Percutaneous Endoscopic Gastrostomy Placement In Patients Research Articles

Abstract TMP36: Anatomical Predictors of Gastrostomy Tube Placement After Large Vessel Occlusion Ischemic Stroke

Dysphagia is a common neurologic deficit after ischemic stroke; as a result, patients often require percutaneous endoscopic gastrostomy (PEG) tube placement for safe maintenance of sufficient caloric intake. Right hemispheric strokes have previously been associated with post-stroke dysphagia. We examined whether topographic locations of post-stroke diffusion-weighted MRI (DWI) lesions associated with the need for placement of PEG tube. A registry of 898 patients evaluated for acute treatment of suspected large vessel occlusion (LVO) stroke was used. 65 patients underwent post-stroke PEG placement, and 65 additional patients were selected as propensity matches based on age, baseline NIH Stroke Scale score, and recanalization status. Binary masks of 24-to-72-hour post-stroke DWI lesions were co-registered to standard template space. Voxel-based lesion symptom mapping (V2.6), rewritten to perform logistic regression at each voxel, was used to generate statistical maps of lesion contribution to PEG placement. Uncorrected t-statistic maps demonstrated voxels in the right frontal, parietal, and temporal regions were associated with post-stroke PEG placement. Upon controlling for age and/or recanalization status, lesions in the right parietal lobe were associated with need for PEG. After controlling for lesion volume, this association weakened; once all variables were controlled for, there were no topographical regions associated with PEG placement. In this limited series, there is not a topographic region on post-stroke diffusion MRI that is significantly associated with need for PEG placement in patients with LVO stroke after controlling for appropriate covariates. PEG tube requirement may be a composite outcome, dependent on various inputs notably including lesion volume.

Percutaneous endoscopic gastrostomy in children receiving peritoneal dialysis: A tertiary centre long-term experience and literature review.

Children with severe chronic kidney disease receiving maintenance peritoneal dialysis (PD) are often malnourished and may require nutritional supplementation. Recent PD guidelines address laparoscopic and open surgical gastrostomy as safe approaches in children established on PD, while existing evidence on percutaneous endoscopic gastrostomy (PEG) is still lacking; as well as the role of perioperative antibiotic and antifungal prophylaxis. Hence, this study aimed to report our experience with PEG placement in patients on PD and compare it with the available literature. We retrospectively reviewed the medical records from patients on PD, who underwent PEG placement at a tertiary referral centre between 2000 and 2020. Data on perioperative management, complications and outcomes were retrieved. An extensive literature search was performed; studies describing PEG placement and perioperative prophylaxis in patients on PD were used as a comparison. Descriptive statistical analysis was conducted. Seven patients (five males) were included. Perioperative antibiotic and antifungal prophylaxis were standard practice. At a median follow-up of 27 months (10-75), the peritonitis rate was 0.2 patient/years. No statistical significance was found between the peritonitis rate before and after PEG placement (p = 0.2). Patients' demographics and postoperative complications were comparable to the reported studies. Based on our experience, our technique of PEG insertion with antimicrobial prophylaxis is feasible and associated with an acceptable complication risk in patients on PD. Further multicentric studies about surgical technique in patients on PD will be necessary to verify the feasibility of PEG and standardise the perioperative protocol.

Slow vital capacity as a useful indicator of the prognosis after percutaneous endoscopic gastrostomy in patients with amyotrophic lateral sclerosis.

Forced vital capacity (FVC) is recommended as a respiratory function test in patients with amyotrophic lateral sclerosis (ALS). However, in ALS associated with orofacial palsy, FVC may be an unreliable test. Slow vital capacity (SVC) is an easier and more reliable test even in cases with bulbar symptoms. However, it remains unclear whether respiratory function tests using SVC and FVC are associated with prognosis after percutaneous endoscopic gastrostomy (PEG) placement. This study aimed to confirm whether both SVC and FVC are related to prognosis after PEG placement in patients with ALS. We conducted this retrospective observational cohort study of 69 consecutive patients diagnosed with sporadic ALS who underwent PEG placement between July 2007 and February 2020. We analyzed the association with mortality 6 months after PEG placement and evaluated long-term prognosis. Forty-four patients met the inclusion criteria. In cases with decreased SVC (p < .01) and FVC (p < .01), a significant difference was observed in mortality 6 months after PEG placement, with an optimal cut-off of SVC ≤57.4% (sensitivity, 0.828; specificity, 0.867) and FVC ≤57.3% (sensitivity, 0.828; specificity, 0.867). Multivariate analysis showed that onset age ≥ 65 years (p < .05), SVC ≤57.4% (p < .01), and FVC ≤57.3% (p < .01) were associated with survival after PEG placement. SVC, like FVC, is an important prognostic factor after PEG placement in patients with ALS, and there is a possibility that evaluation using SVC can complement respiratory function testing even in cases where the evaluation of FVC is limited.

Abstract WP305: Predictors of Early Improvement of Swallow Function in Acute Ischemic Stroke Patients With Severe Dysphagia

Introduction: Dysphagia is a common complication of stroke that often improves with time. Percutaneous endoscopic gastrostomy (PEG) tubes are used to bridge patients with dysphagia until oral feeding is safe. We sought to evaluate factors associated with early improvement in swallow for patients in whom PEG tube was deferred after an initial failed instrumental assessment of swallow (IAS) study. Methods: Consecutive cases of AIS were identified from our inpatient registry (6/14- 4/15). We included patients who failed an initial IAS with Fiberoptic Endoscopic Evaluation of Swallowing or Modified Barium Swallow Study. Speech language pathologists (SLP) calculated Penetration-Aspiration (PEN-ASP) scores (1-2 normal; 3-5 penetration; 6-8 aspiration) based on performance on IAS. Recovery of swallow was defined as improvement in the PEN-ASP category with thin or nectar-thickened liquids. Univariate analyses and multiple logistic regression were used to assess predictors of improvement in swallow with demographic data, medical history, stroke etiology, and NIHSS as independent variables. Results: Among 104 patients who failed an IAS an average of 5.5 days after hospital admission, PEG was deferred in 60 pending repeat IAS. Younger patients (62.9±13.1 vs 69.3±14.2) and those with lower NIHSS (median 10.5; IQR 5,15 vs median 13.5; IQR 8.0, 20) were more often referred for second IAS (p &lt; 0.05). Improvement in swallow function was seen in 45% of patients on a 2 nd IAS performed an average of 3.9 days after the initial study. Race, but not stroke etiology, stroke severity, stroke location or other clinical factors, was associated with recovery of swallow. The odds (adjusted) of improving on a subsequent evaluation in African Americans (AA) were 5.91 (95% CI: 1.56, 22.40 ) times higher than the odds for Whites. Conclusion: Our study shows that AA race is associated with early improvement in swallow function for reasons that are unclear. There was no association with age, stroke severity, or stroke etiology. Further analysis of factors associated with recovery of swallow is necessary in order to avoid PEG placement in patients with rapid recovery. A follow-up IAS 3-4 days after an initial study should be considered in select patients before PEG placement.

Success of Percutaneous Endoscopic Gastrostomy by Single Balloon Enteroscopy in Patients Who Have Undergone Roux-en-Y Gastric Bypass.

Data is limited regarding the success and safety of percutaneous endoscopic gastrostomy (PEG) placements by single balloon enteroscopy (SBE) in patients with Roux-en-Y gastric bypass (RNY-GB) anatomy. We report on 23 cases of PEG placements by SBE with overall technical success of reaching the excluded stomach 70% and with PEG placement success rate of 69%. No intra-procedural adverse events occurred. This technique seems safe when feasible for PEG placement in patients with RNY-GB anatomy.

Mo1160 Peg Tube Can Be Successfully Placed in Patients on Uninterrupted Dual-Antiplatelet Therapy Without any Complications: Time to Change Clinical Practice

Anti-platelet drugs such as aspirin and clopidogrel can cause increased bleeding by inhibiting the formation of the initial platelet plug. Consequently, anti-platelet therapy is often stopped prior to placement of a percutaneous endoscopic gastrostomy (PEG) tube due to fear of internal bleeding. Current guidelines suggest holding clopidogrel for 5-7 days prior to elective PEG placement. Our study aims to study the experience of our high-volume center (>320 PEGs/year) regarding bleeding episodes after PEG placement in patients on uninterrupted anti-platelet therapy.

Incidence of abdominal wall metastases following percutaneous endoscopic gastrostomy placement in patients with head and neck cancer.

Percutaneous endoscopic gastrostomy (PEG) tubes are an effective modality for enteral nutrition in patients with head and neck cancer; however, there have been documented case reports of "seeding" of the abdominal wall by the theoretic risk of dragging the tube along the tumor during PEG placement. The objective of this study is to determine the incidence and contributing risk factors leading to metastasis to the abdominal wall following PEG placement in patients with head and neck cancer. A retrospective chart review was performed on patients diagnosed with head and neck malignancy who underwent PEG placement between 1/5/2009 and 12/22/2014. Variables collected included development of abdominal wall metastases, type of malignancy and tumor characteristics, smoking history, PEG placement technique, and survival following recurrence. Data were then analyzed for overall trends. Out of 777 patients analyzed, a total of five patients with head and neck malignancy were identified with abdominal wall metastasis following PEG tube placement with an overall incidence of 0.64% over an average follow-up of 27.55months. All of these patients underwent PEG tube insertion via a Pull technique. One patient was found to have a clinically evident and symptomatic stomal metastasis, while the other four patients had radiologically detected metastases either on CT or PET scan. All of the identified patients were found to have stage IV oral cancer at time of initial diagnosis of their head and neck malignancy, followed by widespread distant metastatic disease at time of presentation with their PEG site stomal metastasis. Abdominal wall metastases following PEG placement are a rare but serious complication in patients with head and neck malignancy.

Safety of percutaneous endoscopic gastrostomy tube placement in patients with continuous-flow ventricular assist devices

In this retrospective study, the safety of percutaneous endoscopic gastrostomy (PEG) tube placement was evaluated as maintaining adequate nutritional support for patients with left ventricular assist devices is crucial. Nineteen...

560 Risk of Early Post-Procedure Bleeding With Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Patients Using Clopidogrel

560 Risk of Early Post-Procedure Bleeding With Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Patients Using Clopidogrel

Feasibility and Safety of Overtubes for PEG-Tube Placement in Patients with Head and Neck Cancer.

Background. Percutaneous endoscopic gastrostomy (PEG) placement using the “pull” technique is commonly utilized for providing nutritional support in head and neck cancer (HNC) patients, but it may be complicated by peristomal metastasis in up to 3% of patients. Overtube-assisted PEG placement might reduce this risk. However, this technique has not been systemically studied for this purpose to date. Methods. Retrospective analysis of consecutive patients with HNC who underwent overtube-assisted PEG placement at Westmead Hospital, Australia, between June 2011 and December 2013. Data were extracted from patients' endoscopy reports and case notes. We present our technique for PEG insertion and discuss the feasibility and safety of this method. Results. In all 53 patients studied, the PEG tubes were successfully placed using 25 cm long flexible overtubes, in 89% prophylactically (before commencing curative chemoradiotherapy), and in 11% reactively (for treatment of tumor related dysphagia or weight loss). During a median follow-up period of 16 months, 3 (5.7%) patients developed peristomal infection and 3 others developed self-limiting peristomal pain. There were no cases of overtube-related adverse events or overt cutaneous metastases observed. Conclusions. Overtube-assisted PEG placement in patients with HNC is a feasible, simple, and safe technique and might be effective for preventing cutaneous metastasis.

Safety of percutaneous endoscopic gastrostomy after trauma laparotomy

BackgroundTrauma patients frequently require long-term enteral access because of injuries to the head, neck, or gastrointestinal tract. Noninvasive methods for gastrostomy placement include percutaneous endoscopic gastrostomy (PEG) and percutaneous radiographic gastrostomy (PRG). In patients with recent trauma laparotomy, PEG placement is felt to be relatively contraindicated because of the concerns about altered anatomy. We hypothesize that there is no increased rate of complications related to PEG placement in patients with trauma laparotomy compared with those without laparotomy provided that basic safety principles are followed. Materials and methodsThis retrospective study evaluates all percutaneous gastrostomies (both PEG and PRG) placed in trauma patients admitted at a level I trauma center between January 1, 2007 and March 30, 2010. The electronic medical records of the 354 patients were reviewed through 30 days after procedure, and patients were further subdivided by the history of laparotomy. Statistical analysis was performed using Fisher exact test or two-tailed t-test, as appropriate. ResultsIn patients with no prior trauma laparotomy, successful PEG placement occurred in 92.2% of patients, the remainder underwent PRG placement. Of patients with prior trauma laparotomy, 82.4% had successful PEG placement. Two percent of attempted PEG placements failed in patients with no previous trauma laparotomy, whereas 11.8% failed in patients with recent trauma laparotomy. The overall complication rate was 2.0%, with no recorded complications in patients with trauma laparotomy before PEG placement. ConclusionsThese data suggest that surgeons should not consider recent trauma laparotomy a contraindication to PEG placement.

Percutaneous endoscopic gastrostomy tube placement in left versus right middle cerebral artery stroke: Effects of laterality

Prolonged dysphagia after middle cerebral artery (MCA) territory strokes may require percutaneous endoscopic gastrostomy (PEG) tube feeding. We examined the predictors of PEG placement among patients with MCA stroke. It was hypothesized that stroke laterality was a predictor. A retrospective cohort study of existing data from Hartford Hospital Stroke Database was done. A total of 157 patients with acute ischemic MCA stroke were included. Patients were divided into the "PEG" group (n = 24) and "no PEG" group (n = 133). Existing demographic, clinical and swallowing data were compared between the 2 groups. Demographic data were similar between the groups. The "PEG" group had a higher admission National Institute of Health Stroke Scale (NIHSS) score, higher proportion of patients who had thrombolytic administration, in- hospital aspiration pneumonia and inability to be assessed on first swallow evaluation. Multivariate analysis revealed that all, except thrombolytic administration may predict PEG placement. Admission NIHSS score, in-hospital aspiration pneumonia and inability to undergo first swallow evaluation may predict PEG placement in patients with acute MCA stroke. Stroke laterality was not associated. This knowledge facilitates early identification of patients that may require PEG tube placement for early nutrition provision and discharge to rehabilitation.

New Model for Predicting Surgical Feeding Tube Placement in Patients With an Acute Stroke Event

The need for surgical feeding tube placement after acute stroke can be uncertain and associated with further morbidity. Retrospective data were recorded and compared across patients with acute ischemic stroke and intracerebral hemorrhage. We identified all feeding tubes placed as percutaneous endoscopic gastrostomy (PEG) tubes. A prediction score for PEG tube placement was developed separately for patients with acute ischemic stroke and intracerebral hemorrhage using logistic regression models of variables known by 24 hours from admission. Of 407 patients included, 51 (12.5%) underwent PEG tube placement (25 acute ischemic stroke and 26 intracerebral hemorrhage). The odds of a patient with acute ischemic stroke with PEG score ≥3 of getting a PEG are greater than those with PEG score <3 (odds ratio, 15.68; 95% confidence interval, 4.55-54.01). The odds of a patient with intracerebral hemorrhage with PEG score ≥3 of getting a PEG are greater than those with PEG score <3 (odds ratio, 12.49; 95% confidence interval, 1.54-101.29). The PEG score, comprised by variables known within the first day of admission, may be a powerful predictor of PEG placement in patients with acute stroke.

PWE-177 An Audit to Evaluate the Safety and Efficacy of Percutaneous Endoscopic Gastrostomy (PEG) Placement in Patients with Learning Disabilities

IntroductionGuidelines exist to aid clinicians in selecting patients likely to benefit from percutaneous endoscopic gastrostomy (PEG) placement. Patients with learning disabilities (LD) are distinct from those with dementia in whom...

Abstract WP291: Outcomes and Predictors of Percutaneous Endoscopic Gastrostomy tube placement in Acute Ischemic Stroke versus Intracerebral Hemorrhage

Background: The circumstances for morbidity differ between acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH). The need for Percutaneous Endoscopic Gastrostomy (PEG) tube placement may be associated with further morbidity. This study aims to identify differences in outcomes between AIS and ICH patients who undergo PEG placement. Methods: We conducted a retrospective analysis of patients admitted consecutively within 24 hours of acute stroke to Tulane University Hospital from 07/2008-12/2010. Demographic and clinical data were recorded throughout admission and compared across patients with AIS and ICH using Chi square and t-test with nonparametric tests when appropriate. A prediction score was developed separately for AIS and ICH patients by using 55% of the dataset and tested on the remaining 45%. Associations were further evaluated as potential score variables using logistic regression. ROC curves were used to evaluate the final score. Results: Seventy-six patients who had a PEG placed were identified and included in the analyses (42 AIS and 34 ICH). Of patients with PEG, a greater proportion of ICH patients had dysarthria (p=0.0137) or impaired consciousness (p=0.0018) on admission than AIS patients. Patients with ICH and PEG had more tracheostomy placement (p=0.0216), increased length of stay (8 vs. 6 days; p=0.0005), increased discharge NIHSS Score (21 vs. 3; p&lt;0.0001), and increased discharge modified Rankin Scale (4 vs 3; p&lt;0.0001) compared to patients with AIS and PEG. The odds of an AIS patient with PEG score ≥3 of getting a PEG are greater than those with PEG score &lt;3 (OR 25.806, 95% CI 11.370-58.572). The odds of an ICH patient with PEG score ≥3 of getting a PEG are greater than those with PEG score &lt;3 (OR 4.627, 95% CI 1.839-11.642). Conclusions: The PEG score may be a powerful predictor of PEG placement in patients with acute stroke. Impaired consciousness and dysarthria are significant driving forces in PEG placement in ICH vs. AIS patients.

Early Insertion of Percutaneous Endoscopic Gastrostomy in Patients with Isolated Elevated White Blood Cell Counts

Purpose: Percutaneous Endoscopic Gastrostomy (PEG) is a common procedure for patients with dysphagia. Several large prospective trials for PEG have evaluated the efficacy of the procedure. Traditionally gastroenterologists have been hesitant to perform PEG insertions in patients with elevated white blood cell (wbc) counts. Literature review shows that very few published studies have analyzed the complications of PEG placement in otherwise non infected patients with isolated elevated WBC counts. The aim of our study was to analyze complications of PEG placement in patients with isolated elevated WBC counts as compared to patients with normalized wbc counts at the time of PEG placement. Methods: This was a retrospective cohort analysis of a total of 465 patients, 60 men and 405 women who underwent PEG placement. All patients who underwent PEG placement in IMC and NYMH from January 2005 to June 2010 were included in the study. The patients were followed up for a period of one year following PEG placement. Patients with fever, hematological malignancies or on steroids were excluded. A cut off value of 11,000/ml WBCs or above was considered elevated in the study. Patients in group 1 had elevated WBC counts at PEG insertion and patients in group 2 had normal WBC counts. All patients in this study were free from active infections at the time of surgery. This was supported by clinical, laboratory, microbiological and radiologic data obtained from chart review. All patients received preoperative antibiotics as short-term prophylaxis. The data was analyzed using IBM SPSS 20.0. The comparisons between the groups were made using student's t test, Chi-square test and ANOVA. Results: There was significant reduction of 5.19 days in the length of hospital stay with early insertion of PEG (p 0.03). There was no statistically significant increased risk of complications with early insertion of PEG in the presence of isolated elevated WBC counts. There were no cases of severe complications including necrotizing fasciitis, esophageal perforation, colocutaneous fistula, peritonitis, ileus, gastric outlet obstruction or death secondary to PEG placement in either group. Conclusion: In our study, there was no evidence of increased complications or mortality related to early PEG placement in patients with isolated elevated WBC counts. Therefore it is reasonable to consider early PEG placement in patients with isolated elevated wbc counts rather than delaying the PEG procedure for WBC counts to normalize. In our study, early insertion of PEG led to reduction in the average length of hospital stay by 5.19 days (p 0.03). This can lead to substantial reduction in health care costs. Further prospective studies are needed to confirm our findings.Table: Results of PEG placement in isolated elevated wbc counts vs normalized wbc counts

Percutaneous Endoscopic Gastrostomy Complication Rates and Compliance With the American Society for Gastrointestinal Endoscopy Guidelines for the Management of Antithrombotic Therapy

The American Society for Gastrointestinal Endoscopy (ASGE) has published recommendations in regards to anticoagulant (AC) and antiplatelet (AP) therapy management during endoscopic procedures. So far, no study has assessed either ASGE recommendation compliance during percutaneous endoscopic gastrostomy (PEG) placement or procedure-associated complication rates as related to the observance of these recommendations. The aims of this study were to compare the incidence and type of complications during PEG placement in patients receiving or not receiving AC and/or AP therapy and to determine the compliance with ASGE's AC and AP management guidelines. Medical files of patients who underwent PEG placement from January 2004 to December 2008 were reviewed. Clinical and procedure-related data were recorded. Patients were separated into 1 of 2 groups: patients under AP and/or AC therapy prior to PEG placement (n = 51) and a control group of patients (n = 40) not receiving any AP and/or AC treatment at least 6 months prior to the procedure. A total of 91 patients (51 cases) were included. Groups were comparable in demographics and clinical characteristics. No differences in the frequency and type of complications were found between groups. ASGE's recommendations were not followed in any of these patients. Overall PEG placement complication rate was 13.7%. AP therapy may be safely discontinued closer to the time of endoscopic procedure than the time currently recommended by the ASGE guidelines.

Enteral nutrition in patients with dementia and stroke

Patients suffering from dementia or significant cognitive impairment (SCI) due to neurologic injury routinely receive percutaneous endoscopic gastrostomy (PEG) due to swallowing difficulty or lack of appetite. This review discusses current data and opinion regarding the risks and benefits of PEG in these populations. The current data regarding PEG placement in patients with dementia or SCI due to neurologic injury do not confirm either improvement or worsening of survival. Significant risk factors for poor prognosis after PEG include sex, hypoalbuminemia, age, chronic heart failure, and subtotal gastrectomy. Complications associated with enteral nutrition are minor and easily controlled when managed by a nutritional team. Alternative options for feeding elderly demented patients are available for family members considering PEG. In contrast to previously published data regarding worse clinical outcomes in the dementia and SCI populations receiving PEG, recent data suggest that clinical outcomes in this population are no different than in other patient populations receiving PEG. A prospective, randomized study is needed to ascertain whether PEG is appropriate and beneficial in the dementia/SCI populations.

Is percutaneous endoscopic gastrostomy tube placement safe in patients with ventriculoperitoneal shunts?

To investigate whether percutaneous endoscopic gastrostomy (PEG) tube placement is safe in patients with ventriculoperitoneal (VP) shunts. This was a retrospective study of all patients undergoing PEG insertion at our institution between June 1999 and June 2006. Post-PEG complications were compared between two groups according to the presence or absence of VP shunts. VP shunt infection rates, the interval between PEG placement and VP shunt catheter insertion, and long-term follow-up were also investigated. Fifty-five patients qualified for the study. Seven patients (12.7%) had pre-existing VP shunts. All patients received prophylactic antibiotics. The complication rate did not differ between VP shunt patients undergoing PEG (PEG/VP group) and non-VP shunt patients undergoing PEG (control group) [1 (14.3%) vs 6 (12.5%), P = 1.000]. All patients in the PEG/VP group had undergone VP shunt insertion prior to PEG placement. The mean interval between VP shunt insertion and PEG placement was 308.7 d (range, 65-831 d). The mean follow-up duration in the PEG/VP group was 6.4 mo (range, 1-15 mo). There were no VP shunt infections, although one patient in the PEG/VP group developed a minor peristomal infection during follow-up. Complications following PEG placement in patients with VP shunts were infrequent in this study.

Racial Disparities in Utilization and Timing of Percutaneous Endoscopic Gastrostomy (PEG) Placement in 21,558 Noncancer Medicare Patients with Alzheimer's Dementia

Background: PEG placement is a common method for delivering artificial nutrition and hydration (ANH) to patients with Alzheimer's dementia who are unable to sustain sufficient oral intake. We have previously shown that the incident rate of PEG placement has nearly tripled from 1992 to 2003. It is unclear whether racial differences impact on the timing and utilization of PEG placement. Objective: To describe racial characteristics associated with PEG placement in patients with Alzheimer's dementia.