Double-blind randomized clinical trial of percutaneous endoscopic gastrostomy versus radiologically inserted gastrostomy in children

The Insertion and Management of Gastrostomies in Children in the United Kingdom - A Survey of Practice

BACKGROUND

Gastrostomy insertion is one of the most frequently performed procedures by specialist paediatric surgeons. We aimed to determine practice across the United Kingdom (UK) and in particular to identify areas where there was consistency or variation in practice between practitioners and centres.

METHODS

A structured survey was distributed to all consultant practitioners who insert gastrostomies in the UK. Practice surrounding a range of aspects of gastrostomy care including insertion technique, device use, post-operative management and subsequent care were determined.

RESULTS

Of total 135 practitioners who insert gastrostomies, responses were received from 103 (76%) with responses received from all UK centres. There was variation between centres in the provision of pre-operative information, and between practitioners in preferred device, insertion techniques, post-operative feeding practice and change/removal procedures. The most frequently preferred device for primary gastrostomy insertion was a Freka® PEG (36%) button device (30%), CorFlo™ PEG (21%), or G-tube (10%). Laparoscopy was always used when inserting either PEG or button device by over 50% of respondents and selectively used by the majority of the remainder. Feeds were started between 1 and 24 h post-insertion, most practitioners (64%) plan a minimum one night hospital stay but a third plan for more than one night.

CONCLUSION

There is considerable variation in practice for most stages of the pathway for children having a gastrostomy. Further work is warranted to understand the relationship between different practices and patient outcomes, resource use and cost and subsequently to develop best practice guidelines.

LEVEL OF EVIDENCE: 3

Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy for enteral feeding: A systematic review and meta-analysis

BACKGROUND

Percutaneous radiological gastrostomy (PRG) and percutaneous endoscopic gastrostomy (PEG) are minimally invasive gastrostomy techniques for individuals requiring prolonged enteral feeding. Recent meta-analyses concerning their efficacy and safety mainly included retrospective studies and yielded conflicting results. This meta-analysis of randomized controlled trials (RCTs) aimed to compare efficacy, safety, and procedure time between PRG and PEG for enteral feeding.

METHODS

MEDLINE, Embase, and the Cochrane Library were searched for eligible RCTs comparing PRG and PEG for enteral feeding through February 23, 2024. The primary outcome was technical success. The secondary outcomes were (1) adverse events (AEs), (2) mortality, and (3) procedure time. We used the random-effects model to calculate pooled risk ratio (RR) and mean difference (MD) with corresponding 95% CIs for dichotomous and continuous outcomes, respectively.

RESULTS

Five RCTs with 544 patients (268 PRG and 276 PEG) were included. There was similar technical success (RR = 1.02; 95% CI = 0.98-1.05; I² = 35%; moderate certainty of evidence because of inconsistency), overall mortality (RR = 1.25; 95% CI = 0.63-2.47; I² = 47%; very low certainty of evidence because of inconsistency, indirectness, and imprecision), and overall AEs risk (RR = 1.06; 95% CI = 0.63-1.76; I² = 81%; low certainty of evidence because of inconsistency and imprecision) between the two groups. However, compared with PEG, the procedure time was longer in the PRG group (MD = 19.35 min; 95% CI = 0.95-37.75 min; I² = 98%; very low certainty of evidence because of inconsistency and imprecision).

CONCLUSION

PRG and PEG demonstrate similar efficacy and safety; however, the endoscopic technique may boast a shorter procedure time.

Outcomes in Enteral Access Based on Specialty and Approach: A Single-Center Three-Year Experience

INTRODUCTION

Interventional radiologic, endoscopic, and surgical approaches are commonly utilized to establish durable enteral access in adult patients. The purpose of this study is to examine differences in nutritional outcomes in a large cohort of patients undergoing enteral access creation.

METHODS

Adult patients who underwent enteral access procedures by interventional radiologists, gastroenterologists, and surgeons between 2018 and 2020 at a single institution were reviewed. Included access types were percutaneous endoscopic gastrostomy (PEG), open or laparoscopic gastrostomy, laparoscopic jejunostomy, and percutaneous gastrostomy (perc-G), percutaneous jejunostomy , or primary gastrojejunostomy.

RESULTS

912 patients undergoing enteral access cases met the criteria for inclusion. PEGs and perc-Gs were the most common procedures. PEGs had higher Charlson scores (4.5 [3.0-6.0] versus 2.0 [1.0-2.0], P = 0.007) and lower starting albumin (3.0 [2.6-3.4] versus 3.6 [3.5-3.8] g/dL, P < 0.0001). Time to goal feeds (4 [2-6] vs 4 [3-5] d, P = 0.970), delta prealbumin (3.6 [0-6.5] versus 6.2 [2.3-10] mg/L, P = 0.145), time to access removal (160 [60-220] versus 180 [90-300] d, P = 0.998), and enteral access-related complications (19% versus 16%, P = 0.21) between PEG and perc-G were similar and differences were not statistically significant. A greater percent change in prealbumin was noted for perc-G (10 [-3-20] versus 41.7% [11-65], P = 0.002).

CONCLUSIONS

Despite having higher Charlson scores and worse preoperative nutrition, there is a similar incidence of enteral access-related complications, time to goal feeds, delta prealbumin, or time to access removal between PEG and perc-G patients. Our data suggest that access approach should be made on an individual basis, accounting for anatomy and technical feasibility.

Impact of Scoliosis Severity on Gastrostomy-Related Complications in Children

OBJECTIVES

This study aimed to determine the relationship between scoliosis and risk of developing complications in patients who underwent gastrostomy.

METHODS

Patients who underwent percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy (SG) between 2012 and 2022 were included. Leakage, discharge, granuloma, and hyperemia were considered minor complications, while visceral injury, ileus, and re-do surgery were considered major complications. The degree of scoliosis was calculated using the Cobb angle. The SG and PEG groups were compared by evaluating the complications and their correlation with scoliosis.

RESULTS

A total of 104 patients with a mean age of 5.0 ± 5.3 were included; 58% of patients were treated with SG. Patients in the SG group were younger ( P < 0.001). Minor complications were significantly more common in the PEG group ( P = 0.018). There was no difference between the groups in terms of major complications ( P = 1.000). Scoliosis was observed in 32.7% of the patients (n = 34). In the SG group, no correlation was found between the Cobb angle and the frequency of minor ( P = 0.173) or major complications ( P = 0.305). There was no significant difference between the Cobb angles of patients with and without minor complications in the PEG group ( P = 0.478); the Cobb angles of patients with major complications (75°) were significantly higher than those without (36°) ( P = 0.030).

CONCLUSION

Gastrostomy is important for weight gain and nutritional needs of children. This study showed that the risk of complications in SGs did not correlate with the degree of scoliosis and that the risk of major complications in PEGs increased in patients with a high degree of scoliosis.

The Use of Blended Diets in Children With Enteral Feeding Tubes: A Joint Position Paper of the ESPGHAN Committees of Allied Health Professionals and Nutrition

OBJECTIVES

This joint position paper of the Committees of Allied Health Professionals (CAHP) and Nutrition (CON) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) provides a comprehensive guide for health professionals to manage blended diets in children via gastrostomy tubes.

METHODS

A systematic literature search was performed from 1992 to 2021 using Pubmed, MEDLINE, and Cochrane Database of Systematic Reviews and recent guidelines reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion. Final consensus was obtained by multiple e-mail exchange and virtual meetings of the CAHP and CON.

RESULTS

Reported benefits of blended diets include reduced GERD and infections, improved defecation, level of alertness and attention span, skin conditions, and appearance of hair and nails. Families report a sense of greater normality. Small case series, cross-sectional surveys, questionnaire-based small case studies, reports of personal experience, and single-center pilot studies are available in the medical literature. A total of 20 recommendations for practice were made based on the results and consensus process.

CONCLUSIONS

There is little evidence published to formally inform about the potential health benefits or risks of this practice and how to use it in the best way. This leaves health professionals caring for such patients in a relative vacuum regarding what to consider when providing a duty of care to patients and carers who wish to pursue this method of feeding. This article provides guidelines for safe and appropriate use of a BD, but more research is needed.

Gastrostomy Tube Use in Pediatrics: A Systematic Review

CONTEXT

Despite frequency of gastrostomy placement procedures in children, there remains considerable variability in preoperative work-up and procedural technique of gastrostomy placement and a paucity of literature regarding patient-centric outcomes.

OBJECTIVES

This review summarizes existing literature and provides consensus-driven guidelines for patients throughout the enteral access decision-making process.

DATA SOURCES

PubMed, Google Scholar, Medline, and Scopus.

STUDY SELECTION

Included studies were identified through a combination of the search terms "gastrostomy," "g-tube," and "tube feeding" in children.

DATA EXTRACTION

Relevant data, level of evidence, and risk of bias were extracted from included articles to guide formulation of consensus summaries of the evidence. Meta-analysis was conducted when data afforded a quantitative analysis.

EVIDENCE REVIEW

Four themes were explored: preoperative nasogastric feeding tube trials, decision-making surrounding enteral access, the role of preoperative imaging, and gastrostomy insertion techniques. Guidelines were generated after evidence review with multidisciplinary stakeholder involvement adhering to GRADE methodology.

RESULTS

Nearly 900 publications were reviewed, with 58 influencing final recommendations. In total, 17 recommendations are provided, including: (1) tTrial of home nasogastric feeding is safe and should be strongly considered before gastrostomy placement, especially for patients who are likely to learn to eat by mouth; (2) rRoutine contrast studies are not indicated before gastrostomy placement; and (3) lLaparoscopic placement is associated with the best safety profile.

LIMITATIONS

Recommendations were generated almost exclusively from observational studies and expert opinion, with few studies describing direct comparisons between GT placement and prolonged nasogastric feeding tube trial.

CONCLUSIONS

Additional patient- and family-centric evidence is needed to understand critical aspects of decision-making surrounding surgically placed enteral access devices for children.

Data Sharing and Reanalyses Among Randomized Clinical Trials Published in Surgical Journals Before and After Adoption of a Data Availability and Reproducibility Policy

Importance

Clinical trial data sharing holds promise for maximizing the value of clinical research. The International Committee of Medical Journal Editors (ICMJE) adopted a policy promoting data sharing in July 2018.

Objective

To evaluate the association of the ICMJE data sharing policy with data availability and reproducibility of main conclusions among leading surgical journals.

Design, Setting, and Participants

This cross-sectional study, conducted in October 2021, examined randomized clinical trials (RCTs) in 10 leading surgical journals before and after the implementation of the ICMJE data sharing policy in July 2018.

Exposure

Implementation of the ICMJE data sharing policy.

Main Outcomes and Measures

To demonstrate a pre-post increase in data availability from 5% to 25% (α = .05; β = 0.1), 65 RCTs published before and 65 RCTs published after the policy was issued were included, and their data were requested. The primary outcome was data availability (ie, the receipt of sufficient data to enable reanalysis of the primary outcome). When data sharing was available, the primary outcomes reported in the journal articles were reanalyzed to explore reproducibility. The reproducibility features of these studies were detailed.

Results

Data were available for 2 of 65 RCTs (3.1%) published before the ICMJE policy and for 2 of 65 RCTs (3.1%) published after the policy was issued (odds ratio, 1.00; 95% CI, 0.07-14.19; P > .99). A data sharing statement was observed in 11 of 65 RCTs (16.9%) published after the policy vs none before the policy (risk ratio, 2.20; 95% CI, 1.81-2.68; P = .001). Data obtained for reanalysis (n = 4) were not from RCTs published with a data sharing statement. Of the 4 RCTs with available data, all of them had primary outcomes that were fully reproduced. However, discrepancies or inaccuracies that were not associated with study conclusions were identified in 3 RCTs. These concerned the number of patients included in 1 RCT, the management of missing values in another RCT, and discrepant timing for the principal outcome declared in the study registration and reported in the third RCT.

Conclusions and Relevance

This cross-sectional study suggests that data sharing practices are rare in surgical journals despite the ICMJE policy and that most RCTs published in these journals lack transparency. The results of these studies may not be reproducible by external researchers.

Remote ischemic conditioning in necrotizing enterocolitis: study protocol of a multi-center phase II feasibility randomized controlled trial

PURPOSE

Remote ischemic conditioning (RIC) is a maneuver involving brief cycles of ischemia reperfusion in an individual's limb. In the early stage of experimental NEC, RIC decreased intestinal injury and prolonged survival by counteracting the derangements in intestinal microcirculation. A single-center phase I study demonstrated that the performance of RIC was safe in neonates with NEC. The aim of this phase II RCT was to evaluate the safety and feasibility of RIC, to identify challenges in recruitment, retainment, and to inform a phase III RCT to evaluate efficacy.

METHODS

RIC will be performed by trained research personnel and will consist of four cycles of limb ischemia (4-min via cuff inflation) followed by reperfusion (4-min via cuff deflation), repeated on two consecutive days post randomization. The primary endpoint of this RCT is feasibility and acceptability of recruiting and randomizing neonates within 24 h from NEC diagnosis as well as masking and completing the RIC intervention.

RESULTS

We created a novel international consortium for this trial and created a consensus on the diagnostic criteria for NEC and protocol for the trial. The phase II multicenter-masked feasibility RCT will be conducted at 12 centers in Canada, USA, Sweden, The Netherlands, UK, and Spain. The inclusion criteria are: gestational age < 33 weeks, weight ≥ 750 g, NEC receiving medical treatment, and diagnosis established within previous 24 h. Neonates will be randomized to RIC (intervention) or no-RIC (control) and will continue to receive standard management of NEC. We expect to recruit and randomize 40% of eligible patients in the collaborating centers (78 patients; 39/arm) in 30 months. Bayesian methods will be used to combine uninformative prior distributions with the corresponding observed proportions from this trial to determine posterior distributions for parameters of feasibility.

CONCLUSIONS

The newly established NEC consortium has generated novel data on NEC diagnosis and defined the feasibility parameters for the introduction of a novel treatment in NEC. This phase II RCT will inform a future phase III RCT to evaluate the efficacy and safety of RIC in early-stage NEC.

Endoscopic vs laparoscopic paediatric gastrostomies: Time to change our practice?

BACKGROUND

Gastrostomy insertion is a common procedure for paediatric surgeons, with the percutaneous endoscopic gastrostomy (PEG) technique long favoured for its simplicity and speed. However, there is growing evidence to suggest that primary laparoscopic balloon gastrostomy (LBG) insertions may have lower complication rates. This study aimed to determine the relative safety and healthcare resource burden of PEG and LBG.

METHODS

A retrospective review of all primary gastrostomy insertions (2011-2019). Primary outcome measures included return to theatre for emergency laparotomy and healthcare burden (total gastrostomy-related admissions, length of stay and total theatre utilisation).

RESULTS

338 PEGs and 277 LBGs were inserted with a minimum follow-up period of six months. Following PEG insertion 12/338(3.6%) children required an emergency laparotomy for gastrostomy-related complications. This compared to 2/277(0.7%) following LBG insertion (ARR2.8% (95%CI0.6-5.0), p < 0.0267). When considering all gastrostomy related admissions, there was no significant difference in total theatre utilisation (PEG = 85 [IQR58-117] minutes, LBG = 86 [IQR75-105] minutes, p = 0.12). However, PEGs were found to have an overall longer length of stay 4 [IQR3-7] vs 3 [IQR2-4] days.

CONCLUSIONS

LBGs carry a significantly lower rate of major complications and are not associated with an increased healthcare burden. LBG should be considered as the first line method of gastrostomy insertion in children.

Pediatric interventional radiology - does it add value?

Although attempts have been made to show that pediatric interventional radiology adds value in children's hospitals, none has been particularly persuasive. An analysis of individual procedures would seem to be the most scientific approach, but there are numerous problems, including the effects that different health care systems have on clinical practice and the difficulty of generalizing the results of a single-center study to other hospitals, even within the same type of health care system. It is unsurprising that there are no published randomized controlled trials comparing both the costs and outcomes of specific pediatric interventional radiology procedures with surgical alternatives, and in fact these may not be feasible. There is only anecdotal evidence of the value of pediatric interventional radiology in multidisciplinary teams in children's hospitals. Currently, the best justification may be the counterfactual: demonstrating what can go wrong if pediatric interventional radiology expertise is not available.

Radiologically Inserted Gastrostomy (RIG) at a Tertiary Center: Periprocedural Safety including Rationalization of Antibiotic Prophylaxis

Introduction Long-term percutaneous enteral nutrition forms an important part of treatment for patients with an inability to meet nutrient requirements orally. Radiologically inserted gastrostomy (RIG) is an alternative to the traditionally performed percutaneous endoscopic gastrostomy technique. However, there is marked heterogeneity in the way that RIG is performed. In addition, the role for antibiotic prophylaxis during RIG insertion is not clearly established. This study aimed to assess the safety of RIG insertion using our technique including the role of antibiotics in RIG insertion.

Method Retrospective study over 5 years at a tertiary teaching hospital. Periprocedural or early complications within the first 2 weeks of the procedure were collected and correlated with the use of prophylactic antibiotics.

Results A total of 116 patients met the inclusion criteria. 18-French tube was used in 96.6%. Note that 58.6% of procedures were done with intravenous sedation. Prophylactic 1 g cefazolin was used in 70 patients with 1 case of infection. Procedures were performed without antibiotics in 46 patients with 3 infections, p = 0.20.

There were two major complications (1.7%) consisting of right gastric artery injury requiring embolization and gastric wall injury requiring laparotomy. There were 12 minor complications (10.3%) including 4 cases of infection, 3 of severe pain, 1 of minor bleeding, 2 of early dislodgement, and 2 of leak/bypass of gastric contents around the tube.

Conclusion The technique used for RIG insertion at our institution results in a low complication rate. In addition, this study shows no significant difference in early peristomal infection rate with the use of antibiotic prophylaxis.

PEG site metastasis in oropharyngeal squamous cell carcinoma managed with cetuximab and radiotherapy: A case report

Percutaneous endoscopic gastrostomy (PEG) tube insertion is commonplace in head and neck cancer (HNC) patients. A rare but serious complication of PEG insertion in HNC is PEG site metastasis (PSM), which may precipitate rapid deterioration. We present the first case of PSM in a HNC patient managed without chemoradiotherapy and/or surgery, but rather with concurrent radiotherapy and cetuximab, followed by second-line pembrolizumab. Following histopathologic diagnosis of PSM, positron emission tomography confirmed primary site recurrence and multiple metastases in the axilla, abdomen and pelvis, managed palliatively with focal abdominal wall radiotherapy, pembrolizumab and carboplatin. The patient deteriorated and passed away 20 months after initial HNC diagnosis, 5 months after confirmation of PSM. Patients and clinicians should be aware of PSM in HNC. Though a proven prevention strategy is yet to be confirmed, prompt PSM diagnosis spares the patient unnecessary antibiotics for presumed infection and suggests the possibility of intra-abdominal metastases.

Open Primary Button Versus Laparoscopic Percutaneous Endoscopic Gastrostomy: Results From a Case-control Study

OBJECTIVES

Open primary balloon gastrostomy (PBG) presents a potential alternative to percutaneous endoscopic gastrostomy (PEG) in children as it obviates the need for change under general anaesthetic; however, the complication profile of PBG compared to PEG is not well defined. Previous series comparing the two have been hampered by the groups not being equivalent. Our paediatric surgical centre has offered PBG as an alternative PEG since 2014. We used a matched case-control study to compare outcomes for PBG and PEG.

METHODS

Patients undergoing PBG were used as "cases" and matched 1:3 by age and diagnosis to patients undergoing PEG, demographics, and clinical data as "controls." Primary outcome was rate of complications classified according to Clavien-Dindo (I-V). Secondary outcomes included time to feed and length of stay. Non-parametric, categorical and multivariate logistic regression analyses were performed. Data here presented as median with interquartile range (IQR).

RESULTS

We included 140 patients (35 PBG:105 PEG). The 2 groups were comparable for sex, weight at surgery, and follow-up duration. Median operative time was longer for PBG (43 min [IQR 36.5-61.5] vs 27.5 min [18.25-47.75], P < 0.001). Multivariate analysis demonstrated a statistically significant, higher incidence of symptomatic granulation tissue in PBG (10 [29%] vs 6 [6%], P = 0.0008), this remained significant on multivariate analysis (OR 7.56 [2.33-23.5], P = 0.001), no other complication remained significant. The overall complication rate was not statistically different.

CONCLUSIONS

PBG and PEG have similar overall complication rates; however, PBG appears to have a higher incidence of granulation tissue. This observation must be weighed against the need for further general anaesthetic which is not insignificant in medically complex children.

Development of a web-based assessment tool that evaluates the meal situation when a child has a percutaneous endoscopic gastrostomy

BACKGROUND

Children with cancer often suffer side effects from their treatment, for example nausea and vomiting, which can lead to malnutrition. If a child cannot eat orally, a percutaneous endoscopic gastrostomy (PEG) can improve his or her well-being, psychosocial development and growth by enabling the supply of nourishment and facilitating the administration of necessary medicines. Few data exist on children's comfort when using a PEG. The aim of this study was firstly to develop three versions of a web-based assessment tool in which children, families, and healthcare professionals would be able to register their observations and assessments for evaluating the meal situation when a child has a PEG and secondly to validate the content of the tool.

METHODS

A qualitative design was chosen with purposive sampling of participants. Five children with cancer, five parents, five registered nurses and five paediatricians participated first in an interview and then in a member check of the web-based tool. The data were analysed with manifest qualitative content analysis.

RESULTS

The results highlighted four categories of issues which needed to be revised in the web-based tool: words which were difficult for the participants to understand, items which contained several questions, items which needed to be split into more items to be answerable and the layout of the questionnaire. The web-based tool was revised according to the categories, and then a member check evaluated and finally confirmed the revisions.

CONCLUSIONS

A web-based tool may be able to evaluate the meal situation when a child with cancer has a PEG. The tool may be able to detect early failures of the PEG, facilitating early action from the healthcare professionals in supporting the child and his or her parents in their care of the PEG. In the long run, this web-based tool may also be able to increase the quality of care of children living with a PEG.

Non-vascular interventional radiology in the paediatric alimentary tract

Paediatric interventional radiology is an evolving speciality which is able to offer numerous minimally invasive treatments for gastrointestinal tract pathologies. Here we describe interventions performed by paediatric interventional radiologists on the alimentary tract from the mouth to the rectum. The interventions include sclerotherapy, stricture management by dilation, stenting and adjunctive therapies such as Mitomycin C administration and enteral access for feeding, motility assessment and administration of enemas.

Percutaneous endoscopic gastrostomy. Indications, care and complications

Percutaneous endoscopic gastrostomy (PEG) is an effective and safe method for nutritional support in patients with malnutrition and impossibility of oral intake with an estimated survival higher than the months that require enteral nutrition beyond four weeks. The main indications include neoplasms of the upper air-digestive tract and neurological diseases, with dementia currently considered a controversial indication. Anatomical alterations and infectious diseases are the most frequent contraindications. There are different endoscopic techniques; the most widely used being the "pull" method, with a low mortality. Complications are more frequent in patients with multiple pathologies and the elderly. Wound infection, extraction of the tube, tube blockage and bronchoaspiratory pneumonia are the most prevalent complications. Adequate prior preparation of the patient and exhaustive maintenance of the tube can reduce the appearance of these.

Feeding tubes in children

PURPOSE OF REVIEW

A practical guide to different feeding tubes available for nutritional support in children, focused on indications, placement methods and complications.

RECENT FINDINGS

Enteral nutritional support refers to the delivery of nutrition into the gastrointestinal tract distal to the oesophagus. Different feeding tubes are available for exclusive or supplemental nutritional support in children who are unable to independently sustain their own growth, nutritional and hydration status. Gastric feeding is the first choice; however, jejunal feeding provides a good alternative route in the presence of contraindications or intolerance. Feeding tubes can be short or long term: nasogastric and nasojejunal tubes provide short-term nutrition support, gastrostomy and jejunostomy tubes, long-term enteral feeding. The latter are established surgically through the formation of a stoma, an artificial connection between gastric or jejunal lumen and the abdominal wall, performed either endoscopically (percutaneous endoscopic gastrostomy, percutaneous endoscopic gastrojejunostomy) or surgically (gastrostomy, direct jejunostomy). Awareness of different available options, technical considerations and potential risks will inform the decision-making process for an individual patient to ensure the correct balance between adequate enteral nutritional and unnecessary morbidity.

SUMMARY

Successful administration of nutrition support requires knowledge of the correct indication, route and specific functional details of the appropriate feeding tube.

Bronchoscope-Guided Percutaneous Endoscopic Gastrostomy Tube Placement by Interventional Pulmonologists: A Feasibility and Safety Study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tube placement is a procedure frequently done in the intensive care unit. The use of a traditional endoscope can be difficult in cases of esophageal stenosis and theoretically confers an increased risk of infection due to its complex architecture. We describe a technique using the bronchoscope, which allows navigation through stenotic esophageal lesions and also minimizes the risk of endoscopy-associated infections.

METHODS

Prospective series of patients who had PEG tube placement guided by a bronchoscope. Procedural outcomes including successful placement, duration of the entire procedure, time needed for passage of the bronchoscope from the oropharynx to the major curvature, PEG tube removal rate, and mortality were collected. Procedural adverse events, including infections and long-term PEG-related complications, were recorded.

RESULTS

A total of 84 patients underwent bronchoscope-guided PEG tube placement. Percutaneous endoscopic gastrostomy tube insertion was completed successfully in 82 (97.6%) patients. Percutaneous endoscopic gastrostomy tube placement was performed immediately following percutaneous tracheostomy in 82.1%. Thirty-day mortality and 1-year mortality were 11.9% and 31%, respectively. Overall, minor complications occurred in 2.4% of patients, while there were no major complications. No serious infectious complications were identified and no endoscope-associated hospital acquired infections were documented.

CONCLUSIONS

The use of the bronchoscope can be safely and effectively used for PEG tube placement. The use of bronchoscope rather than a gastroscope has several advantages, which include the ease of navigating through complex aerodigestive disorders such as strictures and fistulas as well as decreased health-care utilization. In addition, it may have a theoretical advantage of minimizing infections related to complex endoscopes.

The challenges of surgical research in children

Trials in children needed