Endoscopic approaches to enteral nutritional support

When to feed after percutaneous endoscopic gastrostomy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Initiation of feeding after percutaneous endoscopic gastrostomy (PEG) placement has been debated. Randomized controlled trials (RCTs) have been performed on early feeding compared with delayed feeding after PEG placement with varying results. Therefore, a meta-analysis was conducted examining early vs delayed feeding after placement of a PEG.

METHODS

A comprehensive search of databases was conducted in January 2024. Peer-reviewed published RCTs comparing early feeding (≤4 h) with delayed feeding (>4 h) were identified and included in the meta-analysis. Meta-analysis was completed using pooled estimates of overall complications, individual complications, mortality ≤72 h, and number of day 1 significant gastric residual volumes.

RESULTS

Six RCTs (n = 467) were included in the analysis. Comparison of early feeding with delayed feeding after PEG showed no statistically significant differences for overall complications (P = 0.18), mortality ≤72 h (P = 0.3), and number of day 1 significant gastric residual volumes (P = 0.05). No differences were also noted for individual complications, including vomiting, wound infection, bleeding, or diarrhea.

CONCLUSION

Feeding ≤4 h after PEG have no differences in minor and major complications compared with that of delayed feeding. Early feeding ≤4 h is safe and should be recommended in future guidelines.

Risk of Bleeding After Percutaneous Endoscopic Gastrostomy in Patients Using Antithrombotic Drugs

BACKGROUND

The rate of using antithrombotic (AT) drugs is frequently high in patients who require percutaneous endoscopic gastrostomy (PEG). The aim of this study was to determine whether the risk of bleeding after PEG increases in patients whose AT drugs were discontinued according to the European Society Gastrointestinal Endoscopy guidelines (warfarin for 5 d, low molecular weight heparin for 24 h, DOAC for 3 d, and clopidogrel for 7 d).

PATIENTS AND METHODS

Data from 243 patients, who underwent PEG tube placement and received AT drugs and 206 patients who did not between 2018 and 2021 in our hospital, were evaluated retrospectively. Bleeding was defined as requiring blood transfusion, hematemesis and/or melena, decreased hemoglobin, or bleeding from PEG.

RESULTS

A total of 243 (54.1%) patients (121 (49.7%), women, mean age (75.7 y) who underwent PEG and received AT drugs, and 206 (45.9%) patients who did not (92 (44.6%), women, mean age (63.15 y). The medications and bleeding rates of the patients are given in Table 1. The rate of bleeding in patients using AT medication was significantly higher than that in patients not using medication (Table 2) ( P = 0.007). When the AT drugs were compared among themselves, the bleeding risk did not differ. Bleeding was detected in 10 patients with bleeding from the PEG tube in 4 with melena. Bleeding detected in 14 patients was controlled with adrenaline injections. None of the patients required transfusion or repeat endoscopies. No bleeding-related deaths were reported.

CONCLUSION

Even if patients receiving AT drugs are treated as recommended by international guidelines, it should be kept in mind that bleeding may occur after PEG, and the patients should be followed accordingly.

Managing complications of percutaneous tracheostomy and gastrostomy

Percutaneous tracheostomy and gastrostomy are some of the most commonly performed procedures at bedside in the intensive care unit. While they are generally considered safe, they can be associated with numerous short and long-term complications, many of which can occur long after their placement and cause significant morbidity. Performers of these procedures should possess a comprehensive understanding of procedural indications and contraindications, and know how to recognize and manage complications that may arise. In this review, we highlight complications of percutaneous tracheostomy and describe strategies for their prevention and management, with a special focus on post-tracheostomy tracheal stenosis. Other complications reviewed include bleeding, pneumothorax and subcutaneous emphysema, posterior wall injury, tube displacement, tracheomalacia, tracheoinominate artery fistula, tracheo-esophageal fistula, and stomal cellulitis. Gastrostomy complications and their management are also discussed including bleeding, internal organ injury, necrotizing fasciitis, aspiration pneumonia, buried bumper syndrome, tumor seeding, wound infection, tube displacement, peristomal leakage, and gastric outlet obstruction. In light of the potentially serious outcomes associated with complications of percutaneous tracheostomy and gastrostomy, the emphasis should be placed on risk-reduction strategies to minimize morbidity and mortality. We therefore present detailed pragmatic and comprehensive checklists to serve as a reference for clinicians involved in performing these procedures.

Buried Bumper Syndrome: a rare complication during radical chemoradiotherapy for head and neck cancer

Patients undergoing radical treatment particularly chemoradiotherapy for cancer of the upper aerodigestive tract frequently experience progressive deterioration in swallow during and immediately after treatment. It is important to identify patients at high risk of compromised feeding early, following diagnosis, so that alternate feeding routes, such as percutaneous endoscopic gastrostomies (PEGs), can be promptly and prophylactically instituted, in keeping with the UK Head and Neck Cancer Guidelines (2016).

Endoscopic Enteral Access

Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed.

Nutrition Management in Acute Pancreatitis

Acute pancreatitis (AP) is one of the most prevalent gastrointestinal conditions necessitating inpatient care. In the United States, over 275,000 patients are hospitalized for management of AP, with an estimate that over $2.5 billion is spent annually in treatment, with incidence continuing to rise. AP is a highly inflammatory and catabolic state, putting all patients with the condition at risk of malnutrition. Numerous approaches to nutrition support in pancreatitis have been evaluated and remain controversial. In this narrative review, we aim to give an overview of indications for nutrition and approach to management of nutrition in severe and predicted severe AP based on currently available data.

Gastric Outlet Obstruction due to Malposition of Gastrostomy Tube: A Rare and Commonly Misdiagnosed Condition

Nearly all disease processes worsen with malnutrition. However, providing adequate and optimal nourishment can be challenging in individuals who are not able to eat. Insertion of a gastrostomy tube is a well-established method for providing enteral access for long-term nutritional support. Although enteral tube feedings are generally well tolerated, gastrostomy tube placement is associated with several complications. An uncommon, and often initially misdiagnosed, complication of gastrostomy tube placement is gastric outlet obstruction (GOO), which refers to the clinical outcome of any disease process that mechanically obstructs gastric emptying. GOO is a clinical syndrome characterized by nausea, postprandial nonbilious vomiting, epigastric pain, early satiety, abdominal distention, and insidious weight loss due to mechanical obstruction in the distal stomach, pylorus, or duodenum. Rarely, migration and malposition of a gastrostomy tube can lead to this condition. Therefore, physicians should be aware of GOO as a rare complication of gastrostomy tube placement. Often, simple adjustment of the tube can lead to rapid improvement and resolution of the patient's clinical condition as well as prevent needless medical tests, overly aggressive management, and further complications. Here, we present an interesting case of a woman who developed a GOO after unintended migration of a gastrostomy tube.

Complications of Jejunostomy Feeding Tubes: A Single Center Experience of 546 Cases

INTRODUCTION

Adequate perioperative nutrition is critical for the success of surgical outcomes. Jejunostomy feeding tube placement may ensure enteral feeding access; however, these types of tubes have had variable reported rates of dysfunction/morbidity. The aim of our study was to report our experience with jejunostomy feeding tube placement and the long-term outcomes following complex foregut surgery.

METHODS

We performed a review of all of our jejunostomy feeding tube placement patients from 1/1/2010 until 7/1/2018. The indication for surgery and primary operation were recorded. All adverse events related to the jejunostomy were recorded during the entire duration of tube access. Social "hassle-factor" issues were also reported, including the number of "jejunostomy-related" phone calls, reinsertion and related placement studies, and readmissions pertaining to jejunostomy-associated complications.

RESULTS

During the study period, 542 primary procedures were performed with secondary jejunostomy placement. Jejunostomy-related adverse events occurred in 22.0% of patients (n = 119/542); 12.0% (n = 65/542) were dislodged tubes, 6.0% (n = 30/542) clogged tubes; 5% (n = 25/542) leaking tubes, and 2.8% (n = 15/542) site infections. Tube dysfunctions initiated 244 reinsertion/placement studies in 107 patients, 20 jejunostomy tube-related readmissions, and 78 phone calls to providers for tube dysfunction. Adverse event rates differed significantly between groups (p < 0.001), with esophagogastric resection adverse event rates of 42.3% versus 19.2% for pancreatic ablations.

DISCUSSION

Jejunostomy feeding tubes resulted in adverse events in less than a third of patients. Patient-related hassle must be communicated preoperatively in order to prevent jejunostomy tube-related morbidity. Optimal early and late jejunostomy feeding optimization varies based on preoperative patient comorbidities, type of operation, and the need for adjuvant oncology therapy.

A Case of Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (LAPEG) for Gastric Volvulus

Background

Percutaneous endoscopic gastrostomy (PEG) is the standard modality for long-term enteral nutrition for patients with dysphagia. Compared with open gastrostomy, though PEG is an extremely safe procedure with fewer complications, there are severe cases due to anatomical features. For these cases, laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) is the optimal method.

Case Presentation

A 52-year-old man had a disturbance in swallowing because of cerebral infarction. We attempted PEG under gastrointestinal fiberscope (GIF) and colon fiberscope inspection; however, the procedure was unsuccessful because it was impossible to move the transverse colon downward. We therefore attempted LAPEG to observe the stomach and other organs. Under laparoscopic observation, we diagnosed gastric volvulus, classified as the organo-axial type. For this reason, inserting the tube through the skin was very difficult. We easily corrected the gastric volvulus by using laparoscopic forceps and were finally able to place the PEG tube safely.

Discussion

Gastric volvulus is rare in clinical practice. The treatment of gastric volvulus depends on whether mucosal ischemia is present. Endoscopic reduction of gastric volvulus is effective for many patients. Surgical treatment should be considered for patients with gastric volvulus that frequently recurs. In our patient, completely inserting the GIF was impossible; therefore, we could not correctly diagnose gastric volvulus. Laparoscopy-assisted PEG is a useful and safe technique for placing a gastrostomy tube in patients presenting with anatomical difficulties. Moreover, in our patient, gastropexy was performed with PEG. Therefore, LAPEG may be used to prevent the recurrence of gastric volvulus. Gastropexy is a useful option in LAPEG.

Conclusions

Laparoscopy has the advantage of allowing a direct inspection of the stomach while gastrostomy is performed and may reveal complications to PEG insertion. Furthermore, in our patient, gastropexy was performed with PEG.

A Systematic Review and Meta-Analysis on Outcomes and Complications of Percutaneous Endoscopic Versus Radiologic Gastrostomy for Enteral Feeding

BACKGROUND

The optimal technique for long-term enteral feeding has not yet been established. Both percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are widely used. Aim was to extensively review outcomes of PEG and PRG.

MATERIALS AND METHODS

A systematic review using Medline, Embase, and Cochrane was performed, using standardized tools for assessing bias. Main outcomes were infectious and tube-related complications, procedure related and 30-day mortality. Pooled risk differences (RDs) with corresponding 95% confidence intervals (95% CIs) were calculated using random effects. Arcsine transformations were applied.

RESULTS

In total, 344 studies were identified, of which 16 were included, reporting on 934 PEGs and 1093 PRGs. No differences were found for infectious complications [RD, 0.03 (-0.05 to 0.11)], procedure-related mortality [RD, 0.01 (-0.04 to 0.06)], or 30-day mortality [RD, 0.06 (-0.01 to 0.13)]. Tube-related complications were higher in PRG [RD, 0.16 (0.06-0.26)]. Subgroup analysis was performed for head and neck cancer (HNC) and motor neuron disease. In HNC, this revealed significantly lower tube-related complications and procedure-related mortality after PEG. In motor neuron disease, no differences were seen. The level of evidence appears sufficient considering the low degree of heterogeneity.

CONCLUSIONS

No differences were found with regard to mortality or infectious complications. PEG showed lower risk of tube-related complications. Subgroup analysis revealed PEG to be favorable in HNC based on lower rates of procedure-related mortality and tube-related complications. Local experience and availability should be taken into account in the decision process.

Direct percutaneous endoscopic jejunostomy using single-balloon enteroscopy without fluoroscopy: a case series

BACKGROUND

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method to provide enteral nutrition to individuals when gastric feeding is not possible or contraindicated. The aim of this study was to analyze the efficacy and safety of DPEJ tube placement with the Gauderer-Ponsky technique by the pull method, using single-balloon enteroscopy (SBE) without fluoroscopy.

METHODS

This is a retrospective analysis of patients undergoing SBE for DPEJ placement in a referral hospital between January 2010 and March 2016. Technical success, clinical success and procedure related complications were recorded.

RESULTS

Twenty-three patients were included (17 males, median age 71 years, range 37-93 years). The most frequent indications for DPEJ were gastroesophageal cancer (n = 10) and neurological disease (n = 8). Eighty-seven percent of the patients had a contraindication to percutaneous endoscopic gastrostomy (PEG) and PEG was unsuccessful in the remaining patients. The technical success rate was 83% (19/23), transillumination was not possible in three patients and an accidental exteriorization of the bumper resulting in a jejunal perforation occurred in one patient. The clinical success was 100% (19/19). The median follow-up was five months (range 1-35 months). Apart from the case of jejunal perforation and the two cases of accidental exteriorization, there were no other complications during follow-up. The 6-month survival was 65.8% and the 1-year survival was 49.3%.

CONCLUSION

DPEJ can be carried out successfully via SBE without fluoroscopy with a low rate of significant adverse events. Although, leaving the overtube in place during the bumper pulling can be useful for distal jejunal loops, it can be safely removed in proximal loops to minimize complications.

Race Differences in Gastrostomy Tube Placement After Stroke in Majority-White, Minority-Serving, and Racially Integrated US Hospitals

We sought to determine individual and system contributions to race disparities in percutaneous endoscopic gastrostomy (PEG) tube placement after stroke. Ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of ethnic/racial minority stroke patients (< 25% ethnic/racial minorities ["majority-white hospitals"], 25-50% ethnic/racial minorities ["racially integrated hospitals"], or > 50% ethnic/racial minorities ["minority-serving hospitals"]). Logistic regression was used to evaluate the association between ethnicity/race and PEG utilization within and between the different hospital strata. Among 246,825 stroke admissions, patients receiving care in minority-serving hospitals had higher odds of PEG compared to patients in majority-white hospitals, regardless of individual patient race (adjusted odds ratio [OR] 1.24, 95% CI 1.12-1.38). Ethnic/racial minorities had higher odds of PEG than whites in any hospital strata; however, this discrepancy was largest in majority-white hospitals (OR 1.62, 95% CI 1.48-1.76), and smallest in minority-serving hospitals (OR 1.22, 95% CI 1.11-1.33; p for interaction < 0.001). Ethnic/racial minority patients had similar odds of PEG in any hospital strata, while white patients had increasing odds of PEG in racially integrated and minority-serving compared to majority-white hospitals (OR 1.28, 95% CI 1.15-1.43 in racially integrated, and OR 1.39, 95% CI 1.23-1.57 in minority-serving, compared to majority-white hospitals, p for trend < 0.001). The likelihood of PEG after ischemic stroke was increased in minority-serving compared to majority-white hospitals. White patients had higher odds of PEG in minority-serving compared to majority-white hospitals, indicating a systemic difference in PEG placement across hospitals.

Modified technique for percutaneous endoscopic gastrojejunostomy placement

The placement of percutaneous endoscopic gastrojejunostomy (PEG-J) provides diet delivery beyond the angle of Treitz, and it is associated with decrease of complications related to gastroparesis, such as aspiration pneumonia. There are many different techniques to perform a PEG-J described in the literature, with variable degrees of technical success. In this article, we suggest modifications to the technique of PEG-J placement in order to reduce time of procedure and minimize the risk of technical failure.

Endoscopy versus fluoroscopy for the placement of postpyloric nasoenteric tubes in critically ill patients: A meta-analysis of randomized controlled trials

INTRODUCTION

Early postpyloric nasoenteric nutrition is considered an accepted method of nutritional support in critically ill patients. Both endoscopy and fluoroscopy placement of postpyloric nasoenteric tubes (PNTs) have the highest percentages of placement success rate. We aimed to evaluate the differences in efficacy and safety between endoscopy and fluoroscopy methods for the placement of PNTs in critically ill patients.

METHOD

We searched MEDLINE, Embase, and electronic databases of Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing endoscopy and fluoroscopy placement of PNTs in critically ill patients. Two reviewers assessed the quality of each study and collected data independently. We performed the meta-analysis with Cochrane Collaboration RevMan 5.3.

RESULTS

Three randomized controlled trials involving 243 patients were included. There were no significant differences in the placement success rate (RR, 0.99; 95% CI, 0.93, 1.06; z = 0.20, P = .84,) or procedure time (standardized mean difference, -0.08; 95% CI, -6.93, 6.77; z = 0.02, P = .98) between the 2 groups. No severe complications (digestive tract hemorrhage, perforation, respiratory problems, hemodynamic instability, or death) were noted in the three studies. There was a slight difference in the incidence of minor complications (RR, 8.12; 95% CI, 1.07, 61.53; z = 2.03, P = .04) between the 2 groups.

CONCLUSIONS

Endoscopy and fluoroscopy placement of PNTs can be accurately and safely performed in critically ill patients. Endoscopy may be at least equally as safe as fluoroscopy for the placement of PNTs.

Racial and Socioeconomic Disparities in Gastrostomy Tube Placement After Intracerebral Hemorrhage in the United States

BACKGROUND AND PURPOSE

Percutaneous endoscopic gastrostomy (PEG) tubes are widely used for enteral feeding of patients after intracerebral hemorrhage (ICH). We sought to determine whether PEG placement after ICH differs by race and socioeconomic status.

METHODS

Patient discharges with ICH as the primary diagnosis from 2007 to 2011 were queried from the Nationwide Inpatient Sample. Logistic regression was used to evaluate the association between race, insurance status, and household income with PEG placement.

RESULTS

Of 49 946 included ICH admissions, a PEG was placed in 4464 (8.94%). Among PEG recipients, 47.2% were minorities and 15.6% were Medicaid enrollees, whereas 33.7% and 8.2% of patients without a PEG were of a race other than white and enrolled in Medicaid, respectively (P<0.001). Compared with whites, the odds of PEG were highest among Asians/Pacific Islanders (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.32-1.99) and blacks (OR 1.42, 95% CI 1.28-1.59). Low household income (OR 1.25, 95% CI 1.09-1.44 in lowest compared with highest quartile) and enrollment in Medicaid (OR 1.36, 95% CI 1.17-1.59 compared with private insurance) were associated with PEG placement. Racial disparities (minorities versus whites) were most pronounced in small/medium-sized hospitals (OR 1.77, 95% CI 1.43-2.20 versus OR 1.31, 95% CI 1.17-1.47 in large hospitals; P value for interaction 0.011) and in hospitals with low ICH case volume (OR 1.58, 95% CI 1.38-1.81 versus OR 1.29, 95% CI 1.12-1.50 in hospitals with high ICH case volume; P value for interaction 0.007).

CONCLUSIONS

Minority race, Medicaid enrollment, and low household income are associated with PEG placement after ICH.

Clinical Evaluation of Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (LAPEG)

Percutaneous endoscopic gastrostomy (PEG) is the standard modality for long-term enteral nutrition; however, complications are common. To avoid these complications, we introduce laparoscopic-assisted PEG (LAPEG) and describe its advantages. The aim of this study was to describe the advantages of LAPEG relative to other procedures. We retrospectively reviewed the records of 19 patients who underwent LAPEG at our institution from June 2008 to February 2013. They were thought to be difficult cases for PEG. LAPEG was successfully performed in 18 patients (average age, 78.5 years; range, 50-98 years). The average surgical duration was 32.4 ± 6.2 minutes. No major intraoperative or postoperative complications were observed. Feeding tubes were successfully placed in all patients within some days. LAPEG is a safe, effective, and simple procedure. The strongest advantage of LAPEG is the possibility of observing the intraperitoneal condition and the ability to perform PEG safely without any complications. LAPEG should be the first-choice procedure if it is difficult to accomplish conventional PEG.

Pneumoperitoneum with subcutaneous emphysema after percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy is a safe way for enteral nutrition in selected patients. Generally, complications of this procedure are very rare but due to patients general health condition, delayed diagnosis and treatment of complications can be life threatening. In this study, we present a PEG-related massive pneumoperitoneum and subcutaneous emphysema in a patient with neuro-Behçet.

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.

Percutaneous endoscopic gastrostomy: Indications, technique, complications and management

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

Percutaneous endoscopic gastrostomy (PEG): retrospective analysis of a 7-year clinical experience

AIMS

Since its description in 1980, percutaneous endoscopic gastrostomy has become the modality of choice for providing enteral access to patients who require long-term enteral nutrition. This study aimed to evaluate current indications and complications associated with PEG feeding.

METHODS

We conducted a retrospective analysis of all patients who referred to our endoscopic unit of the Department of Gastroenterology and Hepatology of the Medical Center University of Sarajevo for PEG tube placement over a period of 7 years. Medical records of 359 patients dealing with PEG tube placement were reviewed to assess indications, technical success, complications and the need for repeat procedures.

RESULTS

The indications for enteral feeding tube placement were malignancy in 44% (n=158), of which 61% (n=97) patients were suffering of head and neck cancer and 39% (n=61) of other malignancy. Central nervous disease was the indication in 48.7 % (n=175) of patients. Cerebrovascular accidents (CVA) accounted for 20% (n=73), head injury for 16% (n=59) and cerebral palsy for 11% (n=38). In 6.13% (n=22) of patients minor complications occur which included wound infection (0.8%), inadvertent PEG removal (2.5%) and tube blockage (1.1%). 11 patients experienced major complications including hemorrhage, tube migration and perforation. There were no deaths related to PEG procedure placement and the overall 30-day mortality rate due to primary disease was 15.8%. Oral feeding was resumed in 23% of the patients and the tube was removed subsequently after 6 -12 months.

CONCLUSIONS

Percutaneous endoscopic gastrostomy is a save and minimally invasive endoscopic procedure associated with a low morbidity (9.2%) rate, easy to follow-up and to replace when blockage occurs. Over a seven-year period we noticed an increase of 63% in PEG placement at our department.

Endoscopist’s approach to nutrition in the patient with pancreatitis

Nutritional therapy has an important role in the management of patient with severe acute pancreatitis. This article reviews the endoscopist’s approach to manage nutrition in such cases. Enteral feeding has been clearly validated as the preferred route of feeding, and should be started early on admission. Parenteral nutrition should be reserved for patients with contraindications to enteral feeding such as small bowel obstruction. Moreover, nasogastric feeding is safe and as effective as nasojejunal feeding. If a prolonged course of enteral feeding (> 30 d) is required, endoscopic placement of feeding gastrostomy or jejunostomy tubes should be considered.

Feeding tube placement: errors and complications

Feeding tube placement for enteral nutrition (EN) support is widely used in both critically ill and stable chronically ill patients who are unable to meet their nutrition needs orally. Nasal or oral feeding tubes can be performed blindly at the bedside or with fluoroscopic or endoscopic guidance into the stomach or small bowel. Percutaneous feeding tubes are used when EN support is required for longer periods (>4-6 weeks) and are most commonly placed endoscopically or radiographically. Although generally safe and effective, there is a wide spectrum of known complications associated with feeding tube placement. Errors made at the time of feeding tube placement can result in a number of these procedural and postprocedural complications. In many cases, a single error at the time of placement can result in numerous complications. A thorough knowledge of these errors and avoiding them in practice will decrease iatrogenic complications in a vulnerable population. In addition, early recognition and management of complications will further minimize morbidity and even mortality in enteral feeding tube placement. This article reviews the common errors leading to complications of enteral feeding tube placement and their prevention and management.

Risk of bleeding after percutaneous endoscopic gastrostomy (PEG)

BACKGROUND

Patients who undergo percutaneous endoscopic gastrostomy (PEG) placement are often on anticoagulation and/or antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. Data on the safety of peri-procedural use of these drugs is limited.

AIMS

To assess the risk and to identify any predictive factors for post-PEG bleeding, and to determine if clopidogrel increases the risk of bleeding following PEG.

METHODS

A retrospective chart audit was conducted from January 1, 2002 to June 30, 2011.

RESULTS

A total of 1,541 patients underwent PEG placement during this period. Gastrointestinal bleeding after PEG placement occurred in 51 cases (3.3%) and bleeding directly attributed to PEG was noted in six patients (0.4%). Multivariate logistic regression analysis of variables (age, gender, length of hospitalization, indication for PEG, antiplatelet or anticoagulant medications) showed that heparin infusion (P = 0.018) and length of hospitalization (P = 0.029) were statistically significant predictors of bleeding. The mean period for cessation and resumption of clopidogrel with PEG placement were 2.2 and 1.3 days, respectively.

CONCLUSION

Although PEG is classified as a high-risk endoscopic procedure, bleeding with PEG placement was rare, even with use of anticoagulation and antiplatelet medications. In selected patients on heparin infusion undergoing PEG, delaying the procedure, alternative use of low-molecular-weight heparin or close monitoring and frequent assessments should be considered. Clopidogrel did not contribute to an increase in bleeding risk, despite being held for a much shorter peri-procedural period as recommended by expert consensus.

Mental incapacity in hospitalised patients undergoing percutaneous endoscopic gastrostomy insertion

BACKGROUND & AIMS

Decisions to insert percutaneous endoscopic gastrostomy (PEG) tubes may be difficult because patients have serious underlying disease, and the procedure has associated risks. Patients may also lack mental capacity to consent to PEG insertion. This study aimed to prospectively determine the prevalence of mental incapacity in hospitalised patients undergoing PEG insertion.

METHODS

Mental capacity was assessed using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) in 72 consecutive inpatients referred for PEG insertion. Cognitive function was measured using the Mini-Mental State Examination (MMSE). Sixty eight inpatients and 69 outpatients having diagnostic upper gastrointestinal (UGI) endoscopy were similarly studied.

RESULTS

Thirty nine of the PEG patients had suffered stroke, and none had a primary diagnosis of dementia. Seventy four % (53/72) of inpatients referred for PEG, 22% (15/68) of inpatients having UGI endoscopy, and 3% (2/69) of outpatients having UGI endoscopy, lacked mental capacity, p < 0.001. MMSE scores were normal in just 18% of inpatients having PEG, in 72% of inpatients having UGI endoscopy, and in 91% of outpatients having UGI endoscopy, p < 0.001.

CONCLUSION

Amongst inpatients undergoing PEG insertion there is a high prevalence (three-quarters patients) of mental incapacity to consent to this important intervention. Decisions have to be made on behalf of most inpatients referred for PEG insertion.

Percutaneous endoscopic gastrostomy complication rates and compliance with the American Society for Gastrointestinal Endoscopy guidelines for the management of antithrombotic therapy

BACKGROUND

The American Society for Gastrointestinal Endoscopy (ASGE) has published recommendations in regards to anticoagulant (AC) and antiplatelet (AP) therapy management during endoscopic procedures. So far, no study has assessed either ASGE recommendation compliance during percutaneous endoscopic gastrostomy (PEG) placement or procedure-associated complication rates as related to the observance of these recommendations. The aims of this study were to compare the incidence and type of complications during PEG placement in patients receiving or not receiving AC and/or AP therapy and to determine the compliance with ASGE's AC and AP management guidelines.

METHODS

Medical files of patients who underwent PEG placement from January 2004 to December 2008 were reviewed. Clinical and procedure-related data were recorded. Patients were separated into 1 of 2 groups: patients under AP and/or AC therapy prior to PEG placement (n = 51) and a control group of patients (n = 40) not receiving any AP and/or AC treatment at least 6 months prior to the procedure.

RESULTS

A total of 91 patients (51 cases) were included. Groups were comparable in demographics and clinical characteristics. No differences in the frequency and type of complications were found between groups. ASGE's recommendations were not followed in any of these patients.

CONCLUSIONS

Overall PEG placement complication rate was 13.7%. AP therapy may be safely discontinued closer to the time of endoscopic procedure than the time currently recommended by the ASGE guidelines.

Feeding jejunostomy tubes placed during esophagectomy: are they necessary?

BACKGROUND

Jejunostomy tubes (JT) are routinely placed at the time of esophagectomy and can be associated with low--but not insignificant--morbidity. Increased emphasis on evidence-based medicine prompted this critical review of JT use during esophagectomy and factors that predict the absolute need for JT.

METHODS

All esophagectomies performed at one tertiary care institution from 1995 through 2009 were retrospectively reviewed. Statistical analyses were performed to determine preoperative variables that would assist in selecting patients who should receive a JT.

RESULTS

A total of 143 JTs were placed in 151 patients undergoing esophagectomy for carcinoma (83.4%), high-grade dysplasia (13.2%), and perforation (2.6%). Of these, 110 patients (76.9%) had returned to oral intake before discharge (median, 7 days), whereas 33 patients (23.1%) still required tube feedings. Of 8 patients who did not undergo intraoperative JT placement, 6 had resumed oral intake at discharge. Two patients were discharged on total parenteral nutrition. Logistic regression analysis of preoperative variables showed a body mass index of less than 18.5 kg/m2 conferred a likelihood of requiring a JT at discharge (odds ratio, 7.56; p<0.05). Age, sex, albumin level, type of esophagectomy, histology, stage, preoperative neoadjuvant therapy, and type of cancer were not significant predictors of JT need at discharge.

CONCLUSIONS

The only absolute indication for JT placement after esophagectomy was a body mass index of less than 18.5 kg/m2. Other patients may have selective JT placement based on the surgeon's judgment.

Novel endoscopic triangulation approach to percutaneous transgastric placement of jejunal extension feeding tube

In patients who have surgically-altered upper gastrointestinal anatomy, postoperative endoscopic enteral nutrition options can be limited by issues such as bowel stenosis and/or acute angulation. This report details the use of an endoscopic triangulation method combining per-oral and percutaneous transgastric approaches to overcome an efferent gastrojejunostomy limb stenosis, to successfully place a jejunal extension feeding tube through a newly placed PEG site. This description provides an alternative endoscopically feasible option for successful enteral nutrition access, thus obviating the need for additional operations to place surgical feeding tubes or to commit patients to long-term total parenteral nutrition.

Nasogastric or nasointestinal feeding in severe acute pancreatitis

AIM: To assess the rate of spontaneous tube migration and to compare the effects of naso-gastric and naso-intestinal (NI) (beyond the ligament of Treitz) feeding in severe acute pancreatitis (SAP).

METHODS: After bedside intragastric insertion, tube position was assessed, and enteral nutrition (EN) started at day 4, irrespective of tube localization. Patients were monitored daily and clinical and laboratory parameters evaluated to compare the outcome of patients with nasogastric (NG) or NI tube.

RESULTS: Spontaneous tube migration to a NI site occurred in 10/25 (40%) prospectively enrolled SAP patients, while in 15 (60%) nutrition was started with a NG tube. Groups were similar for demographics and pancreatitis aetiology but computed tomography (CT) severity index was higher in NG tube patients than in NI (mean 6.2 vs 4.7, P = 0.04). The CT index seemed a risk factor for failed obtainment of spontaneous distal migration. EN trough NG or NI tube were similar in terms of tolerability, safety, clinical goals, complications and hospital stay.

CONCLUSION: Spontaneous distal tube migration is successful in 40% of SAP patients, with higher CT severity index predicting intragastric retention; in such cases EN by NG tubes seems to provide a pragmatic alternative opportunity with similar outcomes.

Enteral nutrition access devices

The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, performing a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such situations, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the ASGE Governing Board. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to endoscopy in patients requiring enteral feeding access by using the keywords "endoscopy," "percutaneous," "gastrostomy," "jejunostomy," "nasogastric," "nasoenteric," "nasojejunal," "transnasal," "feeding tube," "enteric," and "button." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Endoscopic placement of enteral feeding tubes

Malnutrition is common in patients with acute and chronic illness. Nutritional management of these malnourished patients is an essential part of healthcare. Enteral feeding is one component of nutritional support. It is the preferred method of nutritional support in patients that are not receiving adequate oral nutrition and have a functioning gastrointestinal tract (GIT). This method of nutritional support has undergone progression over recent times. The method of placement of enteral feeding tubes has evolved due to development of new feeding tubes and endoscopic technology. Enteral feeding can be divided into methods that provide short-term and long-term access to the GIT. This review article focuses on the current range of methods of gaining access to the GIT to provide enteral feed.

Nasoenteral feeding tube placement by nurses using an electromagnetic guidance system (with video)

BACKGROUND

The early institution of feeding in patients who need postpyloric feeding tubes is often hampered by a limited availability of endoscopists experienced in safe tube positioning.

OBJECTIVE

To test the feasibility of having nurses place postpyloric feeding tubes by using a universal path finding system device.

DESIGN

Prospective study.

SETTING

Academic hospital.

PATIENTS

The success rate and learning curve of a senior nurse placing postpyloric feeding tubes in 50 patients was studied, followed by a study in 160 patients on the success rates and learning curves of 4 inexperienced nurses instructed by the senior nurse. Finally, the success rate of postpyloric feeding tube placement by the senior nurse in 50 critically ill patients was investigated.

INTERVENTION

Postpyloric feeding tube positioning by nurses using an electromagnetic universal path-finding system device enabling them to follow the path of the tip of the feeding tube on a monitor screen.

MAIN OUTCOME MEASUREMENTS

Success was defined by postpyloric positioning of the feeding tube. The ultimate aim was to reach at least the duodenojejunal flexure.

RESULTS

In the first part, the senior nurse was successful in 72% of cases. There was a clear learning curve. In the second part, the 4 newly instructed nurses had a success rate of 89.4% without an evident learning curve. In the third part, successful feeding tube positioning was achieved in 78% of critically ill patients. Of the 217 successfully positioned tubes, 74% reached at least the duodenojejunal flexure. In half of the unsuccessful cases, an explanation for the failure was found at endoscopy. No complications were seen.

LIMITATIONS

The generalization to less-specialized hospitals should be investigated.

CONCLUSION

Postpyloric positioning of feeding tubes by nurses at the bedside without endoscopy is feasible and safe. Nurses may take over some of the tasks of doctors in a time of high endoscopic needs.

Gastrostomy tube placement by radiological versus endoscopic methods in an acute care setting: a retrospective review of frequency, indications, complications and outcomes

OBJECTIVES

To describe the current practice of placing gastrostomy tubes (endoscopic and radiological), patient characteristics, indications for enteral support, complications and outcomes over a 13-month period, and explore factors that influenced complications and outcomes. Second, to provide Canadian data regarding feeding tube placement because no current literature reflecting these practices for Canadian hospitals is available.

METHODS

Retrospective chart reviews were conducted. Patients who had initial percutaneous endoscopic gastrostomy (PEG) or percutaneous radiological gastrostomy (PRG) tubes inserted for nutritional purposes were included in the study.

RESULTS

A total of 136 charts which included 30 PEG and 44 PRG procedures were reviewed. The PRG group was older than the PEG group (mean [+/-SD+/-5D; age 68+/-19 years versus 55+/-21 years, respectively; P=0.008). Patients in PEG group had longer lengths of hospital stay and more intensive care unit admissions than the PRG group (P=0.029). The main reason for tube insertion was dysphagia/aspiration (PEG [60%] and PRG [77%]). Minor complications were comparable between the two groups (P=0.678). There were three cases of major complications overall. More subjects in the PRG group died (18%) while in hospital than in the PEG group (3%) (P=0.055). No procedure-related deaths occurred in either group.

CONCLUSIONS

Both methods of tube insertion provided a safe route for nutrition delivery despite a significant cost differential with PEGs costing 44% more than PRGs. Characteristics such as age, presence of ascites and severity of disease influenced the method of insertion despite the lack of current guidelines. Overall, the present study provides new descriptive data in a Canadian context.

DPEJ placement in cases of PEG insertion failure

BACKGROUND AND STUDY AIMS

PEG placement is routinely used for enteral feeding; in some cases PEG is not feasible or indicated due to technical difficulties, such as gastric herniation, organ interposition, or presence of gastroparesis. In these cases, surgical gastrostomy or jejunostomy are possible alternatives; more recently, direct percutaneous jejunostomy (DPEJ) has been proposed to avoid surgical intervention. The aim of the study was to evaluate the necessity, technical feasibility and outcome of DPEJ in a group of patients consecutively proposed for PEG placement.

PATIENTS AND METHODS

In each patient proposed for PEG placement, an upper gastrointestinal endoscopy was performed, and then a pull traction removal gastrostomy tube (18-20 F) was inserted. When PEG was not feasible or contraindicated, a variable stiffness pediatric videocolonscope was used to reach the jejunum: then DPEJ was performed with the same technique and materials as PEG. In both groups enteral feeding was started 24h after the endoscopic procedure, using an enteral feeding pump and the same nutritional schedules.

RESULTS

In a 1-year period 90 patients were proposed for PEG placement; PEG could not be performed for technical reasons in 8 (gastric herniation in 1; organ interposition in 7) and gastroparesis in 1. In one patient both PEG and DPEJ were not feasible for organ interposition. The duration of the endoscopic procedure was slightly longer in DPEJ (mean 20 min versus 15 min). No complications related to the endoscopic procedure were observed in both DPEJ and PEG patients. No nutritional complication were observed in the DPEJ group.

CONCLUSION

In our experience, PEG was not feasible or contraindicated in about 10% of patients proposed for. In these patients, DPEJ was placed: the procedure resulted to be feasible and safe with the use of a pediatric videocolonscope to easily reach the jejunum. The insertion of DPEJ did not change the nutritional management of enteral feeding. However, long-term effects or complications remain to be evaluated in larger studies.

Complications of enteral access

Innovation in endoscope design and application of lessons and techniques from minimally invasive surgery is allowing endoscopists to explore new frontiers in enteral access and meet the demands of an increasingly savvy and aging 'baby boomer' population that has high health care expectations. Another small but very labor intensive group of patients that is contributing both to increased awareness and to the demand for specialized nutrition support services, is made up of patients with intestinal failure. With steadily accruing experience in the care of these patients on long term home parenteral and enteral nutrition, as well as the improved outcomes for intestinal transplantation, these services are poised for exponential growth in coming years. The endoscopist whose practice involves enteral access should be capable of providing the whole gamut of enteral access services allowing individualization of approach to ensure the best possible outcomes for a given patient and indication. Experience with management of the many common complications of enteral access is a pre-requisite for successful long-term outcomes. While it would be desirable that such enteral access be provided within a broader multi-disciplinary model of specialized nutrition support, in the current climate of a tightening health care economy that may be counsel for perfection.

Ethical and medicolegal issues related to percutaneous endoscopic gastrostomy placement

Enteral nutrition, in many respects more than other medical interventions, has been in the limelight concerning the ethics of withdrawing or withholding nutritional support. This article describes the ethical and legal issues surrounding enteral nutrition, identifies the elements of informed consent for enteral nutrition, provides an overview of the endoscopic gastrostomy procedure, and offers recommendations for addressing ethicolegal issues in enteral nutrition.

Use of small-bore feeding tubes: successes and failures

PURPOSE OF REVIEW

Early enteral nutrition is the preferred option for feeding patients who cannot meet their nutrient requirements orally. This article reviews complications associated with small-bore feeding tube insertion and potential methods to promote safe gastric or postpyloric placement. We review the available bedside methods to check the position of the feeding tube and identify inadvertent misplacements.

RECENT FINDINGS

Airway misplacement rates of small feeding tubes are considerable. Bedside methods (auscultation, pH, aspirate appearance, air bubbling, external length of the tube, etc.) to confirm the position of a newly inserted small-bore feeding tube have limited scientific basis. Radiographic confirmation therefore continues to be the most accurate method to ascertain tube position. Fluoroscopic and endoscopic methods are reliable but costly and are not available in many hospitals. Rigid protocols to place feeding tubes along with new emerging technology such as CO2 colorimetric paper and tubes coupled with signaling devices are promising candidates to substitute for the blind placement method.

SUMMARY

The risk of misplacement with blind bedside methods for small-bore feeding tube insertion requires a change in hospital protocols.

Interventional upper endoscopy: the pediatric perspective

Pediatric endoscopy has evolved from a purely observational modality into one with the potential for many therapeutic applications. Common therapeutic uses of endoscopy in children now include treatment of variceal bleeds and foreign body retrieval and newer procedures such as endoluminal gastroplication and endoscopic pyloromyotomy. Continuing research in pediatric endoscopy will allow pediatric gastroenterologists to perfect existing interventional endoscopic techniques and to learn to perform new ones.