Percutaneous Endoscopic Gastrostomy Site Research Articles

Factors Associated With Short-Term Complications After Percutaneous Endoscopic Gastrostomy Tube Insertion: A Retrospective Cohort Study.

Percutaneous endoscopic gastrostomy (PEG) tube placement is generally safe but is associated with a range of complications. Minor complications include infections, granuloma formation, leakage, and blockages, while major complications encompass aspiration pneumonia, hemorrhage, and more serious conditions such as necrotizing fasciitis and colonic fistula. This study aimed to assess the rate of short-term complications within one month of endoscopic PEG insertion, focusing on their correlation with patient characteristics. This retrospective cohort study analyzed data from patients who underwent PEG insertion between January 2020 and December 2022. It evaluated the incidence of complications in relation to variables such as the indication for the procedure, the patient's immune status, albumin and CRP levels, and the setting of the procedure (inpatient vs. outpatient). The study included 121 patients, with a mean age of 69.73 years, comprising 71 males (58.7%) and 50 females (41.3%). Neurological indications accounted for 64.5% of the cases. Notably, 67.8% of the patients were immunocompromised. Within 30 days of PEG insertion, 16.5% experienced complications, including GI bleeding (4.1%), infection at the PEG site (11.6%), and peritonitis (0.8%). Complications were significantly higher in immunocompromised patients and those with non-neurological indications. Higher serum albumin and lower CRP levels were associated with fewer complications, though the association was not statistically significant. The study highlights that gastrostomy site infection is the most common short-term complication following PEG insertion. Immune status and the reason for PEG insertion emerged as key factors influencing the likelihood of complications.

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY RESULTS IN A SECONDARY STATE HOSPITAL

Introduction: The aim of this study was to determine the indications of Percutaneous endoscopic gastrostomy (PEG) patients treated in a secondary state Burdur hospital over a period of three years, the unit where the patient was hospitalized, survival time with PEG therapy, and the complications observed in these patients. Methods: Patients who underwent PEG in the endoscopy unit of our hospital, between January 2019 and January 2022, were retrospectively evaluated. Age, gender, the unit of inpatient, indications for PEG therapy, complications after PEG, and survival status of the patients were recorded in the form of case reports. Patients with coagulation disorders, hemodynamic instability, peritonitis, sepsis, infection at the insertion area, peritonitis carcinomatosis, a history of total gastrectomy and gastric varices were excluded. Results:The median age of the 120 patients included in the study was 79 (17–100) years, and 66 (55%) of the patients were male. Complications were observed in 14 (11.7%) patients, all of which were minor, including seven (5.8%) PEG site infections, three (2.5%) PEG site leakages, three (2.5%) PEG occlusions, and one (0.9%) PEG removal. It was determined that 73 (60.8%) patients survived at least 30 days; the patients were most frequently referred by the neurology unit, with a rate of 52.7%. The most common indications for PEG insertion were cerebrovascular disease (56.7%) and dementia (29.2%). Conclusion: Maintenance of nutritional requirements via PEG allows for the preservation of mucosal integrity and barrier function, intestinal immune response, and normal flora. It is superior to other enteral feeding methods due to the lower risk of aspiration. In conclusion, our study, which presented the experiences of the PEG insertion and therapy in a secondary state hospital, stated that the complication rates, indications, and referring clinics were found to be consistent with available literature.

S2569 Bleeding From Peg Tube Insertion Site due to a Gastroepiploic Artery Pseudoaneurysm

Introduction: Percutaneous endoscopic gastrostomy (PEG) is generally regarded as a safe procedure with rare complications. Gastroepiploic artery aneurysms (GEAAs) are extremely rare with only 22 cases reported in the literature and constituting 3-4% of all splanchnic artery aneurysms. GEAAs carry a mortality rate of 70% due to a 90% rate of rupture and can lead to complications like hemorrhagic shock. Therefore, early detection and management is necessary for survival. Case Description/Methods: A 55-year-old male with PEG tube placed for ALS-associated dysphagia presented with bleeding around the PEG tube site 10 days after placement. He was admitted twice for the complaint. On his first admission, EGD was normal and it was suspected that he had bleeding subcutaneously around the PEG site that self-resolved. He was discharged but promptly returned the next day with profuse bleeding around PEG tube. Emergent repeat EGD was again negative. This time, the diagnosis was confirmed with CTA of the abdomen that demonstrated a branch of the gastroepiploic artery that had an 8mm pseudoaneurysm. Interventional radiology successfully performed US-guided thrombin injection with successful thrombosis of the pseudoaneurysm. The patient’s PEG site bleeding stopped, and patient successfully discharged. Discussion: Gastric bleeding following PEG tube placement is rare and usually occurs secondary to injury of the small gastric vessels. Due to the rotated configuration of stomach, caution should be exercised when penetrating during the PEG insertion. The gastroepiploic artery (GEA) runs along the greater curvature and may be injured during PEG tube placement although this is rare. The bleeding in our patient was due to a pseudoaneurysm of the GEA as evident from CT scan. GEA peudoaneurysms are a very rare complication that occur due to iatrogenic injury to the artery. GEA pseudoaneurysms can present as abdominal pain, bleeding, and even shock due to intraperitoneal hemorrhage. Due to the risk of fatal bleeding by GEA pseudoaneurysms, early detection and management is needed. Our patient was treated with percutaneous thrombin injection leading to resolution of bleeding. Other treatment options include trans arterial embolization and more invasive including surgical repair. Systemic embolization is the main complication of thrombin injection and can be prevented by placing the needle tip away from the neck of the pseudoaneurysm. (Figure).Figure 1.: A (axial) and B (sagittal): Arrows represent a small 8 mm pseudoaneurysm off of the gastroepiploic artery at the level of the gastrostomy tube insertion site.

Percutaneous endoscopic gastrostomy using the introducer method with ultra-slim endoscopy in amyotrophic lateral sclerosis patients with respiratory compromise: A safe technique.

Percutaneous endoscopic gastrostomy (PEG) placement is recommended in patients with amyotrophic lateral sclerosis (ALS), but the procedure is considered high risk. In this study, we aimed to compare the outcome of ALS patients with and without PEG. The success of the procedure and complications of PEG insertion were also explored. Patients with ALS who met the criteria for enteral feeding support were consecutively recruited. Patients who consented had PEG insertion using the modified technique of introducer method with transoral ultra-slim endoscopy. A total of 64 patients were recruited, of which 36 (56%) patients consented to PEG. The median age of all patients was 65years and 59% were male. There was no difference in demographic and clinical characteristics between patients who agreed to a PEG and those who did not. The mortality rate at 6 and 12months was lower in the PEG cohort compared with non-PEG, but this was not statistically significant (6months: 28.6% vs 32.2%, P=0.561; 12months: 38.9% vs 50.0%, P=0.374). Amongst the PEG cohort, 61% were stratified high risk and 31% moderate risk. Thirty-one percent of them required long-term home noninvasive ventilation. All patients (100%) underwent successful PEG insertion at single attempt using the modified approach. The complications reported over a period of 6months were infected PEG site (17%), dislodged gastrostomy tube (14%), and minor bleeding (8%). In ALS patients with moderate to high risk of PEG insertion, the introducer technique utilizing ultra-slim endoscopy guidance was well tolerated and safe.

A multidisciplinary approach to reducing percutaneous endoscopic gastrostomy tube site infections within 30 days of placement

Percutaneous endoscopic gastrostomy (PEG) site infection is a known complication of PEG tube placement. Whilst difficult to know the true incidence of PEG site infections as rates vary1, it is thought that infection rates fluctuate between 5% and 25%2. Thirty day infection rates form part of an annual audit of PEG insertions at a large District General Hospital (DGH). The mean infection rate from 2018-2019 was 11.8%. In 2020, it was concerning to note that the infection rate rose to 41% (16 out of 39 cases) which led to a multidisciplinary process review.

S2208 Primary Squamous Cell Carcinoma as a Long-Term Complication of Percutaneous Endoscopic Gastrostomy Placement

Introduction: Common complications associated with percutaneous endoscopic gastrostomy (PEG) placement include aspiration, bleeding, leakage, irritation, abdominal pain, and infection. Previous case reports have described the PEG site as a location for metastatic malignancy, especially in the setting of head and neck cancers (often an indication for PEG placement). We present a rare case of primary squamous cell carcinoma (SCC) which developed in the setting of long-term PEG placement. Case Description/Methods: Patient is a 51-year-old woman with developmental delay and dystonia secondary to DYT1 gene mutation. Given her developmental delay, a PEG was placed for nutritional support and had been in place for thirty-two years. She presented with a 2-cm abscess at her PEG site and was discharged with oral antibiotics following incision and drainage (I+D). She noted persistent leakage of bloody and foul-smelling drainage from her PEG tube (figure 1). She returned with worsening irritation surrounding the PEG site and was noted to have a 5x7 cm area of erythema with overlying fluctuant abscess. Again, she underwent I+D and was started on IV antibiotics. Cross sectional imaging demonstrated irregular soft tissue thickening involving the greater curvature of the stomach, adjacent to the PEG site, extending into the gastrostomy tube tract. A biopsy of the skin surrounding the PEG tube was performed and demonstrated well-differentiated and invasive SCC. A subsequent PET scan showed locally invasive disease with PEG site involvement extending into the abdominal wall. There were no additional areas concerning for malignancy (no indications of an alternative primary site). Given the burden of locally invasive disease, surgical resection was deferred and she was offered palliative radiation. Discussion: The development of SCC at the PEG site is an uncommon occurrence and previous case reports typically describe these events as metastasis from a head/neck primary site. There has been at least one additional documented case of primary SCC at the PEG site but this occurred in an immunosuppressed patient. Chronic irritation of the skin, which is a known complication of PEG placement, possibly contributed to the development of SCC in this patient. Aggressive wound care and close monitoring for suspicious mucosal changes should be considered in patients with long-term PEG placement.Figure 1.: Squamous Cell Carcinoma along the PEG site.

Clinical characteristics and pathogens in percutaneous endoscopic gastrostomy site infection in patients with head and neck cancer: A 16-year retrospective study.

ObjectivesWound infection is the most common complication associated with percutaneous endoscopic gastrostomy (PEG) placement, with an incidence between 4% and 30%. In this study, we compared the characteristics of PEG site infection between the head and neck cancer (HNC) group and the non‐HNC group.MethodsThis study was conducted at Kangdong Sacred Heart Hospital at the Ilsong Head and Neck Cancer Center. We retrospectively collected and analyzed data on patients who underwent PEG insertion from October 2003 to May 2019 to evaluate the risk factors and microbiological etiologies of PEG site infection.ResultsA total of 316 (HNC group [n = 129] and non‐HNC group [n = 187]) patients undergoing PEG insertion were included in this study. Moreover, 67 episodes of PEG site infection were diagnosed, with an overall prevalence of 21.2%. PEG site infections were significantly higher in the HNC group than in the non‐HNC group (32.6% vs 13.4%, P <.001). Pseudomonas aeruginosa is the most common pathogen associated with a PEG site infection. Multidrug‐resistant (MDR) P aeruginosa was more frequent in the HNC group than in the non‐HNC group (78.6% vs 25.0%, P = .006).ConclusionsFor appropriate treatment, P aeruginosa, especially MDR P aeruginosa, should be considered when selecting empirical antibiotics for PEG site infection in patients with HNC.Level of Evidence: 4

Bleeding Risk and Mortality Associated With Uninterrupted Antithrombotic Therapy During Percutaneous Endoscopic Gastrostomy Tube Placement.

Antithrombotic therapy is often interrupted before the placement of a percutaneous endoscopic gastrostomy (PEG) tube because of potentially increased risk of hemorrhagic events. The aim of our study was to evaluate the risk of bleeding events and overall complication rates after PEG in patients on uninterrupted antiplatelet and anticoagulation therapy in a high-volume center. Data regarding demographics, diagnoses, comorbidities, and clinical outcomes pertinent to PEG were collected from 2010 to 2016. Furthermore, data regarding antithrombotic therapy along with the rate of minor or major complications including bleeding associated with this procedure were analyzed. Significant bleeding was defined as postprocedure bleeding from PEG site requiring a blood transfusion and/or surgical/endoscopic intervention. We included 1,613 consecutive PEG procedures in this study, of which 1,540 patients (95.5%) received some form of uninterrupted antithrombotic therapy. Of those patients, 535 (34.7%) were on aspirin, 256 (16.6%) on clopidogrel, and 119 (7.7%) on both aspirin and clopidogrel. Subcutaneous heparin was uninterrupted in 980 (63.6%), intravenous heparin in 34 (2.1%), warfarin in 168 (10.9%), and direct-acting oral anticoagulation in 82 (5.3%) patients who overlapped on multiple drugs. We observed 6 significant bleeding events in the entire cohort (0.39%), and all were in subcutaneous heparin groups either alone or in combination with aspirin. No clinically significant bleeding was noted in patients on uninterrupted aspirin, warfarin, clopidogrel, or direct-acting oral anticoagulation groups. Only 5 patients (0.31%) had PEG-related mortality. The risk of significant bleeding associated with the PEG placement was minimal in patients on uninterrupted periprocedural antithrombotic therapy.

Laryngeal carcinoma experimental model suggests the possibility of tumor seeding to gastrostomy site

Some studies state that laryngeal squamous cell carcinoma (LSCC) is associated with possible direct tumor cell seeding to percutaneous endoscopic gastrostomy (PEG) site. However, there is a lack of experimental proof that LSCC tumor tissue can adhere and grow in distant sites. Therefore, we aimed to investigate the growth pattern of LSCC implants on chicken embryo chorioallantoic membrane (CAM) and evaluate possible associations between clinical course of the disease and behavior of experimentally implanted LSCC tumors. Our results show that implanted LSCC tissue survives on CAMs in 95% of cases while retaining essential morphologic characteristics and proliferative capacity of the original tumor. We identified the increased CAM vascularization, an infiltrative growth pattern of the implant and formation of distant isolated metastatic nodes on the CAMs. LSCC tumors with worse differentiation degree (G2 or G3) adhered to the experimental CAMs significantly better than G1. These results facilitate the understanding of tumor biology and allow hypothetisezing that dissemination and direct implantation of LSCC cells into the stomal wall during the pull PEG procedure might be possible.

Percutaneous endoscopic gastrostomy: A prospective study

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure for establishing enteral access for nutrition. There is a paucity of literature on PEG from the Indian subcontinent. With the rate of complications in the literature showing a downward trend, we aimed to analyze the same in our institute following a standard procedure of PEG tube placement. Methods: The prospective study was conducted including patients referred for PEG placement from August 2017 to December 2019. Data were recorded on a proforma. The primary aim of the study was to determine the rate of complications in patients undergoing PEG, whereas the secondary aim was to determine whether early feeding was associated with increased rate of infection or other complications. Patients were reviewed after 3 days, 1 month, and every 3 months thereafter later with clinical examination. Results: Sixty-seven (83.75%) males and 13 (16.25%) females with a median age of 51 years (range 1–85) were included in the study. Forty-one (51.25%) patients had comorbidities with hypertension being the most common (n = 28). Postoperative placement of the PEG tube was done in 47 (58.75%) patients. Seventy-four patients had underlying neurological or neurosurgical conditions. At the time of PEG placement, 59 (73.75%) had tracheostomy. All procedures were performed in the endoscopic suite, of which two were performed as day care procedures. There were no intraprocedural complications. Feed was started within 2 h in 45 (56.25%) patients and all tolerated feed well. There were no major postprocedural complications. Thirteen patients had clinically suspected PEG site infection, of which 11 patients had a culture-positive organism. All responded to conservative management. Thirty-two patients were on follow-up at a median follow-up period of 2 years. Conclusion: The incidence of complications following PEG tube placement is low. With the standardization of the PEG technique, no major complications were seen in our study. Early PEG feeding was not associated with an increase in the rate of complications.

Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG)—Single-Center Experience and Outcome

AbstractBackground Gastrointestinal route is considered for feeding in subjects who are unable to swallow, either as a temporary or permanent option. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode for long-term enteral nutrition. The aim was to study the outcome of protocol-based PEG placement in a tertiary medical center.Materials and Methods All the patients who underwent PEG placement between January 2017 and December 2019 were included in the retrospective study. Study variables were entered into a uniform structured proforma. The procedure was done by two people using Ponsky-Gauderer pull-technique. Fluoroscopy guidance was considered for placement in special situations. Post-procedure, all the patients were regularly followed as per protocol to evaluate for adverse events.Results One hundred and eighteen patients with placement of PEG were included in the study. The mean age of the patients was 49.6 ± 7 years with 67.8% males. The most common indication of PEG was inability to swallow associated with head injury (43, 36.4%), followed by carcinoma esophagus (35, 29.8%) and stroke (24, 20.3%). Fluoroscopy was useful in 38 (32%) for PEG site identification. Tube dislodgement (16, 13.5%) and aspiration pneumonia (20, 16.9%) were the common adverse events. Age more than 60 years and dysphagia in neurologic disorders accounted for more than 60% of adverse events. Forty-nine (42%) of the PEG patients expired due to either primary illness or due to sepsis after a median time of 139 days (range: 32–288 days). There was no difference in the survival in patients with or without PEG-related complications (p = 0. 74).Conclusions Fluoroscopy assistance helps in accurate PEG placement in one third. Age &gt; 60 years and dysphagia in neurologic disorders were independent risk factors associated with PEG tube complications.

An Unusual Cause of Esophageal Mass and Bleeding

Question: A 63-year-old man with a history of human immunodeficiency virus infection on antiretroviral therapy, syphilis (treated with penicillin), dysphagia percutaneous endoscopic gastrostomy tube placement, presented for esophagogastroduodenoscopy for the evaluation of worsening anemia and coffee ground gastric aspirate from percutaneous endoscopic gastrostomy site. Of note, 3 months ago patient had presented with upper gastrointestinal (GI) bleeding and was found to have severe esophagitis (negative for metaplasia or dysplasia) with a bleeding site which required Endoclip placement.

General principles for the prevention and treatment of complications of percutaneous endoscopic gastrostomy (review of literature)

We considered the views of researchers presented in the modern literature on both the problem as a whole and discussion questions regarding the causes of development, preventive measures, and methods of treating percutaneous endoscopic gastrostomy complications, such as clogging of the gastrostomy tube, peristomal wound infections, necrotic fasciitis, pneumoperitoneum, buried bumper syndrome, growth of granulations in the gastrostomy zone, postoperative bleeding and intraparietal hematoma of the gastric wall, traumatic dislocation of the gastrostomy tube, peritonitis after percutaneous endoscopic gastrostomy, peristomal leakage, сolonic fistula, liver injury and abdominal wall metastasis at the percutaneous endoscopic gastrostomy site.

Pneumoperitoneum and PEG Dislodgement Secondary to Noninvasive Ventilation after PEG Tube Placement

We present a previously undescribed complication after noninvasive ventilation (NIV) for respiratory failure in a patient who required percutaneous endoscopic gastrostomy (PEG) tube placement for long-term nutrition after a complicated coronary bypass operation. A 54-year-old female diagnosed with unilateral vocal cord paralysis after emergent coronary artery bypass grafting (CABG) underwent an uncomplicated PEG tube placement. She was placed on intermittent NIV because of respiratory failure 24 hours after PEG placement, and NIV was continued for several days. Three days later, she was noted to have pneumoperitoneum on an upright chest X-ray. Abdominal CT scan revealed a large amount of pneumoperitoneum with the PEG tube in the correct position and no extravasation of enteric contrast from the stomach. Tube feeds were held and NIV was discontinued. Nonetheless, six days later, the patient was found on CT scan to have partial displacement of the PEG tube with leakage from the gastrotomy requiring operative repair. This case highlights the vulnerability of PEG tubes to management practices in the early postoperative period. Abdominal distention secondary to NIV likely caused pressure necrosis of the PEG site with dislodgement of the tube. This case elicits considerations regarding future management practices of patients receiving NIV in the early postoperative period after PEG placement.

2006 Epigastric Artery Aneurysm Bleeding Post-Percutaneous Endoscopic Gastrostomy

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is commonly used to provide enteral nutrition in patients unable to maintain adequate nutrition orally. There is limited data on aneurysmal bleeding following PEG. When this occurs, it is typically severe and is a life-threatening complication leading to hemorrhagic shock. Prompt recognition and treatment are imperative to survival. Extensive literature review revealed five case reports of post-PEG pseudoaneurysm. We present a summary of reported cases and their respective management. CASE DESCRIPTION/METHODS: We present a case of a 50-year-old female, status post orthotopic liver transplant, who had a complicated post-op course and ICU stay. The patient developed a cerebral infarct in Pons region which led to dysphagia. Therefore underwent PEG tube placement by “pull” technique. Later on, the patient experienced recurrent episodes of PEG site bleeding. She underwent EGD which showed massive upper GI bleed from percutaneous endoscopic gastrostomy fistula tract. Hemostasis was initially achieved using bear claw but also required endoclips and surgical intervention in the end. CT imaging revealed a pseudoaneurysm at the PEG site within the rectus muscle, arising from the epigastric artery, measuring 19.8 mm × 17.8 mm. It was treated with thrombin injection. The resolution of aneurysmal bleed was confirmed on follow up imaging. DISCUSSION: We found 5 similar cases with patients 70 to 85 years old, who predominantly had a pull technique PEG tube placement. Imaging confirmed gastrostomy site pseudoaneurysm, involing left gastric or gastroepiploic artery, was a complication in all cases which were either treated by lipiodol injection, angiographic embolization and/or thrombin injection. Our patient had a pseudoaneurysm involving epigastric artery which is a novel presentation. Placement of PEG with transillumination carries a risk of rare complication if inserted in an upper triangle involving superior epigastric artery. Therefore an attempt must be made to keep PEG away from the superior epigastric triangle. Pull technique is used much more commonly and It is unlikely to be the cause of these aneurysmal complications however, data is limited and more review studies are needed. Also, more evidence is needed to compare outcomes of the transillumination method vs US/fluoroscopic guidance placement.

2743 Tumor Seeding at Gastrostomy Site Secondary to Percutaneous Endoscopic Gastrostomy Placement in Esophageal Squamous Cell Carcinoma

INTRODUCTION: Insertion of a percutaneous endoscopic gastrostomy (PEG) tube in many patients with oropharyngeal and esophageal cancer is standard of care to ensure enteral feeding. The most commonly applied pull-through insertion technique involves direct contact with the tumor. We present a case of direct invasion of tumor through stomach wall attributed to PEG tube placement via pull technique. CASE DESCRIPTION/METHODS: A 72-year-old female with squamous cell carcinoma of esophagus undergoing chemotherapy and radiation, s/p PEG tube placement, was hospitalized for femur replacement after a fracture of her right femur secondary to a minor fall. GI service was consulted for severe irritation visualised around the PEG site. Patient reported that her dysphagia symptoms had much improved owing to ongoing treatment, so she had not used her PEG in a few weeks. Physical exam revealed tenderness to deep palpation in left upper quadrant. External bolster of the PEG tube was noted at 7cm with purulent drainage, sloughed skin and erythema at the insertion site. She was started on broad spectrum antibiotics and CT scan was obtained to evaluate for deep infection which reported a superficial ulcerating wound with an 8.1 × 4.1 cm soft, tissue lesion along the track of the PEG tube concerning for seeding along the surgical tract. It extended from the skin to the greater curvature of stomach with loss of fat plane concerning for direct invasion. Biopsies from the gastrostomy site and right femur revealed squamous cell carcinoma. Direct seeding through the stomach wall at the time of PEG tube placement was the working diagnosis. Decision of not removing the PEG tube was made given extensive tumor at site and concern for non-healing fistula formation. DISCUSSION: Cancer metastatic to a PEG tube exit site is a dreaded complication with carcinoma of the upper aerodigestive tract. Rare reports in medical literature regarding increased risk of developing seeding from the "pull-through" technique of PEG tube placement. Use of laparoscopic, open, or the "push" technique of PEG tube placement in patients with head and neck cancer may prevent direct implantation of malignant cells into an enteral access site. Management involves multi-disciplinary approach with treatment options including radiation, resection of site and chemotherapy. However, our case further emphasizes the importance of avoiding techniques that may put patients at risk for a, albeit rare, disease and life altering complication.

Incidence of Percutaneous Endoscopic Gastrostomy Site Wound Infection among Frail Elderly Patients Admitted in a Tertiary Medical Center

Nutrition is an important determinant of health in elderly patients. It also contributes to their overall quality of life and longevity. Percutaneous endoscopic gastrostomy (PEG) tube is used to provide enteral access in patients who are unable to swallow to improve nutrition.

Pre-operative percutaneous endoscopic gastrostomy tube placement does not increase post-operative complications or mortality in oesophageal cancer.

The percutaneous endoscopic gastrostomy (PEG) tube in patients with oesophageal cancer is controversial, owing to a perceived risk of tumour seeding at the PEG site, theoretical difficulty in formation of gastric conduit during oesophagectomy and a fear of increased post-operative complications, including anastomotic leak. We aimed to assess the impact of PEG tubes on nutritional status and post-operative complications in patients with oesophageal cancer who underwent PEG tube insertion prior to neo-adjuvant treatment. We performed a retrospective review of 800 patients with oesophageal or gastro oesophageal junction (GOJ) cancer, who underwent PEG insertion from June, 2010 to May, 2015. Out of these, 168 patients who fulfilled the inclusion criteria were analysed further. All of them were followed up for 3 years after treatment to assess overall survival. Thus, the follow up of the last patient included in the study was completed on May, 31, 2018. The average body mass index (BMI) of patients was maintained following PEG tube, during neo-adjuvant treatment (22.34±4.84 before PEG vs. 21.85±3.90 after PEG, P value: 0.1). Out of 168 patients, 33 (19.7%) developed a complication following PEG tube, with PEG site infection as the most common in 24 (14.2%). PEG-related mortality at 1 month was 0%. Ninety out of 168 patients (59%) underwent surgery after neo-adjuvant treatment. Three patients had tumour seeding at the PEG site and thus surgery could not be performed. Gastric conduit formation was possible in all 99 patients. Postoperative complications were seen in 17/99 (17%) patients, including surgical site infections in 7 (7.07%), anastomotic leak in 6 (6.06%) and anastomotic stricture in 4 (4.04%). Overall survival at 3 years was 87%. Pre-operative PEG tube in oesophageal cancer is safe and does not compromise the future anastomosis. Also, it helps in maintaining the nutritional status during neo-adjuvant treatment.

Prediction of risk of adverse events related to percutaneous endoscopic gastrostomy: a retrospective study

Background:Percutaneous endoscopic gastrostomy (PEG) is a popular method for long-term enteral feeding. Our aim was to determine potential risk factors for adverse events related to PEG, as well as consequent prolonged hospitalization.Methods:Data were retrospectively collected from the admission records of a tertiary center between July 2015 and June 2018. Possible predictors of the 3 following outcomes were evaluated: minor PEG-related adverse events, major PEG-related adverse events, and length of hospital stay. Data were tested for correlation using the Spearman coefficient and for association using Kruskal-Wallis tests for significance.Results:A total of 362 admissions involving 146 patients were included in the study. Of the admissions, 221 (61.0%) had only minor adverse events, 100 (27.6%) had only major adverse events, and 41 (11.3%) had both. Eighty (22.1%) had PEG-site infection and 128 (35%) had aspiration pneumonia. Serum albumin levels at presentation were negatively correlated with the length of hospitalization (P<0.001), which also differed between patients presenting with major and minor adverse events (P<0.001 and P=0.026). The Charlson comorbidity index was positively correlated with the duration of hospitalization (P<0.001). Higher index scores were found more among patients presenting with aspiration pneumonia (P=0.004) and lower scores were found among patients presenting with PEG site infection and inadvertent PEG removal compared with those presenting with a major complication (P<0.001).Conclusion:The patient’s general medical condition and nutritional status are the greatest risk predictors for developing adverse events related to their PEG feeding, as well as a consequent extended hospital stay.

Percutaneous endoscopic gastrostomy site infections-Incidence and risk factors.

Percutaneous endoscopic gastrostomy (PEG) placement is the modality of choice for long-term enteral nutrition in view of technical ease and cost-effectiveness. Peristomal infection (PI) remains the most common complication following PEG tube placement. The aim of this study was to assess the incidence and risk factors for PI and outline a microbiological profile that can aid in prophylactic and therapeutic strategies. A retrospective study of 781 patients who underwent PEG placement (Cook PEG-Pull-S-20Fr/24Fr) from 2010 to 2015 at our tertiary care center were included. Relevant data were collected from the hospital electronic medical records. The incidence of PI was computed and potential risk factors were assessed using univariate analysis. The microbiological profile was created along with sensitivity patterns after reviewing the culture reports. Statistical analysis was performed using SPSS version 20.0. PEG tube placement was performed in 781 patients (mean age 55.9 ± 36.1; M:F = 2:75). The major indication was oropharyngeal malignancies. PI was seen in 171 patients (21.9%). Diabetes mellitus, duration of hospital stay more than 7days, and hypoalbuminemia were found to be significant risk factors for the development of PI (p < 0.05). Patients who had chemotherapy or radiotherapy before PEG placement had a higher incidence of peristomal infections (p 0.00). Pseudomonas and Klebsiella were the most common organisms causing infection. PI remains a significant complication of PEG placement. Pseudomonas and Klebsiella are the most common organisms and prophylactic antibiotic protocols should be tailored accordingly. Elective PEG before the institution of chemotherapy/radiotherapy in patients with oropharyngeal malignancies is recommended.