A PEG tube through the liver

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a well-established, minimally invasive, and easy to perform procedure for nutrition delivery, applied to individuals unable to swallow for various reasons. PEG has a high technical success rate of insertion between 95% and 100% in experienced hands, but varying complication rates ranging from 0.4% to 22.5% of cases.

AIM

To discuss the existing evidence of major procedural complications in PEG, mainly focusing on those that could probably have been avoided, had the endoscopist been more experienced, or less self-confident in relation to the basic safety rules for PEG performance.

METHODS

After a thorough research of the international literature of a period of more than 30 years of published "case reports" concerning such complications, we critically analyzed only those complications which were considered - after assessment by two experts in PEG performance working separately - to be directly related to a form of malpractice by the endoscopist.

RESULTS

Malpractice by the endoscopist were considered cases of: Gastrostomy tubes passed through the colon or though the left lateral liver lobe, bleeding after puncture injury of large vessels of the stomach or the peritoneum, peritonitis after viscera damage, and injuries of the esophagus, spleen, and pancreas.

CONCLUSION

For a safe PEG insertion, the overfilling of the stomach and small bowel with air should be avoided, the clinician should check thoroughly for the proper trans-illumination of the light source of the endoscope through the abdominal wall and ensure endoscopically visible imprint of finger palpation on the skin at the center of the site of maximum illumination, and finally, the physician should be more alert with obese patients and those with previous abdominal surgery.

Outcomes of PEG placement by acute care surgeons compared to those placed by gastroenterology

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes are placed by gastroenterologists (GI) and surgeons throughout the country. At Rhode Island Hospital, before July of 2017, all PEGs were placed by GI. In July of 2017, in response to a growing need for PEGs, acute care surgeons (ACS) also began performing PEGs at the bedside in ICUs. The purpose of this study was to review and compare outcomes of PEG tubes placed by ACS and GI.

METHODS

Retrospective chart review of patients who received a PEG placed by ACS or GI at the bedside in any ICU from December 2016 to September 2019. Charts were reviewed for the following outcomes: Success rates of placing PEG, duration of procedure, major complications, and death. Secondary outcomes included discharge disposition, and rates of comfort measures only after PEG.

RESULTS

In 2017, 75% of PEGs were placed by GI and 25% surgery. In 2018, 47% were placed by GI and 53% by surgery. In 2019, 33% were placed by GI and 67% by surgery. There was no significant difference in success rates between surgery (146/156 93.6%) and GI (173/185 93.5%) (p 0.97). On average, GI performed the procedure faster than surgery [Median 10 (7-16) min vs 16 (13-21) mins, respectively, p < 0.001]. There were no significant differences between groups in any of the PEG outcomes or complications investigated.

CONCLUSION

Bedside PEG tube placement appears to be a safe procedure in the ICU population. GI and Surgery had nearly identical success rates in placing PEGs. GI performed the procedure faster than surgery. There were no significant differences in the reviewed patient outcomes or complications between PEGs placed by ACS or GI. Of note, when a complication occurred, ACS PEG patients typically were managed in the OR while GI tended to re-PEG patients highlighting a potential difference in management that should be further investigated.

Transhepatic Insertion of Percutaneous Endoscopic Gastrostomy Tube

Inadvertent injury to interposing organs during percutaneous endoscopic gastrostomy (PEG) tube placement is a feared complication of this common and generally safe procedure. Transhepatic PEG insertion is likely an underrepresented complication which may be identified incidentally on imaging or present with life-threatening conditions such as sepsis or massive bleeding. Use of ultrasound in patients with known hepatomegaly may possibly help avoid this complication. We hereby report a case of transhepatic PEG insertion, one of 16 only other cases published in the literature, and review the characteristics of the previous reported cases.