Initial Percutaneous Endoscopic Gastrostomy Research Articles

Complexity of needs in amyotrophic lateral sclerosis (ALS) patients using the ENP-E scale in the north-eastern region of Spain.

This study aimed to explore the clinical characteristics of amyotrophic lateral sclerosis (ALS) patients in Spain's north-eastern region, their inclusion in chronic care programmes, and their psychosocial and spiritual needs (PSNs). A longitudinal descriptive study in adult patients with ALS. We analyzed clinical variables and participation in chronicity and PSNs assessment using the tool Psychosocial and Spiritual Needs Evaluation scale in end-of-life patients (ENP-E scale). 81 patients (average age 65.6 ± 11.7) were studied. At the study's outset, 29.7% employed non-invasive ventilation (NIV), increasing to 51.9% by its conclusion. Initial percutaneous endoscopic gastrostomy (PEG) utilization was 14.8%, rising to 35.85%. Chronic care programme participation was as follows: home care (24.7% initially, 50.6% end), palliative care (16% initially, 40.7% end), case management (13.6% initially, 50.6% end), and advance care planning registration (6.2% initially, 35.8% end). At study start, 47.8% of patients (n = 46) showed moderate-to-severe complexity in PSNs assessment using the ENP-E scale, without showing differences in age, sex, and time of evolution; whereas, on the evolutionary analysis, it was 75% (n = 24). A higher evolutionary complexity was observed in males <60 and >70 years, with no PEG and evolution of ALS of <2 and ≥5 years, and not included in chronicity programmes. When assessing concerns, physical pain and family aspects stand out in all measurements. Forty-eight percent of patients at study start and 71% at end of study showed external signs of emotional distress. Most ALS patients showed a high degree of complexity and were not integrated in chronicity programmes. A "care path" is proposed to integrate ALS patients in these programmes and systematically assess their needs.

Immediate-use strategy is as safe and effective as delayed-use strategy following percutaneous endoscopic gastrostomy tube placement: A retrospective cohort study.

Percutaneous endoscopic gastrostomy (PEG) tube placement is the most common enteral access for long-term feeding. The aim of our study is to assess the feasibility and safety of immediate PEG tube use after initial placement. We conducted a single-center retrospective cohort study between August 2006 and August 2016. Prior to August 2011, tube feedings were delayed for ≥4 h after initial PEG placement, compared with immediate use (<1 h) after August 2011. Primary outcomes were complication rates within 30 days of placement. Secondary outcomes were impact of morbidity, mortality, length of stay, and need for repeat PEG placement. Our study included 1296 patients during the 10-year period, of which 704 underwent delayed use and 592 underwent immediate use (744 inpatient and 552 outpatient). There were no significant differences between the delayed-use and immediate-use PEG with regard to complications (3.4% vs 4.4%; P = 0.76). Subgroup analysis also reflected no significant differences in complications between inpatient and outpatient groups. For inpatients, there were no substantial differences in inpatient mortality (3.9% vs 3.3%; P = 0.70), mortality within 30 days of discharge (13.8% vs 13.1%; P = 0.15), readmissions (38.2% vs 34.3%; P = 0.23), repeat PEG placement (0.7% vs 1.5%; P = 0.46), and length of stay (13.3 vs 13.9 days; P = 0.99). Patients who received immediate enteral nutrition after PEG tube placement did not have any increased complications, morbidity, or mortality; and it is just as safe when compared with patients who received delayed feeding.

S2346 Metastatic Implantation of Esophageal Adenocarcinoma to PEG Tube Site: A Case Report

Introduction: Patients with esophageal cancer often need a Percutaneous Endoscopic Gastrostomy (PEG) tube to provide nutrition. However, metastasis of the original tumor to the gastrostomy site may occur as a rare, but noteworthy complication. Case Description/Methods: A 64-year-old male had a PEG tube placed after he was diagnosed with Stage 2 esophageal adenocarcinoma with extension into the proximal stomach in Sep 2018. Following this, he received chemo and radiation therapy and did well. A follow up EGD demonstrated no evidence of malignancy, but a non-malignant duodenal narrowing / stenosis was noted. Subsequently, the patient suffered persistent leakage around his PEG tube; due to this and duodenal stenosis, his gastrostomy tube (G-tube) was removed and a jejunostomy tube (J-tube) was placed with surgical closure of the gastrostomy site (Figure). A few months later, when the patient was admitted with melena and severe anemia, an upper endoscopy performed revealed a hard, 3-4 cm malignant appearing mass with recent evidence of bleeding noted on the greater curvature of the stomach at the previous PEG tube site. Biopsies from this area showed invasive moderately differentiated adenocarcinoma with histological features similar to the previous adenocarcinoma. Though re-initiation of chemotherapy and radiation did result in improvement of the patient’s stomach neoplasm, his wound healing complications at the J-tube site persisted, resulting in delay of his treatment. In October 2021, there was recurrence of his stomach cancer. Due to persistent difficulties with wound healing and recurrent illnesses, the patient elected to forgo further treatment in favor of comfort care. He subsequently passed away peacefully. Discussion: Our experience with this case and review of the literature indicate that, in patients with esophageal cancer, usage of the “pull-string” technique as well as length of time of PEG tube placement are associated with a significantly higher risk of metastatic implantation. To avoid this rare complication, potential alternative techniques such as the “push” technique for PEG tube placement or radiologically / surgically placed G-tubes or J-tubes should be considered in patients with oropharyngeal or esophageal cancer for nutrition.Figure 1.: Endoscopic image revealing a malignant-appearing mass on the greater curvature of the stomach at initial PEG tube site.

Percutaneous endoscopic gastrostomy tube replacement after head and neck surgery: A case report.

IntroductionPercutaneous endoscopic gastrostomy (PEG) has been available since the 1980s. Routine replacement is conducted at bedside with relatively few complications. Two replacement methods have come into practice: the percutaneous method and the endoscopic method. The laparoscopic method has recently become favorable in the pediatric population.Presentation of caseHerein, we describe a situation in which a gastrostomy tube was replaced at bedside on a patient with previous head and neck surgery for lingual cancer. The percutaneous traction method was used, and gastrostomy tube replacement into the gastric lumen could not be confirmed on subsequent imaging. The patient was ultimately taken to surgery for an open procedure where it was discovered that initial PEG placement had traversed the small bowel mesentery en route to the gastric lumen.DiscussionThe PEG tube is not a permanent device and routine exchange every 6–12 months is recommended. The percutaneous method and endoscopic method for gastrostomy tube replacement have both been used routinely, each with their set of complications. A third technique, laparoscopic placement, is the preferred modality in the pediatric population. Advantages are twofold: direct visualization of the stomach, thus eliminating inadvertent hollow viscus injury, and applicability in infants too small to undergo endoscopy necessary for PEG tube placement.ConclusionConsideration for laparoscopic placement or replacement in the head and neck cancer patient population, in which interval endoscopy is impossible, is thus advocated.

Factors affecting late complications of percutaneous endoscopic gastrostomy tube replacement.

Late complications associated with percutaneous endoscopic gastrostomy (PEG) tube in patients are common occurrences. We aimed to identify risk factors associated with PEG-related late complications. Patients who underwent PEG exchange were retrospectively collected from electronic medical records between January 2015 and November 2020. Medical records were reviewed longitudinally from the PEG replacement date until the first complication event, death, or the end of the study. The late complication was defined as the PEG-related complications six months after the initial PEG placement. Potential risk factors were tested using Cox proportional hazard. A total of 116 patients (mean age 80.5±17.6 years, 52.6% male) were enrolled with a 12 (4-23) months median follow-up. The indications were mostly neurologic disease (89.7%). Non-balloon PEG was used in 93 (80.2%) patients with balloon-type in 23 (19.8%) patients. PEG-related late complications developed in 35 (30.2%) patients with a median time of 9 (4-23) months. In the multivariate analysis, the PEG-related late complication rate was significantly higher in patients with balloon-type PEG tube (HR 5.54; 95%CI, 2.55-12.05; p<0.001) and also showed a significantly higher cumulative incidence of developing complications (54.9% vs. 12.8% at one year and 76% vs. 22.8% at two years, p<0.001). The most common complication was PEG dislodgement (n=14, 40%). Late-onset of PEG tube-associated complications is a common problem. The significant factor associated with PEG tube complication was balloon-type PEG placement.

Endoscopic Management of Gastrojejunal and Jejunocutaneous Fistulae: A Percutaneous Endoscopic Gastrostomy Complication in a Pediatric Patient

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a method of gastric feeding access that has had increasing use by pediatric surgeons in recent years. Known risks of the procedure include bleeding, infection, and accidental placement into the liver, colon, and small bowel.1–3 Endoscopic management of PEG complications is a rapidly evolving field.4,5 This video describes the use of endoscopic techniques to manage a PEG complication in a pediatric patient. Materials and Methods: The patient was a 15-year-old boy who suffered a stroke resulting in ventilator and tube feed dependence. For long-term feeding access, the patient underwent a (PEG) procedure. The patient had difficulty tolerating gastric tube feeds and the decision was made to convert the gastrostomy to a gastrojejunostomy. Fifty-nine days after the initial PEG procedure, the patient was taken to the operating room for conversion to a gastrojejunostomy tube. After PEG removal, attempts were made to place a guidewire through the tract into the stomach. However, the guidewire did not go in the expected direction. Fluoroscopic and endoscopic evaluation raised concern for communication with the small bowel. An advanced surgical endoscopist was then consulted. The gastrostomy site was identified and traversed with an ultraslim endoscope. The gastrostomy site entered immediately into small bowel. A jejunocutaneous fistula was noted on the opposite site of the bowel, suggesting that the original PEG had traversed a loop of small bowel in a through-and-through manner. The tracts appeared stable and there was no evidence of contamination or insufflation leaking into the peritoneal cavity. Attention was then turned to closing the jejunocutaneous fistula, which could only be accessed through the gastrojejunal fistula. Given that only an ultraslim endoscope, without a proper working channel for the desired intervention, could access the site, an endoclip device was affixed to the side of the ultraslim endoscope. The jejunocutaneous fistula was then closed with five endoclips. Next, the gastrojejunal fistula was closed using an over-the-scope clip. Fluoroscopic evaluation with air insufflation demonstrated complete closure. Finally, to afford enteral access, a PEG was performed using the pull technique. Endoscopic and fluoroscopic observation confirmed good positioning. Results: An upper gastrointestinal contrast study on postoperative day 3 demonstrated no signs of fistula or leak. Tube feeds were initiated and slowly advanced to goal by postoperative day 7. The patient tolerated his gastric tube feeds and had no further surgical complications. Conclusion: This case has several key learning points. First, it demonstrates the high clinical suspicion for PEG complication that must be held when a patient fails to tolerate feeds. Second, it demonstrates how the skilled use of endoscopic and surgical principles can provide minimally invasive definitive management of PEG complications. Next, this case demonstrates how a thorough understanding of the benefits and drawbacks of available endoscopic tools can lead to innovative solutions to difficult problems. Finally, this case demonstrates the advanced care that can be offered to patients when a multidisciplinary approach is utilized. C.G.D., D.J.M., A.Y.T., and M.C.S.: No competing financial interests exist. E.M.P.: Speaking/teaching: Cook Biotech, Inc., C.R. Bard, Inc., Boston Scientific Corp. Ovesco; Research Support: C.R. Bard, Inc.; Consultant: Boston Scientific Corp., Actuated Medical, Inc., Medtronic, Baxter, Surgimatrix, CMR Surgical; Royalties: UpToDate, Inc., Springer. Runtime of video: 7 mins 45 secs This video was presented as a video presentation at the 2020 American College of Surgeons Virtual Clinical Congress, on October 3, 2020.

Airway Management for Initial PEG Insertion in the Pediatric Endoscopy Unit: A Retrospective Evaluation of 168 Patients.

PurposePercutaneous endoscopic gastrostomy (PEG) tube placements are commonly performed pediatric endoscopic procedures. Because of underlying disease, these patients are at increased risk for airway-related complications. This study compares patient characteristics and complications following initial PEG insertion with general endotracheal anesthesia (GETA) vs. anesthesia-directed deep sedation with a natural airway (ADDS).MethodsAll patients 6 months to 18 years undergoing initial PEG insertion within the endoscopy suite were considered for inclusion in this retrospective cohort study. Selection of GETA vs. ADDS was made by the anesthesia attending after discussion with the gastroenterologist.ResultsThis study included 168 patients (GETA n=38, ADDS n=130). Cohorts had similar characteristics with respect to sex, race, and weight. Compared to ADDS, GETA patients were younger (1.5 years vs. 2.9 years, p=0.04), had higher rates of severe American Society of Anesthesiologists (ASA) disease severity scores (ASA 4–5) (21% vs. 3%, p<0.001), and higher rates of cardiac comorbidities (39.5% vs. 18.5%, p=0.02). Significant associations were not observed between GETA/ADDS status and airway support, 30-day readmission, fever, or pain medication in unadjusted or adjusted models. GETA patients had significantly increased length of stay (eβ=1.55, 95% confidence interval [CI]=1.11–2.18) after adjusting for ASA class, room time, anesthesia time, fever, and cardiac diagnosis. GETA patients also had increased room time (eβ=1.20, 95% CI=1.08–1.33) and anesthesia time (eβ=1.50, 95% CI=1.30–1.74) in adjusted models.ConclusionStudy results indicate that younger and higher risk patients are more likely to undergo GETA. Children selected for GETA experienced longer room times, anesthesia times, and hospital length of stay.

Percutaneous endoscopic versus radiologic gastrostomy for enteral feeding: a retrospective analysis on outcomes and complications.

Background and study aims Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are techniques used for long-term enteral feeding. Our primary aim was to analyze procedure-related and 30-day mortality and complications between PEG and PRG in relation to indications. Patients and methods A single-center retrospective analysis was performed thath included all adult patients receiving initial PEG (January 2008 until April 2016) and PRG (January 2010 until April 2016). Outcomes were mortality (procedure-related, 30-day), complications (early (≤ 30 days) and late) and success rates. Results A total of 760 procedures (469 PRG and 291 PEG) were analyzed. Most common indications were head and neck cancer (HNC), cerebrovascular accident (CVA) and amyotrophic lateral sclerosis (ALS). Success rates for placement were 91.2 % for PEG and 97.1 % for PRG ( P = 0.001). Procedure-related mortality was 1.7 % in PEG and 0.4 % in PRG ( P = 0.113). The 30-day mortality was 10.7 % in PEG and 5.1 % in PRG ( P = 0.481 after multivariate logistic regression) CVA was associated with higher 30-day mortality, whereas ALS, higher body weight, and prophylactic placements in HNC were associated with lower rates. Tube-related complications were less frequent in PEG, both early (2.7 % vs. 26.4 %, P ≤ 0.001) and late (8.6 % vs. 31.5 %, P ≤ 0.001). The percentage of major complications and infections did not differ. Conclusions With respect to procedure-related and 30-day mortality, PEG and PRG compare equally. PRG had a higher procedural success rate. Tube-related complications and pain are less frequent after PEG compared to PRG. The choice for either PEG or PRG therefore should primarily be based on local facilities and expertise.

An Uncommon Complication of Percutaneous Endoscopic Gastrostomy Tube Placement

Question: A 75-year-old nursing home resident was referred by her local medical officer with a 5-month history of an enlarging exophytic growth from around her percutaneous endoscopic gastrostomy (PEG) site. Her initial PEG was placed 7 years prior, when she suffered a large cerebral hemorrhage, with secondary oropharyngeal dysphagia. At the time, she was already suffering from early cognitive impairment, which had progressed over the subsequent years. The growth was noticed after a new feeding tube was replaced percutaneously, without endoscopic assistance, when the previous PEG was accidentally dislodged. In the months leading up to her assessment, there were observations from the patient’s family of altered behavior, including frequent gesturing at the PEG site, suggestive of some associated discomfort. Examination of the PEG site revealed a 3-cm, exophytic, fleshy mass that encircled the PEG tube (Figure A). No ulceration was evident. The origin of the lesion seemed to arise deep to the cutaneous layer. The PEG tube seemed to be freely mobile and was in good position. No evidence of organomegaly, ascites, or peritonism was identified on examination. A biopsy was performed of the lesion (Figure B). Computed tomography was performed (Figure C–E). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Laparoscopy-Assisted Percutaneous Endoscopic Gastrostomy in a Patient with Distorted Anatomy

Percutaneous endoscopic gastrostomy (PEG), which was first introduced in 1980, was quickly adopted for use in pediatric and adult patients. However, problems such as severe kyphoscoliosis, interposed organs, or other forms of distorted anatomy, may prevent effective and safe PEG tube placement. In such cases, laparoscopy-assisted PEG (LAPEG) is a useful optional procedure for patients with distorted anatomy and an initial unsuccessful PEG attempt. Furthermore, less invasive measures are preferable over surgical gastrostomy. We present a 27-year-old-male patient with severe kyphoscoliosis and a history of PEG-related complications with a colocutaneous fistula appearing 10 months earlier in whom a feeding tube was successfully placed by LAPEG. There were no LAPEG-related complications in the perioperative period, either technical or metabolic. After discharge, the patient was effectively fed using the bolus method. (Korean J Med 2014;87:318-322)

Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study

Percutaneous endoscopic gastrostomy (PEG) is performed to provide nutrition to patients with swallowing difficulties. A multicenter study was conducted to evaluate the predictors of complications and mortality after PEG placement. This study retrospectively analyzed patients who underwent initial PEG placement between January 2004 and December 2011 at seven tertiary hospitals in the Republic of Korea. All 1,625 patients underwent PEG placement by the pull-string method. The median age of the patients was 66 years, and 1,108 of the patients were men. The median follow-up period was 254 days. The common indications were stroke (31.6%) and malignancy (18.9%). The complication rate was 13.2%. The prophylactic use of antibiotics (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.38-0.88; p = 0.010) reduced the PEG-related infection rate, but the actual usage rate was 81.1%. The use of anticoagulants (OR, 7.26; 95% CI, 2.23-23.68; p = 0.001) and the presence of diabetes mellitus (OR, 4.02; 95% CI, 1.49-10.87; p = 0.006) increased the risk of bleeding, but antiplatelet therapy did not. The procedural, 30-day, and overall mortality rates were 0.2, 2.4 and 14.0%, respectively. Serum albumin levels lower than 31.5 g/L (OR, 8.55; 95% CI, 3.11-23.45; p < 0.001) and C-reactive protein levels higher than 21.5 mg/L (OR, 3.01; 95% CI, 1.27-7.16; p = 0.012) increased the risk of 30-day mortality, and the patients who had both risk factors had a significantly shorter median survival time than those who did not (1,740 vs 3,181 days) (p < 0.001, log-rank). The findings showed PEG to be a safe and feasible procedure, but the patient's nutritional and inflammatory status should be considered in predicting the outcomes of PEG placement.

Gastrointestinal: PEG feeding tube migration into the colon; a late manifestation

A 53 year-old man presented with a 5-month history of severe diarrhoea and abdominal cramping immediately occurring after tube feeding. The Percutaneous Endoscopic Gastrostomy (PEG) tube was inserted 2 years previously, for enteral feeding, following diagnosis of an oropharyngeal carcinoma. The patient had no signs or symptoms of peritonitis. The skin surrounding the tube was inflamed with brown odorous fluid exuding. Upon checking the tube position using upper endoscopy no inner bumper was seen within the stomach. A fistulogram through the feeding tube revealed typical haustration of the colon rather than expected gastric appearances (Figure 1A). CT confirmed misplacement, localizing the position of the bumper in the transverse colon (Figure 1B, arrow). A gastrocolic fistula could not be visualized. Colonoscopy showed the inner bumper located near the splenic flexure (Figure 2A). The colon surrounding the inner bumper showed a soft tissue proliferation which was histologically identified as heterotopic gastric tissue (Figure 2B, arrows). The tube was removed endoscopically using a wire loop. Subsequently, a new PEG tube was inserted using ultrasound guidance. On insertion there were no signs of a persistent colocutaneous or gastrocolic fistula and tube feeding was restarted. Figure 1 Figure 2 Prior to the original PEG tube insertion, this patient had a history of polytrauma and underwent splenectomy. Anatomically, this facilitated an interposition of the colon between the anterior abdominal wall and the stomach. This, potentially, resulted in the placement of the initial PEG tube transcolonically on its way into the stomach, causing the development of an iatrogenic gastrocolic fistula. Over time, the inner PEG bumper imperceptibly migrated from the stomach into the colon, ultimately causing the reported symptoms. The heterotopic gastric tissue around the tube in the colonic wall provides independent proof for this migration. Since introduction of percutaneous endoscopic gastrostomy in 1980 by Gauderer and colleagues, the procedure has become a well-accepted and safe technique for long-term feeding of patients. The technique is performed by puncturing the stomach through the abdominal wall. The gastric wall is visualized through the abdominal wall by transillumination using a gastroscope and a fingerprint impression applied to the abdominal wall indents the gastric wall, aiding direct puncture of the needle into the stomach. In general the complication rate is low and migration of a PEG tube into the colon originally positioned in the stomach is an extraordinarily rare complication, typically occurring within days to month after insertion. It has also been found in patients with previous abdominal surgery. Characteristically, symptoms of a colonic PEG migration include sudden onset of diarrhoea and cramping, immediately after tube feeding and an odorous faecal exudate from the stoma. In most cases the PEG tubes can be removed endoscopically with spontaneous closure of the colocutaneous fistula within days. Contributed by

Outcomes of percutaneous endoscopic gastrostomy versus radiologically inserted gastrostomy tube insertion at a tertiary hospital

summary Background and aims: Percutaneous endoscopic gastrostomy (PEG) and radiologically inserted gastrostomy (RIG) techniques are common methods for inserting a gastrostomy tube to provide nutrition. The aim of this study was to compare the outcomes between PEG and RIG placements at a tertiary referral centre. Methods: A retrospective review was conducted on all patients who had an initial PEG or RIG inserted at our institution between January 2007 and April 2009. Basic demographics, indication for insertion, periand post-procedural complications, tube dislodgment, tube discontinuation and death were compared. Results: A total of 177 gastrostomy insertions in 175 patients (PEG: 80, RIG: 97) were included with a median follow up of 405 days (4e939). Baseline characteristics were similar between groups. There were no deaths related to insertion and only one major complication of peritonitis. Stomal site infection was the most common post-procedural complication [PEG: 14%, RIG:13%]. Tube dislodgment was significantly higher in the RIG group [PEG: 5 (6%), RIG:38 (39%), p < 0.005] with RIG having an odds ratio of 58 (95%CI 5e619, p < 0.001) for dislodgment on multivariate analysis. Other complications occurred with similar frequency between groups: pneumonia [PEG: 5%, RIG: 4%]; and bleeding [PEG: 1%, RIG:1%]. The 30 day and 1 year mortality rates were similar between the groups [PEG: 4%, RIG:5%; and PEG: 23%, RIG:27% respectively] as was gastrostomy tube discontinuation rates. Conclusions: Both PEG and RIG insertion techniques compare favourably in terms of the majority of major and minor complications and long-term outcomes. However tube dislodgment rates are significantly higher following RIG insertion supporting an endoscopic approach where possible to minimise the risk of tube malposition resulting in peritoneal contamination.

Retrospective analyses of complications associated with transcutaneous replacement of percutaneous gastrostomy and jejunostomy feeding devices

Feeding device replacement is often required for long-term maintenance after initial percutaneous endoscopic gastrostomy or jejunostomy placement. Although there are several case reports on serious complications of gastrostomy device replacement, there are few reports of an overall analysis of the complications associated with feeding device replacement. To evaluate the frequency and variety of complications of transcutaneous replacement of feeding devices. A retrospective study. Single center: Nishimino Kosei Hospital. This study involved 363 consecutive patients undergoing a total of 1265 percutaneous gastrostomy or jejunostomy device replacements from March 2000 to September 2010. A new replacement device was inserted through the ostomy tract by using an obturator after traction removal of the previous device. Endoscopic treatments were performed in the cases of fistula disruption or hemorrhage. Complications and their outcomes. Gastrostomy and jejunostomy devices were replaced 1126 and 139 times, respectively. There were 16 complications (1.3% of total replacements) consisting of 10 cases of fistula disruption caused by misplacement of replacement devices into the peritoneal cavity, 4 cases of hemorrhage, and 1 case each of colocutaneous fistula and device breakage. Anticoagulation or antiplatelet medications were continued in all 4 hemorrhage cases but in only 27 of 347 (7.7%) complication-free cases (P < .0001). There were no replacement-related adverse events that required surgical repair. A single center, retrospective analysis. Fistula disruption and hemorrhage were the most common complications associated with device replacement. In patients on anticoagulants, caution is necessary to avoid hemorrhage after replacement. It is also important to verify that the replaced device is located in the GI tract lumen before feeding.

Sa1644 Evaluation of Forces Required for Inadvertent Removal of Percutaneous Endoscopic Gastrostomy (PEG) Devices

Sa1644 Evaluation of Forces Required for Inadvertent Removal of Percutaneous Endoscopic Gastrostomy (PEG) Devices John C. Fang, Kristen Hilden Gastroenterology, University of Utah, Salt Lake City, UT Introduction: Solid mushroom type bolster or water filled balloons are the most common internal retention devices for PEG’s. It is these internal retention devices that resist accidental or inadvertant removal of PEG’s from external traction. For a balloon type replacement PEG’s the removal force may differ by differ by size (volume) of retention balloon or whether balloon bursts upon removal. The difference in forces required to remove PEG’s with these different retention devices have not been previously reported. Methods: Four solid internal bolster initial placement PEG’s were placed into 2 live pigs. Eleven days later the initial PEG’s were removed and replacement balloon PEG’s were placed and removed immediately. Force of external traction removal was measured using strain gauge meter and measured in psi. The 4 initial placement solid internal bolster PEG’s (14-24F Endovive Standard PEG) and 26 balloon type replacement PEG’s (14-24F Endovive Standard Profile Balloon Replacement Feeding Tubes (n 20), Kimberly Clark MIC Gastrostomy Feeding Tubes (n 6)) were tested. Balloons were inflated with sterile H2O to various volumes (5-20 cc) per manufacturers directions. For balloon type PEG’s the balloons were left inflated when removal forces were tested. Results: The force to remove retention balloons (n 26) was significantly greater than the force required to remove the solid internal bolster PEG’s(n 4)(14.4 0.6 vs.7.4 0.9 respectively;p 0.0004). The force to remove undeflated balloon PEG’s did not differ by volume of the balloon (p NS for comparisons of different sized balloons). The force to remove undeflated balloon type PEG’s did not differ by whether the balloon burst upon removal or not (16.1 3.0 vs. 14.4 2.7 respectively)(see tables). Conclusions: Balloon type PEG’s required significantly more force to remove than solid internal bolster PEG’s. The force for removing balloon type replacement PEG’s did not differ by volume that the balloon was inflated to or whether retention balloons burst (vs. not bursting) during traction removal. This data has important implications for choosing and designing PEG’s in patients at risk for inadvertent removal.

Outcomes After Percutaneous Endoscopic Gastrostomy Insertion in Children

Percutaneous endoscopic gastrostomy (PEG) insertion is indicated for provision of enteral nutrition when oral feeding is not possible or inadequate. The aim of this study was to review the early and late morbidity of percutaneous gastrostomy insertion in children including major and minor complications. Methods: A retrospective chart review of children who underwent percutaneous endoscopic gastrostomy by the Dept of Gastroenterology, RCH in the last 4 years was undertaken. Patient demographics, indications for gastrostomy, and the incidence of major and minor complications were recorded. Early complications were defined as those occurring within one week of insertion and late complications as those occurring after the first week. Results: 60 patient charts have been reviewed to date. The median age of insertion was 5 years (range 2months-15.5years). Indications for PEG insertion included inadequate intake (39/60, 65%), unsafe swallow or aspiration risk (19/60, 32%), and complicated metabolic requirements (2/60, 3%) in two patient's with glycogen storage disorders. Four patients (6.6%) developed major complications after insertion. Two patients developed early complications with presumed peritonitis after the procedure requiring intravenous antibiotics and gut rest. Late complications included one patient with buried bumper syndrome at the time of conversion to a skin level device 3 months after initial PEG placement. The other patient developed pneumoperitoneum on conversion to gastrostomy button. Minor complications however were common and occurred in 80% (48) of patients. Most occurred late and included granulation tissue formation (56%, 34), site infection (8%, 5), inadvertent device avulsion (8%, 5), gastric ulcer related to the gastrostomy device (1.5%,1) and skin stomal pressure ulcer (5%, 3). All patients with major complications (6.6%) were managed successfully without any surgical intervention. Patients with inadvertent tube avulsion were able to be converted easily to a skin level device and did not require any further intervention. Other minor complications were managed conservatively. All patients were still alive at 12 months follow up. Conclusions: Major complications after PEG insertion are rare and do not impact significantly on long-term patient morbidity. Minor complications however are common and usually occur late, of which granulation tissue formation is the most frequent. PEG insertion is a safe procedure in children for the provision of enteral nutrition.

Gastrostomy Tube Placement by Radiological versus Endoscopic Methods in an Acute Care Setting: A Retrospective Review of Frequency, Indications, Complications and Outcomes

To describe the current practice of placing gastrostomy tubes (endoscopic and radiological), patient characteristics, indications for enteral support, complications and outcomes over a 13-month period, and explore factors that influenced complications and outcomes. Second, to provide Canadian data regarding feeding tube placement because no current literature reflecting these practices for Canadian hospitals is available. Retrospective chart reviews were conducted. Patients who had initial percutaneous endoscopic gastrostomy (PEG) or percutaneous radiological gastrostomy (PRG) tubes inserted for nutritional purposes were included in the study. A total of 136 charts which included 30 PEG and 44 PRG procedures were reviewed. The PRG group was older than the PEG group (mean [+/-SD+/-5D; age 68+/-19 years versus 55+/-21 years, respectively; P=0.008). Patients in PEG group had longer lengths of hospital stay and more intensive care unit admissions than the PRG group (P=0.029). The main reason for tube insertion was dysphagia/aspiration (PEG [60%] and PRG [77%]). Minor complications were comparable between the two groups (P=0.678). There were three cases of major complications overall. More subjects in the PRG group died (18%) while in hospital than in the PEG group (3%) (P=0.055). No procedure-related deaths occurred in either group. Both methods of tube insertion provided a safe route for nutrition delivery despite a significant cost differential with PEGs costing 44% more than PRGs. Characteristics such as age, presence of ascites and severity of disease influenced the method of insertion despite the lack of current guidelines. Overall, the present study provides new descriptive data in a Canadian context.

Misplacement of Percutaneously Inserted Gastrostomy Tube Into the Colon: Report of 6 Cases and Review of the Literature

With the increasing use of percutaneous endoscopic gastrostomy (PEG), rare complications are seen; one of them is misplacement of the tube into the colon. We describe the various clinical pictures and treatment approaches. Case series from our hospital and case reports from the literature are presented. Symptoms, time interval from symptoms to diagnosis, time elapsed from initial PEG insertion to replacement or to regression, regression of gastrostomy tube to the colon vs colonic placement of reinserted tube, and treatment approaches are evaluated. We identified and studied 6 patients in our hospital who had misplacement of a PEG into the colon. A review of the English literature revealed another 22 adult cases with this complication. Of the total 28 cases, 8 had previous abdominal pathology. Seventeen patients developed symptoms after tube replacement, whereas in 11 the tube had not been changed. Fourteen had diarrhea, 11 presented with fecal discharge in or around the tube, and 3 were asymptomatic. Thirteen showed colocutaneous fistula without residual connection to the stomach. Ten patients were treated surgically and 14 conservatively by removal of the tube. One patient had colonoscopic clipping of the fistula. Gastroenterologists should adhere strictly to cautionary measures to prevent misplacement of PEG into the colon. In patients with PEG feeding, the clinician should suspect misplacement of the tube into the colon when there is recurrent severe diarrhea of undigested food or fecal content in the tube, particularly after tube replacement. Treatment may be conservative in most cases.

Morbidity and mortality after percutaneous endoscopic gastrostomy in children with neurological disability

Gastrostomy placement has become an integral mechanism for delivering nutritional support to children with severe neurological disability. Its impact on gastroesophageal reflux and mortality remains contentious. We examined the morbidity and long-term mortality of a group of children with severe neurological disability after percutaneous endoscopic gastrostomy (PEG). We retrospectively identified all children with severe neurological disability who had a PEG at the Royal Children's Hospital in Melbourne between 1990 and 1997. Data were obtained from medical records. Ninety-eight children with neurological disability (M:F 1.8:1.0; median age 3.5 years, interquartile range 1.1-8.7 years) had an initial PEG in this period and were able to be followed for 6-14 years. As a group, they were underweight for their age with a Z score at PEG of -3.52 (SD 3.33), but had increased weight-for-age Z scores by 1.05 after a mean period of 6.1 months. Fourteen subsequently required fundoplication for reflux. Mortality rates were 11% after 1 year, 21% after 2 years, 27% after 3 years and 39% after 13 years. Mortality was increased in those children who were older at the time of PEG (P = 0.06). Gastroesophageal reflux, underweight-for-age and gender were not significantly related to mortality. Children with severe neurological dysfunction who require gastrostomy feeding have a substantial long-term mortality, but this may be unrelated to PEG placement.

Healthcare costs associated with percutaneous endoscopic gastrostomy among older adults in a defined community.

The effectiveness of percutaneous endoscopic gastrostomy (PEG) in older adults remains controversial. Although prior studies have examined the safety of PEG and its impact on nutrition, there are limited data on the economic costs. The purpose of this study is to describe the healthcare costs associated with PEG tube feeding over 1 year. Prospective cohort study. Small community of approximately 60,000 residents served by two hospital systems. One hundred five (70%) of 150 patients age 60 and older receiving PEG over a 24-month period in the targeted community who permitted access to their medical records. Patients were interviewed at baseline and every 2 months for 1 year to obtain information on use of enteral formula, complication rates, and health services use. We obtained inpatient charge data for all hospitalizations and PEG procedures for 1 year. Censoring patients at death or 1 year post-PEG, the mean number of days of PEG tube feeding was 180 (range 5-365). The average cost for PEG tube feeding for this cohort of patients was $7,488 (median $3,691) in 1997 and 1998. The average daily cost of PEG tube feeding was $87.21 (median $33.50). The estimated cost of providing 1 year of feeding via PEG is $31,832 (median $12,227). The main components of this cost include the initial PEG procedure (29.4%), enteral formula (24.9%), and hospital charges for major complications (33.4%). Direct charges associated with PEG tube feeding over 1 year are conservatively estimated at $31,832; there was considerable variation in charges because of the cost of rare but costly major complications. Also, feeding patients via PEG resulted in cost shifts in terms of the primary payor. The economic cost of PEG tube feeding is another consideration in decision making for long-term enteral feeding among older adults.