Balloon Gastrostomy Research Articles

Percutaneous Endoscopic Gastrostomy with T-Fasteners versus "Pull Technique": Analysis of Complications.

The T-fasteners gastrostomy (T-PEG) has become increasingly popular over recent years as an alternative to the "pull-technique" gastrostomy (P-PEG). This study aimed to compare P-PEG and T-PEG complications. A retrospective observational study of pediatric patients who underwent percutaneous endoscopic gastrostomy (PEG) placement. P-PEG was performed using the standard Ponsky technique and was replaced after 6 months by a balloon gastrostomy under sedation. T-PEG was performed using three percutaneous T-fasteners (that allow a primary insertion of a balloon gastrostomy). The balloon was replaced by a new one after 6 months without sedation. Complications were recorded. In total, 146 patients underwent PEG placement, 70 P-PEG and 76 T-PEG. The mean follow-up was 3.9 years (standard deviation = 9.6). Age, weight, and associated comorbidities were comparable (p > 0.05). The overall complications were 17 (24.2%) in the P-PEG group and 16 (21.0%) in the T-PEG group (p > 0.05). P-PEG was associated with more sedation for button replacement (97 vs. 2.6% [p < 0.05]). P-PEG was associated with more early tube dislodgement during the first replacement (7.2 vs. 1.4% [p = 0.092]). Two of the five dislodged gastrostomies in the P-PEG group underwent laparotomy due to peritonitis, whereas the only dislodged gastrostomy in the T-PEG group was solved endoscopically. Altogether, P-PEG was associated with more complications that required urgent endoscopy, laparotomy, or laparoscopy (18.6 vs. 6.6% [p < 0.05]). P-PEG was associated with more sedation, complications during first button replacement, and complications requiring urgent endoscopy, laparotomy, or laparoscopy compared with T-PEG.

Radiologically inserted gastrostomy tube in neurological disease: A retrospective study

Objectives: This study aimed to compare the safety and efficacy of balloon and non-balloon (or dilator) gastrostomy devices in radiologically inserted gastrostomy (RIG) for patients with neurological disease. Material and Methods: A retrospective analysis of 152 patients was conducted at a tertiary care hospital from July 2017 to September 2020. 104 and 48 patients were included in the balloon and non-balloon groups, respectively. The frequency of complications per specific neurological indication as well as the breakdown of the different complications pertaining to each indication was recorded for analysis. The recovery time, fluoroscopy time, contrast volume, peak radiation, and pain management dosages for each procedure were all reviewed to evaluate for statistical differences between the balloon and non-balloon groups. An adjusted model odds ratio (OR) was conducted to evaluate how each of the variables (type of gastrostomy tube, body mass index [BMI], age, and gender) affected the frequency of complications within our cohort. Results: This study included 152 patients, with an average age of 65.17 years (interquartile range [IQR] = 12.66) and an average BMI of 26.97 (IQR = 7.19). The majority of patients were male (71.1%). The most common indication for the procedure was stroke (24.3%), followed by post-intubation dysphagia (16.4%) and intracranial hemorrhage (11.8%). Amyotrophic lateral sclerosis (ALS) and altered mental status had a similar prevalence at 9.9%. The overall complication rate was 33.8%, overall mortality rate 3.3%, 30-day mortality rate of 2.6%, and no other major complications according to CIRSE criteria. Notably, patients with neurodegenerative disorders exhibited comparable rates of minor complications: 33.3% in ALS (5/15 patients), 50% in myasthenia gravis (1/2 patients), and 100% in muscular dystrophy (1/1 patient). The study compared two groups: the balloon group (104 patients) and the dilator group (48 patients). The balloon group received significantly lower preoperative sedation in the form of fentanyl (Avg = 4.46 min vs. 6.54 min, P = 0.287). The balloon group had shorter fluoroscopy time, lower radiation exposure dose, and shorter operating time compared to the dilator group, though not statistically significant. In the logistic regression model, there was no statistical difference in complication rates between the dilator and balloon groups. BMI, age, and gender did not significantly affect minor complication rates. Conclusion: RIG tube insertions may serve as a valuable, alternative approach in providing enteral support in patients with neurological disease.

Literature review of techniques for primary laparoscopic balloon gastrostomy and report of our experience of consecutive 80 children using the Seldinger technique

Literature review of techniques for primary laparoscopic balloon gastrostomy and report of our experience of consecutive 80 children using the Seldinger technique

S2101 Acute Obstructive Pancreatitis as a Complication of Percutaneous Endoscopic Balloon Gastrostomy

S2101 Acute Obstructive Pancreatitis as a Complication of Percutaneous Endoscopic Balloon Gastrostomy

An Incidental Discovery of a Serious Complication

An Incidental Discovery of a Serious Complication

Abstract No. 572 Outcomes of balloon percutaneous gastrostomy tube placements

Gastrostomy tube failures contribute to increased patient burden and are associated with hospital readmission and increased utilization of healthcare resources. The purpose of this study is to compare the outcomes of the novel balloon gastrostomy technique with the standard serial dilation.

S3127 A Complication of Endoscopic Balloon Gastrostomy Tube Placement

S3127 A Complication of Endoscopic Balloon Gastrostomy Tube Placement

Endoscopic vs laparoscopic paediatric gastrostomies: Time to change our practice?

Background: Gastrostomy insertion is a common procedure for paediatric surgeons, with the percutaneous endoscopic gastrostomy (PEG) technique long favoured for its simplicity and speed. However, there is growing evidence to suggest that primary laparoscopic balloon gastrostomy (LBG) insertions may have lower complication rates. This study aimed to determine the relative safety and healthcare resource burden of PEG and LBG. Methods: A retrospective review of all primary gastrostomy insertions (2011–2019). Primary outcome measures included return to theatre for emergency laparotomy and healthcare burden (total gastrostomy-related admissions, length of stay and total theatre utilisation). Results: 338 PEGs and 277 LBGs were inserted with a minimum follow-up period of six months. Following PEG insertion 12/338(3.6%) children required an emergency laparotomy for gastrostomy-related complications. This compared to 2/277(0.7%) following LBG insertion (ARR2.8% (95%CI0.6–5.0), p < 0.0267).When considering all gastrostomy related admissions, there was no significant difference in total theatre utilisation (PEG = 85 [IQR58–117] minutes, LBG = 86 [IQR75–105] minutes, p = 0.12). However, PEGs were found to have an overall longer length of stay 4 [IQR3–7] vs 3 [IQR2–4] days. Conclusions: LBGs carry a significantly lower rate of major complications and are not associated with an increased healthcare burden. LBG should be considered as the first line method of gastrostomy insertion in children.

Balloon gastrostomy feeding tube replacement: Involving local health-care facilities or general practitioner would reduce costs

Rationale: In France, the balloon gastrostomy feeding tube (BGT) replacement is a medical act, mainly performed in specialized care facilities (CF), which remain rare. However, this can legally take place in a local CF or by the general practitioner (GP), which could reduce transport costs. The objectives were i) to describe the BGT replacement activity performed in a specialized Nutrition Unit, including transport costs, ii) to estimate these costs if the act had been carried out in local CF or at home by the GP.

Open Primary Button Versus Laparoscopic Percutaneous Endoscopic Gastrostomy: Results From a Case-control Study.

Open primary balloon gastrostomy (PBG) presents a potential alternative to percutaneous endoscopic gastrostomy (PEG) in children as it obviates the need for change under general anaesthetic; however, the complication profile of PBG compared to PEG is not well defined. Previous series comparing the two have been hampered by the groups not being equivalent. Our paediatric surgical centre has offered PBG as an alternative PEG since 2014. We used a matched case-control study to compare outcomes for PBG and PEG. Patients undergoing PBG were used as "cases" and matched 1:3 by age and diagnosis to patients undergoing PEG, demographics, and clinical data as "controls." Primary outcome was rate of complications classified according to Clavien-Dindo (I-V). Secondary outcomes included time to feed and length of stay. Non-parametric, categorical and multivariate logistic regression analyses were performed. Data here presented as median with interquartile range (IQR). We included 140 patients (35 PBG:105 PEG). The 2 groups were comparable for sex, weight at surgery, and follow-up duration. Median operative time was longer for PBG (43 min [IQR 36.5-61.5] vs 27.5 min [18.25-47.75], P < 0.001). Multivariate analysis demonstrated a statistically significant, higher incidence of symptomatic granulation tissue in PBG (10 [29%] vs 6 [6%], P = 0.0008), this remained significant on multivariate analysis (OR 7.56 [2.33-23.5], P = 0.001), no other complication remained significant. The overall complication rate was not statistically different. PBG and PEG have similar overall complication rates; however, PBG appears to have a higher incidence of granulation tissue. This observation must be weighed against the need for further general anaesthetic which is not insignificant in medically complex children.

A comparison of balloon and nonballoon gastrostomy tubes in children

PurposeThe purpose of this study was to compare primary outcomes following insertion of balloon and nonballoon gastrostomy tubes (G-tubes). MethodsA retrospective chart review over a 5-year period comparing the need for emergency, radiologic, or operative interventions between balloon and nonballoon G-tube devices was performed. Results145 patient charts were reviewed (46.8% female, 53.1% male). The indication for G-tube insertion was failure to thrive in 83.4%. Average age at insertion was 4.3 years (0–17.9 years). 37.2% had a balloon type G-tube, and 62.8% had a nonballoon type. Patients with a nonballoon device had 1.14 (0–15) ER visits related to the G-tube vs. 0.48 (0–6) visits with a balloon device. Of the ER visits for patients with a nonballoon device, 26.9% were replaced in ER, 38.5% in radiology, and 34.6% required an operation for replacement. For patients with a balloon device, 47.8% were replaced in the ER, 52.2% were replaced in radiology (GJ), and none required operative replacement. The majority of patients who initially had a nonballoon G-tube placed required a second operation for device change (95.7%). Patients with nonballoon devices required significantly more operations (average 2.55, range 0–16) vs patients with balloon devices (average 0.40, range 0–3) (p < .05). ConclusionsBalloon-type G-tubes require less ER visits and operative interventions compared to nonballoon G-tubes. Level of evidenceC

3:18 PM Abstract No. 113 Retrograde balloon gastrostomy tube placement in children less than 15 kilograms

3:18 PM Abstract No. 113 Retrograde balloon gastrostomy tube placement in children less than 15 kilograms

Initial experience with percutaneous endoscopic gastrostomy with T-fastener fixation in pediatric patients.

Background and study aims Insertion of a percutaneous endoscopic gastrostomy (PEG) with push-through technique and T-fastener fixation (PEG-T) has recently been introduced in pediatric patients. The T-fasteners allow a primary insertion of a balloon gastrostomy. Due to limited data on the results of this technique in children, we have investigated peri- and postoperative outcomes after implementation of PEG-T in our department. Patients and methods This retrospective chart review included all patients below 18 years who underwent PEG-T placement from 2010 to 2014. Main outcomes were 30-day postoperative complications and late gastrostomy-related complications. Results In total, 87 patients were included, and median follow-up time was 2.4 years (1 month – 4.9 years). Median age and weight at PEG-T insertion were 1.9 years (9.4 months – 16.4 years) and 10.4 kg (5.4 – 33.0 kg), respectively. Median operation time was 28 minutes (10 – 65 minutes), and 6 surgeons and 3 endoscopists performed the procedures. During the first 30 days, 54 complications occurred in 41 patients (47 %). Most common were peristomal infections treated with either local antibiotics in 11 patients (13 %) or systemic antibiotics in 11 other patients (13 %). 9 patients (10 %) experienced tube dislodgment. Late gastrostomy-related complications occurred in 33 patients (38 %). The T-fasteners caused early and late complications in 9 (10 %) and 11 patients (13 %), respectively. Of these, 4 patients (5 %) had subcutaneously migrated T-fasteners which were removed under general anesthesia. Conclusion We found a high rate of complications after PEG-T. In particular, problems with the T-fasteners and tube dislodgment occurred frequently after PEG-T insertion.

Reducing the Unintended Dislodgement of Gastrostomy Tubes in a Long-Term Acute Care Hospital: A QA/QI Pilot Study.

BackgroundSince their introduction in 1980, gastrostomy tubes have become effective means of providing both short-term and long-term enteral access and nutritional support. These feeding tubes are ubiquitous in many health care facilities that care for the elderly, but carry high rates of unintended dislodgement - a complication that, if not detected promptly, is associated with substantial morbidity and health care costs. This study determined the dislodgment rate of gastrostomy tubes at 90 days in a cohort of 221 patients and tested the hypothesis that the implementation of a concise protocol to care for patients’ gastrostomy tubes would reduce these unintended dislodgements.MethodsThe dislodgment rate of gastrostomy tubes at 90 days in a cohort of 221 patients was determined. In addition, a randomized controlled trial was conducted in a long-term acute care hospital in which patients were alternately allocated to either of two geographically separate units: 1) a selected unit where a concise protocol to care for patients’ gastrostomy tubes was implemented, and 2) a separate unit where standard care was provided. Enrollment included patients diagnosed with dysphagia - who were receiving mechanical ventilatory support for chronic respiratory failure - who were being administered feedings, fluids and medications via a balloon gastrostomy tube. The primary endpoint was the number of unintended dislodgements of gastrostomy tubes during a 90-day study period.ResultsIn a cohort of 221 patients with balloon gastrostomy tubes placed that was observed for a period of 90 days, 64 (29.0%) had unintended gastrostomy tube dislodgement (P < 0.028). A total of 34 patients were enrolled in the randomized controlled trial with 17 in the treatment group and 17 in the control group. All subjects were followed for a maximum of 90 days. During the study period, there was one episode of unintended gastrostomy tube dislodgement (5.9%) in the treatment group, compared with six episodes (35.3%) in the control group (P < 0.047) and the previous cohort of 221 patients (P < 0.028).ConclusionThis study showed a significant reduction in dislodgements after implementation of a protocol that is an innovative, straightforward and economical solution to the problem of the unintended dislodgement of gastrostomy tubes.

The “omega” jejunostomy tube: A preferred alternative for postpyloric feeding access

AimWe present our technique for construction of the “Omega Jejunostomy” (OJ), a novel method of postpyloric feeding using a pouched-jejunal loop capable of accommodating a balloon gastrostomy button. We describe potential indications for the procedure and outcomes in a complex patient population. Materials and methodsWe retrospectively reviewed records of patients who underwent an OJ at our institution between 2005 and 2014. Primary outcomes include operating time, length of hospital stay, time to feeding goals, and postoperative complications. ResultsWe identified 12 children (6 males) with multiple comorbidities who underwent OJ procedures. The median age at surgery was 11years (range 3months–23years). Eleven patients had failed previous alternative feeding access or antireflux procedures. All patients eventually reached their feeding goals. Eight were at goal feeds in <10days. Two achieved goal feeds <1month, one <4months, and one within 7months. There was one OJ failure because of fistula formation requiring surgical revision, and one child was treated successfully but died of unrelated causes. Four children eventually transitioned to PO or G-tube feeds, and six were tolerating feeds via OJ at last follow-up (8–74months). ConclusionsOJ provides a durable alternative to gastrojejunostomy tube for patients who are poor candidates for or have failed Nissen fundoplication. It is technically easier to perform than a gastroesophageal disconnect procedure, has minimal surgical comorbidities, and can provide durable feeding access and achievement of goal feeds in a complex and refractory patient subset.

First balloon gastrostomy tube changes in the community 12 weeks post stoma formation: an audit of outcomes

Replacement of balloon gastrostomy tubes (BGT) is not without risk and BSG guidelines are at best vague about the safe interval between original gastrostomy placement and first replacement. Because of concerns about the risks with inadequately formed stoma tracks, it was not our policy to perform first changes of BGTs in the community until a successful replacement had taken place in hospital. Following requests for a change in this policy to reduce hospital visits and to improve patient experiences, it was agreed that first changes could be undertaken by selected community based nurses no sooner than 12 weeks after initial gastrostomy tube placement. A risk assessment tool was developed with application of strict criteria for tube exchange including absence of peristomal bleeding, infection, pain, swelling or leakage. Those on anticoagulants were excluded. After appropriate nurse training, a prospective audit was set up with data recorded on a secure database over 2 years from 1st January, 2011 to 31st December, 2012. Only those hospital contracts requesting first time replacement of BGTs and agreeing with the 12 week rule were included. The condition of the stoma, size of replacement BGT, immediate and delayed complications up to 72 hours post procedure and the need for hospital admission or referral to another healthcare professional were recorded. During this audit, 6839 BGTs were changed by our nurses nationwide [planned exchange 5865(85.8%); unplanned 974(14.2%)] with 74 being first time replacements (1.1%) of which 71 were planned. Replacement BGT size was 12 – 14 French. The mean (median) interval between original insertion and replacement was 107 (101) days +/-27 SD. All stomas appeared healthy with no evidence of infection or leakage. Complications were: minor bleeding in 7 of which 1 was referred to hospital; pain in 1; failed replacement requiring hospital admission in 1 and some difficulty inserting new tube in 5. There were no delayed complications reported. First time community BGT changes by our nurses using our strict protocols appear safe with few hospital readmissions and no delayed or major complications. This practice could save many more hospital visits if extended to more patients with BGTs discharged to the community using appropriately trained nurses but this practice would not apply to those patients fitted with a PEG with a fixed internal flange. We cannot speculate on the safety of changing BGTs earlier than 12 weeks after initial BGT placement when the stoma track has not yet fully matured.

Modification of U-Stitch Laparoscopic Gastrostomy Technique to Minimize Suture Knot Abscess Formation.

Aim U-stitch laparoscopic gastrostomy is a commonly used technique for placement of balloon gastrostomy for pediatric patients. The U-stitch method was modified by others whereby the stay sutures are placed in a subcutaneous tissue. Although this modification has been reported to be superior, it has led to suture knot abscess formation which was not reported in the original method. We developed further modification whereby the stay-suture knots are positioned within the gastrostomy tract instead of the subcutaneous tissue which minimizes suture knot abscess formation. Methods Modified U-stitch technique was used to place the balloon gastrostomy. The U-stitch stay sutures are placed to hold the stomach to the abdominal wall. These sutures are subcutaneously tunneled toward the gastrostomy tract and tied to the opposing sutures with the resulting knots lying within the tract of the gastrostomy. Chart reviews of patients who underwent this modified U-stitch method were done. Results A total of 27 consecutive patients were evaluated. Minimal follow-up period was 6 months. No suture knot abscess complication was found. One patient for whom we used a polyglactin (Vicryl; Ethicon Inc., Cincinnati, Ohio, United States) suture developed cellulitis around the gastrostomy site which cleared with antibiotic. Remaining 10 patients for whom we used Vicryl suture and 16 patients for whom polydioxanone (PDS; Ethicon Inc.) suture was used did not develop any infections. Conclusion Subcutaneous placement of stay suture within the open gastrostomy tract rather than within closed subcutaneous tissue may minimize suture knot abscess formation.

Thinking Outside the Box of the Gastrostomy Kit: Stylet-Assisted Technique for Challenging Gastrostomy Tube Replacements

n 84-year-old man with dementia presented with Aa 6-hour history of unintended dislodgement of a percutaneous endoscopic gastrostomy (PEG) tube (24 Fr Pull PEG; US Endoscopy, Mentor, OH), placed 4 months earlier. Physical examination showed a PEG stoma that was partially closed in the epigastrium, preventing insertion of the balloon gastrostomy tube (PEG24-BRT-S; Cook Medical, Inc, Bloomington, IN). After confirming the permeability of the gastrocutaneous tract with a nasogastric tube (Figure A), replacement using a stylet-assisted technique was planned (Figure B). The balloon gastrostomy tube was strengthened by passing a stylet inside (Satin-Slip 10Fr Intubating Stylet; Mallinckrodt Medical, St. Louis, MO), providing increased stiffness while retaining some flexibility, and leaving 2.5 cm of free stylet distal to the balloon gastrostomy tube tip for guidance (Figure C). This stylet is composed of an outer plastic layer and an inner malleable metallic wire that was left 2 cm behind the plastic layer, enhancing its safety (Figure C). The stylet was introduced into the gastric lumen carefully until a minor resistance was felt, indicating contact of the stylet with the opposite gastric wall. The balloon gastrostomy tube then was smoothly advanced over the stylet (Figure D). After replacement of the balloon gastrostomy tube, the stylet was removed, and the balloon was inflated. Adequate positioning was confirmed by prompt aspiration of gastric fluid contents through the gastrostomy tube. Since its advent in 1980, PEG now is recognized as an efficient and successful means of providing long-term enteral nutrition. Despite its safety, PEG placement may result in complications, such as early and late unintentional removals, which occur in up to 5.3% of cases. Late dislodgements occur when the fistula has maturated, preventing peritoneal leakage, thus resulting in less morbidity and consequent underestimation in earlier studies when compared with early removals. A recent study reported a higher rate of late dislodgments of up to 12.8%. After tube displacement, the gastrocutaneous track is prone to closure within 12 to 24 hours. If the fistula has begun to close, insertion of the malleable PEG tube may be difficult, leading to bending of the tube when axial force is applied. The stylet-assisted technique appears to be a safe and useful approach for challenging gastrostomy tube replacements.

Changement de sonde de gastrostomie à ballonnet de l’adulte

Balloon gastrostomy feeding tubes are medical devices dedicated to the administration of enteral nutrition when its duration exceeds one month. The first placement of these devices is performed in a specialized center. There are different types of gastrostomy feeding tubes, including balloon gastrostomy feeding tubes. During the course of patient's disease, these devices are replaced on a regular basis, due to loss of functionality, deterioration of materials, or accidental ablation. The replacement after an accidental ablation is an emergency because the gastrostomy orifice is usually closing in few hours. Two or three months after the first placement, the balloon gastrostomy feeding tube could be replaced in an ambulatory general practice. This medical procedure can be performed at hospital, in a doctor's office, or at patient's home. The ambulatory replacement is supposed to increase the comfort and the quality of life of many patients, and would certainly allow money savings. We propose here a descriptive protocol of the required equipment and the different steps of the replacement of a balloon gastrostomy feeding tube. This document is intended for all hospital physicians, general practitioners, and specialists and nurses, who wish to perform this procedure.

Problems with use of a Foley catheter in enteral tube feeding.

This article discusses the unlicensed use of a Foley catheter in home enteral tube feeding in the community. It is now clear that patients on long-term enteral feeding in the community may require replacement of their feeding tubes due to deterioration, damage or tube dislodgment. Often, these conventional feeding tubes such as percutaneous endoscopic gastrostomy and radiologically inserted gastrostomy tubes are replaced with similar tubes or with balloon gastrostomy tubes. However, the use of a Foley catheter in place of conventional feeding tubes as replacement tube has been observed in a number of patients in practice and documented in literature. The Foley catheter is significantly less expensive and easily accessible than conventional feeding tubes or balloon gastrostomy tubes. However, its use as an enteral feeding tube has implications for practice in terms of its use as unlicensed product, consent, ethics and professional responsibilities. Issues relating to body image and quality of life are also discussed.