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1.  Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy in Children and Adolescents 
Objective:
Pediatric gastric access for long-term enteral feeding may be performed via a laparotomy, laparoscopy, or a percutaneous approach. In children and adolescents, laparoscopic-assisted gastrostomy may be difficult due to a thick abdominal wall. Therefore, if the abdominal wall is estimated to be >2 cm on physical examination, or in children in whom a percutaneous endoscopic gastrostomy was unsuccessfully attempted by a gastroenterologist, we routinely perform a laparoscopic-assisted percutaneous endoscopic gastrostomy.
Methods:
From January 1998 through February 2003, we retrospectively reviewed 15 cases of a laparoscopic-assisted percutaneous endoscopic gastrostomy. Instruments used to perform this technique are a percutaneous endoscopic gastrostomy kit, an Olympus flexible endoscope, and one 5-mm STEP port placed through an infraumbilical incision for a 5-mm, 30-degree scope.
Results:
Age range was 2 years to 20 years (mean, 10). Operative time ranged from 20 minutes to 45 minutes. When a concurrent laparoscopic Nissen fundoplication was performed (n = 6), the percutaneous endoscopic gastrostomy was placed after completion of the Nissen fundoplication. No intraoperative complications occurred, and all tubes were successfully placed. Feeds were instituted the following day and advanced to goal. To date, no postoperative complications have occurred, and revision has not been necessary.
Conclusions:
Laparoscopic-assisted percutaneous endoscopic gastrostomy in children and adolescents is safe and effective. Utilizing laparoscopy permits evaluation of the peritoneum and lysis of adhesions, if necessary. Moreover, laparoscopy provides excellent exposure for accurate placement of the PEG, while avoiding injury to other organs.
PMCID: PMC3015611  PMID: 16121876
Laparoscopy; Percutaneous endoscopic gastrostomy
2.  Current considerations in direct percutaneous endoscopic jejunostomy 
For patients who are unable to meet their nutritional needs orally, enteral feeding via a percutaneous approach has become the mainstay of therapy. However, traditional enteral feeding methods, such as percutaneous endoscopic gastrostomy, may not be viable options for patients with severe gastroparesis or gastric outlet obstruction. Direct percutaneous endoscopic jejunostomy (DPEJ) is an enteral access method that was first described more than 20 years ago and has gained popularity among gastroenterologists. This review discusses the indications for and contraindications to DPEJ, the procedure, the application of DPEJ in specific subsets of patients with gastrointestinal disorders, and presents a brief tabular summary of complications and success rates of DPEJ in case series published since 2000.
BACKGROUND:
Direct percutaneous endoscopic jejunostomy (DPEJ) is a well-known approach to deliver postpyloric enteral nutritional support to individuals who cannot tolerate gastric feeding. However, it is technically difficult, and some case series have reported significant procedural failure rates. The present article describes current indications, successes and complications of DPEJ placement
METHODS:
A MEDLINE database search was performed to identify relevant articles using the key words “direct percutaneous endoscopic jejunostomy”, “percutaneous endoscopic gastrostomy”, and “percutaneous endoscopic gastrostomy with a jejunal extension tube”. Additional articles were identified by a manual search of the references cited in the key articles obtained in the primary search.
RESULTS:
DPEJ is gradually becoming more common in the treatment of patients who cannot tolerate gastric feeding. Differences in patient selection and technique modifications may contribute to the various success rates reported. Failure is most often due to inadequate transillumination or gastroduodenal obstruction. Currently, there are limited data to evaluate the safety and effectiveness of DPEJ.
CONCLUSION:
The clinical use of DPEJ is increasing. With appropriate care and expertise, DPEJ may prove to be reliable and safe.
PMCID: PMC3275411  PMID: 22312608
Adverse events; Application; Direct percutaneous endoscopic jejunostomy; Percutaneous endoscopic gastrostomy
3.  A Simple and Safe Minimally Invasive Technique for Laparoscopic Gastrostomy 
Described is a 2-port laparoscopic technique for the placement of a gastric feeding tube in patients who may not be candidates for endoscopic PEG tube insertion.
Introduction:
Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. However, PEG tubes are not always feasible. The aim of the present study was to determine the feasibility, complications, and adequacy of feeding support of a novel laparoscopic gastrostomy technique in adults where PEG tubes were neither feasible nor safe.
Methods:
A retrospective chart review of patients who underwent a laparoscopic gastrostomy from August 2007 to July 2008 was performed. Demographic and outcome data were abstracted.
Results:
Fourteen patients underwent laparoscopic gastrostomy. Nine had obstructing head/neck cancer, 2 had severe head trauma, and one was morbidly obese. Nine patients had previous abdominal surgery. The mean operative time was 29.8 minutes (±7.2). There were no conversions to open gastrostomy. Two ports (5mm and 10mm) were used in the majority of patients (78.5%). No major complications were observed. The mean follow-up was 3.1 months (range, 2 to 8).
Conclusion:
This innovative 2-port laparoscopic technique for gastrostomy tube placement is safe and effective. It allows for the quick, accurate, and safe insertion of the feeding tube under direct visualization and avoids open techniques in patients where PEG tubes are not feasible.
doi:10.4293/108680810X12674612014626
PMCID: PMC3021287  PMID: 20529529
Laparoscopy; Percutaneous endoscopic gastrostomy
4.  Comparison of Laparoscopic Versus Open Approach to Gastrostomy Tubes 
The authors describe a laparoscopic Stamm gastrostomy and compare it with the open approach.
Background and Objectives:
Gastrostomy tube insertion for enteral access may be performed through laparotomy (open) or through the laparoscopic approach. This study's purpose is to compare outcomes of these different approaches.
Methods:
A retrospective chart review of all patients (age >18 years) who underwent insertion of a gastrostomy tube as a single elective procedure between 2004 and 2012 was performed. Primary end points included postoperative overall and tube-related morbidity, tube revision rates, and operative time.
Results:
During the study period, 71 patients had a gastrostomy tube inserted via either the open (n = 46) or the laparoscopic (n = 25) approach. Preoperative variables including age, gender, body mass index, albumin, and American Society of Anesthesiologists score were statistically comparable between groups. There was no difference in rates of previous upper abdominal surgery (24% vs 26%, P = .590) or gastric surgery (12% vs 13%, P = .720) in the laparoscopic and open groups, respectively. Previous percutaneous endoscopic gastrostomy tube insertion rates were higher in the laparoscopic group (32% vs 6.5%, P = .005). Operative time was significantly longer in the laparoscopic group (76.8 ± 7 vs 55.8 ± 3, P = .003) but was not affected by previous abdominal surgery or higher body mass index. Overall morbidity, tube-related morbidity, and tube revision rates were similar between groups. However, there was a trend toward increased major complication rates in the open group (6.5% vs 0%, P = .190).
Conclusion:
Laparoscopic gastrostomy tube insertion is safe and feasible, even in patients who have had prior upper abdominal surgery. Patients with a prolonged prognosis, obesity, and intact neurologic capacity may benefit the most from this approach.
doi:10.4293/108680813X13693422520927
PMCID: PMC3939338  PMID: 24680139
Gastrostomy; Outcomes; Laparoscopy
5.  Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study 
BMJ : British Medical Journal  2004;329(7464):491-494.
Problem Despite lack of evidence that enteral feeding tubes benefit patients with dementia, and often contrary to the wishes of patient and family, patients with dementia who have difficulty swallowing or reduced food intake often receive feeding tubes when hospitalised for an acute illness.
Design We conducted a retrospective chart review of all patients receiving percutaneous endoscopic gastrostomy or jejunostomy tubes between March and September 2002. QI interventions including a palliative care consulting service and educational programmes were instituted. We conducted a second chart review for all patients receiving feeding tubes between March and September 2003.
Setting 652 bed urban acute care hospital.
Key measures for improvement We measured the number of feeding tubes placed in patients with dementia, the number of feeding tubes placed in patients with dementia capable of taking food by mouth, and the number of feeding tubes placed in patients with dementia with an advance directive stating the wish to forgo artificial nutrition and hydration.
Strategies for change Medical and allied health staff received educational programmes on end of life care and on feeding management of patients with dementia. A palliative care consulting team was established.
Effects of change After the interventions, the number of feeding tubes placed in all patients and in patients with dementia was greatly reduced.
Lessons learnt Multidisciplinary involvement, including participation by the administration, was essential to effect change in practice. The intensive focus on a particular issue and rapid change led to “culture shift” within the hospital community. The need to establish unified goals of care for each patient was highlighted.
Background A growing body of research over the past decade has questioned the utility of placing feeding tubes (percutaneous endoscopic gastrostomy (PEG) or jejunostomy) in patients with advanced dementia.1 Studies have found no evidence that feeding tubes in this population prevent aspiration,23 prolong life,4-6 improve overall function,7 or reduce pressure sores.8 Additionally, the quality of life of a patient with advanced dementia can be adversely affected when a feeding tube is inserted. The patient may require wrist restraints to prevent pulling on the tube13 or may develop cellulitis at the gastrostomy site, develop decubitus ulcers,1 be deprived of the social interaction and pleasure surrounding meals,910 and require placement in a nursing home. Unfortunately, many doctors are unfamiliar with this literature or face barriers—attitudinal, institutional, or imposed by the healthcare industry—to applying its findings to their practice.11 Thus feeding tubes are placed in patients who will not benefit from this intervention and whose quality of life in the terminal stage of their illness will be adversely affected. With the expected increase of elderly people with dementia,12 a great change in doctors' knowledge, attitudes, and practice is necessary to prevent even greater numbers of patients receiving this futile treatment.
PMCID: PMC515202  PMID: 15331474
6.  Percutaneous endoscopic gastrostomy: Indications, technique, complications and management 
Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the “pull” technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.
doi:10.3748/wjg.v20.i24.7739
PMCID: PMC4069302  PMID: 24976711
Gastrostomy tube; Percutaneous; Enteral feeding; Indication; Contraindication; Complication; Management
7.  Extraperitoneal Closure of Persistent Gastrocutaneous Fistula in Children 
Extraperitoneal closure of gastrocutaneous fistula can be safe and effective. This approach can allow for rapid resumption of feeding and a shortened length of stay.
Background and Objectives:
Gastrostomy feeding in children is well established for nutritional support. Gastrostomy tubes may be permanent or temporary. After removal, spontaneous closure may occur, but persistence of the tract requires surgical repair. Laparotomy with gastric repair and fascial closure is the standard technique for treatment of a persistent gastrocutaneous fistula. We describe a technique of extraperitoneal excision of the fistulous tract and our results using this method.
Methods:
We reviewed 21 cases of extraperitoneal gastrocutaneous fistula closure in which a Foley catheter traction technique was used and were performed over the last 8 y. The technique involves insertion of a small Foley catheter with traction applied to the fistulous tract and core excision with electrocautery. Closure of the tract without fascial separation was accomplished and early feedings were allowed.
Results:
Ten males and 11 females underwent closure with this technique. The duration of the gastrostomy ranged from 1 y to 6 y, with a mean of 3.3 y. The time from removal to surgical repair was 3 wk to 1 y, with a mean of 4.3 mo; 15 had gastrostomy alone, and 6 had gastrostomy in combination with Nissen fundoplication. Open gastrostomy had been done in 10 patients and laparoscopic gastrostomy in 11 patients. Half of the patients had an ambulatory procedure. One patient developed a superficial wound infection, and there was 1 recurrence requiring intraperitoneal closure.
Conclusion:
Extraperitoneal closure for gastrocutaneous fistula is safe and effective. The technique allows for rapid resumption of feeds and a shortened length of stay. Minimal morbidity occurs with this technique, and it is well tolerated in the pediatric population.
doi:10.4293/108680812X13517013317590
PMCID: PMC3662724  PMID: 23743365
Gastrostomy; Gastrostomy closure; Gastrocutaneous fistula
8.  Gastrostomy tube dislodgment acute pancreatitis 
Percutaneous gastrostomy is well established root for long term feeding of patients who cannot be fed orally. The risks of percutanous gastrostomy insertion are low. Tube related complications often resolved by placing a Foley catheter or other balloon gastrostomy tube as a temporary solution. Gastrostomy tube related gastric, duodenal and billiary obstruction were reported. Gastrostomy tube related pancreatitis is scarcely described. We described a patient who suffered a pancreatitis related to Foley catheter gastrostomy dislodgment. Reviewing all reported cases of gastrostomy related pancreatitis revealed higher incidence in patient with Foley catheter used as gastrostomy and revealed questionable trends in conducting tube replacement. We suggest a proper manner for tube replacement and concluded that should a Foley catheter used as a temporary solution a replacement should be schedule in a timely manner to avoid life threatening complications.
doi:10.1186/1749-7922-9-23
PMCID: PMC3974449  PMID: 24674106
Pancreatitis; Gastrostomy; Percutaneous endoscopic gastrostomy (PEG); Foley catheter
9.  Small Bowel Obstruction Caused by Intraluminal Migration of Retained Percutaneous Endoscopic Gastrostomy Internal Bumper 
INTRODUCTION
Early complications associated with percutaneous endoscopic gastrostomy are well documented. Late complications associated with retained gastrostomy flange are rare. It is unclear why some patients with retained gastrostomy flange (internal bumper) develop mechanical obstruction and others do not. We report a case of mechanical obstruction with perforation occurring 6 months after the tube was cut.
PATIENT AND METHODS
A 76-year-old hemiplegic patient with no swallowing reflex and who previously was on long-term percutaneous gastrostomy feeding tube underwent removal of the feeding tube but the internal bumper was left in situ due to encrustation.
RESULTS
Due to migration of the retained flange, the patient developed small bowel obstruction.
CONCLUSIONS
Retained internal bumper is potentially dangerous and we recommend endoscopic retrieval of such flange.
doi:10.1308/147870807X227728
PMCID: PMC2121259  PMID: 18201462
Small intestinal obstruction; Percutaneous endoscopic gastrostomy (PEG); Internal bumper; Gastric flange
10.  Assessment of the percutaneous endoscopic gastrostomy feeding tube as part of an integrated approach to enteral feeding. 
Gut  1992;33(5):613-616.
The insertion of percutaneous endoscopic gastrostomy has been well documented. The possible benefits for patient nutrition and nursing practice have, however, not been assessed. We report a study of enteral feeding by percutaneous endoscopic gastrostomy in 30 patients, the majority with a persistent vegetative state. All patients had previously been fed through a nasogastric tube using manual administration and a dietitian assessed protein calorie intake. Based upon body mass index (weight/height2), midarm circumference and triceps skinfold thickness, 20 (67%) were malnourished, with 10 patients having a body mass index less than 17 (severe malnutrition); attributed to high rates of both tube displacement and feed regurgitation. Patients were observed over six to 12 months after percutaneous endoscopic gastrostomy insertion combined with overnight continuous pump feeding. All patients attained a body mass index greater than 17, and 17 (56%) of the total number achieved the normal range with no change in protein-calorie intake (pre: 2110 kcal, post: 1880 kcal). Complications of percutaneous endoscopic gastrostomy in the study group included peritonitis (one), tube site infection (two) and displacement (two); all without serious sequelae. As part of an integrated approach percutaneous endoscopic gastrostomy proved a safe and efficient method of enteral feeding and justifies wider consideration in the United Kingdom.
PMCID: PMC1379288  PMID: 1612476
11.  Gastrostomy in the Treatment of Dysphagia 
California Medicine  1965;102(4):280-284.
The patient who has had prolonged, severe dysphasia deserves special attention. One method of treatment is the use of a permanent gastrostomy. The authors, modifying the principles of the Beck-Jianu gastrostomy, were able to improve the primary complication of gastrostomy, namely excoriation of the skin secondary to leaking of gastric contents onto the abdominal wall. After operation various tests were utilized to attempt to force gastric contents through the gastrostomy tube onto the abdominal wall. Regurgitation of gastric contents through the modified Beck-Jianu gastrostomy did not occur.
Images
PMCID: PMC1515724  PMID: 14288145
12.  A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. 
BMJ : British Medical Journal  1996;312(7022):13-16.
OBJECTIVE--To compare percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. DESIGN--Randomised prospective study of inpatients with acute stroke requiring enteral nutrition. SETTING--One university hospital (Nottingham) and one district general hospital (Derby). SUBJECTS--30 patients with persisting dysphagia at 14 days after acute stroke: 16 patients were randomised to gastrostomy tube feeding and 14 to nasogastric tube feeding. MAIN OUTCOME MEASURES--Six week mortality; amount of feed administered; change in nutritional state; treatment failure; and length of hospital stay. RESULTS--Mortality at 6 weeks was significantly lower in the gastrostomy group with two deaths (12%) compared with eight deaths (57%) in the nasogastric group (P < 0.05). All gastrostomy fed patients (16) received the total prescribed feed whereas 10/14 (71%) of nasogastric patients lost at least one day's feed. Nasogastric patients received a significantly (P < 0.001) smaller proportion of their prescribed feed (78%; 95% confidence interval 63% to 94%) compared with the gastrostomy group (100%). Patients fed via a gastrostomy tube showed greater improvement in nutritional state, according to several different criteria at six weeks compared with the nasogastric group. In the gastrostomy group the mean albumin concentration increased from 27.1 g/l (24.5 g/l to 29.7 g/l) to 30.1 g/l (28.3 g/l to 31.9 g/l). In contrast, among the nasogastric group there was a reduction from 31.4 g/l (28.6 g/l to 34.2 g/l) to 22.3 g/l (20.7 g/l to 23.9 g/l) (P < 0.003). In addition, there were fewer treatment failures in the gastrostomy group (0/16 versus 3/14). Six patients from the gastrostomy group were discharged from hospital within six weeks of the procedure compared with none from the nasogastric group (P < 0.05). CONCLUSION--This study indicates that early gastrostomy tube feeding is greatly superior to nasogastric tube feeding and should be the nutritional treatment of choice for patients with acute dysphagic stroke.
PMCID: PMC2349687  PMID: 8555849
13.  Percutaneous endoscopic gastrostomy tube replacement: A simple procedure? 
Replacement of gastrostomy tube in patients undergoing percutaneous endoscopic gastrostomy (PEG) is generally considered as a safe and simple procedure. However, it could be associated with serious complications, such as gastrocutaneous tract disruption and intraperitoneal tube placement, which may lead to chemical peritonitis and even death. When PEG tube needs a replacement (e.g., occlusion or breakage of the tube), clinicians must realize that the gastrocutaneous tract of PEG is more friable than that of surgical gastrostomy because there is no suture fixation between gastric wall and abdominal wall in PEG. In general, the tract of PEG begins to mature in 1-2 wk after placement and it is well formed in 4-6 wk. However, this process could take a longer period of time in some patients. Accordingly, this article describes three major principles of a safe PEG tube replacement: (1) good control of the replacement tube along the well-formed gastrocutaneous tract; (2) minimal insertion force during the replacement, and, most importantly; and (3) reliable methods for the confirmation of intragastric tube insertion. In addition, the management of patients with suspected intraperitoneal tube placement (e.g., patients having abdominal pain or signs of peritonitis immediately after PEG tube replacement or shortly after tube feeding was resumed) is discussed. If prompt investigation confirms the intraperitoneal tube placement, surgical intervention is usually required. This article also highlights the fact that each institute should have an optimal protocol for PEG tube replacement to prevent, or to minimize, such serious complications. Meanwhile, clinicians should be aware of these potential complications, particularly if there are any difficulties during the gastrostomy tube replacement.
doi:10.4253/wjge.v5.i1.14
PMCID: PMC3547115  PMID: 23330049
Percutaneous endoscopic gastrostomy; Gastrostomy tube replacement; Gastrostomy tube exchange; Gastrostomy tube reinsertion; Complication; Peritonitis; Prevention; Management
14.  Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. 
BMJ : British Medical Journal  1992;304(6839):1406-1409.
OBJECTIVE--To compare percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. DESIGN--Randomised 28 day study of inpatients requiring long term enteral nutrition. SETTING--Three Glasgow teaching hospitals. SUBJECTS--40 patients with dysphagia for at least four weeks secondary to neurological disorders: 20 patients (10 women) were randomised to nasogastric feeding and 20 (eight women) to endoscopic gastrostomy. MAIN OUTCOME MEASURES--Treatment failure (blocked or displaced tubes on three or more occasions or refusal to continue treatment); duration of feeding; intake of liquid diets; complications; nutritional status at end of trial. RESULTS--One patient in each group died before starting feeding. Treatment failure occurred in 18 of the 19 nasogastric patients and in none of the gastrostomy group. The mean (SE) duration of feeding for the nasogastric group was 5.2 (1.5) days. No complications occurred in the nasogastric group but three (16%) of the gastrostomy group developed minor problems (aspiration pneumonia (two patients) wound infection (one)). Gastrostomy patients received a significantly greater proportion of their prescribed feed (93% (2%)) compared with the nasogastric group, (55% (4%); p less than 0.001) and also gained significantly more weight after seven days of feeding (1.4 (0.5) kg v 0.6 (0.1) kg; p less than 0.05). Analyses at days 14, 21, and 28 were not possible due to the small numbers remaining in the nasogastric group. CONCLUSION--Percutaneous endoscopic gastrostomy tube feeding is a safe and effective method of providing long term enteral nutrition to patients with neurological dysphagia and offers important advantages over nasogastric tube feeding.
PMCID: PMC1882203  PMID: 1628013
15.  Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for patients with head and neck cancer: a systematic review 
Journal of Radiation Research  2014;55(3):559-567.
There are two main enteral feeding strategies—namely nasogastric (NG) tube feeding and percutaneous gastrostomy—used to improve the nutritional status of patients with head and neck cancer (HNC). But up till now there has been no consistent evidence about which method of enteral feeding is the optimal method for this patient group. To compare the effectiveness of percutaneous gastrostomy and NGT feeding in patients with HNC, relevant literature was identified through Medline, Embase, Pubmed, Cochrane, Wiley and manual searches. We included randomized controlled trials (RCTs) and non-experimental studies comparing percutaneous gastrostomy—including percutaneous endoscopic gastrostomy (PEG) and percutaneous fluoroscopic gastrostomy (PFG) —with NG for HNC patients. Data extraction recorded characteristics of intervention, type of study and factors that contributed to the methodological quality of the individual studies. Data were then compared with respect to nutritional status, duration of feeding, complications, radiotherapy delays, disease-free survival and overall survival. Methodological quality of RCTs and non-experimental studies were assessed with separate standard grading scales. It became apparent from our studies that both feeding strategies have advantages and disadvantages.
doi:10.1093/jrr/rrt144
PMCID: PMC4014167  PMID: 24453356
percutaneous gastrostomy; gastrostomy; nasogastric tubes; enteral nutrition; head and neck neoplasms
16.  Percutaneous Endoscopic Gastrostomy Tube Placement for End-stage Palliation of Malignant Gastrointestinal Obstructions 
Background/Aim:
Decompression of malignant gastrointestinal obstructions is an uncommon indication for percutaneous endoscopic gastrostomy (PEG) tubes. The purpose of this study is to determine the efficacy of venting PEG tubes in relieving nausea and vomiting and assessing complications associated with tube placement.
Patients and Methods:
This study is a retrospective chart review of patients with PEG tubes placed to decompress malignant gastrointestinal obstructions between January 2005 and September 2010 by the gastroenterology service at our institute. Patient demographics, symptom relief, procedural complications, diet tolerability and home palliation were reviewed.
Results:
Seven PEG tubes were inserted to decompress malignant gastrointestinal obstructions. The mean patient age was 62 years (range 37-82 years). The underlying primary malignancies were small intestine (1), appendiceal (1), pancreatic (2), and colon (3) cancer. Gastric outlet obstruction was present in 3 (43%) patients while small bowel obstruction occurred in 4 (57%) patients. There was relief of nausea and vomiting in 6 (86%) patients. Procedural complications were present in 1 (14%) patient and involved superficial cellulitis followed by peristomal leakage. Patients with gastric outlet obstruction continued to have limited oral intake while patients with small bowel obstruction tolerated varying degrees of oral nutrition. Six (86%) patients were discharged home after PEG tube placement, but only 2 (33%) were able to undergo end-stage palliation at home without re-admission for hospital palliation.
Conclusions:
Venting PEG tubes significantly reduce the symptoms of nausea and vomiting in patients with metastatic gastrointestinal obstruction due to primary gastrointestinal malignancies. Complications associated with tube placement were minimal.
doi:10.4103/1319-3767.93808
PMCID: PMC3326983  PMID: 22421713
Gastrointestinal obstruction; gastrostomy; malignancy; palliation
17.  Percutaneous Endoscopic Gastrostomy, Duodenostomy and Jejunostomy 
Although enteral feeding by nasal gastric tube is popular for the patients who have a swallowing disability and require long-term nutritional support, but have intact gut, this tube sometimes causes aspiration pneumonia or esophageal ulcer. For these patients, conventional techniques for performance of a feeding gastrostomy made by surgical laparotomy have been used so far. However, these patients are frequently poor anesthetic and operative risks. Percutaneous endoscopic gastrostomy (PEG) which can be accomplished with local anesthesia and without the necessity for laparotomy has become popular in the clinical treatment for these patients. PEG was performed in 31 cases, percutaneous endoscopic duodenostomy (PED) in 1 case, and percutaneous endoscopic jejunostomy (PEJ) in 2 cases. All patients were successfully placed, and no major complication and few minor complications (9%) were experienced in this procedure. After this procedure, some patients could discharge their sputa easily and their pneumonia subsided. PED and PEJ for the patients who had previously received gastrostomy could also be done successfully with great care. Our experience suggests that PEG, PED, and PEJ are rapid, safe, and useful procedures for the patients who have poor anesthetic or poor operative risks.
doi:10.1155/DTE.1.37
PMCID: PMC2362464  PMID: 18493339
18.  Gastrostomy Intraperitoneal Bumper Migration in a Three-Year-Old Child: A Rare Complication following Gastrostomy Tube Replacement 
Case Reports in Gastroenterology  2014;8(3):381-386.
Feeding gastrostomy is used worldwide for adults and children with feeding impairment to obtain long-term enteral nutrition. Percutaneous endoscopic gastrostomy insertion is considered the gold standard, but after the first months requires gastrostomy tube replacement with a low-profile button. The replacement is known as an easy procedure, but several minor and major complications may occur during and after the manoeuvre. We describe intraperitoneal bumper migration in a 3-year-old boy, a rare complication following gastrostomy tube replacement, and we discuss the recent literature regarding similar cases.
doi:10.1159/000369964
PMCID: PMC4280460  PMID: 25565933
Bumper migration; Gastrostomy; Gastrostomy tube replacement
19.  A swallowed sewing needle migrating to the liver 
Context:
Swallowing foreign bodies is a common problem in children. Although most objects pass through the gastrointestinal tract with no untoward effect; long, sharppointed, or slender objects can perforate the gut. Migration of a swallowed object to the liver is extremely rare and very few cases have been reported in the literature up to now. The aim of this study is to draw attention to this subject once again by contributing a case report of a child with hepatic migration of a swallowed sewing needle.
Case Report:
A 16-year-old girl presented to the emergency room of pediatrics department in our hospital with complaints of abdominal pain, nausea and vomiting. Physical examination revealed tenderness on the right upper quadrant of the abdomen. Laboratory examination revealed increased hepatic enzymes as well as increased white blood cell count. Abdominal ultrasonography and computed tomography examinations revealed foreign body in the liver accompanied by surrounding abscess formation. The foreign body (sewing needle) was removed surgically after two operations.
Conclusion:
The children may not be able to remember the swallowing of the foreign body or they may try to hide such a condition. The radiological diagnosis in such cases which can be achieved by X-rays, ultrasonography or computed tomography is of critical importance, as well as getting detailed patient history for foreign body swallowing.
PMCID: PMC3364664  PMID: 22666694
foreign body swallowing; migration; hepatic; liver
20.  Percutaneous endoscopic gastrostomy in 41 patients: indications and clinical outcome. 
Percutaneous endoscopic gastrostomy, under local anaesthetic, was successfully used in 40 out of 41 patients referred for nutritional support. The indications were neurological disorders of swallowing in 32 patients, head and neck cancer in four patients and supplemental feeding in a miscellaneous group of five patients. The main complications of this procedure were one failed insertion and one peritubal infection. At prospective follow-up, the tube continued to function in 16 patients (seven at home) a mean of 184 days post-insertion (range 6-610 days). In 11 patients resumption of swallowing at a mean of 122 (20-390) days allowed tube removal. Thirteen patients died from their disease, a mean of 96 (12-320) days post-insertion. Patient tolerance and patient and carer satisfaction have been excellent and early results suggest that recovery of speech and swallowing in acute neurological disorders may be enhanced. Percutaneous endoscopic gastrostomy should be performed in all patients referred for a gastrostomy and should be considered in all patients requiring long-term tube feeding.
PMCID: PMC1293491  PMID: 1625260
21.  Percutaneous endoscopic gastrostomy in a general hospital: prospective evaluation of indications, outcome, and randomised comparison of two tube designs. 
Gut  1994;35(11):1551-1556.
The indications for percutaneous endoscopic gastrostomy (PEG) and patient outcome, were examined prospectively in the setting of a general hospital. In the course of 26 months, 76 patients underwent PEG (median age 62 years (range 18-99)) and were followed up for 6887 patient days. The median (range) duration of PEG feeding was 93 (3-785) days. The procedure was carried out for neurological indications in 76% of cases (stroke 51%) and 53% of patients were severely malnourished (body mass index < 17 kg/m2) at the time of referral. In 12 (16%) patients swallowing recovered and the PEG was removed after a median (range) of 55 days (20-150). Three (4%) deaths were related to PEG (one oesophageal perforation, one haemorrhage, and one aspiration pneumonia). One patient developed peritonism and ileus, which resolved with conservative treatment. Minor complications included local sepsis 3%, tube blockage 12%, and tube connector leak 5%. During seven days of observation, demands on nursing time for routine care of the PEG were the same as for nasogastric tube feeding, median (range) 21 (4-42) v 16 (4-40) min/day respectively, but in about half the latter cases the tube had to be replaced at least once. Over 15 months, 29 patients were randomised to receive a 1.9 mm inner, 2.9 mm (9F) outer diameter Fresenius and 27 a 3.0 mm inner, 4.0 mm (12F) outer diameter Bower polyurethane tube and were followed for 2920 and 2388 patient days respectively. There was no difference in the insertion time (median (range) 20 (10-45) v 24 (10-45) min respectively) or number of patients with complications (three v eight patients NS), although there were more minor mechanical problems (three v 12, p < 0.01) with the 12F tube. The internal anchoring device of the 12F tube allowed its non-endoscopic removal, a method applicable too 16% of cases. No tubes were removed because of blockage.
PMCID: PMC1375610  PMID: 7828971
22.  Gastroenteric tube feeding: Techniques, problems and solutions 
Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.
doi:10.3748/wjg.v20.i26.8505
PMCID: PMC4093701  PMID: 25024606
Enteral tube feeding; Percutaneous endoscopic gastrostomy; Refeeding syndrome; Enteral nutrition; Buried bumper syndrome; Nasoenteral tubes; Colocutaneous fistulae
23.  Protocol for a randomized controlled trial of early prophylactic feeding via gastrostomy versus standard care in high risk patients with head and neck cancer 
BMC Nursing  2014;13:17.
Background
Patients with head and neck cancer are at high risk of malnutrition and dysphagia. Enteral tube feeding via a gastrostomy or nasogastric tube is often required in response to dysphagia, odynophagia or side effects of treatment that lead to dehydration and/or weight-loss. A recent systematic review concluded that the optimal method of tube feeding remains unclear; however prophylactic gastrostomy, placed in anticipation of its use during and after treatment, is common practice, following a number of demonstrated benefits. However the majority of these studies have been undertaken in patients receiving radiotherapy alone. More recent studies in patient populations receiving concurrent chemoradiotherapy are showing that despite prophylactic gastrostomy placement significant weight loss still occurs, placing the patient at risk of the consequences of malnutrition. Therefore we set out to investigate innovative prophylactic nutrition support via the gastrostomy to optimise the nutritional outcomes of patients with head and neck cancer.
Methods/Design
Patients with head and neck cancer will be eligible for this single centre randomised controlled trial if they are identified for referral for a prophylactic gastrostomy using local guidelines. Patients will be excluded if they are: under the age of eighteen; pregnant; unable to give informed consent; or severely malnourished or moderately malnourished with significant dysphagia requiring a liquid or puree diet. All eligible patients who consent for the study will be allocated randomly to either the intervention or control group (usual care). The intervention group will commence prophylactic supplementary nutrition support via the gastrostomy immediately following placement compared to usual care where nutrition support is commenced via the gastrostomy when clinically indicated during treatment. Key outcome measures will be percentage weight loss, body composition, nutritional status and quality of life, measured at baseline and three months post treatment.
Discussion
To our knowledge this is the first study to evaluate the effectiveness of early prophylactic tube feeding compared to commencement of feeding during treatment, as per current standard practice, in patients undergoing prophylactic gastrostomy prior to treatment for head and neck cancer.
Trial registration
This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.
doi:10.1186/1472-6955-13-17
PMCID: PMC4083037  PMID: 25002833
Prophylactic; Gastrostomy; Head and neck cancer; Nutrition support; Enteral nutrition; Quality of life
24.  SWALLOWED FOREIGN BODIES 
California Medicine  1953;79(4):293-296.
Of 98 swallowed foreign bodies demonstrated, 71 with fate definitely known are reported. Seventeen of 20 foreign bodies in the esophagus had esophagoscopic removal. Only two of 51 foreign bodies in the gastrointestinal tract had laparotomy, while 49 were spontaneously passed.
Early esophagoscopic removal of foreign bodies lodged in the esophagus and conservative management of foreign bodies which have passed the esophagogastric junction are recommended. Laparotomy is rarely indicated in the management of swallowed foreign bodies, although various observers are not in full agreement as to the circumstances in which “watchful waiting” is advisable nor as to how long it is permissible to wait for spontaneous passage.
In 20 of 71 cases of swallowed foreign bodies, the objects were in the esophagus at the time the patient was first examined. Esophagoscopic removal was carried out in 17 cases. In two cases a foreign body was passed per rectum and in one was vomited. Laparotomy for removal was done in only two of the 51 cases in which the foreign body was already in the stomach or bowel at the time of examination, and in one of them the operation probably could have been avoided.
Images
PMCID: PMC1521983  PMID: 13094540
25.  Percutaneous endoscopic gastrostomy in children 
Korean Journal of Pediatrics  2011;54(1):17-21.
Purpose
Percutaneous endoscopic gastrostomy (PEG) can improve nutritional status and reduce the amount of time needed to feed neurologically impaired children. We evaluated the characteristics, complications, and outcomes of neurologically impaired children treated with PEG.
Methods
We retrospectively reviewed the records of 32 neurologically impaired children who underwent PEG between March 2002 and August 2008 at our medical center. Forty-two PEG procedures comprising 32 PEG insertions and 10 PEG exchanges, were performed. The mean follow-up time was 12.2 (6.6) months.
Results
Mean patient age was 9.4 (4.5) years. The main indications for PEG insertion were swallowing difficulty with GI bleeding due to nasogastric tube placement and/or the presence of gastroesophageal reflux disease (GERD). The overall rate of complications was 47%, with early complications evident in 25% of patients and late complications in 22%. The late complications included one gastro-colic fistula, two cases of aggravated GERD, and four instances of wound infection. Among the 15 patients with histological evidence of GERD before PEG, 13 (87%) had less severe GERD, experienced no new aspiration events, and showed increased body weight after PEG treatment.
Conclusion
PEG is a safe, effective, and relatively simple technique affording long-term enteral nutritional support in neurologically impaired children. Following PEG treatment, the body weight of most patients increased and the levels of vomiting, GI bleeding, and aspiration fell. We suggest that PEG with post-procedural observation be considered for enteral nutritional support of neurologically impaired children.
doi:10.3345/kjp.2011.54.1.17
PMCID: PMC3040361  PMID: 21359056
Gastrostomy; Child; Complication; Gastroesophageal reflux disease

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