Percutaneous endoscopic gastrostomy in the dementia patient: helpful or hindering?

Percutaneous endoscopic gastrostomy (PEG) is a common technique performed worldwide. Recently, the use of PEG in the dementia patient with dysphagia for nutrition support has been called into question. Some reviews have reported no improvement in survival with PEG tubes in this population. Higaki and colleagues now present a large review of PEG tube placement in patients with dementia, which demonstrates a similar survival rate in patients without dementia receiving PEG tubes. The question of the utility of PEG tube placement for nutrition support in the dementia population requires an organized, prospective analysis to concretely answer the question.     

Decreasing use of percutaneous endoscopic gastrostomy tube feeding for veterans with dementia-racial differences remain

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) tube placement is a widely used method for long-term enteral feeding of demented patients unable to take sufficient food by mouth. National time trends in PEG tube use over the last decade have not been previously reported. The objective of this study was to determine whether use of PEG tubes for patients with dementia has changed over time and by race. DESIGN: Retrospective cohort study. SETTING: All Veterans Affairs hospitals. PARTICIPANTS: Using an administrative database of the Veterans Health Administration, all veterans with dementia and all veterans who received a PEG tube were identified between fiscal years 1990-2001. MEASUREMENTS: Proportion of PEG tube placement for dementia patients over time and by race. RESULTS: Four hundred thirteen thousand six hundred twenty-seven dementia patients aged 60 and older were identified, of whom 6,464 (1.6%) received a PEG tube. Use of PEG tubes for dementia patients increased during the first half of the decade but subsequently decreased almost to baseline after peaking in 1996 (1990: 1.2%, 1996: 1.8%, 2001: 1.3%). Time trends in the use of PEG tube feeding for dementia patients varied by race. Specifically, the relative risk for PEG tube placement in African-American dementia patients increased from 1.65 (95% confidence interval (CI)=1.25-2.17, FY 1990) to 1.97 (95% CI=1.62-2.4, FY 2001). CONCLUSION: Although the overall use of PEG tube feeding for dementia patients decreased over time, rates in use and changes in use over time varied significantly by race. Reasons for the differential use of this procedure should be explored.     

Percutaneous endoscopic gastrostomy:Indications,technique,complications and management

Percutaneous endoscopic gastrostomy(PEG)is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition.Besides its wellknown advantages over parenteral nutrition,PEG offers superior access to the gastrointestinal system over surgical methods.Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide,knowing its indications and contraindications is of paramount importance in current medicine.PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish.Broadly,the two main indications of PEG tube placement are enteral feeding and stomach decompression.On the other hand,distal enteral obstruction,severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients.Although generally considered to be a safe procedure,there is the potential for both minor and major complications.Awareness of these potential complications,as well as understanding routine aftercare of the catheter,can improve the quality of care for patients with a PEG tube.These complications can generally be classified into three major categories:endoscopic technical difficulties,PEG procedure-related complications and late complications associated with PEG tube use and wound care.In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance.Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the"pull"technique being the most common method.In the last section of this review,the reader is presented with a brief discussion of these procedures,techniques and related issues.Despite the mentioned PEG tube placement complications,this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.     

Effects of percutaneous endoscopic gastrostomy tube placement on gastric antral motility and gastric emptying

Background Percutaneous endoscopic gastrostomy (PEG) is the preferred method for providing enteral nutritional support in patients with dysphagia. We examined gastric antral myoelectrical activity and gastric emptying before and after PEG tube placement to evaluate the effects of PEG on gastric motility.Methods PEG was performed in 41 patients; 21 fed by total parenteral nutrition (TPN) and 20 who received nasogastric tube feeding (NGF). Antral myoelectrical activity and gastric emptying were examined before and 4 weeks after PEG tube placement.Results The percentage of normal-range electrogastrograms (EGGs) was significantly lower in the TPN group than in the NGF group in both the pre- and postprandial periods before PEG tube placement. Enteral feeding after PEG tube placement improved gastric motility in the patients with TPN. The percentage of normal-range EGGs increased significantly after PEG tube placement in both the pre- and postprandial periods, and plasma concentrations of paracetamol increased significantly after PEG tube placement in patients with TPN. A total of 7.3% of the patients developed the complication of gastroesophageal reflux (GER) after PEG tube placement. Gastric myoelectrical activity and gastric emptying were improved in these patients with GER after PEG tube placement. In contrast, the prevalence of esophageal hiatus hernia was significantly higher in patients with GER after PEG tube placement than in patients without GER after PEG tube placement.Conclusions Prolonged TPN with bowel rest induces physiological dysfunction of gastric motility. Enteral nutrition is the preferable physiological nutritional route. GER after PEG tube placement is not related to gastric motility. Esophageal hiatus hernia seems to be a major risk factor for GER complications after PEG tube placement.     

Prognosis factors of short and long-term survival in elderly hospitalized patients after percutaneous endoscopic gastrostomy

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice to achieve long-term enteral nutrition. The risks and benefits of PEG in elderly hospitalized patients have been poorly documented. The objective of this study was to describe the outcome of elderly patients one-year after insertion of a PEG tube.PATIENTS AND METHODS: Hospital records of 73 patients who underwent PEG for enteral nutrition were reviewed retrospectively. Data on patient age and sex, preexisting medical conditions such as dementia or pressure sores, indication for PEG, concomitant infection, complications of PEG and death were obtained from the hospital charts.RESULTS: The main indication for PEG was anorexia (49%). Before insertion of the gastrostomy tube, 44% of the patients had pressure scores, 30% had concomitant infection, 45% had dementia. PEG complications were observed in 51 patients. The survival rate at 1, 6 and 12 months was 0.68 [95% confidence interval - CI 95%: 0.56-0.78], 0.48 [CI 95%: 0.36-0.59] and 0.37 [CI 95%: 0.26-0.48] respectively. The presence of an infectious disease or of pressure sores at the time of PEG tube insertion were independently associated with mortality. Median survival of patients with these two factors was 32 days [CI 95%: 11-98].CONCLUSION: According to these results, the PEG tubes should be inserted with a delay from infectious diseases and before the occurrence of pressure sores.     

Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) feeding has been validated in specific clinical situations such as acute stroke with dysphagia and oropharyngeal malignancy. The perception that gastrostomy insertion is safe and technically simple has led to an increase in the demands for PEG insertion, encompassing clinical applications such as in patients with dementia, in whom its role has not been justified. The purpose of this study was to compare the mortality of patients with dementia who were fed by PEG to that of other subgroups of patients requiring gastrostomy feeding. METHODS: The study focused on a cohort of 361 consecutive patients requiring PEG feeding between August 1992 and July 1997 from two District General Hospitals (Rotherham District General Hospital and Doncaster Royal Infirmary) in South Yorkshire. A retrospective cohort survival analysis was performed using the Kaplan-Meier survival method and Cox proportional hazards analysis. RESULTS: In all patients requiring gastrostomy feeding there is a high initial mortality of 28% at 30 days. However, patients with dementia have a worse prognosis compared to other subgroups, with 54% having died at 1 month and 90% at 1 yr (log rank test p < 0.0001). This difference remained significant (log rank p < 0.0001) after adjusting for age at the time of PEG insertion. CONCLUSIONS: This is the first demonstration in the United Kingdom that the mortality of patients with dementia who are fed by gastrostomy is considerable. Consequently, we may wish to advise against gastrostomy feeding in selected patients within this clinical setting.     

Early Initiation of Post-PEG Feeding

Since its introduction in 1980, percutaneous endoscopic gastrostomy (PEG) has become the procedure of choice for long-term enteral feeding in patients who are unable to take adequate oral nutrition. Traditionally, gastroenterologists have waited for 24 hr after PEG tube placement before initiating feedings. However, recently published data have described the safety and efficacy of initiating PEG tube feedings as early as 3 hr after PEG tube placement. The objectives of this study were to determine how many hours after PEG tube placement practicing gastroenterologists initiate feedings and to determine whether they were aware of the pertinent literature. A four-page questionnaire was mailed to 35 practicing gastroenterologists, and the data gathered were analyzed using the SAS statistical package. A majority (81.5%) were aware of articles published in the last six years regarding the safety and efficacy of early initiation of feeding after PEG; of interest, however, only 10.7% were initiating feedings less than 3 hr after PEG tube placement. In conclusion, there exists a discrepancy between published recommendations and clinical practice regarding early initiation of feedings after PEG tube placement in this group of gastroenterologists who were surveyed.     

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.     

Long-Term Survival in Patients Undergoing Percutaneous Endoscopic Gastrostomy and Jejunostomy

Percutaneous endoscopic gastrostomy (PEG) used to supply enteral nutrition has supplanted surgically placed feeding tubes in many institutions. These tubes are currently placed in: 1) patients with reversible disease with potential for recovery (stroke, Guillain-Barré syndrome); 2) patients with incurable disease with potential for extended survival (head and neck cancer, amyotrophic lateral sclerosis); or 3) patients who are terminal or seriously debilitated (head trauma, systemic malignancies). Few data are currently available regarding long-term survival, survival difference between various patient populations, and incidence of recovery of oral intake with subsequent PEG tube removal. In this study, records of 191 patients in whom PEG tubes were placed were retrospectively reviewed and information collected regarding underlying diseases (malignant vs nonmalignant), survival, and incidence of subsequent tube removal. Of the patients, 68 (36%) had cancer, and 123 (64%) had benign disease (usually stroke or other neurologic disorder). Survival curve analysis demonstrated that one-third of patients were dead within 60 days of PEG placement, and half were dead in the first 6 months. Total deaths were 115 (60%) at a median time of 164 days. No mortality was directly related to acute or subsequent PEG tube complications. Feeding tubes were removed in 41 patients (21%), 10 with cancer (5%), and 31 without (16%, p less than 0.05). These data on limited patient survival and low incidence of recovery of oral intake suggest that facilitation of hospital discharge into a less expensive home care or step-down facility is the most likely goal to be realized after PEG placement. Further, these results raise questions regarding the appropriateness of PEG placement in patients with anticipated early mortality or low likelihood of hospital discharge.     

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy

There are a variety of techniques for gastrostomy tube placement. Endoscopic and radiologic approaches have almost entirely superseded surgical placement. However, an aging population and significant advancements in modern healthcare have resulted in patients with increasingly complex medical issues or postsurgical anatomy. The rising prevalence of obesity has also created technical challenges for proceduralists of many specialties. When patients with these comorbidities develop the need for long-term enteral nutrition and feeding tube placement, standard approaches such as percutaneous endoscopic gastrostomy (PEG) by endoscopists and percutaneous image-guided gastrostomy (PIG) by interventional radiologists may be technically difficult or impossible. For these challenging situations, laparoscopic-assisted PEG (LAPEG) is an alternative option. LAPEG combines the advantages of PEG with direct intraperitoneal visualization, helping ensure a safe tube placement tract free of intervening organs or structures. In this review, we highlight some of the important factors of first-line gastrostomy techniques, with an emphasis on the utility and procedural technique of LAPEG when they are not feasible.     

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.     

Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy

AIM:To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy(PEG)could be a valuable option for patients with complicated anatomy.METHODS:A retrospective analysis of twelve patients(seven females,five males;six children,six young adults;mean age 19.2 years)with cerebral palsy,spastic quadriparesis,severe kyphoscoliosis and interposed organs and who required enteral nutrition(EN)due to starvation was performed.For all patients,standard PEG placement was impossible due to distorted anatomy.All the patients qualified for the laparoscopyassisted PEG procedure.RESULTS:In all twelve patients,the laparoscopy-assisted PEG was successful,and EN was introduced four to six hours after the PEG placement.There were no complications in the perioperative period,either technical or metabolic.All the patients were discharged from the hospital and were then effectively fed using bolus methods.CONCLUSION:Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.     

Indications for percutaneous endoscopic gastrostomy in complex tuberculosis patients.

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) is a widely used method for providing long-term administration of tube feeding. Different indications in relation to diseases, impairments and nutritional factors for PEG placement have been mentioned in guidelines. Treatment with PEG has not been described previously for tuberculosis (TB). Our aim was to identify and describe indications and contributing factors for PEG placement in TB patients. METHODS: A retrospective medical record review was conducted of 32 TB patients who required PEG from March 1996 to April 2004. Indications and contributing factors for PEG placement were analysed. RESULTS: PEG placement was based on three different indications. In 18 patients, PEG was used to administer tube feeding, in 4 patients anti-tuberculosis drugs were administered and in 10 patients both tube feeding and antituberculosis drugs were administered. Contributing factors for PEG placement were swallowing disabilities, weakness, anti-tuberculosis drugs and their side effects, pain of neuralgic origin, hiccups and refusal of food and drugs. CONCLUSIONS: In TB, imminent and overt malnutrition, as well as the administration of drugs with a curative aim, are new indications for PEG placement. The use of PEG can overcome various problems in TB treatment and prevent treatment default.     

The safe use of percutaneous gastrostomy for enteral nutrition in patients with Crohn's disease

OBJECTIVE: To determine the safety of percutaneous endoscopic gastrostomy (PEG) tube placement for nutritional support and/or defined therapeutic enteral nutrition (TEN) in adult patients with Crohn's disease. DESIGN: A prospective, observational study of patients with Crohn's disease in whom PEG tubes were placed for nutritional support or TEN. SETTING: A specialist nutrition clinic at a gastroenterology tertiary referral centre in Harrow, UK. PARTICIPANTS: Nine patients with Crohn's disease. Seven patients had nutritional failure and were unable to tolerate nasogastric feeding, and two patients were recruited in whom TEN therapy for active disease was indicated. The age range was 21-52 years (median, 30 years). Five patients were female; all had had previous ileo-colonic resections, one had a gastro-enterostomy and one had a non-healing Crohn's-related gastric ulcer. INTERVENTIONS: PEG insertion (Fresenius, Frecka 9 Fr) was performed at endoscopy with intravenous sedation. Follow-up with tubes in situ was for a median of 37 weeks (range, 4-276 weeks), and for a further median of 80 weeks (range, 52-120 weeks) in those whose tubes have been removed. MAIN OUTCOME MEASURES: The level of disease activity, nutritional status/body mass index and any complications associated with PEG tube placement were recorded. RESULTS: PEG was achieved in all patients; the only complication was a minor superficial entry site infection. Five patients continue to use PEG feeding to good effect, including healing of the Crohn's-associated ulcer. One patient now eats normally having regained target weight, and three require parenteral nutrition, having failed to achieve nutritional sufficiency despite an optimal enteral regimen via the PEG. An adverse body image in one of these patients (an opiate abuser with a long psychiatric history) was probably contributory to PEG failure. There was no peristomal or fistulous disease. CONCLUSIONS: Although nutrition via PEG is not always successful, failures are of enteral nutrition, and not of the means. PEG use in selected patients with Crohn's disease appears safe and can prove a useful addition to therapeutic options.     

Percutaneous endoscopic gastrostomy and outcome in dementia

The use of percutaneous endoscopic gastrostomy for the administration of food and medications in patients with dementia has been on an increase. Many studies have failed to demonstrate the positive outcome expected of this feeding modality for the indications that required tube placement. Hence, the concept of feeding through gastrostomy tubes has become the subject of much discussion and controversy in recent times. We have reviewed the literature with regard to outcome in older patients with dementia and percutaneous endoscopic gastrostomy with respect to nutritional parameters, quality of life, and survival. A brief discussion on ethical and legal aspects is included. Much of the data do not suggest that outcome in dementia is favorably improved after percutaneous gastrostomy.     

Enteral nutrition via percutaneous endoscopic gastrostomy and nutritional status of patients: five-year prospective study

BACKGROUND: Since it was described in 1980, percutaneous endoscopic gastrostomy (PEG) has been a widely used method for insertion of a gastrostomy tube in patients who are unable to swallow or maintain adequate nutrition. The aim of the present paper was to determine the complications of PEG insertion and to study pre- and post-procedural nutritional status. METHODS: During the period of March 1999-September 2004, placement of PEG tube was performed in 85 patients (22 women and 63 men). Patient nutritional status was assessed before and after PEG insertion via anthropometric measurements. RESULTS: The most frequent indication for PEG insertion was neurological disorders (65.9%). Thirty patients died due to primary disease and two patients due to PEG-related complications within 5 years. There were 14 early complications in 10 patients (15.2%; <30 days), and 18 late complications in 12 patients (19.6%). Total mortality was 37.6%. All complications other than four were minor. Before PEG insertion, patients were assessed with subjective global assessment and it was determined that 43.2% of them had severe, and 41.9% of them had mild malnutrition. After PEG insertion, significant improvements on patient nutrition levels was observed. CONCLUSION: Percutaneous endoscopic gastrostomy is a minimally invasive gastrostomy method with low morbidity and mortality rates, is easy to follow up and easy to replace when clogged.     

Complications and outcome of percutaneous endoscopic gastrostomy in different patient groups

A retrospective study of percutaneous endoscopic gastrostomy (PEG) was performed to evaluate the complications of PEG and determine the role of prophylactic antibiotics in preventing early wound infection and to evaluate the outcome of patients in different groups (neurological disease, head injury, AIDS). Percutaneous endoscopic gastrostomy was performed on 50 patients between March 1991 and November 1993 and the survey was completed in July 1994. The average time to PEG placement post-cerebrovascular accident or head injury was 5 weeks. No deaths were attributable to the procedure. Four of 50 (8%) patients died in the first 30 days (early mortality). Wound infection (early eight, late five) was the most common complication: two of 13 patients receiving prophylactic antibiotics and six of 37 not receiving antibiotics had early wound infection. At completion of follow-up 19 of 26 patients with neurological disease had died (median survival = 370 days), three resumed oral feeding and four continued PEG feeding. All head injury patients (n= 6) were alive and had resumed oral feeding; five returned home. All AIDS patients (n= 7) died within 12 months (median survival = 138 days), although improved nutritional state was found after gastrostomy feeding. In conclusion, PEG placement is a useful procedure to assist feeding in multiple patient groups. Wound infection is a common but not life threatening complication. The need for prophylactic antibiotics to prevent early wound infection has not been proven. The 5 week delay in PEG insertion may contribute to lower early mortality. The 100% survival rate in head injury patients may reflect their young age and absence of underlying medical illness. In AIDS patients, improved nutritional state is not known to translate into better quality of life or prolonged survival.     

CLINICAL INVESTIGATION OF UPPER GASTROINTESTINAL HEMORRHAGE AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

Background: Upper gastrointestinal (GI) hemorrhage after percutaneous endoscopic gastrostomy (PEG) is sometimes reported as one of the serious complications. Our purpose was to clarify the cause of upper GI hemorrhage after PEG. Patients and Methods: We retrospectively investigated the causes of upper GI hemorrhage among a total of 416 patients out of 426 consecutive patients who underwent PEG in our institution, excluding 10 patients who showed upper GI tumors on PEG placement. Results: Among 17 patients who developed upper GI hemorrhage after PEG, three and four patients showed PEG tube placement and replacement‐related hemorrhage, respectively; these lesions were vascular or mucosal tears around the gastrostomy site. Ten patients experienced 12 episodes of upper GI hemorrhage during PEG tube feeding. The lesions showing bleeding were caused by reflux esophagitis (five patients), gastric ulcer (two patients), gastric erosion due to mucosal inclusion in the side hole of the internal bolster (two patients), and duodenal diverticular hemorrhage (one patient). Anticoagulants were administered in six patients, including four patients with replacement‐related hemorrhage and one patient each with reflux esophagitis and gastric ulcer. Conclusions: Reflux esophagitis was the most frequent reason for upper GI hemorrhage after PEG. The interruption of anticoagulants should be considered for the prevention of hemorrhage on the placement as well as replacement of a gastrostomy tube.     

Mini-laparoscopically guided percutaneous gastrostomy and jejunostomy

BACKGROUND: Percutaneous endoscopic tube placement can be problematic under certain circumstances: absence of transillumination of the abdominal wall, percutaneous jejunostomy in patients with a PEG tube and recurrent aspiration, enteral feeding access after gastrectomy, and obstruction of the upper GI tract. As an alternative in these problematic situations, a technique was developed for placing feeding tubes under visual control by using mini-laparoscopy. METHODS: Placement of a feeding tube with mini-laparoscopy with the patient under conscious sedation was considered for 17 patients in whom standard PEG placement was impossible. Techniques used were the following: combined mini-laparoscopy/endoscopy for placement of a percutaneous gastrostomy or jejunostomy, and mini-laparoscopic-guided direct tube placement in cases of obstruction of the upper GI tract. OBSERVATIONS: In 13 patients, mini-laparoscopic-assisted tube placement was successful. In 4 patients, adhesions or peritoneal carcinomatosis prevented laparoscopic visualization of the stomach or small bowel. The combined mini-laparoscopic/endoscopic approach allowed a successful insertion of gastric tubes in 6 patients and jejunal tubes in 4 patients. Direct insertion of a percutaneous endoscopic jejunostomy tube without enteroscopy was feasible in all 3 patients with obstruction of the upper GI tract. No complication occurred. CONCLUSIONS: Mini-laparoscopy-assisted tube placement is a simple and safe alternative when endoscopic percutaneous tube placement is problematic or not feasible.     

Long-Term Enteral Feeding: A Retrospective Comparison of Delivery via Percutaneous Endoscopic Gastrostomy and Nasoenteric Tubes

The use of percutaneous endoscopic gastrostomy (PEG) tubes for enteral feeding is widespread, although their superiority to other feeding devices, such as nasoenteric tubes (NET), has not been substantiated. We retrospectively compared clinical outcomes in patients who received enteral feeding via PEG (n = 80) or NET (n = 29) from 1984 to 1988. Mean follow-up was 192 days in the PEG group and 141 days in the NET group. Changes in nutritional and performance status were similar in both groups. Aspiration pneumonia occurred within 14 days of tube placement in 6% and 24% (p = 0.01) of the PEG and NET patients, respectively. With the exception of tube replacement, cumulative rates of minor and major complications (including aspiration pneumonia) were similar in both groups during follow-up. None of the clinical variables that were assessed correlated with the development of aspiration pneumonia. Mortality was similar in both groups. These results suggest that, for long-term enteral feeding, PEG offers no substantial advantages over NET with respect to patient nutrition, performance, or survival. The reasons for the observed difference in short-term aspiration pneumonia rates are unknown, and must be investigated prospectively.