Percutaneous endoscopic gastrostomy feeding in AIDS*

Reduced energy intake is the most important reason for weight loss in advanced human immunodeficiency virus (HIV) infection. From January 1989 to August 1995 enteral feeding via a percutaneous endoscopic gastrostomy tube (PEG) was offered to all human immunodeficiency virus(HIV)/AIDS patients attending Fairfield Hospital, Melbourne who were unable to maintain 85% ideal body weight. A total of 71 patients received enteral feeding (1000–2000 kcal/day) for a median period of 161 days (range 4–644 days). Fifty-one (72%) patients gained 5.8 ± 4.4kg (range 0.4 - 19.2kg). Nine gained 10 kg or more. The median time to maximum weight was 74 days after PEG insertion. Those who gained weight had a longer median survival, but this difference was not statistically significant (210 vs 109 days, P=0.07). The only predictor of weight gain was a CD4 count greater than 100/μL. Patients who gained weight reported improved quality of life and increased independence. However, early complications, especially wound infection, were common. Although these data have been gathered retrospectively, our experience suggests that enteral feeding can maintain or improve nutritional status and may improve quality of life in advanced HIV infection.     

Small bowel obstruction from a dislodged feeding tube

Elderly nursing home patients may suffer from inadequate oral nutritional intake for a variety of reasons. In some of them, nutritional status cannot be maintained without the use of enteral feeding. Nasogastric tube feeding is associated with significant patient discomfort, and may lead to significant complications. Thus, in those who require long-term enteral tube feeding, a gastrostomy tube may be necessary. Although surgical insertion may occasionally be required, percutaneous insertion with upper endoscopy assistance is usually safe and feasible. This case represents an unusual complication of such a gastrostomy tube, which draws attention to the need for appropriate care of these tubes.     

Gastroenteric tube feeding: Techniques,problems and solutions

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.     

Prevention of late complications by half-solid enteral nutrients in percutaneous endoscopic gastrostomy tube feeding

BACKGROUND: Percutaneous endoscopic gastrostomy feeding is accompanied by unique complications, which are not easily controlled. OBJECTIVE: In an attempt to decrease complications, we used half-solid nutrients for percutaneous endoscopic gastrostomy feeding in an 85-year-old woman. The patient had been receiving enteral nutrients via percutaneous endoscopic gastrostomy, and we examined whether this approach can reduce complications. She presented with regurgitation of enteral nutrients and recurrent respiratory infections. METHODS: Half-solid enteral nutrients, prepared by mixing liquid enteral nutrients with agar powder, were administered via percutaneous endoscopic gastrostomy. RESULTS: Symptoms of gastroesophageal reflux disappeared immediately after the start of half-solid enteral nutrient feeding. CONCLUSION: Gastroesophageal reflux and leakage, two intractable late complications of percutaneous endoscopic gastrostomy tube feeding, can be alleviated by the solidification of enteral nutrients. Since this method allows quick administration of nutrients, it is also expected to help prevent the occurrence of decubitus ulcers and reduce the burden to the caregiver.     

The provision of a percutaneously placed enteral tube feeding service

There is overwhelming evidence that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost. Short-term enteral access is usually achieved via naso-enteral tube placement. For longer term tube feeding there are recognised advantages for enteral feeding tubes placed percutaneously. The provision of a percutaneous enteral tube feeding service should be within the remit of the hospital nutrition support team (NST). This designated team should provide a framework for patient selection, pre-assessment and post-procedural care. Close working relations with community-based services should be established. An accredited therapeutic endoscopist should be a member of the NST and direct the technical aspects of the service. Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Specialist units should be identified where a more comprehensive service is provided, including direct jejunal placement (DPEJ), as well as radiological and laparoscopically placed tubes. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment. Careful adherence to the important technical details of tube insertion will reduce peri-procedural complications. Post-procedural complications remain relatively common, however, and an awareness of the correct approach to managing them is essential for all clinicians involved in providing a percutaneous enteral tube feeding service. Finally, ethical considerations should always be taken into account when considering long-term enteral feeding, especially for patients with a poor quality of life.     

Pneumoperitoneum after Percutaneous Endoscopic Gastrostomy

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. Although pneumoperitoneum can be seen after surgery and in association with certain endoscopic procedures, it has not been seen after percutaneous endoscopic gastrostomy. We describe a patient who developed a benign pneumoperitoneum after insertion of a percutaneous gastrostomy tube.     

Tube feeding - who, how and when

Summary. The concept of enteral nutrition is well established for a long time. During the past twenty years different percutaneous tube feeding techniques have been established. The most popular method is the percutaneous endoscopic gastrostomy (PEG) which is applied as a pull-through technique in Germany. In some patients this approach is not successful and alternative techniques must be used (e. g. introducer method). In some patients nasal or percutaneous feeding tube have to be placed directly into the intestine. There are different systems available for this approach which have to be clearly indicated. As a second step after initiation of enteral nutrition therapy quality of life can be improved by implanting secondary systems (e. g. button gastrostomy).A standardized technique for inserting tubes is essential to have a successful long-term outcome in enteral nutrition and care after has to be integrated into the regimen. The aim of this article is to demonstrate different enteral nutrition tube techniques their indication, contraindication and long-term follow-up.     

Changes in arterial oxygen saturation before and after enteral feeding tube insertion in dysphagic stroke patients

OBJECTIVE: to determine whether insertion of nasogastric or percutaneous endoscopic gastrostomy feeding tubes is associated with hypoxaemia. METHODS: dysphagic stroke patients had their arterial oxygen saturation measured by pulse oximetry continuously for 10 minutes before, during and after tube insertion. RESULTS: in 14 patients nasogastric tube insertion had little effect on oxygen saturation. Six patients maintained oxygen saturation during percutaneous endoscopic gastrostomy insertion (whilst on 2 litres oxygen/min) but had a significantly lower median oxygen saturation (P = 0.03) after the procedure (when oxygen was discontinued) and four of these had oxygen saturation of < or =90%. CONCLUSIONS: in this small group of stroke patients, difficult insertions of nasogastric and percutaneous endoscopic gastrostomy tubes were associated with moderate hypoxaemia. Clinicians should be aware of the potential impact of tube insertion and ensure patients are appropriately monitored and if necessary receive supplemental oxygen, after as well as during the procedure.     

Chronic anorexia nervosa: enteral nutrition via percutaneous endoscopic gastrostomy and liaison psychiatry

Anorexia nervosa is a complex mental disorder characterized by altered eating behaviour often resulting in life-threatening weight loss (<85% of expected body weight) associated with amenorrhea and a disturbance of body image. Although classified as mental health disorders, they may lead to serious medical consequences and have the highest rate of premature death of any mental health diagnosis. We report our experience with the use of enteral feeding via percutaneous endoscopic gastrostomy in a 39-year-old woman with chronic restricter anorexia nervosa treated in liaison psychiatry and psychotherapy. On admission to psychiatry unit, the patient presented seriously deteriorated general condition and a body mass index (BMI) of 10 (BMI = weight kg/height m(2)). She refused oral feeding, but eventually accepted nasogastric feeding. In preparation for her continuing long-term (>1 month) enteral feeding at home, a percutaneous endoscopic gastrostomy was performed and a home nutrition support regimen that met her energy-protein intake requirements was prescribed. During the follow-up period, an overall improvement in nutritional status, general condition, mood and cognitive functioning was observed. Patient compliance with refeeding is notoriously problematic; however, enteral feeding interventions may be feasible in the long-term treatment of selected anorexia nervosa patients when closely followed-up by a multidisciplinary medical team.     

Percutaneous endoscopic gastrostomy in cystic fibrosis: patient acceptance and effect of overnight tube feeding on nutritional status

BACKGROUND: Malnutrition remains a common problem in cystic fibrosis (CF) patients, despite pancreatic enzymes and hypercaloric diet advice. When oral supplementation fails, additional overnight gastrostomy tube-feeding is a therapeutic option. METHODS: In our centre gastrostomy tube feeding is proposed when weight for height drops below 85% despite intensive dietetic counselling. All the CF patients at our centre (n = 11) receiving gastrostomy tube feeding were evaluated for changes in nutritional status and pulmonary function. Complications of percutaneous endoscopic gastrostomy were inventarised and patients older than 7 years and all the parents were asked to fill in a questionnaire concerning subjective well-being with gastrostomy supplemental feeding. RESULTS: The patients received 40% of the recommended daily allowances (RDA) for energy by tube feeding. Total daily energy intake increased by 30%. Within 3 months this resulted in a significant improvement in nutritional status expressed as percentage of ideal weight for height or body mass index z-score. After 6 months a significant catch-up growth was detectable. Pulmonary function remained stable. The complications were local irritation (n = 4), night sweating (n = 1) and bed-wetting (n = 1). The gastrostomy was well accepted. CONCLUSION: Gastrostomy appears to be a good and safe way to improve nutritional status, growth and mood of the CF child. As decreased pulmonary function plays a crucial role in the growth of the CF child, full normalisation of growth pattern is not achieved despite catch-up. Gastrostomy tube feeding should perhaps be used earlier to optimalise growth.     

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.     

Half-solid enteral nutrient prevents chronic complications of percutaneous endoscopic gastrostomy tube feeding

An 85-year-old woman was receiving enteral feeding via percutaneous endoscopic gastrostomy (PEG). The patient exhibited symptoms of gastro-esophageal reflux, leakage of nutrient from the PEG insertion point, vomiting, pyrexia, dyspnea when given nutrients and recurrent pneumonia. We therefore gave a half-solid nutrient, which was made by a mixture of agar powder and conventional liquid nutrient Immediately after starting the half-solid nutrient feeding via PEG, the patients no longer exhibited the above symptoms apart from mild pyrexia, which also vanished two weeks later. This case suggested that simply changing the fluidity of nutrients can contribute to a reduction of complications expected to occur in patients on PEG tube feeding.     

Ultrasound guidance in the placement of a percutaneous endoscopic gastrostomy (PEG): An adjuvant technique in patients with abdominal wall varices?

Malnutrition in patients with liver disease is common. As a result, enteral feeding may be indicated. Percutaneous endoscopic gastrostomy insertion is rarely performed because the presence of varices is considered to be a contraindication. We report a case of percutaneous endoscopic gastrostomy insertion in a patient with both gastric and oesophageal varices. The use of abdominal ultrasound may provide an adjuvant tool for percutaneous endoscopic gastrostomy insertion. This novel technique may minimise the risk of complications in selected patients.     

Endoscopic gastrostomy in patients with complicated heart diseases]

Complicated cardiologic patients with brain ischemia and heart failure need long term enteral nutrition. Long term nasoenteral tube feeding may cause complications that could be avoided with percutaneous endoscopic gastrostomy. The aim of this study was to evaluate the indications for percutaneous endoscopic gastrostomy and its main complications. Twelve patients were submitted to percutaneous endoscopic gastrostomy (eight male) with main age of 62.42 +/- 22.10 years old. Brain ischemia was the main indication of percutaneous endoscopic gastrostomy and occurred after 35.58 +/- 26.79 days, after initiated enteral nutrition. There were no complications during procedure. On late post operatory period there were local infection in one cases, treated with local care. In conclusion, percutaneous endoscopic gastrostomy is a secure technique with low incidence of complications and its indication should be earlier.     

Enteral nutrition by endoscopic means; I. Techniques, indications, types of enteral feed

Enteral nutritional support plays a major role in the management of patients who are critically ill in intensive care units (ICU), those with poor volitional intake, persons with chronic neurological or mechanical dysphagia, and individuals with gut dysfunction. Part I of this review will briefly discuss the principles governing nasoenteral feeding and will describe in detail the endoscopic-assisted methods for placing enteral feeding tubes. These include percutaneous endoscopic gastrostomy, jejunal extension through a percutaneous endoscopic gastrostomy or direct endoscopic jejunostomy, and the "one-step button". In addition, the types of enteral food with focus on disease-specific enteral diets will be discussed. Finally, the latest innovations in enteral feeding including immune-enhancing nutrients such as arginine, omega-3 fatty acids, glutamine, and nucleotides advocated for critically ill patients will be discussed. Questions regarding possible complications and long-term results of the various methods of enteral feeding will be discussed separately in part II.     

Endoscopic Clips Prevent Displacement of Intestinal Feeding Tubes: A Long-Term Follow-Up Study

Background Displacement of jejunal feeding tubes is a major problem in enteral feeding. Although endoscopic clips have been used to prevent migration of the tube during placement, the long-term effect of the clips on tube displacement is unknown. Objectives The purpose of this study was to examine the long-term effect of endoscopic clips on preventing displacement of the jejunal feeding tube. Design A retrospective study. Setting A single tertiary medical center. Main outcome measurements The success rate of the procedure and the functional duration of the feeding tube. Results About 93% of patients had a percutaneous endoscopic gastrostomy jejunal (PEGJ) tube successfully placed with use of endoscopic clips. About 7% had tube migration and repeat procedures were successful. The mean functional duration of the tube was 55 days. Limitations Retrospective, single-center. Conclusions Use of endoscopic clips can prevent migration during placement of the feeding tube and can also reduce tube displacement in the long term.     

Advances in Enteral Nutrition Techniques

The increasing use of enteral nutrition in hospitals has led to an expanded role for the gastroenterologist and surgeon in providing enteral access. New concepts in immunonutrition and gut support in critically ill patients have popularized early postoperative feeding. There is an ongoing need to update physicians on the diverse enteral access techniques now available. In addition to standard percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) techniques, this review focuses on reflux prevention through double-lumen feeding-suction tubes, and describes the use of steerable catheters for rapid insertion of nasojejunal and PEJ tubes without endoscopy. Low-profile "button"-type devices, one-step button placement, replacement gastrostomy devices, and special enteral techniques for patients with cancer are also reviewed.     

Percutaneous transgastric irrigation drainage in combination with endoscopic necrosectomy in necrotizing pancreatitis (with videos)

BACKGROUND: Endoscopic drainage of pancreatic acute and chronic pseudocysts and pancreatic necrosectomy have been shown to be beneficial for critically ill patients, with complete endoscopic resolution rates of around 80%. OBJECTIVE: Our purpose was to describe an improved endoscopic technique used to treat pancreatic necrosis. DESIGN: Case report. SETTING: University hospital. PATIENTS AND INTERVENTIONS: Two patients with large retroperitoneal necroses were treated with percutaneous transgastric retroperitoneal flushing tubes and a percutaneous transgastric jejunal feeding tube by standard percutaneous endoscopic gastrostomy access in addition to endoscopic necrosectomy. RESULTS: Intensive percutaneous transgastric flushing in combination with percutaneous normocaloric enteral nutrition and repeated endoscopic necrosectomy led to excellent outcomes in both patients. LIMITATIONS: Small number of patients. CONCLUSIONS: The "double percutaneous endoscopic gastrostomy" approach for simultaneous transgastric drainage and normocaloric enteral nutrition in severe cases of pancreatic necroses is safe and effective. It could be a promising improvement to endoscopic transgastric treatment options in necrotizing pancreatitis.     

经皮内镜胃造瘘和空肠造瘘术研究进展

经皮内镜胃造瘘(PEG)和空肠造瘘术(PEJ)人工肠内营养可有效避免患者营养状况进一步恶化,提高患者生活质量。随着对治疗目的更清晰的认识以及内镜技术的进步,PEG/PEJ适应证增加而禁忌证相对减少,操作技术及并发症防治研究有了许多进展。     

Percutaneous endoscopic gastrostomy for enteral feeding

Percutaneous endoscopic gastrostomy was performed for enteral feeding in a patient with orocutaneous fistula. The method of construction of the gastrostomy tube from locally available material is described.