Risk factors for early and late procedure-related adverse events in percutaneous endoscopic gastrostomy: A single center, retrospective study

[Intrajejunal levodopa in Parkinson's disease: Optimization of PEG application]

The various forms of Percutaneous Endoscopic Gastrostomy (PEG) are highly relevant in neurology, as pump-administered intrajejunal levodopa application is one of the indispensable forms of therapy in advanced Parkinson's disease. Optimal PEG placement and follow-up are therefore significant for the success of the therapy. However, the standard intrajejunal administration of levodopa gel via a JET-PEG, i. e. a PEG with an internal catheter inserted into the jejunum, is not without problems for various reasons. In particular, the considerable cumulative complication rates demand a reconsideration of the situation. The very limited absorption area of the drug in the region of the flexura duodenojejunalis must also be taken into account. Causes of complications are predominantly a non-optimal application technique of PEG and internal catheter as well as the frequent lack of an adequate follow-up. In this paper, the details of a modified and optimized application technique compared to the conventional techniques are presented. These new methods have proved their usefulness in clinical applications for years, and additionally a new application form, the Hybrid-PEG, is presented. However, many of the details derived from anatomical/physiological, surgical and endoscopic aspects must be strictly observed during the application in order to reduce or avoid minor and major complications. In particular, problems are caused by local infections in the area of the insertion point of the PEG including peritonitis, leaks and buried bumper syndrome (BBS). The relatively frequent dislocations of the internal catheter also prove to be particularly troublesome. These can ultimately be avoided by clip fixation of the catheter tip down in the jejunum. In particular, the use of the newly developed Hybrid-PEG, a combination of endoscopically controlled gastropexy with three sutures and subsequent central thread-pull-through of the PEG tube, can significantly reduce the complication rate and thus achieve a decisive improvement for patients. The aspects discussed here are highly relevant for all those involved in the therapy of advanced Parkinson's disease. Trustful interdisciplinary collaboration between neurology and endoscopy/surgery/gastroenterology is a prerequisite for good clinical outcomes.

Thoracic impedance pneumography in propofol-sedated patients undergoing percutaneous endoscopic gastrostomy (PEG) placement in gastrointestinal endoscopy: A prospective, randomized trial

STUDY OBJECTIVE

To assess the efficacy of an ECG-based method called thoracic impedance pneumography to reduce hypoxic events in endoscopy.

DESIGN

This was a single center, 1:1 randomized controlled trial.

SETTING

The trial was conducted during the placement of percutaneous endoscopic gastrostomy (PEG).

PATIENTS

173 patients who underwent PEG placement were enrolled in the present trial. Indication was oncological in most patients (89%). 58% of patients were ASA class II and 42% of patients ASA class III.

INTERVENTIONS

Patients were randomized in the standard monitoring group (SM) with pulse oximetry and automatic blood pressure measurement or in the intervention group with additional thoracic impedance pneumography (TIM). Sedation was performed with propofol by gastroenterologists or trained nurses.

MEASUREMENTS

Hypoxic episodes defined as SpO2 < 90% for >15 s were the primary endpoint. Secondary endpoints were minimal SpO2, apnea >10s/>30s and incurred costs.

MAIN RESULTS

Additional use of thoracic impedance pneumography reduced hypoxic episodes (TIM: 31% vs SM: 49%; p = 0.016; OR 0.47; NNT 5.6) and elevated minimal SpO2 per procedure (TIM: 90.0% ± 8.9; SM: 84.0% ± 17.6; p = 0.007) significantly. Apnea events >10s and > 30s were significantly more often detected in TIM (43%; 7%) compared to SM (1%; 0%; p < 0.001; p = 0.014) resulting in a time advantage of 17 s before the occurrence of hypoxic events. As a result, adjustments of oxygen flow were significantly more often necessary in SM than in TIM (p = 0.034) and assisted ventilation was less often needed in TIM (2%) compared with SM (9%; p = 0.053). Calculated costs for the additional use of thoracic impedance pneumography were 0.13$ (0.12 €/0.11 £) per procedure.

CONCLUSIONS

Additional thoracic impedance pneumography reduced the quantity and extent of hypoxic events with less need of assisted ventilation. Supplemental costs per procedure were negligible.

KEY WORDS

thoracic impedance pneumography, capnography, sedation, monitoring, gastrointestinal endoscopy, percutaneous endoscopic gastrostomy.

Complications and survival following percutaneous endoscopic gastrostomy tube placement

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) is considered a safe and effective method for nutritional support in patients with malnutrition and swallowing impairment with an estimated survival of over two months. Some indications, such as advanced cognitive decline, contraindicate the technique.

MATERIALS AND METHODS

All patients who underwent PEG placement between January 2001 and May 2019 were included. Clinical data, indication, complications, and mortality were retrospectively analyzed.

RESULTS

A total of 648 patients (46.5% male, mean age 70±18.5 years) were included. The most common indications for PEG were advanced cognitive decline (31.5%) and cerebrovascular disease (18.8%). The mean follow-up was 12.07 months (IQR 3.27-34.73). 39.5% of patients experienced complications (systemic 17.9%, local 28.5%). The most frequent were bronchoaspiration (9.7%) and rupture/dysfunction (13.9%), respectively. The presence of early complications (HR 1.63 [1.20-2.21]) and age (HR 1.02 [1.01-1.02]) were associated with shorter survival time, while female sex was a protective factor (HR 0.78 [0.66-0.94]).

CONCLUSIONS

PEG is not without complications, with 39.5% of patients experiencing them. Patients with advanced dementia, male sex, older age, and systemic complications have lower survival following PEG placement.

Evaluation of 644 Percutaneous Endoscopic Gastrostomy Patients in a Single Center

OBJECTIVE

Our study aimed to review and evaluate the indications, complications, complication-related risk factors, and mortality rates of percutaneous endoscopic gastrostomy (PEG) performed in a single university hospital.

METHODS

We retrospectively examined hospital records of all 819 patients who underwent PEG between January 2010 and January 2019. Patients whose information was not available for various reasons, who had a history of gastrectomy, who were under 18 years old, and/or who had undergone PEG before, were excluded from the study.

RESULTS

The mean age of the patients was 65.12 ± 15.42 years, and the majority of the patients (60.6%) were female. In the vast majority of patients, the PEG indication was due to neurological causes (71.5%), among which the majority was a stroke. The overall complication rate in our study was 11.2%. The most common was a peristomal infection in 37 (5.7%) patients. Patients who were not under any antibiotic treatment and/or had diabetes mellitus had a higher risk for peristomal infection. Dementia increased the risk of tube dislodgement. The use of clopidogrel, the simultaneous use of aspirin and clopidogrel, and hypertension were independent risk factors for bleeding complications. The one-year mortality risk was significantly higher in patients who underwent PEG due to neurological causes compared to those who underwent PEG due to malignancy or other reasons (p = 0.021, p = 0.038, respectively).

CONCLUSION

The PEG procedure is a safe and feasible technique due to its low complication and mortality rate in patients with swallowing disorders who need long-term nutritional support.

Gastrostomy Tube Insertion Complications and Patient Care Outcomes in a Tertiary Care Hospital

Background

Percutaneous endoscopic gastrostomy (PEG) is a widely known procedure where an endoscopist inserts a tube through the stomach to provide enteral nutrition. The existing literature shows inconsistent results regarding complication rates, and very few studies have examined the relationship between patient characteristics and PEG outcomes. Therefore, we aimed to investigate PEG tube insertion outcomes and determine different variables associated with these outcomes.

Methods

This retrospective record review included 207 patients who underwent PEG tube insertion at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, between 2010 and 2021. We obtained variables such as demographics, complications, and length of hospitalization. The Student t-test, chi-square test, and Mann-Whitney test were used in the data analysis.

Results

Of 207 patients, 106 were male (51.2%). The patient's median age was 10 years, and the median length of hospital stay was two days. The PEG-related complication rate was 32.4%, while the 1-year adverse outcome rate was 44.9%. The most common complications were unspecified fever (21.3%) and vomiting (14%). We found a significant relationship between dysphagia and length of hospitalization (P=0.015) and between age and the occurrence of tube leakage (P=0.021). Another significant relationship was found between the number of PEG insertions and gastrostomy-site infection (P=0.046).

Conclusions

This study's results indicate the importance of a thorough review of patients' medical records; some patient characteristics can be valuable predictors of PEG outcomes. Thus, we urge physicians to study each patient to anticipate PEG tube insertion outcomes carefully. Moreover, we recommend that researchers with access to larger patient registries study more variables to reach unified guidelines that ensure the best possible outcomes.

Factors predicting major complications, mortality, and recovery in percutaneous endoscopic gastrostomy

Background and Aim

Percutaneous endoscopic gastrostomy (PEG) has been used in patients with dysphagia and inadequate food intake via an oral route. Despite being a procedure with a high success rate, complications and death have been reported. The aim was to identify the factors related to major complications and mortality, as well as PEG removal prognostic factors due to improvement of their general condition.

Methods

Patient characteristics, comorbidities, laboratory data, concomitant medication, sedation, and indication for PEG placement were collected. Major complications, mortality, and PEG removal factors were assessed.

Results

A total of 388 patients were enrolled. There were 15 (3.9%) cases of major complications, with major bleeding being the most frequent in 6 (1.5%) patients. Corticosteroids were the independent variable associated with major complications (odds ratio [OR] 5.85; 95% confidence interval [CI] 1.71–20; P = <0.01). Advanced cancer (hazard ratio [HR] 0.5; 95% CI 0.3–1; P = 0.05), albumin (HR 0.6; 95% CI 0.4–0.9; P = <0.01), and C‐reactive protein (CRP) (HR 1.1; CI 1–1.2; P = 0.01) were considered risk factors for mortality. Previous pneumonia (HR 0.4; CI 0.2–0.9; P = 0.02) was a factor for permanent use of a PEG; however, oncological indication (HR 8.2; CI 3.2–21; P = <0.01) was factors for PEG withdrawal.

Conclusions

Chronic corticosteroid users potentially present with major complications. Low albumin levels and elevated CRP were associated with death. Previous aspiration pneumonia was a factor associated with permanent use of PEG; however, patients with oncological indication were the most benefited.

Development and Pilot Validation of an Instrument Assessing Sensorimotor Skills for Percutaneous Gastral Puncture

Introduction

The acquisition of sensorimotor skills, so-called "technical skills", plays an essential part in the professional and continuing educational training of medical and nursing staff. Facilities turn to simulator training to promote the safe and accurate performance of endoscopic examinations. Thus, this study aimed to develop and pilot-test a corresponding assessment instrument to monitor necessary sensorimotor or "technical" skills of the examiner for a safe percutaneous endoscopic gastrostomy (AS-PEG).

Materials and Methods

Instrument development and pilot validation involved four stages: identification of potential items and initial draft of the AS-PEG; expert panel with 11 experts (content validity index [CVI] calculated); empirical validation using a quasi-experimental intervention on simulators; revision of the pilot AS-PEG taking expert assessment, and empirical testing into consideration.

Results

The initial instrument yielded 13 categories and 44 items describing the PEG procedure. Experts rated 30 out of 44 items (68%) extremely or very important for the safety of the puncture of the stomach. Initial item-CVIs ranged from 0.00 to 1.00; scale-CVI was 0.61. Twenty-four trainees (7 physicians, 17 nurses) participated in the pilot simulation study. On average, 8:25 min were required for PEG placement (min-max 5:59-13:38 min, SD = 1:43). The revised AS-PEG version was reduced to 14 items with a range of the item CVI from 0.8 to 1.0, and a scale-CVI of 0.90.

Conclusion

The AS-PEG instrument facilitates the evaluation of sensorimotor skills during percutaneous gastric puncture procedures within the context of PEG placement, across professions and without relating to the number of procedures previously performed. The instrument is economical and shows satisfying content validity.

Percutaneous endoscopic gastrostomy: dealing with the issue of dislodgement

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is accepted as an efficient method to provide long-term enteral nutrition. PEG accidental dislodgement (device exteriorization confirmed by expert evaluation) rate is high and can lead to major morbidity.Objective: To identify independent risk factors for PEG accidental dislodgement.Methods: Retrospective, single-center study, including consecutive patients submitted to PEG procedure, for 38 consecutive months. Every patient had 12 months minimum follow-up after PEG placement. Univariate analysis selected variables with at least marginal association (p < .15) with the outcome variable, PEG dislodgement, which were included in a logistic regression multivariate model. Discriminative power was assessed using area under curve (AUC) of the receiver operating curve (ROC).Results: We included 164 patients, 67.7% (111) were female, mean age was 81 years. We report 59 (36%) PEG dislodgements, of which 13 (7.9%) corresponded to early dislodgements. The variables with marginal association were hypoalbuminemia (p = .095); living at home (p = .049); living in a nursing home (p = .074); cerebrovascular disease (CVD) (p = .028); weight change of more than 5 kg, either increase or decrease (p = .001); psychomotor agitation (p < .001); distance inner bumper-abdominal wall (p = .034) and irregular appointment follow-up (p = .149). At logistic multivariate regression, the significant variables after model adjustment were CVD OR 4.8 (CI 95% 2.0-11.8), weight change OR 4.7 (CI 95%1.6-13.9) and psychomotor agitation OR 18.5 (CI 95% 5.2-65.6), with excellent discriminative power (AUC ROC 0.797 [CI95% 0.719-0.875]).Conclusion: PEG is a common procedure and accidental dislodgement is a frequent complication. CVD, psychomotor agitation and weight change >5 kg increase the risk of this complication and should be seriously considered when establishing patients' individual care requirements.

Survival Analysis of Enterally Fed Patients: Prognosis and Mortality Risk According to Baseline Characteristics

BACKGROUND

Enteral nutrition is widely used. However, its benefits remain unclear in specific conditions like dementia. This study assesses the survival of enterally fed patients and the baseline characteristics associated with higher mortality.

METHODS

A retrospective analysis of biochemical and clinical data from 377 patients (age 77.5 ± 13.8) who received enteral tube feeding (ETF) at a tertiary hospital in Spain was performed. Kaplan-Meier and Cox regressions were used to analyze survival expectancy and mortality risk (MR). Risk was evaluated for 30/180 days and up to 5 years.

RESULTS

The most common individual diagnoses leading to ETF prescription were dementia (37.9%) and head/neck/upper-gastrointestinal-tract cancer (17.5%). Comorbidities (high blood pressure [HBP] and/or diabetes) were present in 72.4% of patients. The first 30 days after tube placement showed the highest mortality rate, corresponding to 85.4% of patients that did not continue being tube-fed. Multivariate Cox analysis (P < .05, 95% CI) showed HBP and glycemia to be predictive of overall (hazard ratio [HR] = 1.600; HR = 1.756) and long-term (HR = 3.092; HR = 4.539) death. In the short-term, only glycemia showed an increased MR (HR = 1.572).

CONCLUSION

This enterally fed population showed a noticeably high initial mortality rate. Despite official recommendations against it, ETF is very common in advanced dementia. Baseline characteristics are useful for identifying patients that would be less benefited by the intervention. Accordingly, families should be informed about realistic outcomes and risks derived from this procedure.

Prophylactic percutaneous endoscopic gastrostomy in patients with head and neck cancer: Influence on nutritional status, utilisation rate and complications

BACKGROUND

Patients with head and neck cancer (HNC) are at high risk for malnutrition because of tumour localisation and therapy. Prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement is common practice to prevent malnutrition.

OBJECTIVE

To investigate the benefits of prophylactic PEG tube placement for HNC patients in terms of the influence on patients' nutritional status, utilisation rate, complications and to identify the predictors of PEG tube utilisation.

METHODS

All consecutive HNC patients who underwent prophylactic PEG tube insertion between 1 January 2011 and 31 December 2012 prior to therapy were enrolled. The PEG tube utilisation rate, complications, the patients' nutritional status and tumour therapy were evaluated with the help of electronic patient charts and telephone interviews.

RESULTS

A total of 181 patients (48 female, median 67.5 years) were included. The PEG utilisation rate in the entire cohort was 91.7%. One hundred and forty-nine patients (82.3%) used the PEG tube for total enteral nutrition, 17 patients (9.4%) for supplemental nutrition and 15 patients (8.3%) made no use of the PEG tube. Peristomal wound infections were the most common complications (40.3%) in this study. A high Nutritional Risk Screening (NRS) score prior to tube insertion was found to be independently associated with PEG utilisation. No significant weight changes were observed across the three patient subgroups.

CONCLUSIONS

The overall PEG tube utilisation rate was high in this study. However, given the high rate of infections, diligent patient selection is crucial in order to determine which patients benefit most from prophylactic PEG tube insertion.

MDCT evaluation of complications of percutaneous gastrostomy tube placement

Percutaneous gastrostomy tube placement is a commonly performed procedure to provide enteral alimentation to patients unable to tolerate oral feeds. Percutaneous gastrostomy is a relatively safe procedure, and serious complications like gastrointestinal bleeding, perforated viscus, and adjacent organ injury are rare. The most common complications after gastrostomy tube placement occur early and are usually minor. The purpose of this review article is to describe the techniques of percutaneous gastrostomy tube insertion and imaging protocol for gastrostomy tube evaluation, and describe the early, late, and anytime complications. The article will also illustrate very rare late complications of gastrostomy tube placement like gastro-hepatic fistula, gastro-colic fistula, buried bumper syndrome, and gastrostomy site hernia.