Percutaneous Endoscopic Gastrostomy Site Research Articles

Percutaneous Endoscopic Gastrostomy Sites Infected by Methicillin-resistant Staphylococcus aureus: Impact on Outcome

The impact of methicillin-resistant Staphylococcus aureus (MRSA) colonization of percutaneous endoscopic gastrostomy (PEG) sites on morbidity and mortality is uncertain. We investigated the impact of known prior MRSA colonization on the incidence of symptomatic PEG site wound infection and mortality. Consecutive patients who had PEG tubes inserted recently at our hospital were identified. The presence or absence of MRSA colonization before PEG placement was noted. Patients were observed for wound infection, and swabs were taken from the site if there was clinical infection. Mortality within 30 days of PEG placement was determined. A total of 83 patients underwent PEG placement; 23 (28%) of these patients had known MRSA colonization before PEG placement. Of these, 13 (57%) developed symptomatic MRSA infection of the PEG site. The remaining 60 patients (72%) had no known prior MRSA colonization. In these patients, 9 (15%) developed symptomatic MRSA infection of the PEG site. The overall incidence of wound infection was 37% (31) of the total undergoing PEG placement, of whom 71% (22) had developed MRSA infection. The mortality of those with symptomatic MRSA infection of the PEG site was 9% (2/22), whereas the mortality from non-MRSA-infected PEGs was 20% (12/61). Patients with prior MRSA colonization had a significantly higher risk of developing symptomatic MRSA infection of the PEG site. However, there was still a significant risk (15%) of developing MRSA infection of the PEG site for patients with no known prior MRSA infection. MRSA infection of the PEG site did not affect mortality.

Care and Long‐Term Maintenance of Percutaneous Endoscopic Gastrostomy Tubes

Placement of a percutaneous endoscopic gastrostomy (PEG) tube creates a controlled perforation of a hollow viscous organ and an acute surgical wound. Physicians who place PEG tubes endoscopically or fluoroscopically often do not have the opportunity to provide these patients with long-term follow-up care. Thus, nutrition support specialists who do treat these patients may be the one member of the health care team who is in the most advantageous position for ongoing inspection and maintenance of the access device. Carefully monitored surveillance and adherence to routine principles of wound care assure the health of the skin, the underlying tissue, and the tract into the abdominal cavity through which the PEG passes. Having knowledge of the types of tubes placed, performing a regular physical examination of the PEG site, and maintaining good communication with the endoscopist results in early identification of problems, promotes rapid simple strategies to correct deficiencies, and the opportunity to minimize long-term complications. Dietitians, wound-care ostomy nurses, and other nutrition support specialists are encouraged to be more proactive with their participation in the care and management of the PEG site.

REDUCING THE RISK OF PERISTOMAL INFECTION AFTER PEG PLACEMENT

Percutaneous endoscopic gastrostomy (PEG) was first described in 1980 as an effective means of enteral nutrition where oral intake is not possible. PEG placement is safe and has now replaced the nasogastric tube in patients who need long-term feeding. Although it is relatively safe with a very low associated mortality, minor complications, especially local and systemic infection, remain a problem. Of these, peristomal wound infections are the most common complication of PEG. In patients indicated for this procedure who are aged and/or frail, this complication may pose a critical problem. In the commonly used pull or push methods for PEG placement, the PEG tube is readily colonized by oropharyngeal bacteria. Infection of the PEG site is considered to be associated with contamination of the PEG catheter. There are important measures that should be taken to prevent peristomal infection. A number of rigorous studies have shown that prophylactic antibiotics are effective in reducing the risk of peristomal infection. As methicillin-resistant Staphylococcus aureus (MRSA) or other resistant organisms are emerging as a major pathogen in peristomal infection, however, currently recommended antibiotic prophylaxis regimens might be inappropriate. Alternative regimens and other approaches to prevent contamination of the PEG tube during the procedure are required.

Antibiotic prophylaxis for percutaneous endoscopic gastrostomy for non‐malignant conditions: a double‐blind prospective randomized controlled trial

The use of antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion has been encouraged following development of guidelines by a number of professional societies within the past few years. However, not all evidence supports routine prophylaxis, particularly in patients with 'benign' disease indications for percutaneous endoscopic gastrostomy insertion. To identify whether prophylactic antibiotic usage is beneficial in patients undergoing percutaneous endoscopic gastrostomy insertion without malignant disease. Adult patients without malignant disease who were referred for percutaneous endoscopic gastrostomy insertion at our unit were assessed for participation in this prospective, double-blind, randomized controlled study. Patients were randomized to receive either placebo or 2.2 g co-amoxiclav (or 2 g cefotaxime if penicillin-allergic) at time of percutaneous endoscopic gastrostomy insertion. Clinical endpoints studies were percutaneous endoscopic gastrostomy site or systemic infection and death within 7 days of percutaneous endoscopic gastrostomy insertion. Results : Ninety-nine patients completed the study (51 antibiotics, 48 placebo). Outcomes in the antibiotic and placebo groups respectively were: percutaneous endoscopic gastrostomy site infection, 11% vs. 47% (P < 0.01); systemic infection, 16% vs. 38% (P < 0.05); and death, 8% vs. 15% (P = 0.5). Antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion reduces both percutaneous endoscopic gastrostomy site and systemic infections in patients without malignant disease.

Incision vs. Non-Incision Technique of PEG Tube Placement, Success Rate and Early Complications

Purpose: Percutaneous endoscopic gastrostomy (PEG) tube placement with and without skin incision were compared with regard to success of technique, ease of placement, and early PEG site complications in a randomized, controlled, double blinded prospective study. Methods: 50 consecutive patients were randomized to PEG tube placement by pull technique with either 4 mm skin incision (n = 25) or no skin incision (n = 25). Patients were blinded to type of technique used. 92% of patients in each group received antibiotics. Peak pull-forces required to pull PEG through the abdominal wall, bleeding scores and time of procedure were recorded by an operator. All patients received standardized wound care. At days 2 and 7 post-PEG placement an investigator blinded to the type of technique assessed patients for PEG site skin infection, bleeding, and pain. Results: PEG placement was 100% successful in both groups of patients with no differences in procedure time. The mean procedure time for the incision group was 14.6 min; for the non-incision group it was 15.6 min (P > 0.05). Mean bleeding score during procedure was higher in the incision group 0.4 vs. non-incision group 0.12 (P < 0.05), while mean peak pull-forces were higher in the non-incision group 19.04 lb vs. incision group 11.69 lb (P < 0.05). One patient in the incision group required suturing and pressure to control continuing oozing of blood after the procedure. Mean infection scores were 0.16 for the incision group vs. 0 for the non-incision group (P > 0.05) on day 2, and 0.43 for the incision group vs. 1.37 for the non-incision group (P = 0.055) on day 7. Purulent MRSA PEG site abdominal wall infection in one patient from the non-incision group necessitated early PEG tube withdrawal and additional antibimicrobial therapy. Mean bleeding scores were 0.25 for the incision group vs. 0 for the non-incision group (P < 0.05) on day 2, and 0.13 for the incision group vs. 0.08 for the non-incision group (P > 0.05) on day 7. There was no statistically significant difference in pain scores on day 2 or 7. The mean pain score was <1 in both groups. Conclusions: PEG tube placement was feasible in all patients with both incision and non-incision techniques. When compared with the incision technique, the non-incision technique required significantly more forces to pull the PEG tube through the abdominal wall, was associated with lower periprocedural bleeding, and had higher mean infection scores on post-procedure day 7.

Major Complications from PEG Tube Placement

Percutaneous endoscopic gastrostomy (PEG) represents the most common method for enteral access for long term nutritional support. Although it is safely placed in most patients, serious complications can occur during placement of these tubes. Case Information: Patient A is a 21 y/o male who was involved in a motor vehicle accident and developed prolonged respiratory failure. Enteral access was obtained in the operating room during trachesotomy by placing a PEG tube. Post procedure the patient was noted to have severe abdominal pain. MRI of the abdomen showed the PEG tube traversing through the liver into the stomach. The tube was subsequently removed with complete resolution of the patient's abdominal pain. Patient B is a 73 y/o male who sustained a cardiorespiratory arrest and underwent a PEG placement at an outside hospital. He was transferred to our hospital due to a fecal leak around his PEG site. Upon arrival, he was noted to have lower gastrointestinal bleed and underwent urgent colonoscopy that showed PEG tube traversing through-and-through the distal transverse colon. He subsequently underwent exploratory laparotomy to remove the PEG tube. Discussion: Major complications from PEG tube placement include transhepatic placement, colocutaneous fistula, buried bumper syndrome, necrotizing fasciitis, esophageal perforation and gastric perforation. Complications as illustrated above, although rare, can cause serious complications necessitating the removal of the PEG tube Conclusion: One needs to be vigilant to recognize PEG tube complications to prevent further morbidity in these seriously ill patients. [figure 1][figure 2]FigureFigure

A victory against MRSA

Patients were being transferred from nursing homes to hospital with MRSA in their PEG sites. The intervention of two nurses has eradicated the problem.

Metastatic head and neck carcinoma to a percutaneous endoscopic gastrostomy site

Percutaneous endoscopic gastrostomy (PEG) tube placement is a safe and widely accepted alternate route for enteral alimentation in the head and neck cancer patient population. Cancer metastatic to a PEG tube exit site is a rare but serious complication of this procedure. We sought to determine the route of spread responsible for PEG site metastases such that we may prevent further occurrences of this highly morbid condition. We also report a case of PEG site metastasis at our institution. We performed a MEDLINE search for the years 1962 to 2002 and conducted a review of the literature. In the case at our institution, a 63-year-old man was referred to our institution with recurrent squamous cell carcinoma of the right base of tongue; he also had a 1.5-cm left apical lung nodule. He underwent PEG tube placement at the time of staging panendoscopy. Six months after the original tube placement, he had an ulcerated mass develop at the PEG site; biopsy of the mass revealed squamous cell carcinoma histologically identical to the base of tongue tumor. He also had recurrent lung cancer and four hepatic lesions develop. In our MEDLINE search, of the five patients diagnosed with PEG site disease >10 months after PEG placement, all five (100%) had synchronous distant metastatic disease. In the group of patients diagnosed with PEG site metastases < or =10 months after PEG placement, only four (24%) of 17 had synchronous distant metastatic disease. All patients underwent PEG placement by means of the "pull" technique. Direct implantation with a variable-sized initial tumor burden can explain all cases of PEG site metastasis. The presence of distant metastases is representative of the natural history of advanced head and neck malignancies. Smaller initial tumor implants present later than would larger initial tumor burdens, when the patient is more likely to have distant metastatic disease. In the case at our institution, the patient did not respond to treatment for his hepatic and PEG site metastases and his lung cancer, and he died 4 months after detection of the PEG site metastasis. PEG site metastases are iatrogenic complications of PEG tube placement in patients with squamous cell carcinoma of the upper aerodigestive tract. The 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.

Metastatic head and neck carcinoma in a percutaneous endoscopic gastrostomy site

Metastatic head and neck carcinoma in a percutaneous endoscopic gastrostomy site

Prevention of percutaneous endoscopic gastrostomy site infections caused by methicillin-resistant Staphylococcus aureus

Percutaneous endoscopic gastrostomy (PEG) is widely used to maintain enteral nutrition in patients who are unable to swallow. Peristomal wound infection is the most common complication of this procedure. In a hospital endemic for methicillin-resistant Staphylococcus aureus (MRSA), MRSA can be the most common organism associated with these infections. We have evaluated a strategy consisting of screening, skin decontamination and glycopeptide prophylaxis for preventing PEG-site infections. None of the 34 patients who received the decontamination protocol and glycopeptide prophylaxis (Group A) developed PEG-site infections within one month of surveillance. Two patients were infected with MRSA after that period. One of seven patients who received the decontamination protocol alone (Group B) was infected within the period of surveillance, while another patient was infected after that period. Both were infected with MRSA. None of nine patients who received glycopeptide prophylaxis alone (Group C) were infected. The results suggest that the strategy of screening, decontamination and glycopeptide prophylaxis is effective in the prevention of PEG-site infections with MRSA. Further trials are necessary to confirm these findings.

Percutaneous Endoscopic Gastrostomy Site Metastasis in a Patient with Esophageal Cancer

Percutaneous Endoscopic Gastrostomy Site Metastasis in a Patient with Esophageal Cancer

Percutaneous endoscopic gastrostomy before multimodality therapy in patients with esophageal cancer

Background Percutaneous endoscopic gastrostomy (PEG) has not been widely used in esophageal cancer because of concerns about safety of dilatation, suitability of the stomach as an esophageal replacement, and potential for inoculation metastasis. Methods Experience with PEG in consecutive patients presenting with new esophageal cancer from March 1991 to March 2001 was reviewed retrospectively. PEG was planned in 119 of 179 (66%) of these patients excluding those presenting moribund and those for whom early resection was planned. The PEG was placed using an endoscopic method with wire-guided endoscopic bougienage or laser ablation or both as needed. Success of placement, requirement for dilatation and ablation, PEG-related complications, tolerance of enteral feeds, and impact on therapy were evaluated. Results PEG placement was possible in 87% of patients (103 of 119). Dilatation or laser ablation or both was required in 46% (47 of 103). There was no procedure-related mortality. Thirty-day mortality was 13.5%. Major PEG-related complications were observed in 4% (4 of 103) and minor PEG-related complications in 12% (12 of 103). PEG removal was required in 4 patients and interruption of enteral feeds required in 33 (32%). No instances of esophageal disruption or tumor inoculation metastasis were noted. PEG takedown and site closure at the time of operation was uncomplicated and use of the stomach as an esophageal substitute was possible in all 61 resected patients. Rates of anastomotic leak, stricture, and gastric emptying delay were similar to those for patients proceeding to resection without prior PEG (leak: PEG = 8% [5 of 61] versus non-PEG = 10.5% [2 of 19]), (stricture: PEG = 37% [22 of 61] versus non-PEG = 32.5% [6 of 19]), (delay: PEG = 9.8% [6 of 61] versus non-PEG = 10.5% [2 of 19]). Analysis of variables showed PEG to be significantly related to attainment of target doses of chemoradiotherapy ( p = 0.034), and survival at 12 months ( p = 0.02). Conclusions PEG in esophageal cancer is safe and useful and does not compromise the stomach or esophagogastric anastomosis. Further study is required to define the efficacy of PEG as a means of nutritional support and its impact on survival.

Huge submucosal hematoma of the stomach after accidental removal of the PErcutaneous endoscopic gastrostomy tube

We report a case of massive hemorrhage and aspiration pneumonia as complications of percutaneous endoscopic gastrostomy (PEG). Three months after insertion of a PEG tube, the patient accidentally pulled out the tube by himself. After the accident, the patient experienced hematemesis, which caused aspiration pneumonia. The button-type tube was reinserted into the PEG fistula for hemostasis. The bleeding stopped temporarily; however, 21 days later, the patient relapsed into a condition of massive PEG site bleeding and hematemesis. He was transferred to our hospital, Kuniyoshi Hospital, to control the bleeding and aspiration pneumonia. Endoscopy revealed a sliding type of large hiatal hernia and a huge submucosal hematoma with an ulceration at the lower part of the gastric body. Emergency surgery including local gastrectomy, gastrostomy, jejunostomy and tracheostomy were helpful to treat these complications. Endoscopists should be aware how to treat these complications. One should not hesitate to perform open surgery when other treatments fail.

Changing wound-care practice: management of percutaneous endoscopic gastrostomy sites

Following the involvement of the wound-care service in the management of problem percutaneous endoscopic gastrostomy (PEG) sites in the Doncaster Trust, the scope of the service has been extended. In light of experience obtained from managing PEG sites and associated skin problems, and the evidence of clinical outcomes after treatment, educational and treatment policies have been implemented. These policies have raised the profile of the service and improved patient outcomes in the Trust and in areas of the community that have adopted our practices.

An assessment of open access referral for percutaneous endoscopic gastrostomy in a district general hospital

To determine the indications, technical success and outcomes of open access percutaneous endoscopic gastrostomy (PEG) insertion in the district general hospital setting. This study was a retrospective audit of patients receiving PEG by the thread pull method from November 1998 to November 1999, followed by a prospective audit of patients receiving PEG from December 1999 to May 2000. Prophylactic antibiotics were not used. Patient data were collected using a computerized endoscopy unit record system. Clinical assessment was performed and case notes were reviewed. Whenever necessary, telephone follow-up of patients in the community was performed. Sixty-five consecutive, unselected patients underwent PEG and 64 were followed up for a total of 7799 patient days. Fifty-seven of 64 (89%) were in-patients. The median age of the patients was 74 years (range, 26-95 years). Indications, technical success, early complications and long-term outcomes of PEG. Cerebrovascular disease was the most common indication for PEG (35/64 (55%)). Technical success was achieved in 62/64 (97%) patients. No serious complications from the procedure were reported: PEG site infection was rare (1/64). Pneumonia was uncommon (8/64 (12.5%)). There were eight (12.5%) deaths during the first week after PEG insertion and 18/64 (28%) during the first month. Mortality at 1 year was 36/64 (56%). Ten of 64 patients (16%) recovered to PEG removal; 18 (28%) continue to be fed via PEG. This audit demonstrates that referral patterns, technical success and long-term outcome of open access referral for PEG in a district general hospital setting are consistent with published series from specialist and tertiary referral centres.

Percutaneous endoscopic gastrostomy in children with malignant disease.

The objective of the study was to assess both the possible complications of percutaneous endoscopic gastrostomy (PEG) in pediatric cancer patients and its effect on weight development. The medical records of 18 children with a median age of 2.5 years (range, 0.5-14.2 years) were reviewed. The diagnoses were leukemia, central nervous system tumors, solid tumors, and lymphoma. The indications for PEG were anticipated therapy-related nutritional problems and inadequate food intake, weight loss, swallowing problems in relation to paresis of the pharynx, and relapse of the disease. Ten children received a PEG at treatment start, and eight children received it at a median time of 3.4 months (range, 0.9-27.4 months) after treatment start. The median duration of having a PEG in place was 12.3 months (range, 1.2-24.0 months). At admission the median weight for age expressed as standard deviation (SD) was -0.11 (range, -2.78-2.68). There was a significant (p =.005) decrease in the median SD from admission until PEG installation. There was also a significant increase in the median SD from the start of PEG use until 1 (p =.04) and 2 (p =.039) months after start. The most common complications were episodes of inflammation of the PEG site, which were successfully treated with topically or orally administered antibiotics, and episodes of infection, which required intravenously administered antibiotics. Taking into consideration the medical condition of the children in the study group and the considerable length of time with a PEG in place, we believe that nutrition via PEG in children with cancer has several advantages and is rarely associated with other than minor complications.

Early Initiation of Enteral Feeding After Percutaneous Endoscopic Gastrostomy Tube Placement

Enteral feeding through the percutaneous endoscopic gastrostomy (PEG) tube is usually initiated about 12 to 24 hours after insertion of the tube. There have been earlier studies evaluating the efficacy of early initiation of enteral feedings that had encouraging results. However, delayed initiation of feeding following PEG placement continues to be practiced widely. We believe that feeding can be done earlier without any increase in associated morbidity or mortality and with obvious reduction in the need for parenteral nutrition and healthcare costs. We evaluated a protocol to initiate enteral nutrition 4 hours after the PEG tube insertion with subsequent discharge of the outpatients on the same day. We conducted a prospective study to assess the efficacy of early initiation of PEG feeding. We enrolled 77 patients in our study who were having PEG tubes placed for enteral feeding. Only patients who had a PEG placed for gastric venting procedures were excluded from our study. During the course of our study, no patient had to be excluded for the latter reason. Patients were evaluated by the physician performing the procedure, 4 hours after the tube was inserted. Their vital signs were checked, and a thorough abdominal examination was performed. Minimal tenderness around the PEG site was the most frequent finding. Otherwise, all the patients had a benign abdominal examination. The tube was flushed with 60 mL of sterile water. Following the examination, orders were given to restart the feedings. These patients were followed for a 30-day period to evaluate complications associated with PEG tube placement and early initiation of PEG feeding. There was one case of aspiration pneumonia (1.3%) and one death that was attributed to the underlying disease out of our 77 patients. Early initiation of enteral feeding after PEG tube placement can be successfully completed with a systematic protocol and close observation. Not only was this protocol found to be safe, it can also have significant cost savings by eliminating the need for inpatient hospitalization for the procedure.

Percutaneous endoscopic gastrostomy: strategies for prevention and management of complications.

The placement of percutaneous endoscopic gastrostomy (PEG) tubes is within the realm of the head and neck surgeon because most are proficient in the use of rigid and flexible esophagoscopes. The ability to provide comprehensive care for the patient with head and neck cancer provides further incentive for the head and neck surgeon to adopt this technique. Although it is a technically simple procedure, the surgeon must be aware of the range of complications that can occur with PEG. We review our experience with PEG focusing on the complications as well as strategies for the prevention and management of these complications. A retrospective review of the records of patients who underwent PEG at Stanford University by the Head and Neck Surgery Service between July 1992 and December 1998 was conducted. A total of 103 patients were identified, of which 84 (82%) were patients with head and neck cancers. Complications associated with PEG were identified. All PEGs were performed using the pull technique. There was no mortality associated with the procedure. Minor complications occurred in 11 cases (10.7%). These included cellulitis (4), ileus (3), tube extrusion (1), clogged lumen (1), and peristomal leakage (2). The only major complication was a single case of PEG site metastasis. The review of our experience with PEG tube placement revealed a low complication rate. Safe PEG placement was achieved by transillumination of the abdominal wall and confirmation by ballottement. In addition, appropriate patient selection, use of perioperative antibiotics, as well as meticulous post-procedure care contributed to the low rate of complications. For the patients with head and neck cancer, a barrier should be placed between the tumor and the instrumentation at the time of tube placement.

3501 Endoscopic fibrin sealant injection with application of hemostatic clips: a novel method of closing a refractory gastrocutaneous fistula.

Background: Management of non-healing gastrocutanous fistula is difficult especially in debilitated patients. Methods: On an elderly man with advanced stage esophageal cancer and sever oxygen-dependent lung disease; who had persistent acid leakage from the percutaneous endoscopic gastrostomy site, small stripes of absorbable fiber(Surgicel)were introduced from the cutaneous side of the fistula and fibrin sealant(Tisseel® VH)with its two components was endoscopically injected through a specially designed syringe(Duploject® applicator) and catheter (Duplocath® 180, Immuno AG,Vienna, Austria) in addition to applying of four hemeostatic clips(Rotatable clip fixing device HX-5LR-1. Olympus,America INC,Melville,N.Y) on the gastric aspect of the fistula. Results: stopping of the leakage was successful,permanent and prevented more morbidity with no complication. Conclusion: We believe that our new technique is a novel and successful one, but large study is needed to define the proper candidates and success rate.

Percutaneous endoscopic gastrostomy: a review of indications, complications and outcome.

Percutaneous endoscopic gastrostomy (PEG) was first described in 1980 as an effective method of feeding via the stomach in situations where oral intake is not possible. Its simplicity has led to its potential use in areas of dubious clinical benefit. Our unit has faced a major increase in referrals for PEG insertion over the last 2 years. For this reason we decided to audit our PEG insertion procedures with regard to indications, complications, outcome and follow up. We studied 168 patients who had an initial PEG insertion during the period 1 February 1996-31 January 1998. The medical records of these patients were reviewed with regard to the procedure, antibiotic use and complications. All patients (or carers or next of kin) were contacted by telephone to provide details regarding late complications and follow up. There were 87 females and 81 males (aged 16-98 years, median age 70 years). At 2 years, 67% were alive. The most frequent indication for PEG insertion was a neurological condition, the commonest being stroke. Most patients received either ticarcillin/clavulanic acid or cephazolin antibiotic prophylaxis before and after the procedure. In six patients (3.6%) infection at the PEG site required intravenous antibiotics. Four of these six patients did not have antibiotic prophylaxis. Only two deaths could be directly related to the procedure. Three died within 7 days of the procedure due to unrelated medical complications. Sixteen patients died within 1 month, the majority of these patients did not leave hospital. One-fifth of the patients (35/168) had their PEG removed due to the re-establishment of oral feeding, with median time of use, 4.3 months. It is a safe, effective feeding method in the elderly, but experience with case selection, the procedure and careful follow up remain essential. The use of prophylactic antibiotics resulted in few significant infections of the PEG site. Up to one-fifth of patients will require their PEG only for a short term.