Percutaneous Endoscopic Gastrostomy Tube Insertion Research Articles

Timing and impact of percutaneous endoscopic gastrostomy insertion in patients with amyotrophic lateral sclerosis: a comprehensive analysis

Dysphagia is common in amyotrophic lateral sclerosis (ALS) patients, often requiring percutaneous endoscopic gastrostomy (PEG) for enteral nutrition. We retrospectively analyzed data from 188 Korean patients with ALS who underwent PEG tube insertion at five-time points: symptom onset (t1), diagnosis (t2), recommended time for gastrostomy (t3), PEG insertion (t4), and one-year post-insertion (t5). The recommended time point for gastrostomy (T-rec for gastrostomy) was defined as the earlier time point between a weight loss of more than 10% and advanced dysphagia indicated by the ALSFRS-R swallowing subscore of 2 or less. The T-rec for gastrostomy was reached at 22 months after symptom onset, followed by PEG insertion at 30 months, resulting in an 8-month delay. During the delay, the ALSFRS-R declined most rapidly at 1.7 points/month, compared to 0.8 points/month from symptom onset to diagnosis, 0.7 points/month from diagnosis to T-rec for gastrostomy, and 0.6 points/month after the PEG insertion. It is crucial to discuss PEG insertion before significant weight loss or severe dysphagia occurs and minimize the delay between the recommended time for gastrostomy and the actual PEG insertion. A stratified and individualized multidisciplinary team approach with careful symptom monitoring and proactive management plans, including early PEG insertion, should be prioritized to improve patient outcomes.

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: Insertion and Management

Percutaneous endoscopic gastrostomy (PEG) is the modality of choice for long-term enteral feeding in patients in whom oral intake is challenging. Compared with parenteral nutrition, gastrostomy feeding is the preferred choice for sustained nutritional support. Delivery of nutrients directly to the gastrointestinal tract and enhanced cellular immunity associated with this approach are clinically beneficial to patients. Endoscopic gastrostomy is favored for its high clinical success rates and economic advantages and is associated with minor discrepancies with regard to morbidity, mortality, and tube function compared with surgical gastrostomy. PEG procedures can be broadly classified into the pull- and push-types. Although PEG is a comparatively safe procedure, high risk of bleeding is a well-known complication of PEG placement, which necessitates prophylactic antibiotic therapy and careful periprocedural management in patients who receive antiplatelet and anticoagulant agents. Tube dislodgement, peristomal leakage, or infection following PEG placement may require tube replacement or removal. In this review, we investigated the concerns associated with early vs. delayed feeding in concordance with current guidelines. We also describe the indications for PEG tube insertion, post-procedural care strategies, and management of complications.

S780 Risk of Bleeding During Percutaneous Endoscopic Gastrostomy Tube Insertion in Patients on Continued Antiplatelet Therapy: A Systematic Review and Meta-analysis

S780 Risk of Bleeding During Percutaneous Endoscopic Gastrostomy Tube Insertion in Patients on Continued Antiplatelet Therapy: A Systematic Review and Meta-analysis

Compliance With Percutaneous Endoscopic Gastrostomy Tube Insertion Guidelines and Associated Complications in a Tertiary Care Setting: A Clinical Audit.

Percutaneous endoscopic gastrostomy (PEG) tube insertion is a widely utilized enteral access technique offering long-term nutritional support for patients unable to tolerate oral intake. While the PEG tube provides numerous advantages, adherence to evidence-based guidelines is crucial to minimize complications. This study aims to evaluate adherence to PEG tube insertion guidelines and analyze associated complication rates in a tertiary care setting. A retrospective clinical audit was conducted at Quaid-e-Azam International Hospital, Islamabad. Data were collected over three years from patients undergoing PEG tube insertion by a single consultant gastrointestinal surgeon. Adherence to guidelines was evaluated using a 10-item checklist developed based on European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Complication rates and patient characteristics were analyzed. The study included 70 participants (mean age = 72.21 ± 13.17). The PEG tube insertion rate was 100%. The mean checklist score was 8.34 ± 1.2. Laboratory investigations were performed for 98.6% of patients. 91.4% of patients had a life expectancy exceeding 30 days. 60% of patients received an anticoagulation hold. Prophylactic antibiotics were administered to 90% of patients. Psychological counseling and dietician consultation were offered to 38.6% and 64.2% of patients, respectively. Caregivers received specialized training in 98.5% of cases. 12.8% of patients experienced early complications post-procedure, and 14.2% experienced late complications. PEG tube removal occurred in 27% of patients, with only one patient experiencing complications after removal. Adherence to PEG tube insertion guidelines was observed in various aspects of patient care, resulting in a low incidence of complications. Comprehensive auditing and guideline adherence are essential to ensure optimal patient safety and procedural outcomes.

Risk Factors and Role of Antibiotic Prophylaxis for Wound Infections after Percutaneous Endoscopic Gastrostomy.

The incidence of wound infections after percutaneous endoscopic gastrostomy (PEG) varies widely in recent studies. The present study systematically investigates the underlying risk factors for the development of wound infections in a large cohort of patients over a long-term follow-up period. A retrospective cohort study of patients undergoing PEG insertion using either the pull or push technique was conducted and patients followed up for 3 years. Tube-related wound infections were identified, and pathogens regularly cultured from wound swabs. Adjusted analysis was performed via univariate and multivariate logistic regression analysis. 616 patients were included in this study. A total of 25% percent of patients developed wound infections upon PEG tube insertion and 6.5% showed recurrent infections. Nicotine abuse (p = 0.01), previous ischemic stroke (p = 0.01) and head and neck cancer (p < 0.001) showed an increased risk for wound infection after PEG placement. Moreover, radio-chemotherapy was associated with the occurrence of wound infections (p < 0.001). Infection rates were similar between pull and push cohorts. The most common bacterial pathogen detected was Enterobacterales (19.2%). Staphylococcus aureus, Pseudomonas aeruginosa and enterococci were frequently detected in recurrent infection (14.2%, 11.4% and 9.6%, respectively). Antibiotic prophylaxis showed no effect on infection rates. Wound infections after PEG placement are common and occasionally occur as recurrent infections. There is potential for improvement in everyday clinical practice, particularly regarding antibiotic prophylaxis in accordance with guidelines.

Survival Following Percutaneous Endoscopic Gastrostomy in Neurology Intensive Care Unit Patients

Background: We aimed to determine factors affecting mortality and survival after Percutaneous endoscopic gastrostomy (PEG) in patients who were hospitalized in the neurology intensive care unit during the coronavirus disease-2019 (COVID-19) pandemic Materials and Methods: The clinical and demographic data of 29 patients aged 18 years and older who received PEG tube insertion during hospitalization in the Neurology Intensive Care Unit of XXX Hospital, Turkey, between February 2020 and May 2021 were examined retrospectively. Patients’ demographics, clinical characteristics, and survival status were recorded. Results: We included 29 patients (16 females and 13 males) into our study. Median age was 71 (33–89) years among survivors and 75.5 (48–90) years among those who died. The groups were similar with respect to age (p = 0.119) and sex (p = 0.806). Mortality rate after PEG insertion was 66%. Mean overall survival after PEG tube insertion was 129.49 days (95% CI: 91.21–167.78). Cox regression revealed that having multiple comorbidities increased the likelihood of mortality by 2.822-fold (95% CI: 1.001–7.968, p = 0.049). Conclusions: These findings show that having multiple comorbidities was the most important factor associated with mortality among PEG recipients who were admitted to the Neurology Intensive Care Unit during the COVID-19 pandemic. Since multiple comorbidities cause shorter survival, it appears that the decision to insert PEG tubes must be made extremely cautiously among these patients. However, more comprehensive studies should be conducted to clarify the effect of COVID-19 on mortality rates and survival time after PEG.

Percutaneous Endoscopic Gastrostomy Placement in Trauma Patients: Early vs Delayed Initiation of Enteral Feeding.

In critically ill trauma patients, adequate nutrition is essential for the body's healing process. Currently, there is no clinical standard for initiating feeds after percutaneous endoscopic gastrostomy (PEG) tube placement. We aimed to demonstrate that early enteral nutrition (EN) is as safe as delayed EN in patients who have undergone PEG tube insertion. We conducted a multi-center, retrospective cohort study of 384 patients from the Prisma Health Trauma Registries who received PEGs. Feeding intolerance was defined as high gastric residuals, nausea, emesis, sustained diarrhea, or ileus. The probability that a patient would experience intolerance was 11.7% in those fed within 6hours, 5.1% among patients fed between 6 and 12hours, 6.0% among patients fed between 12 and 24hours, and 7.6% among patients fed after 24hours, for which no statistically significant difference was detected. These findings support that early EN after PEG placement is safe in critically ill, trauma patients.

Retrospective analysis of the methods and complications following the insertion of a PEG tube in children

IntroductionA long-term intragastric feeding is the indication for percutaneous endoscopic gastrostomy (PEG) placement in a patient. The procedure is performed in children with central nervous system (CNS) disorders, congenital heart defects and neoplastic or metabolic diseases. The PEG placement procedure is most commonly performed by a gastroscopy procedure.AimThe study aimed to retrospectively analyse the methods applied and complications following PEG tube insertion in patients of the Regional Specialist Children's Hospital in Olsztyn, Poland, in the years 2000–2019.Material and methodsA retrospective analysis was conducted of medical histories and records of children qualified for PEG placement procedure. PEG procedure was performed on 48 children: 24 boys and 24 girls. The mean age was 7 years. PEG was inserted in cerebral plasy in 30 patients, congenital defects in 11 and genetic disorders in 7.Results and discussionThe reasons for PEG insertion included dysphagia in 30 children, no weight gain in 7, aspiration of gastric contents to the bronchial tree in 6, and feeding difficulties in 10. Two methods for performing PEG insertion procedure were employed: a gastroscopy alone (31 cases) and a laparoscopic-assisted gastroscopy (17). The following complications were: local complications at the incision site (28), PEG dysfunction (13), vomiting (9), sepsis (2), buried bumper syndrome (1), oesophagitis (1), and gastrointestinal fistula (1).ConclusionsThe PEG placement procedure is burdened with a significant number of complications, however, they are mainly related to local inflammation or PEG dysfunction.

S1940 Acute Pancreatitis: Caused by Dislodged PEG Tube?

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a common endoscopic procedure and a preferred route for long-term enteral nutrition for patients incapable of oral intake or for whom oral intake is insufficient. The insertion of PEG tubes is a relatively safe procedure with complications which include bleeding, aspiration, perforation, periostomal leaks, tube dislodgement and occlusion, gastric outlet obstruction due to tube migration and accidental removal. Acute pancreatitis secondary to PEG migration is rare. We present a patient with acute pancreatitis secondary to PEG tube migration. Case Description/Methods: A 57-year-old woman known to have severe developmental delays, seizure disorder, bipolar 1 disorder presented with nausea, vomiting and abdominal pain. She is bedridden and nonverbal at baseline. She gets nutrition through a PEG tube for severe oropharyngeal dysphagia. Abdominal examination revealed significant biliary drainage from the gastrostomy site and tenderness present without rigidity or guarding. Labs showed WBC of 17.7 and lipase levels greater than 4,000 U/L. AST, ALT, alkaline phosphatase and total bilirubin were within normal range (31, 6, 94 and 0.9 respectively). CT abdomen without IV contrast revealed peripancreatic soft tissue stranding and pancreatic edema, the tip of the PEG tube in the second part of the duodenum (Figure). Her home medications are verified and are not known to cause acute pancreatitis (AP). So she was suspected to have AP from PEG tube migration. The tube was repositioned and she was treated with Ringer lactate. Four days later, her symptoms resolved and lipase level was within normal range (282 U/L). Discussion: In comparison to other methods, enteral feeding has the benefit of maintaining gut mucosal integrity and decreasing the possibility for bacterial translocation. Migration of the PEG tube has been associated with gastric outlet obstruction and biliary obstruction. In rare cases, this can present as AP either through ampullary obstruction at the second part of the duodenum or through compression of the pancreatic head itself. This case highlights the inclusion of PEG tube induced pancreatitis as a differential for AP in patients receiving enteral feeding. Proper placement of the tube, regular examination of the site and marking the PEG position can help avoid migration and complications. The treatment for acute pancreatitis secondary to PEG tube migration is PEG tube removal followed by placement of a new PEG tube or repositioning.Figure 1.: Peripancreatic soft tissue stranding and pancreatic edema, the tip of the PEG tube in the second part of the duodenum.

An Analysis of Percutaneous Endoscopic Gastrostomy Complications.

To determine the indications of early and late complications in 224 patients who underwent Percutaneous Endoscopic Gastrostomy (PEG) procedure. Observational study. Department of General Surgery, Karatay University and Medipol University, Turkey, from January 2014 to December 2020. Patients' age, gender, primary diseases, PEG indications, morbidity, mortality, and complications were recorded by performing the PEG procedure. Hospitalisation, follow-up periods of the patients, and the re-insertion of PEG were evaluated. The most common indication for PEG tube insertion was nutritional disorder associated with cerebrovascular diseases in 81 (37%) patients. No mortality was perceived due to the PEG tube insertion. However, mortality was observed in 84 (38.4%) patients in the first six months, in 6 (2.7%) patients between the sixth and twelfth month, and in 8 (3.7%) patients after the twelfth month. All these mortalities were attributed to the primary disease. In the early and late periods, complications were observed in the total of 45 (20.4%) patients. Among them, 17 (7.7%) patients experienced early period complications, whereas 28 (12.7%) patients experienced late period complications. Enteral nutrition should be preferred in order to avoid complications of parenteral nutrition in the patients who need long-term nutrition. In enteral nutrition, PEG should be preferred to surgical gastrostomy because it has less morbidity and mortality, can be done at the bedside and outpatiently when necessary, does not require general anesthesia, and is cheaper and practical. Gastrostomy, Percutaneous Endoscopic gastrostomy, Enteral nutrition, PEG complications.

Nasogastric Feeding Tube/Dobhoff Placement: A Multidisciplinary Approach to the Management of Malnutrition During Radiation Therapy in Patients With Head and Neck Cancer.

BackgroundRadiation therapy (RT)-associated oral mucositis, xerostomia, thick mucoid saliva, nausea/vomiting, and loss of taste may result in significantly compromised oral intake in patients undergoing treatment for head and neck cancers (HNC). Feeding tube placement allows patients to receive enteral nutrition and continue the planned course of treatment.ObjectivesRT-associated oral mucositis, xerostomia, and loss of taste may result in significantly compromised oral intake in patients undergoing treatment for head and neck cancers. We sought to determine if reactive nasogastric (NG) tube placement was an effective strategy for nutritional support in these patients and if invasive percutaneous endoscopic gastrostomy (PEG) tube insertion could be avoided.MethodsThis is an institutional review board (IRB)-approved study of patients treated for head and neck cancer using definitive or adjuvant RT with or without concurrent chemotherapy between June 2017 and December 2020. We evaluated the indications for NG tube (Dobhoff) placement, time of placement during the course of RT, patient tolerance of NG tube, and median duration of NG tube placement. In addition, we followed weight loss during treatment, treatment interruptions, and treatment-related toxicities. Complications associated with having the NG tube, if the NG tube needed to be replaced during treatment, and if the patient had any hospitalization during the course of treatment were tracked.ResultsOf the 441 patients treated for head and neck cancer during the time period of this study, 47 required reactive NG tube placement for nutritional support. Patients included 40 with primary oropharynx, three with oral cavity, two with larynx, one with nasopharyngeal, and one was unknown. Chemotherapy was given concurrently with radiation in 87.2% (n=41) patients. The median time of NG tube placement was during Week 5 of the six to seven-week course of RT. The median percentage of weight loss from baseline to the date of NG tube placement was 12.9% (range, -0.9% to 25.9%). The median rate of weight loss decreased by 8.7% from the date of NG tube placement to the end of treatment. The median duration of NG tube placement was 29 days (range, 5 to 151 days). There were no serious medical complications associated with having the NG tube in place during treatment. Twenty-seven point six percent (27.6%; n=13) of patients had the NG tube dislodged or displaced and needed replacement. Thirty-eight point three percent (38.3%; n=18) of patients with an NG tube had to be hospitalized during the course of RT, with the predominant symptoms being failure to thrive (22.2%; n=4) and nausea/vomiting 22.2% (n=4). Six point four percent (6.4%; n=3) of patients requested the removal of the NG tube due to local irritation. Seventy-six point six percent (76.6%; n=36) of patients did not require further nutritional support with the placement of a percutaneous endoscopic gastrostomy (PEG) tube.ConclusionThis study indicates that clinic placement of an NG tube for patients receiving RT for head and neck cancer is a safe and effective way to maintain nutrition during treatment. The rate of weight loss decreased after the patient had an NG tube placed. The placement procedure is well-tolerated and there were no complications associated with having the NG tube during treatment. PEG tube insertion was avoided in approximately 80% of the patients.

Comparison of Pull and Introducer Techniques for Percutaneous Endoscopic Gastrostomy.

ObjectiveTo compare indications, success rates and complications of pull [P] and introducer [I] techniques for percutaneous endoscopic gastrostomy (PEG).MethodsIn this retrospective study, inpatients who underwent primary PEG tube insertion between January 2015 and February 2020 at the Endoscopy Center of the First Affiliated Hospital of Fujian Medical University were included.ResultsA total of 103 inpatients were included in this study (P group, n = 67; I group, n = 36). The rates of tube replacement within first six months in the P and I groups were 1.5% and 11.1%, respectively (P = 0.049). The most common primary indication of PEG was malignancy. The proportion of patients with esophageal cancer was significantly lower in the P group (24.4% vs 54.2%, P = 0.015). No significant difference was found in the overall, major, or minor complications between the two groups. In patients with esophageal stenosis, the pull method was a risk factor for complications (P = 0.03; odds ratio [OR] = 12, 95% confidence interval [CI]: 1.164–123.684). Logistic regression analysis showed that the risk factors for major and minor complications were the admission-to-gastrostomy interval (OR = 1.078, 95% CI: 1.016–1.145, P = 0.014) and lack of antibiotic use (OR = 4.735, 95% CI: 1.247–17.979, P = 0.022), respectively.ConclusionBoth PEG techniques have high clinical success rates. The introducer technique is more suitable for patients with esophageal stricture, which has lower minor complications, but higher rate of tube replacement compared to the pull technique. Use of antibiotics may reduce minor complications following PEG. Early PEG insertion may help to reduce post-PEG major complications.

A rare cause of GI bleed

A 67-year-old female with a history of pancreatic cancer with gastric outlet presented with maroon-colored bleeding from the percutaneous endoscopic gastrostomy (PEG) tube for 1 day. On examination, necrotic tissue with surrounding cellulitis was noticed around the PEG tube insertion site, and the internal bumper of the tube was palpated superficially under the skin. Imaging demonstrated an abnormally migrated bumper just beneath the skin. Buried bumper syndrome is a rare complication of in situ PEG tube, and in this article, we present the clinical images of a patient and discuss briefly the risk factors, diagnosis, and management of the condition.

Underlying disease for percutaneous endoscopic gastrostomy tube placement predicts short- and long-term mortality.

PEG (percutaneous endoscopic gastrostomy) is a well established endoscopic procedure for enteral feeding. However, patients with a shorter life expectancy will not benefit from PEG tube placement. Furthermore, some specific evolving diseases will never benefit from PEG. The aim of the study focuses on short and long term mortality rates after PEG tube placement in a referral gastroenterology centre (Geneva University Hospital). 219 patients were enrolled in this study. All patients scheduled for a PEG procedure between January 2011 and December 2014 were included. Nine patient parameters were collected for further analysis as well as the main underlying disease requiring PEG tube placement. Patients were subsequently divided into 4 groups according to underlying disease: Group 1) swallowing disorders of neurologic origin; Group 2) swallowing disorders associated with upper digestive tract neoplasia ; Group 3) nutritional support for a non GI reason ; Group 4) Other. 219 patients had undergone a PEG tube placement. 33 patients died within 60 days after the procedure. After one year, 71 patients died. Global survival was 870 days. The nutritional support group had the better survival rate with 1276 days compared to the swallowing groups and others. The multivariate analysis has highlighted the underlying disease as the only associated parameter with short and long term mortality. PEG tube placement is associated with high short and long term mortality depending on the underlying disease. We outlined the potential role of PEG tube insertion as a supportive transient approach for nutritional support.

Percutaneous endoscopic gastrostomy in children: A tertiary center experience.

Percutaneous endoscopic gastrostomy (PEG) is a common procedure in children. The outcomes of PEG could be affected by the associated disease. We aimed to evaluate the outcomes and safety of PEG tube placement in a tertiary care center with special attention to patients with cardiac disease, ventriculoperitoneal (VP) shunt, or peritoneal dialysis (PD) catheter. This retrospective study included 113 pediatric patients who had PEG tube insertion from 2011 to 2021. Eighteen patients (15.93%) had cardiac disease, five patients (4.42%) had PD catheters, and three patients (2.65%) had VP shunt. The median age was 3 years (interquartile range: 1-6), and females represented 55% of our patients. The weight ranged from 2.57 to 60 kg, and the most common indication for insertion was neurological disease (n=56; 49.56%). The median operative time was 30 (20-45) minutes. Pneumonia and vomiting were the most frequent complications (n=20, 17.7%). Thirty-day mortality occurred in four patients (3.54%) and 1-year mortality in 10 patients (8.85%). Nine patients (7.96%) required fundoplication, and four patients (3.53%) had tube removal and reinsertion. There was no association between weight and postoperative complications (odds ratio: 0.97; P=.48). There were no differences in postoperative complications among patients with cardiac diseases, PD catheters, and VP shunts. No complications were reported in patients with VP shunt. One patient with cardiac disease and one patient with PD catheter required fundoplication. Removal and reinsertion were needed in one patient with a PD catheter. PEG is feasible in low-weight infants with a low complication rate. The complication rate is low in patients with VP shunt, PD catheter, and cardiac patients.

Race and prevalence of percutaneous endoscopic gastrostomy tubes in patients with advanced dementia.

Millions of Americans may face hard decisions when it comes to providing nutrition for their loved ones with advanced dementia. This study aimed to ascertain whether there is a difference in feeding tube placement between White and Black patients with advanced dementia and whether this potential difference varied by patient's other demographic and clinical characteristics. This is a retrospective, observational study conducted at Novant Health, a 15-hospital system in the southeastern United States. Data were obtained from Epic systems and included all hospital admissions with a diagnosis of advanced dementia, a total of 21,939, between July 1, 2015, and December 31, 2018. Descriptive statistics and logistics analyses were conducted to assess the relationship between receiving percutaneous endoscopic gastrostomy (PEG) and race, controlling for demographic and clinical characteristics. Among patients admitted with advanced dementia, the multivariable logistic regression, controlled for age, gender, LOS, palliative care, and vascular etiology showed that Blacks had higher odds of having PEG tubes inserted than White patients (OR 1.97; CI 1.51-2.55; P < 0.001). Patients with longer stays had higher odds of PEG tube insertion. Females had lower odds of PEG tube insertion than males. There was no statistical significance in PEG insertion based on age, etiology, and palliative care consult. The reasons for the observed higher odds of receiving PEG tubes among Black patients than White patients are likely multifactorial and embedded in a different approach to end-of-life care conversations by providers and caregivers of Black and White patients. Providers may need to be more aware of potential unconscious biases when talking to caregivers, especially in race-discordant relationships, have courageous conversations with caregivers, and be more aware of the importance of keeping in mind families' and caregivers' culture, including spirituality, when making end-of-life decisions.

Nutritional Impact of Percutaneous Endoscopic Gastrostomy: A Retrospective Single-center Study.

Several conditions may cause difficulties with oral feeding. Percutaneous endoscopic gastrostomy (PEG) is commonly performed on patients who require enteral feeding for >2-3 weeks. This study examined the nutritional state of patients who required enteral feeding and underwent PEG to quantify the benefits of the procedure. This retrospective study included patients who underwent PEG at the Chungnam National University Hospital between January 2013 and December 2018. A gastroenterologist performed all PEG procedures using the pull technique, and all patients were followed up for >3 weeks postoperatively. The BMI and lymphocyte count, along with the levels of hemoglobin, total protein, albumin, total cholesterol, BUN, and creatinine pre-PEG and between 3 weeks and 6 months post-PEG were evaluated. Overall, 151 patients (116 males; mean age 64.92 years) were evaluated. Of these patients, 112 (74.2%), 34 (22.5%), and five (3.3%) underwent PEG tube insertion because of neurological diseases, malignancy, and other conditions, respectively. The BMI and the hemoglobin, total protein, albumin, and total cholesterol levels were significantly higher post-PEG than pre-PEG. These findings highlight the usefulness of PEG in the management of nutritionally poor patients with difficulties in feeding orally.

Is percutaneous gastrostomy tube insertion contraindicated in adult peritoneal dialysis patients? A single-centre experience of three successful cases: It is time to revisit.

Percutaneous endoscopic gastrostomy (PEG) tube placement in adults who are already established on peritoneal dialysis (PD) remains challenging due to the limited experience and data in this area which lacks clear guidance. Given the fact that peritoneal dialysis is one of the relative contraindications for PEG tube insertion, and PEG tube on its own is a risk for peritonitis, how to overcome these obstacles and utilize the advantage of PEG tube for feeding malnourished PD patients remains uncertain. Here we report our unique successful experience of treating three adult peritoneal dialysis patients in whom the PEG tube was inserted successfully with no complications. To the best of our knowledge, this is the first successful case series in the literature for treating adult prevalent PD patients by PEG tube placement.

Percutaneous Endoscopic Gastrostomy Placement under NIV in Amyotrophic Lateral Sclerosis with Severe Ventilatory Dysfunction: A Safe and Effective Procedure

Introduction: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder with an inexorably progressive course which leads to a progressive neuromuscular weakness. Weight loss is one of the major bad prognostic factors in ALS. The placement of percutaneous endoscopic gastrostomy (PEG) is of paramount importance in patients with dysphagia to improve the disease outcomes, although some fear exists regarding the possible ventilatory complications during the procedure. The aim of this study was to evaluate the safety and effectiveness of PEG tube insertion under non-invasive ventilation (NIV) in patients with ALS and severe ventilatory impairment. Methods: A retrospective study of all consecutive PEGs placed in our department from May 2011 to January 2018 in patients with ALS was performed. The procedure was performed under non-invasive positive-pressure ventilation for ventilatory support. Results: We included 59 patients with ALS with severe ventilatory impairment, 58% were female, with a mean age of 67.2 ± 10.1 years and a median follow-up of 6 [2–15] months. The main indication for PEG placement was dysphagia (98%). The median time for PEG tube insertion since the established diagnosis of ALS was 12 [6–25] months and 4 [2–18] months since the beginning of bulbar symptoms. The majority of the patients had placed a 20-Fr PEG (63%) and under mild sedation with midazolam (80%), all under NIV. There were no immediate complications during and after the procedure (no episodes of aspiration or orotracheal intubation) and mortality. Conclusion: The placement of PEG is a very important procedure in patients with ALS and severe ventilatory impairment. The interdisciplinary department collaboration permitted the placement of PEG under NIV, in a safe and effective procedure in this special population.