Postgastrostomy deformity of the stomach

Temporary postoperative tube gastrostomy may produce permanent deformity of the stomach as visualized on an upper gastrointestinal series. Six cases were studied illustrating two configurations of the gastric deformity. These appear to be related to the location of the gastrostomy opening in the stomach. The findings were either anterior displacement of the gastric antrum with adherence to the anterior abdominal wall or acute angulation of the gastric body in a medial and anterior direction.     

Gastrocolic fistula as a cause of persistent diarrhea in a patient with a gastrostomy tube

Joo YJ, Koo JH, Song SH. Gastrocolic fistula as a cause of persistent diarrhea in a patient with a gastrostomy tube.A 60-year-old man with a history of recurrent strokes secondary to moyamoya disease underwent insertion of a percutaneous radiologic gastrostomy tube because of severe dysphagia. Feeding was continued for 5 months after the procedure without complications. Persistent diarrhea began 2 weeks after admission for comprehensive rehabilitation. Conservative treatment was not effective. Sigmoidoscopy showed a U-shaped tube suggestive of a gastrocolic fistula in the transverse colon. This was confirmed by means of a tubogram obtained through a gastrostomy tube. The diarrhea resolved after changing the gastrostomy tube. This case report highlights the importance of considering other uncommon conditions, such as a gastrocolic fistula, in the differential diagnosis of persistent diarrhea in a patient with a gastrostomy tube.     

Fluoroscopically guided percutaneous gastrostomy: Tube function and malfunction

We describe our experience with fluoroscopically guided percutaneous gastrostomy, assessing in particular the functional performance of inserted tubes. We also examine the ability of radiological investigations to detect intraperitoneal gastrostomy leakage after the procedure. A functioning gastrostomy tube was established and maintained for as long as was required in 34 (89.5%) of 38 patients referred during a 21-month period. This necessitated further gastrostomy tube placements in 13 patients. On average, inserted gastrostomy tubes functioned for 10.75 weeks and during the review period a total of 34 malfunctioning tubes required replacement or removal. This was most commonly due to tube dislodgement, blockage, or intraperitoneal leakage. We found increasing pneumoperitoneum on sequential postprocedure erect chest films a reliable sign in the diagnosis of the latter complication. In conclusion, while we have been disappointed with aspects of individual tube function, our satisfactory overall functional success rate indicates that percutaneous gastrostomy is an effective method for establishing and maintaining enteral feeding. We also propose a protocol for the management of suspected intraperitoneal leakage based on the findings on postprocedure erect chest films.     

A nasogastric tube inserted into the gastrocutaneous fistula

We reported a case in which a nasogastric tube was inserted into the gastrocutaneous fistula, diagnosed by abdominal computed tomography. A 78-year-old man with a history of recurrent cerebral hemorrhage had a percutaneous endoscopic gastrostomy tube due to dysphagia for 2 years. However, soft tissue infection at the gastrostomy site caused the removal of the tube. Immediately, antibiotic agents were infused. For appropriate hydration and medication, a nasogastric tube was inserted. However, there was no significant improvement of the soft tissue infection. Moreover, the amount of bloody exudate increased. Abdominal computed tomography revealed the nasogastric tube placed under the patient's skin via gastrocutaneous fistula. The nasogastric tube was removed, and an antibiotic agents were maintained. After 3 weeks, the signs of infection fully improved, and percutaneous endoscopic gastrostomy was performed again. This case shows necessities of an appropriate interval between removal of the gastrostomy tube and insertion of a nasogastric tube, and suspicion of existence of gastrocutaneous fistula.     

Persistence of gastrocutaneous fistula after removal of gastrostomy tubes in children: prevalence and associated factors

BACKGROUND AND STUDY AIMS: The aims of this study were to determine the prevalence of gastrocutaneous fistula after removal of gastrostomy tubes in children and to identify associated risk factors. PATIENTS AND METHODS: The records of children who had undergone removal of gastrostomy tubes between January 1992 and December 2002 were reviewed retrospectively. Persistent gastrocutaneous fistula was defined as the absence of closure of the gastrostomy 1 month after tube removal. Factors that might influence spontaneous closure of the gastrostomy were studied, including age, underlying disease, nutritional status, type of gastrostomy, replacement of the gastrostomy tube by a button, abdominal wall thickness, duration of gastrostomy tube or button placement, and complications related to the presence of the gastrostomy (infection, granulation tissue). RESULTS: A total of 44 patients were included in the study (mean age 20 months, range 1 day to 14 years). Of these, 28 had undergone percutaneous endoscopic gastrostomy and 16 surgical gastrostomy. The mean time to spontaneous closure was 6 +/- 7 days. Persistent gastrocutaneous fistula developed in 11 patients (25 %) and in seven of these patients this required surgical closure (16 %). The mean duration of gastrostomy placement was significantly longer in patients who went on to develop a gastrocutaneous fistula than in patients who did not develop a fistula (39 +/- 19 months vs. 22 +/- 23 months, respectively, P < 0.03). No other significant association was found between the time required for spontaneous closure and the characteristics of patients or the type of gastrostomy. CONCLUSIONS: Persistent gastrocutaneous fistula is common after removal of gastrostomy tubes in children. Surgical closure should be considered when a gastrostomy has not closed spontaneously 1 month after removal of the gastrostomy tube.     

Eight years' experience of gastrostomy tube management

BACKGROUND AND STUDY AIMS: Increasingly, patients fed by gastrostomy tube are surviving the lifespan of the device. Data are scarce concerning the factors affecting the longevity and failure of gastrostomy tubes or the criteria for selection of replacement devices which leads to cost-effective patient management. The aims of the study were: to set criteria for selection of replacement gastrostomy tubes; to determine the causes of gastrostomy tube failure, and the factors affecting device longevity; and to examine the effect of initiating an educational programme for caregivers on resource utilization in long-term enteral nutrition patients. MATERIALS AND METHODS: We analyzed the clinical gastrostomy tube database compiled prospectively over 8 years by the nutrition team at Ninewells Hospital, Dundee. RESULTS: For 363 gastrostomy tubes inserted in 304 patients (160 women; median age 71), the median duration of gastrostomy tube use was 138 days. The total follow-up was 294 patient-years. Death occurred before the first gastrostomy tube replacement in 48 % of patients, but 20 % resumed oral nutrition. Tube failure mechanisms were: dislodgment, 28 %; perishing of tube material, 25 %; tube-related Candida albicans infection, 16 %; leakage, 7 %; and unspecified, 7 %. Of the balloon tubes and gastrostomy buttons, 8 % needed early replacement due to dislodgment and/or leakage. The cost per day for replacement percutaneous endoscopic gastrostomy (PEG) was Euro 2.12, for balloon tubes it was Euro 0.62, and for gastrostomy buttons Euro 1.80. Despite an increasing PEG insertion rate throughout the study period, yearly referrals for PEG-related problems dropped by 30 % between 1997 to 1999, coinciding with the initiation of an educational programme for caregivers. CONCLUSION: Tube longevity is mainly limited by the patient's diagnosis and prognosis. The choice of replacement device should be based on clinical factors. The use of more durable materials in the manufacture of gastrostomy tubes may prolong tube life and reduce cost. Education of patients and caregivers by a multidisciplinary nutrition support team promotes independence and limits demand on the service.     

GASTROSTOMY-RELATED PANCREATITIS IN A CHILD: A FATAL CASE

A case of acute pancreatitis following gastrostomy feeding tube insertion is presented. This is a rare and fatal complication, which has not been described before. The role of the gastrostomy catheter and total enteral nutrition in the causation of acute pancreatitis is discussed. Pathologists and clinicians should be aware of this disastrous and potentially avoidable condition.     

Bedside percutaneous ultrasound gastrostomy tube placement by critical care physicians

Critically ill patients often require gastrostomy tubes. Percutaneous endoscopic gastrostomy has become the most common method of placement but is not widely performed by critical care physicians, in part due to their lack of familiarity and training in upper gastrointestinal endoscopy. Percutaneous ultrasound gastrostomy (PUG) is a novel procedure for gastrostomy tube placement that utilizes ultrasound‐based methods already familiar to critical care physicians. This technical note describes bedside PUG in the first five intensive care unit patients. All patients received timely gastrostomy placement, without complication, and were able to quickly achieve goal enteral nutrition.     

Peritonitis after gastrostomy tube replacement in the emergency department

Peritonitis is a potentially fatal complication of the malpositioning of a gastrostomy feeding tube. We report a case of peritonitis that occurred subsequent to replacement of a gastrostomy tube in the emergency department.     

Enteral feeding and percutaneous endoscopic gastrostomy

Many patients are unable to eat and others are malnourished. Such patients need nutritional support, and enteral feeding offers one way of providing such support. It may be needed for a short time during acute or critical illness or for prolonged periods in chronic illness. Short-term feeding is usually given through a nasogastric tube, while permanent feeding access is indicated for long-term feeding, most commonly through a gastrostomy. Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive technique for placing a feeding tube and causing minimal discomfort. This article reviews enteral feeding focusing on PEG and considers the after care and complications of this method of feeding.     

Operating gastrostomy tubes: Insertion and removal for minimally invasive transgastric ulcer surgery

Summary

Some patients with bleeding peptic ulcer either continue to bleed or rebleed following endoscopic interventional therapy. Open surgery may be the only method capable of arresting haemorrhage. This requires a general anaesthetic and laparotomy. Many patients are elderly and have concomitant medical problems placing them at increased risk from surgery. A less invasive method for gaining access to the gastric cavity may benefit these patients.

Operating gastrostomy tubes (a laparoscopic port attached to a gastrostomy tube) were placed through the anterior abdominal wall directly into a porcine stomach. This allowed both visual and operative access anywhere in the stomach, apart from the pyloric canal. 20 experimental bleeding ulcers were created and complete haemostasis was achieved by under-running with laparoscopic equipment. Operating gastrostomy ports were removed and the resulting gastrostomy closed using a new percutaneous method. No infection or fistula formation occurred following gastrostomy removal.

This is a minimally invasive method for gaining access to the gastric cavity with laparoscopic equipment, enabling surgical procedures to be performed. Insertion and removal of operating gastrostomy ports may be able to be performed under a local anaesthetic and sedation, which may allow some transgastric surgical procedures to be performed without a general anaesthetic.     

Transcervical approach to percutaneous endoscopic gastrostomy tube insertion in a patient with head and neck cancer

This is the case of a 48‐year‐old woman with recurrent head and neck cancer. Six years before presenting at our institution, she was diagnosed with a moderately differentiated squamous cell carcinoma involving the right maxilla and underwent surgical resection followed by chemoradiation. More recently, she presented at our institution with oral bleeding and pain. Examination revealed severe trismus, and biopsy demonstrated recurrent squamous cell carcinoma. She underwent surgical resection with a plan for simultaneous placement of a feeding gastrostomy tube. Owing to the near non‐existent mouth opening, traditional per‐oral placement of a percutaneous endoscopic gastrostomy (PEG) tube was impossible. Intraoperatively, following tumor resection, endoscopy was performed via direct pharyngeal access through a right cervical incision. The PEG tube was then placed uneventfully. Numerous studies have shown the superiority of PEG tubes over either radiologically or surgically placed gastrostomy tubes. This report describes an approach to PEG placement in a patient in whom per‐oral placement was not feasible.     

The technique of percutaneous endoscopic gastrostomy. A safe and cost-effective alternative to operative gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is an attractive method of providing enteral nutrition to patients who are candidates for operative gastrostomy or nasoenteric tube feeding; it is currently the procedure of choice for selected nutritionally compromised patients. PEG may be considered for patients who need short- or long-term enteral support; those unable to swallow or who cannot maintain adequate oral intake are ideal candidates. Several techniques are used to perform PEG; each involves the placement of a gastrostomy tube at a point where the stomach and abdominal walls are in closest contact. PEG can be done at the bedside without general anesthesia. Feeding can begin within 24 hours of PEG placement. Major complications (peritonitis and pulmonary aspiration) occur infrequently.     

Clinically significant benign pneumoperitoneum as a complication of percutaneous endoscopic gastrostomy

Benign pneumoperitoneum is a complication of percutaneous endoscopic gastrostomy (PEG) feeding tube placement. The rate of occurrence is reported as up to 25%. It is usually an incidental finding that arises immediately following the procedure. We report a case of pneumoperitoneum that developed a significant time after the initial procedure. The patient developed intractable vomiting and had to be fed parenterally. The pneumoperitoneum resolved and the gastrostomy tube feed was re-started.     

Care of the gastrostomy tube in the home

Education is needed to reduce complications for the patient with a gastrostomy tube. Literature regarding education related to the gastrostomy tube in the home is not evidenced based, varies, and is confusing. The home care nurse needs to provide accurate and up-to-date information to assist the patient in managing care.     

Complications of percutaneous endoscopic and fluoroscopic gastrostomy tube insertion procedures in 378 patients.

Gastrostomy tubes are used for primary and supplemental feeding and gastric decompression. The purpose of the study was to compare the complication rate of gastrostomy tube placement by either endoscopic or fluoroscopic technique. Between 1996 and 2004, the surgical and radiological services at a Level I trauma hospital placed gastrostomy tubes in 378 patients (endoscopy=268, fluoroscopy=110). The percutaneous gastrostomy group comprised 71% of the cohort with a mean age of 51+/-21 (range: 1-93 years of age), and the percutaneous radiographic gastrostomy group comprised the remaining cohort (29%) with a mean age of 57+/-19 (range: 17-95 years of age). Fifty-eight percent of the percutaneous gastrostomy group were female (n=155) and 42% were male (n=113), whereas the gender distribution for the percutaneous radiographic gastrostomy group was 33% female (n=36) and 67% male (n=74).There was an overall complication rate of 36% (22% and 70% for the endoscopic and fluoroscopic methods, respectively). The most frequent complication in both types of techniques was tube dislodgement (endoscopic=32% [19/268]; fluoroscopic=27% [21/110]). There were very few serious complications. Women had a higher rate of postprocedure complications than did men, at 35% versus 27%. We conclude that gastrostomy tube placement by either endoscopic or fluoroscopic methods results in a number of complications, though most of them are minor. Patients must therefore be informed that this is not a complication-free procedure.     

Acute obstructive pancreatitis secondary to migration of a gastrostomy tube into duodenum

Percutaneous endoscopic gastrostomy (PEG) tube is a common procedure. This discusses the rare complication of acute pancreatitis, due to tube migration, causing obstruction of the ampulla of Vater. Radiological confirmation of tubes prior to the usage may aid in preventing this reversible complication.     

Percutaneous endoscopic gastrostomy. What are the benefits, what are the risks?

One way to nutritionally support patients who cannot swallow is to administer formula directly into the stomach. Placing a gastrostomy tube percutaneously using endoscopy avoids the risks of general anesthesia and wound healing that accompany surgical gastrostomy. Although certain conditions (eg, sepsis, coagulation disorder, portal hypertension) are contraindications to the procedure, it can be done in patients who have had previous abdominal surgery and in those with severe illness. A commercially available feeding formula is used. The type chosen and the frequency of administration are based on the patient's specific needs. With regular medical monitoring and daily care of the gastrostomy site, appropriately selected patients may be safely maintained with enteral feeding for months. An advantage of the percutaneously inserted tube is that it is easily removed when the patient regains the ability to eat, and the fistula heals rapidly.     

Peritonitis Secondary to the Migration of a Trans-Hepatically-Placed Percutaneous Endoscopic Gastrostomy Tube: A Case Report

Burke DT, Geller AI. Peritonitis secondary to the migration of a trans-hepatically-placed percutaneous endoscopic gastrostomy tube: a case report.Enteral feeding by percutaneous endoscopic gastrostomy (PEG) tube has become a commonly used method of supplying nutrition to patients with impaired neurologic function. In this case study we describe a 33-year-old brain-injured patient whose PEG insertion was complicated by inadvertent malpositioning and subsequent infection. After initially being placed through the liver, the PEG tube migrated out several weeks later, resulting in intra-abdominal feed collection, peri-hepatic abscess formation, and peritonitis. Physicians should be aware of the potential for inadvertent positioning through other viscera, and consider optimal methods of intraprocedural monitoring and post placement verification.