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Alchoikani N, Donnelly C, Lawther S. The "cut and push" method of removing percutaneous endoscopic gastrostomy tube is not safe in paediatric patients. Pediatr Surg Int 2023; 40:4. [PMID: 37993741 DOI: 10.1007/s00383-023-05575-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE A "cut and push" (CP) approach has been described in the literature for removal of percutaneous endoscopic gastrostomy (PEG) tubes. The aim of this study is to investigate the safety profile of this method in children. METHOD Our study included all children who underwent CP procedure for either removal or replacement of Freka PEG tube at our centre between January 2016 and August 2021. Parents contacted to establish if the internal component had been seen in the stools post-procedure. If not seen, a plain film of chest, abdomen and pelvis was arranged followed by computerised tomography (CT) scan. The presence of the internal component as a retained foreign body on imaging was evaluated along with any complication. RESULTS Of the 27 patients included, six (22.2%) patients had the internal component seen in the stool. Five (18.5%) patients in total had a retained internal component with three (11.1%) patients had major complications requiring complex surgical interventions, and two (7.4%) patients required endoscopic retrieval. CONCLUSION Our study reports more severe complications that required complex surgical interventions compared to the previous studies. We believe that this method of removal is not safe in children and should be abandoned. Also, patients with Down syndrome might be at higher risk of retention and complications.
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Affiliation(s)
- Nasib Alchoikani
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.
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Claxton H, Dick K, Taylor R, Allam M, Stedman F, Keys C, Hall NJ. ‘Cut and push’ as an alternative to endoscopic retrieval of PEG type gastrostomy tubes. Pediatr Surg Int 2023; 39:94. [PMID: 36715765 PMCID: PMC9885393 DOI: 10.1007/s00383-023-05382-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE Percutaneous Endoscopically placed Gastrostomy (PEG) tubes are frequently used in children. The traditional endoscopic method to remove/change the PEG device requires general anaesthesia in children. A minimally invasive alternative is the 'Cut and Push' method (C&P): avoiding the risks/wait times of general anaesthesia and reducing resource burden. Data regarding the safety/effectiveness of C&P in children are lacking with concerns raised about the possibility of gastrointestinal obstruction. METHODS We retrospectively reviewed all cases of PEG removal / change to button in children (< 18 years) between December 2020 and January 2022. Cases were identified from a prospectively maintained database and all cases of C&P included. Parents/carers were asked if the child had suffered any complications following C&P and if flange was visualised in stools. RESULTS During the time period, 27 PEGs were either removed or changed to button via C&P. The average waiting time for C&P was 14.29 days, significantly shorter than the minimum 6-month waiting time for elective endoscopy. Our evaluation revealed no complications of C&P at median 70 days (range 25-301). In three cases the flange was visualised in the stool, at 2 days, 3 days and 5 weeks following C&P respectively. DISCUSSION These data support the available literature suggesting C&P is an effective means to facilitate minimally invasive and prompt PEG removal/change to button in children. We recommend minimum weight and age parameters for this procedure and further evaluation of the safety and resource implications of this technique.
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Affiliation(s)
- Harry Claxton
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, 18 Woodham Park Road, Woodham, Addlestone, Surrey, Southampton, KT153ST UK
| | - Karen Dick
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, 18 Woodham Park Road, Woodham, Addlestone, Surrey, Southampton, KT153ST UK
| | - Rhoda Taylor
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, 18 Woodham Park Road, Woodham, Addlestone, Surrey, Southampton, KT153ST UK
| | - Maddie Allam
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, 18 Woodham Park Road, Woodham, Addlestone, Surrey, Southampton, KT153ST UK
| | - Francesca Stedman
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, 18 Woodham Park Road, Woodham, Addlestone, Surrey, Southampton, KT153ST UK
| | - Charlie Keys
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, 18 Woodham Park Road, Woodham, Addlestone, Surrey, Southampton, KT153ST UK
| | - Nigel J. Hall
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, 18 Woodham Park Road, Woodham, Addlestone, Surrey, Southampton, KT153ST UK ,University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
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Attia AC, Childers WK. Percutaneous endoscopic gastrostomy tube replacement after head and neck surgery: A case report. Int J Surg Case Rep 2022; 96:107323. [PMID: 35779317 PMCID: PMC9283987 DOI: 10.1016/j.ijscr.2022.107323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Percutaneous endoscopic gastrostomy (PEG) has been available since the 1980s. Routine replacement is conducted at bedside with relatively few complications. Two replacement methods have come into practice: the percutaneous method and the endoscopic method. The laparoscopic method has recently become favorable in the pediatric population. PRESENTATION OF CASE Herein, we describe a situation in which a gastrostomy tube was replaced at bedside on a patient with previous head and neck surgery for lingual cancer. The percutaneous traction method was used, and gastrostomy tube replacement into the gastric lumen could not be confirmed on subsequent imaging. The patient was ultimately taken to surgery for an open procedure where it was discovered that initial PEG placement had traversed the small bowel mesentery en route to the gastric lumen. DISCUSSION The PEG tube is not a permanent device and routine exchange every 6-12 months is recommended. The percutaneous method and endoscopic method for gastrostomy tube replacement have both been used routinely, each with their set of complications. A third technique, laparoscopic placement, is the preferred modality in the pediatric population. Advantages are twofold: direct visualization of the stomach, thus eliminating inadvertent hollow viscus injury, and applicability in infants too small to undergo endoscopy necessary for PEG tube placement. CONCLUSION Consideration for laparoscopic placement or replacement in the head and neck cancer patient population, in which interval endoscopy is impossible, is thus advocated.
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Affiliation(s)
- Aria C. Attia
- UPMC Harrisburg, 205 S Front St, Harrisburg, PA 17104, United States of America,Corresponding author.
| | - William Kurtis Childers
- UPMC Harrisburg, Department of General Surgery, 205 S Front St, Harrisburg, PA 17104, United States of America
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Melling G, Farley J. Complication rates associated with traction removal of percutaneous endoscopic gastrostomy tubes. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S22-S26. [PMID: 35404661 DOI: 10.12968/bjon.2022.31.7.s22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) tubes are removed and/or replaced for reasons such as tube malfunction, degradation, patient's device preference, and when stopping enteral feeding. AIMS To identify the types and rate of complications associated with traction removal of a PEG tube and if this is associated with the size of the PEG or length of time it had been in situ prior to removal. METHODS This retrospective study looked at the tube removal/replacement reports written by the Enteral Feeding Nursing Service over an 8-year period at a large teaching hospital trust in the north of England. FINDINGS The PEG tube removal reports of 127 patients were reviewed. Five types of complication were identified, categorised as retained bumper (5.5%); intraperitoneal placement of new device (3.17%); misplacement of replacement device into colon (a consequence of the insertion procedure not the removal of the PEG) (0.78%): gastrocutaneous fistula (0.78%); and inability to remove the tube (1.57%). The complication of retained bumpers was associated with an average length of time in situ prior to removal of the PEG tube of 29 months. In the cases of intraperitoneal placement, the PEG tube had been in situ for an average of 6 months. Nurses were unable to remove the PEG tube on two occasions; each had been in situ for approximately 4 years prior to attempted removal. CONCLUSION the complication rates are low following removal of a PEG tube using a traction pull. There was no clear correlation between length of time in situ or tube size and complication rate.
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Affiliation(s)
- Georgina Melling
- Clinical Nurse Specialist Enteral Feeding, Leeds Teaching Hospitals NHS Trust
| | - Joshua Farley
- Clinical Nurse Specialist Enteral Feeding, Leeds Teaching Hospitals NHS Trust
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To Pull or to Scope: A Prospective Safety and Cost-effectiveness of Percutaneous Endoscopic Gastrostomy Tube Replacement Methods. J Clin Gastroenterol 2019; 53:e37-e40. [PMID: 29369238 DOI: 10.1097/mcg.0000000000000993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) tubes are routinely used as an effective method for providing enteral nutrition. The need for their exchange is common. GOALS We aimed to examine the comparative safety and cost-effectiveness of PEG percutaneous counter-traction "pulling" approach or by endoscopically guided retrieval. STUDY A prospective 215 consecutive patients undergoing PEG tube insertion were included. Fifty patients in total were excluded. The patients were examined for demographics, indications for PEG replacement, as well as procedure-related complications and procedural costs. RESULTS Group A included 70 patients (42%) with PEG tubes replaced endoscopically, whereas group B included 95 patients (58%) with PEG tubes replaced percutaneously. Baselines characteristics were similar between the 2 groups (P=NS). Group A and group B had similar immediate complication rates including 4 patients in group B (4.2%), and 2 patients in group A (2.8%) (P=0.24). Complications included a conservatively managed esophageal perforation, and self-limited mild bleeding groups A and group B, respectively. The mean procedure cost was significantly higher in the endoscopic PEG replacement group compared with the percutaneous PEG replacement group ($650 vs. $350, respectively). CONCLUSION Percutaneous PEG replacement appears as safe as endoscopic PEG replacement, however, percutaneous tube exchange is less costly.
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Thomas H, Yole J, Livingston MH, Bailey K, Cameron BH, VanHouwelingen L. Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to "cut" the tube and allow the bumper to pass enterally? J Pediatr Surg 2018. [PMID: 29526351 DOI: 10.1016/j.jpedsurg.2018.02.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques. METHODS We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications. RESULTS We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004). CONCLUSION This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper. LEVELS OF EVIDENCE Level III-Treatment study, Retrospective comparative study.
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Affiliation(s)
- Heather Thomas
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Julia Yole
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michael H Livingston
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Karen Bailey
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Brian H Cameron
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lisa VanHouwelingen
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada.
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Abstract
Placement of gastrostomy tubes in infants and children has become increasingly commonplace. A historical emphasis on use of open gastrostomy has been replaced by less invasive methods of placement, including percutaneous endoscopic gastrostomy and laparoscopically assisted gastrostomy procedures. Various complications, ranging from minor to the more severe, have been reported with all methods of placement. Many pediatric patients who undergo gastrostomy tube placement will require long-term enteral therapy. Given the prolonged time pediatric patients may remain enterally dependent, further quality improvement and education initiatives are needed to improve long-term care and outcomes of these patients.
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Affiliation(s)
- Maireade E McSweeney
- Division of Gastroenterology and Nutrition, Department of Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - C Jason Smithers
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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Lee CG, Kang HW, Lim YJ, Lee JK, Koh MS, Lee JH, Yang CH, Kim JH. Comparison of complications between endoscopic and percutaneous replacement of percutaneous endoscopic gastrostomy tubes. J Korean Med Sci 2013; 28:1781-7. [PMID: 24339709 PMCID: PMC3857375 DOI: 10.3346/jkms.2013.28.12.1781] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 09/30/2013] [Indexed: 12/28/2022] Open
Abstract
When replacing percutaneous endoscopic gastrostomy (PEG) tubes, an internal bolster may be retrieved either percutaneously or endoscopically. The aim of this study was to compare the complications of percutaneous and endoscopic method during PEG tube replacement. The medical records of 330 patients who received PEG tube replacement were retrospectively analyzed. According to the removal method of internal bolster, we categorized as endoscopic group and percutaneous group. Demographic data, procedure-related complications and risk factors were investigated. There were 176 cases (53.3%) in endoscopic group and 154 cases (46.7%) in percutaneous group. The overall immediate complication rate during PEG tube replacement was 4.8%. Bleeding from the stoma (1.3%) occurred in percutaneous group, whereas esophageal mucosal laceration (7.4%) and microperforation (0.6%) occurred in endoscopic group. The immediate complication rate was significantly lower in the percutaneous method (OR, 6.57; 95% CI, 1.47-29.38, P=0.014). In multivariate analysis, old age was a significant risk factor of esophageal laceration and microperforation during PEG tube replacement (OR, 3.83; 95% CI, 1.04-14.07, P=0.043). The percutaneous method may be more safe and feasible for replacing PEG tubes than the endoscopic method in old patients.
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Affiliation(s)
- Chang Geun Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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Renji E, Nathan AK, Dalzell MA. Hidden treasure in an endoscopically retrieved oesophageal trichobezoar. BMJ Case Rep 2013; 2013:bcr-2012-007858. [PMID: 23334492 DOI: 10.1136/bcr-2012-007858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 12-year-old girl with Smith-Lemli-Opitz syndrome and gastrostomy dependency presented with multiple episodes of coffee ground vomits. An upper gastrointestinal endoscopy revealed a trichobezoar in the lower oesophagus, with a 'hidden treasure'-a retained end of a G tube at the core. Endoscopic retrieval led to resolution of symptoms. Literature is scant with only one previous report of an oesophageal trichobezoar. Techniques of removal of percutaneous endoscopic gastrostomy in children are reviewed. The pathogenesis, preventative measures and management for oesophageal trichobezoars are discussed.
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Affiliation(s)
- Elizabeth Renji
- Department of Paediatric Gastroenterology, Alderhey Childrens Hospital, Liverpool, UK.
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Srinivasan R, Irvine T, Dalzell AM. Traction removal of percutaneous endoscopic gastrostomy devices in children. Dig Dis Sci 2010; 55:2874-7. [PMID: 20033842 DOI: 10.1007/s10620-009-1090-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 12/03/2009] [Indexed: 12/24/2022]
Abstract
BACKGROUND There are few published data on non-endoscopic removal of percutaneous endoscopic gastrostomy devices in children. AIMS To describe prospective data acquired for traction removal of percutaneous endoscopic gastrostomy devices at a single pediatric center over a 5-year period. METHODS Data were obtained from endoscopy records, computerized hospital patient information systems and case note analysis. The device that could be removed by traction was the Corflo (Merck) 12-Fr percutaneous endoscopic gastrostomy tube with a collapsible internal retention dome. All procedures were performed under general anesthesia. RESULTS Between 2002-2006, 220 children underwent percutaneous endoscopic gastrostomy removals (166 by traction, 51 endoscopically and 3 Foley catheter to button conversions). The median duration between percutaneous endoscopic gastrostomy insertion and low profile button device substitution was 0.83 years (0.12-3.86). Complications from traction removal included internal retention dome separation in two cases (allowed to pass per rectum, uneventfully), failure to a insert a low profile button device needing percutaneous endoscopic gastrostomy reinsertion, enterocutaneous fistula requiring surgical closure in one patient and laparoscopy for suspected low profile button device misplacement in one instance. The material cost of endoscope disinfection (£10) and disposable usage (£80) avoided by traction removal was calculated at £90 per procedure. CONCLUSION No mortality occurred as a result of the traction removal of percutaneous endoscopic gastrostomy tubes. Laparoscopy for suspected low profile button device misplacement was needed in one case (0.60%). Traction removal of percutaneous endoscopic gastrostomy tubes was generally safe and a cost-saving procedure in our experience.
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Affiliation(s)
- Ramesh Srinivasan
- Department of Pediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
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