Reappraisal of Pneumoperitoneum After Percutaneous Endoscopic Gastrostomy

Endoscopic Complications Are More Frequent in Levodopa-Carbidopa Intestinal Gel Treatment via JET-PEG in Parkinson's Disease Patients Compared to Nutritional PEG in Non-Parkinson's Disease Patients

Background: To date, no studies comparing complication rates between patients with nutritional percutaneous endoscopic gastrostomy (N-PEG) and Parkinson's disease (PD) patients with percutaneous endoscopic gastro-jejunostomy (JET-PEG) for treatment administration have been published. Our study aimed to compare complication rates and the number of re-endoscopies between N-PEG and JET-PEG patients. Methods: Individuals requiring N-PEG or JET-PEG insertion between 2014 and 2021 were included in this single-center retrospective observational study. Complications were divided into time-related medical and technical complications. Reasons for post-insertion re-endoscopies and their number were also analyzed. Results: Eighty-seven subjects, 47 (54.02%) in JET-PEG group and 40 (45.98%) in the N-PEG group, were included. Early and technical complications were more frequent in JET-PEG vs. N-PEG subjects (70% vs. 10% [p < 0.001], and 54.5% vs. 5.1% [p < 0.001], respectively). The presence of psychiatric disease was associated with a higher number of early complications (p < 0.002). All three types of complications were significantly more frequent in subjects where a healthcare professional did not handle PEG (p < 0.001). Subjects with JET-PEG required a higher number of re-endoscopies compared to the N-PEG group (57.1% vs. 35%, p = 0.05). Conclusions: Complications are significantly more common in individuals with JET-PEG than those with N-PEG, which can be attributed to higher mobility in PD patients.

Clinical Practice Guideline for Percutaneous Endoscopic Gastrostomy

With an aging population, the number of patients with difficulty swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. Long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach, aided endoscopically, which may be an alternative to a nasogastric tube when enteral nutritional is required for 4 weeks or more. This paper is the first Korean clinical guideline for PEG. It was developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tubes removal for PEG based on the currently available clinical evidence.

Incidence of Pneumoperitoneum After Gastrostomy Tube Removal

We present the case of an 88-year-old man with a previous medical history of severe colitis and colonic strictures who presented with hematemesis. The patient was found to have a lower esophageal ulcer without any signs of perforation. Esophagogastroduodenoscopy (EGD) revealed a scar in the greater curvature of the stomach from a previously removed gastrostomy tube two months prior. On CT imaging, an incidental finding of pneumoperitoneum was also found alongside stomach perforation near the healing scar. Due to the lack of evidence of any other colonic perforation, the patient was believed to have developed this pneumoperitoneum status post-gastrectomy tube removal two months prior to presentation. Pneumoperitoneum has a wide range of presenting symptoms that vary in severity and nature, and our patient failed to present with any physical or laboratory signs of infection. Over the course of the next four months, the patient was monitored with serial CT scans, during which the pneumoperitoneum resolved. In this report, we present a case of a patient who was found to develop pneumoperitoneum post-gastric tube removal and its complete resolution without surgical or procedural intervention.

Pneumoperitoneum After Jejunostomy Tube Placement Managed by Needle Decompression: A Case Report

Percutaneous endoscopic feeding tube placement is a commonly performed procedure in patients who cannot take food by mouth. While it is considered a safe and effective method of providing nutritional support, like any medical procedure, it can lead to complications. Feeding tube placement, including percutaneous endoscopic jejunostomy (PEJ), is associated with several complications, including bleeding, site infection, aspiration, buried bumper, tube dislodgement, and pneumoperitoneum. We report a case of a 20-year-old male with multiple medical issues who underwent a PEJ that was complicated by bowel distension. The patient developed tension pneumoperitoneum post-procedure, which was treated with a bedside needle decompression. This case report highlights the significance of promptly recognizing and intervening in complications that may arise during a frequently performed medical procedure, PEJ tube placement, to prevent serious consequences, including bowel ischemia.

Symptomatic Pneumoperitoneum After Gastrostomy Tube Placement Managed by Pneumocentesis

Pneumoperitoneum is a known complication of percutaneous endoscopic gastrostomy tube placement that typically resolves spontaneously with conservative management. We describe the case of a 72-year-old man who developed abdominal pain and distention after percutaneous endoscopic gastrostomy tube placement who was subsequently found to have a moderate-sized pneumoperitoneum. Despite supportive care, his abdominal pain failed to improve. We report paracentesis with air aspiration as an intervention for benign pneumoperitoneum resulting in rapid and durable resolution of abdominal complaints.

Massive Incidental Pneumoperitoneum in an Amyotrophic Lateral Sclerosis Patient

In this report, we present the case of a 61-year-old male patient diagnosed with amyotrophic lateral sclerosis (ALS), who presented to the ER with worsening shortness of breath, several hours following elective percutaneous endoscopic gastrostomy (PEG) tube placement. During his hospitalization, he was diagnosed with massive pneumoperitoneum, a potential complication of such procedures. We aim to provide a general overview of this condition and to discuss the special considerations in the treatment of ALS.

Percutaneous Endoscopic Gastrostomy Tube Gone Wrong: Endoscopic Closure to the Rescue

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly performed endoscopic procedures and a first-line treatment for the establishment of enteral access in those with intolerance or contraindication to oral feedings. A small amount of pneumoperitoneum in the immediate postprocedure period is well reported after PEG tube placement. However, pneumoperitoneum resulting from displaced gastric bumper within 24 hours postprocedure is uncommon and rarely reported in the literature. Timely diagnosis and early endoscopic management can help tackle such an unusual complication.

Prevention and management of major complications in percutaneous endoscopic gastrostomy

Background

Percutaneous endoscopic gastrostomy is a commonly used endoscopic technique where a tube is placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition. Several placement techniques are described in the literature with the ‘pull’ technique (Ponsky-Gardener) as the most popular one. Independent of the method used, placement includes a ‘blind’ perforation of the stomach through a small acute surgical abdominal wound. It is a generally safe technique with only few major complications. Nevertheless these complications can be sometimes life-threatening or generate serious morbidity.

Method

A narrative review of the literature of major complications in percutaneous endoscopic gastrostomy.

Results

This review was written from a clinical viewpoint focusing on prevention and management of major complications and documented scientific evidence with real cases from more than 20 years of clinical practice.

Conclusions

Major complications are rare but prevention, early recognition and popper management are important.

Percutaneous Gastrostomy Tube Placement: Recognizing When Things Go Wrong

Percutaneous radiologic gastrostomy is a commonly performed, minimally invasive procedure for long-term enteral access in patients with a variety of conditions. Compared with other methods, it is less invasive, less costly, and safe, with a high technical success rate. The risk of complications is low, and most require only conservative management. Early, accurate diagnosis of more severe complication is crucial, as these may require prompt intervention. Therefore, radiologists should understand the imaging features, clinical presentation, and management of gastrostomy-related complications. This article will review the indications for long-term enteral access, discuss the available methods, summarize the percutaneous radiologic technique, and highlight the associated complications from gastrostomy placement.

Diagnosis and treatment of pediatric benign pneumoperitoneum: A case report series of 9 patients

INTRODUCTION

Benign pneumoperitoneum (BPPT) is defined as asymptomatic free intraabdominal air or as pneumoperitoneum without peritonitis. Symptomatic free air requires surgical anagement, but management of asymptomatic pneumoperitoneum is controversial. In this study, we investigate the diagnosis and treatment of BPPT in children.

CLINICAL FINDINGS

The clinical data of 9 pediatric patients with BPPT who were admitted to our hospital from January 2000 to January 2015 were retrospectively analyzed to summarize the diagnosis and treatment. Overall, 9 cases were included with 8 males and 1 female, aged from 4 days to 4 years. Among them there were 6 newborns (including 1 premature infant). Patients were all admitted to hospital with the major clinical symptom of abdominal distension, including 2 cases accompanied by tachypnea, 2 cases with vomiting, 1 case with diarrhea, and 2 cases with fever. No previous constipation or obstructive defecation existed. Six newborns had meconium defecation within 24 hours after birth. Physical examination revealed all patients with relaxed abdominal wall except 1 patient with abdominal distension had slight muscle stiffness and hyperactive bowel sounds. Abdominal X-ray suggested free air under the diaphragm in all cases.

INTERVENTIONS/OUTCOMES

All patients except for one case of laparotomy were conservatively treated and cured with fasting, infection prevention, rehydration, abdominocentesis, and close observation. Nine cases of patients were all discharged with no death occurrence. After discharge follow-up of 7 months to 6 years was conducted. There was no recurrence of similar symptoms, and children were in good growth and development.

CONCLUSION

The diagnosis of BPPT mainly relies on clinical symptoms in patient, careful abdominal examination, abdominal X-ray combined with abdominocentesis, and the exclusion of gastrointestinal perforation for confirmation. Conservative treatment can cure the disease. Attention should be paid to distinguish with surgical pneumoperitoneum to avoid unnecessary surgical exploration.

Thirty-day mortality after percutaneous gastrostomy by endoscopic versus radiologic placement: a systematic review and meta-analysis

Background/Aims

A percutaneous gastrostomy can be placed either endoscopically (percutaneous endoscopic gastrostomy, PEG) or radiologically (radiologically-inserted gastrostomy, RIG). However, there is no consistent evidence of the safety and efficacy of PEG compared to RIG. Recently, 30-day mortality has become considered as the most important surrogate index for evaluating the safety and efficacy of percutaneous gastrostomy. The aim of this meta-analysis was to compare the 30-day mortality rates between PEG and RIG.

Methods

Major electronic databases (MEDLINE, Embase, Scopus, and Cochrane library) were queried for comparative studies on the two insertion techniques of gastrostomy among adults with swallowing disturbance. The primary outcome was the 30-day mortality rate after gastrostomy insertion. Forest and funnel plots were generated for outcomes using STATA version 14.0.

Results

Fifteen studies (n=2,183) met the inclusion criteria. PEG was associated with a lower risk of 30-day mortality after tube placement compared with RIG (odds ratio, 0.60; 95% confidence interval [CI], 0.38–0.94; P=0.026). The pooled prevalence of 30-day mortality of PEG was 5.5% (95% CI, 4.0%–6.9%) and that of RIG was 10.5% (95% CI, 6.8%–14.3%). No publication bias was noted.

Conclusions

The present meta-analysis demonstrated that PEG is associated with a lower probability of 30-day mortality compared to RIG, suggesting that PEG should be considered as the first choice for long-term enteral tube feeding. Further prospective randomized studies are needed to evaluate and compare the safety of these two different methods of gastrostomy.

The role of surgery in the treatment of endoscopic complications

As the number, diversity, and complexity of endoscopic complications has increased, so too has the number, diversity, and complexity of operative interventions required to treat them. The most common complications of endoscopy in general are bleeding and perforation, but each endoscopic modality has specific nuances of these and other complications. Accordingly, this review considers the surgical complications of endoscopy by location within the gastrointestinal tract, as opposed to by complication types, since there are many complication types that are specific for only one or few locations, such as buried-bumper syndrome after percutaneous endoscopic gastrostomy and pancreatitis after endoscopic retrograde cholangiopancreatography, and since the management of a given complication, such as perforation, may be vastly different in one area than in another area, such as perforations of the esophagus versus the retroperitoneal duodenum versus the intraperitoneal duodenum. It is hoped that this review will provide guidance for gastroenterologists considering a particular procedure, either to assess the risks for surgical complications in preparation for patient counseling, or assist in assessing a patient who seems to be having a severe complication, or to learn what operation might be required to treat a given complication and how that operation might be performed. As with many operations, those for the treatment of endoscopic complications are typically performed only when less invasive, nonoperative strategies fail.