Percutaneous endoscopic gastrostomy tube has now become a preferred option for the long-term nutritional support device for patients with dysphagia. There is a considerable debate about the health issues related to the quality of life of these patients. Our aim of the study was to assess the outcome and perspectives of patients/care givers, about the acceptability of percutaneous endoscopic gastrostomy tube placement.
This descriptive analytic study conducted in patients, who have undergone percutaneous endoscopic gastrostomy tube placement during January 1998 till December 2004. Medical records of these patients were evaluated for their demographic characteristics, underlying diagnosis, indications and complications. Telephonic interviews were conducted till March 2005, on a pre-tested questionnaire to address psychological, social and physical performance status, of the health related quality of life issues.
A total of 191 patients' medical records were reviewed, 120 (63%) were males, and mean age was 63 years. Early complication was infection at PEG tube site in 6 (3%) patients. In follow up over 365 ± 149 days, late complications (occurring 72 hours later) were infection at PEG tube site in 29 (15 %) patient and dislodgment/blockage of the tube in 26 (13.6%). Interviews were possible with 126 patients/caretakers. Karnofsky Performance Score of 0, 1, 2, 3 and 4 was found in 13(10%), 18(14%), 21(17%), 29(23%) and 45(36%) with p-value < 0.001. Regarding the social and psychological aspects; 76(60%) would like to have the PEG tube again if required, 105(83 %) felt ease in feeding, and 76(60%) felt that PEG-tube helped in prolonging the survival. Regarding negative opinions; 49(39 %) felt that the feeding was too frequent, 45(36 %) felt apprehensive about dependency for feeding and 62(49%) were concerned about an increase in the cost of care.
PEG-tube placement was found to be relatively free from serious immediate and long- term complications. Majority of caregivers and patient felt that PEG-tube helped in feeding and prolonging the survival. Studies are needed to assess the real benefit in terms of actual nutritional gain and quality of life in such patients.
To describe the current practice of placing gastrostomy tubes (endoscopic and radiological), patient characteristics, indications for enteral support, complications and outcomes over a 13-month period, and explore factors that influenced complications and outcomes. Second, to provide Canadian data regarding feeding tube placement because no current literature reflecting these practices for Canadian hospitals is available.
Retrospective chart reviews were conducted. Patients who had initial percutaneous endoscopic gastrostomy (PEG) or percutaneous radiological gastrostomy (PRG) tubes inserted for nutritional purposes were included in the study.
A total of 136 charts which included 30 PEG and 44 PRG procedures were reviewed. The PRG group was older than the PEG group (mean [± SD] age 68±19 years versus 55±21 years, respectively; P=0.008). Patients in PEG group had longer lengths of hospital stay and more intensive care unit admissions than the PRG group (P=0.029). The main reason for tube insertion was dysphagia/aspiration (PEG [60%] and PRG [77%]). Minor complications were comparable between the two groups (P=0.678). There were three cases of major complications overall. More subjects in the PRG group died (18%) while in hospital than in the PEG group (3%) (P=0.055). No procedure-related deaths occured in either group.
Both methods of tube insertion provided a safe route for nutrition delivery despite a significant cost differential with PEGs costing 44% more than PRGs. Characteristics such as age, presence of ascites and severity of disease influenced the method of insertion despite the lack of current guidelines. Overall, the present study provides new descriptive data in a Canadian context.
Feeding tubes; Gastrostomy; Percutaneous endoscopic gastrostomy; Percutaneous radiological 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.
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.
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.
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).
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.
Laparoscopy; Percutaneous endoscopic gastrostomy
AIM: To investigate and predict enteral nutrition problems after percutaneous endoscopic gastrostomy (PEG).
METHODS: We retrospectively analyzed data for 252 out of 285 patients who underwent PEG at our hospital from 1999 to 2008. Enteral nutrition problems after PEG were defined as: (1) patients who required ≥ 1 mo after surgery to switch to complete enteral nutrition, or who required additional parenteral alimentation continuously; or (2) patients who abandoned switching to enteral nutrition using the gastrostoma and employed other nutritional methods. We attempted to identify the predictors of problem cases by using a logistic regression analysis that examined the patients’ backgrounds and the specific causes that led to their problems.
RESULTS: Mean age of the patients was 75 years, and in general, their body weight was low and their overall condition was markedly poor. Blood testing revealed that patients tended to be anemic and malnourished. A total of 44 patients (17.5%) were diagnosed as having enteral nutrition problems after PEG. Major causes of the problems included pneumonia, acute enterocolitis (often Clostridium difficile-related), paralytic ileus and biliary tract infection. A multivariate analysis identified the following independent predictors for problem cases: (1) enteral nutrition before gastrectomy (a risk reduction factor); (2) presence of esophageal hiatal hernia; (3) past history of paralytic ileus; and (4) presence of chronic renal dysfunction.
CONCLUSION: Enteral nutrition problems after PEG occurred at a comparatively high rate. Patient background analysis elucidated four predictive factors for the problem cases.
Percutaneous endoscopic gastrostomy; Enteral nutrition; Complication, Risk factor; Predictor
Eight patients were studied to evaluate the efficacy of a surgeonled percutaneous endoscopic gastrostomy (PEG). Three patients underwent PEG at the time of elective surgery (carcinoma larynx-2, carcinoma tonsil-1), two underwent placements during emergency surgery for neck trauma (blunt injury-1, penetrating injury-1) and three for palliation (recurrent tongue carcinoma-1, recurrent epilaryngeal carcinoma-1, metastatic neck nodes-1). For patients undergoing intraoperative PEG, the operative time was prolonged by an average of 12 minutes. There were no major procedural or feedingrelated complications in any of the patients. Individual subjective tolerability was good in all patients. A surgeonled PEG is a simple and safe means of combining all the advantages of enteral nutrition with none of the disadvantages of nasogastric tube feeding in emergency, elective head and neck operations and in palliation. The procedure merits wider use in head and neck surgery units in India.
percutaneous endoscopic gastrostomy; head and neck surgery; nutrition
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.
Enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube is often part of management in patients with dysphagia due to neurological or oropharyngeal disease. Gastrostomy placement can affect normal innate defense mechanisms in the upper gut, resulting in bacterial overgrowth. In this study microbiological investigations were done with gastric and duodenal aspirates from 20 patients undergoing PEG tube placement and PEG tubes from 10 patients undergoing tube replacement. Aspirate and PEG tube microbiotas were assessed by using viable counts and selective solid media followed by aerobic and anaerobic incubation to assess cell viabilities. The antibiotic susceptibility profiles of the isolates were determined by the disk diffusion method, and gas chromatography was used to study the bacterial metabolic products in the aspirates. The aspirates and PEG tubes contained mainly streptococci, staphylococci, lactobacilli, yeasts, and enterobacteria. Enterococci were detected only in PEG tube biofilms and not in aspirates. Gastric pH affected the composition of the aspirate microbiotas but not the total microbial counts. Staphylococci, Escherichia coli, and Candida spp. were isolated only from antibiotic-treated patients, despite the sensitivities of the bacteria to the agents used. Antibiotic treatment had no effect on the incidence of infection or the length of hospital stay in these patients.
AIM: To investigate whether single endoscopist-performed percutaneous endoscopic gastrostomy (PEG) is safe and to compare the complications of PEG with those reported in the literature.
METHODS: Patients who underwent PEG placement between June 2001 and August 2011 at the Baskent University Alanya Teaching and Research Center were evaluated retrospectively. Patients whose PEG was placed for the first time by a single endoscopist were enrolled in the study. PEG was performed using the pull method. All of the patients were evaluated for their indications for PEG, major and minor complications resulting from PEG, nutritional status, C-reactive protein (CRP) levels and the use of antibiotic treatment or antibiotic prophylaxis prior to PEG. Comorbidities, rates, time and reasons for mortality were also evaluated. The reasons for PEG removal and PEG duration were also investigated.
RESULTS: Sixty-two patients underwent the PEG procedure for the first time during this study. Eight patients who underwent PEG placement by 2 endoscopists were not enrolled in the study. A total of 54 patients were investigated. The patients’ mean age was 69.9 years. The most common indication for PEG was cerebral infarct, which occurred in approximately two-thirds of the patients. The mean albumin level was 3.04 ± 0.7 g/dL, and 76.2% of the patients’ albumin levels were below the normal values. The mean CRP level was high in 90.6% of patients prior to the procedure. Approximately two-thirds of the patients received antibiotics for either prophylaxis or treatment for infections prior to the PEG procedure. Mortality was not related to the procedure in any of the patients. Buried bumper syndrome was the only major complication, and it occurred in the third year. In such case, the PEG was removed and a new PEG tube was placed via surgery. Eight patients (15.1%) experienced minor complications, 6 (11.1%) of which were wound infections. All wound infections except one recovered with antibiotic treatment. Two patients had bleeding from the PEG site, one was resolved with primary suturing and the other with fresh frozen plasma transfusion.
CONCLUSION: The incidence of major and minor complications is in keeping with literature. This finding may be noteworthy, especially in developing countries.
Gastrostomy; Gastric feeding tube; Enteral nutrition; Enteral feeding; Endoscopy; Gastrointestinal
A small, but significant, number of children require long-term nutritional support. The aim of this study was to demonstrate the safety and efficacy of providing a percutaneous endoscopic gastrostomy (PEG) service for children in a district general hospital and to raise awareness of the suitability of the procedure to be performed on paediatric surgery lists in similar hospitals across the UK.
PATIENTS AND METHODS
A multidisciplinary paediatric nutrition team was established and all children accepted for PEG insertion between 1995 and 2007 were entered onto a database prospectively and are included in this study. PEG tubes were inserted by the standard pull-through technique under general anaesthetic.
A total of 172 procedures were performed in 76 children. The median age at first tube insertion was 3 years (range, 0.5–18 years). Length of follow-up ranged from 1 month to 12.6 years. Fifty-eight children (76%) had a neurological abnormality, the commonest being cerebral palsy. All but one procedure were performed successfully, of which 63 (37%) were new insertions, 99 change of tube, 4 changed from surgical gastrostomy and 6 from PEG to button gastrostomy. The median hospital stay was 2 days (range, 2–7 days) for new insertions and 1 day for tube changes. There were 10 (6%) early complications within 30 days, the commonest being peritubal infection (6). The 39 late complications included 16 peritubal infection/granulomata, 9 ‘buried bumpers’, 4 worsening of gastro-oesophageal reflux disease, 2 gastrocolic fistulae, 3 gastrocutaneous fistulae and 4 tubal migration. There was no mortality.
We have demonstrated that paediatric PEG procedures and continuing management by a supporting team can be successfully and efficiently provided in the district general hospital. It should be possible for the majority of similar hospitals to provide local access and increase the availability of PEG feeding for children.
Percutaneous endoscopic gastrostomy; PEG; Children enteral feeding; Paediatric surgery
Objective To evaluate a new and simpler strategy of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG).
Design Single centre, two arm, randomised, controlled, double blind clinical trial.
Setting Endoscopy unit in Karolinska University Hospital, Stockholm, Sweden, between 3 June 2005 and 31 October 2009.
Participants 234 patients with an indication for PEG who gave informed consent to participate.
Intervention A single 20 ml dose of the oral solution of sulfamethoxazole and trimethoprim (also known as co-trimoxazole or Bactrim; F Hoffmann-La Roche Ltd, Basel, Switzerland) deposited in the PEG catheter immediately after insertion. The control group received standard prophylaxis consisting of a single intravenous dose of 1.5 g cefuroxime (Zinacef; GlaxoSmithKline, London) administered before insertion of the PEG tube.
Main outcome measure Primary outcome was the occurrence of clinically evident wound infection within 14 days after insertion of the PEG catheter. Secondary outcomes were positive bacterial culture and blood tests (highly sensitive C reactive protein and white blood cell count). All randomised patients were included in an intention to treat analysis.
Results Of the 234 patients included in this study, 116 were randomly assigned to co-trimoxazole and 118 to cefuroxime. At follow-up 7-14 days after insertion of the PEG catheter, wound infection was found in 10 (8.6%) patients in the co-trimoxazole group and 14 (11.9%) in the cefuroxime group, which corresponds to a percentage point difference of −3.3% (95% confidence interval −10.9% to 4.5%). The per protocol analysis, which comprised 100 patients in each group, gave similar results—10% and 13% infection in the co-trimoxazole and cefuroxime groups, respectively (percentage point difference −3.0%, 95% CI −11.8% to 5.8%). Both these analyses indicate non-inferiority of co-trimoxazole compared with cefuroxime because the upper bounds of the confidence intervals are lower than the pre-determined non-inferiority margin of 15%. Analyses of the secondary outcomes supported this finding.
Conclusion 20 ml of co-trimoxazole solution deposited in a newly inserted PEG catheter is at least as effective as cefuroxime prophylaxis given intravenously before PEG at preventing wound infections in patients undergoing PEG.
Trial registration Current Controlled Trials ISRCTN18677736.
Numerous procedures have been developed to provide adequate enteral nutrition to patients with gastrointestinal disorders. Previously, operative placement of a feeding gastrostomy or jejunostomy tube was the accepted means of gaining chronic enteral access. However, improved technology and experience with endoscopic techniques have quickly replaced primary operative placement of enteral access. Direct percutaneous endoscopic jejunostomy (D-PEJ) is a procedure that was designed to deliver enteral feeding solutions for patients with proximal disease after unsatisfactory results from percutaneous endoscopic gastrostomy tubes with jejunal extensions (PEG-J). As with any procedure, it is associated with complications. We present the first reported case of a colojejunal fistula resulting from a D-PEJ placement. While D-PEJ has been shown to be relatively safe, complications related to the inherent limitations of the procedure need to be considered when the patient experiences unusual post-procedure symptoms and worked up appropriately.
Colojejunal fistula; Complications; D-PEJ; Feeding tube
Percutaneous endoscopic gastrostomy (PEG) was performed on 28 elderly patients (mean age 82 years) who were dysphagic and intolerant of naso-gastric feeding. Twenty-six patients were recovering from a stroke; the interval between the onset of stroke and PEG averaged 63 days. The procedure was successful and well tolerated by all patients. Nineteen (68%) still had a functioning PEG a median of 14 weeks after placement. One patient whose swallowing recovered had the tube removed 6 months after its insertion. Seven patients (25%) subsequently died from their underlying disease, a mean of 92 days following PEG. There was one procedure-related death from peritonitis. PEG is a useful alternative to surgical gastrostomy in selected elderly patients with dysphagia who are intolerant of naso-gastric feeding.
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.
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.
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.
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.
Gastrostomy; Child; Complication; Gastroesophageal reflux disease
Since its description in 1980, percutaneous endoscopic gastrostomy has become the modality of choice for providing enteral access to patients who require long-term enteral nutrition. This study aimed to evaluate current indications and complications associated with PEG feeding.
We conducted a retrospective analysis of all patients who referred to our endoscopic unit of the Department of Gastroenterology and Hepatology of the Medical Center University of Sarajevo for PEG tube placement over a period of 7 years. Medical records of 359 patients dealing with PEG tube placement were reviewed to assess indications, technical success, complications and the need for repeat procedures.
The indications for enteral feeding tube placement were malignancy in 44% (n=158), of which 61% (n=97) patients were suffering of head and neck cancer and 39% (n=61) of other malignancy. Central nervous disease was the indication in 48.7 % (n=175) of patients. Cerebrovascular accidents (CVA) accounted for 20% (n=73), head injury for 16% (n=59) and cerebral palsy for 11% (n=38). In 6.13% (n=22) of patients minor complications occur which included wound infection (0.8%), inadvertent PEG removal (2.5%) and tube blockage (1.1%). 11 patients experienced major complications including hemorrhage, tube migration and perforation. There were no deaths related to PEG procedure placement and the overall 30-day mortality rate due to primary disease was 15.8%. Oral feeding was resumed in 23% of the patients and the tube was removed subsequently after 6 -12 months.
Percutaneous endoscopic gastrostomy is a save and minimally invasive endoscopic procedure associated with a low morbidity (9.2%) rate, easy to follow-up and to replace when blockage occurs. Over a seven-year period we noticed an increase of 63% in PEG placement at our department.
PEG; enteral nutrition; tube feeding.
Percutaneous endoscopic gastrostomy (PEG) is now the technique of choice for patients requiring long-term enteral feeding. It is a good method for feeding patients with neurological dysphagia and can safely be kept in situ for long periods. PEG feeding requires a multidisciplinary approach, involving doctors, nurses, pharmacists, speech therapists, dieticians and carers. The insertion of a PEG, which requires two operators and two endoscopy nurses, is described in full. Feeding can commence after a few hours. Various types of feed and feed-ing patterns are described and their relative merits discussed. Although psychological problems may occur following PEG insertion, the procedure is usually well accepted by patients.
Percutaneous endoscopic gastrostomy (PEG) has replaced surgical gastrostomy in patients requiring long-term enteral nutrition. Increasing numbers of patients are being referred for PEG placement. Concern has been raised about patient selection and subsequent follow-up of these patients in the community. We report the views of Northern Ireland GPs to PEGs and how management may be improved.
is a common management problem in patients with cystic fibrosis (CF).
Various approaches to supplemental nutrition by both parenteral and
enteral routes have been used.
Aim—To analyse the
efficacy and acceptability of supplemental overnight feeding using a
percutaneous endoscopic gastrostomy (PEG) in patients with CF.
with CF (43 adults; age >17 years) with severe pulmonary disease.
success and complications of PEG insertion were documented together
with changes in nutritional and pulmonary status of the cohort.
tubes were successfully inserted in all patients, with immediate
complications (respiratory depression) in two (4%) and late
complications in 13 (25%). Feeding was well tolerated by 50/51 (98%)
of the cohort during a mean (SEM) follow up of 14.5 (2.1) months. The
adult cohort had a significant increase in weight and body mass index
at six months which was maintained at 12 months. Serum albumin
concentration remained stable at six months but had fallen by 12 months, although the differences were not statistically
significant. These results were reflected in the paediatric cohort.
Pulmonary function in those followed up for one year had apparently
stabilised, but the number of admissions to hospital over the year
before and the year after PEG did not change. Half of the cohort were
accepted for heart-lung/lung transplantation, the improvement in
nutritional status being a prerequisite for this.
PEG tube feeding is well tolerated and results in a significant
improvement in nutritional status and an apparent stabilisation of
pulmonary function in severely malnourished CF patients with advanced
cystic fibrosis; malnutrition; enteral nutrition; percutaneous endoscopic gastrostomy
Background. Oral intake of many patients with locally advanced head and neck cancer (LAHNC) decrease during chemoradiotherapy (CRT). Although prophylactic percutaneous endoscopic gastrostomy (PEG) is recommended, not a few patients complete CRT without using PEG tube. Patients and Methods. The subjects were patients with LAHNC who received CRT. We retrospectively investigated the incidence and duration of nutritional support during and after CRT, and predicting factors of nutritional support. For patients who required nutritional support, we also checked the day of initiation and the duration of nutritional support. Results. Of 53 patients, 29 patients (55%) required nutritional support during and/or after CRT. While no clear relation between requirement of nutritional support and variables including age, T stage, N stage, clinical stage and chemotherapy regimen, there could be some relationships between tumor primary sites and the requirement and duration of nutritional support. 17 (77%) of 22 patients with oropharynx cancer(OP) required nutritional support and prolonged for 4.4 months, and 11 (46%) of 24 patients with hypopharynx cancer(HP) required nutritional support and prolonged for 21.9 months. Conclusion. Nutritional support is indicated many HNC patients treated with CRT and primary sites may have some relation to its indication and duration.
Our clinical experience suggested that elemental diets were associated with a reduction in aspiration pneumonia among bedridden patients with percutaneous endoscopic gastrostomy (PEG). We compared the effects of elemental and standard liquid diets on the risk of clinical aspiration pneumonia and gastric emptying in bedridden patients receiving PEG feedings.
Study 1: consecutive bedridden PEG patients received elemental diets or standard liquid diets in the same fashion. The frequency of defecation, diet aspirated from the trachea, and aspiration pneumonia during hospitalization were prospectively recorded. Study 2: a randomized, crossover trial using elemental or standard liquid diets containing 13C sodium acetate as a tracer given to bedridden PEG patients who had experienced aspiration pneumonia. 13C breath tests were performed to estimate gastric emptying.
Study 1: 127 patients were enrolled, 60 with elemental and 67 with standard liquid diets. The diet was aspirated from the trachea in none (0%) with the elemental diet vs. 8 (11.9%) with standard liquid diets (P=0.0057); aspiration pneumonia developed none with the elemental diet vs. 5 (7.5%) with standard liquid diets (P=0.031) (number needed to treat 14, 95% confidence interval 7–85). Study 2: 19 patients were enrolled. The elemental diet was associated with a significant increase in the 10, 30 or 50% emptying (excretion) time (P<0.001) and increased the area under the curve (% dose/h) compared with the standard liquid diet (P<0.05).
Elemental diets were associated with more rapid gastric empting and fewer episodes of aspiration than standard liquid diets in bedridden PEG patients. They may be preferred for bedridden PEG patients especially who have experienced aspiration pneumonia. Properly performed randomized-controlled trials are needed to prove this potential benefit.
To systematically review evidence bearing on the management of patients with amyotrophic lateral sclerosis (ALS).
The authors analyzed studies from 1998 to 2007 to update the 1999 practice parameter. Topics covered in this section include slowing disease progression, nutrition, and respiratory management for patients with ALS.
The authors identified 8 Class I studies, 5 Class II studies, and 43 Class III studies in ALS. Important treatments are available for patients with ALS that are underutilized. Noninvasive ventilation (NIV), percutaneous endoscopic gastrostomy (PEG), and riluzole are particularly important and have the best evidence. More studies are needed to examine the best tests of respiratory function in ALS, as well as the optimal time for starting PEG, the impact of PEG on quality of life and survival, and the effect of vitamins and supplements on ALS.
Riluzole should be offered to slow disease progression (Level A). PEG should be considered to stabilize weight and to prolong survival in patients with ALS (Level B). NIV should be considered to treat respiratory insufficiency in order to lengthen survival (Level B), and may be considered to slow the decline of forced vital capacity (Level C) and improve quality of life (Level C). Early initiation of NIV may increase compliance (Level C), and insufflation/exsufflation may be considered to help clear secretions (Level C).
= American Academy of Neurology;
= amyotrophic lateral sclerosis;
= forced vital capacity;
= high frequency chest wall oscillation;
= mechanical insufflation/exsufflation;
= maximal inspiratory pressure;
= noninvasive ventilation;
= peak cough expiratory flow;
= transdiaphragmatic pressure;
= percutaneous endoscopic gastrostomy;
= quality of life;
= radiologically inserted device;
= sniff nasal pressure;
= tracheostomy invasive ventilation.
Since its introduction in 1980, the percutaneous endoscopic gastrostomy (PEG) tube has become an efficient means of providing long-term enteral access. Conveniently, the soft inner bumper allows PEG removal with relatively minimal external traction. Consequently, a major complication is accidental dislodgement, from which significant morbidity may occur. Clinicians have perhaps underestimated and underappreciated this complication, not only in the acute setting but over the lifetime of the PEG tube.
A retrospective analysis of PEG placements conducted at the authors’ institution identified all PEG tubes placed between July 1, 2007 and July 1, 2010 by one faculty surgeon. Patient charts were reviewed for 30-day mortality, complications, and subsequent management. Patients were reviewed until intentional removal of the PEG, cessation of records, or patient mortality.
A total of 563 PEGs were identified. The 30-day mortality rate was 7.8% (44/563), and the 7-day early accidental dislodgement rate was 4.1% (23/563). The total lifetime accidental PEG dislodgement rate was 12.8% (72/563). Of the 72 dislodged PEGs, 49 occurred after discharge from rehabilitation or nursing facilities. The vast majority required an emergency department visit, a level 3 surgical consultation, a replacement gastrostomy tube, and a radiographic confirmation of tube positioning, resulting in charges totaling an average of $1,200.
Many large PEG reviews report an early accidental dislodgement rate of 0.6% to 4.0%. The most clinically significant accidental removals occur in the first 7 days after placement, and open gastrostomy may cause obvious morbidity. The early dislodgement rate in this study (4.1%) is consistent with those currently reported. However, if cases are followed longitudinally, a significantly higher rate of late dislodgement (12.8%) is seen. Frequently placed into neurologically impaired or elderly patients, the PEGs that dislodge months and years later require expensive management. The late removal complication and its associated costs are overlooked and underestimated.
Complications; Costs; Intensive care
AIM: To investigate factors predicting failure of percutaneous endoscopic gastrostomy (PEG) to eliminate gastroesophageal reflux (GER).
METHODS: Twenty-nine consecutive mechanically ventilated patients were investigated. Patients were evaluated for GER by pH-metry pre-PEG and on the 7th post-PEG day. Endoscopic and histologic evidence of reflux esophagitis was also carried out. A beneficial response to PEG was considered when pH-metry on the 7th post-PEG day showed that GER was below 4%.
RESULTS: Seventeen patients responded (RESP group) and 12 did not respond (N-RESP) to PEG. The mean age, sex, weight and APACHE II score were similar in both groups. GER (%) values were similar in both groups at baseline, but were significantly reduced in the RESP group compared with the N-RESP group on the 7th post-PEG day [2.5 (0.6-3.8) vs 8.1 (7.4-9.2, P < 0.001)]. Reflux esophagitis and the gastroesophageal flap valve (GEFV) grading differed significantly between the two groups (P = 0.031 and P = 0.020, respectively). Histology revealed no significant differences between the two groups.
CONCLUSION: Endoscopic grading of GEFV and the presence of severe reflux esophagitis are predisposing factors for failure of PEG to reduce GER in mechanically ventilated patients.
Esophagitis; Gastroesophageal reflux; Percutaneous endoscopic gastrostomy
In those cases where a PEG tube cannot be placed safely, a laparoscopic-assisted technique may be a viable option to complete the procedure.
Percutaneous endoscopic gastrostomy (PEG) is the most common way of placing a feeding tube. Sometimes PEG cannot be used to safely place a feeding tube, most commonly secondary to an inability to transilluminate the abdominal wall. Whereas open gastrostomy was previously necessary in such cases, laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) is a viable option and is reviewed here.
All patients referred for surgical feeding tube placement after unsuccessful PEG were considered for LAPEG. A diagnostic laparoscopy was performed to identify the reason for the failed PEG attempt. Additional ports were placed as needed for the retraction of organs and lysis of adhesions. The stomach was visualized, and the PEG was placed.
Eight patients who underwent an unsuccessful PEG were taken to the operating room for LAPEG. All patients had successful LAPEG placement. No postoperative complications occurred. The most common reason identified for failed PEG attempt was adhesions followed by overlying organs. Average OR time was 32 minutes.
When conventional PEG placement is not possible, LAPEG placement should be considered as a time efficient, minimally invasive alternative to open gastrostomy.
PEG; Gastrostomy; Laparoscopic
To present our experience with head and neck squamous cell carcinoma (HNSCC) seeding of percutaneous endoscopic gastrostomy (PEG) sites and to review all reported cases to identify risk factors and develop strategies for complication avoidance.
Materials and methods
The records of 4 patients with PEG site metastasis from HNSCC were identified from the authors’ institution. Thirty-eight further cases were reviewed following a PubMed search and evaluation of references in pertinent articles.
Review of 42 cases revealed the average time from PEG to diagnosis of metastatic disease to be 8 months. Average time to death from detection of PEG disease was 5.9 months. One-year survival following PEG metastasis was 35.5% with an overall mortality of 87.1%.
PEG site metastatic disease portends a poor prognosis. Early detection and aggressive therapy may provide a chance of cure. Changes in PEG technique or in timing of adjunctive therapies are possible avenues in further research to prevent this complication.
Percutaneous endoscopic gastrostomy; Head and neck cancer; PEG; Metastasis; Prophylactic irradiation
This study was undertaken to test the extent to which a new antibiotic prophylaxis regimen for percutaneous endoscopic gastrostomy (PEG), identified as a justified and simpler alternative to conventional regimen in a randomised clinical trial, has been adopted in clinical practice.
A Swedish nationwide implementation survey, conducted in February 2013, assessed the level of clinical implementation of a 20 ml dose of oral solution of sulfamethoxazole and trimethoprim deposited in the PEG catheter immediately after insertion. All hospitals inserting at least five PEGs annually were identified from the Swedish Patient Registry. A clinician involved in the PEG insertions at each hospital participated in a structured telephone interview addressing their routine use of antibiotic prophylaxis.
All Swedish hospitals inserting PEGs (n=60).
Representatives of PEG insertions at each of the 60 eligible hospitals participated (100% participation).
Main outcome measures
Use of routine antibiotic prophylaxis for PEG.
A total of 32 (53%) of the 60 hospitals had adopted the new regimen. It was more frequently adopted in university hospitals (67%) than in community hospitals (41%). An annual total of 1813 (70%) of 2573 patients received the new regimen. Higher annual hospital volume was associated with a higher level of adoption of the new regimen (80% in the highest vs 31% in the lowest).
The clinical implementation of the new antibiotic prophylaxis regimen for PEG was high and rapid (70% of all patients within 3 years), particularly in large hospitals.
NUTRITION & DIETETICS; SURGERY