Percutaneous Endoscopic Gastrostomy Tube Removal Research Articles

Fast-track discharge following percutaneous endoscopic gastrostomy removal in head and neck cancer patients after remission: a feasibility and safety study

Introduction and AimHead and neck cancer patients (HNCP) often require enteral nutritional support during chemoradiotherapy (CRT) possibly using a percutaneous endoscopic gastrostomy (PEG). Patients achieving complete oncological response and successfully resuming normal oral intake, will be scheduled for the removal of PEG post-treatment. We aim to evaluate the feasibility and safety of PEG tube removal with immediate discharge. MethodsProspective, observational, unicentric study, including all HNCP scheduled for PEG removal from October 2020 to February 2022. HNCP in remission had PEG removal with discharge after 30minutes and re-beginning cold liquid diet after 3hours. Additional therapy with omeprazole 40mg bid orally for 4 weeks was prescribed. Patients were scheduled for re-evaluation appointment after 1 month. ResultsDuring the study period, 120 HNCP scheduled for PEG removal were enrolled, with an adverse events rate of 6,7%, including seven (5.8%) persistent gastrocutaneous fistulas (GCF) and one (0.8%) parastomal hernia. 6/7 GCF solved with medical therapy alone (additional 4 weeks of PPI),1/7 required endoscopic therapy and the parastomal hernia was referred for surgery. There was no association between adverse events and patient age (p 0,343), tumor location (p=0,305) or stage (p=0,605), diabetes mellitus diagnosis (p=0,813), smoking habits (p=0,274), PEG duration (p=0,645), caliber (p=0,587) or previous PEG infections (p=0,659). ConclusionPEG removal with immediate discharge is safe, has low rate of adverse events that mostly resolve with medical therapy.

Complication rates associated with traction removal of percutaneous endoscopic gastrostomy tubes

Background: percutaneous endoscopic gastrostomy (PEG) tubes are removed and/or replaced for reasons such as tube malfunction, degradation, patient's device preference, and when stopping enteral feeding. Aims: to identify the types and rate of complications associated with traction removal of a PEG tube and if this is associated with the size of the PEG or length of time it had been in situ prior to removal. Methods: This retrospective study looked at the tube removal/replacement reports written by the Enteral Feeding Nursing Service over an 8-year period at a large teaching hospital trust in the north of England. Findings: the PEG tube removal reports of 127 patients were reviewed. Five types of complication were identified, categorised as retained bumper (5.5%); intraperitoneal placement of new device (3.17%); misplacement of replacement device into colon (a consequence of the insertion procedure not the removal of the PEG) (0.78%): gastrocutaneous fistula (0.78%); and inability to remove the tube (1.57%). The complication of retained bumpers was associated with an average length of time in situ prior to removal of the PEG tube of 29 months. In the cases of intraperitoneal placement, the PEG tube had been in situ for an average of 6 months. Nurses were unable to remove the PEG tube on two occasions; each had been in situ for approximately 4 years prior to attempted removal. Conclusion: the complication rates are low following removal of a PEG tube using a traction pull. There was no clear correlation between length of time in situ or tube size and complication rate.

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.

S3691 Where Is the Bumper? A Case of Percutaneous Endoscopic Gastrostomy (PEG) Tube Malfunction

Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes are used for enteral access in patients requiring nutritional support. PEG tube placement and removal generally are regarded as safe procedures. However, complications can be experienced in 16-70%, ranging from benign pneumoperitoneum to gastric outlet obstruction, buried bumper syndrome, and bowel perforation. Our case describes a retained internal bumper during PEG tube removal that undergoes spontaneous passage. Case Description/Methods: Our patient is a 71-year-old male with a past medical history of tongue cancer treated with chemoradiation and subsequent dysphagia due to esophageal strictures necessitating PEG tube placement. He presented to the hospital with nausea, recurrent emesis, and an inability to tolerate tube feeds. His PEG tube was placed to gravity with one liter of output and relief of symptoms. A plan was made to proceed with gastrojejunostomy (G-J) tube to mitigate his symptoms. During bedside removal of his PEG tube, the internal bumper was noted to no longer be attached to the tube (Figure 1A). A Foley catheter was placed in the tract to maintain its patency. As the bumper was presumed to be retained in the stomach, esophagogastroduodenoscopy was performed but there was no evidence of foreign body throughout the exam. A computed tomography scan of his abdomen was obtained urgently and showed passage of the bumper into the jejunum (Figure 1B). Serial abdominal radiographs were obtained over the following day showing migration of the bumper into the rectum and was subsequently passed in his stool. Thereafter, the patient has successfully G-J tube placement by interventional radiology. His tube feeds were advanced to goal rate and the patient was no longer having any nausea or vomiting. Discussion: Retained PEG tube internal bumper is a rare complication of PEG tube removal. Prior case reports have described bumper migration into the small bowel where it became lodged and resulted in small bowel obstruction. At least one prior case resulted in small bowel perforation. In cases of bowel obstruction, surgical intervention is warranted. However, in most cases this complication simply warrants clinical monitoring for evidence of obstruction or passage of the PEG bumper; in most reported cases, endoscopic retrieval was not attempted or feasible, and resolved via spontaneous bumper passage through the gastrointestinal tract.Figure 1.: (A) PEG tube with internal bumper no longer attached. (B) CT scan of abdomen showing PEG tube bumper in the jejunum (orange arrow).

S2481 Closure of Refractory Gastrocutaneous Fistula With Endoscopically Guided Percutaneous Suturing With the Use of SpyBite Biopsy Forceps

Introduction: Persistent gastrocutaneous fistula (GCF) is a rare but well-known complication of long-term Percutaneous Endoscopic Gastrostomy (PEG) tube use. To avoid invasive surgery, endoscopic closure has been used as an initial step for treatment but is not always successful. We report a case of successful GCF closure with a novel endoscopically guided percutaneous suturing technique using the SpyBite biopsy forceps. Case Description/Methods: Our case is a 28-year-old male with a history of cystic fibrosis (CF) complicated by malnutrition, requiring PEG tube placement since childhood. After starting CF therapy with elexacaftor/tezacaftor/ivacaftor and achieving optimal nutritional status, his PEG tube was removed. Unfortunately, he developed a persistent GCF. Initial attempts at closure with over-the-scope-clip and endoscopic suturing failed. The decision was made to proceed with GCF closure by endoscopically guided percutaneous suturing using the SpyBite forceps. Under endoscopic guidance, 2 16G long angiocaths were advanced into the gastric lumen, one caudal and one cranial to the fistula tract in a sterile fashion. A 2-0 silk suture was advanced through one angiocath and externalized using SpyBite biopsy forceps through the other angiocath. The angiocaths were then removed over the suture and the loop was tied down using a surgical knot. This process was repeated 2 more times along the fistula tract, 5mm from each other. Internal closure of the GCF was then performed using endoscopic suturing. One interrupted and 2 running sutures were placed along the border and cinched to reinforce the site. There were no immediate adverse events or delayed skin inflammation. The patient had no further leakage from the GCF site at follow-up 2 weeks later (Figure). Discussion: With the emergence of novel CF therapies, the dependence on feeding tubes has decreased. Unfortunately, these patients are at high risk of GCF formation after PEG tube removal. Given the difficulty in closing GCF, we advocate a multimodality approach, as described here, using transcutaneous and endoscopic suturing. In previously described endoscopically guided percutaneous suturing, the suture loop is externalized through the GCF tract or the mouth. Our technique differs in using SpyBite forceps to externalize the suture through a second catheter. This method is simple and provides a safe and effective alternative for the closure of refractory GCFs.Figure 1.: A-B: Gastrocutaneous fistula before (A) and after closure (B). C-D: 2-0 silk suture inserted through the angiocath and SpyBite forceps inserted through the second angiocath. The suture was grasped with SpyBite forceps and pulled through the second angiocath to form a loop (C: external view, D: endoscopic view) E-F: The suture was pulled externally, and a surgical knot was performed (E: external view, F: endoscopic view).

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.

Management of MACROGLOSSIA: Case Series and Suggested Algorithm

Idiopathic macroglossia is a rare entity of true tongue enlargement without an underlying etiology. There are only a few case reports on the diagnosis and management of idiopathic macroglossia. This study's purpose was to present a series of patients with idiopathic macroglossia and suggest a treatment algorithm. This was a retrospective case series of a cohort of patients with macroglossia who were treated by the Oral and Maxillofacial Surgery service at the University of Texas Health Science Center at Houston (UTHealth)and Emory University. The patient's medical comorbidities, history of present illness, clinical presentation, radiographic findings, and disease management were studied. The outcome variables include normalization of the tongue size, dependence on parenteral nutrition, and tolerating tracheostomy decannulation. Five patients with a mean age of 45years were included in the study. All of the patients (n=5, 100%) in our cohort developed macroglossia following prolonged oral intubation, with 3.5weeks being the average length of intubation. All patients presented with difficulty feeding orally and breathing. The average tongue dimension was 12.20 x 6.25cm. All tongue enlargements were located in the anterior 2/3 of the tongue, and all patients had displaced anterior dentition. In addition, 60% of the patients (n=3) experienced altered tongue sensation (pain and/or decreased taste). These patients were surgically managed with tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement followed by partial glossectomy (n=5, 100%). We defined successful outcomes as 1) modifying the tongue to a functional, nonprotruding form, 2) tracheostomy decannulation and 3) PEG tube removal. Tracheostomy decannulation and PEG tube removal were achieved in 80% of the patients (n=4). In this patient cohort, we were unable to identify the cause of the pathology based on existing clinical data. When the etiology is unclear or irreversible, management should involve tracheostomy and surgical feeding access for the initial stabilization, followed by modified glossectomy to improve form, function, and cosmesis thereby improving the overall quality of life.

Complication rates associated with traction removal of percutaneous endoscopic gastrostomy tubes.

Percutaneous endoscopic gastrostomy (PEG) tubes are removed and/or replaced for reasons such as tube malfunction, degradation, patient's device preference, and when stopping enteral feeding. To identify the types and rate of complications associated with traction removal of a PEG tube and if this is associated with the size of the PEG or length of time it had been in situ prior to removal. This retrospective study looked at the tube removal/replacement reports written by the Enteral Feeding Nursing Service over an 8-year period at a large teaching hospital trust in the north of England. The PEG tube removal reports of 127 patients were reviewed. Five types of complication were identified, categorised as retained bumper (5.5%); intraperitoneal placement of new device (3.17%); misplacement of replacement device into colon (a consequence of the insertion procedure not the removal of the PEG) (0.78%): gastrocutaneous fistula (0.78%); and inability to remove the tube (1.57%). The complication of retained bumpers was associated with an average length of time in situ prior to removal of the PEG tube of 29 months. In the cases of intraperitoneal placement, the PEG tube had been in situ for an average of 6 months. Nurses were unable to remove the PEG tube on two occasions; each had been in situ for approximately 4 years prior to attempted removal. the complication rates are low following removal of a PEG tube using a traction pull. There was no clear correlation between length of time in situ or tube size and complication rate.

Over-the-Scope Clip Closure of Persistent Gastrocutaneous Fistula After Percutaneous Endoscopic Gastrostomy Tube Removal: A Report of Two Cases (secondary publication)

Over-the-Scope Clip Closure of Persistent Gastrocutaneous Fistula After Percutaneous Endoscopic Gastrostomy Tube Removal: A Report of Two Cases (secondary publication)

Delayed percutaneous endoscopic gastrostomy tube removal in patients with oropharyngeal carcinoma

Early nutritional intervention through enteral feeding can reduce treatment alterations and complications in patients with Oropharyngeal Cancer (OPC) undergoing Chemoradiation Treatment (CRT).

Re-PEGing: An Endoscopic Approach to Inadvertent Early PEG Tube Withdrawal

Introduction: Percutaneous endoscopic gastrostomy (PEG) is the modality of choice for enteral feeding access in patients with dysphagia. A common complication is inadvertent removal of the tube. If it occurs early after placement, there is a potential for leak of gastric contents through the gastric wall defect, and a risk of peritonitis and sepsis. The standard approach to this problem has been either observation, or, in patients with peritoneal signs, surgical exploration. An alternative approach, “re-PEGing”, which patches the gastric wall defect to the anterior abdominal wall, was described by Galat in 1990, but did not gain acceptance. We adopted this approach, and report our successful experience with seven patients. Methods: The records of 352 patients who underwent PEG placement between January 2015 and March 2018 in a 528-bed hospital were reviewed. Seven patients with removal of PEG tube within four weeks of placement, who were treated with re-PEGing, were identified. Clinical data were collected and analyzed. Results: Seven patients had PEG tube withdrawal within a range of one to 25 days after placement. In five patients, there was evidence of violation of the peritoneal cavity either on physical exam or on imaging studies showing peritoneal air or fluid. In two of these patients, an attempt had been made for direct replacement of the tube through the gastro-cutaneous tract with a balloon-catheter, resulting in intraperitoneal placement. All patients received a short course of broad spectrum antibiotics, and underwent re-PEGing within 24 hours. In five patients, the post-procedural course was uneventful. Two patients had sepsis attributed to a pulmonary source, and were managed conservatively. All patients recovered without residual peritoneal infection. Conclusion: Early PEG tube withdrawal results in the anatomical equivalent of gastric perforation, as well as loss of enteral feeding access. Immediate re-PEGing addresses these two issues non-surgically. So why has this safe, efficient, and minimally invasive procedure not been widely adopted? The most likely explanation is the clinician’s ‘gestalt’ that gastric perforation is a contraindication to upper endoscopy, and should rather be approached surgically. However, our successful experience with re-PEGing, even in cases with peritoneal violation, supports a paradigm shift in the perception and practice of replacing early PEG tube withdrawal.496_A Figure 1. Summary of “re-PEGed” patients, with time to removal from original placement, comment on peritoneal violation, and if a second PEG was placed to improve gastric and abdominal patching (double PEG). Direct tube replacement (DTR). Early Removal of PEG Tube (ERPT).496_B Figure 2. CT abdomen with contrast through PEG tube, demonstrating the dome of the tube within the abdominal wall (white arrow), with contrast spreading between the muscle layers of the abdominal wall (yellow arrow).496_C Figure 3. Endoscopic view of a double-PEG, placed to improve the apposition and patching of the gastric and abdominal walls.

Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to "cut" the tube and allow the bumper to pass enterally?

The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques. We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications. We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004). This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper. Level III-Treatment study, Retrospective comparative study.

Percutaneous endoscopic gastrostomy for patients requiring for long-term enteral nutrition: A retrospective study of 84 patients

Background and Aims: Existed studies about Percutaneous Endoscopic Gastrostomy (PEG) were mainly aimed at certain patient populations and data came from China are quite limited. Our aim was to investigate whether PEG in South China is effective and to compare the indications and complications of PEG with those reported in the literature. Materials and Methods: Patients underwent PEG procedure during the period from January 2000 to October 2014 in Nanfang Hospital were retrospectively collected and analysed. The patients’ lymphocyte counts, leukocyte counts, serum albumin, hemoglobin, serum total protein, weight and BMI before and after PEG operation were reviewed as the main outcome measurement. Indications, complications and success rates of PEG procedure were also evaluated. Results: A total of 84 patients (61 males, 23 females) were enrolled, with an average age of 55.01 ± 15.16 y (range 3.0-92 y). The overall success rate is about 98.8%. The most common indication for PEG in South China is head and neck cancer (27/84, 32.1%). Significant differences were observed in parameters such as lymphocyte counts, serum albumin, serum total protein, body weight, BMI before and after PEG operation.(1.29 vs. 1.76, p=0.005; 33.58 vs. 33.66, p=0.012; 62.82 vs. 67.29, p=0.018; 43.62 vs. 48.29, p=0.044; 16.24 vs. 18, p=0.030; respectively). The most common procedure-related complication was PEG tube removal (6/84, 7.14%), which were all well managed. Conclusions: This is the first retrospective case series evaluating PEG procedure in South China. Our results indicate that PEG is an effective and safe method for long-term enteral nutrition.

Comparison of removal techniques in the management of buried bumper syndrome: a retrospective cohort study of 82 patients.

Background and study aims Buried bumper syndrome is an infrequent complication of percutaneous endoscopic gastrostomy (PEG) that can result in tube dysfunction, gastric perforation, bleeding, peritonitis or death. The aim of this study was to compare the efficacy of different PEG tube removal methods in the management of buried bumper syndrome in a large retrospective cohort. Patients and methods From 2002 to 2013, 82 cases of buried bumper syndrome were identified from the databases of two endoscopy referral centers. We evaluated the interval between gastrostomy tube placement and diagnosis of buried bumper syndrome, type of treatment, success rate and complications. Four methods were analyzed: bougie, grasp, needle-knife and minimally invasive push method using a papillotome, which were selected based on the depth of the buried bumper. Results The buried bumper was cut free with a wire-guided papillotome in 35 patients (42.7 %) and with a needle-knife in 22 patients (26.8 %). It could be pushed into the stomach with a dilator without cutting in 10 patients (12.2 %), and was pulled into the stomach with a grasper in 12 patients (14.6 %). No adverse events (AEs) were registered in 70 cases (85.4 %). Bleeding occurred in 7 patients (31.8 %) after cutting with a needle-knife papillotome and in 1 patient (8.3 %) after grasping. No bleeding was recorded after using a standard papillotome or a bougie ( P < 0.05). Ten of 22 patients (45.5 %) treated with the needle-knife had a serious AE and 1 patient died (4.5 %). Conclusions We recommend that incomplete buried bumpers be removed with a bougie. In cases of complete buried bumper syndrome, the bumper should be cut with a wire-guided papillotome and pushed into the stomach.

Wandering Gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe and effective method of providing nutrition to patients with neurologic deficits or proximal gastrointestinal pathology. Complications that follow this common procedure include dislodgement, dysfunction, infection, gastric/colonic perforation, bleeding, peritonitis, or death. The emergency physician should be aware of the complications and symptoms/signs associated for appropriate management of these patients. We present a case of a young lady who developed a cerebral infarction following amniotic fluid embolism during her cesarean section and had undergone a PEG tube placement. She developed displacement of this PEG tube and underwent another PEG tube placement. She later presented to us with PEG tube migration into the transverse colon and required surgical removal of the same PEG tube.

A Comparison of Outcomes Using Intensity-Modulated Radiation Therapy and 3-Dimensional Conformal Radiation Therapy in Treatment of Oropharyngeal Cancer

Approximately 50% of head and neck cancer survivors experience dysphagia and related morbidity. Intensity-modulated radiation therapy (IMRT) is increasingly used to treat oropharyngeal cancers with excellent oncologic outcomes, but few studies have compared it with conventional 3-dimensional conformal radiation therapy (3D-CRT) to determine whether it can decrease treatment-related toxic and adverse effects. To determine whether IMRT improves percutaneous endoscopic gastrostomy (PEG) tube and treatment-related toxicity outcomes compared with 3D-CRT in patients with oropharyngeal squamous cell carcinoma. Retrospective review of 159 patients with oropharyngeal primary tumors with no history of chemotherapy, radiation therapy, or surgery of the head and neck who underwent definitive treatment with radiotherapy for oropharyngeal squamous cell carcinoma at the Hollings Cancer Center outpatient clinic, Medical University of South Carolina, from 2000 to 2009. Doses of 70 Gy in 35 daily fractions of radiotherapy delivered via IMRT or 3D-CRT. Primary end points included PEG tube dependence 1 year after radiotherapy start, weight loss during treatment, and change in Eastern Cooperative Oncology Group performance status. Secondary end points included overall and disease-free survival, disease recurrence, and toxic effect profiles. The IMRT group (n = 103) had a significantly lower rate of PEG tube dependence 1 year after treatment initiation than the 3D-CRT group (n = 56) for all patients (P = .02) and for those with advanced T stage (P = .01) and a shorter time to PEG tube removal (P < .001). Acute grade 3 or greater toxic effects to skin and mucous membranes occurred less frequently in the IMRT group (P = .02 and P < .001, respectively). The 2 groups did not differ significantly in weight loss, treatment failure (hazard ratio, 0.82 [95% CI, 0.47-1.41]), overall survival (P = .45), or disease-free survival (P = .26). The use of IMRT significantly improves PEG tube and toxicity-related outcomes compared with 3D-CRT in the treatment of oropharyngeal primary cancers. Given the association between mucosal toxic effects, PEG tube dependence, and dysphagia, these findings may be an indication of improved swallowing outcomes with IMRT.

A safe "cut, tie and thread-pull" method for percutaneous endoscopic gastrostomy tube removal in children with congenital craniofacial anomalies and pharyngeal stenosis.

Percutaneous endoscopic gastrostomy (PEG) is a widely used method for tube feeding with enteral nutrition. Both PEG's insertion and PEG's removal are usually easy and uncomplicated. The latter can be, however, of substantial difficulty in children with distorted anatomy, such as pharyngeal stenosis or endured craniofacial trauma, when regular endoscopy is contraindicated. The aim of the study was to assess the very simple, but rarely used method for percutaneous removal of the tube by pulling the thread. Four children (4 males, mean age 4.1 year) were analyzed. In all of them the procedure was successful, quick and uncomplicated. To conclude, the thread method should be recommend in case the endoscopic removal is impossible.

Multipurpose use of the over-the-scope-clip system ("Bear claw") in the gastrointestinal tract: Swiss experience in a tertiary center.

To evaluate the outcome of over-the-scope-clip system (OTSC) for endoscopic treatment of various indications in daily clinical practice in Switzerland. This prospective, consecutive case series was conducted at a tertiary care hospital from September 2010 to January 2014. Indications for OTSC application were fistulae, anastomotic leakage, perforation, unroofed submucosal lesion for biopsy, refractory bleeding, and stent fixation in the gastrointestinal (GI) tract. Primary technical success was defined as the adequate deployment of the OTSC on the target lesion. Clinical success was defined as resolution of the problem; for instance, no requirement for surgery or further endoscopic intervention. In cases of recurrence, retreatment of a lesion with a second intervention was possible. Complications were classified into those related to sedation, endoscopy, or deployment of the clip. A total of 28 OTSC system applications were carried out in 21 patients [median age 64 years (range 42-85), 33% females]. The main indications were fistulae (52%), mostly after percutaneous endoscopic gastrostomy tube removal, and anastomotic leakage after GI surgery (29%). Further indications were unroofed submucosal lesions after biopsy, upper gastrointestinal bleeding, or esophageal stent fixation. The OTSC treatments were applied either in the upper (48%) or lower (52%) GI tract. The mean lesion size was 8 mm (range: 2-20 mm). Primary technical success and clinical success rates were 85% and 67%, respectively. In 53% of cases, the suction method was used without accessories (e.g., twin grasper or tissue anchor). No endoscopy-related or OTSC-related complications were observed. OTSC is a useful tool for endoscopic closure of various GI lesions, including fistulae and leakages. Future randomized prospective multicenter trials are warranted.

Risk Factors for Percutaneous Endoscopic Gastrostomy Tube Placement During Chemoradiotherapy for Oropharyngeal Cancer

Patients with oropharyngeal squamous cell carcinoma undergoing chemoradiotherapy may require percutaneous endoscopic gastrostomy (PEG) tube placement because of dehydration or significant weight loss. To determine the need for the reactive placement of a PEG tube during chemoradiotherapy for oropharyngeal cancer and to identify patient or tumor factors associated with reactively requiring the placement of a PEG tube. Single-institution retrospective review of 297 patients treated with intensity-modulated radiation therapy and concurrent chemotherapy for oropharyngeal squamous cell carcinoma between May 1, 2004, and June 30, 2012, with a minimum follow-up period of 3 months. Placement of a PEG tube. Logistic regression analysis was used to identify independent risk factors associated with symptomatic requirement for the reactive placement of a PEG tube. In total, 128 patients did not receive a prophylactic PEG tube within 10 days of initiation of chemoradiotherapy. Fifteen of 128 patients (11.7%) required the reactive placement of a PEG tube during or within 3 months of chemoradiotherapy. The median time to PEG tube removal was 3.3 months, and 14 of 15 patients had their PEG tube removed at the last follow-up analysis. Independent risk factors for PEG tube placement included the following: accelerated irradiation fractionation (odds ratio, 4.3; 95% CI, 1.1-16.5; P = .04), a tumor T classification of 3 or higher (odds ratio, 3.5; 95% CI, 1.0-11.9; P = .04), a cumulative cisplatin dose of 200 mg/m² or higher (odds ratio, 6.7; 95% CI, 1.2-36.7; P = .03), and a body mass index (calculated as weight in kilograms divided by height in meters squared) of less than 25 (odds ratio, 5.8; 95% CI, 1.4-23.9; P = .02). Although the overall risk is low, a body mass index of less than 25, accelerated irradiation fractionation, a tumor T classification of 3 or higher, and a cumulative cisplatin dose of 200 mg/m² or higher are associated with symptomatic need for the reactive placement of a PEG tube in patients with oropharyngeal cancer.

Safety and Feasibility of Interventional Pulmonologists Performing Bedside Percutaneous Endoscopic Gastrostomy Tube Placement

Prior to the 1980s, permanent feeding tube placement was limited to an open surgical procedure until Gauderer and colleagues described the safe placement of percutaneous endoscopic gastrostomy (PEG) tubes. This procedure has since expanded beyond the realm of surgeons to include gastroenterologists, thoracic surgeons, and interventional radiologists. In some academic centers, interventional pulmonologists (IPs) also perform this procedure. We describe the safety and feasibility of PEG tube placement by IPs in a critically ill population. Prospectively collected data of patients in a medical ICU undergoing PEG tube placement from 2003 to 2007 at a tertiary-care center were reviewed. Inclusion criteria included all PEG tube insertions performed or attempted by the IP team. Data were collected on mortality, PEG tube removal rate, total number of days with PEG tube, and complication rates. Follow-up included hospital length of stay and phone contact after discharge. Procedural and long-term PEG-related complications were recorded. Seventy-two patients were studied. PEG tube insertion was completed successfully in 70 (97.2%), with follow-up data in 69 of these 70. Thirty-day mortality was 11.7%. No deaths or immediate complications were attributed to PEG tube placement. PEG tube removal occurred in 27 patients, with a median time to removal of 76 days. Bedside PEG tube placement can be performed safely and effectively by trained IPs. Because percutaneous tracheostomy is currently performed by IPs, the ability to place both PEG and tracheostomy tubes at the same time has the potential for decreased costs, anesthesia exposure, procedural times, ventilator times, and ICU days.