Percutaneous endoscopic gastrostomy (PEG): a practical approach for long term management

Development and implementation of a Sezer gastrostomy care bundle using the Knowledge to Action framework

BACKGROUND

This project aimed to develop an evidence-based nursing care bundle after gastrostomy feeding tube insertion and implement it into clinical practice using the Knowledge to Action (KTA) framework.

METHODS

This mixed-method design project was conducted in a university hospital between December 2021 and June 2022. The project was carried out in four phases: (1) development of an evidence-based care bundle, (2) education for care bundle training, (3) implementation of the care bundle, (4) evaluation of the care bundle. Nurses' compliance with bundles was measured using All-or-None measurement. The analysis of the qualitative interview conducted was performed using the content analysis method of Graneheim and Lundman.

RESULTS

The developed Sezer gastrostomy care bundle consists of three parameters (peristomal area care, tube feeding, and medication administration through the feeding tube) and a total of 14 elements to be applied by nurses under these parameters. Compliance rates for peristomal area care, tube feeding, and medication administration through feeding tube parameters were 100%, 98.66%, and 98.66%, respectively. Two themes and six subthemes emerged: (1) reflection of using the Sezer gastrostomy care bundle on nursing care and (2) adoption of Sezer gastrostomy care bundle.

CONCLUSION

The gastrostomy care bundle was developed in accordance with the Institute of Healthcare Improvement's recommendations. The KTA framework provided an appropriate structure to transform evidence into practice, meticulously address barriers, evaluate outcomes, and ensure sustainability. The project found that nurses complied with all its parameters. Studies evaluating the effect of the gastrostomy care bundle on patient outcomes are recommended.

Hemorrhagic shock from gastric pseudoaneurysm post-percutaneous endoscopic gastrostomy: a case report

Percutaneous endoscopic gastrostomy (PEG) is widely used for long-term enteral nutrition in patients unable to maintain adequate oral intake. Despite advancements in PEG techniques, complications remain a concern. We report a case of a 94-year-old bedridden man who developed significant complications after PEG placement using the pull method. Initially, minor bleeding at the puncture site was managed using traction compression. However, the patient later experienced hemorrhagic shock owing to pulsatile bleeding around the gastrostomy site. Despite attempts to control the bleeding through traction and transfusions, a pseudoaneurysm adjacent to the PEG button was identified. The patient underwent successful transcatheter arterial embolization (TAE). Post-TAE, no further bleeding or hematoma was observed, and imaging confirmed the resolution of the pseudoaneurysm and hematoma. Methicillin-resistant Staphylococcus aureus (MRSA) infection was detected at the gastrostomy site, which contributed to complications. Despite successful management of the bleeding, the patient's overall condition deteriorated, and he died on postoperative day 66. This case underscores the importance of vigilant monitoring and management of PEG-related complications, particularly infections that may precipitate severe vascular events.

[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.

Optimised endoscopic access for intrajejunal levodopa application in idiopathic Parkinson's syndrome

Pump-guided intrajejunal levodopa administration is one of the indispensable forms of therapy in advanced Parkinson's syndrome, along with deep brain stimulation and subcutaneous apomorphine injection. The standard application of levodopa gel via a JET-PEG, i.e. a percutaneous endoscopic gastrostomy (PEG) with an inserted internal catheter into the jejunum, has not been unproblematic due to the restricted absorption area of the drug in the region of the flexura duodenojejunalis and especially due to the sometimes considerable accumulated complication rates of a JET-PEG. Causes of complications are mainly a non-optimal application technique of PEG and internal catheter as well as the often missing adequate follow-up care. This article presents the details of a-compared to the conventional technique-modified and optimised application technique, which has been clinically proven successfully for years. However, many details derived from anatomical, physiological, surgical and endoscopic aspects must be strictly observed during the application to reduce or avoid minor and major complications. Local infections and buried bumper syndrome cause particular problems. The relatively frequent dislocations of the internal catheter (which can ultimately be avoided by clip-fixing the catheter tip) also prove to be particularly troublesome. Finally, using the Hybrid technique, a new combination of an endoscopically controlled gastropexy with 3 sutures and subsequent central thread pull-through (TPT) of the PEG tube, the complication rate can be dramatically reduced and thus a decisive improvement achieved for patients. The aspects discussed here are highly relevant for all those involved in the therapy of advanced Parkinson's syndrome.

Impact of Mobile Apps in Conjunction With Percutaneous Endoscopic Gastrostomy on Patients' Complications, Quality of Life, and Health-Related Self-Care Behaviors: Randomized Clinical Trial

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is commonly chosen for long-term enteral nutrition support. However, common complications of PEG include wound infection, leakage, obstruction, bleeding, dislodgement, pneumonia, peritonitis, and more. The anticipation of these complications by both patients and their family caregivers underscores the essential requirement of ongoing technical guidance for the daily care of PEG and the adoption of preventative strategies.

OBJECTIVE

This study aimed to establish and compare a health education program utilizing a tracking system for PEG using a mobile app (PEG app) and instant messaging software versus a paper-based health education program with instant messaging software. Their effectiveness in preventing complications, avoiding hospital readmissions, improving self-care practices, and enhancing quality of life outcomes was assessed.

METHODS

A randomized controlled trial design was used, and the study sample consisted of patients from a medical center in central Taiwan who underwent thoracic surgery or gastroenterology procedures. Inclusion criteria were being a new case undergoing his or her first gastric tube insertion and having the ability to operate a smartphone. Exclusion criteria were cases requiring tube replacement or nasogastric tubes. A total of 74 participants were enrolled, with 37 participants in the experimental group and 37 participants in the control group. Data collection took place from hospitalization until 1 month after discharge. The experimental group received care using the gastric tube tracking system (PEG app) and the Line app that included phone, text, and photo capture capabilities, while the control group received routine nursing care and used the Line app.

RESULTS

The experimental group demonstrated a significant reduction in the occurrence of complications compared with the control group (χ21=12.087, P=.001). Specifically, the occurrence of leakage events was significantly lower in the experimental group than in the control group (χ21=12.906, P=.001). However, the experimental group exhibited superior self-care ability compared with the control group (t72=2.203, P=.03). There was no significant difference in overall quality of life scores between the experimental and control groups (t72=1.603, P=.11). However, the experimental group showed better social aspects of quality of life than the control group (t72=2.164, P=.03).

CONCLUSIONS

Integration of the PEG app with instant messaging can enhance self-care ability, improve social aspects of quality of life, and reduce complications. The study results suggest that the PEG app could be used as an adjunct tool to promote patients' self-directed management of their gastric tube at home, particularly for patients who have undergone their first PEG placement and are being discharged from the hospital.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300071271; https://tinyurl.com/4vvy584e.

Efficacy and cost-effectiveness analysis of pretreatment percutaneous endoscopic gastrostomy in unresectable locally advanced esophageal cancer patients treated with concurrent chemoradiotherapy (GASTO 1059)

BACKGROUND

We launched a single-arm phase II study to determine the efficacy and cost-effectiveness of percutaneous endoscopic gastrostomy (PEG) before concurrent chemoradiotherapy (CCRT) in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

Eligible patients received pretreatment PEG and enteral nutrition during CCRT. The primary outcome was the change of weight during CCRT. The secondary outcome included nutrition status, loco-regional objective response rate (ORR), loco-regional progression-free survival (LRFS), overall survival (OS), and toxicities. A 3-state Markov model was applied for cost-effectiveness analysis. Eligible patients were matched and compared with those who had nasogastric tube feeding (NTF) or oral nutritional supplements (ONS).

RESULTS

Sixty-three eligible patients received pretreatment PEG-based CCRT. The mean change of weight during CCRT was -1.4% (standard deviation, 4.4%), and after CCRT, 28.6% of patients gained weight and 98.4% had normal albumin levels. The loco-regional ORR and 1-year LRFS were 98.4% and 88.3%. The incidence of grade ≥3 esophagitis was 14.3%. After matching, another 63 patients were included in the NTF group and 63 in the ONS group. More patients gained weight after CCRT in the PEG group (p = 0.001). The PEG group showed higher loco-regional ORR (p = 0.036) and longer 1-year LRFS (p = 0.030). In cost analysis, the PEG group showed an incremental cost-effectiveness ratio of $3457.65 per quality-adjusted life-years (QALY) compared with the ONS group with a probability of cost-effectiveness of 77.7% at the $10,000 per QALY willingness-to-pay threshold.

CONCLUSION

Pretreatment PEG is associated with better nutritional status and treatment outcome in ESCC patients treated with CCRT compared with ONS and NTF. Pretreatment of PEG can be cost-effective because of its significant clinical benefits.

Trends Regarding Racial Disparities Among Malnourished Patients With Percutaneous Endoscopic Gastrostomy (PEG) Tubes

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) is performed in patients who cannot tolerate oral intake and who may require more than 30 days of nutritional support. These patients are at high risk for malnutrition, which itself can contribute to worsening clinical status. Racial disparities regarding access to sources of nutrition have been established. We aim to determine if such racial disparities regarding the diagnosis of malnutrition exist in this high-risk population.

METHODS

The National Inpatient Sample (NIS) was queried for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses coding for PEG tube placement with or without a diagnosis of malnutrition. Results were stratified by race. Rates of PEG tube complications were assessed. Categorical and continuous data were assessed via chi-squared and analysis of variance (ANOVA) tests respectively. Binary and multiple logistic regression was used to control for confounders.

RESULTS

Black patients had the highest rates of malnutrition diagnoses, mechanical complications from gastrostomy placement, and the lowest rates of palliative care discussions. Asian or Pacific Islander patients had the highest rates of aspiration pneumonia, gastrointestinal bleeding, the greatest mortality rates, and the longest hospital stays.

DISCUSSION

Racial minorities had worse outcomes while Caucasians had shorter hospital stays and lower complication rates. Such disparities can be multifactorial in etiology, with lack of nutritional access, poor doctor-patient communication, and differential rates of insurance coverage contributing to poorer outcomes among racial minorities. More change is required to promote equity when managing patients with end-of-life diseases necessitating methods of nutritional support.

Mortality and complications after percutaneous endoscopic gastrostomy: a retrospective multicentre study

Background

Percutaneous endoscopic gastrostomy (PEG) is the method of choice for patients in need of long-term nutritional support or gastric decompression. Although it is considered safe, complications and relatively high mortality rates have been reported. We aimed to identify risk factors for complications and mortality after PEG in routine healthcare.

Methods

This retrospective study included all adult patients who received a PEG between 2013 and 2019 in Region Norrbotten, Sweden.

Results

389 patients were included. The median age was 72 years, 176 (45%) were women and 281 (72%) patients received their PEG due to neurological disease. All-cause mortality was 15% at 30 days and 28% at 90 days. Malignancy as the indication for PEG was associated with increased mortality at 90 days (OR 4.41, 95% CI 2.20–8.88). Other factors significantly associated with increased mortality were older age, female sex, diabetes mellitus, heart failure, lower body mass index and higher C-reactive protein levels. Minor and major complications within 30 days occurred in 11% and 15% of the patients, respectively. Diabetes increased the risk of minor complications (OR 2.61, 95% CI 1.04–6.55), while those aged 75 + years were at an increased risk of major complications, compared to those younger than 65 years (OR 2.23, 95% CI 1.02–4.85).

Conclusions

The increased risk of death among women and patients with malignancy indicate that these patients could benefit from earlier referral for PEG. Additionally, we found that age, diabetes, heart failure, C-reactive protein and body mass index all impact the risk of adverse outcomes.

Comparison of Pull and Introducer Techniques for Percutaneous Endoscopic Gastrostomy

Objective

To compare indications, success rates and complications of pull [P] and introducer [I] techniques for percutaneous endoscopic gastrostomy (PEG).

Methods

In this retrospective study, inpatients who underwent primary PEG tube insertion between January 2015 and February 2020 at the Endoscopy Center of the First Affiliated Hospital of Fujian Medical University were included.

Results

A total of 103 inpatients were included in this study (P group, n = 67; I group, n = 36). The rates of tube replacement within first six months in the P and I groups were 1.5% and 11.1%, respectively (P = 0.049). The most common primary indication of PEG was malignancy. The proportion of patients with esophageal cancer was significantly lower in the P group (24.4% vs 54.2%, P = 0.015). No significant difference was found in the overall, major, or minor complications between the two groups. In patients with esophageal stenosis, the pull method was a risk factor for complications (P = 0.03; odds ratio [OR] = 12, 95% confidence interval [CI]: 1.164–123.684). Logistic regression analysis showed that the risk factors for major and minor complications were the admission-to-gastrostomy interval (OR = 1.078, 95% CI: 1.016–1.145, P = 0.014) and lack of antibiotic use (OR = 4.735, 95% CI: 1.247–17.979, P = 0.022), respectively.

Conclusion

Both PEG techniques have high clinical success rates. The introducer technique is more suitable for patients with esophageal stricture, which has lower minor complications, but higher rate of tube replacement compared to the pull technique. Use of antibiotics may reduce minor complications following PEG. Early PEG insertion may help to reduce post-PEG major complications.

Oral and maxillofacial conditions, dietary aspects, and nutritional status of children with congenital Zika syndrome

OBJECTIVE

The aim of this study was to investigate oral and maxillofacial outcomes in children with congenital Zika syndrome (CZS) and the presence of nonnutritive sucking habits, functional habits, and features related to breastfeeding and nutrition of these children.

STUDY DESIGN

We conducted a cross-sectional study with 45 children with CZS and 50 healthy controls in Sergipe state, Brazil, from February 2018 to June 2018. Demographic and clinical data, including breastfeeding and feeding data, were obtained for each child. Additionally, oral and maxillofacial evaluation was performed.

RESULTS

Low weight (prevalence rate [PR] 8.33; 95% confidence interval [CI] 2.02-34.45), nonexclusive breastfeeding up to 6 months (PR 1.56; 95% CI 1.18-2.08); mouth breathing (PR 3.46; 95% CI 1.83-6.52); difficulty in swallowing (PR 6.00; 95% CI 2.53-14.25); and excessive salivation (PR 4.81; 95% CI 2.18-10.62) were more frequent in children with CZS. Children with CZS were more likely to have abnormal insertion of the upper labial frenulum (PR 7.04; 95% CI 2.23-22.20); ogival palate (PR 3.70; 95% CI 1.63-8.40), dental enamel defects (PR 2.22; 95% CI 1.05-4.69); and delayed dental eruption (PR 8.89; 95% CI 1.16-68.32) compared with healthy children.

CONCLUSIONS

Children with CZS had a higher frequency of problems related to breastfeeding, low weight, and oral and maxillofacial abnormalities compared with healthy children.

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.