Gastrostomy Tube Removal Research Articles

Nonoperative Closure of Persistent Gastrocutaneous Fistulas in Children with 2-Octylcyanoacrylate

A persistent gastrocutaneous fistula (pGCF) is an all-too-common complication following removal of a gastrostomy tube (GT) in a child and is associated with significant morbidity. The most common initial methods to manage pGCF include local would care and occlusion techniques. Failure of this approach is followed by surgical excision of the fistula tract and closure of the gastrostomy under general anesthesia. We report the first use of a tissue adhesive, 2-octylcyanoacrylate (2OC) (Dermabond; Ethicon, Sommerville, NJ) as a non-surgical method to close pGCF in children. The families of children presenting to the pediatric surgical division for management of a pGCF were offered the option of 2OC closure. Children not receiving or who failed to achieve closure with 2OC therapy underwent surgery for excision of the pGCF with primary closure of the stomach and soft tissues. Seven children underwent 2OC therapy. 57% (4 of 7) of the children had complete closure of the pGCF with 2OC therapy. Three children underwent operative closure without complication. The tissue adhesive 2OC can successfully close a pGCF in children after GT removal. This therapy is cost-effective, non-invasive, does not require general anesthesia, and can be performed in an outpatient setting.

A safe and simple method for removal and replacement of a percutaneous endoscopic gastrostomy tube after “buried bumper syndrome”

A safe and simple method for removal and replacement of a percutaneous endoscopic gastrostomy tube after “buried bumper syndrome”

Supracricoid Partial Laryngectomy: Swallowing, Voice, and Speech Outcomes

The purpose of the study was to describe the swallowing and vocal function of patients after supracricoid partial laryngectomy (SCPL) as they changed over the first postoperative year. Ten patients with laryngeal carcinoma underwent SCPL at Johns Hopkins Hospital between August 2003 and May 2005. Clinical and videofluoroscopic swallowing examinations and perceptual, acoustic, aerodynamic, and video-stroboscopic voice evaluations were completed before operation and at 3 weeks (swallowing only) and 2 (voice only), 6, and 12 months after operation. The mean time to gastrostomy tube removal was 82 days. The patients tolerated an increased variety of foods over the first postoperative year. All patients initially used therapeutic strategies to swallow safely, and some still required them at 1 postoperative year. Over the year, the perceptual ratings of voice quality improved significantly. There were no consistent changes in acoustic or aerodynamic measures. The number of patients who used multiple vibratory sources to phonate increased over the year. The patients tolerated regular diets, yet continued to exhibit silent aspiration and a variety of decompensations. Their voices were breathy, rough, and strained. Their voice quality ratings improved over the year. Group changes were not captured, and it appears that the changes in speech and voice 2 months after surgery were subtle.

Traction Removal of Percutaneous Endoscopic Gastrostomy Devices in Children

There are few published data on non-endoscopic removal of percutaneous endoscopic gastrostomy devices in children. To describe prospective data acquired for traction removal of percutaneous endoscopic gastrostomy devices at a single pediatric center over a 5-year period. Data were obtained from endoscopy records, computerized hospital patient information systems and case note analysis. The device that could be removed by traction was the Corflo (Merck) 12-Fr percutaneous endoscopic gastrostomy tube with a collapsible internal retention dome. All procedures were performed under general anesthesia. Between 2002-2006, 220 children underwent percutaneous endoscopic gastrostomy removals (166 by traction, 51 endoscopically and 3 Foley catheter to button conversions). The median duration between percutaneous endoscopic gastrostomy insertion and low profile button device substitution was 0.83 years (0.12-3.86). Complications from traction removal included internal retention dome separation in two cases (allowed to pass per rectum, uneventfully), failure to a insert a low profile button device needing percutaneous endoscopic gastrostomy reinsertion, enterocutaneous fistula requiring surgical closure in one patient and laparoscopy for suspected low profile button device misplacement in one instance. The material cost of endoscope disinfection (£10) and disposable usage (£80) avoided by traction removal was calculated at £90 per procedure. No mortality occurred as a result of the traction removal of percutaneous endoscopic gastrostomy tubes. Laparoscopy for suspected low profile button device misplacement was needed in one case (0.60%). Traction removal of percutaneous endoscopic gastrostomy tubes was generally safe and a cost-saving procedure in our experience.

Treatment of Persistently Leaking Post PEG Tube Gastrocutaneous Fistula in Elderly Patients with Combined Electrochemical Cautery and Endoscopic Clip Placement

Persistent leakage from a gastrocutaneous fistula (GCF) created for the purpose of percutaneous endoscopic gastrostomy (PEG) tube placement is a common problem in elderly patients. Conservative methods often prove unsuccessful and surgical closure is usually not performed because of poor surgical risk. With advances in endoscopic technology, several nonsurgical approaches have emerged. These new methods have been reported in the past as case reports. The purpose of this study is to report a case series of eleven elderly patients with persistent leakage from gastrocutaneous fistulas who underwent combined electrochemical cautery and endoscopic clip placement. Eleven patients had failed conservative therapy and were deemed unsuitable candidates for surgical closure. Electric and chemical cauterization was used to de-epithelialize the fistulous tract. The edges of the internal orifice of the gastrocutaneous fistula were approximated using endoclips during an esophagogastroduodenoscopy. Patients were observed postprocedure for leakage. This procedure resulted in complete closure of the gastrocutaneous fistula in nine patients (82%). One patient had partial closure of the fistula which was sealed using a new PEG tube. Gastrocutaneous fistula is a common complication in elderly patients after removal of gastrostomy tubes. Simple endoscopic procedures have shown promising results in the treatment of this complication.

The “Cut and Push” Method of Percutaneous Endoscopic Gastrostomy Tube Removal in Adult Patients: The Ipswich Experience

The standard method of removing percutaneous endoscopic gastrostomy (PEG) tubes in the United Kingdom is by repeat gastroscopy and retrieval of the internal PEG bumper by the oral route. However, the endoscopic removal method may not always be necessary by use of the "cut and push" method. This involves cutting the tube at skin level and allowing the internal bumper to pass naturally. A local database of all patients undergoing a PEG insertion was created in February 2002. All PEG tube removals by the "cut and push" method over a 5-year period at Ipswich Hospital were reviewed. Between February 2002 and December 2007, 89 Fresenius Freka 15 Fr tubes were removed by the "cut and push" method. The original indications for the PEG tubes that were removed were head and neck malignancy (55), cerebrovascular accident (24), and other miscellaneous causes (10). The mean age of the patients was 62.7 years (range 19-98 years). The average duration of the tube in-situ before removal was 6.7 months (range 1-28). No complications were recorded during the mean follow-up period of 26.8 months (range 1-66 months). Follow-up data provide further evidence that the "cut and push" method is a safe and cost-effective method for removing 15 Fr PEG tubes in adult patients and that an abdominal radiograph is not routinely required.

Percutaneous endoscopic gastrostomy tube removal and replacement after “buried bumper syndrome”: the simple way

Percutaneous endoscopic gastrostomy (PEG) feeding tubes are required for an increasing number of patients with long-term nutritional requirements. "Buried bumper syndrome" (BBS) occurs in 2-6% of PEG placements. In the past, this has been a difficult problem to resolve. The authors aimed to design a safe and simple method of dealing with BBS that can be performed by any endoscopist on a routine endoscopic list with the patient under sedation. For 6 years, the authors have used a minimally invasive way to deal with BBS. They have successfully treated 20 BBS patients on a routine endoscopy list with the patient under sedation. The existing PEG is divided 5 cm from the skin. A pair of stent-grasping forceps is inserted via the tube. A snare then is passed via the gastroscope, caught in the stent-grasping forceps, and brought out via the PEG tube. Next, the tube is split as deeply as possible into the PEG exit site, and the snare is closed around the tube. Gentle traction is applied along the endoscope, allowing the internal bumper to concertina and pop through the mucosa. Another PEG can now be placed at a separate site, although the authors have successfully used the same tract. All the patients were followed up, with no further problems related to BBS. The authors' method is a simple way of addressing the difficult BBS problem. It can be used to remove and replace a PEG with a buried bumper on a routine endoscopy list with the patient under sedation.

"How Are We Defining Our Terms Here?": The Defining the Semantic Meaning of Terms in Bioethical Debates

All the papers in this final issue of thirty-third volume of The Journal of Medicine and Philosophy share a common theme concerning the role that the definitions of certain key terms play in bioethical debates. Each paper included herein discusses the role that certain terms, such as, life, death, sovereignty, disability, potentiality, personhood, and autonomy play, in particular, bioethical debates and how those definitions shape those very same debates. The first paper included in this issue is “Biopolitics, Terri Schiavo, and the Sovereign Subject of Death” by Jeffrey P. Bishop (2008). He explores the discussion that cropped up surrounding the famous case of Terri Schiavo, the Florida woman in a persistent vegetative state for over fifteen years whose husband and parents had a legal dispute over the removal of a percutaneous endoscopic gastrostomy tube, commonly referred to as a feeding tube, from her stomach, with the assistance of the philosophical writings of Michel Foucault and Giorgio Agamben. According to Bishop, the Terri Schiavo case illustrates a set of circumstances where life and politics become indistinguishable from one another, “wherein life is completely inscribed within the law” (2008, 539). The state, thereby, politicizes “bare life,” life understood only in its most basic purely biological sense, a process which Bishop argues has been documented by Michel Foucault in his writings. However, Foucault has failed to understand the logical conclusion of such a process because he ignores, as Agamben points out, the “fundamental aporia at the heart of constituting and constituted power.” The ultimate possibility that is raised here is a medical totalitarianism where the political state has complete power over determinations concerning life and death. The most obvious example that Bishop takes from the writings of Agamben is, of course, that of the Nazi concentration camps. Bishop writes, “Agamben notes that the most notorious place where life was fully politicized was the camps of Nazi Germany, where lebensunwertes Leben, life unworthy of life, was completely politically inscribed” (2008, 542). What is illustrated by the case of Terri Schiavo is someone whose life, such as it is, and Bishop argues that in actuality before she eventually died, she occupied a space between life and death, was entirely politicized. The risk that is opened up for the rest of us, who, unlike Terri Schiavo in the fifteen years prior to her physical death, are genuinely capable of actualizing our lives in something, at least, potentially fuller than the barest form of mere biological existence, is manifest in the various manners in which both social liberals and social conservatives have politicized life by inscribing it within the law whereby all of us live within a totalizing biopolitics of one variety or another that controls the indistinct boundaries between life and death.

Laparoendoscopic Evaluation and Treatment of Massive Pneumoperitoneum Occurring 1 Year After Gastrostomy Tube Removal

A 48-year-old man presented with massive pneumoperitoneum approximately 1 year after removal of a gastrostomy tube. A combined laparoscopic and endoscopic evaluation was used to identify and resect the gastric perforation at the previous gastrostomy site. To our knowledge, this is the longest interval reported in the literature for development of pneumoperitoneum after percutaneous endoscopic gastrostomy. A laparoendoscopic approach to evaluation and treatment of pneumoperitoneum in this setting is described.

Fluoroscopy-Guided Removal of Pull-Type Gastrostomy Tubes

These case reports demonstrate a radiologic interventional technique for removal of pull-type gastrostomy tubes. This approach proved to be a safe and efficient procedure in two patients. The procedure may be applicable in situations where endoscopic attempts fail.

Treatment of Persistent Gastrocutaneous Fistula with Combined Electro-Chemical Cautery and Endoscopic Clips

Percutaneous Gastrostomy Tube (PEG tube) placement is a common endoscopic procedure performed for short or long term enteral nutrition supplementation. With the aging population, endoscopically placed gastrostomy tubes have become a frequent presence in nursing homes and hospitals. Gastrostomy tubes provide quick access to the alimentary tract and are used routinely for feeding and administering medications in populations that are unable to effectively swallow for a variety of etiologies. Development of gastrocutaneous fistula is a potential complication after removal of PEG tube. The standard treatment for such a chronic fistula is laparotomy with surgical closure of fistula tract, but is often contraindicated because of comorbidities. Conservative treatments have been tried with limited success. Seven patients with chronic non-healing gastrocutaneous fistulas were treated with electrochemical cauterization and endoscopic clip placement. The external portion of the fistula tract was cauterized using silver nitrate and internal portion was cauterized using gold probe cautery to de-epithelialize the fistula. Once the area was successfully denuded, one or two endoscopic clips were deployed to approximate the denuded tissue. Patients were placed on intravenous proton pump inhibitors to increase intragastric pH and intravenous metoclopramide to increase gastric motility. The combined electro-chemical cautery and endoscopic clip closure resulted in either complete closure of the persistent gastrocutaneous fistula or reduction in size of the fistula allowing replacement with a standard size PEG tube. One patient had persistent leakage from the gastrocutaneous fistula that ultimately required surgical intervention. Complications following gastrostomy tube removal are infrequent, but can lead to significant morbidity and possible mortality. Conservative treatment of gastrocutaneous fistula include mechanical devices causing obstruction of the fistula or pharmacologic measures such as raising gastric pH by high does PPIs or improving gastric motility with metoclopramide. Success rate of above mentioned measures is very low in clinical practice. Jonathan et al described successful closure of chronic gastrocutaneous fistulas in three children using combined electro-chemical cauterization and endoscopic clips. This method has not been described in the adult population. Combined electro-chemical cauterization and endoscopic clip closure is an alternative to surgical closure of chronic gastrocutaneous fistula. Further studies are required to determine long term success and efficacy of such therapy.

Closure of a Nonhealing Gastrocutaneous Fistula Using an Endoscopic Clip

Gastrocutaneous fistula after gastrostomy tube removal may persist for a prolonged period. We present a case of a 58-year-old woman with a GCF that had persisted for 5 months following the removal of an endoscopically-placed gastrostomy tube (PEG). Conservative therapy with anti-acid medications and administering motility agents was unsuccessful. For the closure of the GCF, the endoscopic metal clips were used to close the fistula.

Dysphagia after sequential chemoradiation therapy for advanced head and neck cancer

Assess impact of sequential chemoradiation therapy (SCRT) for advanced head and neck cancer (HNCA) on swallowing, nutrition, and quality of life. Prospective cohort study of 59 patients undergoing SCRT for advanced head and neck cancer. Follow-up median was 47.5 months. Regional Cancer Center. Median time to gastrostomy tube removal was 21 weeks. Eighteen of 23 patients who underwent modified barium swallow demonstrated aspiration; none developed pneumonia. Six of 7 with pharyngoesophageal stricture underwent successful dilatation. Functional Assessment of Cancer Therapy-Head and Neck Scale questionnaires at median 6 months after treatment revealed "somewhat" satisfaction with swallowing. At the time of analysis, 97% have the gastronomy tube removed and take soft/regular diet. Early after treatment dysphagia adversely affected weight, modified barium swallow results, and quality of life. Diligent swallow therapy, and dilation as needed, allowed nearly all patients to have their gastronomy tubes removed and return to a soft/regular diet. Dysphagia is significant after SCRT but generally slowly recovers 6 to 12 months after SCRT. C-4.

Persistent Gastrocutaneous Fistula after Percutaneous Gastrostomy Tube Removal

Persistent gastrocutaneous fistula after removal of a percutaneous gastrostomy (PEG) tube is an uncommon complication [1]; the fistulous tract usually closes spontaneously within 48-72 hours. Factors involved in failure of closure are the duration of PEG tube placement, obesity, persistent cough, fibrosis of the tract, and underlying debilitating disease. Conservative approaches have included parenteral therapy, reduction of the acidic pH of the stomach, and pharmacological acceleration of the gastric emptying time [2] [3]. Traditionally, surgical therapy has been reserved for patients who prove refractory to these measures, though there have been a few reports of patients who have been managed with endoscopic clips [4] [5]. We present a patient with a persistent gastrocutaneous fistula after PEG removal who was treated endoscopically with clips placed across the internal gastric opening.

Complications Associated with Endoscopic Removal of Percutaneous Endoscopic Gastrostomy (PEG) Tubes in Children

Complications Associated with Endoscopic Removal of Percutaneous Endoscopic Gastrostomy (PEG) Tubes in Children

Caregiver attitudes towards gastrostomy removal after renal transplantation

Gastrostomy tube (G-tube) removal has been suggested at 3 months following successful renal transplantation (Tx). We noticed a delay in the removal of G-tubes in our pediatric patients following Tx and therefore conducted a cross-sectional single center survey on all renal transplant recipients to assess the causes of delayed G-tube removal. In total, 17 of 23 patients completed the survey, including all patients with G-tubes (n = 10) and seven patients without G-tubes. Median age at Tx of gastrostomy patients was significantly lower than that of patients without a G-tube (median 3.0 yr, range 1.2-4.7 yr vs. median 14 yr, range 6-17 yr, p < 0.0001) and significantly younger than in previous studies on gastrostomies. At the time of the survey, only three of 10 patients had their G-tube removed at 22, 41 and 61 months after Tx at the ages of 3, 5.5 and 9 yr, respectively. The median age at recent follow up of the remaining seven patients was 4.7 yr (range 2.6-8.75 yr). The most important reason for continued use was fluid intake and medication. Results of our survey showed appropriate concern regarding the risk of prolonged use of the gastrostomy. Caregivers felt that benefits of the gastrostomy in the post-transplant period outweighed the risks. Caregivers felt pressured towards removal by the physicians. Our findings support the decision to remove gastrostomies based on individual patient needs and total fluid intake rather than a fixed time following successful Tx.

Combined endoscopic cautery and clip closure of chronic gastrocutaneous fistulas

Chronic gastrocutaneous fistula with intermittent drainage is a common outcome after removing long-standing gastrostomy tubes. The standard treatment is surgery with laparotomy and excision of the fistula tract. This study describes the results of an endoscopic closure technique by using a combination of electrocautery and metal clips. Three patients with gastrocutaneous fistulas (duration 3 months to 3 years) after gastrostomy tube removal were treated endoscopically by electrocautery of the tract and application of metal clips. Treatment resulted in complete fistula closure in two patients and partial closure in a third patient. Combined endoscopic therapy with electrocautery and clipping may be an alternative to surgical closure of chronic gastrocutaneous fistulas.

329 Gastrostomy tube removal in CF — is it wise?

329 Gastrostomy tube removal in CF — is it wise?

ENDOSCOPIC CLOSURE OF GASTROCUTANEOUS FISTULA IN CHILDREN FOLLOWING GASTROSTOMY TUBE REMOVAL

Purpose: Purpose of the study is to report our experience with endoscopic closure of gastrocutaneous (GC) fistula after removal of gastrostomy tube (GT) in four pediatric patients. Earlier, patients with GC fistula were managed by surgical resection and closure of gastrostomy. Methods: Retrospective chart review was performed in four consecutive patients who had undergone endoscopic closure of GC fistula over last six months. GT was removed when patients maintained growth for more than three months without use of the GT. H2 blocker was given if GT site drained for more than a week. If GT site drained more than two weeks after removal of GT, then upper endoscopy (UE) was performed and gastric opening of the fistula was closed with Endoclip®. UE and Endoclip® were repeated in two weeks if drainage persisted or recurred. Supplemental treatment included cauterzation of external granuloma with silver nitrate, application of Flo-Seal® in or around the gastrostomy, and small volume feedings for two weeks. Results: Conclusions: 1. Persistent GC fistula, after removal of GT, may occur in patients in whom GT had been in place for more than 10 months. 2. Endoscopic application of clip (supplemented with external topical silver nitrate and Flo-SealR) is successful in achieving closure of GC fistula, thus avoiding surgery. 3. More than one session of UE with clip application may be required for successful closure of GC fistula.Table: Clinical features and response to Endoclip®

Persistence of gastrocutaneous fistula after removal of gastrostomy tubes in children: prevalence and associated factors.

The aims of this study were to determine the prevalence of gastrocutaneous fistula after removal of gastrostomy tubes in children and to identify associated risk factors. The records of children who had undergone removal of gastrostomy tubes between January 1992 and December 2002 were reviewed retrospectively. Persistent gastrocutaneous fistula was defined as the absence of closure of the gastrostomy 1 month after tube removal. Factors that might influence spontaneous closure of the gastrostomy were studied, including age, underlying disease, nutritional status, type of gastrostomy, replacement of the gastrostomy tube by a button, abdominal wall thickness, duration of gastrostomy tube or button placement, and complications related to the presence of the gastrostomy (infection, granulation tissue). A total of 44 patients were included in the study (mean age 20 months, range 1 day to 14 years). Of these, 28 had undergone percutaneous endoscopic gastrostomy and 16 surgical gastrostomy. The mean time to spontaneous closure was 6 +/- 7 days. Persistent gastrocutaneous fistula developed in 11 patients (25 %) and in seven of these patients this required surgical closure (16 %). The mean duration of gastrostomy placement was significantly longer in patients who went on to develop a gastrocutaneous fistula than in patients who did not develop a fistula (39 +/- 19 months vs. 22 +/- 23 months, respectively, P < 0.03). No other significant association was found between the time required for spontaneous closure and the characteristics of patients or the type of gastrostomy. Persistent gastrocutaneous fistula is common after removal of gastrostomy tubes in children. Surgical closure should be considered when a gastrostomy has not closed spontaneously 1 month after removal of the gastrostomy tube.