1
|
Palle SK, Leung DH. Advanced cystic fibrosis liver disease: Endovascular, endoscopic, radiologic, and surgical considerations. Pediatr Pulmonol 2024; 59 Suppl 1:S115-S122. [PMID: 39105344 DOI: 10.1002/ppul.27174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 06/29/2024] [Accepted: 07/03/2024] [Indexed: 08/07/2024]
Abstract
Up to 90% of people with CF (pwCF) will have some form of hepatobiliary involvement. This manuscript aims to explore the different endovascular, endoscopic, radiological and surgical procedures available to diagnose and manage the most severe form of CF hepatobiliary involvement (CFHBI) known as advanced cystic fibrosis liver disease (aCFLD), seen in 10% of pwCF. These procedures and interventions include liver biopsy, hepatic venous pressure gradient measurement, gastrostomy tube placement to optimize nutrition, paracentesis, endoscopic variceal control of bleeding and portosystemic shunting before liver transplantation. By utilizing advanced diagnostic or surgical techniques, healthcare professionals of pwCF can more effectively manage patients with CFHBI and aCFLD and potentially improve patient outcomes.
Collapse
Affiliation(s)
- Sirish K Palle
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
2
|
Fugazza A, Capogreco A, Cappello A, Nicoletti R, Da Rio L, Galtieri PA, Maselli R, Carrara S, Pellegatta G, Spadaccini M, Vespa E, Colombo M, Khalaf K, Repici A, Anderloni A. Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques. World J Gastrointest Endosc 2022; 14:250-266. [PMID: 35719902 PMCID: PMC9157691 DOI: 10.4253/wjge.v14.i5.250] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/03/2021] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.
Collapse
Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Antonio Capogreco
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Annalisa Cappello
- Unit of Gastroenterology and Digestive Endoscopy, AUSL Bologna Bellaria-Maggiore Hospital, Bologna 40121, Italy
| | - Rosangela Nicoletti
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Leonardo Da Rio
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Piera Alessia Galtieri
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Roberta Maselli
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Gaia Pellegatta
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Kareem Khalaf
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20072, Milan, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| |
Collapse
|
3
|
Wei M, Ho E, Hegde P. An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit. J Thorac Dis 2021; 13:5277-5296. [PMID: 34527366 PMCID: PMC8411178 DOI: 10.21037/jtd-19-3728] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/06/2020] [Indexed: 01/03/2023]
Abstract
Critically ill patients are at increased risk for malnutrition as they often have underlying acute and chronic illness, stress related catabolism, decreased appetite, trauma and ongoing inflammation. Malnutrition is recognized as a leading cause of adverse outcomes, higher mortality, and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes provide a safe and effective route to provide supplemental enteral nutrition to these patients. PEG placement has essentially replaced surgical gastrostomy as the modality of choice for longer term feeding in patients. This is a highly prevalent procedure with 160,000 to 200,000 PEG procedures performed each year in the United States. The purpose of this review is to provide an overview of current knowledge and practice standards with regards to placement of PEG tube in the Intensive Care Unit (ICU). When a patient is considered for a PEG tube, it is important to evaluate the treatment alternatives and identify the best option for each patient. In this review, we provide the advantages and disadvantages of various feeding modalities and devices. We review the indications and contraindications for PEG tube placement as well as the risks of this procedure. We then describe in detail the per-oral pull, per-oral push, and direct percutaneous techniques for PEG tube placement. Additionally, we review the feasibility of having interventional pulmonologists place PEG tubes in the ICU.
Collapse
Affiliation(s)
- Margaret Wei
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Elliot Ho
- Division of Advanced Interventional Thoracic Endoscopy/Interventional Pulmonology, University of California San Francisco - Fresno, Fresno, CA, USA
| | - Pravachan Hegde
- Division of Advanced Interventional Thoracic Endoscopy/Interventional Pulmonology, University of California San Francisco - Fresno, Fresno, CA, USA
| |
Collapse
|
4
|
Arvanitakis M, Gkolfakis P, Despott EJ, Ballarin A, Beyna T, Boeykens K, Elbe P, Gisbertz I, Hoyois A, Mosteanu O, Sanders DS, Schmidt PT, Schneider SM, van Hooft JE. Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:81-92. [PMID: 33260229 DOI: 10.1055/a-1303-7449] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.
Collapse
Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Asuncion Ballarin
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Torsten Beyna
- Department of Gastroenterology and Therapeutic Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
| | - Kurt Boeykens
- Nutrition Support Team, AZ Nikolaas Hospital, Sint-Niklaas, Belgium
| | - Peter Elbe
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Gisbertz
- Department of Gastroenterology, Bernhoven Hospital, Uden, The Netherlands
| | - Alice Hoyois
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ofelia Mosteanu
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital and University of Sheffield, United Kingdom
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Stéphane M Schneider
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Gastroentérologie et Nutrition, Nice, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
5
|
Shah I, Bhurwal A, Mehta H, Maas D, Koneru G, Cohen AS, Kadkhodayan KS. Trends and outcomes of percutaneous endoscopic gastrostomy in hospitalized patients with malignant and nonmalignant ascites: a nationwide population study. Ann Gastroenterol 2020; 33:656-660. [PMID: 33162742 PMCID: PMC7599344 DOI: 10.20524/aog.2020.0531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/15/2020] [Indexed: 01/07/2023] Open
Abstract
Background Patients with ascites resulting from chronic debilitating diseases often require non-oral enteral nutrition and undergo placement of a percutaneous endoscopic gastrostomy (PEG) tube. The aim of our study was to assess the nationwide trends and outcomes of PEG tube placement among patients with ascites. Methods Using the Nationwide Inpatient Sample (NIS), we conducted a retrospective analysis of adult patients (≥18 years) who underwent PEG tube placement (n=789,167) from 2010-2014. We divided these patients into 2 groups: with or without ascites. We compared demographics, complications, and in-hospital outcomes between the groups. STATA-13 was used for statistical analysis. Statistical significance was assigned at P<0.05. Results Patients with ascites who underwent PEG tube placement were found to have a significantly higher rate of complications, including peritonitis (7.52 vs. 0.72%; P<0.001), aspiration pneumonia (20.41 vs. 2.69%; P<0.001), hemoperitoneum (0.72 vs. 0.19%; P<0.001), procedure-related hemorrhage (1.69 vs. 0.9%; P<0.001) and esophageal perforation (0.51 vs. 0.47%; P<0.001). In addition, these patients also had higher in-hospital mortality (16.33% vs. 7.02%; P<0.001) despite having a relatively lower prevalence of comorbidities. Length of stay was longer in the ascites group (28.08 vs. 19.45 days; 0.001). Over the study period, however, we observed an increasing trend for PEG tube placement in hospitalized patients with ascites. Conclusion PEG tube placement in hospitalized patients with ascites is associated with significantly higher mortality, a longer stay, and more procedure-related complications.
Collapse
Affiliation(s)
- Ishani Shah
- Department of Medicine, Creighton University / St. Joseph's Hospital and Medical Center, Phoenix, AZ (Ishani Shah, Daniel Maas)
| | - Abhishek Bhurwal
- Department of Medicine, Division of Gastroenterology (Abhishek Bhurwal)
| | - Harsh Mehta
- Department of Medicine, Saint Barnabas Medical Center, Livingston, NJ (Harsh Mehta)
| | - Daniel Maas
- Department of Medicine, Creighton University / St. Joseph's Hospital and Medical Center, Phoenix, AZ (Ishani Shah, Daniel Maas)
| | - Gopala Koneru
- Department of Medicine, University of Cincinnati, Cincinnati, OH (Gopala Koneru)
| | - Aaron S Cohen
- Department of Gastroenterology, Valleywise Health (Aaron S. Cohen)
| | - Kambiz S Kadkhodayan
- Department of Medicine, Division of Gastroenterology, Creighton University/St. Joseph's Hospital and Medical Center, Phoenix, AZ (Kambiz S. Kadkhodayan), USA
| |
Collapse
|
6
|
Affiliation(s)
- Colin G DeLong
- Department of Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA
| | - Eric M Pauli
- Department of Surgery, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA.
| |
Collapse
|
7
|
First Documented Case of Percutaneous Endoscopic Gastrostomy (PEG) Tube-Associated Bacterial Peritonitis due to Achromobacter Species with Literature Review. Case Rep Gastrointest Med 2020; 2020:4397930. [PMID: 32047677 PMCID: PMC7007964 DOI: 10.1155/2020/4397930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/24/2019] [Accepted: 11/11/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction. Achromobacter species (spp.) peritonitis has seldom been identified in medical literature. Scarce cases of Achromobacter peritonitis described previously have been correlated with peritoneal dialysis and more sparingly with spontaneous bacterial peritonitis. Achromobacter exhibits intrinsic and acquired resistance, especially in chronic infections, to most antibiotics. This article conducts a literature review of all previously reported Achromobacter spp. peritonitis and describes the first reported case of Achromobacter peritonitis as a complication of percutaneous endoscopic gastrostomy (PEG) tube placement. Discussion. Achromobacter peritonitis as a complication of PEG-tube placement has not been previously reported. In our patients' case, the recently placed PEG-tube with ascitic fluid leakage was identified as the most plausible infection source. Although a rare bacterial peritonitis pathogen, Achromobacter may be associated with wide antimicrobial resistance and unfavorable outcomes. Conclusion. No current guidelines provide significant guidance on treatment of PEG-tube peritonitis regardless of microbial etiology. Infectious Disease Society of America identifies various broad-spectrum antibiotics targeting nosocomial intra-abdominal coverage; some of these antimicrobial selections (such as cefepime and metronidazole combination) may yet be inadequate for widely resistant Achromobacter spp. Recognizably, the common antibiotics utilized for spontaneous bacterial peritonitis, i.e., third generation cephalosporins and fluoroquinolones, to which Achromobacter is resistant and variably susceptible, respectively, would be extensively insufficient. Piperacillin/tazobactam (P/T) and carbapenem were identified to provide the most reliable coverage in vitro; clinically, 5 out of the 8 patients who received either P/T or a carbapenem, or both, eventually experienced clinical improvement.
Collapse
|
8
|
Nutrition Support of Children With Chronic Liver Diseases: A Joint Position Paper of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2019; 69:498-511. [PMID: 31436707 DOI: 10.1097/mpg.0000000000002443] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic liver disease places patients at increased risk of malnutrition that can be challenging to identify clinically and treat. Nutrition support is a key aspect of the management of these patients as it has an impact on their quality of life, morbidity, and mortality. There are significant gaps in the literature regarding the optimal nutrition support for patients with different types of liver diseases and the impact of these interventions on long-term outcomes. This Position Paper summarizes the available literature on the nutritional aspects of the care of patients with chronic liver diseases. Specifically, the challenges associated with the nutritional assessment of these subjects are discussed, and recently investigated approaches to determining the patients' nutritional status are reviewed. Furthermore, the pathophysiology of the malnutrition seen in the context of chronic liver disease is summarized and monitoring, as well as treatment, recommendations are provided. Lastly, suggestions for future research studies are described.
Collapse
|
9
|
|
10
|
Gasparetto A, Rosenberg M, Hunter D, Golzarian J, D'Souza D. Percutaneous gastric tube placement: Comparison of trans-abdominal and trans-oral approach in patients with chronic ascites. Diagn Interv Imaging 2018; 100:25-29. [PMID: 30220588 DOI: 10.1016/j.diii.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to compare the trans-abdominal (TA) and trans-oral (TO) approaches for fluoroscopic-guided gastrostomy tube placement in patients with chronic ascites. MATERIALS AND METHODS A 10-year review of clinical imaging and medical records at a single institution identified 29 patients with chronic recurrent ascites who underwent gastrostomy (GT) or gastro-jejunostomy tube (GJT) placement. In 22 patients (18 women, 4 men) aged from 22 to 76 years of age (mean age, 57.7±13.1 years), a GT or GJT was placed with the TO approach, and in 7 (7 women) from 31 to 86 years of age (mean age, 63±16.8 years) with the TA approach. RESULTS Technical success was 100% in both groups with one (1/22; 5%) immediate complication in the TO group. Fluoroscopy time was significantly greater in the TO group (P=0.002). Leakage of ascites was significantly more frequent in the TA group (P=0.04). There was no significant difference in bleeding or inflammation (P=0.14 and P=0.43, respectively). The cumulative tract related complication rate was significantly greater in the TA group (P=0.03). CONCLUSION Fluoroscopy times and the overall incidence of tract-related complications, in particular leakage of ascites from the stoma, are more frequent in patients in chronic ascites who underwent TA gastrostomy tube placement compared to those who underwent TO placement.
Collapse
Affiliation(s)
- A Gasparetto
- University of Minnesota, Department of Radiology, 420, Delaware St SE, 55455 Minneapolis, MN, United States
| | - M Rosenberg
- University of Minnesota, Department of Radiology, 420, Delaware St SE, 55455 Minneapolis, MN, United States
| | - D Hunter
- University of Minnesota, Department of Radiology, 420, Delaware St SE, 55455 Minneapolis, MN, United States
| | - J Golzarian
- University of Minnesota, Department of Radiology, 420, Delaware St SE, 55455 Minneapolis, MN, United States
| | - D D'Souza
- University of Minnesota, Department of Radiology, 420, Delaware St SE, 55455 Minneapolis, MN, United States.
| |
Collapse
|