Enteral Access Research Articles

Small-bore feeding tubes placed with an electromagnetic imaging device leads to cost avoidance and decreased time to initiation of enteral nutrition.

The Cortrak Enteral Access System (CEAS) was previously approved by the United States Food and Drug Administration (FDA) to be used in lieu of radiographic confirmation imaging for feeding tubes placed by trained clinicians. Following an institutional protocol change in 2016, our registered dietitians had the option to forgo radiographic confirmation imaging for tubes placed using the CEAS. Our research aimed to determine the difference in the number of radiographic confirmation images for feeding tubes placed using the CEAS between preprotocol and postprotocol environments and the associated cost avoidance after the institutional policy change. We retrospectively reviewed data from 506 tube placements (n = 253 per protocol environment) in adult patients with diverse diagnoses admitted to various in-patient care units. There was a significant reduction in the mean number of radiographic images per tube placement (preprotocol = 1.10 [95% CI, 1.05-1.15]; postprotocol = 0.36 [95% CI, 0.30-0.41]; P < 0.001), leading to a cost avoidance of $67,282.80 for the 253 tube placements and a potential cost avoidance of $279,236 over the 5-year postprotocol environment. Additionally, the mean time to initiation of enteral nutrition was significantly reduced by 2.65 h in the postprotocol environment (P < 0.001). Our findings suggest that using the CEAS can reduce the number of radiographic images, provide cost avoidance, and improve nutrition outcomes. However, updated 2022 FDA regulatory changes to the use of the CEAS for tube confirmation lead to an uncertain future for this practice because of safety concerns.

Addressing the unique needs and quality of life issues for adults receiving long-term home enteral nutrition.

Individuals who require home enteral nutrition (EN)-and, subsequently, their families-undergo major changes in family dynamics. They would benefit from an approach that provides ongoing nutrition, hydration, enteral access, and quality of life assessments from knowledgeable clinicians. Most individuals and families will be new to the enteral access device, handling and administration of the nutrition formula, medication delivery through feeding tubes, and troubleshooting associated complications. Educational sessions are typically given but may not be comprehensive enough to meet all needs, especially in the first weeks to months of home EN therapy. Quality of life assessments obtained in the early stages of EN support would help clinicians identify and focus on areas that need special attention for that individual and family. Ongoing clinical care is essential because over time, the nutrition prescription, delivery methods and schedules typically require alterations and feeding tubes need to be assessed and replaced. In addition to these important physical dimensions of care, attention should be placed on the psychological, cognitive, social, and ethical aspects of life for these individuals and their families.

Enteral formula compared to Nissen-Fundoplication: Data from a retrospective analysis on tolerance, utility, applicability, and safeness in children with neurological diseases.

Approximately 46-90% of children with neurological disorders (NDs) suffer from gastrointestinal diseases, such as gastro-esophageal reflux disease (GERD), constipation, or malnutrition. Therefore, enteral feeding is often necessary to achieve nutritional requirements. The treatment of GERD could be based on pharmacological therapy, nutritional treatment (changing the type of formula), or surgical treatment (Nissen Fundoplication, NF). The aim of this study was to describe and compare resource consumption between NE based on different formulas and NF in patients with ND. We performed a retrospective analysis on all children with neurological damage (age: 29 days-17 years) treated from January 2009 to January 2019 due to nutritional problems and food and/or gastrointestinal intolerances. For all patients, demographic and anthropometric characteristics, symptoms, type of nutrition (formula and enteral access), and number and type of outpatient or emergency room visits were collected. Patients with <24 months of age at the closing of the database and with <24 months of follow-up were excluded. Out of 376 children, 309 children (M: 158; median age: 4 IQR 1-10) were enrolled, among which, 65 patients (NF group M: 33; median age: 5.3 IQR 1.8-10.7) underwent NF. Vomit, GERD, and dysphagia were more represented in the NF group (p < 0.05). Our analysis shows that the NF group seems to present a lower number of hospitalization and a lower number of visits for non-GI disorders, but a higher number of visits for GI disorders compared to non-NF. In the NF group, a higher prevalence of the use of amino-acid-based formula and free diet is observed, with a trend for the lower prevalence of casein-based or whey+casein-based formula (Fisher test p = 0.072). The median cost of a patient enrolled in the database is € 19,515 ± 540 ($ 20,742.32 ± 573.96) per year, with no significant difference between the two groups. Regarding formula, at baseline, 76 children consumed a free diet, 24 a casein-based formula, 139 a whey+casein-based formula, 46 a whey-based formula, and 24 an amino-acid-based formula. In conclusion, compared to EN, NF may not improve the clinical aspect and related costs in children with NDs. Considering the psychological and QoL burden for patients, in a "step-up" strategy, EN could be proposed as an efficient alternative to NF.

Transpyloric misplacement and intramural dislocation: two novel complications related to balloon-type G-tubes.

To the Editor: Percutaneous endoscopic gastrostomy (PEG) remains the standard enteral nutrition access in clinical practice with limited complication potential. Beyond mushroom and/or disk-tip tubes (pull technique), in the introducer technique balloon-type G-tubes are implanted, warranting regular, often nurse-led exchanges. Herein, two novel complications related to tube exchange are presented. A frail male patient with advanced diffuse idiopathic skeletal hyperostosis (DISH)–related dysphagia reported on worsening enteral nutrition tolerance (intermittent administration) due to abdominal pain since the last bedside tube exchange by a specialized nutrition team in the nursing home. On endoscopy, transpyloric misplacement likely related to inadvertent duodenal guidewire insertion (Fig. 1A), resistant to repositioning by external traction (Fig. 1B), was detected. Endoscopy-directed repositioning was easily performed after balloon deflation and withdrawal into the stomach, and other potential causes for deterioration of nutrition tolerance, such as ulcer disease, were excluded. In retrospective, this uncommon and as yet unreported complication may have been avoided by strictly keeping attention to the distance markings during tube exchange, although the mere distance between the PEG exit point and the pylorus was indeed short.Figure 1.: Patient 1: (A) Endoscopic visualization of transpyloric misplacement of a balloon-type G-tube, causing discomfort due to inadvertent duodenal instead of gastric administration of the enteral nutrition regimen. (B) Failed repositioning by external pulling without balloon deflation (not shown uncomplicated repositioning under endoscopic guidance after balloon deflation). Patient 2: (C) Marked edema and hyperemia along endoscopic impression of a “subepithelial lesion” consistent with intramural balloon dislocation. (D) The latter was confirmed after balloon deflation, resulting in collapse of the lesion, and the PEG tract became visible in the vicinity.The second patient with a history of head and neck cancer presented with high-grade abdominal pain. Of note, the patient had only been discharged from a nearby hospital the same day after reinsertion of a balloon-type G-tube using the same PEG stoma after external loss of the previous tube during care measures. CT scans indicated minor free abdominal and intramural air in the stomach along suspected tube dislocation. This was confirmed during urgent endoscopy under CO2, revealing a markedly edematous and hyperemic “pseudotumor” in the antrum (Fig. 1C). After balloon deflation, the stoma entry site was found in the vicinity (Fig. 1D), and the balloon-type tube was repositioned correctly under endoscopic vision, obviating the need for surgery. It remains unclear why this complication occurred despite endoscopic guidance of tube exchange. On a speculative basis, incomplete balloon blocking and/or too aggressive tube retraction during care measures postendoscopy might be discussed. To the best of our knowledge, transpyloric misplacement and intramural dislocation have not yet been reported in the literature and represent two novel, clinically relevant complications related to balloon-type G-tubes.1 Nevertheless, similar to more common G-tube–related complications, such as buried bumper syndrome, strict adherence to tube exchange protocols and proper tube care are of utmost importance. Conflicts of interest The authors report no conflicts of interest.

Using an Electromagnetic Guidance System for Placement of Small-Bowel Feeding Tubes to Reduce Feeding Start Times.

Cardiothoracic surgery patients have an increased risk for aspiration and may require enteral access for nutrition. In a cardiothoracic intensive care unit, feeding start times were delayed because of scheduling conflicts with support services. An electromagnetic device (Cortrak 2 Enteral Access System, Avanos Medical) was introduced to allow advanced practice providers (nurse practitioners and physician assistants) to independently establish postpyloric access and reduce dependence on ancillary services. A quality improvement study was performed. Pre- and postimplementation data included order time, service arrival, tube placement time, tube positioning, and feeding start times for 207 placements. Pre- and postimplementation surveys were conducted to evaluate advanced practice provider satisfaction with enteral tube placement practices. Feeding start time for initial placement decreased by 35.5% (15.6 hours to 10 hours); for subsequent placement, by 55.2% (15.5 hours to 7.0 hours). Assistance by support services decreased by 80.4% (before implementation, 100 of 100 placements [100%]; after implementation, 21 of 107 placements [19.6%]; P < .001; ϕ = 0.815). Overall, advanced practice provider satisfaction increased. Most participants said that using the electromagnetic device was faster, nutrition was delivered sooner, and implementation was a valuable practice change. Using an electromagnetic device decreased feeding start times, reduced the need for support services, and increased advanced practice provider satisfaction with small-bowel feeding tube placement practices.

How many tests does it take? Minimizing preoperative testing prior to surgical placement of gastrostomy tubes in children.

Gastrostomy tubes (GTs) provide life-saving enteral access for children. Although upper gastrointestinal (UGI) series and impedance studies (ISs) detect gastroesophageal reflux disease (GERD) or malrotation, their benefit for preoperative evaluation of asymptomatic patients requiring GT placement is controversial. This study investigated the value of routine preoperative testing and whether specific patient characteristics could guide the selective use of these studies. The charts of children who underwent GT placement from 2003 to 2019 were reviewed retrospectively. Demographics, preoperative evaluation, and postoperative course were evaluated. Three hundred forty-three patients underwent GT placement, 61% with preoperative testing. Seven of 190 UGI (4%) series demonstrated malrotation, and 39 of 141 (28%) ISs revealed severe GERD. Although all malrotations were surgically addressed, only 59% (23/39) of IS-proven GERD cases prompted simultaneous fundoplication. Age <1 year was associated with a positive UGI series (6.7% positive vs 1.0%; P < 0.05), but no other patient characteristics were associated with either positive UGI series or IS. Elimination of the 96% of UGI series that did not alter care represented a cost savings of $89,487-$229,665 and avoided the radiation exposure from testing; elimination of the 84% of ISs that did not alter eventual treatment would have saved $127,776-$266,563. Routine preoperative evaluation with UGI series and IS can increase healthcare costs without substantially altering care. The only patients potentially benefiting from routine UGI series were <1 year old. Instead, a targeted, symptom-based preoperative evaluation may streamline the process by decreasing preoperative testing and minimizing cost and radiation exposure.

Fistuloclysis - A useful tool in patients with intestinal failure

fistuloclysis is a technique described by Teubner et al. whereby a fistula is used as a route of nutritional administration. This procedure is an alternative to the management of patients with intestinal failure receiving parenteral nutritional support. we present two clinical cases of patients with different medical histories but who coincided in malnutrition, abdominal sepsis with fistulas, and their awaiting intestinal reconnection. In both cases nutritional support was administered with parenteral nutrition and enteral nutrition through fistuloclysis. enteral nutrition through fistuloclysis improves function of the intestinal barrier, reduces the rate of intrahospital infection in critically ill patients, improves immune function, prevents atrophy of the intestinal mucosa, and that is why as soon as an enteral access is located we must take advantage of this route so that our patients may experience the benefits of fistuloclysis regardless of caloric intake.

When Should the Appropriateness of PEG be Questioned?

This review aims to analyze the evidence regarding the appropriateness of PEG placement in the following clinical situations: short bowel syndrome, head and neck cancer, dementia and palliative use in malignant bowel obstruction. Percutaneous endoscopic gastrostomy (PEG) tubes are placed for a variety of clinical indications by numerous different specialties. First described in 1980, PEG tubes are now the dominant method of enteral access. Typically, PEG tubes are technically feasible procedures that can come with significant risk for both minor and major complications. Therefore, it is important to perform an in-depth, patient specific risk-benefit analysis when considering insertion. By analyzing the current evidence regarding benefits in these situations, superimposed by the lens of biomedical ethics, we make recommendations that are accessible to any provider who may be a consultant or proceduralist, helping to provide informed care that is in the patient's best interest.

Laparoscopic Roux-en-Y feeding jejunostomy as a long-term solution for severe feeding problems in children

Enteral feeding is a common problem in children with gastric emptying disorders. Traditional feeding methods in these patients often show a high rate of complications and maintenance issues. Laparoscopic Roux-en-Y feeding jejunostomy (LRFJ) has been described in a few patients as a minimal invasive option for enteral access in these children. The aim of this study is to evaluate the outcomes of the LRFJ procedure in our tertiary referral center. We conducted a retrospective case-series including all patients, aged 0–18 years old, that underwent a LFRJ procedure between August 2011 and December 2020 for the indication of oral feeding intolerance due to delayed gastric emptying. Outcomes evaluated were complications (short and long term) and parenteral satisfaction. In total, 12 children were identified that underwent LRFJ for the indication of oral feeding intolerance due to delayed gastric emptying. A total of 16 complications were noted in 8/12 patients (67%). Severity classified by Clavien-Dindo were grade I (n = 13), grade II (n = 1), and grade IIIB (n = 2). In 11/12 patients, parents were satisfied with the results. Conclusions: Although minor complications after LRFJ are common in our patients, this technique is a safe solution in patients with gastric emptying disorders leading to a definitive method of enteral feeding and high parenteral satisfaction.What is Known:• Traditional tube feeding in children (duodenal, PEG-J-tubes) with severe delayed gastric emptying can be challenging with a high rate of complications and maintenance issues.• Open loop jejunostomy and Roux-en-Y jejunostomy are alternative, permanent methods of feeding but either invasive or are accompanied by severe complications. Little is known in the literature about laparoscopic Roux-en-Y feeding jejunostomy.What is New:• Laparoscopic Roux-en-Y feeding jejunostomy is a permanent, safe and minimal invasive alternative option for enteral feeding in children with severe delayed gastric emptying..

LBSUN345 Diagnostic Dilemma In A Case of Vipoma

Abstract Introduction Vasoactive intestinal polypeptide secreting tumors (VIPoma) are rare neuroendocrine tumors that have nonspecific features of watery diarrhea, hypokalemia and achlorhydria. With an incidence of 1 in a million per year, it is diagnosed based on serum VIP levels (&amp;gt;75pg/ml) followed by imaging studies to localize the tumor and look for metastases. We present a challenging case of VIPoma that was successfully managed with surgical exploration despite classic yet nonspecific clinical features and poor evidence on imaging. Case Discussion A 78-year-old Caucasian woman presented with persistent secretory diarrhea for 2 months. Past medical history was significant for intractable peptic ulcer disease and Billroth II reconstruction. Laboratory investigations showed severe hypokalemia (2.1 mmol/l), serum bicarbonate 13 and chloride 117. Blood glucose and calcium levels were within normal range. Stool studies confirmed secretory diarrhea with stool osmotic gap of 10 mOsm/kg but no growth. Serum gastrin, parathyroid hormone, chromogranin and urine 24-hour 5-hydroxy indoleacetic acid (5-HIAA) levels were within normal limits. Plasma VIP levels were elevated at 79 pg/mL. Computed tomography of the abdomen and pelvis did not show any evidence of pancreatic tumor or biliary ductal dilatation. Endoscopic ultrasound could not fully evaluate the head of pancreas but showed unremarkable liver, pancreatic body and tail. Capsule endoscopy was unremarkable as well. An octreotide scan, however, demonstrated increased activity near the head of the pancreas and abdominal aorta. As clinical picture and octreotide scan findings were consistent with VIPoma, operative exploration for possible pancreaticoduodenectomy was pursued. No evidence of palpable or occult metastatic disease was found; but intraoperative color doppler ultrasound localized two lesions less than 1 cm in size at the level of the uncinate process and ampulla. An open pancreaticoduodenectomy was performed and the existing Billroth II anatomy was modified to accommodate pancreatojejunostomy, gastrojejunostomy and choledochojejunstomy. A jejunostomy tube was placed for enteral access. At 2-month post-operative follow-up, the patient had significant improvement of his diarrhea. Radiographic resolution was noted on repeat octreotide scan 4 months following resection. Conclusion VIPomas are usually diagnosed by elevated VIP levels and imaging studies are used to localize the tumor for further treatment. However, this case highlights that in secretory diarrhea with elevated VIP level and no alternate diagnosis, despite negative imaging studies further exploration with octreotide scan is warranted. Surgical exploration may show the site of lesion and appropriate surgical intervention may lead to resolution of VIPoma. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Efficacy and Safety of Percutaneous Radiological Gastrostomy (PRG) as a Rescue Measure for Enteral Feeding in Patients with Advanced Head, Neck, and Upper Digestive Malignancies.

Background Percutaneous radiologic gastrostomy is an established mode of enteral feeding for nutritional support for patients with dysphagia from upper digestive tract malignancy. Its role as a rescue measure in patients with advanced malignancy, presenting with absolute dysphagia and failure of nasogastric tube insertion has not been well established. Purpose This study was performed to assess technical success and long-term outcomes of percutaneous radiologic gastrostomy (push type) for nutritional support for patients with absolute dysphagia as a last ditch nonsurgical rescue effort for enteral access. Materials and Methods This was a prospective observational study of 31 patients who underwent push-type percutaneous radiologic gastrostomy over a period of 2 years (March 2017-March 2019). The study was a part of a larger trial approved by the institutional ethics committee. Patients were followed till the removal of tube, death, or 1 year, whichever was earlier. Gastrostomy tube-related problems and complications were documented. Descriptive summary statistics were employed to analyze the success rate and complications. Results Thirty-one patients with mean age 56 years (26-78 years) including 18 males and 13 females with head and neck squamous cell cancer and esophageal cancer presenting with absolute dysphagia or significant dysphagia with failed nasogastric or endoscopic enteral access were included. Overall technical success was 93.5% (29/31), achieved in 26/31 patients with just fluoroscopy guidance and 3/5 patients with computed tomography guidance. One major (3.3%) and two minor (6.5%) complications were encountered. Five out of 29 gastrostomy tubes had to be exchanged, after a mean of 44 days (1-128 days) after insertion. Conclusion Percutaneous radiologic gastrostomy is a safe and effective intervention even as a rescue measure in patients with absolute dysphagia from advanced upper digestive tract malignancies.

Laparoscopic Janeway gastrostomy as preferred enteral access in specific patient populations: A systematic review and case series.

BACKGROUNDNutrition is one of the fundamental needs of both patient and non-patient populations. General trends promote enteral feeding as a superior route, with the most common enteral access being the percutaneous endoscopic gastrostomy (PEG) as the first-line procedure, with surgical access including Witzel gastrostomy, Stamm Gastrostomy, Janeway gastrostomy (JG) as secondary means.AIMTo describe cases and technique of laparoscopic Janeway gastrostomy (LJG) and perform a systematic review of the data.METHODSWe successfully performed two LJG procedures, after which we conducted a literature review of all documented cases of LJG from 1991 to 2022. We surveyed these cases to show the efficacy of LJG and provide comparisons to other existing procedures with primary outcomes of operative time, complications, duration of gastrostomy use, and application settings. The data were then extracted and assessed on the basis of the Reference Citation Analysis (https://www.referencecitationanalysis.com/).RESULTSWe presented two cases of LJG, detailing the simplicity and benefits of this technique. We subsequently identified 26 articles and 56 cases of LJG and extrapolated the data relating to our outcome measures. We could show the potential of LJG as a viable and preferred option in certain patient populations requiring enteral access, drawing reference to its favorable outcome profile and low complication rate.CONCLUSIONThe LJG is a simple, reproducible procedure with a favorable complication profile. By its technical ease and benefits relating to the gastric tube formed, we propose this procedure as a viable, favorable enteral access in patients with the need for permanent or palliative gastrostomy, those with neurologic disease, agitation or at high risk of gastrostomy dislodgement, or where PEG may be infeasible.

IATROGENIC PNEUMOMEDIASTINUM AND PNEUMOTHORAX AFTER SMALL-BORE FEEDING TUBE PLACEMENT IN A PATIENT WITH EHLERS-DANLOS SYNDROME

IATROGENIC PNEUMOMEDIASTINUM AND PNEUMOTHORAX AFTER SMALL-BORE FEEDING TUBE PLACEMENT IN A PATIENT WITH EHLERS-DANLOS SYNDROME

Safety of Percutaneous Endoscopic Gastrostomy Placement in Patients With SARS-CoV-2 Infection.

Coronavirus disease 2019 (COVID-19) can lead to ventilator-dependent chronic respiratory failure and a need for tube feeding. Percutaneous endoscopic gastrostomy (PEG) placement provides more sustainable longer-term enteral access with fewer side effects compared to the long-term nasogastric tube placement. Bleeding is a recognized complication of PEG placement, and many COVID-19 patients are on antiplatelets/anticoagulants, yet minimal data exist on the safety of PEG tube placement in this context. A retrospective chart review identified patients who underwent PEG placement between January 2020 and January 2021 at a single institution. Success was defined as PEG placement and use to provide enteral nutrition with no complications requiring removal within 4 weeks. Thirty-six patients with and 104 age- and sex-matched patients without COVID-19 infection were included. More COVID-19 patients were obese, on anticoagulants, had low serum albumin levels and had a tracheostomy in place. Of those patients, 8.3% with COVID-19 developed PEG-related complications compared to 16.3% without (P = 0.28). PEG success rates in patients with and without COVID-19 were similar at 97.2% and 92.3%, respectively (P = 0.44). PEG tube placement is comparatively safe in COVID-19 patients who need long-term enteral access.

S3691 Where Is the Bumper? A Case of Percutaneous Endoscopic Gastrostomy (PEG) Tube Malfunction

Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes are used for enteral access in patients requiring nutritional support. PEG tube placement and removal generally are regarded as safe procedures. However, complications can be experienced in 16-70%, ranging from benign pneumoperitoneum to gastric outlet obstruction, buried bumper syndrome, and bowel perforation. Our case describes a retained internal bumper during PEG tube removal that undergoes spontaneous passage. Case Description/Methods: Our patient is a 71-year-old male with a past medical history of tongue cancer treated with chemoradiation and subsequent dysphagia due to esophageal strictures necessitating PEG tube placement. He presented to the hospital with nausea, recurrent emesis, and an inability to tolerate tube feeds. His PEG tube was placed to gravity with one liter of output and relief of symptoms. A plan was made to proceed with gastrojejunostomy (G-J) tube to mitigate his symptoms. During bedside removal of his PEG tube, the internal bumper was noted to no longer be attached to the tube (Figure 1A). A Foley catheter was placed in the tract to maintain its patency. As the bumper was presumed to be retained in the stomach, esophagogastroduodenoscopy was performed but there was no evidence of foreign body throughout the exam. A computed tomography scan of his abdomen was obtained urgently and showed passage of the bumper into the jejunum (Figure 1B). Serial abdominal radiographs were obtained over the following day showing migration of the bumper into the rectum and was subsequently passed in his stool. Thereafter, the patient has successfully G-J tube placement by interventional radiology. His tube feeds were advanced to goal rate and the patient was no longer having any nausea or vomiting. Discussion: Retained PEG tube internal bumper is a rare complication of PEG tube removal. Prior case reports have described bumper migration into the small bowel where it became lodged and resulted in small bowel obstruction. At least one prior case resulted in small bowel perforation. In cases of bowel obstruction, surgical intervention is warranted. However, in most cases this complication simply warrants clinical monitoring for evidence of obstruction or passage of the PEG bumper; in most reported cases, endoscopic retrieval was not attempted or feasible, and resolved via spontaneous bumper passage through the gastrointestinal tract.Figure 1.: (A) PEG tube with internal bumper no longer attached. (B) CT scan of abdomen showing PEG tube bumper in the jejunum (orange arrow).

Tube Feeding in Neurologically Disabled Children: Hot Topics and New Directions.

Tube feeding is a therapeutic intervention that is aimed at providing nutritional support and is important in the nutritional and gastrointestinal management of children with neurological disability (ND) worldwide. Since the publication of the first European Society of Gastroenterology, Hepatology, and Nutrition (ESPGHAN) consensus paper in 2017, some aspects of tube-feeding modalities have attracted the interest of the scientific community more than others, including the type of enteral formulas, enteral access, and the challenging practice of tube weaning. The purpose of this review was to report on the most recent hot topics and new directions in tube-feeding strategies for children with ND.

Adjunctive techniques for percutaneous enteral access in children: a pictorial review.

Primary percutaneous gastrostomy and gastrojejunostomy tube placements are fundamental procedures performed in pediatric interventional radiology, with both antegrade and retrograde techniques described. In pediatric patients, however, challenges may arise due to smaller patient size and anatomical variations. Several adjunctive techniques may facilitate safe percutaneous access in the setting of a limited percutaneous gastric access window. These include the intra-procedural use of cone beam computed tomography (CT), percutaneous needle decompression in the setting of distended air-filled bowel interposed between the stomach and abdominal wall, post-pyloric balloon occlusion to facilitate gastric distension, ultrasound-guided gastric puncture, and intra-gastric contrast-enhanced ultrasound (ceUS) to define the relationship of the gastric wall and the anterior abdominal wall. Adjunctive techniques may increase successful primary percutaneous gastroenteric tube placement and may improve operator confidence in safe placement.

Strangulated Paraesophageal Hernia Requiring Laparoscopic Total Gastrectomy

Introduction: Hiatal hernias are classified into four types.1 A type III hiatal hernia is a combination of types I and II where both the fundus and gastroesophageal junction herniate through the hiatus.2 Elective surgical repair is indicated for all types of symptomatic paraesophageal hernias. Emergency repair is indicated when a patient presents with associated obstruction, strangulation, uncontrolled bleeding, or perforation.3 In cases where gastric necrosis occurs, a gastrectomy may be required. A total gastrectomy can be performed either laparoscopically or open. A laparoscopic total gastrectomy has been shown to be a safe procedure with reduced length of stay but requires a well-trained laparoscopic team.4 This video illustrates a laparoscopic total gastrectomy for a necrotic stomach secondary to a gastric necrosis and perforation from an incarcerated paraesophageal hernia. Materials and Methods: A 74-year-old female presented to the emergency department with acute abdominal pain. CT of the abdomen and pelvis showed a type III hiatal hernia with intra-abdominal and intrathoracic free air. She was emergently taken to the operating room for a diagnostic laparoscopy. Intraoperatively, a large strangulated, necrotic, and perforated paraesophageal hernia involving >75% of the stomach was noted. The entire stomach was reduced with 4 cm of intra-abdominal esophagus. The distal esophagus was then transected. The duodenum was then transected distal to the pylorus. The gastric specimen was removed, and the patient was left in discontinuity because of multiple vasopressor requirements. The operation took 151 minutes with 75 mL of blood loss. Results: The patient was on multiple vasopressors throughout the case and transferred to the surgical intensive care unit for postoperative management. The patient underwent renal replacement therapy and was unable to be weaned from vasopressors. She developed severe sepsis-induced coagulopathy and was not medically stable for re-exploration the ensuing day. The patient remained on intravenous antibiotics and antifungals throughout this time. Owing to escalation of care and lack of thoracic surgery at this facility, the patient was transferred to a tertiary center. Over the next week, the vasopressors were discontinued. Bilateral chest tubes and abdominal drains were placed by interventional radiology. On postoperative day 21 from the index case, there was a change in the volume and color of the chest tube output and a CT chest showed an esophageal stump blowout. She subsequently underwent a right video-assisted thoracoscopic surgery wherein a mediastinal abscess was encountered and the distal esophagus was necrotic requiring further resection. On postoperative day 26, she returned to the operating room for placement of jejunostomy feeding tube; however, the abdomen was diffusely frozen and intra-abdominal abscesses were encountered. She remains in discontinuity without enteral access and was discharged to a long-term acute care facility. Conclusion: Strangulated paraesophageal hernias are rare but have significant morbidity when they occur. This case reinforces the need to repair paraesophageal hernias electively before severe complications. Despite the severity of the case, a laparoscopic approach was effective in performing a total gastrectomy in the acute phase and achieving source control. No competing financial interests exist. Runtime of video: 7 mins 4 secs Source: The source of the study was obtained from Trumbull Regional Medical Center. Authors have no conflict of interests or obligations from Trumbull Regional Medical Center. Patient Consent: Authors have received and archived patient consent for video recording and publication in advance of video recording of the procedure.

Outcomes of Gastrostomy Tubes in Newborns With Congenital Heart Disease and Comparison of Techniques

IntroductionGastrostomy tube (GT) placement for enteral access is one of the most common procedures for infants with numerous conditions such as congenital heart disease (CHD). Discrepancies in the literature exist regarding outcomes of newborns with CHD undergoing GT placement. This study sought to characterize postoperative outcomes and readmission complications in this patient population. MethodsThe Nationwide Readmission Database was queried from 2010 to 2014 for all newborns who underwent GT placement during their index hospitalization. Newborns with or without CHD other than an isolated atrial or ventricular septal defect were compared using standard statistical tests. A propensity score–matched analysis was performed among newborns with or without CHD using > 100 covariates. ResultsSeven thousand seven hundred thirty six patients underwent GT placement. Newborns with CHD (27%) more frequently underwent open GT (59% versus 55%) and less frequently underwent laparoscopic (17% versus 19%) or percutaneous (24% versus 26%) GT placement compared to those without CHD, P = 0.043. GT-related complications on index admission were similar between groups (7% versus 7%, P = 0.770). Newborns with CHD had higher overall readmission rates (39% versus 31%), more GT-related readmission complications (7% versus 3%), and higher readmission costs ($35,787 versus $20,073) compared to newborns without CHD, all P < 0.001. Laparoscopic GT was associated with the lowest rate of GT-related complications (0%) and overall readmission rates (27%) compared to open or percutaneous endoscopic gastrostomy (all P < 0.001). ConclusionsCompared to newborns without CHD, newborns with CHD had higher rates of overall readmissions, readmission costs, and GT-related complications on readmission. The laparoscopic GT approach was underused despite fewer complications and readmissions.

Factors Associated With Gastrostomy Tube Complications in Infants With Congenital Heart Disease

IntroductionChildren with congenital heart disease (CHD) often experience feeding intolerance due to aspiration, inability to tolerate feed volume, or reflux within the first few months of life, requiring a surgically placed gastrostomy tube (GT) for durable enteral access. However, complications such as GT dislodgement, cellulitis, and leakage related to GT use are common. GT-related complications can lead to unscheduled pediatric surgery clinic or emergency room (ER) visits, which can be time consuming for the family and increase overall healthcare costs. We sought to identify factors associated with GT complications within 2 wk after GT surgery and 1-y after discharge home following GT placement in infants with CHD. MethodsWe performed a retrospective cohort study using the Society of Thoracic Surgeons database and electronic medical records from a tertiary children's hospital. We identified infants <1 y old underwent CHD surgery followed by GT surgery between September 2013-August 2018. Demographics, pre-operative feeding regimen, comorbidities, and GT-related utilization were measured. Postoperative GT complications (e.g., GT cellulitis, leakage, dislodgement, obstruction, and granulation tissue) within 2 wk after the GT surgery and an unplanned pediatric surgery clinic or ER visit within 1-y after discharge home were captured. Bivariate comparisons and multivariable logistic regression evaluated factors associated with GT complications and unplanned clinic or ER visits. A Kaplan–Meier failure curve examined the timing of ER/clinic visits. ResultsOf 152 infants who underwent CHD then GT surgeries, 66% (N = 101) had postoperative GT complications. Overall, 83 unscheduled clinic visits were identified after discharge, with 37% (N = 31) due to concerns about granulation tissue. Of 137 ER visits, 48% (N = 66) were due to accidental GT dislodgement. Infants who were hospitalized for ≥2 wk after GT surgery had more complications than those discharged home within 2 wk of the GT surgery (40.6% versus 15.7%, P = 0.002). Infants receiving oral nutrition before CHD surgery (38.6% versus 60%, P=<0.001) or with single ventricle defects (19.8% versus 37.3%, P = 0.02) had fewer GT complications. After adjusting for type of cardiac anomaly, infants receiving oral nutrition prior to CHD surgery had a decreased likelihood of GT complications (odds ratio OR 0.46; 95% confidence intervals CI:0.23-0.93). A Kaplan–Meier failure curve demonstrated that 50% of the cohort experienced a complication leading to an unscheduled ER/clinic visit within 6 mo after discharge. ConclusionsUnplanned visits to the ER or pediatric surgery clinic occur frequently for infants with CHD requiring a surgically placed GT. Oral feedings before cardiac surgery associated with fewer GT complications. Prolonged hospitalization associated with more GT complications. Optimizing outpatient care and family education regarding GT maintenance may reduce unscheduled visits for this high-risk, device-dependent infant population.