National trends in gastrointestinal access procedures: an analysis of Medicare services provided by radiologists and other specialists

Who Places Feeding Tubes and in What Scenario?

PURPOSE OF REVIEW

Enteral feeding is commonly used to provide patients with nutrition. Access via feeding tubes can be attained by multiple medical specialties through a variety of methods.

RECENT FINDINGS

There are limited data available on direct comparisons amongst gastroenterologist, interventional radiologists and surgeons, although there appears to be similar rates of complications. Fluroscopically and surgically placed feeding tubes may have a higher technical success rate than endoscopically placed tubes. The preferred specialty for feeding tube placement varies per institution, often due to logistical matters over technique or concern for complications. Ideally, a multidisciplinary team should exist to determine which approach is best in a patient-specific manner.

A Rare Case of Anterograde Gastroduodenal Intussusception Caused by Migrated Percutaneous Endoscopic Gastrostomy Feeding Tube

Gastroduodenal intussusception is a critical condition in which stomach protrudes into the duodenum. It is a very rare condition in adults. Most common causes include intra luminal lesions in the stomach including benign or malignant tumors of the stomach. Most common tumors included are gastrointestinal stromal tumors (GISTs), gastric carcinoma, gastric lipoma, gastric leiomyoma, and gastric schwannoma. It is extremely rare to be caused by migration of percutaneous feeding tube. A 50-year-old woman with a past medical history (PMH) of dysphagia status post percutaneous endoscopic gastrostomy (PEG) tube, history of spastic quadriplegia, presented with acute nausea, vomiting and abdominal distention, and was found to have gastroduodenal intussusception in computed tomography (CT) scan. Condition resolved after retracting PEG tube. Endoscopy did not reveal any intra luminal lesions. External fixation using Avanos Saf-T-Pexy T-fasteners was performed to prevent recurrence of this condition. Most common of causes of gastroduodenal intussusception are GIST tumors of stomach. CT abdomen is the most accurate test and upper endoscopy is needed to rule out any intra luminal causes. Treatment of choice is either endoscopic or surgical resection. External fixation is essential to prevent recurrence.

Nationwide Trends in Tube-Related Genitourinary Interventions for Medicare Beneficiaries

PURPOSE

To evaluate national trends in tube-related genitourinary interventions, with specific attention to primary operator specialty.

METHODS

Using a 5% national sample of Medicare claims data from 2005 to 2015, all claims associated with nephrostomy tube, nephro-ureteral tube, and ureteral stent placement and exchange were identified. The annual volume of the nine billable procedures were analyzed to evaluate trends in the number of procedures performed and primary operator specialty over time. The Charleston Comorbidity Index (CCI) was used to evaluate patient comorbidities and to determine differences in patient populations treated by interventional radiologists and urologists.

RESULTS

The total volume of tube-related genitourinary interventions has increased over the course of the study period, representing 455.0 services per 100,000 Medicare Fee-for-Service beneficiaries in 2005 to 607.2 services in 2015, an increase of 33.4%. Interventional radiologists performed the majority of all procedures in all procedure types and for each year (>90%) with the exception of nephro-ureteral catheter placement or ureteral stent placement, for which urologists performed the overwhelming majority of procedures each year (>85%). Interventional radiologists performed 63% of their total number of procedures on patients with a CCI = 3 or higher, and urologists performed 42% of their total number of procedures on patients with a CCI = 3 or higher (P < .01).

CONCLUSION

Tube-related genitourinary interventions have demonstrated persistent growth over the 2005 to 2015 decade. Interventional radiologists are the dominant providers for the majority of these interventions compared with urologists while delivering care to a patient population with a higher number of comorbidities.

An expanding role for interventional radiology: Medicare trends in fluoroscopic, endoscopic, and surgical enteric tube placement and maintenance from 2010 to 2018

BACKGROUND

The purpose of this study is to provide an update on trends in physician volume and payments for enteric tube placement and maintenance procedures by method, provider specialty, and practice setting amongst Medicare beneficiaries from 2010 to 2018.

MATERIALS AND METHODS

Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 were extracted using current procedural terminology (CPT) codes for gastrostomy and jejunostomy placement, as well as conversion of gastrostomy to gastrojejunostomy, fluoroscopy guided and non-image guided replacement. Total volumes and provider reimbursement were analyzed by provider specialty and practice setting.

RESULTS

Volume of de novo placement of all enteric tubes decreased from 157,123 to 106,549 (-32.2%). While endoscopic placement decreased from 133,658 to 81,171 (-39.3%), the volume of fluoroscopic placement increased from 17,999 to 21,277 (18.2%). Fluoroscopic placement was largely performed by interventional radiology (IR) (91.7% in 2018). Surgical placement decreased from 5466 to 4101 (-25.0%). Volume of fluoroscopic replacement increased from 24,799 to 38,470 (55.1%), while non-image guided replacements decreased from 61,377 to 55,116 (-10.2%). Share of both fluoroscopic and non-image guided replacements by advanced practice providers (APPs) more than doubled over this time period.

CONCLUSION

De novo placement of enteric tubes decreased from 2010 to 2018, likely related to increased awareness of the complications and limited benefits in scenarios such as end of life care. In contrast to the diminishing volume for gastroenterologists, there was increased participation by IR in both placement and maintenance procedures under fluoroscopic guidance.

SUMMARY STATEMENT

Decreasing placement of enteric tubes suggests shifting attitudes and recommendations around end-of-life care. Increase in role by IR/APPs highlights the need for comprehensive care in these patients.

Management of early PEG tube dislodgement: simultaneous endoscopic closure of gastric wall defect and PEG replacement

A 53-year-old man with dysphagia underwent uneventful placement of a percutaneous endoscopic gastrostomy (PEG) tube for long-term enteral feeding access. 11 hours after the procedure, it was discovered that he had accidentally dislodged the feeding tube. On physical examination, he was found to have a benign abdomen without evidence of peritonitis or sepsis. He was observed overnight with serial abdominal examinations and nasogastric decompression. In the morning, he was taken back to the endoscopy suite where endoscopic clips were employed to close the gastric wall defect and a PEG tube was replaced at an adjacent site. The patient was fed 24 hours thereafter and discharged from the hospital 48 hours after the procedure. Early accidental removal of a PEG tube in patients without sepsis or peritonitis can be safely treated with simultaneous endoscopic closure of the gastrotomy and PEG tube replacement, resulting in earlier enteral feeding and shorter hospital stay.

Anterograde Gastroduodenal Intussusception: A Rare but Lethal Complication of Percutaneous Endoscopic Gastrostomy Tube Placement

Percutaneous endoscopic gastrostomy (PEG) tube placement is one of the methods of providing enteral nutrition support and is often used in critically ill patients. There are several complications of PEG tube placement, including intussusception. Jejunojejunal and retrograde jejunoduodenogastric intussusception are well-documented complications of PEG tube placement. Here we describe the case of a 25-year-old female who was diagnosed with anterograde gastroduodenal intussusception with the PEG tube acting as a lead point. Our case is unique as, to the best of our knowledge, there are no documented cases of PEG tube-related anterograde gastroduodenal intussusception. The reported patient was found to have extensive gastric pneumatosis and portal venous gas concerning for acute ischemia. Such cases warrant immediate surgical intervention. However, in our case, the patient's family opted for comfort care measures.

Alexis St. Martin Gastropexy: A Novel Technique for Gastropexy During Percutaneous Endoscopic Gastrostomy Tube Placement

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a preferred method of long-term enteral nutritional support. Despite its ease of placement, it has a 4% major complication rate, requiring surgical intervention or hospitalization. Early PEG tube dislodgment can cause peritonitis, requiring emergent laparotomy at significant morbidity and cost. T-fasteners have been used as an adjunct gastropexy, but nearly one third migrate into the abdominal wall within the first 2 weeks. We describe a low-cost, minimally invasive technique using widely available surgical instruments to appose the gastric and abdominal walls.

METHODS

All PEG procedures were performed in our 60-bed surgical intensive care unit. Institutional IRB approval was obtained along with procedure specific consent for all patients. The adjunctive gastropexy procedure was performed on four patients at high risk for early PEG tube dislodgment. Following routine PEG tube placement, both ends of four 2-0 polyglactin ties were brought through the gastric and abdominal walls through separate stab incisions adjacent to the PEG tube exit site in the 3, 6, 9, and 12 o'clock positions. These were tied in the subcutaneous tissue, securing the gastric wall to the abdominal wall.

RESULTS

No PEG tube complications occurred. All patients were discharged to long-term care facilities with PEG tubes intact or electively removed.

CONCLUSIONS

We describe the results of a pilot study for a cost-effective, easily implementable, adjunct technique, named after the namesake of our institution, to decrease the incidence and severity of complications associated with PEG tube dislodgment. It was used in 4 patients at high risk for PEG tube dislodgment with satisfactory early results in all 4. Further recruitment of larger numbers of patients using this technique is ongoing to determine if this technique is truly effective at reducing PEG tube complications.

Gastrostomy Tube Placement by Radiological Methods for Older Patients Requiring Enteral Nutrition: Not to be Forgotten

Background: The use of gastrostomy tubes for long-term nutritional support in older patients is frequent. Percutaneous gastrostomy tube placement may be performed using various techniques, including endoscopic, surgical, and radiologically-guided methods. While percutaneous endoscopic gastrostomy (PEG) placement is the most widely used and accepted approach, experience with the use of percutaneous radiological gastrostomy (PRG) is more limited.

Objective: To evaluate the safety and short-term outcomes of PRG in older patients requiring long-term enteral feeding.

Method: We performed a prospective study involving all patients aged 65 years and older who underwent PRG insertion at the Laniado hospital over a period of 2 years. Adverse events related to the gastrostomy tube insertion were recorded over a period of 3 months following the procedure.

Results: A total of 58 patients were included with a mean age of 78.1 years, and 48% were women. The most frequent indications for enteral feeding were stroke (47%) and dementia (41%). The technical success rate was 100% with no immediate procedure-related mortality or morbidity. One-month mortality was 3%, and overall mortality at 3-month follow-up was 16%. Complications were reported in 39 (67%) of patients, with 17 (29%) experiencing more than 1 complication. While most complications (88%) were minor, major complications occurred in 19 (33%) of the patients. Peritonitis was the cause of death in 2 patients, and tube dislodgment occurred in 17 subjects. During the follow-up period 17 (29%) of patients were re-admitted to hospital, with the cause for re-hospitalization being unrelated to the PRG in half of the cases. Neither bleeding nor deep wound infection was detected in the study group.

Conclusions: PRG is relatively safe and effective for gastrostomy placement in older patients, and this technique may be of value in patients with oral infections and those receiving anti-thrombotic therapy.

Gastric Ulcer from the Pressure of a Gastrostomy Tube: A Rare Cause of Upper Gastrointestinal Bleeding

Gastrostomy tube placement is a well-known procedure for obtaining permanent enteral access and providing long-term nutritional support. Although it is usually well tolerated, a diverse array of complications can occur. A rare, and often unrecognized, complication of gastrostomy tube placement is upper gastrointestinal bleeding secondary to a gastric ulcer caused by pressure from a gastrostomy tube bumper or balloon. Here, we present a case of an elderly woman who experienced hematemesis and bleeding around the gastrostomy site. This report should alert healthcare staff that excessive tightening of the gastrostomy tube retainer or prolonged traction of the gastrostomy tube can cause pressure necrosis manifesting as gastric ulceration.

Gastrostomies Preserve But Do Not Increase Quality of Life for Patients and Caregivers

BACKGROUND & AIMS

Gastrostomies are widely used to provide long-term enteral nutrition to patients with neurologic conditions that affect swallowing (eg, following a cerebrovascular accident or for patients with motor neuron disease) or with oropharyngeal malignancies. The benefits derived from this intervention are uncertain for patients and caregivers. We conducted a prospective, multicenter cohort study to determine how gastrostomies affect health-related quality of life (HRQoL) in recipients and caregivers.

METHODS

We performed a study of 100 patients who received gastrostomies (55% percutaneous endoscopic gastrostomy, 45% radiologically inserted) at 5 centers in the United Kingdom, 100 caregivers, and 200 population control subjects. We used the EuroQol-5D (comprising a questionnaire, index, visual analogue scale) to assess HRQoL for patients and caregivers before the gastrostomy insertion and then 3 months afterward; findings were compared with those from control subjects. Ten patients and 10 caregivers were also interviewed after the procedure to explore quantitative findings. Findings from the EuroQol-5D and semi-structured interviews were integrated using a mixed-methods matrix.

RESULTS

Six patients died before the 3-month HRQoL reassessments. We observed no significant longitudinal changes in mean EuroQol-5D index scores for patients (0.70 before vs 0.710 after; P = .83) or caregivers (0.95 before vs 0.95 after; P = .32) following gastrostomy insertion. The semi-structured interviews revealed problems in managing gastrostomy tubes, social isolation, and psychological and emotional consequences that reduced HRQoL.

CONCLUSIONS

We performed a mixed-methods prospective study of the effects of gastrostomy feeding on HRQoL. HRQoL did not significantly improve after gastrostomy insertion for patients or caregivers. The lack of significant decrease in HRQoL after the procedure indicates that gastrostomies may help maintain HRQoL. Findings have relevance to those involved in gastrostomy insertion decisions and indicate the importance of carefully selecting patients for this intervention, despite the relative ease of insertion.

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy

There are a variety of techniques for gastrostomy tube placement. Endoscopic and radiologic approaches have almost entirely superseded surgical placement. However, an aging population and significant advancements in modern healthcare have resulted in patients with increasingly complex medical issues or postsurgical anatomy. The rising prevalence of obesity has also created technical challenges for proceduralists of many specialties. When patients with these comorbidities develop the need for long-term enteral nutrition and feeding tube placement, standard approaches such as percutaneous endoscopic gastrostomy (PEG) by endoscopists and percutaneous image-guided gastrostomy (PIG) by interventional radiologists may be technically difficult or impossible. For these challenging situations, laparoscopic-assisted PEG (LAPEG) is an alternative option. LAPEG combines the advantages of PEG with direct intraperitoneal visualization, helping ensure a safe tube placement tract free of intervening organs or structures. In this review, we highlight some of the important factors of first-line gastrostomy techniques, with an emphasis on the utility and procedural technique of LAPEG when they are not feasible.

Percutaneous Endoscopic Gastrostomy Placement Without Skin Incision: Results of a Randomized Trial

BACKGROUND

During percutaneous endoscopic gastrostomy (PEG) placement, skin incision is performed as standard practice. We suspected that this time-honored principle is unnecessary.

METHODS

In a prospective, randomized trial, 50 adults undergoing PEG placement were randomized to skin incision omission PEG (IOPEG) and standard PEG (SPEG). Two- and 7-day PEG site evaluations were performed to grade stomal infection, bleeding, pain, and overall satisfaction using a standardized scoring system. Median stomal evaluation scores were compared between groups using a Wilcoxon rank-sum test. Completion rates were compared using a t-test.

RESULTS

Placement success for the IOPEG and SPEG technique was 22/25 (88%) and 24/25 (96%), respectively (p = NS). Three failed IOPEG attempts required an incision to complete due to increased pull force encountered. One SPEG failed due to inability to transilluminate. Stomal evaluation scores of infection, bleeding, pain, leakage, and patient satisfaction were not significantly different at 2 or 7 days. No serious complications occurred as a result of skin incision omission.

CONCLUSIONS

Omitting the skin incision does not significantly alter the placement success rate, patient satisfaction, or the rate of stomal complications, thus dispelling the dogma that a skin incision is mandatory for PEG placement and the myth that incisions reduce infectious complications.

Enteral Access Procedures: An 18-Year Analysis of Changing Patterns of Utilization in the Medicare Population

PURPOSE

To evaluate national trends in enteral access and maintenance procedures for Medicare beneficiaries with regard to utilization rates, specialty group roles, and sites of service.

MATERIALS AND METHODS

Using Medicare Physician Supplier Procedure Summary Master Files for the period 1994-2012, claims for gastrostomy and gastrojejunostomy access and maintenance procedures were identified. Longitudinal utilization rates were calculated using annual enrollment data. Procedure volumes by site of service and medical specialty were analyzed.

RESULTS

Between 1994 and 2012, de novo enteral access procedure utilization decreased from 61.6 to 42.3 per 10,000 Medicare Part B beneficiaries (-31%). Gastroenterologists and surgeons performed > 80% of procedures (unchanged over study period) with 97% in the hospital setting. Over time, relative use of an endoscopic approach (62% in 1994; 82% in 2012) increased as percutaneous (21% to 12%) and open surgical (17% to 5%) procedures declined. Existing enteral access maintenance services increased 29% (from 20.1 to 25.9 per 10,000 beneficiaries). Radiologists (from 13% to 31%) surpassed gastroenterologists (from 36% to 21%) as dominant providers of maintenance procedures. Emergency physicians (from 8% to 23%) and nonphysician providers (from 0% to 6%) have seen rapid growth as maintenance services providers as these services have transitioned increasingly to the emergency department setting (from 18% to 32%).

CONCLUSIONS

Among Medicare beneficiaries, de novo enteral access procedures have declined in the last 2 decades as existing access maintenance services have increased. The latter are increasingly performed by radiologists, emergency physicians, and nonphysician providers.

Improved method of gastrostomy tube replacement using a small-caliber transnasal endoscope

CONCLUSION

Gastrostomy tube replacement using a new approach through the abdominal-wall stoma with a small-caliber trans-nasal endoscope is feasible, fast, and safe compared with the trans-oral approach.

OBJECTIVES

To evaluate the feasibility of a new technique using a trans-nasal endoscope for gastrostomy tube replacement.

METHODS

Between June 2005 and December 2013 in the Peking University Third Hospital, 69 patients underwent gastrostomy tube replacement using the trans-oral approach (conventional method) or a small-caliber trans-nasal endoscope inserted through the abdominal-wall stoma (new method). A retrospective review was performed of the medical records of those patients, including demography and information about the surgical procedure and any complications. Patients were classified into the conventional group and the new method group. Descriptive statistics for all continuous variables were mean ± standard deviation and for categorical variables were number and percentage.

RESULTS

Gastrostomy tube replacement was achieved in 69 of 69 cases (100%); 23 of these procedures were performed using the new method. The surgery time with the conventional method (8.3 ± 2.0 min) was significantly longer than with the new method (6.0 ± 0.9 min, p < 0.001). With the conventional method, there was one patient (2%) with post-operative fever and skin infection; no complications occurred with the new method.

Practice variation in PEG tube placement: trends and predictors among providers in the United States

BACKGROUND

Enteral access placement is performed among a variety of providers and specialties, yet there is a dearth of literature on trends and factors related to enteral access placement in the United States.

OBJECTIVE

To examine trends in the incidence of enteral access procedures performed by gastroenterologists in the United States.

DESIGN

Retrospective review of upper endoscopic procedures that involved PEG tube placement between 2000 and 2010.

SETTING

Endoscopy sites participating in the Clinical Outcomes Research Initiative (CORI).

PATIENTS

Patients undergoing upper endoscopy.

INTERVENTIONS

PEG tube placement.

MAIN OUTCOME MEASUREMENTS

Number of PEG tubes placed.

RESULTS

Overall PEG tube placement by a provider from 2000 to 2010 was 1.7% (number of PEG tubes performed/number of upper endoscopies performed), with the majority of them being performed by gastroenterologists. Very young and very old, non-white racial background (Hispanic: odds ratio [OR] 1.21; 95% CI, 1.13-1.28; black: OR 2.24; 95% CI, 2.12-2.36), and men (OR 1.44; 95% CI, 1.39-1.50) were patient characteristics associated with greater PEG tube placement. In terms of practice setting, PEG tube placement occurred more frequently in community and/or health maintenance organization environments and on the East Coast. With respect to provider characteristics, male providers were less likely than female providers to perform a PEG tube insertion (OR 0.67; 95% CI, 0.64-0.71), and there was a trend that as providers were further out of medical school they were less likely to perform a PEG tube procedure. Interestingly, surgeons (OR 6.69; 95% CI, 6.18-7.24) and other providers (non-pediatric/non-general practice) (OR 3.22; 95% CI, 2.63-3.94) were more likely to perform PEG tube procedures than were gastroenterologists.

LIMITATIONS

Participation in CORI is voluntary and may not capture data on non-gastroenterologist providers.

CONCLUSION

Significant practice variation was noted in PEG tube placement in the United States with respect to patient and provider characteristics, geographic region, and endoscopy settings.

Feasibility and Safety of Overtubes for PEG-Tube Placement in Patients with Head and Neck Cancer

Background. Percutaneous endoscopic gastrostomy (PEG) placement using the “pull” technique is commonly utilized for providing nutritional support in head and neck cancer (HNC) patients, but it may be complicated by peristomal metastasis in up to 3% of patients. Overtube-assisted PEG placement might reduce this risk. However, this technique has not been systemically studied for this purpose to date. Methods. Retrospective analysis of consecutive patients with HNC who underwent overtube-assisted PEG placement at Westmead Hospital, Australia, between June 2011 and December 2013. Data were extracted from patients' endoscopy reports and case notes. We present our technique for PEG insertion and discuss the feasibility and safety of this method. Results. In all 53 patients studied, the PEG tubes were successfully placed using 25 cm long flexible overtubes, in 89% prophylactically (before commencing curative chemoradiotherapy), and in 11% reactively (for treatment of tumor related dysphagia or weight loss). During a median follow-up period of 16 months, 3 (5.7%) patients developed peristomal infection and 3 others developed self-limiting peristomal pain. There were no cases of overtube-related adverse events or overt cutaneous metastases observed. Conclusions. Overtube-assisted PEG placement in patients with HNC is a feasible, simple, and safe technique and might be effective for preventing cutaneous metastasis.

Radiologically Guided Placement of Mushroom-retained Gastrostomy Catheters: Long-term Outcomes of Use in 300 Patients at a Single Center

PURPOSE

To assess long-term outcomes including risk of complications and nutritional benefits of mushroom-retained (pull-type) gastrostomy catheters placed in patients by interventional radiologists.

MATERIALS AND METHODS

All patients who received pull-type gastrostomy tubes between 2010 and 2013 were retrospectively reviewed, including 142 men (average weight, 169.6 lb [76.32 kg]; mean age, 65.2 years; range, 22-92 years) and 158 women (average weight, 150.4 lb [67.68 kg]; mean age, 65.2 years; range, 18-98 years). Indications for placement were cerebrovascular accident (n = 80), failure to thrive (n = 71), other central nervous system disorder (n = 51), head and neck cancer (n = 47), and other malignancy (n = 51). Complications were recorded per Society of Interventional Radiology practice guidelines. Patient weight was documented at specific follow-up intervals. Statistical analysis was performed by using the Student t test and one-way analysis of variance for the effects of sex and indication for placement, respectively, on average weight change.

RESULTS

The technical success rate was 98.4% (300 of 305 patients). Major and minor complications occurred at a rate of 3.7% (n = 11) and 13% (n = 39), respectively. Follow-up weight during the early (≤45 days), intermediate (≤180 days), and long-term (>180 days) periods was available for 71% (n = 214), 36% (n = 108), and 15% (n = 44) of the 300 patients, respectively. Weight gain occurred in 77% (160 of 214), 60% (65 of 108), and 73% (32 of 44) of the patients, respectively. Patients who gained weight gained 6.7, 10.6, and 16.3 lb (3.02, 4.77, and 7.34 kg) during each follow-up period, respectively. Average weight gain at follow-up in all patients was 4.2, 0.6, and 5.4 lb (1.89, 0.27, and 2.43 kg), respectively. No significant differences in average weight change were seen among groups when they were classified according to sex or indication for placement.

CONCLUSION

Placement of mushroom-retained gastrostomy catheters is a viable long-term treatment option for enteral nutrition, with complication rates similar to those reported for other gastrostomy techniques. Improvement in nutrition status measured as weight gain was seen in most patients in both early and long-term periods.

Preventing retrograde jejunoduodenogastric intussusception as a complication of a long-term indwelling gastrostomy tube

Gastrostomy tubes are frequently used to provide enteral access in a variety of patient populations. Long-term complications are usually minor and include ulceration of the surrounding skin, clogging or dislodgment of the feeding tube, and superficial abscess; severe long-term complications are rare. Here we report a case of a life-threatening complication from an indwelling gastrostomy tube, specifically retrograde jejunoduodenogastric intussusception. Computed tomography and intraoperative images, as well as a review of literature, provide a detailed picture for diagnosis and treatment. Although feeding tubes are now routine and associated with low morbidity, physicians should remain aware of this potentially lethal complication in order to minimize the increased morbidity and mortality from intussusception and subsequent bowel ischemia.

A novel procedure for gastrocutaneous fistula closure

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes have allowed for a safe and efficient way to feed patients who cannot tolerate oral feeding, yet have a functioning gastrointestinal tract. Gastrocutaneous fistulas (GCF) after PEG removal are an unusual and rare complication in adults and may be in part due to poor tissue healing, delayed gastric emptying, or increased gastric acid production. Various approaches have been reported to treat PEG-related gastric fistulas; however, their success rate is variable and patients frequently require repeat procedures or >1 technique in combination, including acid suppression therapy, silver nitrate ablation of the PEG tract lining, argon plasma coagulation, fibrin glue, and/or endoclipping. Upon our review, there have been no published case series reporting the use of endoscopic banding to close persistent GCFs after PEG removal.

STUDY DESIGN

Four patients with persistent GCFs after PEG removal were taken for esophagogastroduodenoscopy with banding of the fistula site. This procedure was chosen due to its relative ease of application. Patient follow-up was by telephone within 3 days of having the procedure and then again 1 to 2 weeks afterward, to ensure that there was no persistent leakage through the fistula tract.

RESULTS

Of the 4 patients who had persistent GCFs after PEG removal, endoscopic banding resulted in complete closure of the fistula in 3 of our 4 patients. In 1 case, banding was unsuccessful secondary to scarring from prior radiation treatment as well as having a previous PEG tube placed 1 inch from the current fistula site. In this case, a second PEG tube was placed through the original PEG stoma, leading to cessation of the gastric leak. The first case resulted in no recurrence after 3 years. The second and third cases have shown no recurrence after 3 months. The fourth case resulted in a second PEG tube to manage persistent drainage through the tract after unsuccessful banding of the site due to complex endoscopic and anatomic issues.

CONCLUSIONS

Endoscopic closure of a GCF, regardless of technique used, can help avoid surgical intervention. Anatomic changes from any previous treatment modalities may decrease the success rate of fistula banding. However, in our patients, endoscopic banding proved to be a safe and relatively simple alternative in closing persistent GCFs due to prior PEG tubes.

Improvement in nutritional status and quality of life in patients after percutaneous endoscopic gastrostomy

AIM: To evaluate the nutritional status and quality of life in patients after percutaneous endoscopic gastrostomy (PEG).

METHODS: Seventy-three patients who had undergone PEG were followed at 1 mo, 3 mo and 6 mo after feeding tube placement to determine the changes in white blood cell count, lymphocyte count, plasma hemoglobin, total protein, albumin, transferrin protein, body weight, and body mass index (BMI). The incidence of complications such as pneumonia and reflux esophagitis was also recorded. Changes in quality of life before and after PEG were measured with the Short Form 36 Health Survey questionnaire.

RESULTS: A total of 107 PEG procedures were performed in 73 patients. Nutritional status and weight loss were significantly improved after PEG. The levels of hemoglobin, total protein, albumin, transferrin, and body mass index significantly improved at 1 mo, 3 mo and 6 mo after enteral nutrition, showing significant differences before and after PEG (all P < 0.05). The incidence of pulmonary infection decreased from 63.0% preoperatively to 16.7% postoperatively, and that of reflux esophagitis decreased from 27.4% to 7.6%. At 1 mo, 3 mo and 6 mo after feeding tube placement, there was a significant improvement in patients' physical health and mental health, as well as physiological function, social function.

CONCLUSION: The nutritional status, levels of hemoglobin, total protein, albumin and transferrin, as well as body mass index significantly improved in patients after PEG. The incidence of complications and quality of life also improved in patients after PEG.

Use of percutaneous endoscopic gastrostomy in stroke patients: Recent progress

There is much controversy over the use of percutaneous endoscopic gastrostomy (PEG) for management of dysphagia in stroke patients. An analysis of recent studies in this field indicates that appropriate timing of PEG in selected appropriate patients will provide therapeutic benefit.

[Invasive procedures in patients hospitalized in Spanish internal medicine departments]

AIMS

Invasive procedures (IP) have become routine techniques that benefit an important number of patients on improving their quality of life or avoiding more aggressive treatments. We have conducted a study on the IPs performed in Spanish Internal Medicine (IM) Departments between 2005 and 2009.

PATIENTS AND METHODS

IP performed to patients admitted to Spanish Internal Medicine departments were analyzed based on the information obtained from the Minimum Basis Data Set (CMBD). IP was defined as the following: filter placement in the inferior vena cava, chest tube placement, biliary, esophageal and colon prosthesis placement, pleurodesis, nephrostomy, external biliary drain placement, gastrostomy tube placement, thoracocentesis and peritoneal catheter placement.

RESULTS

During the study period, a total of 75,853 invasive procedures on 70,239 admittances were performed in 2,766,673 patients (2.5%). IP subjects were younger (68.1 vs 71.4; P<.001), predominantly male (61.9 vs 53.2%; P<.001), with higher mortality (14.6 vs 9.9%; P<.001) and longer stay (18.4 vs 9.6 days; P<0.001). Cost of admittance was clearly higher than the rest of the patients (5,600€ vs 3,835€; P<.001).

CONCLUSIONS

IPs are performed on a low percentage of IM Department hospitalized patients. They are costly, entail high mortality and a longer stay period compared to the mean population admitted to IM. A considerable proportion of the patients receiving IP suffer from neoplastic diseases, frequently in advances stages, which justifies the high inhospital mortality of this population.

Laparoscopic-assisted colectomy in a patient with colon cancer after percutaneous endoscopic gastrostomy

BACKGROUND

A number of patients undergo percutaneous endoscopic gastrostomy (PEG) under various conditions. Open colectomy is usually performed for colon cancer in patients with PEG because the safety of the laparoscopic approach for such patients has not been established. However, if the laparoscopic approach is possible in patients with PEG, it will be less invasive and more helpful in rehabilitation into society.

CASE PRESENTATION

We describe the case of a 64-year-old male with a T1 adenocarcinoma of the ascending colon 2 years after surgery for nasal cancer and PEG for dysphagia. The patient did not have any distant metastases or malignant tumors on preoperative computed tomography and positron-emission tomography. He underwent laparoscopic-assisted colectomy (LAC) with lymph node dissection. No complications developed during or after the surgery.

CONCLUSIONS

LAC could be a potential option for the treatment of colon cancer in patients who have undergone PEG. To our knowledge, this is the first recorded case of an ascending colon cancer treated with LAC under the condition of gastrostoma.

Technique for Percutaneous Fluoroscopically Guided G-Tube Placement in a High-BMI Patient

Enteral feeding is still the preferred method of nutritional support even in patients with excessive body mass index. Often, this mass poses a hindrance in performing routine procedures. We present a case describing the technique used to safely place a fluoroscopically guided G-tube in a patient with a significant nutritional deficit after repair of a ruptured thoracic aneurysm. Her admission weight was in excess of 180 Kg. However, protracted respiratory insufficiency and mechanical ventilation prolonged her hospital course. The G-tube was successfully placed using a fluoroscopically guided technique. The advantages of such an approach are discussed.

Evolving roles of radiologists, nephrologists, and surgeons in endovascular hemodialysis access maintenance procedures

PURPOSE

The aim of this study was to evaluate the changing relative roles of radiologists, nephrologists, and surgeons performing endovascular hemodialysis access maintenance procedures.

METHODS

Medicare Physician Supplier Procedure Summary Master Files from 2001 through 2008 were analyzed for procedure codes for hemodialysis access angiography, angioplasty, percutaneous thrombectomy, and open surgical interventions. Using physician specialty code data, component procedure volume for all 3 endovascular services was extracted for radiologists, nephrologists, and surgeons. Percentage changes were calculated for all groups. National trends in percutaneous and open interventions were compared.

RESULTS

Between 2001 and 2008, the total Medicare fee-for-service component procedure volume for dialysis access angiography, angioplasty, and percutaneous thrombectomy increased by 102%, 171%, and 52%, respectively. In 2008, radiologists performed 50% of angiography, 47% of angioplasty, and 46% of declotting procedures, down from 82%, 82%, and 84%, respectively, in 2001. In contrast, nephrologists increased from 4%, 5%, and 4% to 22%, 27%, and 21% of services, and surgeons increased from 7%, 5%, and 4% to 22%, 19%, and 16%. As percutaneous procedures increased in frequency, open surgical interventions declined by 43%.

CONCLUSION

Nationally, endovascular hemodialysis access maintenance procedures have increased as open surgical interventions have declined. Nephrologists and surgeons have both experienced marked relative increases in endovascular procedure volumes as radiologists, previously by far the predominant providers of these services, now only perform approximately half.

National fluid shifts: fifteen-year trends in paracentesis and thoracentesis procedures

PURPOSE

The aim of this study was to evaluate national trends in paracentesis and thoracentesis procedures and the relative roles of specialty groups providing these services.

METHODS

Medicare Physician Supplier Procedure Summary Master Files from 1993 to 2008 were analyzed for paracentesis and thoracentesis procedure codes. Using physician specialty identifier codes, procedure volumes were extracted for radiologists, primary care physicians, and surgeons for both procedures. Volume data were extracted for gastroenterologists and pulmonary and critical care medicine physicians, respectively, for paracentesis and thoracentesis. Frequency by site of service was similarly evaluated. Relative changes were calculated.

RESULTS

Between 1993 and 2008, paracentesis procedures on Medicare fee-for-service beneficiaries increased by 133% (from 64,371 to 149,699), and thoracentesis procedures decreased by 14% (from 147,363 to 127,444). Services by radiologists increased by 964% (from 10,456 to 111,275) and 358% (from 14,531 to 66,602), respectively, while all other targeted groups experienced declines. For paracentesis, radiologist and gastroenterologist procedure shares changed from 16% and 32%, respectively, in 1993 to 74% and 6% in 2008. For thoracentesis, radiologist and pulmonary and critical care medicine physician shares changed from 10% and 49% to 52% and 27%. Relative shifts in site of service to the hospital outpatient setting occurred for both procedures.

CONCLUSIONS

Since 1993, paracentesis procedures on Medicare beneficiaries have more than doubled, while thoracentesis volumes have declined slightly. Radiologists now far exceed gastroenterologists and pulmonary and critical care medicine physicians, respectively, as the predominant providers of these services. Those shifts are likely attributable to both the incremental safety of imaging guidance and also the unfavorable economics of these procedures.

Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment

CONTEXT

Tube-feeding is of questionable benefit for nursing home residents with advanced dementia. Approximately two-thirds of US nursing home residents who are tube fed had their feeding tube inserted during an acute care hospitalization.

OBJECTIVE

To identify US hospital characteristics associated with higher rates of feeding tube insertion in nursing home residents with advanced cognitive impairment.

DESIGN, SETTING, AND PATIENTS

The sample included nursing home residents aged 66 years or older with advanced cognitive impairment admitted to acute care hospitals between 2000 and 2007. Rate of feeding tube placement was based on a 20% sample of all Medicare Claims files and was assessed in hospitals with at least 30 such admissions during the 8-year period. A multivariable model with the unit of the analysis being the hospital admission identified hospital-level factors independently associated with feeding tube insertion rates, including bed size, ownership, urban location, and medical school affiliation. Measures of each hospital's care practices for all patients with serious chronic illnesses were evaluated, including intensive care unit (ICU) use in the last 6 months of life, the use of hospice services, and the ratio of specialist to primary care physicians. Patient-level characteristics were also considered.

MAIN OUTCOME MEASURE

Endoscopic or surgical insertion of a gastrostomy tube during a hospitalization.

RESULTS

In 2797 acute care hospitals with 280,869 admissions among 163,022 nursing home residents with advanced cognitive impairment, the rate of feeding tube insertion varied from 0 to 38.9 per 100 hospitalizations (mean [SD], 6.5 [5.3]; median [interquartile range], 5.3 [2.6-9.3]). The mean rate of feeding tube insertions per 100 admissions was 7.9 in 2000, decreasing to 6.2 in 2007. Higher insertion rates were associated with the following hospital features: for-profit ownership vs government owned (8.5 vs 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.21-1.46), larger size (>310 beds vs <101 beds: 8.0 vs 4.3 insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35-1.63), and greater ICU use in the last 6 months of life (highest vs lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20-3.06). These differences persisted after controlling for patient characteristics. Specialist to primary care ratio and hospice use were weakly or not associated with feeding tube placement.

CONCLUSION

Among nursing home residents with advanced cognitive impairment admitted to acute care hospitals, for-profit ownership, larger hospital size, and greater ICU use was associated with increased rates of feeding tube insertion, even after adjusting for patient-level characteristics.

Peritonitis from peg tube insertion in surgical intensive care unit patients: identification of risk factors and clinical outcomes

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes are routinely inserted in the surgical intensive care unit (SICU). Poor tissue healing or technical issues after tube insertion can lead to peritonitis requiring a laparotomy. This study aimed to identify risk factors leading to peritonitis.

METHODS

A retrospective study reviewed of PEG tubes inserted in SICU patients from 2003 to 2006. Age, sex, body mass index (BMI), organ dysfunction, vasopressor use, fluid balance, steroid use for medical reasons, and nutritional status of the patients were noted. The patients with acute spinal cord injury who received high-dose steroids were excluded from the study. Mortality and peritonitis requiring laparotomy were the outcomes. Logistic regression performed with SAS version 9.1 (Cary, NC) was used for analysis.

RESULTS

Of 322 patients, 16 (5%) required a laparotomy for peritonitis, and 74 (23%) died during the hospital stay. The major predictors of the need for a laparotomy were higher BMI (p = 0.0005) and a serum albumin level lower than 2.5 gm/dL (p = 0.0008). Patients with both a BMI exceeding 30 kg/m(2) and an albumin level lower than 2.5 gm/dL were 25 times more likely to need a laparotomy (95% confidence interval [CI], 7.74-83.3). The mean time from tube placement to laparotomy was 11 days. Of the 16 patients who required laparotomy, 9 died during the hospitalization. Patients requiring a laparotomy were five times more likely to die during the hospitalization than patients not requiring a laparotomy (p = 0.004; 95% CI, 1.68-13.07). The mean time from laparotomy to death was 23 days. Signs of sepsis and worsening abdominal examination developed in all 16 laparotomy patients. Dislodged tube with gastric wall not opposed to the abdominal wall was the most common finding at laparotomy.

CONCLUSION

Approximately 5% of patients undergoing PEG insertion in the SICU require laparotomy for peritonitis and are more likely to die during the hospitalization. Higher BMI and a lower serum albumin level, by contributing to poor healing, increase the risk of peritonitis.

Large or small bore, push or pull: a comparison of three classes of percutaneous fluoroscopic gastrostomy catheters

PURPOSE

To compare the tube performance and complication rates of small-bore, large-bore push-type, and large-bore pull-type gastrostomy catheters.

MATERIALS AND METHODS

A total of 160 patients (74 men, 86 women; mean age, 66.9 years, range, 22-95 y) underwent percutaneous fluoroscopic gastrostomy placement between January 2004 and March 2006. Choice of catheter was based on the preference of the attending radiologist. Data were collected retrospectively with institutional review board approval. Radiology reports provided information on the catheter, indication for gastrostomy, technical success, and immediate outcome. Chart review provided data on medical history, postprocedural complications, progress to feeding goal, and clinical outcomes. Statistical analysis was performed to compare the three classes of gastrostomy catheters.

RESULTS

All 160 catheters were placed successfully. Patients who received small-bore catheters (14 F; n = 88) had significantly more tube complications (17% vs 5.6%) and were less likely to meet their feeding goal (P = .035) compared with patients with large-bore catheters (20 F; n = 72). No difference was observed in terms of major or minor complications. Large-bore push-type (n = 14) and pull-type catheters (n = 58) were similar in terms of complication rates. Patients who received large-bore push-type catheters achieved their feeding goals in significantly less time than those with large-bore pull-type catheters (average, 3.8 days vs 6.0 days; P = .04).

CONCLUSIONS

Patients who received small-bore gastrostomy catheters are significantly more prone to tube dysfunction. Large-bore catheters should be preferentially used, with push-type catheters performing better with regard to the time to achieve feeding goal.

An interventional radiology clinical rotation to enhance student learning

To achieve the goal of adequately preparing graduating nurses for entry into practice, an undergraduate clinical nursing curriculum was enhanced by including an interventional radiology clinical rotation. The author describes the basics of this experience and the planning steps prior to implementation, including hospital approval, preceptor selection, and evaluation of the overall clinical experience.