When the Solution Becomes the Problem

Abstract

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) tubes are placed for numerous clinical indications. Different endoscopic techniques can be used such as pull method or introducer technique. Common complications include wound infections, tube dysfunction, bleeding, localized pain and gastric outlet obstruction. Introducer technique has been reported to be associated with decreased complications. T-fastener gastropexy is a component of introducer technique. T-fasteners have been shown to obviate the need for emergent replacement after early tube dislodgement. They are expected to fall off about two weeks after placement. We report 3 cases of PEG placement using the introducer technique where the T fasteners caused preventable complications. Report: We report 3 cases of Caucasian men(mean age 69), one with esophageal carcinoma, one with squamous cell carcinoma of the mandible and one with metastatic lung cancer; all of whom were referred for failure to thrive secondary to dysphagia. All underwent 18 French Kimberly-Clark® MIC PEG placement via step dilation method and had 3 T-fasteners placed. All received peri-procedure intravenous third generation cephalosporin. All then presented in about 3-4 weeks post procedure with complications. First patient presented with erythema, fluid drainage and skin ulceration around a T-fastener site with concern for abscess. However, a CT Abdomen did not show any abscess. On evaluation, none of the three fasteners had fallen off. Second patient presented with local erythema and redness around a T- fastener that was still found to be in place. Third patient had significant pain at T-fastener site secondary to hair trapping within the fastener. Adherent T-Fasteners were removed in all patients, and the first two were sent out on short antibiotic courses (first one on oral Augmentin and Ciprofloxacin, second on topical Bactrim). Patients did not develop further complications that required repeat evaluations. Discussion: Variable rates of complications secondary to PEG placement have been reported in literature. Complications can be immediate or delayed. Fasteners ideally fall off in about two weeks after procedure, but can stick and can cause local wound infections, erythema and pain. Some patients can be immunosuppressed and vulnerable to local infections with subsequent systemic progression. Therefore, after reviewing these cases, a policy change was made at our institution. Now patients are instructed to call gastroenterology clinic two weeks post PEG placement and are requested to come in if all T-fasteners have not fallen off. We hope to reduce local wound infections and PEG placement related complications by this simple intervention