Enteral Access In Patients Research Articles

SLiC technique

Percutaneous endoscopic gastrostomy (PEG) has been an invaluable method for obtaining long-term enteral access and represents one of the first forays in the field of minimally invasive surgery. However, the traditional "pull" method for PEG tube placement continues to have some disadvantages, especially in patients with near-obstructive head and neck cancers. We describe a new "SLiC" technique for establishing percutaneous gastrostomy using a radially expandable trocar. This technique is initially developed and refined on a porcine model and then successfully implemented on five human patients. The SLiC technique can be done safely and efficiently with a pediatric-sized gastroscope and avoids the need for radiation from fluoroscopy. It is a good alternative for obtaining enteral access in patients who would otherwise not be well suited for a traditional PEG tube.

Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head and neck cancer

Abdominal wall metastasis after PEG tube placement has been reported in patients with head and neck cancer. The incidence of this occurrence is unknown. Evaluation of the incidence of abdominal wall metastasis as a complication of PEG tube placement in patients with head and neck cancer. Retrospective chart review. H. Lee Moffitt Cancer Center and Research Institute, Nutritional Support Services. Head and neck cancer patients requiring nutritional support with PEG tube placement. Of the 304 patients with head and neck cancer, 218 had active disease with a viable tumor in the oropharynx or hypopharynx at the time of PEG placement. Two of these patients, both with active disease (0.92%), developed a PEG site metastasis. There is a small but definite risk for tumor implantation in the gastrostomy site when using the pull technique in patients with active head and neck cancer. Careful assessment of the oropharynx and hypopharynx before PEG tube placement and the use of alternative techniques for enteral access in patients with untreated or residual malignancy are recommended to minimize this risk. Use of other percutaneous techniques that do not involve traversing the hypopharynx with the catheter may help to prevent tumor translocation. When head and neck cancers metastasize to the gastrostomy site, patient survival appears limited even with extensive resection.

Effect of Percutaneous Endoscopic Gastrostomy on Gastro-esophageal Reflux and Gastric Emptying

BACKGROUNDS: Percutaneous endoscopic gastrostomy (PEG) has gained broad acceptance as an effective method for achieving enteral access in patients who need chronic nutritional support. It was reported that gastro-esophageal reflux (GER) was less observed with PEG feeding as compared with naso-gastric tube feeding, and that the posture under feeding may affect GER. However, real change in GER before and after the PEG placement remains unknown. AIMS: We investigated GER using ambulatory pH monitoring, and gastric emptying before and after the PEG. The effect of posture while feeding on the GER was also evaluated. METHODS: Twenty patients (8 men and 12 women; mean age, 79.4 years) who need continuous nutritional support due to various diseases such as a stroke, were registered. Under the written informed consent from patients or their families, ambulatory 24-h esophago-gastric pH monitoring, and the gastric emptying test were performed before (with naso-gastric tube feeding) and 1 month after the PEG placement. Seventy-two hours before the monitoring, drugs which affect gastric acid secretion and/or gastric motility were stopped. The content and pattern of feeding through the tube were fixed. Gastric emptying time was determined by the paracetamol method in which serum acetaminophen level was measured 45 min after drinking the semi-liquid test meal (200 mL, 200 kcal) with acetaminophen (20 mg/kg). Some patients after PEG were fed at Fowler position on the first day and at supine position on the second day with 48-h pH monitoring. RESULTS: The mean of intra-esophageal pH was increased after PEG placement (before: 5.59±0.16, after: 6.05±0.21). The time ratio of intra-esophageal pH less than 4 was significantly decreased (before: 9.5±3.1%, after: 5.8±2.5%), suggesting that GER was less observed with PEG feeding. Gastric acidity evaluated by the mean intra-gastric pH and holding time ratio of intra-gastric pH more than 3, was not varied with PEG placement. Gastric emptying was delayed in patients as compared with those in healthy volunteers, but PEG did not modify gastric emptying. The posture under feeding did not affect GER, gastric acidity, and gastric emptying. CONCLUSIONS: GER was less observed with PEG feeding as compared with naso-gastric tube feeding, suggesting the advantage of PEG feeding in regardless the posture while feeding.

Percutaneous endoscopic gastrostomy

p ercutaneous endoscopic gastrostomy (PEG) has gained popularity since its introduction in 1981.1 The indications for PEG are to provide enteral access in patients who have either temporarily or permanently lost the ability to eat or in patients who need gastric decompression. Contraindications are similar to those for all types of gastrostomies and include uncontrollable ascites, coagulopathy, prior total gastrectomy, or pathology of the gastric wall. Previous intra-abdominal surgery, including a Billroth II gastric resection, is not a contraindication for PEG placement, nor is the presence of peptic ulcer disease found during endoscopic examination. However, the PEG should not be placed through an ulcer bed. A duodenal or pyloric channel ulcer with gastric outlet obstruction is a contraindication for a PEG if the PEG is to be used for enteral feeding. Currently available PEG kits have 20-22 French gastrostomy tubes. Should simultaneous gastric decompression and jejunal feeding be desired, then initial placement with a larger-diameter tube (28 French) is recommended. Percutaneous or endoscopically removable gastrostomy tubes are available. Percutaneous removal is an advantage for patients who need the PEG for short-term nutrition (3-6 months) or patients in whom a second endoscopy at a later time may be difficult. A patient who has undergone head and neck surgery is an ideal candidate for the percutaneous removable kits, whereas the uncooperative patient who may pull out the PEG, before tract formation occurs, may need the endoscopically removable PEG. There are several choices for replacement gastrostomy tubes, which do not require a repeat endoscopy. The original PEG can be removed in 4 6 weeks after insertion and a replacement can then be inserted. A Foley catheter can be used in the short term, but the tube is long and migration may occur because external bolsters are not available. Migration to, and blockage of, the pylorus or the duodenum may present clinically as gastric outlet obstruction with nausea and vomiting. Shorter Foley replacement gastrostomy tubes are available with an external bolster to prevent migration. A gastrostomy button may be the best replacement option. The gastrostomy button has a Malecot-type end to hold the tip in the stomach and is available in several lengths to traverse the abdominal wall. The feeding port is covered with a screw or snap top. The buttons barely protrude above skin level and are equipped with a flap valve to prevent reflux. They can be an ideal option for a patient who does not want a tube protruding under his or her clothing. PEG may be performed at the patient's bedside or in the endoscopy suite with the patient supine. Antibiotics are given before the procedure to reduce the risk of wound infection. The patient's mouth is mechanically prepared with a topical anesthetic spray while the abdomen is prepaired using sterile technique. After appropriate sedation, esophagogastroduodenoscopy is performed with complete examination of the esophagus, stomach, and duodenum.

Percutaneous endoscopic gastrostomy reduces total hospital costs in head-injured patients

Background: Gastrostomies provide reliable long-term enteral access in patients with traumatic brain injuries. The impact of technique of gastrostomy on total hospital cost is not known. Methods: A retrospective analysis of patients who sustained head trauma and required gastrostomies for long-term enteral access between 1 July 1990 and 1 July 1996 was performed. Results: The patients who received percutaneous endoscopic gastrostomies (PEG) were similar to patients who received Stamm gastrostomies (OPEN) with respect to age, injury severity score, mechanism of injury, associated injuries, complication rates, and deaths. Total hospital costs ($ × 10 3) were lower for patients who had PEGs placed in the intensive care unit (78.2 ± 37.4) or endoscopy suite (71.9 ± 37.7) compared with PEGs placed in the operating room (122.4 ± 75.7) or OPEN gastrostomies (119.8 ± 65.1). Conclusions: In head-injured patients, PEGs are a reliable method of obtaining long-term enteral access with a complication rate equivalent to Stamm gastrostomies. If performed in either the intensive care unit or the endoscopy suite, PEGs are associated with significantly reduced total hospital costs.

Laparoscopic Janeway gastrostomy: an alternative to celiotomy for the management of a dislodged percutaneous gastrostomy.

After its in t roduct ion in 1980 (1), percutaneous endoscopic gastrostomy (PEG) rapidly replaced open gastrostomy as the procedure of choice for providing enteral access in patients who are unable to nourish themselves because of central nervous system disorders. Patients with altered sensorium sometimes pull on medical appliances that are irritating to them. If a newly placed PEG is dislodged in this manner , celiotomy has traditionally been required to close the resulting gastric perforation, clear spilled gastric contents, and replace the gastrostomy tube. Patients who require PEG placement for neurologic indications are often poor candidates for celiotomy because of their associated comorbid conditions. This article describes a laparoscopic technique for the managemen t of a dislodged, recently placed PEG tube that incorporates the site of perforation into a gastric tube such as that originally described byJaneway (2) and recently adapted to laparoscopic use by French surgeons (3, 4).

Bowel Obstruction from Retained Inner Bumper following Removal of Gastrostomy Tube: A Case Report

Percutaneous endoscopic gastrostomy is an effective means of obtaining enteral access in patients who need chronic nutritional support. We describe a complication resulting from the inability to remove an inner bumper. This bumper migrated into the terminal ileum, where it lodged, causing bowel obstruction. Literature review revealed no reports of similar complications.

Percutaneous approaches to enteral alimentation

Feeding gastrostomy and jejunostomy provide effective access for long-term enteral nutrition. Traditional operative techniques for the performance of these procedures requires laparotomy and often, general anesthesia. This report describes our experience with two relatively new methods, percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy. Results of percutaneous gastrostomy and jejunostomy to date in 323 cases include a morbidity of 5.9 percent and a 0.3 percent operative mortality. Percutaneous endoscopic gastrostomy and jejunostomy should become the procedures of choice for the establishment of enteral access in patients requiring long-term enteral alimentation.