“Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality,complications,or outcomes”:Commentary

In this commentary,we summarize some of the key points of the original paper“Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality,complications,or outcomes”and offer support for the proposed results.Specifically,we address how early percutaneous endoscopic gastrostomy(PEG)tube placement may reduce hospital length of stay and costs.We also discuss topics related to the article including PEG weaning and post-stroke nutritional formulation.However,we note that concerns purported by previous studies that early PEG placement may worsen outcomes are not fully addressed,and further research is needed.

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

BACKGROUND Percutaneous endoscopic gastrostomy(PEG)is a well-established,minimally invasive,and easy to perform procedure for nutrition delivery,applied to individuals unable to swallow for various reasons.PEG has a high technical success rate of insertion between 95%and 100%in experienced hands,but varying complication rates ranging from 0.4%to 22.5%of cases.AIM To discuss the existing evidence of major procedural complications in PEG,mainly focusing on those that could probably have been avoided,had the endoscopist been more experienced,or less self-confident in relation to the basic safety rules for PEG performance.METHODS After a thorough research of the international literature of a period of more than 30 years of published“case reports”concerning such complications,we critically analyzed only those complications which were considered-after assessment by two experts in PEG performance working separately-to be directly related to a form of malpractice by the endoscopist.RESULTS Malpractice by the endoscopist were considered cases of:Gastrostomy tubes passed through the colon or though the left lateral liver lobe,bleeding after puncture injury of large vessels of the stomach or the peritoneum,peritonitis after viscera damage,and injuries of the esophagus,spleen,and pancreas.CONCLUSION For a safe PEG insertion,the overfilling of the stomach and small bowel with air should be avoided,the clinician should check thoroughly for the proper trans-illumination of the light source of the endoscope through the abdominal wall and ensure endoscopically visible imprint of finger palpation on the skin at the center of the site of maximum illumination,and finally,the physician should be more alert with obese patients and those with previous abdominal surgery.

Effect of percutaneous endoscopic gastrostomy on gastroesophageal reflux in mechanically-ventilated patients

AIM： To investigate the effect of percutaneous endoscopic gastrostomy （PEG） on gastroesophageal reflux （GER） in mechanically-ventilated patients. METHODS ： In a prospective, randomized, controlled study 36 patients with recurrent or persistent ventilatorassociated pneumonia （VAP） and GER 〉 6% were divided into PEG group （n=16） or non-PEG group （n = 20）. Another 11 ventilated patients without reflux （GER 〈 3%） served as control group. Esophageal pH-metry was performed by the ＂pull through＂ method at baseline, 2 and 7 d after PEG. Patients were strictly followed up for semi-recumbent position and control of gastric nutrient residue. RESULTS： A significant decrease of median （range） reflux was observed in PEG group from 7.8 （6.2-15.6） at baseline to 2.7 （0-10.4） on d 7 post-gastrostomy （P 〈 0.01）, while the reflux increased from 9 （6.2-22） to 10.8 （6.3-36.6） （P〈 0.01） in non-PEG group. A significant correlation between GER （%） and the stay of nasogastric tube was detected （r= 0.56, P〈 0.01）. CONCLUSION： Gastrostomy when combined with semi- recumbent position and absence of nutrient gastric residue reduces the gastroesophageal reflux in ventilated patients.

Investigation and prediction of enteral nutrition problems after percutaneous endoscopic gastrostomy

AIM： To investigate and predict enteral nutrition problems after percutaneous endoscopic gastrostomy （PEG）. METHODS： We retrospectively analyzed data for 252 out of 285 patients who underwent PEG at our hospital from 1999 to 2008 after PEG were defined as： Enteral nutrition problems （1） patients who required ≥ 1 mo after surgery to switch to complete enteral nutrition, or who required additional parenteral alimentation continuously; or （2） patients who abandoned switching to enteral nutrition using the gastrostoma and employed other nutritional methods. We attempted to identify the predictors of problem cases by using a logistic regression analysis that examined the patients＇ backgrounds and the specific causes that led to their problems. RESULTS： Mean age of the patients was 75 years, and in general, their body weight was low and their overall condition was markedly poor. Blood testing revealed that patients tended to be anemic and malnourished. A total of 44 patients （17.5%） were diagnosed as having enteral nutrition problems after PEG. Major causes of the problems included pneumonia, acute enterocolitis （often Clostridium difficile-related）, paralytic ileus and biliary tract infection. A multivariate analysis identified the following independent predictors for problem cases： （1） enteral nutrition before gastrectomy （a risk reduction factor）; （2） presence of esophageal hiatal hernia; （3） past history of paralytic ileus; and （4） presence of chronic renal dysfunction. CONCLUSION： Enteral nutrition problems after PEG occurred at a comparatively high rate. Patient background analysis elucidated four predictive factors for the problem cases.

Percutaneous endoscopic gastrostomy—Too often?Too late?Who are the right patients for gastrostomy?

Percutaneous endoscopic gastrostomy is an established method to provide nutrition to patients with restricted oral uptake of fluids and calories.Here,we review the methods,indications and complications of this procedure.While gastrostomy can be safely and easily performed during gastroscopy,the right patients and timing for this intervention are not always chosen.Especially in patients with dementia,the indication for and timing of gastrostomies are often improper.In this patient group,clear data for enteral nutrition are lacking;however,some evidence suggests that patients with advanced dementia do not benefit,whereas patients with mild to moderate dementia might benefit from early enteral nutrition.Additionally,other patient groups with temporary or permanent restriction of oral uptake might be a useful target population for early enteral nutrition to maintain mobilization and muscle strength.We plead for a coordinated study program for these patient groups to identify suitable patients and the best timing for tube implantation.

Inhibitory effects of carbon dioxide insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy

AIM:To evaluate the inhibitory effects of carbon dioxide (CO2) insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy (PEG).METHODS:A total of 73 consecutive patients who were undergoing PEG were enrolled in our study.After eliminating 13 patients who fitted our exclusion criteria,60 patients were randomly assigned to either CO2 (30 patients) or air insufflation (30 patients) groups.PEG was performed by pull-through technique after threepoint fixation of the gastric wall to the abdominal wall using a gastropexy device.Arterial blood gas analysis was performed immediately before and after the procedure.Abdominal X-ray was performed at 10 min and at 24 h after PEG to assess the extent of bowel distension.Abdominal computed tomography was performed at 24 h after the procedure to detect the presence of pneumoperitoneum.The outcomes of PEG for 7 d postprocedure were also investigated.RESULTS:Among 30 patients each for the air and the CO2 groups,PEG could not be conducted in 2 patients of the CO2 group,thus they were excluded.Analyses of the remaining 58 patients showed that the patients' backgrounds were not significantly different between the two groups.The elevation values of arterial partial pressure of CO2 in the air group and the CO2 group were 2.67 mmHg and 3.32 mmHg,respectively (P = 0.408).The evaluation of bowel distension on abdominal X ray revealed a significant decrease of small bowel distension in the CO2 group compared to the air group (P < 0.001) at 10 min and 24 h after PEG,whereas there was no significant difference in large bowel distension between the two groups.Pneumoperitoneum was observed only in the air group but not in the CO2 group (P = 0.003).There were no obvious differences in the laboratory data and clinical outcomes after PEG between the two groups.CONCLUSION:There was no adverse event associated with CO2 insufflation.CO2 insufflation is considered to be safer and more comfortable for PEG patients because of the lower incidence of pneumoperitoneum and less distension of the small bowel.

Percutaneous endoscopic gastrostomy and gastrooesophageal reflux in neurologically impaired children

AIM:To investigate the effects of percutaneous endoscopic gastrostomy(PEG) feeding on gastro-oesophageal reflux(GOR) in a group of these children using combined intraluminal pH and multiple intraluminal impedance(pH/MII) . METHODS:Ten neurologically impaired children underwent 12 h combined pH/MII procedures at least 1 d before and at least 12 d after PEG placement. METHODS:Prior to PEG placement(pre-PEG) a total of 183 GOR episodes were detected,156(85.2%) were non-acidic.After PEG placement(post-PEG) a total of 355 episodes were detected,182(51.3%) were nonacidic.The total number of distal acid reflux events statistically significantly increased post-PEG placement(prePEG total 27,post-PEG total 173,P=0.028) and themean distal pH decreased by 1.1 units.The distal reflux index therefore also significantly increased post-PEG [pre-PEG 0.25(0-2) ,post-PEG 2.95(0-40) ].Average proximal pH was lower post-PEG but the within subject difference was not statistically significant(P=0.058) . Median number of non-acid GOR,average reflux height,total acid clearance time and total bolus clearance time were all lower pre-PEG,but not statistically significant. CONCLUSION:PEG placement increases GOR episodes in neurologically impaired children.

Survival of geriatric patients after percutaneous endoscopic gastrostomy in Japan

AIM: To examine the long term survival of geriatric patients treated with percutaneous endoscopic gastrostomy (PEG) in Japan. METHODS: We retrospectively included 46 Japanese community and tertiary hospitals to investigate 931 consecutive geriatric patients (≥ 65 years old) with swallowing difficulty and newly performed PEG between Jan 1st 2005 and Dec 31st 2008. We set death as an outcome and explored the associations among patient’s characteristics at PEG using log-rank tests and Cox proportional hazard models. RESULTS: Nine hundred and thirty one patients were followed up for a median of 468 d. A total of 502 deaths were observed (mortality 53%). However, 99%, 95%, 88%, 75% and 66% of 931 patients survived more than 7, 30, 60 d, a half year and one year, respectively. In addition, 50% and 25% of the patients survived 753 and 1647 d, respectively. Eight deaths were considered as PEG-related, and were associated with lower serum albumin levels (P = 0.002). On the other hand, among 28 surviving patients (6.5%), PEG was removed. In a multivariate hazard model, older age [hazard ratio (HR), 1.02; 95% confidence interval (CI), 1.00-1.03; P = 0.009], higher C-reactive protein (HR, 1.04; 95% CI: 1.01-1.07; P = 0.005), and higher blood urea nitrogen (HR, 1.01; 95% CI: 1.00-1.02; P = 0.003) were significant poor prognostic factors, whereas higher albumin (HR, 0.67; 95% CI: 0.52-0.85; P = 0.001), female gender (HR, 0.60; 95% CI: 0.48-0.75; P < 0.001) and no previous history of ischemic heart disease (HR, 0.69; 95% CI: 0.54-0.88, P = 0.003) were markedly better prognostic factors. CONCLUSION: These results suggest that more than half of geriatric patients with PEG may survive longer than 2 years. The analysis elucidated prognostic factors.

Over-the-scope-clip closure of long lasting gastrocutaneous fistula after percutaneous endoscopic gastrostomy tube removal in immunocompromised patients:A single center case series

Over-the-scope-clips (OTSC®) have been shown to be an effective and safe endoscopic treatment option for the closure of gastrointestinal perforations, leakages and fistulae. Indications for endoscopic OTSC® treatment have grown in number and also include gastro cutaneous fistula (GCF) after percutaneous endoscopic gastrostomy (PEG) tube removal. Non-healing GCF is a rare complication after removal of PEG tubes and may especially develop in immunosuppressed patients with multiple comorbidities. There is growing evidence in the literature that OTSC® closure of GCF after PEG tube removal is emerging as an effective, simple and safe endoscopic treatment option. However current evidence is limited to the geriatric population and short standing GCF, while information on closure of long standing GCF after PEG tube removal in a younger population with significant comorbidities is lacking. In this retrospective single-center case-series we report on five patients undergoing OTSC® closure of chronic GCF after PEG tube removal. Four out of five patients were afflicted with long lasting, symptomatic fistulae. All five patients suffered from chronic disease associated with a catabolic metabolism (cystic fibrosis, chemotherapy for neoplasia, liver cirrhosis). The mean patient age was 43 years. The mean dwell time of PEG tubes in all five patients was 808 d. PEG tube dwell time was shortest in patient 5 (21 d). The mean duration from PEG tube removal to fistula closure in patients 1-4 was 360 d (range 144-850 d). The intervention was well tolerated by all patients and no adverse events occured. Successful immediate and long-term fistula closure was accomplished in all five patients. This single center case series is the first to show successful endoscopic OTSC® closure of long lasting GCF in five consecutive middle-aged patients with significant comorbidities. Endoscopic closure of chronic persistent GCF after PEG tube removal using an OTSC® was achieved in all patients with no immediate or long-term complications. OTSC® is a promising endoscopic treatment option for this condition with a potentially high immediate and long term success rate in patients with multiple comorbidities.

Is percutaneous endoscopic gastrostomy tube placement safe in patients with ventriculoperitoneal shunts?

AIM:To investigate whether percutaneous endoscopic gastrostomy (PEG) tube placement is safe in patients with ventriculoperitoneal (VP) shunts.METHODS: This was a retrospective study of all patients undergoing PEG insertion at our institution between June 1999 and June 2006. Post-PEG complications were compared between two groups according to the presence or absence of VP shunts. VP shunt infection rates, the interval between PEG placement and VP shunt catheter insertion, and long-term follow-up were also investigated.RESULTS: Fifty-five patients qualified for the study. Seven patients (12.7%) had pre-existing VP shunts. All patients received prophylactic antibiotics. The complication rate did not differ between VP shunt patients undergoing PEG (PEG/VP group) and non-VP shunt patients undergoing PEG (control group) [1 (14.3%) vs 6 (12.5%), P=1.000]. All patients in the PEG/VP group had undergone VP shunt insertion prior to PEG placement. The mean interval between VP shunt insertion and PEG placement was 308.7 d (range, 65-831 d). The mean follow-up duration in the PEG/VP group was 6.4 mo (range, 1-15 mo). There were no VP shunt infections, although one patient in the PEG/VP group developed a minor peristomal infection during follow-up.CONCLUSION: Complications following PEG placement in patients with VP shunts were infrequent in this study.

Percutaneous endoscopic gastrostomy and jejunostomy:Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight.Therefore,oral feeding is the main approach for such patients.When physiological nutrition is not possible,positioning of a nasogastric,nasojejunal tube,or other percutaneous devices may be feasible alternatives.Creating a percutaneous endoscopic gastrostomy(PEG)is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk.Many diseases require nutritional support by PEG,with neurological,oncological,and catabolic diseases being the most common.PEG can be performed endoscopically by various techniques,radiologically or surgically,with different outcomes and related adverse events(AEs).Moreover,some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent.These conditions highlight many ethical problems that become difficult to manage as treatment progresses.The aim of this manuscript is to review all current endoscopic techniques for percutaneous access,their indications,postprocedural follow-up,and AEs.

Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes

BACKGROUND Percutaneous Endoscopic Gastrostomy(PEG)tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake.The 2011 ASGE guidelines recommend delaying PEG tube placement for two weeks,as half of patients with dysphagia improve within 2 wk.There are few studies comparing outcomes based on timing of PEG tube placement,and there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehab and skilled nursing facilities.AIM To assess the safety of early(≤7 d post stroke)vs late(>7 d post stroke)PEG tube placement and evaluate whether pre-procedural risk factors could predict mortality or complications.METHODS We performed a retrospective study of patients undergoing PEG tube placement for dysphagia following a stroke at two hospitals in Saint Louis,MO between January 2011 and December 2017.Patients were identified by keyword search of endoscopy reports.Mortality,peri-procedural complication rates,and post-procedural complication rates were compared in both groups.Predictors of morbidity and mortality such as protein-calorie malnutrition,presence of an independent cardiovascular risk equivalent,and presence of Systemic inflammatory response syndrome(SIRS)criteria or documented infection were evaluated by multivariate logistic regression.RESULTS 154 patients had a PEG tube placed for dysphagia following a stroke,92 in the late group and 62 in the early group.There were 32 observed deaths,with 8 occurring within 30 d of the procedure.There was an increase in peri-procedural and post-procedural complications with delayed PEG placement which was not statistically significant.Hospital length of stay was significantly less in patients with early PEG tube placement(12.9 vs 22.34 d,P<0.001).Protein calorie malnutrition,presence of SIRS criteria and/or documented infection prior to procedure or having a cardiovascular disease risk equivalent did not significantly predict mortality or complications.CONCLUSION Early PEG tube placement following a stroke did not result in a higher rate of mortality or complications and significantly decreased hospital length of stay.Given similar safety outcomes in both groups,early PEG tube placement should be considered in the appropriate patient to potentially reduce length of hospital stay and incurred costs.

Time trends and outcomes of gastrostomy placement in a Swedish national cohort over two decades

BACKGROUND Percutaneous endoscopic gastrostomy(PEG)and laparoscopically inserted gastrostomy have become the gold standard for adult patients and children,respectively,requiring long-term enteral nutrition support.Procedure-related mortality is a rare event,often reported to be zero in smaller studies.National data on 30-d mortality and long-term survival rates after gastrostomy placement are scarce in the literature.AIM To study the use of gastrostomies in Sweden from 1998-2019 and to analyze procedure-related mortality and short-term(<30 d)and long-term survival.METHODS In this retrospective,population-based cohort study,individuals that had received a gastrostomy between 1998-2019 in Sweden were included.Individuals were identified in the Swedish National Patient Register,and survival analysis was possible by cross-referencing the Swedish Death Register.The cohort was divided into three age groups:Children(0-18 years);adults(19-64 years);and elderly(≥65 years).Kaplan-Meier with log-rank test and Cox regression were used for survival analysis.RESULTS In total 48682 individuals(52%males,average age 60.9±25.3 years)were identified.The cohort consisted of 12.0%children,29.5%adults,and 58.5%elderly.An increased use of gastrostomies was observed during the study period,from 13.7/100000 to 22.3/100000 individuals(P<0.001).The use of PEG more than doubled(about 800 to 1800/year),with a corresponding decrease in open gastrostomy(about 700 to 340/year).Laparoscopic gastrostomy increased more than ten-fold(about 20 to 240/year).Overall,PEG,open gastrostomy,and laparoscopic gastrostomy constituted 70.0%(n=34060),23.3%(n=11336),and 4.9%(n=2404),respectively.Procedure-related mortality was 0.1%(n=44)overall(PEG:0.05%,open:0.24%,laparoscopic:0.04%).The overall 30-d mortality rate was 10.0%(PEG:9.8%,open:12.4%,laparoscopic:1.7%)and decreased from 11.6%in 1998-2009 vs 8.5%in 2010-2019(P<0.001).One-year and ten-year survival rates for children,adults,and elderly were 93.7%,67.5%,and 42.1%and 79.9%,39.2%,and 6.8%,respectively.The most common causes of death were malignancies and cardiovascular and respiratory diseases.CONCLUSION The annual use of gastrostomies in Sweden increased during the study period,with a shift towards more minimally invasive procedures.Although procedure-related death was rare,the overall 30-d mortality rate was high(10%).To overcome this,we believe that patient selection should be improved.

Mortality Trend and Predictors of Mortality in Dysphagic Stroke Patients Postpercutaneous Endoscopic Gastrostomy

Background：Percutaneous endoscopic gastrostomy （PEG） feeding is widely used in stroke patients suffering from persistent dysphagia;however,predicting the risks and benefits of PEG insertion in the individual patient is difficult.The aim of our study was to investigate if candidate risk factors could predict short-term mortality risk in poststroke patients who had PEG tube insertion for persistent dysphagia.Methods：This was a retrospective study of 3504 consecutive stroke patients admitted to two metropolitan hospitals during the period January 2005 to December 2013 and who also underwent PEG insertion for feeding due to persistent dysphagia.Results：A total of 102 patients were included in the study.There were 22 deaths in 6 months after insertion of PEG tubes and 20 deaths of those occurred within 3 months post PEG.Those who survived beyond 6 months showed significantly lower mean age （75.9 ± 9.0 years vs.83.0 ± 4.9 years,P 〈 0.001）,a lower mean American Society of Anesthesia （ASA） score （3.04 ± 0.63 vs.3.64 ± 0.58,P 〈 0.001） compared to nonsurvivors.In multiple Logistic,age （P =0.004,odds ratio [OR] =1.144;95% confidence interval [CI]：1.044-1.255）;ASA （P =0.002,OR =5.065;95% CI：1.815-14.133） and albumin level pre-PEG insertion （P =0.033,OR =0.869;95% CI：0.764-0.988）were the independent determinants of mortality respectively.Conclusions：We propose that age,ASA score and albumin level pre-PEG insertion to be included as factors to assist in the selection of patients who are likely to survive more than 3 months post PEG insertion.

Percutaneous endoscopic gastrostomy with Funada-style gastropexy greatly reduces the risk of peristomal infection

Background and aims:Peristomal wound infections are common complications of percutaneous endoscopic gastrostomy(PEG).The Funada-style gastropexy device has two parallel needles with a wire loop and suture thread,and was developed about 20 years ago in Japan.This kit has allowed us to perform dual gastropexy very easily;PEG with gastropexy has become a very popular technique in Japan.The present study aimed to compare the advantages and disadvantages of PEG with the gastropexy technique with the standard‘pull’method.Methods:We retrospectively reviewed 182 consecutive,non-randomized patients undergoing PEG in our hospital,and a comparative analysis was made between the gastropexy(87 patients)and non-gastropexy(95 patients)groups.Results:The rates of patients having erythema(11.6%vs.47.9%;P<0.001),exudates(2.3%vs.14.9%;P<0.01)and infection(0%vs.6.4%;P紏0.01)in the peristomal area were lower in the gastropexy than in the non-gastropexy group.The rate of minor bleeding from the peristomal area was higher in the gastropexy than in the non-gastropexy group(12.8%vs.2.1%;P<0.01),but no patient required a blood transfusion.Mean procedure time was longer in the gastropexy group than in the non-gastropexy group(31 vs.24 min;P<0.001).The 30-day mortality rates were 4.7%and 5.3%respectively,and these deaths were not related to the gastrostomy procedure.Conclusion:PEG with gastropexy markedly reduces peristomal inflammation.Although minor bleeding and a longer procedure time were disadvantages,there were no severe complications.The findings suggested that PEG with Funada-style gastropexy was a safe and feasible method for reducing early complications of PEG.

Advances and challenges of gastrostomy insertion in children

When oral feeding cannot provide adequate nutritional support to children,enteral tube feeding becomes a necessity.The overall aim is to ultimately promote appropriate growth,improve the patient’s quality of life and increase carer satisfaction.Nasogastric tube feeding is considered appropriate on a short-term basis.Alternatively,gastrostomy feeding offers a more convenient and safer feeding option especially as it does not require frequent replacements,and carries a lower risk of complications.Gastrostomy tube feeding should be considered when nasogastric tube feeding is required for more than 2-3 wk as per the ESPEN guidelines on artificial enteral nutrition.Several techniques can be used to insert gastrostomies in children including endoscopic,image guided and surgical gastrostomy insertion whether open or laparoscopic.Each technique has its own advantages and disadvantages.The timing of gastrostomy insertion,device choice and method of insertion is dependent on the local expertise,patient requirements and family preference,and should be individualized with a multidisciplinary team approach.We aim to review gastrostomy insertion in children including indications,contraindications,history of gastrostomy,insertion techniques and complications.

Retrograde jejunoduodenogastric intussusception due to a replacement percutaneous gastrostomy tube presenting as upper gastrointestinal bleeding

Percutaneous endoscopic gastrostomy (PEG) tube complications can be serious or life threatening. Retrograde intussusception is a very rare complication of PEG tubes with only 9 cases reported in the literature. We describe a case of retrograde intussusception, associated with the use of a Foley catheter as a replacement gastrostomy tube, presenting with upper gastrointestinal bleeding. To our knowledge, this is the first reported case of PEG-related retrograde intussusception successfully managed in a non-surgical manner. Retrograde intussusception likely occurred due to migration of the replacement tube with resultant securing and invagination of the proximal jejunum when the gastrostomy tube was anchored to the abdominal wall.

Bowel intussusception caused by a percutaneously placed endoscopic gastrojejunostomy catheter: A case report

BACKGROUND In adults,bowel intussusception is a rare diagnosis and is mostly due to an organic bowel disorder.In rare cases,this is a complication of a percutaneously placed endoscopic gastro(jejunostomy)catheter.CASE SUMMARY We describe a case of a 73-year-old patient with a history of myocardial infarction,chronic idiopathic constipation and Parkinson’s disease.For the admission of his Parkinson’s medication,a percutaneous endoscopic gastrostomy with jejunal extension(PEG-J)was placed.The patient presented three times at the emergency department of the hospital with intermittent abdominal pain with nausea and vomiting.There were no distinctive abnormalities from the physical and laboratory examinations.An abdominal computed tomography scan showed a small bowel intussusception.By push endoscopy,a jejunal bezoar at the tip of the PEG-J catheter was found to be the cause of small bowel intussusception.The intussusception was resolved after removing the bezoar during push enteroscopy.CONCLUSION Endoscopic treatment of bowel intussusception caused by PEG-J catheter bezoar.

Buried bumper syndrome:A critical analysis of endoscopic release techniques

Buried bumper syndrome(BBS)is the situation in which the internal bumper of the gastrostomy tube,due to prolonged compression of the tissues between the external and the internal bumper,migrates from the gastric lumen into the gastric wall or further,into the tract outside the gastric lumen,ending up anywhere between the stomach mucosa and the surface of the skin.This restricts liquid food from entering the stomach,since the internal opening is obstructed by gastric mucosal overgrowth.We performed a comprehensive search of the PubMed literature to retrieve all the case-reports and case-series referring to BBS and its management,after which we focused on the endoscopic techniques for releasing the internal bumper to re-establish the functionality of the tube.From the“push”and the“push and pull T”techniques to the most sophisticated-using high tech instruments,all 10 published techniques have been critically analysed and the pros and cons presented,in an effort to optimize the criteria of choice based on maximum efficacy and safety.

Acute pancreatitis and cholangitis: A complication caused by a migrated gastrostomy tube

Percutaneous endoscopic gastrostomy (PEG) is generally considered safe with a low rate of serious complications. However, dislocation of the PEG-tube into the duodenum can lead to serious complications. An 86-year old Japanese woman with PEG-tube feeding sometimes vomited after her family doctor replaced the PEG-tube without radiologic confirmation. At her hospitalization, she complained of severe tenderness at the epigastric region and the PEG-tube was drawn into the stomach. Imaging studies showed that the tip of PEG-tube with the infl ated balloon was migrated into the second portion of the duodenum, suggesting that it might have obstructed the bile and pancreatic ducts, inducing cholangitis and pancreatitis. After the PEG- tube was replaced at the appropriate position, vomiting and abdominal tenderness improved dramatically and laboratory studies became normal immediately. Our case suggests that it is important to secure PEG-tube at the level of skin, especially after replacement.