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.Pro...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.展开更多
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...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.展开更多
BACKGROUND Percutaneous endoscopic gastrostomy(PEG)and percutaneous radiological gastrostomy(PRG)are minimally invasive techniques commonly used for prolonged enteral nutrition.Despite safe,both techniques may lead to...BACKGROUND Percutaneous endoscopic gastrostomy(PEG)and percutaneous radiological gastrostomy(PRG)are minimally invasive techniques commonly used for prolonged enteral nutrition.Despite safe,both techniques may lead to complications,such as bleeding,infection,pain,peritonitis,and tube-related complications.The literature is unclear on which technique is the safest.AIM To establish which approach has the lowest complication rate.METHODS A database search was performed from inception through November 2022,and comparative studies of PEG and PRG were selected following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.All included studies compared the two techniques directly and provided absolute values of the number of complications.Studies with pediatric populations were excluded.The primary outcome of this study was infection and bleeding.Pneumonia,peritonitis,pain,and mechanical complications were secondary outcomes.The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials(RoB2)and we used The Risk of Bias in Nonrandomized Studies(ROBINS-I)to analyze the retrospective studies.We also performed GRADE analysis to assess the quality of evidence.Data on risk differences and 95%confidence intervals were obtained using the Mantel-Haenszel test.RESULTS Seventeen studies were included,including two randomized controlled trials and fifteen retrospective cohort studies.The total population was 465218 individuals,with 273493 having undergone PEG and 191725 PRG.The only outcome that showed a significant difference was tube related complications in retrospective studies favoring PEG(95%CI:0.03 to 0.08;P<0.00001),although this outcome did not show significant difference in randomized studies(95%CI:-0.07 to 0.04;P=0.13).There was no difference in the analyses of the following outcomes:infection in retrospective(95%CI:-0.01 to 0.00;P<0.00001)or randomized(95%CI:-0.06 to 0.04;P=0.44)studies;bleeding in retrospective(95%CI:-0.00 to 0.00;P<0.00001)or randomized(95%CI:-0.06 to 0.02;P=0.43)studies;pneumonia in retrospective(95%CI:-0.04 to 0.00;P=0.28)or randomized(95%CI:-0.09 to 0.11;P=0.39)studies;pain in retrospective(95%CI:-0.05 to 0.02;P<0.00001)studies;peritonitis in retrospective(95%CI:-0.02 to 0.01;P<0.0001)studies.CONCLUSION PEG has lower levels of tube-related complications(such as dislocation,leak,obstruction,or breakdown)when compared to PRG.展开更多
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”a...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.展开更多
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 h...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.展开更多
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 patie...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.展开更多
Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known...Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the “pull” technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.展开更多
Percutaneous endoscopic gastrostomy(PEG) is a widely used method of nutrition delivery for patients with longterm insufficiency of oral intake. The PEG complication rate varies from 0.4% to 22.5% of cases, with minor ...Percutaneous endoscopic gastrostomy(PEG) is a widely used method of nutrition delivery for patients with longterm insufficiency of oral intake. The PEG complication rate varies from 0.4% to 22.5% of cases, with minor complications being three times more frequent. Buried bumper syndrome(BBS) is a severe complication of this method, in which the internal fixation device migrates alongside the tract of the stoma outside the stomach. Excessive compression of tissue between the external and internal fixation device of the gastrostomy tube is considered the main etiological factor leading to BBS. Incidence of BBS is estimated at around 1%(0.3%-2.4%). Inability to insert, loss of patency and leakage around the PEG tube are considered to be a typical symptomatic triad. Gastroscopy is indicated in all cases in which BBS is suspected. The depth of disc migration in relation to the lamina muscularis propria of the stomach is critical for further therapy and can be estimated by endoscopic or transabdominal ultrasound. BBS can be complicated by gastrointestinal bleeding, perforation, peritonitis, intra-abdominal and abdominal wall abscesses, or phlegmon, and these complications can lead to fatal outcomes. The most important preventive measure is adequate positioning of the external bolster. A conservative approach should be applied only in patients with high operative risk and dismal prognosis. Choice of the method of release is based on the type of the PEG set and depth of disc migration. A disc retained inside the stomach and completely covered by the overgrowing tissue can be released using some type of endoscopic dissection technique(needle knife, argon plasma coagulation, or papillotome through the cannula). Proper patient selection and dissection of the overgrowing tissue are the major determinants for successful endoscopic therapy. A disc localized out of the stomach(lamina muscularis propria) should be treated by a surgeon.展开更多
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 procedu...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.展开更多
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 f...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.展开更多
AIM:To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy(PEG)could be a valuable option for patients with complicated anatomy.METHODS:A retrospective analysis of twelve patients(seven females,f...AIM:To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy(PEG)could be a valuable option for patients with complicated anatomy.METHODS:A retrospective analysis of twelve patients(seven females,five males;six children,six young adults;mean age 19.2 years)with cerebral palsy,spastic quadriparesis,severe kyphoscoliosis and interposed organs and who required enteral nutrition(EN)due to starvation was performed.For all patients,standard PEG placement was impossible due to distorted anatomy.All the patients qualified for the laparoscopyassisted PEG procedure.RESULTS:In all twelve patients,the laparoscopy-assisted PEG was successful,and EN was introduced four to six hours after the PEG placement.There were no complications in the perioperative period,either technical or metabolic.All the patients were discharged from the hospital and were then effectively fed using bolus methods.CONCLUSION:Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.展开更多
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 ...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.展开更多
文摘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.
文摘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.
文摘BACKGROUND Percutaneous endoscopic gastrostomy(PEG)and percutaneous radiological gastrostomy(PRG)are minimally invasive techniques commonly used for prolonged enteral nutrition.Despite safe,both techniques may lead to complications,such as bleeding,infection,pain,peritonitis,and tube-related complications.The literature is unclear on which technique is the safest.AIM To establish which approach has the lowest complication rate.METHODS A database search was performed from inception through November 2022,and comparative studies of PEG and PRG were selected following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.All included studies compared the two techniques directly and provided absolute values of the number of complications.Studies with pediatric populations were excluded.The primary outcome of this study was infection and bleeding.Pneumonia,peritonitis,pain,and mechanical complications were secondary outcomes.The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials(RoB2)and we used The Risk of Bias in Nonrandomized Studies(ROBINS-I)to analyze the retrospective studies.We also performed GRADE analysis to assess the quality of evidence.Data on risk differences and 95%confidence intervals were obtained using the Mantel-Haenszel test.RESULTS Seventeen studies were included,including two randomized controlled trials and fifteen retrospective cohort studies.The total population was 465218 individuals,with 273493 having undergone PEG and 191725 PRG.The only outcome that showed a significant difference was tube related complications in retrospective studies favoring PEG(95%CI:0.03 to 0.08;P<0.00001),although this outcome did not show significant difference in randomized studies(95%CI:-0.07 to 0.04;P=0.13).There was no difference in the analyses of the following outcomes:infection in retrospective(95%CI:-0.01 to 0.00;P<0.00001)or randomized(95%CI:-0.06 to 0.04;P=0.44)studies;bleeding in retrospective(95%CI:-0.00 to 0.00;P<0.00001)or randomized(95%CI:-0.06 to 0.02;P=0.43)studies;pneumonia in retrospective(95%CI:-0.04 to 0.00;P=0.28)or randomized(95%CI:-0.09 to 0.11;P=0.39)studies;pain in retrospective(95%CI:-0.05 to 0.02;P<0.00001)studies;peritonitis in retrospective(95%CI:-0.02 to 0.01;P<0.0001)studies.CONCLUSION PEG has lower levels of tube-related complications(such as dislocation,leak,obstruction,or breakdown)when compared to PRG.
文摘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.
文摘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.
文摘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.
文摘Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the “pull” technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.
基金Supported by Project PRVOUK P37-08 from Charles University PragueCzech Republic
文摘Percutaneous endoscopic gastrostomy(PEG) is a widely used method of nutrition delivery for patients with longterm insufficiency of oral intake. The PEG complication rate varies from 0.4% to 22.5% of cases, with minor complications being three times more frequent. Buried bumper syndrome(BBS) is a severe complication of this method, in which the internal fixation device migrates alongside the tract of the stoma outside the stomach. Excessive compression of tissue between the external and internal fixation device of the gastrostomy tube is considered the main etiological factor leading to BBS. Incidence of BBS is estimated at around 1%(0.3%-2.4%). Inability to insert, loss of patency and leakage around the PEG tube are considered to be a typical symptomatic triad. Gastroscopy is indicated in all cases in which BBS is suspected. The depth of disc migration in relation to the lamina muscularis propria of the stomach is critical for further therapy and can be estimated by endoscopic or transabdominal ultrasound. BBS can be complicated by gastrointestinal bleeding, perforation, peritonitis, intra-abdominal and abdominal wall abscesses, or phlegmon, and these complications can lead to fatal outcomes. The most important preventive measure is adequate positioning of the external bolster. A conservative approach should be applied only in patients with high operative risk and dismal prognosis. Choice of the method of release is based on the type of the PEG set and depth of disc migration. A disc retained inside the stomach and completely covered by the overgrowing tissue can be released using some type of endoscopic dissection technique(needle knife, argon plasma coagulation, or papillotome through the cannula). Proper patient selection and dissection of the overgrowing tissue are the major determinants for successful endoscopic therapy. A disc localized out of the stomach(lamina muscularis propria) should be treated by a surgeon.
文摘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.
文摘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.
文摘AIM:To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy(PEG)could be a valuable option for patients with complicated anatomy.METHODS:A retrospective analysis of twelve patients(seven females,five males;six children,six young adults;mean age 19.2 years)with cerebral palsy,spastic quadriparesis,severe kyphoscoliosis and interposed organs and who required enteral nutrition(EN)due to starvation was performed.For all patients,standard PEG placement was impossible due to distorted anatomy.All the patients qualified for the laparoscopyassisted PEG procedure.RESULTS:In all twelve patients,the laparoscopy-assisted PEG was successful,and EN was introduced four to six hours after the PEG placement.There were no complications in the perioperative period,either technical or metabolic.All the patients were discharged from the hospital and were then effectively fed using bolus methods.CONCLUSION:Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.
文摘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.