Adverse events associated with percutaneous enteral access

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.

Interdisciplinary Approach to Expedited Outpatient Gastrostomy Tube Placement in Head and Neck Cancer Patients: A Single Center Retrospective Study

RATIONALE AND OBJECTIVE

Treatment for head and neck cancer (HNC) can lead to decreased oral intake which often requires gastrostomy tube (g-tube) placement to provide nutritional support. A multidisciplinary team (MDT) consisting of interventional radiology (IR), HNC oncology and surgery, nutrition, and speech language pathology departments implemented an expedited outpatient g-tube placement pathway to reduce hospital stays and associated costs, initiate feeds sooner, and improve communication between care teams. This single center study investigates differences in complications, time to procedure and costs savings with implementing this pathway.

METHODS

142 patients with HNC who underwent elective image guided g-tube placement by IR from 2015 to 2022 were identified retrospectively. 52 patients underwent the traditional pathway, and 90 patients underwent the expedited pathway. Patient demographics, procedure characteristics, periprocedural costs and 90-day complication rates were collected and compared statistically.

RESULTS

The 90-day complication rate was comparable between groups (traditional=32.7%; expedited=22.2%; p-value=0.17). The expedited pathway decreased the time from consult to procedure by 11.1 days (95% CI 7.6 - 14.6; p < 0.001) and decreased charge per procedure by $2940 (95% CI $989-$4891; p < 0.001).

CONCLUSION

A MDT for the treatment of patients with HNC successfully provided enteral nutrition support faster, with fewer associated costs, and in a more patient centered approach than previously done at this institution.

Curriculum for bariatric endoscopy and endoscopic treatment of the complications of bariatric surgery: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Obesity is a chronic, relapsing, degenerative, multifactorial disease that is associated with many co-morbidities. The global increasing burden of obesity has led to calls for an urgent need for additional treatment options. Given the rapid expansion of bariatric endoscopy and bariatric surgery across Europe, the European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This curriculum is set out in terms of the prerequisites prior to training, minimum number of procedures, the steps for training and quality of training, and how competence should be defined and evidenced before independent practice. 1: ESGE recommends that every endoscopist should have achieved competence in upper gastrointestinal endoscopy before commencing training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. 2: Trainees in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery should have basic knowledge of the definition, classification, and social impact of obesity, its pathophysiology, and its related co-morbidities. The recognition and management of gastrointestinal diseases that are more common in patients with obesity, along with participation in multidisciplinary teams where obese patients are evaluated, are mandatory. 3 : ESGE recommends that competency in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery can be learned by attending validated training courses on simulators initially, structured training courses, and then hands-on training in tertiary referral centers.

Feasibility, effectiveness, and safety of edoxaban administration through percutaneous endoscopic gastrostomy: 12-months follow up of the ORIGAMI study

Background and aims

Edoxaban proved to be safe and effective also in fragile patients, but its administration through percutaneous endoscopic gastrostomy (PEG) has not been previously investigated. The purpose of this study was to evaluate the feasibility and the preliminary safety and efficacy profiles of edoxaban administered via PEG in patients with an indication for long-term oral anticoagulation.

Methods

ORIGAMI was a prospective, single-arm, observational study (NCT04271293). Patients with PEG and an indication for long-term anticoagulation were prospectively enrolled. Crushed edoxaban at approved doses was administered via PEG. The primary endpoint was the composite of cardio-embolic events consisting of ischemic stroke, systemic embolism, or symptomatic deep venous thrombosis/pulmonary embolism (DVT/PE). Secondary endpoints were the number of bleeding events and edoxaban plasma concentrations at steady state. We here report the 12-month results.

Results

A total of 12 patients were enrolled. The main indication for PEG implantation was amyotrophic lateral sclerosis (10/12). The primary endpoint of cardio-embolic events did not occur in any patients at 12 months. All patients were in the therapeutic range of steady-state edoxaban plasma levels. Three minor bleedings were observed, while no major bleedings occurred during the observational period. A total of five patients died. All deaths were from non-cardiovascular causes and were consistent with the natural history of the pre-existing severe disease.

Conclusion

Our study suggests that edoxaban administration via PEG is feasible and appears safe and effective in fragile, comorbid patients, resulting in therapeutic plasma concentrations of edoxaban.

Clinical trial registration

[ClinicalTrials.gov], identifier [NCT04271293].

Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.

Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices

Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.

Bleeding Risk and Mortality Associated With Uninterrupted Antithrombotic Therapy During Percutaneous Endoscopic Gastrostomy Tube Placement

INTRODUCTION

Antithrombotic therapy is often interrupted before the placement of a percutaneous endoscopic gastrostomy (PEG) tube because of potentially increased risk of hemorrhagic events. The aim of our study was to evaluate the risk of bleeding events and overall complication rates after PEG in patients on uninterrupted antiplatelet and anticoagulation therapy in a high-volume center.

METHODS

Data regarding demographics, diagnoses, comorbidities, and clinical outcomes pertinent to PEG were collected from 2010 to 2016. Furthermore, data regarding antithrombotic therapy along with the rate of minor or major complications including bleeding associated with this procedure were analyzed. Significant bleeding was defined as postprocedure bleeding from PEG site requiring a blood transfusion and/or surgical/endoscopic intervention.

RESULTS

We included 1,613 consecutive PEG procedures in this study, of which 1,540 patients (95.5%) received some form of uninterrupted antithrombotic therapy. Of those patients, 535 (34.7%) were on aspirin, 256 (16.6%) on clopidogrel, and 119 (7.7%) on both aspirin and clopidogrel. Subcutaneous heparin was uninterrupted in 980 (63.6%), intravenous heparin in 34 (2.1%), warfarin in 168 (10.9%), and direct-acting oral anticoagulation in 82 (5.3%) patients who overlapped on multiple drugs. We observed 6 significant bleeding events in the entire cohort (0.39%), and all were in subcutaneous heparin groups either alone or in combination with aspirin. No clinically significant bleeding was noted in patients on uninterrupted aspirin, warfarin, clopidogrel, or direct-acting oral anticoagulation groups. Only 5 patients (0.31%) had PEG-related mortality.

DISCUSSION

The risk of significant bleeding associated with the PEG placement was minimal in patients on uninterrupted periprocedural antithrombotic therapy.

Association for Bariatric Endoscopy systematic review and meta-analysis assessing the American Society for Gastrointestinal Endoscopy Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for aspiration therapy

A subcommittee of the Association for Bariatric Endoscopy, a division of the American Society for Gastrointestinal Endoscopy (ASGE) comprising experts in the subject area, performed this systematic review and meta-analysis. The systematic review and meta-analysis was reviewed by the ASGE Technology Committee and was ultimately submitted to the ASGE Governing Board for approval. The systematic review and meta-analysis underwent peer review by outside experts in statistics and meta-analysis before receiving final ASGE Governing Board approval. The Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) initiative is an ASGE program whose objectives are to identify important clinical questions related to endoscopy and to establish a priori diagnostic and/or therapeutic thresholds for endoscopic technologies designed to resolve these clinical questions. Once endoscopic technologies meet an established PIVI threshold, those technologies are appropriate to incorporate into clinical practice, presuming the appropriate training in that endoscopic technology has been achieved. ASGE encourages and supports the appropriate use of technologies that meet its established PIVI thresholds.

Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

Endoscopic rescue of early percutaneous endoscopy gastrostomy tube dislodgement

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tube placement is one of the most common methods for establishing durable enteral access. Early PEG dislodgement occurs in < 5% of cases but typically prompts urgent surgical intervention to reestablish the gastrocutaneous tract and prevent intra-abdominal sepsis. To date, there is a single case report in the literature where successful endoscopic "rescue" of an early dislodged PEG tube negated the need for operative intervention. Here, we report our experience with a series of endoscopic PEG rescues for early dislodged PEG tubes.

METHODS

A retrospective analysis of cases was reviewed from two institutions. Patients with early PEG dislodgements underwent PEG rescue using a gastroscope and standard Ponsky "Pull" PEG techniques through the original tract.

RESULTS

Eleven patients were identified from the database and underwent PEG rescue after early PEG dislodgement. Mean operative time was 68 min, and there were no complications related to PEG rescue. PEG rescue permitted safe re-establishment of the gastrostomy tract while avoiding laparoscopic or open surgical intervention in hemodynamically stable patients. All patients tolerated the procedure well and were able to resume use of the PEG tubes shortly after intervention.

CONCLUSION

Endoscopic rescue represents a feasible noninvasive option for PEG tube replacement following early inadvertent PEG tube dislodgement in appropriate clinical settings.

Unsedated Outpatient Percutaneous Endoscopic Gastrostomy in Stroke Patients: Is It Feasible and Safe?

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.

Head and Neck Cancer Tumor Seeding at the Percutaneous Endoscopic Gastrostomy Site

The National Institutes of Health National Cancer Institute estimates that over 13,000 new cases of head and neck cancer (HNC) will be diagnosed in 2017. Patients with HNC often require enteral nutrition (EN) via gastrostomy tube to provide nutrition support and hydration because of tumor obstruction of the oropharynx and/or cumulative effects of chemoradiation therapy. The percutaneous endoscopic gastrostomy (PEG) tube has become the preferred technique for EN access because placement is considered a minimally invasive procedure. There are 3 methods of PEG placement: Gauderer-Ponsky "pull," Sachs-Vine "push," and Russell "push" method. The Gauderer-Ponsky "pull" method has become the preferred method of PEG placement. It has been previously reported that the rate of stomal metastasis can be 0.5%-1% of those undergone the Gauderer-Ponsky "pull" method that is consistent with HNC morphology. Other researchers believe the rate may be as high as 0.5%-3%. This article reviews the 3 methods of PEG placement, as well as all potential complications, including metastatic seeding at the PEG site. In addition, 1 additional case of tumor seeding at the PEG site will be reviewed. Consideration for avoidance of the Gauderer-Ponsky pull method of PEG placement or other methods of feeding tube placement where the gastrostomy tube has to pass through the oral cavity before exiting the abdominal wall in patients with squamous cell carcinoma of the head and neck should be considered.

Role of nutritional status and intervention in oesophageal cancer treated with definitive chemoradiotherapy: outcomes from SCOPE1

BACKGROUND

Malnutrition is common in oesophageal cancer. We aimed to identify nutritional prognostic factors and survival outcomes associated with nutritional intervention in the SCOPE1 (Study of Chemoradiotherapy in OesoPhageal Cancer with or without Erbitux) trial.

METHODS

Two hundred and fifty eight patients were randomly allocated to definitive chemoradiotherapy (dCRT) +/- cetuximab. Nutritional Risk Index (NRI) scores were calculated; NRI<100 identified patients at risk of malnutrition. Nutritional intervention included dietary advice, oral supplementation or major intervention (enteral feeding/tube placement). Univariable and multivariable analyses using Cox proportional hazard modelling were conducted.

RESULTS

At baseline NRI<100 strongly predicted for reduced overall survival (hazard ratio (HR) 12.45, 95% CI 5.24-29.57; P<0.001). Nutritional intervention improved survival if provided at baseline (dietary advice (HR 0.12, P=0.004), oral supplementation (HR 0.13, P<0.001) or major intervention (HR 0.13, P=0.003)), but not if provided later in the treatment course. Cetuximab patients receiving major nutritional intervention had worse outcomes compared with controls (13 vs 28 months, P=0.003).

CONCLUSIONS

Pre-treatment assessment and correction of malnutrition may improve survival outcomes in oesophageal cancer patients treated with dCRT. Nutritional Risk Index is a simple and objective screening tool to identify patients at risk of malnutrition.

Intraabdominal Infections in Older Adults

Intraabdominal infections represent a diagnostic and therapeutic challenge in the elderly population. Atypical presentations, diagnostic delays, additional comorbidities, and decreased physiologic reserve contribute to high morbidity and mortality, particularly among frail patients undergoing emergency abdominal surgery. While many infections are the result of age-related inflammatory, mechanical, or obstructive processes, infectious complications of feeding tubes are also common. The pillars of treatment are source control of the infection and judicious use of antibiotics. A patient-centered approach considering the invasiveness, risk, and efficacy of a procedure for achieving the desired outcomes is recommended. Structured communication and time-limited trials help ensure goal-concordant treatment.