Percutaneous Endoscopic Gastrostomy Removal Research Articles

Oncological and functional outcome after laryngectomy for laryngeal and hypopharyngeal cancer: a population-based analysis in Germany from 2001 to 2020

Prognostic factors for overall survival (OS), percutaneous endoscopic gastrostomy (PEG) dependency, and long-term speech rehabilitation via voice prosthesis (VP) after laryngectomy for laryngeal or hypopharyngeal cancer were investigated in a retrospective population-based study in Thuringia, Germany. A total of 617 patients (68.7% larynx; hypopharynx; 31.3%; 93.7% men; median age 62 years; 66.0% stage IV) from 2001 to 2020 were included. Kaplan–Meier and Cox multivariable regression analyses were performed. 23.7% of patients received a PEG. 74.7% received a VP. Median OS was 131 months. Independent factors for lower OS were stage IV (compared to stage II; hazard ratio [HR] = 3.455; confidence interval [CI] 1.395–8.556) and laryngectomy for a recurrent disease (HR = 1.550; CI 1.078–2.228). Median time to PEG removal was 7 months. Prior partial surgery before laryngectomy showed a tendency for independent association for later PEG removal (HR = 1.959; CI 0.921–4.167). Postoperative aspiration needing treatment was an independent risk factor (HR = 2.679; CI 1.001–7.167) for later definitive VP removal. Laryngectomy continuously plays an important role in a curative daily routine treatment setting of advanced laryngeal or hypopharyngeal cancer in Germany. Long-term dependency on nutrition via PEG is an important issue, whereas use of VP is a stable long-term measure for voice rehabilitation.

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.

The "cut and push" method of removing percutaneous endoscopic gastrostomy tube is not safe in paediatric patients.

A "cut and push" (CP) approach has been described in the literature for removal of percutaneous endoscopic gastrostomy (PEG) tubes. The aim of this study is to investigate the safety profile of this method in children. Our study included all children who underwent CP procedure for either removal or replacement of Freka PEG tube at our centre between January 2016 and August 2021. Parents contacted to establish if the internal component had been seen in the stools post-procedure. If not seen, a plain film of chest, abdomen and pelvis was arranged followed by computerised tomography (CT) scan. The presence of the internal component as a retained foreign body on imaging was evaluated along with any complication. Of the 27 patients included, six (22.2%) patients had the internal component seen in the stool. Five (18.5%) patients in total had a retained internal component with three (11.1%) patients had major complications requiring complex surgical interventions, and two (7.4%) patients required endoscopic retrieval. Our study reports more severe complications that required complex surgical interventions compared to the previous studies. We believe that this method of removal is not safe in children and should be abandoned. Also, patients with Down syndrome might be at higher risk of retention and complications.

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY RESULTS IN A SECONDARY STATE HOSPITAL

Introduction: The aim of this study was to determine the indications of Percutaneous endoscopic gastrostomy (PEG) patients treated in a secondary state Burdur hospital over a period of three years, the unit where the patient was hospitalized, survival time with PEG therapy, and the complications observed in these patients. Methods: Patients who underwent PEG in the endoscopy unit of our hospital, between January 2019 and January 2022, were retrospectively evaluated. Age, gender, the unit of inpatient, indications for PEG therapy, complications after PEG, and survival status of the patients were recorded in the form of case reports. Patients with coagulation disorders, hemodynamic instability, peritonitis, sepsis, infection at the insertion area, peritonitis carcinomatosis, a history of total gastrectomy and gastric varices were excluded. Results:The median age of the 120 patients included in the study was 79 (17–100) years, and 66 (55%) of the patients were male. Complications were observed in 14 (11.7%) patients, all of which were minor, including seven (5.8%) PEG site infections, three (2.5%) PEG site leakages, three (2.5%) PEG occlusions, and one (0.9%) PEG removal. It was determined that 73 (60.8%) patients survived at least 30 days; the patients were most frequently referred by the neurology unit, with a rate of 52.7%. The most common indications for PEG insertion were cerebrovascular disease (56.7%) and dementia (29.2%). Conclusion: Maintenance of nutritional requirements via PEG allows for the preservation of mucosal integrity and barrier function, intestinal immune response, and normal flora. It is superior to other enteral feeding methods due to the lower risk of aspiration. In conclusion, our study, which presented the experiences of the PEG insertion and therapy in a secondary state hospital, stated that the complication rates, indications, and referring clinics were found to be consistent with available literature.

Transabdominal ultrasonography for confirmation of accurate percutaneous endoscopic gastrostomy tube placement: analysis of patient- and procedure-related complications

Technique-related factors, patient-related factors, and localization determine the risk for complications in percutaneous endoscopic gastrostomy (PEG) tube placement. The objective of this study was to identify patient characteristics and ultrasonographic parameters after PEG tube placement concerning localization, which correlate with complications. Patients undergoing PEG-tube placement were examined by abdominal ultrasound after dismissal from the endoscopic recovery room. Patient demographics, PEG characteristics, ultrasonographic parameters and complications were retrospectively analyzed. Of 64 enrolled patients, 59.4% were male and the mean age was 62.3 years. A significant negative correlation between complications at PEG placement and Body-Mass-Index (BMI; kg/m2) was observed (Spearman's Rho: -0.382; p=0.002). A low BMI <18 tended to be more frequent in the group with complication-related PEG removal compared to patients without (18.2% vs. 1.9%). Further descriptive analysis revealed that 4 patients (36.4% of N=11) with and 5 patients (9.4% of N=53) without PEG removal due to complications already had complications at the time of PEG placement. Of the patients with complications during follow-up, those with a peritoneal course (N=10) in ultrasound tended to have a lower BMI (mean ± standard deviation: 22.5±6.5 vs. 26.8±5.9) compared to those without (N=5). In all 4 patients with a triad of follow-up complications, peritoneal course, and complications at PEG placement, the tube was removed due to complications. Post-PEG-placement ultrasonography can help to determine complications in specific procedure-related conditions. A low BMI was found to be a relevant predictor of PEG-related complications, substantiating the need for early intervention in potentially PEG-relevant indications.

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).

Endoscopic Management of Gastrojejunal and Jejunocutaneous Fistulae: A Percutaneous Endoscopic Gastrostomy Complication in a Pediatric Patient

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a method of gastric feeding access that has had increasing use by pediatric surgeons in recent years. Known risks of the procedure include bleeding, infection, and accidental placement into the liver, colon, and small bowel.1–3 Endoscopic management of PEG complications is a rapidly evolving field.4,5 This video describes the use of endoscopic techniques to manage a PEG complication in a pediatric patient. Materials and Methods: The patient was a 15-year-old boy who suffered a stroke resulting in ventilator and tube feed dependence. For long-term feeding access, the patient underwent a (PEG) procedure. The patient had difficulty tolerating gastric tube feeds and the decision was made to convert the gastrostomy to a gastrojejunostomy. Fifty-nine days after the initial PEG procedure, the patient was taken to the operating room for conversion to a gastrojejunostomy tube. After PEG removal, attempts were made to place a guidewire through the tract into the stomach. However, the guidewire did not go in the expected direction. Fluoroscopic and endoscopic evaluation raised concern for communication with the small bowel. An advanced surgical endoscopist was then consulted. The gastrostomy site was identified and traversed with an ultraslim endoscope. The gastrostomy site entered immediately into small bowel. A jejunocutaneous fistula was noted on the opposite site of the bowel, suggesting that the original PEG had traversed a loop of small bowel in a through-and-through manner. The tracts appeared stable and there was no evidence of contamination or insufflation leaking into the peritoneal cavity. Attention was then turned to closing the jejunocutaneous fistula, which could only be accessed through the gastrojejunal fistula. Given that only an ultraslim endoscope, without a proper working channel for the desired intervention, could access the site, an endoclip device was affixed to the side of the ultraslim endoscope. The jejunocutaneous fistula was then closed with five endoclips. Next, the gastrojejunal fistula was closed using an over-the-scope clip. Fluoroscopic evaluation with air insufflation demonstrated complete closure. Finally, to afford enteral access, a PEG was performed using the pull technique. Endoscopic and fluoroscopic observation confirmed good positioning. Results: An upper gastrointestinal contrast study on postoperative day 3 demonstrated no signs of fistula or leak. Tube feeds were initiated and slowly advanced to goal by postoperative day 7. The patient tolerated his gastric tube feeds and had no further surgical complications. Conclusion: This case has several key learning points. First, it demonstrates the high clinical suspicion for PEG complication that must be held when a patient fails to tolerate feeds. Second, it demonstrates how the skilled use of endoscopic and surgical principles can provide minimally invasive definitive management of PEG complications. Next, this case demonstrates how a thorough understanding of the benefits and drawbacks of available endoscopic tools can lead to innovative solutions to difficult problems. Finally, this case demonstrates the advanced care that can be offered to patients when a multidisciplinary approach is utilized. C.G.D., D.J.M., A.Y.T., and M.C.S.: No competing financial interests exist. E.M.P.: Speaking/teaching: Cook Biotech, Inc., C.R. Bard, Inc., Boston Scientific Corp. Ovesco; Research Support: C.R. Bard, Inc.; Consultant: Boston Scientific Corp., Actuated Medical, Inc., Medtronic, Baxter, Surgimatrix, CMR Surgical; Royalties: UpToDate, Inc., Springer. Runtime of video: 7 mins 45 secs This video was presented as a video presentation at the 2020 American College of Surgeons Virtual Clinical Congress, on October 3, 2020.

Evaluation of Reliability and Validity regarding the “Structural Items of Protocol for Percutaneous Endoscopic Gastrostomy Removal for Older People” in Nursing Practice

Evaluation of Reliability and Validity regarding the “Structural Items of Protocol for Percutaneous Endoscopic Gastrostomy Removal for Older People” in Nursing Practice

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy Reduces Major Complications in High-Risk Pediatric Patients.

PurposePercutaneous endoscopic gastrostomy (PEG) is a safe method to feed patients with feeding difficulty. This study aimed to compare the outcomes of conventional PEG and laparoscopic-assisted PEG (L-PEG) placement in high-risk pediatric patients.MethodsIn our tertiary pediatric department, 90 PEG insertions were performed between 2014 and 2019. Children with severe thoracoabdominal deformity (TAD), previous abdominal surgery, ventriculoperitoneal (VP) shunt, and abdominal tumors were considered as high-risk patients. Age, sex, diagnosis, operative time, complications, and mortality were compared among patients who underwent conventional PEG placement (first group) and those who underwent L-PEG placement (second group).ResultsWe analyzed the outcomes of conventional PEG placement (first group, n=15; patients with severe TAD [n=7], abdominal tumor [n=6], and VP shunts [n=2]) and L-PEG placement (second group, n=10; patients with VP shunts [n=5], previous abdominal surgery [n=4], and severe TAD [n=1]). Regarding minor complications, 1 (6.6%) patient in the first group underwent unplanned PEG removal and 1 (10%) patient in the second group had peristomal granuloma. We observed three major complications: colon perforation (6.6%) in a patient with VP shunt, gastrocolic fistula (6.6%) in a patient with Fallot-tetralogy and severe TAD, and pneumoperitoneum (6.6%) caused by early tube dislodgement in an autistic patient with severe TAD. All the three complications occurred in the first group (20%). No major complications occurred in the second group.ConclusionIn high-risk patients, L-PEG may be safer than conventional PEG. Thus, L-PEG is recommended for high-risk patients.

The Effect of Radiation Dose to the Pharyngeal Constrictor Musculature on Weight Loss During Treatment and Feeding Tube Dependence in Head and Neck Cancer

Radiation-associated dysphagia (RAD) is a common toxicity of radiotherapy (RT) for head and neck cancer, reported by nearly 50 percent of patients. Severe dysphagia can lead to feeding tube dependence, which significantly impacts quality of life. Studies have suggested that reduced radiation dose to the pharyngeal constrictor musculature (PCM) using intensity-modulated RT (IMRT) is associated with improved swallowing outcomes by a variety of measures. We aimed to identify dose-volume parameters of radiation to the PCM that are associated with weight loss during RT and percutaneous endoscopic gastrostomy (PEG) dependence as clinical measures of severe RAD. From a single institutional database, 115 patients with newly diagnosed head and neck squamous cell carcinoma of the oral cavity, nasopharynx, oropharynx, hypopharynx and larynx who underwent definitive or postoperative IMRT between January 1, 2014 and December 31, 2017 were identified after exclusion of patients with T1-2 stage larynx cancer, less than 6 months of follow-up and locoregional recurrence at any time. PCM was contoured prospectively and mean dose < 60 Gy was used as the dose constraint when possible. PCM dose-volume parameters were retrospectively collected from IMRT plans and logistic regression was used to analyze these data relative to percent weight loss during RT and duration of PEG use. 57% of patients had surgery prior to RT, 63% received concurrent chemotherapy and 70% had planned RT to the bilateral neck. 57% had some degree of dysphagia prior to RT. PEG tubes were placed prior to, during or just after RT in 45% of patients. The mean and median time from RT to PEG removal were 8.9 and 6.5 months respectively (range 1.9 to 36.7 months). The median percent weight loss during RT was 9.3% (range -5.7 to 23%). Definitive RT, bilateral neck volumes and concurrent chemotherapy were associated with weight loss and prolonged PEG use on univariate analysis. On multivariate analysis, female gender and concurrent chemotherapy were independently associated with prolonged PEG use and age < 60 and normal swallowing prior to RT were independently associated with weight loss > 10%. When adjusting for these significant confounding factors, PCM mean dose, max dose and V50-60 were significantly associated with prolonged PEG use: Means of these individual parameters for PEG use > 6 months were 57 Gy, 72 Gy, 80% and 54% respectively versus 48 Gy, 65 Gy, 58% and 28% for PEG use < 6 months. PCM V40 was significantly associated with > 10% weight loss during RT, with mean V40 of 85% for weight loss > 10% and 70% for weight loss < 10%. In this institutional cohort, IMRT dose to the total PCM correlated with severe RAD. Aiming to keep an overall PCM mean dose < 48 Gy and max dose < 65 Gy during IMRT planning may help reduce prolonged PEG dependence, while a PCM V40 < 70% may be associated with reduced treatment related weight loss.

Novel Adherence Interventions in Perinatally Acquired HIV: PEG Insertion and Pill Glide.

Children, adolescents and young adults (CAYA) with perinatally acquired human immunodeficiency virus (PaHIV) need lifelong antiretroviral therapy (ART) to suppress viral load (VL), maintain health and prevent onward transmission. Many struggle with adherence despite multidisciplinary input. We assessed ART adherence outcomes following two novel interventions: percutaneous endoscopic gastrostomy (PEG) and Pill Glide®, a fruit-flavoured lubricant spray aiding tablet swallowing. Retrospective cohort analysis by database and case-note review of PaHIV CAYA aged < 25years receiving PEG or Pill Glide® between 1995 and 2017 at a single tertiary centre. Nineteen PEGs were inserted in 15 CAYA at a median age of 17 (IQR 6-22) years, median CD4 count 40 cells/µL (IQR 10-220). A viral load (VL) < 50 copies/mL was achieved in 93% with PEG ART. At last follow-up all were alive, median age 23years (IQR 22-28). Nine had PEG removed, after a median of 3.3years (range 0.5-6.8), with a current VL < 50 copies/mL, median CD4 count 940 cells/µL (IQR 261-1353) sustained post PEG removal median was 5.4years (range 1.5-17.8) previously. From 2017 seven CAYA received Pill Glide®, median age 10years (IQR 7-14), median CD4 count 898 cells/µL (range 148-1943), 6/7 with a suppressed VL. All reported increased ease in tablet swallowing and transitioned successfully from crushed tablets/liquids to tablets. At follow-up, all patients had a suppressed VL. Whilst PEG insertion markedly improved rates of viral suppression in CAYA struggling with ART adherence, the use of novel less invasive aids such as Pill Glide® requires further exploration.

Percutaneous Endoscopic Gastrostomy After Cardiothoracic Surgery in Children Less Than 2 Months Old: An Assessment of Long-Term Malnutrition Status and Gastrostomy Outcomes.

Infants with critical congenital heart disease undergoing cardiothoracic surgery commonly experience chronic malnutrition and growth failure. We sought to determine whether placement of a percutaneous endoscopic gastrostomy was associated with reduced moderate-severe malnutrition status and to describe percutaneous endoscopic gastrostomy-related clinical and safety outcomes in this population. Single-center, retrospective cohort study. Two hundred fifty-nine-bed, tertiary care, pediatric referral center. Children with congenital heart disease less than 2 months old undergoing cardiothoracic surgery from 2007 to 2013 with and without percutaneous endoscopic gastrostomy. None. Primary outcomes were weight for age z scores during hospitalization, at 6 months, and 1 year after cardiothoracic surgery. Secondary outcomes were frequency of percutaneous endoscopic gastrostomy revision, percutaneous endoscopic gastrostomy complications, and mortality. Statistical analyses included Wilcoxon rank-sum, Fisher exact, and Student t tests. Two hundred twenty-two subjects met study criteria, and 77 (35%) had percutaneous endoscopic gastrostomy placed at a mean of 45 ± 31 days after cardiothoracic surgery. No differences were noted for demographics, comorbidities, and weight for age z score at birth and at the time of cardiothoracic surgery. The percutaneous endoscopic gastrostomy cohort had greater Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery risk category (4 [4-5] vs 4 [2-4]) and length of stay (71 d [49-101 d] vs 26 d [15-42 d]). Mean weight for age z score at the time of percutaneous endoscopic gastrostomy was -2.8 ± 1.3. Frequency of moderate-severe malnutrition (weight for age z score, ≤ -2) was greater in children with percutaneous endoscopic gastrostomy at discharge (78% vs 48%), 6 months (61% vs 16%), and 1 year (41% vs 2%). Index mortality was lower in children with percutaneous endoscopic gastrostomy at 30 days (8% vs 0%) and hospital discharge (19% vs 4%). However, no mortality differences were observed after discharge. Growth velocity after percutaneous endoscopic gastrostomy was greater (44 ± 19 vs 10 ± 9 g/d). Children tolerated percutaneous endoscopic gastrostomy without hemodynamic compromise, minor percutaneous endoscopic gastrostomy complications, and anticipated percutaneous endoscopic gastrostomy revisions. Children without mortality had percutaneous endoscopic gastrostomy removal at a median duration of 253 days (133-545 d). Children with univentricular physiology had improved in-hospital mean growth velocity (6.3 vs 24.4 g/d; p < 0.01) and reduced 1-year rate moderate-severe malnutrition (66.7% vs 36.9%; p < 0.01) after percutaneous endoscopic gastrostomy placement. Percutaneous endoscopic gastrostomy placement was well tolerated and associated with improved postoperative growth velocity in children with critical congenital heart disease undergoing cardiothoracic surgery less than 2 months old. These findings were also noted in our subanalysis of children with univentricular physiology. Persistent rates of moderate-severe malnutrition were noted at 1-year follow-up. Although potential index mortality benefit was observed, definitive data are still needed.

Mo1303 PERSISTENT GASTROCUTANEOUS FISTULAS AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBE REMOVAL IN HEAD AND NECK CANCER PATIENTS WITH EARLY FEEDING AND DOUBLE-DOSE PPI: A PROSPECTIVE COHORT STUDY WITH A HISTORICAL CONTROL GROUP

Percutaneous endoscopic gastrostomy (PEG) removal is required in head and neck cancer patients (HNCP), after chemoradiotherapy ends and adequate oral intake is reacquired. The PEG tract usually closes spontaneously within 48-72 hours. Persistent gastro-cutaneous fistula (PGCF) is an uncommon complication of PEG removal.

Percutaneous Endoscopic Gastrostomy After Cardiac Surgery: A Temporary Measure in a High-Risk Cohort

A subset of patients who undergo cardiac surgery require percutaneous endoscopic gastrostomy (PEG) tube for enteral access to receive nutritional support. There are limited data evaluating the outcomes of these patients and the duration of nutritional support required. All cardiac surgery patients (1994 to 2017) were stratified by postoperative PEG requirement. Patients were excluded if they required preoperative nutritional support, began nutritional support more than 30 days postoperatively, or if the PEG was placed more than 90 days after the index cardiac operation. Kaplan-Meier survival analysis was used to estimate overall survival and time to PEG removal. A Fine-Gray competing risk model was constructed to determine factors impacting PEG removal. A total of 16,727 cardiac surgery patients were included, with 310 (1.9%) requiring PEG. The median time to PEG placement was 14.5 (interquartile range, 10 to 22) days with 1 (0.3%) PEG procedural mortality. One-year survival was 50.4% vs 91.8% in the general cardiac surgery population. A total of 113 patients had their PEG removed at a median of 255 days. Of living PEG patients at 1 year, 52.1% had their PEG removed. Factors that were associated with PEG removal were age (hazard ratio [HR], 0.98; P= .03), ejection fraction (HR, 1.03; P < .01), and renal failure (HR, 0.50; P < .01). Patients who require PEG after cardiac surgery are a high-risk cohort. However, those who survive their acute illness often recover to a point where nutrition can be maintained without a feeding tube. These data provide meaningful information for counseling patients and their families that are considering PEG after cardiac surgery.

Percutaneous Endoscopic Gastrostomy Tube Removal for Patients With Advanced Dementia: Case Series Study.

BackgroundAlthough the notion of percutaneous endoscopic gastrostomy (PEG) tube placement for patients with dementia has been changing, the number of cases of PEG placement remains high as Japan has become a super-aged society. However, there is insufficient research about the clinical course of dementia patients with PEG, especially regarding PEG extubation after regaining full oral intake. This case series aimed to reveal the demographic data of patients who successfully underwent PEG extubation and to identify clinical factors that might help predict eventual resumption.MethodsThis retrospective case series was identified in a private, community-based long-term care hospital in Sapporo, Japan. Inclusion criteria for the series were: 1) age, ≥75 years, 2) diagnosis of any type of dementia, and 3) resumption of full oral intake after removal of PEG tubes.ResultsEight female patients were identified. Decreased oral intake was triggered by acute medical conditions, such as infectious enteritis. A trial of oral intake was initiated mostly by speech therapists. A majority of the patients ate pureed food. The patients aged ≥85 years with advanced dementia could be weaned from PEG tubes.ConclusionThe series indicates that even patients with limited life expectancy could recover swallowing function by receiving appropriate guidance and care. Constant evaluation for swallowing function even after PEG insertion may be important for PEG extubation.

Prediction of risk of adverse events related to percutaneous endoscopic gastrostomy: a retrospective study

Background:Percutaneous endoscopic gastrostomy (PEG) is a popular method for long-term enteral feeding. Our aim was to determine potential risk factors for adverse events related to PEG, as well as consequent prolonged hospitalization.Methods:Data were retrospectively collected from the admission records of a tertiary center between July 2015 and June 2018. Possible predictors of the 3 following outcomes were evaluated: minor PEG-related adverse events, major PEG-related adverse events, and length of hospital stay. Data were tested for correlation using the Spearman coefficient and for association using Kruskal-Wallis tests for significance.Results:A total of 362 admissions involving 146 patients were included in the study. Of the admissions, 221 (61.0%) had only minor adverse events, 100 (27.6%) had only major adverse events, and 41 (11.3%) had both. Eighty (22.1%) had PEG-site infection and 128 (35%) had aspiration pneumonia. Serum albumin levels at presentation were negatively correlated with the length of hospitalization (P<0.001), which also differed between patients presenting with major and minor adverse events (P<0.001 and P=0.026). The Charlson comorbidity index was positively correlated with the duration of hospitalization (P<0.001). Higher index scores were found more among patients presenting with aspiration pneumonia (P=0.004) and lower scores were found among patients presenting with PEG site infection and inadvertent PEG removal compared with those presenting with a major complication (P<0.001).Conclusion:The patient’s general medical condition and nutritional status are the greatest risk predictors for developing adverse events related to their PEG feeding, as well as a consequent extended hospital stay.

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.

Reliability and Validity of Evaluation Index for Level of Understanding Regarding Configured Items of Care Protocol for Percutaneous Endoscopic Gastrostomy Removal among the Elderly

Reliability and Validity of Evaluation Index for Level of Understanding Regarding Configured Items of Care Protocol for Percutaneous Endoscopic Gastrostomy Removal among the Elderly

Over-the-scope clip placement for closure of gastrointestinal fistula, postoperative leaks and refractory gastrointestinal bleed.

The over-the-scope clip (OTSC) has been successfully used in the closure of fistula, perforation, dehiscence, and endoscopic hemostasis. We describe our experience with the OTSC application. Between April 2014 and April 2015, seven patients underwent OTSC application. In four patients, OTSC was applied for the closure of esophageal fistula, one had OTSC closure of persistent gastrocutaneous fistula after percutaneous endoscopic gastrostomy removal, and OTSC was applied in duodenum in two patients, for duodenal Dieulafoy's lesion after failed conventional endotherapy and massive rebleed in one and duodenal perforation in another. All procedures had technical success with no immediate complication related to OTSC application. Patients were followed up for every month with mean duration of follow up 10.2months. One patient with bronchoesophageal fistula had development of another fistulous opening above the site of OTSC placement, which was successfully closed with another OTSC. One patient had superficial esophageal wall ulcer opposite the OTSC but it healed spontaneously. OTSC provided safe and successful closure in a number of settings.

An audit to evaluate the safety and efficacy of percutaneous endoscopic gastrostomy placement in patients with learning disabilities

Accessible Summary Patients with severe learning disabilities may lose weight and become malnourished for a variety of reasons. Insertion of a feeding tube through the abdomen, directly into the stomach can provide a reliable and permanent route for nutrition to be delivered. Our study of 42 patients has shown that in every case the procedure was performed following a team based assessment of each patient, as is recommended by national advisory groups. We found that the procedure is generally very safe but can require a general anaesthetic. However, complications relating to problems with the feeding tube were very common, and some patients did not gain weight. It is unclear from the literature what effect this intervention has on quality of life and we did not assess this in our study. SummaryPercutaneous endoscopic gastrostomy insertion is an effective method of providing enteral nutrition to patients with neurologically unsafe swallowing or failure of feeding. Patients with severe learning disabilities may develop unsafe swallowing and benefit from percutaneous endoscopic gastrostomy placement. It is unclear whether this intervention improves quality of life. We aimed to describe the efficacy and safety of percutaneous endoscopic gastrostomy insertion in patients with learning disabilities and determine whether multidisciplinary team assessment occurred as per British Society of Gastroenterology recommendations. We performed a retrospective case note audit of 42 patients with severe learning disabilities who underwent percutaneous endoscopic gastrostomy insertion. Forty two patients underwent 117 procedures: 38 index percutaneous endoscopic gastrostomy insertions, 43 percutaneous endoscopic gastrostomy replacements, 35 percutaneous endoscopic gastrojejunostomy replacements and 1 percutaneous endoscopic gastrostomy removal [six procedures (5.1%) were unsuccessful]. General anaesthetic was required for 34 (29%) procedures. Mean weight pre‐percutaneous endoscopic gastrostomy was 39.8 kg and mean weight after a median follow‐up of 21.5 months was 46.1 kg (mean weight gain = 2.3 kg). Thirty day mortality was zero. Complications were common (74%) and included perforation n = 1, aspiration pneumonia n = 13, tube displacement n = 10, and percutaneous endoscopic gastrostomy site infection n = 4. In two cases of unsuccessful percutaneous endoscopic gastrostomy insertion, surgical feeding gastrostomy was required. Ongoing vomiting occurred in six patients (14.3%) prompting conversion to percutaneous endoscopic gastrojejunostomy in five cases. A best interests meeting or multidisciplinary team assessment occurred for all patients. In this cohort, percutaneous endoscopic gastrostomy placement appears to be safe and results in a modest weight gain. Complications occur in the majority. Percutaneous endoscopic gastrojejunostomy should be considered for those with ongoing vomiting.