PEG Site Research Articles

Metastatic tongue squamous cell carcinoma at a percutaneous endoscopic gastrostomy site via introducer technique

AbstractBackgroundPercutaneous endoscopic gastrostomy (PEG) site metastases from head and neck cancers have been reported many times using the pull technique, in which a catheter passes through the oral cavity and pharynx.Case presentationA 69‐year‐old man with recurrent tongue squamous cell carcinoma underwent PEG placement using the introducer technique before chemoradiotherapy. After 6 months, the patient developed a metastasis of tongue carcinoma at the PEG site.ConclusionThe risk of PEG site metastasis is not eliminated even with the introducer technique, which is not in direct contact with the tumor.

Isolated Percutaneous Endoscopic Gastrostomy Site Malignancy Due To Nasopharynx Cancer: A Case Report

PEG (Percutaneous Endoscopic Gastrostomy) procedure is a method used in patients with head and neck cancers whose oral intake is impaired. Although very rare, metastasis may occur due to the possible implantation of tumor cells compatible with primary malignancy at the PEG site. In our case report, we aimed to present a patient who was treated for nasopharyngeal cancer and was found to have a lesion compatible with metastasis at the old PEG site 7 years later.

PEG placements during the COVID-19 pandemic An audit of the procedures performed by a single consultant operator at a tertiary teaching hospital

PEG feeding provides a valuable nutritional access for patients with a functional gastrointestinal tract. The aim of this project was to audit all the PEG procedures performed by a single consultant operator during the Covid-19 pandemic including the indications, outcomes and complications. All the procedure reports were accessed to identify the patients, indications and immediate outcomes. For every patient, all the letters from all specialties were accessed for the dates following the procedure through the clinical records platforms to identify any later complications. A total of 92 procedures were performed between 15/3/2020 and 31/4/2021 in a total of 84 patients. Lists were operating at less than half capacity compared to pre Covid-19. 65 were planned PEG insertions, 17 were planned removals, and 10 were planned replacements. 5 of the procedures were for PEG-J insertion or replacement. The main indication was Head and Neck Ca in 59/92 procedures followed by CVA 9/92, chronic nausea/vomiting/gastroparesis in 6/92, dysphagia with or without aspiration risk in 4/92, MND in 4/92, CNS tumour post-op (pineal gland) in 2/92, cerebral palsy in 1/92, multiple sclerosis in 1/92, neurodegenerative disorder in 1/92, neuromuscular disorder in 1/92, chronic pancreatitis in 1/92, cystic fibrosis in 1/92, depression with poor oral intake in 1/92 and learning difficulties in 1/92. 83/92 procedures were completed successfully. 2 procedures had a failed intubation, 1 because of a subglottal stricture. The rest of the abandoned procedures were due to patient distress (2/92), high oesophageal stricture (1/92), failed cannulation (1/92), body habitus (1/92), stomach not translluminated and patient desaturation (1/92). One of the planned replacements failed because of a buried bumper. In two patients there was a small leak around the PEG site, 1 identified in the endoscopy room, 1 a few weeks later but both were managed conservatively and the PEG was kept in place. No other complications identified. From October 2020 the consistent use of Corflo PEGs reduced the service demands as these can be easily removed in the community. Lists during the COVID-19 pandemic were significantly impacted, especially UGI procedures, as these are aerosol generating procedures. The vast majority of the procedures are completed successfully and there are no significant complications. Most failed procedures are due to patient related factors such as tolerance and anatomical factors. The use of PEGs that can be removed in the community avoiding further endoscopic procedures is a valuable tool especially in this pandemic and early post-pandemic setting.

Applicability, efficacy, and safety of over-the-scope clips in children

Over-the-scope clips (OTSCs) are now becoming popular in endoscopy performed in adults for indications such as acute nonvariceal GI bleeding, anastomotic bleeding, and for closure of gastrocutaneous and postgastrostomy fistulae. Varied sizes of clip are available, but even the smallest, 8.5 to 9.8mm in diameter with its loading device on the tip of the endoscope, increases device and endoscope intubation diameters up to 14.65mm. This may present challenges in terms of the size of the patient in whom it might be used. OTSCs appear to be effective and safe in the hands of those who are trained appropriately in endoscopy on adult patients; however, the experience of OTSC application in children is not reported. Here we present results of a service evaluation of this technology at 2 regional/national referral pediatric endoscopy units in the United Kingdom and the United States. Two tertiary centers' databases were searched to identify cases in which OTSCs were used. Demographics, presentation, anthropometry, comorbidities, efficacy, adverse events, and postprocedure follow-up were recorded, with identification of resolution or recurrence. OTSC procedures were performed on 24 occasions in 20 patients (11 girls) between February 2018 and February 2021. Patients had a mean age of 12 years (range, 5-17) and a mean weight of 44.42 kg (range, 18.2-70.3). Indications were nonhealing PEG site fistulae (n= 7), acute nonvariceal upper GI bleeding (ANUGIB) from gastric ulcers (5), ANUGIB from duodenal ulcers (3), nonhealing bleeding anastomotic ulcer (3), esophageal mucocutaneous fistula (1), and gastric perforation (1). Technical success was achieved in all but 1 case (95%), and clinical success was achieved in 18 cases (90%). The OTSC device appears to be effective in children (minimum age 5 years and minimum weight 18 kg) in a limited number of situations including anastomotic ulcer, closure of leaking PEG site, gastric perforation, and bleeding peptic ulcers. The operator should be an experienced endotherapeutic endoscopist with specific OTSC training, and the type and size of the OTSC device should be carefully considered, along with any comorbidities of the patient that may preclude success and/or lead to potential adverse events such as esophageal perforation.

Soil properties and microbiome of annual and perennial cultivated grasslands on theQinghai–TibetanPlateau

AbstractEfforts to enhance food, fibre, and forage yields and achieve global food security have included the conversion of natural grasslands to cultivated grasslands. The quantitative effects of a global shift in grassland management on soil properties and microbial communities critical to ecosystem function have remained largely unexplored, particularly on China's Qinghai–Tibetan Plateau. Accordingly, the distinct and contrasting effects of annualAvenagrasslands (AAG) versus perennialElymus nutansGriseb. cultivated grasslands (PEG) on the region's soil properties and microbiome were investigated in an effort to examine their contribution to maintaining soil carbon and nutrients. Across three sites per grassland type, soil moisture content (45.55%), soil organic carbon (48.97 g kg−1), soil total nitrogen (5.13 g kg−1), and soil ammonium nitrogen (298.32 mg kg−1) were 19%–32% greater at PEG sites than AAG sites, whereas soil pH (7.81), soil total phosphorus (0.44 g kg−1), and soil available phosphorus (0.81 mg kg−1) were 2%–31% lower. The AAG and PEG site soils had different bacterial and fungal β‐diversities but similar α‐diversities. The relative combined abundance ofGemmatimonadetesandChytridiomycota, and that ofRozellomycotaindividually, were, respectively, higher and lower in AAG versus PEG site soils. This suggests that, on the Qinghai–Tibetan Plateau, contrasting grassland cultivation practices affect soil properties and microbes differently. Given the strong interaction between a soil and its microbiome, changes in a soil's microbial community structure can be expected to substantially alter soil function. This will have important ecological service implications, particularly in terms of carbon storage and water conservation in this ecologically fragile region.

Buried Bumper Syndrome: A common complication of levodopa intestinal infusion for Parkinson disease

BackgroundPercutaneous endoscopic gastrostomy (PEG) is required for Levodopa/Carbidopa Intestinal Gel (LCIG) delivery in patients with advanced Parkinson's disease (PD) as well as for enteral feeding in a variety of neurological disorders. Buried Bumper Syndrome (BBS) is a serious complication of PEG. The frequency of BBS in patients receiving LCIG treatment has never been reported. ObjectivesTo compare the frequency of BBS in patients on LCIG treatment or on enteral feeding over the past 12 years and identify possible risk factors. MethodsWe reviewed prospectively recorded data from 2009 to 2020 on two case-series: LCIG-treated PD patients and non-PD patients on enteral nutrition. We identified all BBS incidences. Patients’ characteristics, clinical manifestations, BBS management, possible risk factors and outcomes were analyzed. ResultsDuring the 12 years, 35 PD patients underwent PEG insertion for LCIG infusion, and 123 non-PD patients for nutritional support. There were eight cases of BBS in six PD patients (17.1%). Six of them were effectively managed without treatment discontinuation. Of the enteral feeding patients, only one developed BBS (0.8%) (p < 0.001). We identified inappropriate PEG site aftercare, weight gain, early onset PD, longer survival, treatment duration, dementia and PEG system design as potential risk factors for BBS development. ConclusionsBBS occurs more frequently in LCIG patients than in patients receiving enteral feeding. If detected early, it can be successfully managed, and serious sequalae or treatment discontinuation can be avoided. Regular endoscopic follow-up visits of LCIG-treated patients and increased awareness in patients and clinicians are recommended.

2754 A Gaping Hole in the Stomach - A Rare PEG Tube Complication

INTRODUCTION: Up to 200,000 gastrostomy tubes (PEG) are placed in the United States each year, with a success rate over of 95%. Here we present a patient with complaints of abdominal pain and discharge from the PEG site, who was found to have an interesting EGD finding. CASE DESCRIPTION/METHODS: A 52 year old cachectic woman with a history of opioid abuse, roux-en-Y gastric bypass for obesity 14 years prior, and PEG placement due to inadequate oral intake almost 3 months prior to her admission, presents to the ED with worsening abdominal pain, nausea, intermittent vomiting and discharge of fecal like material from PEG site for the last few days. On exam patient appeared cachectic, disheveled, and had diffuse erythema of her abdominal wall. Vital signs were significant for hypothermia to 91.3 F, and bradycardia. Labs were significant for sodium of 152. CT abdomen and pelvis showed the PEG tube in satisfactory position. She was started on IV fluids and antibiotics but soon became hypoxic and tachycardic requiring medical ICU care. Subsequently, bleeding around the PEG tube was noted. Hemoglobin dropped from 9.8 to 7.2 within 9 hours. Lavage of the PEG tube revealed coffee ground material. Due to patient’s tenuous respiratory status, it was decided to perform an upper endoscopy by accessing the stomach via the gastrostomy fistula. The PEG tube balloon was deflated and the endoscope was easily inserted without resistance. The peritoneum was immediately visualized, which contained undigested food (Figure 1). The endoscope was withdrawn and was navigated into the body of the stomach, via a large opening. A significant amount of undigested material was seen in the remnant stomach (Figure 2). There was an opening between the remnant stomach and the gastric pouch (Figure 3), which was traversed with the endoscope. The gastric pouch was severely ulcerated and the gastrojejunal anastomosis could not be identified. The patient was then transferred to the hospital where her previous surgery and PEG tube were placed. There, her hospital course was complicated by ARDS requiring intubation. She eventually underwent replacement of PEG tube and after 50 days of hospitalization, she was discharged home. DISCUSSION: Procedure related complications such as perforation can occur anywhere from &lt;0.5-1.8%. In this case, although the PEG tube may have initially been placed in the stomach, the replacement balloon PEG tube may have been inserted into the peritoneum. Complications such as these should always be a consideration.

An audit around the use of salt in the treatment of overgranulation around peg sites

An audit around the use of salt in the treatment of overgranulation around peg sites

PTU-100 A Regional Survey and Retrospective Study of The Risks of Tumour Implantation after Standard Pull-Through PEG Insertion for Head &amp; Neck Cancers – A Theoretical Risk?

Introduction Despite documented low risk ( Methods Firstly, an electronic survey on gastrostomy insertion practices in HNC was circulated to all members of the regional Gastroenterology network (representing 11 NHS hospital trusts in the North West of England). Secondly, in a retrospective study, all PEG placements using pull-through technique for HNC at Lancashire Teaching Hospitals between 2011–2014 were reviewed. Data including patient demographics, tumour site, size, stage and histology, HNC treatments before and after PEG, PEG insertion details, length of follow-up, imaging of the PEG site post procedure and sites of recurrence, were recorded. Data are expressed as the mean (± standard error of the mean) unless stated otherwise. Results The survey of endoscopists (n = 30, 11 consultants) from ten NHS trusts in the North West revealed that seven centres were compliant with BSG guidance (six using radiologically inserted gastrostomy techniques and one offering endoscopic gastropexy as first-line). Three centres use the pull-through technique for HNC. Only 2/30 (7%) of respondents (both consultants) have ever encountered a case of PEG site metastases in their careers post pull-through PEG insertion for HNC. In the retrospective study, 106 HNC patients (age 60 ± 1 years, 77 male, 29 female) were followed-up for 784 ± 40 days post pull-through PEG insertion. Most patients had tumours within the oral cavity (70%), 22% had tumours in the pharynx or below, with the remainder having neck lesions. Overall, in 92% of cases PEG placements were prophylactic (pre-treatment), 49% had documented peg removal at a mean time of 499 ± 45 days, 29% developed recurrent/ metastatic disease and 25% died at 488 ±54 days post PEG insertion. There were no cases of PEG site metastases identified, however only 36% had imaging of the PEG site post-procedure with most recent imaging available at 682 ± 102 days post-procedure. Conclusion Our survey highlights a variation in gastrostomy practices for HNC across the region. Despite the BSG guidelines, some centres still use the pull-through approach and our data suggest the risk of seeding with this approach is low. Reference 1 Westaby D, et al. Gut 2010;59(12):1592–605. Disclosure of Interest None Declared

PTH-245 Endoscopic removal of buried bumper pegs. outcome of a novel technique from a district general hospital

Introduction Buried Bumper syndrome is a known complication following PEG tube insertion. Migration of the internal bumper into the gastrostomy tract may lead to tube blockage or abdominal wall infection. Several removal techniques have been described including balloon push or pull traction, needle-knife technique, foreceps pull, snare technique and external traction. We describe the outcome of a case series from our institution using a novel technique described in 2010 by a German group 1 which utilises a metal rod. To our knowledge, outcomes following this procedure have not yet been reported. Method We maintain a prospective endoscopy database. Electronic case notes were reviewed. Demographic, procedural, safety and outcome data in all patients were recorded. Results 15 procedures of buried bumper PEG removal were undertaken in 12 patients during the period July 2010 to December 2014 by the same endoscopist. Mean age; 67(range 38–90). 10 were male (82%). 11 of 12 (92%) were considered to lack capacity to consent. Indications for initial PEG insertion were: stroke (6), brain injury (3), Huntington’s Chorea (1), Cerebral Palsy (1), Multiple Sclerosis (1). 12 of 15 (80%) buried PEG bumpers were removed using the device. The procedure was unsuccessful in 3 (20%) patients who subsequently underwent a mini-laparotomy. 3 (20%) patients developed aspiration pneumonia following the procedure at a mean of 5 days (range 2–8 day). 1 of these was from the surgical group and 2 from the endoscopically managed group. The 2 in the endoscopy group were successfully managed with antibiotics. In 3 patients (20%) the procedure was performed as a day case. 12 (80%) required inpatient stay following the procedure. Mean length of stay was 7 days. (Range 1–22 days.) 1 patient developed bleeding from the old PEG site post procedure and required endoscopic intervention. 30 day mortality in the group that underwent surgery was 33% (1 patient). Cause of death was aspiration pneumonia. In the endoscopically managed group, the 30 day mortality was 0%. One year mortality was 33% for the surgical group and 8% in the endoscopically managed group. Conclusion Our data suggests that this procedure is safe and effective, particularly when compared to the surgical alternative in this high risk group. The success rate of this procedure was high, suggesting that by utilising this technique, surgery can be avoided in the majority of patients with buried bumper syndrome. Disclosure of interest None Declared. Reference Binnebossal M, Klink CD, et al . Endoscopic Removal of Buried Bumper. Department of Surgery. RWTH Aachen University: Endoscopy. 2010:42:E17–18

Acute Pancreatitis Secondary to Gastrostomy Tube Placement: A Rare Complication

Introduction: Acute pancreatitis secondary to gastrostomy tube (G-tube) balloon migration is a rare complication. We present a case of acute pancreatitis secondary to G-tube placement in a patient with Roux-en-Y foregut anatomy. Case Report: A 33-year-old African American female presented with a one-day history of acute onset epigastric pain with associated fever (100.4F). Past surgical history was notable for Roux-en-Y gastric bypass and cholecystectomy. The patient had no prior history of alcohol use. Two weeks prior to admission, the patient underwent laparoscopic assisted transgastric ERCP for Type II SOD (dilated CBD and severe biliary pain) and was found to have severe papillary stenosis. Biliary sphincterotomy was performed and a G-tube was surgically placed into the excluded stomach for luminal decompression and maintenance of access. On admission, physical exam was notable for hypoactive bowel sounds with tenderness to palpation in the epigastrum, without peritoneal signs. G-tube was in place with minimal erythema at the incision site. Labs were notable for ALT 90U/L, AST 71U/L, alkaline phosphatase 125U/L, total bilirubin 0.7mg/dL, amylase 284U/L, and lipase 683U/L. CT abdomen revealed post-gastric bypass anatomy with the G-tube balloon extending into the second portion of the duodenum. The balloon was seen at the level of the ampulla, exerting a mass effect on the pancreatic head with associated moderate intra- and extra-hepatic biliary ductal dilatation and minimal pancreatic duct dilation. MRCP confirmed mass effect on the distal CBD by the G-tube balloon, with the CBD measuring 1.1cm. There was no filling defect identified in the biliary tree. The G-tube was retracted and balloon partially deflated, with resolution of symptoms and lab abnormalities. Discussion: G-tube placement has known complications including dislodgement, local hemorrhage, perforation, leakage at PEG site, and buried bumper syndrome. Acute pancreatitis secondary to a G-tube is a rare complication. Pancreatitis in this setting is more often caused by balloon migration of replacement tubes and/or Foley tubes, and not by the primary G-tube as seen in our patient. Symptoms typically resolve with medical management and changing/retracting the G-tube. Conclusions: Acute pancreatitis secondary to balloon migration of G-tubes is a rare complication. Increased awareness of this potentially serious complication is prudent, and should be considered as a potential etiology of pancreatitis in all patients with G-tubes. To the best of our knowledge, less than 10 such cases have been reported in the literature.

OC-036 Non-invasive Ventilation During Percutaneous Endoscopic Gastrostomy Insertion In Motor Neurone Disease Patients – A Safe And Effective Multi-disciplinary Approach

IntroductionPercutaneous endoscopic gastrostomy (PEG) is recommended for motor neurone disease patients with dysphagia and accelerated weight loss. However PEG has been suggested as inadvisable in the past in patients with...

Knee arthrodesis with lengthening: Experience of using Ilizarov techniques to salvage large asymmetric defects following infected peri-articular fractures

We present four patients with large bone defects due to infected internal fixation of knee condylar fractures. All were treated by debridement of bone and soft tissue and stabilisation with flap closure if required, followed by bone transport arthrodesis of the knee with simultaneous lengthening. Four patients (three male and one female), mean age 46.5 years (37-57 years), with posttraumatic osteomyelitis at the knee (three proximal tibia and one distal femur) were treated by debridement of infected tissue and removal of internal fixation. Substantial condylar bone defects resulted on the affected side of the knee joint (6-10 cm) with loss of the extensor mechanism in all tibial cases. Two patients required muscle flaps after debridement. All patients received intravenous antibiotics for at least 6 weeks. Bone transport with a circular frame was used to achieve an arthrodesis whilst simultaneously restoring a functional limb length. In three cases a 'peg in socket' docking technique was fashioned to assist stability and subsequent consolidation of the arthrodesis. Arthrodesis of the knee, free of recurrent infection, was successfully achieved in all cases. None has since required further surgery. Debridement to union took an average of 25 months (19-31 months). The median number of interventions undertaken was 9 (8-12). Two patients developed deep vein thrombosis (DVT), one complicated by PE, which delayed treatment. Two required surgical correction of pre-existent equinus contracture using frames. The median limb length discrepancy (LLD) at the end of treatment was 3 cm (3-4 cm). None has required subsequent amputation. Bone loss and infection both reduce the success rate of any arthrodesis. However, by optimising the host environment with eradication of infection by radical debridement, soft-tissue flaps when necessary and bone transport techniques to close the defect, one can achieve arthrodesis and salvage a useful limb. The residual LLD can result from not accounting for later impaction at peg and socket sites, which had the effect of increasing LLD beyond the desirable amount. We therefore recommend continuing the lengthening for an additional 1-2 cm to allow for this.

Metastasis of untreated head and neck cancer to percutaneous gastrostomy tube exit sites

BackgroundPercutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive head and neck tumors. PEG tube placement is considered safe and complications are infrequent. MethodsA comprehensive review of the literature in MEDLINE (1962-2011) was performed. We report herein 3 new cases. ResultsThe literature search revealed 43 previous cases. The interval between PEG placement and diagnosis of metastasis ranged from 1 to 24 months. ConclusionsMetastatic cancer should be considered in patients with head and neck cancer that have persistent, unexplained skin changes at PEG site, anemia, or guaiac positive stools without a clear etiology. The direct implantation of tumor cells through instrumentation is the most likely explanation, although hematogenous and/or lymphatic seeding is also a possibility. Our review of the literature and clinical experience indicate that the “pull” technique of PEG placement may directly implant tumor cells at the gastrostomy site.

Should peristomal infection after percutaneous endoscopic gastrostomy be considered a healthcare-associated infection? Role of antibiotic prophylaxis

BackgroundPercutaneous endoscopic gastrostomy is a widely used method for inserting a gastrostomy tube in patients who are unable to eat but have a normally functioning gut. Peristomal wound infection is...

Clinical Utility of the Buttonhole Technique Using Biohole™ in Hemodialysis Patients

Background/Aims: Buttonhole cannulation has been popular because it provides an easy puncture, is less painful, and requires less time for hemostasis. However, the technique requires a skilled staff and a long time to form the tract. A new buttonhole technique using Biohole(TM), which shortens the time needed for tract formation, has been introduced in Europe, North America, and Japan. Methods: We prepared a cannulation tract using the buttonhole technique and Biohole(TM) over a two-week period and compared the 12-week outcomes between patients who underwent the rope-ladder versus buttonhole techniques. Results: The 40 patients (27 males) had a mean age of 49.1±14.2 years. Thirteen and 27 patients were cannulated with the rope-ladder and buttonhole techniques, respectively. Patients who underwent the buttonhole technique had more initial pain than did those who received the rope-ladder technique (p=0.044). The Biohole(TM) procedure improved puncture pain (5.6 vs. 3.4, p=0.003) and shortened hemostasis time (1.8 vs. 1.3, p=0.001). Over a two-week period, patients using Biohole(TM) experienced dislocation (20.8%), bleeding at peg sites (8.6%), and pain during peg change (2.4%). Over the 12 week study period, patients who underwent the buttonhole technique had insignificantly less pain than did those who received the rope-ladder technique (p=0.088), but the former had less bleeding time than the latter (p=0.000). One patient who received the buttonhole technique experienced one episode of infection (p=0.327). Conclusions: The new buttonhole technique using Biohole(TM) is safe and useful in the short term. A long-term, larger, multicenter study is required to confirm these results. (Korean J Med 2012;82:307-312)

Surgical (open) gastrostomy and repair of the radial forearm donor site

w f o n N d f ercutaneous endoscopic gastrostomy (PEG) has become an ccepted method of providing long term enteral nutritional upport for patients who, it is anticipated, will have their abilty to swallow impaired after serious operations to the head nd neck,1 and in whom simple nasogastric feeding is conraindicated. The tube can be inserted using the pull, push, irect puncture, or Russell method. Radiologically inserted astrostomy (RIG) is another alternative to the surgical (open) astrostomy, but not all techniques are available in all hospials. In patients with active head and neck cancer, use of the ull or push method is associated with a small but definite isk of tumour implantation in the gastrostomy site. Cancer ells that are picked up and implanted into the PEG tract can resent as a metastatic tumour mass at the PEG site between and 16 months after the procedure.2 This is an ominous ign and is associated with extremely poor prognosis; mean urvival is 7 months after diagnosis with one-year survival of %.3 At the Bristol Royal Infirmary, patients with head and neck ancer who have been assessed preoperatively as requiring gastrostomy now have it inserted at the beginning of the peration by an upper gastrointestinal surgeon using an open urgical approach. It is done at the same time as temporary racheostomy, which removes the risks of tumour seeding nd damage to adjacent organs as the trocar is inserted into he stomach under direct vision. It also reduces pressure on

Laparoscopic Paraesophageal Hernia Repair with Acellular Dermal Matrix Cruroplasty

Laparoscopic paraesophageal hernia repair (LPEHR) has been shown to be both safe and efficacious. Compulsory operative steps include reduction of the stomach from the mediastinum, resection of the mediastinal hernia sac, ensuring an appropriate intraabdominal esophageal length, and crural closure. The use of mesh materials in the repair of hiatal hernias remains controversial. Synthetic mesh may reduce hernia recurrences, but may increase postoperative dysphagia and result in esophageal erosion. Human acellular dermal matrix (HADM) may reduce the incidence of hernia recurrence with reduced complications compared with synthetic mesh. A retrospective review of all cases of laparoscopic hiatal hernia repair using HADM from December 2008 through March 2010 at a single institution was performed evaluating demographic information, BMI, operative times, length of stay, and complications. Forty-six LPEHRs with HADM were identified. The mean age of patients was 60.3 years (± 13.9); BMI 30.3 (± 5.3); operative time 182 minutes (± 56); and length of stay 2.6 days (± 1.9). Nine of 46 (19.6%) patients experienced perioperative complications, including subcutaneous emphysema without pneumothorax (n=2), urinary retention (n=1), COPD exacerbation (n=2), early dysphagia resolving before discharge (n=1), esophageal perforation (n=1), delayed gastric perforation occurring 30 days postoperatively associated with gas bloat syndrome (n=1), and PEG site abscess (n=1). There were 2 clinically recurrent hernias (4.3%). Radiographic recurrences occurred in 2 of 26 patients (7.7%). Six of 46 (13%) patients reported persistent dysphagia. LPEHR with HADM crural reinforcement is an effective method of repairing symptomatic paraesophageal hernias with low perioperative morbidity. Recurrences occur infrequently with this technique. No meshrelated complications were seen in this series.

Novel Endoscopic Triangulation Approach to Percutaneous Transgastric Placement of Jejunal Extension Feeding Tube

In patients who have surgically-altered upper gastrointestinal anatomy, postoperative endoscopic enteral nutrition options can be limited by issues such as bowel stenosis and/or acute angulation. This report details the use of an endoscopic triangulation method combining per-oral and percutaneous transgastric approaches to overcome an efferent gastrojejunostomy limb stenosis, to successfully place a jejunal extension feeding tube through a newly placed PEG site. This description provides an alternative endoscopically feasible option for successful enteral nutrition access, thus obviating the need for additional operations to place surgical feeding tubes or to commit patients to long-term total parenteral nutrition.

S1353 Pexact®: Analysis of 319 Procedures Performed at the Digestive Diseases Unit, University Hospital Aintree

Introduction Patients with head and neck cancers can require nutritional support during and after treatment of their cancers. This is commonly done via a gastrostomy. The original “pull though” PEG has an increased risk of tumour implantation at the PEG site. We therefore changed our practice to direct puncture gastrostomy insertion in 2004, using the PEXACT® (fresenius) gastrostomy system, for all head and neck cancer patients. We have previously reported our first year experience of 89 cases. We report our practice since then. Methods All PEXACTS® performed in the unit between November 2005 and November 2009 were identified, using our endoscopy reporting system and from referral register. Further information regarding each patient (readmissions, complications and mortality) was obtained from the hospital patient administration system. Results According to the data available to date, 319 PEXACT® insertions were identified in 317 patients. 79% of patients were male (n=251). Average age was 58 years (18–85 years). 99% (n=316) patients had a head and neck cancer as the indication. Insertion was successful in 99% (n=316) and unsuccessful in 3(0.9%) patients: 2 cases due to poor access and 1 case due to gastric intramucosal haematoma. All patients had prophylactic antibiotics on the ward prior to the procedure. In total six patients died within 30 days (1.9%), 1 within 7 days (0.3%). Of the 30-day deaths, 3 were due to disease progression, one neutropenic sepsis following chemotherapy and two had no record of the cause of death available. Two patients had major procedure related complications (0.6%). On both occasions complications was identified immediately. One of the patients had splenic injury during the procedure and required emergency surgery, the second patient had intra-abdominal haematoma due to laceration of gastric wall which was managed conservatively and resolved spontaneously with good outcome. Ten (3.1%) patients had unplanned admissions within 30 days of their procedure. Four patients were admitted within 7 days (1.3%). Reasons for readmission included displaced or blocked gastrostomy tube n=2 (0.6%), disease progression n=2 (0.6%), gastrostomy site infection n=3 (0.9%) and 1 (0.3%) patient developed an aspiration pneumonia secondary to alcohol excess. There have been no cases of tumour implantation to date. Late displacement of the gastrostomy tube (>30 days after insertion) was common (6.6%). Most were replaced at the bedside. Conclusion PEXACT® is a safe and reliable method of gastrostomy tube placement. Overall, our complication rate has fallen, with only two major procedure related complications during this period. There have been no procedure related deaths. There have been no cases of tumour implantation.