Transnasally placed percutaneous endoscopic gastrostomy probe

HISTORY: A 78-year-old woman in an organic psychotic state with food refusal was referred for a percutaneous endoscopic gastrostomy (PEG), repeated fluid infusions at home having failed to deal with dehydration severe enough to cause coma. She was somnolent on admission; neither a history nor cooperation was obtainable. TREATMENT AND COURSE: Despite premedication with 20 mg diazepam and 100 mg pethidine endoscopy could not be performed through the mouth. A routine gastroscope (9 mm external diameter), however, could be passed transnasally into the stomach without difficulty and the PEG tube also placed transnasally. CONCLUSION: When endoscopic access to the stomach via the mouth fails, introduction via the nose is a possible alternative.     

Postoperative percutaneous endoscopic gastrostomy/jejunostomy

In order to cure complications appeared in the postoperative period two patients were treated with percutaneous endoscopic gastrostomy/jejunostomy (PEG, PEGJ) with the purpose of long-lasting enteral feeding and decompression. The indications of PEG/PEGJ were the following: external gastric fistula in one case and anastomotic leakage in one case. In the patients the PEG was located by intraoperative X-ray examination, this method was not published earlier. Regarding complications of the early postoperative period the PEG and the PEGJ are considered useful and expedient procedures with the aim of lasting enteral feeding and decompression.     

A method for radiologic-assisted gastrostomy when percutaneous endoscopic gastrostomy is contraindicated

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) has been established as a faster and safer procedure than open surgical gastrostomy. It cannot be done, however, for many patients with partially obstructing pharyngeal or esophageal carcinoma, previous gastrectomy, upper abdominal surgery, or bowel distension from distal obstruction. PATIENTS AND METHODS: We attempted percutaneous radiologic-assisted gastrostomy (RAG) in 231 patients referred for gastrostomy, 38 of whom had a relative contraindication for PEG. The procedure involves passing, under radiologic guidance, an orogastric inflation tube that contains a snare. We used a 5-inch long, 18-gauge needle to transabdominally insert a wire into the stomach, avoiding loops of bowel visualized by air contrast. Retrieving the transabdominal wire by snare allowed retrograde passage of the gastrostomy tube as done in standard PEG. RESULTS: The procedure was successful in 230 of 231 cases, including 37 of the 38 patients with contraindications. We could not gain gastric access in 1 patient with a 75% gastrectomy. Overall, 6 patients developed complications and 1 died. There was no procedure-related morbidity or mortality in the patients with contraindications to PEG who underwent successful RAG. Subsequent laparotomy indicated tube passage through the liver in 2 of these cases and small bowel mesentery in 1 case without clinical problems. We performed a percutaneous jejunostomy in the efferent limb of the gastrojejunostomy in 1 patient with a previous gastrectomy. CONCLUSION: The snare technique is simpler and faster than the usual radiologic gastropexy technique, and safer than an endoscopic procedure. It has become our procedure of choice for gaining gastric access.     

Complications of percutaneous endoscopic gastrostomy (PEG)

Percutaneous endoscopic gastrostomy (PEG) is a simple technique for the endoscopic placement of a permanent feeding access. The procedure is relatively safe and the technique well established. PEG can, however, be associated with serious complications and death. Following the rare PEG-related complication of an abdominal dislocation we review technique, indications and complications of this sixteen year old method.     

Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) tube placement is the preferred method for long-term enteral feeding of patients who are unable to take food by mouth. Despite the widespread acceptance of the procedure, no large-scale study of the long-term outcomes of patients receiving PEG tubes has been reported. The objective of this study was to determine the survival of patients in whom PEG tubes are placed. DESIGN: Retrospective cohort study using data obtained from two computerized databases. SETTING: Department of Veterans Affairs hospitals. PATIENTS: Seven thousand three hundred sixty-nine patients who received a PEG tube in fiscal years 1990 through 1992. RESULTS: For the 7,369 patients, the mean age was 68.1 years and 98.6% were men. PEG tubes were most commonly places in patients with cerebrovascular disease (18.9%), other organic neurologic disease (28.6%), or head and neck cancer (15.7%). Although the complication rate of the procedure itself was low (4%), because of the severity of their underlying disease, 1,732 patients (23.5%) died during the hospitalization in which the PEG tube was placed. The median survival of the full cohort was 7.5 months. CONCLUSIONS: This study documents the widespread placement of PEG tubes in severely ill patients, half of whom are in the terminal phase of their illness. Further study is needed to determine whether these patients benefit from PEG tube placement in terms of their quality of life and survival.     

Evaluation of percutaneous endoscopic gastrostomy in a university hospital

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) has become a commonly performed procedure to provide nutritional support for chronically ill patients. The aim of this study was to review the safety and results of PEG in a teaching hospital. METHODOLOGY: A retrospective review of 44 patients who underwent PEG procedure. The indication was long-term enteral feeding in patients who were unable to maintain adequate nutrition by mouth with an otherwise functioning gut. The most common primary diagnosis was cerebrovascular accident (17 patients). All patients were unable to swallow. RESULTS: There were six (13.6%) minor complications, and two mortalities from peritonitis (4.5%). The most common complication was gastrostomy site infection, which did not require exchange of the feeding tube. CONCLUSIONS: PEG is a useful means of providing nutrition in patients unable to swallow without the necessity for laparotomy and general anesthesia. This method provides an adequate avenue for enteral alimentation in selected patients and is relatively safe. Careful attention to the technique of insertion is important to prevent leakage or bowel perforation.     

Simplified "push" technique for percutaneous endoscopic gastrostomy in children

Percutaneous endoscopic gastrostomy (PEG) by the "pull" technique is the standard method in pediatric patients. Modifications have been reported for adults but few in children. Problems with the "pull" technique including pericatheter infection due to contamination of the tube tract with oral flora, repeated insertion of the endoscope, potential esophageal injury from the catheter, and the possible need for another endoscopy for catheter removal, prompted our interest in a simpler technique. The "push" technique requires insertion of the endoscope only once to insufflate and visualize the insertion site. A modified Seldinger technique is used to insert a 14F acrylic Foley catheter. We have used this technique to place PEG tubes in 8 children age 6 weeks to 17 years (mean, 6 years), for failure to thrive due to cystic fibrosis (3), neurological impairment (4), and undetermined cause (1). Operative time averaged 15 minutes. All PEGs were used within 24 hours. This "push" technique of PEG insertion is safe, simple, quick, and obviates many of the potential risks inherent in the "pull" technique. The "push" technique deserves a more widespread application in children.     

A complication of T-fasteners in percutaneous endoscopic gastrostomy (PEG) placement

Two patients with sinus tracts from retained T-fasteners following PEG tube placement are reported. Both patients had the PEG tubes subsequently removed and presented with purulent discharge and granulations near well-healed gastrostomy sites. The management of this complication and a possible method of prevention are discussed.     

Effect of percutaneous endoscopic gastrostomy on gastric emptying in clinically normal cats

OBJECTIVE: To assess the effect of percutaneous endoscopic gastrostomy (PEG) tube placement on gastric emptying in clinically normal cats. ANIMALS: 8 healthy adult 3- to 5-year-old cats. PROCEDURE: Cats were accommodated to the diet for 2 weeks prior to scintigraphy. Caloric needs were divided into 3 feedings/d. Food was withheld for 24 hours after tube placement, then was fed as a third of the caloric needs on day 1, two-thirds on day 2, and full caloric requirements thereafter. Gastric emptying was measured via nuclear scintigraphy. Labeled meals contained 111 MBq (3 mCi) of 99mTc-labeled disofenin. Sixty-second ventral scintigraphic images were acquired immediately, every 20 minutes for the first hour, then every 30 minutes for 4 hours after feeding. Each cat was evaluated 3 times prior to PEG tube placement. Cats were anesthetized, and 16-F mushroom-tipped Pezzar gastrostomy tubes were placed, using a video endoscope. Scintigraphy was repeated on days 1, 4, 7, 11, 14, and 21 after PEG tube placement. RESULTS: Gastric emptying was faster with a PEG tube in place. Percentage of retained gastric activity was significantly lower after PEG for 150, 180, 210, and 240 minutes versus time before PEG tube placement. CONCLUSION: Placement of a PEG tube does not delay gastric emptying in clinically normal cats. CLINICAL RELEVANCE: Gastric retention of food, vomiting, and aspiration pneumonia after PEG tube placement may not be related to delayed gastric emptying.     

Tumour seeding following percutaneous endoscopic gastrostomy placement in head and neck cancer

We report the case of a patient with advanced squamous carcinoma of the supraglottic larynx and hypopharynx who developed metastatic gastric deposits occurring at the site of a percutaneous endoscopic gastrostomy tube, inserted 10 months previously by the pull technique. We review seven previous reports of tumour deposits occurring at the site of placement of a percutaneous endoscopic gastrostomy in patients with head and neck cancer, and consider alternative methods of enteral feeding in such patients.     

The "buried bumper" syndrome--a rare complication of percutaneous endoscopic gastrostomy

Since initially being described in 1980, percutaneous endoscopic gastrostomy (PEG) has had a dramatic impact on enteral access and alimentation techniques. Knowledge of the problems makes it possible to lower the complication rate of this method. We report a case of partial penetration of the gastric wall by the internal bolster of the tube. We focus on the prevention, recognition, and management of this PEG-related problem.     

Percutaneous radiologic, surgical endoscopic, and percutaneous endoscopic gastrostomy/gastrojejunostomy: comparative study and cost analysis

p27kip1 (p27) protein is an inhibitor of cyclin and cyclin-dependent kinase complexes and prevents progression of cells from G1 to the S phase of the cell cycle. p27 might have tumor suppressor activity, and decreased p27 expression is associated with aggressive tumor behavior in several human malignancies. The object of this study was to evaluate p27 expression in prostatic adenocarcinoma treated by radical prostatectomy and to assess its association with numerous morphologic and clinical features. One hundred thirty-eight prostatic adenocarcinomas were evaluated for p27 expression by quantifying nuclear immunohistochemical staining. p27 expression was tested for association with patient age, family history of prostate cancer, preoperative serum prostate-specific antigen level, Gleason score, extraprostatic extension, seminal vesicle involvement, lymph node metastases, tumor-node-metastasis stage, DNA ploidy by flow cytometric analysis, and subclinical biochemical failure. p27 expression was analyzed as a continuous variable, and we also classified the tumors as low expressors (< 50% of cells p27 positive) or high expressors (> 50% of cells p27 positive) for comparison. Patients with adenocarcinomas that exhibited low p27 expression had higher mean Gleason scores than did high expressors (7 vs. 6.2, respectively; P = .002). Low p27 expression correlated with positive surgical margins (P = .05), seminal vesicle involvement (P = .007), lymph node metastasis (P = .03), and aneuploid cancers (P = .003), but it did not correlate with subclinical biochemical failure. p27 expression correlated with a number of prognostic morphologic features in prostatic adenocarcinoma, and the evaluation of p27 expression might provide additional prognostic information.     

Use of single percutaneous endoscopic gastrostomy in management of gastric volvulus in three patients

Gastric volvulus is a rare condition that occurs when the stomach twists either in an organoaxial or mesenteroaxial direction. In patients with recurrent episodes of volvulus, standard therapy is surgical correction. Many patients, however, are not candidates for surgical therapy because of comorbid conditions or advanced age. Our aim was to determine if the insertion of a single percutaneous gastrostomy tube placement would assist in management of gastric volvulus in patients not able to undergo surgical therapy. The alpha-loop maneuver was used to reduce gastric volvulus in three elderly patients. A percutaneous endoscopic gastrostomy tube was then inserted to prevent recurrent volvulus. Single percutaneous gastrostomy tube placement was successful in managing volvulus in these three patients. Single percutaneous endoscopic gastrostomy tube placement is a useful treatment alternative to surgery in patients requiring therapy of gastric volvulus.     

Percutaneous endoscopic gastrostomy in patients with ENT tumors

Oral food intake in patients with obstructing pharyngeal and esophageal carcinomas is commonly insufficient because of tumor-induced dysphagia which gives rise to cachexia unless treated. While entailing an unfavorable prognosis, malnutrition is often a therapy-limiting factor. Tube feeding with liquid formula diets currently offers the most efficient and least-risky approach to long-term use and is best adopted even at a pretreatment stage irrespective of the tumor therapy intended. A feeding tube placed by a percutaneous endoscopically controlled gastrostomy (PEG) increasingly offers an alternative to a nasogastric tube. After using diaphanoscopy, the stomach is punctured from outside under local anesthesia and a feeding tube inserted by means of a retrograde thread or a direct puncture method. A modification of the direct puncture method has been preferred at the Magdeburg University E.N.T. Department. The tube is held in place by thermally activated helical winding of a gastric tube end (using a memory-retaining helix). During the 1991-1996 period 415 patients with obstructing carcinomas of the upper digestive tract were treated with a feeding tube. No fatal complications were observed. Severe complications (peritonitis) occurred in three patients. In 160 patients with PEG the following parameters were recorded: weight-to-size index, body mass index, degree of dysphagia, nutrition status, lymphocyte count, total serum protein and patients' compliance to PEG. The enteral nutrition therapy used was indicated in all of the patients treated with advanced carcinomas of the head and neck. In 81% of the patients the compliance to PEG was positive. Findings demonstrated that long-term intestinal nutrition via PEG was a safe and effective form of treatment. Inserting the tube by the direct puncture method was advantageous for patients with carcinomas in the upper digestive tract as only few mechanical alterations take place along tumorous tissues following PEG while contamination with bacteria and neoplastic cells from the tumor region into the abdomen are precluded.