Common issues in PEG tubes--what every fellow should know

Laparoscopic Insertion of a Percutaneous Gastrostomy Prevented Malnutrition in a Patient with Previous Roux-en-Y Gastric Bypass

Bariatric surgery is a highly effective treatment option for morbid obesity. Short- and long-term effects of bariatric surgery are not limited to weight loss but include resolution of type 2 diabetes, arterial hypertension, improvement of cardiovascular health, and overall mortality. The long life expectancy of patients undergoing bariatric procedures means many of these patients will succumb to other diseases. Altered GI anatomy after bariatric procedures could prove an obstacle in treatment. We present our management of one such occurrence. The patient, who had 5 years previously undergone a Roux-en-Y gastric bypass, presented after a massive subarachnoid hemorrhage which resulted in spastic tetraplegia. He was unable to consume food and was at risk of malnutrition. A decision was made to laparoscopically create a percutaneous gastrostomy (PEG) into the excluded stomach, allowing for the use of standard feeding formula and avoiding the need for parenteral nutrition and prolonged hospitalization due to metabolic complications. The growing number of patients following bariatric procedures directs the need for novelty treatment options suited to the altered anatomy and physiology of the patient post-bariatric surgery. Prompt evaluation of long-term complications after cardiovascular events in patients operated with bariatric surgical technics reduced nutritional complications, rated hospital stay, and improved quality of life. In those patients who, due to the localization of the brain defect, are expected to be unable to feed independently due to the consequences of the latter and have either long-term or lifelong feeding through feeding tubes, it is necessary to establish an enteral feeding pathway through which the patient can receive a standard nutritional formula. This prevents the patient from developing metabolic complications and related complications. At the same time, we enable inpatient accommodation without the risk of dietary complications associated with bariatric surgery.

Can You Save the Site?: A Novel Approach to Percutaneous Endoscopic Gastrostomy Tube Replacement

Inadvertent removal or dislodgement is the most commonly encountered complication in patients with percutaneous endoscopic gastrostomy (PEG) tube. Once the gastrocutaneous fistula is formed, bedside tube replacement can be performed at the same site, within 24 hours of dislodgement. Usually, after this timeframe, the tract closes; hence, it is recommended to perform a replacement at a different site. We report a case of a 52-year-old female who presented after 24 hours of inadvertent PEG tube removal. A replacement was performed successfully via endoscopy at the same site of the erstwhile PEG tube, although it appeared to be closed.

Endoscopic Hemostasis Using an Over-the-Scope Clip For Massive Bleeding After Percutaneous Endoscopic Gastrostomy (PEG) Removal: A Case Report

Percutaneous endoscopic gastrostomy (PEG) is a common method for providing long-term enteral nutrition to patients. PEG tube placement and removal are relatively safe; generally, a PEG tube can be removed using gentle traction, and excessive bleeding is rare. The over-the-scope clip system is a new device that can be used for gastrointestinal hemostasis and for closing gastrointestinal fistulae. In the present case, a 68-year-old man had to remove the PEG tube because of persistent leakage around the PEG tube. Although it was gently removed using traction, incessant bleeding continued, with a Rockall score of 5 points, even after hemocoagulation was attempted. An over-the-scope clip device was used to achieve hemostasis and fistula closure.

Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG)—Single-Center Experience and Outcome

Background Gastrointestinal route is considered for feeding in subjects who are unable to swallow, either as a temporary or permanent option. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode for long-term enteral nutrition. The aim was to study the outcome of protocol-based PEG placement in a tertiary medical center.

Materials and Methods All the patients who underwent PEG placement between January 2017 and December 2019 were included in the retrospective study. Study variables were entered into a uniform structured proforma. The procedure was done by two people using Ponsky-Gauderer pull-technique. Fluoroscopy guidance was considered for placement in special situations. Post-procedure, all the patients were regularly followed as per protocol to evaluate for adverse events.

Results One hundred and eighteen patients with placement of PEG were included in the study. The mean age of the patients was 49.6 ± 7 years with 67.8% males. The most common indication of PEG was inability to swallow associated with head injury (43, 36.4%), followed by carcinoma esophagus (35, 29.8%) and stroke (24, 20.3%). Fluoroscopy was useful in 38 (32%) for PEG site identification. Tube dislodgement (16, 13.5%) and aspiration pneumonia (20, 16.9%) were the common adverse events. Age more than 60 years and dysphagia in neurologic disorders accounted for more than 60% of adverse events. Forty-nine (42%) of the PEG patients expired due to either primary illness or due to sepsis after a median time of 139 days (range: 32–288 days). There was no difference in the survival in patients with or without PEG-related complications (p = 0. 74).

Conclusions Fluoroscopy assistance helps in accurate PEG placement in one third. Age > 60 years and dysphagia in neurologic disorders were independent risk factors associated with PEG tube complications.

Laparoscopic tubularized continent gastrostomy: an alternative to tube gastrostomies

Gastrostomy tubes, placed either endoscopically or laparoscopically, are the most widely used method to deliver enteral feeding to patients unable to be fed by mouth. Tube gastrostomy is quick and low cost and allows the health care professionals for a convenient route to deliver enteral nutrition to their patients. Nevertheless, bearing an indwelling gastric tube could not be as convenient for patients. Complications, such as bowel perforation, tube dislodgement, peristomal infection or bleeding occur in up to 17% of patients, and some other drawbacks of gastric tubes, such as peristomal pain, are often understated. We present our technique for laparoscopic creation of a tubularized continent gastrostomy, originally conceived for the emergency treatment of patients with a dislodged percutaneous endoscopic gastrostomy, to provide them with a reliable new route for gastric feeding. After healing, this gastrostomy does not need an indwelling tube to stay patent, requires only a light gauze dressing and can be used by intermittent catheterization at conventional feeding times during the day. Laparoscopic tubularized continent gastrostomy can be offered to patients as a reliable alternative to tube gastrostomy.

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.

Laparoscopic-assisted percutaneous endoscopic transgastrostomy jejunostomy

Background and Objectives:

New therapeutic protocols for patients with end-stage Parkinson disease include a carbidopa/levodopa combination using continuous, modulated enteral administration via a portable pump. The typical approach involves a percutaneous endoscopic transgastrostomy jejunostomy (PEG-J), which requires a combination of procedures designed to ensure that no organ is interposed between the abdominal wall and the gastric surface. Lack of transillumination in maximal endoscopic light settings is a major contraindication for PEG-J, and we decided to use a different approach to establish enteric access for long-term medication delivery via pump, using a minimally invasive procedure.

Methods:

In all patients, we performed a laparoscopic-assisted percutaneous transgastrostomy jejunostomy (LAPEG-J) after an unsuccessful endoscopic transillumination.

Results:

Five patients with end-stage Parkinson disease were referred to our department after successful therapeutic testing with administration of levodopa/carbidopa via naso-jejunal tube. All patients failed the endoscopic transillumination during the endoscopic procedure and were considered for LAPEG-J. In all patients, the LAPEG-J procedure was uneventful. The most common reason identified for failed transillumination was a high position of the stomach, followed by interposition of the liver or colon between the stomach and anterior abdominal wall. There were no complications regarding the LAPEG-J procedure, and all patients were discharged during the second postprocedural day.

Conclusions:

LAPEG-J provides a simple and safe option for placing a jejunostomy after an unsuccessful PEG-J attempt.

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.

Laparoscopic-assisted percutaneous endoscopic gastrostomy tube placement

In those cases where a PEG tube cannot be placed safely, a laparoscopic-assisted technique may be a viable option to complete the procedure.

Background:

Percutaneous endoscopic gastrostomy (PEG) is the most common way of placing a feeding tube. Sometimes PEG cannot be used to safely place a feeding tube, most commonly secondary to an inability to transilluminate the abdominal wall. Whereas open gastrostomy was previously necessary in such cases, laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) is a viable option and is reviewed here.

Methods:

All patients referred for surgical feeding tube placement after unsuccessful PEG were considered for LAPEG. A diagnostic laparoscopy was performed to identify the reason for the failed PEG attempt. Additional ports were placed as needed for the retraction of organs and lysis of adhesions. The stomach was visualized, and the PEG was placed.

Results:

Eight patients who underwent an unsuccessful PEG were taken to the operating room for LAPEG. All patients had successful LAPEG placement. No postoperative complications occurred. The most common reason identified for failed PEG attempt was adhesions followed by overlying organs. Average OR time was 32 minutes.

Conclusion:

When conventional PEG placement is not possible, LAPEG placement should be considered as a time efficient, minimally invasive alternative to open gastrostomy.

Peritonitis secondary to the migration of a trans-hepatically-placed percutaneous endoscopic gastrostomy tube: a case report

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