Candida peritonitis: a rare complication following early dislodgement of percutaneous endoscopic gastrostomy tube

Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections

SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.

Fungal peritonitis caused by Pichia kudriavzevii following sleeve gastrectomy

A 23-year-old female, who had undergone a sleeve gastrectomy two weeks earlier, presented with abdominal complaints. A CT scan showed portal vein thrombosis, bowel ischemia, and intra-abdominal sepsis. Anastomosis and antibiotic therapy were not successful, and the patient went into multi-organ failure and died. Multiple cultures revealed a yeast fungus confirmed as Pichia kudriavzevii using rRNA gene sequencing. We report the first case of peritonitis in association with P kudriavzevii. In addition to the abdominal complications and surgical interventions, the yeast was found to have significantly contributed to the patient's death. SIMILAR CASES PUBLISHED: None. CONFLICT OF INTEREST: None.

Comparing Outcomes Between "Pull" Versus "Push" Percutaneous Endoscopic Gastrostomy in Acute Care Surgery: Under-Reported Pull Percutaneous Endoscopic Gastrostomy Incidence of Tube Dislodgement

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) complications are often under-reported in the literature, especially regarding the incidence of tube dislodgement (TD). TD can cause significant morbidity depending on its timing. We compared outcomes between "push" and "pull" PEGs. We hypothesized that push PEGs, because of its T-fasteners and balloon tip, would have a lower incidence of TD and complications compared with pull PEGs.

METHODS

We performed a chart review of our prospectively maintained acute care surgery database for patients who underwent PEG tube placement from July 1, 2009 through June 30, 2013. Data regarding age, gender, body mass index, indications (trauma versus nontrauma), and complications (including TD) were extracted. Procedure-related complications were classified as either major if patients required an operative intervention or minor if they did not. We compared outcomes between pull PEG and push PEG. Multiple regression analysis was performed to identify risk factors associated with major complications.

RESULTS

During the 4-y study period, 264 patients underwent pull PEGs and 59 underwent push PEGs. Age, gender, body mass index, and indications were similar between the two groups. The overall complications (major and minor) were similar (20% pull versus 22% push, P = 0.61). The incidence of TD was also similar (12% pull versus 9% push, P = 0.49). However, TD associated with major complications was higher in pull PEGs but was not statistically significant (6% pull versus 2% push, P = 0.21). Multiple regression analysis showed that dislodged pull PEG was associated with major complications (odds ratio 29.5; 95% confidence interval, 11.3-76.9; P < 0.001).

CONCLUSIONS

The incidence of pull PEG TD associated with major complications is under-recognized. Specific measures should be undertaken to help prevent pull PEG TD.

LEVEL OF EVIDENCE

IV, therapeutic.

Reducing Accidental Dislodgement of the Percutaneous Endoscopic Gastrostomy: A Prospective Trial of the "SafetyBreak" Device

BACKGROUND

The percutaneous endoscopic gastrostomy (PEG) is a ubiquitous feeding tube with high rates of accidental dislodgement, with significant morbidity and health care costs. We hypothesized use of a decoupling device is a safe and effective mechanism to reduce dislodgements.

STUDY DESIGN

We studied a prospective cohort of 100 patients from an academic center. Enrollment included patients requiring PEG tube placement with follow up extending through an individual's lifetime use of their PEG tube. The primary endpoint was accidental dislodgement of the principally placed PEG tube. The secondary endpoint was time to accidental dislodgement of the PEG tube.

RESULTS

All 100 patients received the SafetyBreak device and had complete follow-up. Half of the patients had at least a single episode of device decoupling, indicating prevention of dislodgement of the PEG. Eight patients ultimately had dislodgement, resulting in a significantly lower dislodgement rate when compared with a historical cohort (P = .036) and significantly longer survival of the PEG (log rank = 0.005). When compared with a concurrent cohort (without the device) there was also significantly lower dislodgement rate (P = .03) and a trend toward longer survival of the PEG (log rank = 0.08).

CONCLUSIONS

When compared with both a historical and concurrent cohort of patients, the SafetyBreak device reduces accidental dislodgement of PEG tubes. As an increasing number of PEGs are being placed, an increasing number of patients are at risk for dislodgement. The SafetyBreak device is an innovative, economical solution to the problem of accidental dislodgement of the PEG tube.

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Percutaneous endoscopic-guided gastrostomy (PEG) is done routinely on patients who suffer from inability to feed by mouth. PEG is generally considered a safe procedure with a low complication rate. A commonly underreported complication of PEG is malposition. This manuscript is a guideline to diagnosis and management of PEG malposition. We describe the different types of malposition, their diagnosis and management.

Hidden treasure in an endoscopically retrieved oesophageal trichobezoar

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.

Late accidental dislodgement of a percutaneous endoscopic gastrostomy tube: an underestimated burden on patients and the health care system

BACKGROUND

Since its introduction in 1980, the percutaneous endoscopic gastrostomy (PEG) tube has become an efficient means of providing long-term enteral access. Conveniently, the soft inner bumper allows PEG removal with relatively minimal external traction. Consequently, a major complication is accidental dislodgement, from which significant morbidity may occur. Clinicians have perhaps underestimated and underappreciated this complication, not only in the acute setting but over the lifetime of the PEG tube.

METHODS

A retrospective analysis of PEG placements conducted at the authors' institution identified all PEG tubes placed between July 1, 2007 and July 1, 2010 by one faculty surgeon. Patient charts were reviewed for 30-day mortality, complications, and subsequent management. Patients were reviewed until intentional removal of the PEG, cessation of records, or patient mortality.

RESULTS

A total of 563 PEGs were identified. The 30-day mortality rate was 7.8% (44/563), and the 7-day early accidental dislodgement rate was 4.1% (23/563). The total lifetime accidental PEG dislodgement rate was 12.8% (72/563). Of the 72 dislodged PEGs, 49 occurred after discharge from rehabilitation or nursing facilities. The vast majority required an emergency department visit, a level 3 surgical consultation, a replacement gastrostomy tube, and a radiographic confirmation of tube positioning, resulting in charges totaling an average of $1,200.

CONCLUSION

Many large PEG reviews report an early accidental dislodgement rate of 0.6% to 4.0%. The most clinically significant accidental removals occur in the first 7 days after placement, and open gastrostomy may cause obvious morbidity. The early dislodgement rate in this study (4.1%) is consistent with those currently reported. However, if cases are followed longitudinally, a significantly higher rate of late dislodgement (12.8%) is seen. Frequently placed into neurologically impaired or elderly patients, the PEGs that dislodge months and years later require expensive management. The late removal complication and its associated costs are overlooked and underestimated.

Epidemiology of the cerebral palsies

Half of the most severe cases of cerebral palsy (CP) survive to adulthood, but because this longevity is relatively recent, there is no empirical experience of their life expectancy past middle age. The last 2 decades have seen significant developments in the management of persons with CP, involving specialist services from an increasing number of disciplines that require coordination to maximize their effectiveness. This article provides an overview of CP. The author discusses definitions of CP, its epidemiology, pathologies, and range of possible clinical descriptions, and briefly touches on management and prevention.

Attention to small details: big deal for gastrostomies

Gastrostomy tubes are used in the pediatric population when long-term enteral feeding is needed. A common method of placement is percutaneously with endoscopy (PEG, percutaneous endoscopic gastrostomy). Although PEG placement is a straightforward procedure most of the time, it can be associated with a significant rate of minor complications and a smaller but significantly important rate of major complications. Some of these complications may also occur after any type of gastrostomy. We will present representative case studies outlining major complications and discuss how we may be able to prevent them at the time of PEG insertion or during PEG to low-profile button gastrostomy exchange. The proposed guidelines apply to all types of gastrostomies.