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1.  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.
PMCID: PMC4069302  PMID: 24976711
Gastrostomy tube; Percutaneous; Enteral feeding; Indication; Contraindication; Complication; Management
2.  Nutritional support teams increase percutaneous endoscopic gastrostomy uptake in motor neuron disease 
AIM: To examine factors influencing percutaneous endoscopic gastrostomy (PEG) uptake and outcomes in motor neuron disease (MND) in a tertiary care centre.
METHODS: Case notes from all patients with a confirmed diagnosis of MND who had attended the clinic at the Repatriation General Hospital between January 2007 and January 2011 and who had since died, were audited. Data were extracted for demographics (age and gender), disease characteristics (date of onset, bulbar or peripheral predominance, complications), date and nature of discussion of gastrostomy insertion, nutritional status [weight measurements, body mass index (BMI)], date of gastrostomy insertion and subsequent progress (duration of survival) and quality of life (QoL) [Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R)]. In addition, the type of clinician initiating the discussion regarding gastrostomy was recorded as Nutritional Support Team (involved in providing nutrition input viz Gastroenterologist, Speech Pathologist, Dietitian) and other (involved in non-nutritional aspects of patient care). Factors affecting placement and outcomes including length of survival, change in weight and QoL were determined.
RESULTS: Case records were available for all 86 patients (49 men, mean age at diagnosis 66.4 years). Thirty-eight patients had bulbar symptoms and 48 had peripheral disease as their presenting feature. Sixty-six patients reported dysphagia. Thirty-one patients had undergone gastrostomy insertion. The major indications for PEG placement were dysphagia and weight loss. Nine patients required immediate full feeding, whereas 17 patients initially used the gastrostomy to supplement oral intake, 4 for medication administration and 1 for hydration. Initially the PEG regime met 73% ± 31% of the estimated total energy requirements, increasing to 87% ± 32% prior to death. There was stabilization of weight in patients undergoing gastrostomy [BMI at 3 mo (22.6 ± 2.2 kg/m2) and 6 mo (22.5 ± 2.0 kg/m2) after PEG placement compared to weight at the time of the procedure (22.5 ± 3.0 kg/m2)]. However, weight loss recurred in the terminal stages of the illness. There was a strong trend for longer survival from diagnosis among MND in PEG recipients with limb onset presentation compared to similar patients who did not undergo the procedure (P = 0.063). Initial discussions regarding PEG insertion occurred earlier after diagnosis when seen by nutrition support team (NST) clinicians compared to other clinicians. (5.4 ± 7.0 mo vs 11.9 ± 13.4 mo, P = 0.028). There was a significant increase in PEG uptake (56% vs 24%, P = 0.011) if PEG discussions were initiated by the NST staff compared to other clinicians. There was no change in the ALSFRS-R score in patients who underwent PEG (pre 34.1 ± 8.6 vs post 34.8 ± 7.4), although in non-PEG recipients there was a non-significant fall in this score (33.7 ± 7.9 vs 31.6 ± 8.8). Four patients died within one month of the procedure, 4 developed bacterial site infection requiring antibiotics and 1 required endoscopic therapy for gastric bleeding. Less serious complications attributed to the procedure included persistent gastrostomy site discomfort, poor appetite, altered bowel function and bloating.
CONCLUSION: Initial discussion with NST clinicians increases PEG uptake in MND. Gastrostomy stabilizes patient weight but weight loss recurs with advancing disease.
PMCID: PMC3508641  PMID: 23197892
Motor neuron disease; Multidisciplinary management; Nutrition support team; Percutaneous endoscopic gastrostomy; Survival
3.  Percutaneous endoscopic gastrostomy in children 
Korean Journal of Pediatrics  2011;54(1):17-21.
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.
PMCID: PMC3040361  PMID: 21359056
Gastrostomy; Child; Complication; Gastroesophageal reflux disease
4.  Percutaneous Endoscopic Gastrostomy for Enteral Nutrition 
From January to October, 1986, at Wonkwang University Hospital in Iri, percutaneous endoscopic gastrostomy(PEG) was attempted in 26 patients and was successful in 24. This study was designed to review the technique and to evaluate the efficacy of PEG. The mean operation time was 22 minutes (range: 14 to 42 minutes). After feeding started, early positive nitrogen balance was achieved in all patients. All gastrostomies functioned well throughout the patient’s survival with the longest functioning at 10 month. There were no procedure-related deaths, and morbidity was lower and less severe as compared with large-bore nasogastric tube feeding. Complications included minor wound infection in two patients, stomal growth in one patient, leaks around the tube in two patients, and intraperitoneal leak in one patient. No patient developed aspiration pneumonia or required laparotomy for complications from PEG. The gastrostomy tube was easily removed endoscopically when treatment was completed. Feeding via a large-bore tube increased the risk of aspiration pneumonia (72%) and the feeding cost via a small-bore tube with elemental diet exceeded that of PEG by more than tenfold. This author’s experience with these 26 patients has led to the conclusion that PEG is safe, easy to perform, and effective means of creating feeding gastrostomy without laparotomy or general anesthesia. The authors suggest that PEG be the preferred route of alimentation in those patients who are unable to swallow for prolonged periods of time.
PMCID: PMC4534918  PMID: 3155323
Percutaneous endoscopic gastrostomy; Enteral nutrition
5.  The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review 
Over 4.5 million people in North America had a diagnosis of dementia in the year 2000, and more than half had advanced disease with potential aspiration risk. There is much controversy regarding the use and timing of enteral feeding support in these patients with dysphagia. The management of dysphagia is far more complex when considering quality of life, “comfort care” hand feeding, the use of percutaneous endoscopic gastrostomy tube (PEG), and associated mortality rates. This study seeks to critically review the literature that evaluates PEG placement in this population.
A systematic literature review of PubMed, from 1995–2012, was conducted to identify studies relating to PEG placement in dementia patients with dysphagia. The principal outcomes and related survival rates for this population were compared.
In total, 100 articles were identified in the search. Of these, ten met the search criteria and were analyzed. There was one study with a 2b level of evidence, one with 3b, and the remainder had level 4. All studies discussed long-term survival in the PEG versus non-PEG populations. No studies showed definitive evidence to suggest long-term survival rates improved in patients who underwent PEG placement as compared to those who did not. Two studies documented median survival worse in patients over age 80 with dementia and PEG placement.
There is presently no evidence to suggest long-term survival rates improved in patients with advanced dementia who underwent PEG placement for dysphagia. Relevance to quality of life, need for nutrition and hydration, and ethical considerations in the decision process are discussed.
PMCID: PMC4205113  PMID: 25342891
PEG; aspiration; elderly; feeding tube; swallow
6.  Gastrostomy tube placement by radiological versus endoscopic methods in an acute care setting: A retrospective review of frequency, indications, complications and outcomes 
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.
PMCID: PMC2694590  PMID: 19214286
Feeding tubes; Gastrostomy; Percutaneous endoscopic gastrostomy; Percutaneous radiological gastrostomy
7.  Prevalence and Factors Associated with Percutaneous Endoscopic Gastrostomy (PEG) Tube Feeding Among Nursing Home Patients 
Unnecessary percutaneous endoscopic gastrostomy (PEG) tube feeding in nursing homes (NH) is a growing concern and an important area of research. Hawaii has one of the highest rates of PEG tube feeding in NH patients in the US, yet has lower rates than many NHs in Asian countries. We examined prevalence and factors associated with PEG tube feeding in NH patients in Hawaii.
We conducted an observational cohort study of all patients admitted between 2003 and 2006 to an urban 180-bed hospital-affiliated NH in Honolulu, Hawaii. Data were collected from time of admission until discharge or death through 6/30/2011, from electronic and paper medical records and Minimum Data Set (MDS). Data included demographic characteristics, baseline medical conditions, functional status, cognitive status and code status. We created a Charlson Comorbidity Index (CCI) score based on baseline medical conditions on admission, and a disability score (ADL score) and Cognitive Performance Score (CPS) using baseline MDS data. Multivariable logistic regression was used to analyze factors associated with PEG tube feeding.
Of 238 NH patients aged 45–104 years (mean 83 years), 35 (14.7%) had PEG tube feeding. Of the NH cohort, 130 (54.6%) were female, 218 (92.3%) were Asian, 123 (51.9%) had a prior stroke and 163 (72%) had dementia based on CPS score. Among the 35 PEG tube fed patients, 23 (66%) had PEG placement prior to NH admission, 12 (34%) had PEG placement after NH admission, and 26 (74%) patients had PEG tube feeding until death or the end of follow-up (61 days to 8.4 years, mean 2.4 years). Prior stroke was associated with increased likelihood of PEG tube feeding (aOR = 2.52, 95%CI = 1.03–6.17, P = .04); with borderline increased likelihood for high comorbidity index (aOR = 2.21, 95%CI = 0.89–5.52, P = .09) and high ADL disability score (aOR = 2.03, 95%CI = 0.87–4.73, P = .10). DNR status was inversely associated with PEG tube feeding (aOR = 0.31, 95%CI = 0.11–0.85, P = .02). Age, dementia, Medicaid status, previous speech or physical therapy, and weight loss were not significantly associated with PEG tube feeding.
In this predominantly Asian-American NH cohort with high prevalence of PEG tube feeding, prior stroke was strongly associated with PEG tube feeding, while dementia was not. Further study is needed to examine ways to identify and reduce unnecessary tube feeding in this population.
PMCID: PMC3764570
8.  Single endoscopist-performed percutaneous endoscopic gastrostomy tube placement 
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.
PMCID: PMC3710419  PMID: 23864780
Gastrostomy; Gastric feeding tube; Enteral nutrition; Enteral feeding; Endoscopy; Gastrointestinal
9.  Outcomes of Percutaneous Endoscopic Gastrostomy in Hospitalized Patients at a Tertiary Care Hospital in Turkey 
The aim of this study was to perform a retrospective analysis characterizing patients receiving tube feeding following percutaneous endoscopic gastrostomy ( PEG) tube placement between 2004 and 2012 at Erciyes University Hospital in Turkey.
Patients above the age of 18 years, who required long term enteral tube feeding were studied. All PEGs were performed using the pull-through technique by one experienced endoscopist Demographic, clinical outcomes, and PEG-related complication data were collected.
Of the 128 subjects studied, 91 were male (71%) and 37 were female (29%). The mean age of this patient population was 54±19 years. The most common reason for PEG tube insertion was inability to consume oral diet due to complications of cerebrovascular disease (CVD; 27%), while cerebral hypoxia, occuring after non-neurological medical disorders, was the second most common indication (23%). A total of 70 patients (55%) had chronic comorbidities, with hypertension the most common (20%). The most common procedure related complication was insertion site bleeding, which occurred in 4 % of patients. Long term complications, during one year were insertion site cellulitis, gastric contents leakage, and peristomal ulceration occurred in 14%, 5%, and 0.5% of patients, respectively. There were no PEG insertion-related mortalities; one-year mortality was unrelated to the indication for PEG tube insertion.
PEG tube insertion was a safe method to provide enteral access for nutrition support in this hospitalized patient population.
PMCID: PMC3975672  PMID: 24518749
PEG; gastrostomy; enteral nutrition; tube feeding; Turkey
10.  Percutaneous endoscopic gastrostomy feeding in patients with cystic fibrosis 
Gut  1999;44(1):87-90.
Background—Malnutrition 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. 
Patients—53 patients with CF (43 adults; age >17 years) with severe pulmonary disease. 
Methods—The technical success and complications of PEG insertion were documented together with changes in nutritional and pulmonary status of the cohort. 
Results—PEG 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. 
Conclusion—Supplemental 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 pulmonary disease. 

Keywords: cystic fibrosis; malnutrition; enteral nutrition; percutaneous endoscopic gastrostomy
PMCID: PMC1760069  PMID: 9862831
11.  Elemental Diets May Reduce the Risk of Aspiration Pneumonia in Bedridden Gastrostomy-Fed Patients 
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.
PMCID: PMC3647233  PMID: 23399554
12.  Acceptability and outcomes of the Percutaneous Endoscopic Gastrostomy (PEG) tube placement- patients' and care givers' perspectives 
BMC Gastroenterology  2006;6:37.
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.
PMCID: PMC1676010  PMID: 17125502
13.  Laparoscopic-assisted percutaneous endoscopic gastrostomy in two patients who failed percutaneous endoscopic gastrostomy 
•Gastrostomy can be a necessity in a variety of clinical situations either for nutrition or for gastrointestinal discharge.•There are two major techniques: open gastrostomy and minimally invasive gastrostomy.•We describe herein a technique of laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) in 2 cases with different primary pathologies and unsuccessful attempt of Percutaneous endoscopic gastrostomy as the first intention.•LAPEG might be an interesting option by minimizing the risk of intestinal injury and might be a faster and easier procedure than laparoscopic gastrostomy, and should be considered for selected cases.
Percutaneous endoscopic gastrostomy (PEG) is a common procedure to obtain a feeding tube. However, this technique might imply several difficulties and complications. The inability to transilluminate the abdominal wall may occur frequently, especially in obese or multi-operated patients. With the emergence of minimally invasive surgery, laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) might provide a safe and efficient alternative.
Presentation of cases
We report hereby two cases of patients having undergone LAPEG in our institution. Conventional PEGs were deemed impossible because of the absence of transillumination and motivated a surgical approach.
Two obese patients with a Body Mass Index (BMI) of 31 and 45 kg/m2 respectively presented neurological condition (stroke and Parkinson’s disease) requiring a feeding tube. While a PEG was unsuccessful (impossibility to transilluminate), a LAPEG was attempted. The procedure and the recovery were uneventful.
There are different techniques for gastrostomy tube placement: open gastrostomy, PEG and radiologic procedure. The PEG is associated with a significant risk of bowel perforation.
LAPEG seems to be an interesting option in order to avoid an open gastrostomy in patients in whom a PEG cannot be performed. This is especially true in obese patients, where a transillumination cannot be performed. It offers an endoscopic view of the stomach simultaneously to the laparoscopic approach that allows a potential decrease of major complications.
While the literature reports mainly pediatric cases, we present herein two successful LAPEG in adult obese patients. In case of impossibility to perform PEG, this technique allows a safe direct visualization of the stomach and other adjacent organs.
PMCID: PMC4529636  PMID: 26101053
Gastroscopy; Gastrostomy; PEG; Laparoscopy
14.  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.
PMCID: PMC3547115  PMID: 23330049
Percutaneous endoscopic gastrostomy; Gastrostomy tube replacement; Gastrostomy tube exchange; Gastrostomy tube reinsertion; Complication; Peritonitis; Prevention; Management
15.  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
Acta Informatica Medica  2012;20(4):235-237.
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.
PMCID: PMC3558284  PMID: 23378689
PEG; enteral nutrition; tube feeding.
17.  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.
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.
PMCID: PMC3021287  PMID: 20529529
Laparoscopy; Percutaneous endoscopic gastrostomy
18.  Percutaneous endoscopic gastrostomy. 
Postgraduate Medical Journal  1996;72(852):581-585.
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.
PMCID: PMC2398609  PMID: 8977937
19.  Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy Tube Placement 
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.
PMCID: PMC3021284  PMID: 20529530
PEG; Gastrostomy; Laparoscopic
20.  Endoscopic gastrostomy, nasojejunal and oral feeding comparison in aspiration pneumonia patients 
Aspiration pneumonia is a potentially preventable illness requiring attention to small details of patient care. The type, management, and care of feeding should be carried out properly.
Materials and Methods:
This is a prospective clinical study of enteral feeding on patients admitted to hospital with aspiration pneumonia. The known enteral nutritional methods, advantages, and disadvantages were told to the patient or proxy. If they didn’t accept Percutaneous endoscopic gastrostomy (PEG), nasojejunal tube (NJT) was advised. If they denied all of the procedures, oral feeding education was given. A total of 94 patients were enrolled to the study, 29 of them accepted PEG, 42 preferred NJT, and 23 preferred oral route.
A total of 94 patients with a mean age of 77.84, standard deviation 10.784; 95% confidence interval (CI) 75.63-80.03 were enrolled to the study of which 27 (28.7%) patients had a history of aspiration pneumonia. Oral feeding was prominently preferred for patients nursed by a relative (15; 65.2% of Oral feeding group and 16% of total) or a caregiver (7; 30.4% of Oral feeding group and 7.4% of total) while only 1 (4.3% of Oral feeding group and 1.1% of total) with a health-care worker (P = 0.001). Overall re-aspiration rates at the 6th month were 58%, 78%, 91% in EG, NJT, oral groups, respectively. Sixth months’ survival rates of the different feeding groups were not significantly divergent from each other. History of aspiration was also found to be a significant contributor of mortality.
In aspiration pneumonia patients’ long-term survival rates of the different feeding groups were not significantly divergent from each other.
PMCID: PMC3908533  PMID: 24523803
Aspiration pneumonia; emergency department; enteral feeding; mid arm circumference; nasojejunal tube; nutrition; oral feeding; percutaneous endoscopic gastrostomy
21.  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
22.  The Effect on Colon Visualization During Colonoscopy of the Addition of Simethicone to Polyethylene Glycol-Electrolyte Solution: A Randomized Single-Blind Study 
Colonic bubbles associated with polyethylene glycol-electrolyte solution (PEG-ELS) are common and obscure mucosal visualization. This study aimed to determine whether adding simethicone decreases the incidence of bubbles.
Prospective, single-blind, randomized comparison of split dose PEG-ELS vs. PEG-ELS+simethicone (PEG-S) for outpatient colonoscopy. Bubble severity for colonic segments was assessed on withdrawal as A=no/minimal bubbles, B=moderate bubbles/interfere with detecting 5 mm polyp, C=severe bubbles/interfere with detecting 10 mm polyp. Primary end point was Grade B or C bubbles in any colon segment. Secondary end points were cleansing quality, incidence and severity of side effects, and polyp detection.
One hundred and thirty nine patients enrolled; 13 withdrew before colonoscopy. Of 123 patients evaluated, 62 took PEG-S and 61 PEG-ELS. The incidence of grade B or C bubbles was much lower with PEG-S compared with PEG-ELS (2% vs. 38% P=0.001). Overall cleansing (excellent or good) quality was not significantly different for either the whole colon (89% PEG-ELS, 94% of PEG-S, P=0.529) or right colon (88% PEG-ELS, 94% PEG-S, P=0.365). More PEG-S patients had excellent rather than good preps (whole colon 53% vs. 28%, P=0.004; right colon 53% vs. 35%, P=0.044). Need for any flushing was less with PEG-S (38% vs. 70%, P=0.001). The groups were not significantly different with respect to total procedure and withdrawal times, incidence or severity of side effects, or number of polyps/patient or adenomas/patient.
Adding simethicone to PEG-ELS effectively eliminates bubbles, substantially reduces the need for flushing, and results in more excellent preparations.
PMCID: PMC3513841  PMID: 23238113
23.  General Paediatric Surgical Provision of Percutaneous Endoscopic Gastrostomy in a District General Hospital – A 12-Year Experience 
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.
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.
PMCID: PMC2758436  PMID: 19344554
Percutaneous endoscopic gastrostomy; PEG; Children enteral feeding; Paediatric surgery
24.  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.
PMCID: PMC2362464  PMID: 18493339
25.  Comparison of Clinical Outcomes Associated with Pull-Type and Introducer-Type Percutaneous Endoscopic Gastrostomies 
Clinical Endoscopy  2014;47(6):530-537.
Percutaneous endoscopic gastrostomy (PEG) is a method of providing enteral nutrition using endoscopy. The PEG techniques differ according to the insertion method, and include the pull type, push type, and introducer type. The aim of this study was to compare the clinical outcomes associated with the pull-type and introducer-type PEG insertion techniques, which included the adverse events, at our tertiary care center in Korea.
We retrospectively reviewed 141 cases that had undergone PEG insertion at our center from January 2009 to June 2012. The indications for PEG insertion and the acute and chronic complications caused by each type of PEG insertion were analyzed.
The indications for PEG insertion in our cohort included neurologic disease (58.7%), malignancy (21.7%), and other indications (19.6%). Successful PEG insertions were performed on 136 cases (96.5%), and there were no PEG-associated deaths. Bleeding was the most frequent acute complication (12.8%), and wound problems were the most frequent chronic complications (8.8%). There were no statistically significant differences between the pull-type and introducer-type PEG insertion techniques in relation to complication rates in our study population.
PEG insertion is considered a safe procedure. The pull-type and introducer-type PEG insertion techniques produce comparable outcomes, and physicians may choose either of these approaches according to the circumstances.
PMCID: PMC4260101  PMID: 25505719
Percutaneous endoscopic gastrostomy; Pull type; Introducer type; Complication; Indication for PEG

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