG have not decreased, especially peristomal infections. To reduce peristomal infections, we designed a new method of gastrostomy by extracorporeal approach under endoscopic observation, named as extra-corporeal PEG (E-PEG). Methods Experimental studies for E-PEG were performed repeatedly using pigs under general anesthesia to confirm the safty of its procedure for human use. After approval of institutional ethics review board in our university, thirty patients with prior consent participated in this study. The operation time, the incidence rate of complications and the hospital stay were compared between E-PEG and ordinary pull-method PEG groups. Results Two patients (6.7%) in E-PEG group had postoperative complications, i.e., aspiration pneumonia and surgical site infection. The operation time of E-PEG group was 5–16 (mean ± SD: 10.3 ± 2.96) min as compared to 14–37 (mean ± SD: 26.9 ± 8.39) min with pull-method PEG. The postoperative hospital day of E-PEG was within two days except for the two complicated cases. Significance differences of operation time, complication rate and postoperative hospital stay between those groups observed statistically. Conclusions These results indicate that E-PEG was safe, tolerable and speedy when compared ordinary pull-method PEG.     

Percutaneous endoscopic gastrostomy with T-bar fixation in children and infants

Background The standard for placement of pediatric gastrostomy tubes has been percutaneous endoscopic gastrostomy (PEG) using the Ponsky “pull” technique. This study evaluated the safety and efficacy of PEG placement using the “push” technique with T-bar fixation in pediatric patients. This technique generally is limited to the adult population. With this technique, endoscopy is performed. The stomach is insufflated, and the anterior abdominal wall is transilluminated. T-bar fasteners are sequentially deployed to secure the stomach to the anterior abdominal wall. Using a modified Seldinger technique, a gastrostomy tube is placed through the center of the T-bars. Methods A retrospective review of all PEG tubes placed in pediatric patients from 1997 to 2003 using the T-bar gastroscopy “push” technique was conducted. Patients 18 years of age or younger were included in the study. Data collected included patient age, operative time, procedure location, and complications. Results The procedure was performed for 47 children (mean age, 6.4 years), including 15 infants younger than 1 year. The indications for long-term enteral access included failure to thrive (n = 11), feeding disorder secondary to neurologic dysfunction (n = 31), gastroparesis (n = 1), and dysphagia (n = 4). The operative time averaged 23 min (range, 12–45 min). One major complication occurred (gastrocolonic fistula). The one minor complication was early dislodgement of the gastrostomy tube, which required replacement. Conclusion This study found the described technique to be safe and effective for the placement of gastrostomy tubes in infants and children. Presented at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Fort Lauderdale, Florida, 13–16 April 2005     

Percutaneous endoscopic gastrostomy in a patient with a large hiatal hernia using laparoscopy.

Gastropexy via a percutaneous endoscopic gastrostomy has been used for fixation of the stomach to the anterior abdominal wall in patients with hiatal hernias who are poor candidates for more extensive procedures. Altered anatomic relationship of the stomach to other intra-abdominal organs and the abdominal wall may prevent safe placement endoscopically. Visualizing and manipulating the stomach with laparoscopy enables the surgeon to complete the procedure and diminishes the risk of injury to the adjacent organs without compromising the minimally invasive approach.     

Decompressive percutaneous endoscopic gastrostomy in nonmalignant disease

BACKGROUND: Percutaneous endoscopic gastrostomy is the standard for long-term enteral access. It can provide enteral nutrition or gastrointestinal decompression. Utilization of the gastrostomy for decompression has traditionally been reported in the setting of malignant obstruction. However, decompressive gastrostomy can play a role in the treatment of nonmalignant bowel dysfunction as well. METHODS: Over a 2-year period, 20 of 121 percutaneous endoscopic gastrostomies attempted by this surgical endoscopist were for gastrointestinal decompression. RESULTS: Eleven of 18 gastrostomies successfully placed for decompression were for benign conditions. In 5 patients with fistulous disease, the purpose of decompression was to divert the gastrointestinal tract until operative repair. Four of these patients have since undergone definitive surgery. CONCLUSIONS: This series presents the successful use of the percutaneous endoscopic gastrostomy for decompression of nonmalignant conditions. In such scenarios, the drainage gastrostomy can be employed as a bridge to future surgery, or as a means of long-term decompression for bowel dysfunction.     

Prevention of percutaneous endoscopic gastrostomy stoma metastases in patients with active oropharyngeal malignancy

The implantation of metastasis of oropharyngeal or esophageal cancer to percutaneous endoscopic gastrostomy (PEG) stomata is considered an uncommon complication, but it is being recognized with increasing frequency. The incidence of this complication is not known. Multiple theories of metastatic spread have been proposed. We describe a case following retrograde endoscopy via a PEG stoma site. A National Library of Medicine literature search was performed, and case reports and bibliographies were reviewed. We estimate the incidence of this complication as 1% minimum. Direct seeding of the site is the only reasonable hypothesis to explain this phenomenon. Health care providers need to be educated about this problem. Although there is no direct evidence that metastases are spread by direct contact, we believe that transgression of the active primary tumor during gastrostomy tube placement should be avoided. Laparoscopic gastrostomy tube placement provides a safe, effective, and minimally invasive method of enteral access, which avoids transgression of the primary tumor site, and may prevent stomal metastases in patients with active aerodigestive tract malignancies who require gastrostomy.     

Use of percutaneous endoscopic gastrostomy tubes in burn patients

Alimentation and decompression are imperative to the successful management of the severely burned patient. Utilization of percutaneous endoscopic gastrostomy (PEG) tubes for these purposes has become a proven effective procedure in nonburned patients with few major complications. We retrospectively reviewed placement of PEG tubes in 31 burn patients, some of whom had been admitted with additional diagnoses such as inhalation injury and/or dysphagia. In 90% of our burn patients, the use of PEG tubes was without complication. The placement of PEG tubes through burn wound areas or donor sites added no increase in wound complications. In summary, there was no mortality referable to the use of PEG tubes, there were no major operative or wound complications, and feedings were tolerated well. This study reports on the use of PEG tubes in a regional Burn Treatment Cente. It shows that PEG tubes offer safe and effective alimentation and decompression in the management of burned patients.     

Percutaneous endoscopic gastrostomy in the supermorbidly obese patient.

INTRODUCTION: Obesity is reaching epidemic proportions in the United States, and as patients at the extremes of morbid obesity come under the care of surgeons, routine procedures may become increasingly complex in the face of greater body mass. We prospectively evaluated the success rate of percutaneous endoscopic gastrostomy (PEG) placement in a group of morbidly obese patients outside the current classification systems used to stratify obesity. METHODS: Patients with a body mass index (BMI) greater than 60 kg/m2 who presented for PEG over a one year period were prospectively enrolled. Each patient underwent attempted PEG placement using the pull method by a single surgeon. Outcome variables included: successful PEG, wound infection, tube dislodgement, or bleeding. RESULTS: Six patients with BMI > 60 kg/m2 presented for PEG. All patients were in a surgical critical care unit maintained on mechanical ventilation. All underwent successful PEG placement with standard techniques and sustained no post-procedural complications. CONCLUSION: In the hands of an experienced surgical endoscopist, percutaneous endoscopic gastrostomy can be safely performed in patients at the extremes of morbid obesity. Future studies are warranted to validate the results of our small series.     

Laparoscopic Nissen fundoplication with simultaneous percutaneous endoscopic gastrostomy in children

Background: The aim of the study was to evaluate the results of laparoscopic Nissen fundoplication (LNF) with simultaneous percutaneous endoscopic gastrostomy (PEG) in children with gastroesophageal reflux (GER) disease documented by upper gastrointestinal contrast and/or pH monitoring and/or esophageal endoscopy. Methods: Fifteen LNF + PEGs were performed in children with pathologic antecedents: ten neurologically impaired children, two ORL (otorhinolaryngeal) pathologies. Two cases of AIDS, and one neuroblastoma. In one case, disruption of the fundoplication occurred during insufflation of the stomach. The child was reoperated on the 3rd day using an open procedure, so she was excluded from the results of the LNF. Results: Two children had postoperative complications: one with cardiac insufficiency, one case of dehydration. Fourteen LNFs were controlled at 3 months by gastroesophageal X-ray and pH-metry. The 14 gastroesophageal X-rays were normal in 12 cases; gastroesophageal reflux was present in two cases. Twelve pH monitorings were analyzed (two technical failures), the median time pH<4 was 0.2% (0–20). Only one pH monitoring was pathologic (pH<4: 20%). This recurrent reflux to led to a second LNF with a good clinical result. Conclusions: In conclusion, it is possible to perform LNF and PEG during the same operative procedure. Short-term results are satisfactory with 14% recurrent GER. Long-term results need to be evaluated.     

Repeat percutaneous endoscopic gastrostomy (PEG): an outpatient procedure

Summary Patients who have previously undergone percutaneous endoscopic gastrostomy (PEG) with subsequent PEG removal occasionally require elective repeat PEG. Adhesion of the stomach to the abdominal wall after the original PEG allows repeat PEG to be performed as an outpatient procedure and full-volume tube feeding to be started immediately. Elective repeat PEG was performed in ten patients. Repeat PEG was performed at the site of the original PEG in all cases. Six of the ten repeat PEGs were performed as an outpatient procedure. No complications were attributed to repeat PEG, and full-volume tube feedings were tolerated in all cases when attempted. To obviate the need for repeat PEG, we recommend immediate replacement after inadvertent PEG removal and avoiding elective removal of PEGs used in patients with long-term neurologic impairment for at least 6 months. Presented at the SAGES 2nd World Congress of Endoscopic Surgery, Atlanta, Ga., USA, 1990     

Bedside percutaneous endoscopic gastrostomy

Background: Percutaneous endoscopic gastrostomy (PEG) is a good alternative that provides long-term nutritional support and is associated with minimal morbidity. Methods: During a 24-month period, we studied 54 critically injured patients who underwent early PEG to provide enteral nutritional support. Patients were selected due to the inability to tolerate intake by mouth secondary to multiple associated injuries, especially to the central nervous system. Results: All patients sustained multiple injuries with an average Injury Severity Score of 27. The mean Glasgow Coma Scale at the time of admission was 7 and at the time of the PEG was 10. Eleven patients (20%) had an intracranial pressure (ICP) device, and there was no significant increase in the mean ICP before, during, or after the procedure. In 63% of patients, tube feedings were interrupted for a variety of problems in the 72 h preceding the PEG, and in 70% of patients an average of five radiographs were obtained to document tube position. In 95% of patients, the nutritional goal was achieved within 48 h of PEG placement. There were one immediate and two delayed complications after PEG placement. There were two deaths, neither related to the PEG placement. Conclusions: Early PEG in critically injured patients is a safe and effective method of providing access to the GI tract for nutritional support. In patients with significant brain injuries, adequate sedation and the presence of an ICP monitor help to minimize secondary insults to the brain. Received: 5 March 1997/Accepted: 15 May 1997     

Concomitant placement of percutaneous endoscopic gastrostomy and jejunostomy

Summary Percutaneous endoscopic gastrostomies have gained wide use for long-term enteral nutrition. However, gastroesophageal reflux and aspiration pneumonia have occurred following this procedure. Initial enthusiasm concerning the ability of intrajejunal feeding to negate the risk of aspiration has been challenged by some reports. In this report, a new method is described for concomitant placement of endoscopic gastrostomy and feeding jejunostomy wherein the tip of the feeding jejunostomy is placed at least 40 cm distal to the pylorus while the gastrostomy tube is used for drainage. Twenty critically ill patients underwent the procedure utilizing general or local anesthesia. Sixty-day followup showed one uneventful episode of pulmonary aspiration (5%) after retrograde migration of the jejunal tube into the duodenum. All but two patients (90%) tolerated their tube feedings well. This technique can be easily performed with accurate placement of the PEJ tube distal to the pylorus and is associated with minimal risk of aspiration.     

Safety of percutaneous endoscopic gastrostomy after trauma laparotomy

Background

Trauma patients frequently require long-term enteral access because of injuries to the head, neck, or gastrointestinal tract. Noninvasive methods for gastrostomy placement include percutaneous endoscopic gastrostomy (PEG) and percutaneous radiographic gastrostomy (PRG). In patients with recent trauma laparotomy, PEG placement is felt to be relatively contraindicated because of the concerns about altered anatomy. We hypothesize that there is no increased rate of complications related to PEG placement in patients with trauma laparotomy compared with those without laparotomy provided that basic safety principles are followed.

Materials and methods

This retrospective study evaluates all percutaneous gastrostomies (both PEG and PRG) placed in trauma patients admitted at a level I trauma center between January 1, 2007 and March 30, 2010. The electronic medical records of the 354 patients were reviewed through 30 days after procedure, and patients were further subdivided by the history of laparotomy. Statistical analysis was performed using Fisher exact test or two-tailed t-test, as appropriate.

Results

In patients with no prior trauma laparotomy, successful PEG placement occurred in 92.2% of patients, the remainder underwent PRG placement. Of patients with prior trauma laparotomy, 82.4% had successful PEG placement. Two percent of attempted PEG placements failed in patients with no previous trauma laparotomy, whereas 11.8% failed in patients with recent trauma laparotomy. The overall complication rate was 2.0%, with no recorded complications in patients with trauma laparotomy before PEG placement.

Conclusions

These data suggest that surgeons should not consider recent trauma laparotomy a contraindication to PEG placement.     

Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: a prospective, randomized trial

Background Percutaneous endoscopic gastrostomy (PEG) has increasingly replaced surgical gastrostomy (SG) as the primary procedure for the long-term nutrition of patients with swallowing disorders. This prospective randomized study compares PEG with SG in terms of effectiveness and safety. Methods This study enrolled 70 patients with swallowing disorders, mainly attributable to neurologic impairment. All the patients, eligible for both techniques, were randomized to PEG (pull method) or SG. The groups were comparable in terms of age, body mass index, and underlying diseases. Complications were reported 7 and 30 days after the operative procedure. Results The procedures were successfully completed for all the patients. The median operative time was 15 min for PEG and 35 min for SG (p < 0.001). The rate of complications was lower for PEG (42.9%) than for SG (74.3%; p < 0.01). The 30-day mortality rates were 5.7% for PEG and 14.3% for SG (nonsignificant difference). Conclusion The findings show PEG to be an efficient method for gastrostomy tube placement with a lower complication rate than SG. In addition, PEG is faster to perform and requires fewer medical resources. The authors consider PEG to be the primary procedure for gastrostomy tube placement.     

Metastatic implantation of an oral squamous-cell carcinoma at a percutaneous endoscopic gastrostomy site

Percutaneous endoscopic gastrostomy (PEG) has become an important adjunct in the care of the head-and-neck cancer patient. When resection will likely affect swallowing, PEG can be performed just prior to cancer resection. However, it is unclear whether PEG should be the procedure of choice for establishing enteral access in head-and-neck cancer patients. In this report we describe a man with advanced oral squamous cell carcinoma who had a One-Step PEG button inserted immediately prior to his cancer resection. Six months later, the patient developed metastatic squamous-cell carcinoma at the PEG site. Although the mechanism of spread cannot be confirmed, direct seeding from passage through the cancer-filled oral cavity seems likely. Methods of establishing enteral access which avoid tumor-contaminated fields, such as use of an overtube during conventional PEG, open gastrostomy, or laparoscopic gastrostomy, may be more appropriate in head-and-neck cancer patients.     

Esophagectomy in patients with prior percutaneous endoscopic gastrostomy tube placement

Background

The impact of preoperative percutaneous endoscopic gastrostomy (PEG) tube placement in patients undergoing esophagectomy is uncertain.

Methods

A retrospective review was performed in consecutive patients who underwent esophagectomy. Patients were divided into groups based on whether or not they had preoperative PEG placement.

Results

One hundred seventeen patients were studied, 102 without (PEG−) and 15 with PEG+ before PEG tube placement. The overall morbidity and mortality rates were 38% and 3%, respectively. The use of a gastric conduit was similar between groups (94% PEG− vs 87% PEG+, P = .27), and the presence of a PEG before PEG tube placement was not prohibitive in any case. Anastomotic leak rates were similar between groups (11% PEG− vs 15% PEG+, P = .65), and there were no leaks from previous PEG sites.

Conclusion

It appears that preoperative PEG tube placement has no adverse effect on the performance of esophagectomy and may be considered in highly selected patients with poor nutritional status.