PEG Placement Research Articles

Predictive Factors for Pre-Operative PEG Placement

Predictive Factors for Pre-Operative PEG Placement

Prophylactic PEG Tube and Swallowing following Chemoradiation in Head and Neck Cancer Patients

Objectives: (1) Compare swallowing status in patients receiving a prophylactic gastrostomy (PPEG) tube versus relying on oral intake during chemoradiation (CRT) for head and neck cancer. (2) Discuss prognostic factors associated with gastrostomy tube dependence 1 year after completion of CRT. Methods: The Eastern Virginia Medical School Cancer registry identified patients with a new head and neck cancer diagnosis from January 1, 2001, to July 1, 2008. We excluded patients treated with primary surgical therapy, at an outside facility, and with radiation therapy only. Our final cohort of patients who lived at least 1 year with follow-up was 105. Primary outcomes were oral intake status at 1 year and need for esophageal dilation. Results: Eighty-one patients received a PPEG, and 24 did not. There was no difference in swallowing function at 6 months ( P = .27) or the rate of esophageal dilation ( P = .22). Stricture rates were 13% in the initial oral group versus 25% in the PPEG group. Univariate analysis predictors for PEG tube dependence at 1 year were Zubrod score >1 ( P < .001), PPEG ( P = .03), and higher T stage ( P = .008). On multivariate analysis, PPEG ( P = .05), Zubrod score >1 ( P = .000001), and higher T stage ( P = .02) were independent predictors for PEG tube dependence at 1 year. Conclusions: PPEG tube, Zubrod score >1, and higher T stage were independent predictors for PEG tube dependence after chemoradiation. An approach of initial oral intake with placement of therapeutic PEG due to inability to maintain adequate nutrition by mouth should be considered.

OC-036 Non-invasive Ventilation During Percutaneous Endoscopic Gastrostomy Insertion In Motor Neurone Disease Patients – A Safe And Effective Multi-disciplinary Approach

IntroductionPercutaneous endoscopic gastrostomy (PEG) is recommended for motor neurone disease patients with dysphagia and accelerated weight loss. However PEG has been suggested as inadvisable in the past in patients with...

OC-024 Predicting 30-day Mortality Following Peg Insertion: External Validation Of A Previous Scoring System And Analysis For Additional Predictive Factors

IntroductionPercutaneous endoscopic gastrostomy (PEG) insertion is a well-established technique for providing long-term enteral nutrition. However concerns have been raised regarding the high 30-day mortality associated with PEG, and the related...

Sa1625 Randomized Prospective Trial of CO2 vs. Room Air Insufflation During PEG Placement on Pneumoperitoneum Production

Figure 1. Efficacy of Long-term PEG-J Drug Delivery Figure 2. Quality of Life of Patients with Long-term PEG-J Drug Delivery

Single‐Center Experience With 1‐Step Low‐Profile Percutaneous Endoscopic Gastrostomy in Children

The 1-step low-profile percutaneous endoscopic gastrostomy (1-step PEG) uses a single procedure that allows immediate use of a low-profile device. The aim of the present study was to provide our experience with this device and to analyze complications and outcomes after the initial placement. We performed a retrospective chart review of pediatric patients with 1-step PEG placement done by our pediatric gastroenterologists between 2006 and June 2011. Patients were studied for a minimum period of 6 months. A total of 121 patients were included in our study, with 23% infants. The most common indication for 1-step PEG placement was swallowing dysfunction in children with neurological impairment (49%). Postplacement complications included granulation tissue (52%), cellulitis (23%), leakage (21%), vomiting (17%), tissue breakdown (8%), failed placement (6%), embedded bolster (5%), perforation (0.8%), and bowel obstruction (0.8%). One-step PEG was maintained in 46 patients (38%). In the remaining 75 patients (62%), PEGs were changed to a balloon device in 66 patients and were completely removed in 9 patients. The most common indications for change were damaged PEG (19/75) and issues with size (11/75). The time to change ranged from <1 month to >4 years (14 ± 1.3 months). Sixty-eight percent of 1-step PEG changes/removal was performed with an obturator under brief inhalated anesthesia. The 1-step PEG has complication rates and outcomes comparable with standard PEGs.

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Introduction: Dislodgment requiring urgent intervention is an uncommon but morbid complication of PEG insertion. We sought to determine risk factors associated with this. Methods: The hospital database was queried for patients undergoing PEG insertion from 2004-2012. Data for those with dislodgement requiring urgent surgical, endoscopic or other invasive procedures were recorded. Dislodgments requiring only bedside replacement were excluded. The control group consisted of consecutive patients from the most recent 10 month period who had no PEG dislodgements. To determine the role of body habitus in dislodgment, the minimum distance between the skin to the parietal peritoneum at the level of the stomach was measured on computed tomographic (CT) images, if available prior to PEG insertion. Fisher Exact and the Mann Whitney U test were used after testing for normality with the Shapiro-Wilks test. A p value of ≤0.05 was deemed significant. Results: In a 9-year period, 28(1.4%) of 1968 PEGs became dislodged requiring urgent intervention. Compared to the control group of 166 patients, those with dislodgments were younger (median age 56 vs 68, p=0.004) and more likely male (22/28 vs 90/166, p=0.02). No differences were seen regarding prevalence of COPD, CAD, CHF, renal disease, liver disease, chronic steroid use or neurologic diseases except developmental disorders (5/28 vs 4/166, p=0.004). Regarding body mass index, 22% lacked data. In the remainder, dislodgment was associated with lower BMI (median, 22 vs. 28, p=0.008). Regarding abdominal wall thickness, 29% had no pre-PEG insertion CT data. Of the remainder, dislodgment was associated with a thinner abdominal wall (median, 18 vs 23 mm, p=0.02). All of the corrective procedures involved laparotomy except two treated with repeat PEG placement. Four (14%) of the 28 with dislodged PEGs died, with associated sepsis/multi organ failure in three of the four. Conclusions: In this small study, PEG dislodgments requiring urgent intervention are uncommon, and associated with younger age, thinner body habitus and development disorders. These risk factors merit more study through larger prospective trials.

Transnasal PEG tube placement in patients with head and neck cancer

Head and neck cancer (H&NCa) patients have an increased risk of malnutrition and dysphagia because of their malignancy and the adverse events of therapy. Most of these patients require gastrostomies. Four percent to 7% of H&NCa patients are unable to undergo per oral percutaneous gastrostomies. Transnasal endoscopy is an option for gastrostomy placement in selected patients. Clinical, epidemiologic characteristics and outcomes of transnasal PEG (t-PEG) placement. Retrospective analysis. Tertiary care hospital, The University of Texas MD Anderson Cancer Center. All patients who underwent t-PEG placement. Epidemiology, adverse events, and outcomes of t-PEG placement. Sixteen patients underwent t-PEG placement from January 2010 to May 2013. All patients had H&NCa and 56.3% had metastasis. Indications for the transnasal approach were airway compromise, malignant oropharyngeal obstruction, and trismus, among others. All procedures were successful using a 20F gastrostomy tube, push technique, anesthesiologist-guided propofol sedation, and/or nasotracheal intubation. Of all patients, 68.8% were white and 68.8% were men. Mean age was 54 years, and mean body mass index was 20.87. Two patients had a total of 2 adverse events: poor wound healing and wound site infection. Of all patients, 18.75% had leukopenia, 6.25% neutropenia, and 50% lymphopenia. Mean white blood cell count, absolute neutrophil count, and absolute lymphocyte count were 8.6 × 10(9)/L, 6.57 × 10(9)/L, and .93 × 10(9)/L, respectively. Eleven patients were alive, 2 were lost to follow-up, and 3 had died at the time of review. Retrospective analysis, small cohort, patient selection bias. t-PEG placement is a viable and safe option for H&NCa patients when the standard endoscopic approach is not feasible.

Prospective Dysphagia Quality of Life Scores and Treatment Outcomes in Oropharyngeal Cancer Patients: Is it Time to Reconsider the Prophylactic Percutaneous Endoscopic Gastrostomy?

Prospective Dysphagia Quality of Life Scores and Treatment Outcomes in Oropharyngeal Cancer Patients: Is it Time to Reconsider the Prophylactic Percutaneous Endoscopic Gastrostomy?

OC-063 Pain and Anxiety Experienced by Patients following Peg Placement: Abstract OC-063 Table 1

Introduction Abdominal pain following percutaneous endoscopic gastrostomy (PEG) placement is a recognised complication considered to be secondary to a chemical peritonitis. However, the prevalence and degree of severity of pain is poorly characterised. Abdominal pain following liver biopsy is strongly linked to preprocedural anxiety levels 1 . We assessed abdominal pain and anxiety associated with PEG placement. Methods A prospective questionnaire assessed patient anxiety and abdominal pain 1 hour (h) pre PEG placement, 1h post and 24h post using a 10-point Likert scale. The questionnaire was completed by the patient where possible or clinician if not. Abdominal pain was assessed by examination at 1h post procedure. 24h post procedure complications and analgesia requirements were recorded. Patient’s Mini Mental Score (MMSE, 0–30) and Barthel index (0–20) were completed. Results 70 consecutive patients (M:F 45:25) median age 61.5 (19–94) were assessed. The commonest indications were head and neck malignancies (44%) and stroke (11%). PEG placement was on first attempt in 68 cases, with no clinical complications. Mean (StD), MMSE, Barthel, anxiety and pain scores. 24 self-reporting patients had a pain score of 1–3 at 1h post placement and 20 at 24 h. 3 patients reported a pain score of 7–10 at 1 h post placement and 7 at 24 h. 21/49 self-reporting patients and 0/21 non self-reporting had PEG site and/or general abdominal tenderness on clinical examination at 1h. Pain post PEG placement was noted in only 1 clinician-assessed patient. This was at 24 h. 50.7% of patients took analgesia at 24 hours post procedure (all self-reporting). Regression showed no relationship between pre placement anxiety and post placement pain. Conclusion Pain at 1h post PEG placement was common in self-reporting patients and usually mild. By 24h, 41% reported moderate to severe pain often taking analgesia. Preprocedural anxiety did not predict post procedural pain. Clinician examination of all patients at 1h did correlate with self-reported discomfort or predict self reported pain at 24h. Clinician assessment at 1h and 24h where patients could not self assess failed to identify pain. After PEG placement patients should be offered advice on pain and given access to analgesia. It is likely that pain is not identified in debilitated patients and clinicians need to be more alert to its possible presence. Disclosure of Interest None Declared Reference Riley T. Predictors of pain medication use after percutaneous liver biopsy. Digest Dis Sci 2002; 47:2151–53.

PEG status and outcomes in head and neck cancer patients treated with chemoradiotherapy.

e17030 Background: Patients undergoing concomitant chemoradiotherapy may or may not undergo prophylactic PEG placement, depending on baseline weight, medical status and presence of dysphagia. We examined quality of life, performance status and oral outcomes in patients with or without PEG at baseline and 3 months post-treatment. Methods: Thirty-three patients with head and neck cancer were treated with chemoradiotherapy. All were seen baseline and 3 months post-tx. Assessments included the Performance Status Scale (PSS), Karnofsky Performance Status Scale (KPSS), tongue strength, jaw opening, and saliva weight. Patient-rated QOL utilized the MD Anderson Dysphagia Inventory (MDADI) and Eating Assessment Tool (EAT-10) with significance at p&lt;.05. Results: Weight loss from baseline to 3 months post-tx was 15.16 % (p=0.000) and 10.41% (p=0.046) for those without and with PEGs, respectively. At 3 months post-tx, the PEG group performed significantly worse than the no-PEG group on the EAT-10;(p=0.050), worse on the MDADI (p=0.089) and saliva weight (p=0.032). In the no-PEG group, significant decreases from baseline to 3 months post-tx were seen for KPSS (p=0.014), Normalcy of Diet (p=0.001), Eating in Public (p=0.004),tongue strength (p=0.002), jaw opening (p=0.000), saliva weight (p=0.000), EAT-10 (p=0.001) and MDADI (p=0.016). For the PEG group, statistically significant decreases were noticed from baseline to 3 months post-tx in Normalcy of Diet (p=0.027), tongue strength (p=0.034), jaw opening (p=0.027), and saliva weight (p=0.018). Conclusion: Concomitant chemoradiotherapy for treatment of head and neck tumors can result in impaired performance outcomes and QOL over the first 3 months post-tx. However, performance status, tongue strength, jaw ROM and eating QOL were only mildly impaired by 3 months post-tx. Differences were observed in weight loss, performance status, oral outcome variables and QOL for PEG vs. no-PEG groups. However, the magnitude of the differences was not significant with the exception of the EAT-10 &amp; saliva weight, with greater impairment in eating QOL and lower saliva weight in the PEG group.

Sa1550 Risk Factors for Complications and Mortality of Percutaneous Endoscopic Gastrostomy: a Multicenter, Retrospective Study

Background Percutaneous endoscopic gastrostomy (PEG) is performed to provide nutrition to patients with swallowing difficulties. A multicenter study was conducted to evaluate the predictors of complications and mortality after PEG placement.

Transhepatic percutaneous endoscopic gastrostomy

We describe the case of a hepatic injury after the insertion of a PEG. In a cirrhotic woman affected by a locally advanced cancer of the pharynx, the PEG tube was inserted through the edge of the left lobe of the liver. The patient was treated with a conservative approach by managing abdominal pain and the PEG was removed after 4 months without complication. Hepatic injury is a rare complication of PEG placement; in order to avoid it, PEG tube should be inserted to the left of the abdominal midline and the lower edge of the liver should be defined by palpation; in cirrhotic patients, where left hepatic lobe hyper-trophy is common, ultrasound guidance could have been appropriate.

PEG placement in patients with ALS

PEG placement in patients with ALS

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) IN MND: A 10-YEAR EXPERIENCE

Enteral feeding is offered to many patients diagnosed with Motor Neuron Disease (MND) experiencing dysphagia and impaired nutritional status. The evidence for survival advantage after PEG insertion is weakly positive...

PEG Tubes: Assessing the Understanding of the Decision Maker

Purpose: To assess the understanding and perception of decision makers who consent for PEG tube placement for patients unable to consent for themselves. Methods: During the time of informed consent for a PEG tube, the decision maker was asked to participate in a short survey which was conducted after the PEG tube was successfully placed. The survey consisted of mostly yes-or-no questions that asked about various aspects regarding PEG tubes that were discussed at the time of consent. Basic demographic information was also recorded. Patients receiving PEG tubes who were able to provide their own consent were excluded. IRB approval was obtained. Results: 32 surveys were conducted at Einstein Medical Center in Philadelphia, PA between May 2011 and May 2012. 19 (59%) patients presented from a nursing facility. The mean patient age was 75 years (range 18-97), and 28 (88%) patients were African-American. 18 (56%) patients underwent PEG tube placement because of dementia. The mean age of the decision makers was 56 years (range 36-81). The discussion of PEG tube placement was initiated by the medical staff in 27 (84%) patients. All decision makers (100%) reported that they received adequate information regarding the benefits, risks, and purpose of PEG tube placement. Although most reported that they were told about the risks of bleeding, infection, and anesthesia complications (28-31 patients, 88-97%), 15 (47%) reported that they were told that PEG tubes would prevent aspiration. For patients with dementia, 2 (11%) decision makers reported that they were told that PEG tubes extended life and 8 (44%) reported that they were told that PEG tubes improved the quality of life. However, 9 (50%) decision makers believed that PEG tubes extended life and 14 (78%) believed that they improved the quality of life. Conclusion: At our institution, the discussion about PEG tubes seems to be initiated mainly by medical personnel, and dementia continues to be a leading indication for PEG placement. Although decision makers reported being properly informed about the risks of bleeding, infection, and anesthesia complications, many reported that they were told, incorrectly, that PEG tubes would minimize aspiration risks. Many decision makers appear to believe that PEG tubes would improve the quantity and quality of life despite reporting that they were told that they would not do so. Further investigation to study this discrepancy is warranted. The survey results highlight important areas where communication between physician and decision maker can be improved, particularly if non-gastroenterology medical staff participate in the initial discussion.

Transnasal Percutaneous Endoscopic Ggastrostomy (t-PEG) Tube Placement: The MD Anderson Cancer Center (MDACC) Experience

Purpose: Patients with head and neck cancers (H&NCa) are at increased risk for dysphagia and difficulty feeding leading to malnutrition due to the nature of the malignancy and therapy related complications. Significant numbers of these patients require gastrostomy tubes for enteral nutrition support while undergoing treatment. For a variety of reasons, up to 10% of H&NCa patients are unable to have gastrostomy tubes placed via the traditional per oral route. Transnasal endoscopy provides a safe and viable option for gastrotomy tube placement in selected patients. Retrospective analysis and description of the clinical characteristics of patients who underwent t-PEG placement at MDACC. 7 patients had t-PEG tubes placed from December 2010 to May 2012. All patients had H&NCa and 85.7% (6/7) had metastatic disease at the time of tube insertion. Indications for the transnasal approach were: airway compromise, malignant oropharyngeal obstruction, trismus or deep hypopharyngeal ulcer. All procedures were successfully performed using a 20Fr gastrostomy tube (Boston Scientific, Natick, MA) utilizing the PUSH technique under propofol sedation having received prophylactic antibiotics. 57.1% of patients were white and male. Mean age was 52 years and mean BMI was 19.32. Two patients had a total of 3 complications directly related to PEG placement. First patient experienced poor wound healing and bleeding at the insertion site. She had received Avastin® within 30 days of the procedure. The second patient had wound infection 7 days after gastrostomy placement. 28.6%, 14.3% and 71.4% of patients had leukopenia, neutropenia and lymphopenia respectively. Mean WBC, ANC and absolute lymphocyte count was 7.3, 5.94 and 0.73 respectively. At the time of analysis 3/7 patients were alive and 1 patient was lost to follow up. Three patients died, all as consequence of the underlying malignancy. t-PEG placement is a viable and safe option for H&N and other cancer patients where access to the oral cavity or the oropharynx is greatly compromised and the standard endoscopic approach is not possible.

Die kolokutane Fistel – eine seltene Spätkomplikation nach PEG-Anlage

A 43-year-old woman with spastic tetraparesis, mental retardation and long-term tube feeding was admitted for a replacement of the PEG tube, 15 months after placement and regular use of her first feeding tube. New problems had occurred with local infection and a suspected leakage. The gastrostoma showed a local erythema and increased secretion of putrid fluids, furthermore a tendency to diarrhea had developed. Otherwise the abdomen was inconspicuous. All routinely achieved blood tests were normal. Gastroscopy revealed a mucosal scar with a small fistula instead of the expected tip of the PEG tube. A CT scan demonstrated displacement of the tip into the transverse colon. The displaced PEG tube was removed by colonoscopy. After laparoscopic occlusion of the colocutaneous fistula with a surgical stapler and clearing of further adhesions a new PEG was inserted endoscopically during the same operation with laparoscopic guidance through the pneumoperitoneum. The development of a colocutaneous fistula as a result of an unperceived perforation is a rare complication of a PEG placement. Despite of the notable mechanism that the tip of the tube erodes the gastric wall and penetrates into the adjacent colon, the clinic is often oligosymptomatic and can easily been missed.

Basic geriatric assessment does not predict in-hospital mortality after PEG placement

BackgroundPercutaneous endoscopic gastrostomy (PEG) is an established procedure for long-term nutrition. However, studies have underlined the importance of proper patient selection as mortality has been shown to be relatively high in acute illness and certain patient groups, amongst others geriatric patients. Objective of the study was to gather information about geriatric patients receiving PEG and to identify risk factors associated with in-hospital mortality after PEG placement.MethodsAll patients from the GEMIDAS database undergoing percutaneous endoscopic gastrostomy in acute geriatric wards from 2006 to 2010 were included in a retrospective database analysis. Data on age, gender, main diagnosis leading to hospital admission, death in hospital, care level, and legal incapacitation were extracted from the main database of the Geriatric Minimum Data Set. Self-care capacity was assessed by the Barthel index, and cognitive status was rated with the Mini Mental State Examination or subjectively judged by the clinician. Descriptive statistics and group comparisons were chosen according to data distribution and scale of measurement, logistic regression analysis was performed to examine influence of various factors on hospital mortality.ResultsA total of 1232 patients (60.4% women) with a median age of 82 years (range 60 to 99 years) were included. The mean Barthel index at admission was 9.5 ± 14.0 points. Assessment of cognitive status was available in about half of the patients (n = 664), with 20% being mildly impaired and almost 70% being moderately to severely impaired. Stroke was the most common main diagnosis (55.2%). In-hospital mortality was 12.8%. In a logistic regression analysis, old age (odds ratio (OR) 1.030, 95% confidence interval (CI) 1.003-1.056), male sex (OR 1.741, 95% CI 1.216-2.493), and pneumonia (OR 2.641, 95% CI 1.457-4.792) or the diagnosis group ‘miscellaneous disease’ (OR 1.864, 95% CI 1.224-2.839) were identified as statistical risk factors for in–hospital death. Cognitive status did not have an influence on mortality (OR 0.447, CI 95% 0.248-1.650).ConclusionIn a nationwide geriatric database, no component of the basic geriatric assessment emerged as a significant risk factor for mortality after PEG placement, emphasizing individual decision-making.

Metastasis of untreated head and neck cancer to percutaneous gastrostomy tube exit sites

BackgroundPercutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive head and neck tumors. PEG tube placement is considered safe and complications are infrequent. MethodsA comprehensive review of the literature in MEDLINE (1962-2011) was performed. We report herein 3 new cases. ResultsThe literature search revealed 43 previous cases. The interval between PEG placement and diagnosis of metastasis ranged from 1 to 24 months. ConclusionsMetastatic cancer should be considered in patients with head and neck cancer that have persistent, unexplained skin changes at PEG site, anemia, or guaiac positive stools without a clear etiology. The direct implantation of tumor cells through instrumentation is the most likely explanation, although hematogenous and/or lymphatic seeding is also a possibility. Our review of the literature and clinical experience indicate that the “pull” technique of PEG placement may directly implant tumor cells at the gastrostomy site.