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Dolan RS, Duszak R, Bercu ZL, Martin JG, Newsome J, Kokabi N. Comparing the Safety and Cost of Image-Guided Percutaneous Gastrostomy Tube Placement in the Outpatient Versus Overnight Observation Setting in a Single-Center Retrospective Study. Acad Radiol 2021; 28:1081-1085. [PMID: 32527708 DOI: 10.1016/j.acra.2020.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/19/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
RATIONALE AND OBJECTIVES Historically, patients undergoing image-guided percutaneous gastrostomy tube placement have been admitted overnight with feeds commencing 12-24 hours postprocedure. With new expedited feeding protocols starting 3-4 hours postprocedure, same-day discharge is now possible. The purpose of this study was to evaluate the safety and cost of image-guided percutaneous gastrostomy tube placement as an outpatient procedure. MATERIALS AND METHODS In this retrospective study, 131 patients (age 63.9 ± 11.6; 34% female) underwent gastrostomy tube placement as an outpatient procedure with expedited feeding protocol versus 40 patients (age 61.3 ± 12.6; 38% female) who were hospitalized overnight with feeds starting at 12-24 hours, primarily based on operator preference. The two groups were compared regarding complications within 90 days of procedure. Using a subgroup of 33 consecutive patients, procedural costs (total combined insurer and patient payments for professional and hospital services) for outpatients vs. hospitalized patients were compared. RESULTS Complication rates were similar (p = 0.64) for gastrostomy tubes placed on outpatients (0.17 complications/procedure: 4 bleeding, 2 aspiration pneumonia, 1 abdominal abscess, 4 significant pain, 6 cellulitis, 1 surgical consult, 4 malpositioned/fractured tubes) and hospitalized patients (0.20 complications/procedure: 1 aspiration pneumonia, 1 significant pain, 3 cellulitis, 1 surgical consult, 2 fractured tubes). Total combined insurer and patient payments were similar ($2193/outpatient vs $2701/hospitalized patient; p= 0.52). CONCLUSION Outpatient image-guided percutaneous gastrostomy tube placement with an expedited feeding protocol is a safe and cost-comparable alternative to historic overnight hospitalization. Further prospective investigation with a larger sample is warranted.
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Zenilman A, DeFazio J, Griggs C, Picoraro J, Fallon EM, Middlesworth W. Retained gastrostomy bumper resulting in esophageal fistula and spinal osteomyelitis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Unsedated Outpatient Percutaneous Endoscopic Gastrostomy in Stroke Patients: Is It Feasible and Safe? Surg Laparosc Endosc Percutan Tech 2019; 29:383-388. [PMID: 31033632 DOI: 10.1097/sle.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Percutaneous endoscopic gastrostomy (PEG) is an established practice for long-term nutrition in dysphagia-suffering stroke patients. This study sought to determine the feasibility and safety of outpatient, unsedated PEG implementation in stroke patients. This retrospective cohort study involved stroke victims who underwent unsedated outpatient PEG insertion from 2014 to 2017 at our Surgical Endoscopy Unit. Patients were given pharyngeal anesthesia with lidocaine 10% spray, while the PEG tube was placed under local anesthesia. The incidence of intraprocedural and postprocedural complications and 30-day mortality rate were recorded. Data from 127 cases were analyzed. The procedures were performed with minor, transient complications, which resolved after rescue maneuvers. No intraprocedural and postprocedural major complications or death were observed. During the 30-day follow-up, the most important complication involved a single case of accidental PEG removal that was successfully resolved surgically. Unsedated PEG insertion appears to be a feasible, well-tolerated, and safe option for stroke-related dysphagia.
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To Pull or to Scope: A Prospective Safety and Cost-effectiveness of Percutaneous Endoscopic Gastrostomy Tube Replacement Methods. J Clin Gastroenterol 2019; 53:e37-e40. [PMID: 29369238 DOI: 10.1097/mcg.0000000000000993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) tubes are routinely used as an effective method for providing enteral nutrition. The need for their exchange is common. GOALS We aimed to examine the comparative safety and cost-effectiveness of PEG percutaneous counter-traction "pulling" approach or by endoscopically guided retrieval. STUDY A prospective 215 consecutive patients undergoing PEG tube insertion were included. Fifty patients in total were excluded. The patients were examined for demographics, indications for PEG replacement, as well as procedure-related complications and procedural costs. RESULTS Group A included 70 patients (42%) with PEG tubes replaced endoscopically, whereas group B included 95 patients (58%) with PEG tubes replaced percutaneously. Baselines characteristics were similar between the 2 groups (P=NS). Group A and group B had similar immediate complication rates including 4 patients in group B (4.2%), and 2 patients in group A (2.8%) (P=0.24). Complications included a conservatively managed esophageal perforation, and self-limited mild bleeding groups A and group B, respectively. The mean procedure cost was significantly higher in the endoscopic PEG replacement group compared with the percutaneous PEG replacement group ($650 vs. $350, respectively). CONCLUSION Percutaneous PEG replacement appears as safe as endoscopic PEG replacement, however, percutaneous tube exchange is less costly.
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Chhaparia A, Hammami MB, Bassuner J, Hachem C. Trans-Hepatic Percutaneous Endoscopic Gastrostomy Tube Placement: A Case Report of A Rare Complication and Literature Review. Gastroenterology Res 2018; 11:145-149. [PMID: 29707082 PMCID: PMC5916639 DOI: 10.14740/gr966w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 02/05/2018] [Indexed: 12/23/2022] Open
Abstract
Percutaneous endoscopic gastrostomy (PEG) tubes have emerged as the standard of care for long-term enteral feeding. This procedure is relatively safe; however, complications do occur, and one of the most dreaded complications is trauma to the surrounding organs. Hepatic injury during PEG placement is an extremely rare complication of the PEG procedure, with a handful of cases described in the medical literature. We describe the case of an accidental trans-hepatic placement of a PEG tube in a 78-year-old morbidly obese female, even with excellent trans-illumination and manual external pressure achieved during endoscopic placement. Post-procedure, cross-sectional imaging of the abdomen showed a gastrostomy tube traversing the lateral margin of the liver with adjacent small hematoma. Physical exam was unremarkable for abdominal tenderness or guarding/rigidity, and no blood or drainage was noted at the site of PEG insertion. Enteral nutrition was started after 24 h of PEG tube insertion and patient tolerated well with no complications. The patient was discharged to a nursing home but unfortunately died the following week to an unknown cause.
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Affiliation(s)
- Anuj Chhaparia
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.,These authors contributed equally to this article
| | - Muhammad Bader Hammami
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.,Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO, USA.,These authors contributed equally to this article
| | - Juri Bassuner
- Department of Radiology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Christine Hachem
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.,Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO, USA
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de Luca U, Mangia G, Tesoro S, Martino A, Sammartino M, Calisti A. Guidelines on pediatric day surgery of the Italian Societies of Pediatric Surgery (SICP) and Pediatric Anesthesiology (SARNePI). Ital J Pediatr 2018. [PMID: 29530049 PMCID: PMC5848546 DOI: 10.1186/s13052-018-0473-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The Italian Society of Pediatric Surgery (SICP) together with The Italian Society of Pediatric Anesthesia (SARNePI) through a systematic analysis of the scientific literature, followed by a consensus conference held in Perugia on 2015, have produced some evidence based guidelines on the feasibility of day surgery in relation to different pediatric surgical procedures. The main aspects of the pre-operative assessment, appropriacy of operations and discharge are reported.
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Affiliation(s)
- Ugo de Luca
- Day Surgery Unit, Santobono-Pausilipon Pediatric Hospital, Napoli, Italy.
| | - Giovanni Mangia
- Department of Anesthesiology, San Camillo Forlanini Hospital, Roma, Italy
| | - Simonetta Tesoro
- Department of Anesthesiology, Perugia University, Perugia, Italy
| | | | - Maria Sammartino
- Department of Anesthesiology, Policlinico A. Gemelli, Roma, Italy
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Gupta N, Goyal P, Bansal I, Hooda K, Kumar Y, Bearden G. Some Mushrooms are Hard to Digest: Gastrostomy Tube Exchange. Pol J Radiol 2017; 82:392-394. [PMID: 28811846 PMCID: PMC5531532 DOI: 10.12659/pjr.902203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/17/2016] [Indexed: 01/24/2023] Open
Abstract
Background Percutaneous endoscopic gastrostomy (PEG) is an effective and safe mode of enteral nutrition for patients needing chronic enteric nutritional support. Exchanging PEG tubes may result in complications due to inexperience as well as due to lack of protocol. Case Report We encountered a 73 year-old female with unnoticed, accidently detached portion of the internal bumper of a PEG tube in the gastric lumen after a challenging gastrostomy tube exchange. Conclusions This case report discusses the complications associated with gastrostomy tube exchange and proposes a planned protocol for successful gastrostomy tube exchange.
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Affiliation(s)
- Nishant Gupta
- Department of Radiology and Imaging, Saint Vincent's Medical Center, Bridgeport, CT, U.S.A
| | - Pradeep Goyal
- Department of Radiology and Imaging, Saint Vincent's Medical Center, Bridgeport, CT, U.S.A
| | - Itisha Bansal
- Department of Anesthesiology, New York Methodist Hospital, Brooklyn, NY, U.S.A
| | - Kusum Hooda
- Department of Radiology, Yale New Haven Health at Bridgeport Hospital, Bridgeport, CT, U.S.A
| | - Yogesh Kumar
- Department of Radiology, Yale New Haven Health at Bridgeport Hospital, Bridgeport, CT, U.S.A
| | - Gregory Bearden
- Department of Surgery, Baptist Health System Inc., Birmingham, AL, U.S.A
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A Silent and Chronic Complication of Percutaneous Endoscopic Gastrostomy Tube: Small Bowel Enterocutaneous Fistula. Case Rep Gastrointest Med 2016; 2016:5328240. [PMID: 27891266 PMCID: PMC5116343 DOI: 10.1155/2016/5328240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/17/2016] [Indexed: 11/17/2022] Open
Abstract
Percutaneous endoscopic gastrostomy (PEG) has gradually gained the popularity since its invention and become the most preferred method for gastrostomy insertion in recent years. PEG is associated with lower morbidity and mortality and has the advantages of being minimally invasive and more convenient over the conventional open gastrostomy. However, significant rates of major complication still occur. Enterocutaneous fistula is one of the key complications that can be easily neglected due to its asymptomatic nature. We present a case of small bowel enterocutaneous fistula which was only found 8 years after the PEG insertion, being diagnosed after the longest duration of delay in diagnosis reported in literature.
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Ojo O. The challenges of home enteral tube feeding: a global perspective. Nutrients 2015; 7:2524-38. [PMID: 25856223 PMCID: PMC4425159 DOI: 10.3390/nu7042524] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/17/2015] [Accepted: 04/01/2015] [Indexed: 12/14/2022] Open
Abstract
The aim of this review is to provide a global perspective of Home Enteral Tube Feeding (HETF) and to outline some of the challenges of home enteral nutrition (HEN) provisions. It is well established that the number of patients on HETF is on the increase worldwide due to advances in technology, development of percutaneous endoscopic gastrostomy techniques, and the shift in care provisions from acute to community settings. While the significance of home enteral nutrition in meeting the nutritional requirements of patients with poor swallowing reflexes and those with poor nutritional status is not in doubt, differences exist in terms of funding, standards, management approaches and the level of infrastructural development across the world. Strategies for alleviating some of the challenges militating against the effective delivery of HETF including the development of national and international standards, guidelines and policies for HETF, increased awareness and funding by government at all levels were discussed. Others, including development of HEN services, which should create the enabling environment for multidisciplinary team work, clinical audit and research, recruitment and retention of specialist staff, and improvement in patient outcomes have been outlined. However, more research is required to fully establish the cost effectiveness of the HEN service especially in developing countries and to compare the organization of HEN service between developing and developed countries.
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Affiliation(s)
- Omorogieva Ojo
- Faculty of Education and Health,University of Greenwich, Avery Hill Campus, Avery Hill Road, London SE9 2UG, UK.
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Villela EL, Sakai P, Almeida MR, Moura EG, Faintuch J. Endoscopic gastrostomy replacement tubes: Long-term randomized trial with five silicone commercial models. Clin Nutr 2014; 33:221-5. [DOI: 10.1016/j.clnu.2013.04.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 03/26/2013] [Accepted: 04/17/2013] [Indexed: 02/08/2023]
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Lee SP, Lee KN, Lee OY, Lee HL, Jun DW, Yoon BC, Choi HS, Kim SH. Risk factors for complications of percutaneous endoscopic gastrostomy. Dig Dis Sci 2014; 59:117-25. [PMID: 24142070 DOI: 10.1007/s10620-013-2891-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 09/14/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is a commonly performed procedure for patients with severe dysphagia leading to malnutrition. Improved knowledge of risk factors for PEG-related complications might decrease patient discomfort and healthcare costs. AIM The aim of the present study was to investigate factors associated with complications after PEG. METHODS A retrospective review was performed for all patients referred for PEG placement from December 2002 to December 2012 in single-tertiary care center. PEG-related complications and risk factors were evaluated through chart reviews, endoscopic reports, and endoscopic and radiologic images. RESULTS Among a total of 245 consecutive individuals (146 male, mean age 59.2 ± 12.6 years) enrolled, 43 major complications had developed. Multivariate analysis revealed that patients with an internal bolster of a PEG tube in the upper body of stomach were at significant risk for early [OR 6.127 (95 % CI 1.447-26.046)] and late complications [OR 6.710 (95 % CI 1.692-26.603)]. Abnormal leukocyte counts [OR 3.198 (95 % CI 1.174-8.716)], stroke as an indication for PEG [OR 3.047 (95 % CI 1.174-8.882)], and PEG tube placement by an inexperienced endoscopist [OR 3.401 (95 % CI 1.073-10.779)] were significantly associated with early complications. CONCLUSIONS A PEG tube should not be inserted into the upper body of stomach to reduce complication risk, and PEG procedures should be performed by skilled endoscopists to prevent early complications. An abnormal leukocyte count can be a predictor of early complication, and care is needed when PEG is performed for patients with stroke.
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Affiliation(s)
- Sang Pyo Lee
- Department of Internal Medicine, Digestive Disease Centre, Konkuk University School of Medicine, Seoul, Korea
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Dhooge M, Gaudric M. Non-surgical access for enteral nutritional: gastrostomy and jejunostomy, technique and results. J Visc Surg 2013; 150:S19-26. [PMID: 23790717 DOI: 10.1016/j.jviscsurg.2013.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Gastrostomy is the most efficient and best tolerated method of prolonged nutritional support. Jejunostomy is used more rarely. Indications for both techniques have increased because of progress in insertion techniques under endoscopic or radiologic guidance. The procedure is simple and rapid, performed under simple sedation with a success rate over 95% for gastrostomy, irrespective of the technique. Mortality directly related to the technique is less than 5%, but associated co-morbidity also explains a more variable but often higher 30-day mortality. Local care and maintenance of the catheter should help avoid most of the late complications such as peristomal leaks, local infection or sepsis of the tunneled catheter in the abdominal wall. The main indications are neurologic swallowing disorders, mechanical dysphagia from ENT or esophageal disease, when the expected duration of enteral nutrition is at least longer than 3 weeks. In patients with severe dementia, no benefit for either nutritional status or quality of life has been demonstrated. In all cases, adequate patient information and careful evaluation of the risk/benefit ratio are capital.
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Affiliation(s)
- M Dhooge
- Service de gastroentérologie, Hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
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Lohsiriwat V. Percutaneous endoscopic gastrostomy tube replacement: A simple procedure? World J Gastrointest Endosc 2013; 5:14-8. [PMID: 23330049 PMCID: PMC3547115 DOI: 10.4253/wjge.v5.i1.14] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 09/04/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
Replacement of gastrostomy tube in patients undergoing percutaneous endoscopic gastrostomy (PEG) is generally considered as a safe and simple procedure. However, it could be associated with serious complications, such as gastrocutaneous tract disruption and intraperitoneal tube placement, which may lead to chemical peritonitis and even death. When PEG tube needs a replacement (e.g., occlusion or breakage of the tube), clinicians must realize that the gastrocutaneous tract of PEG is more friable than that of surgical gastrostomy because there is no suture fixation between gastric wall and abdominal wall in PEG. In general, the tract of PEG begins to mature in 1-2 wk after placement and it is well formed in 4-6 wk. However, this process could take a longer period of time in some patients. Accordingly, this article describes three major principles of a safe PEG tube replacement: (1) good control of the replacement tube along the well-formed gastrocutaneous tract; (2) minimal insertion force during the replacement, and, most importantly; and (3) reliable methods for the confirmation of intragastric tube insertion. In addition, the management of patients with suspected intraperitoneal tube placement (e.g., patients having abdominal pain or signs of peritonitis immediately after PEG tube replacement or shortly after tube feeding was resumed) is discussed. If prompt investigation confirms the intraperitoneal tube placement, surgical intervention is usually required. This article also highlights the fact that each institute should have an optimal protocol for PEG tube replacement to prevent, or to minimize, such serious complications. Meanwhile, clinicians should be aware of these potential complications, particularly if there are any difficulties during the gastrostomy tube replacement.
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Affiliation(s)
- Varut Lohsiriwat
- Varut Lohsiriwat, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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