Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts

Clinical characteristics of children with severe neurologic impairment: A scoping review

OBJECTIVE

The aim of this study is to extrapolate the clinical features of children with severe neurologic impairment (SNI) based on the functional characteristics and comorbidities described in published studies.

METHODS

Four databases were searched. We included studies that describe clinical features of a group of children with SNI (≥20 subjects <19 years of age with >1 neurologic diagnosis and severe functional limitation) using data from caregivers, medical charts, or prospective collection. Studies that were not written in English were excluded. We extracted data about functional characteristics, comorbidities, and study topics.

RESULTS

We included 102 studies, spanning 5 continents over 43 years, using 41 distinct terms for SNI. The terms SNI and neurologic impairment (NI) were used in 59 studies (58%). Most studies (n = 81, 79%) described ≥3 types of functional characteristics, such as technology assistance and motor impairment. Studies noted 59 comorbidities and surgeries across 10 categories. The most common comorbidities were related to feeding, nutrition, and the gastrointestinal system, which were described in 79 studies (77%). Most comorbidities (76%) were noted in <10 studies. Studies investigated seven clinical topics, with "Gastrointestinal reflux and feeding tubes" as the most common research focus (n = 57, 56%). The next most common topic, "Aspiration and respiratory issues," included 13 studies (13%). Most studies (n = 54, 53%) were retrospective cohorts or case series; there were no clinical trials.

CONCLUSIONS

Despite the breadth of described comorbidities, studies focused on a narrow set of clinical topics. Further research is required to understand the prevalence, clinical impact, and interaction of the multiple comorbidities that are common in children with SNI.

Ventriculoperitoneal Shunt and Gastrostomy Tube Placement and Timing: A Database Analysis

Background Debate exists about the safety of ventriculoperitoneal shunt placement in the presence of a gastrostomy tube and the timing of these procedures from each other. Using a large database, we sought to determine the rates of shunt infection and revision in patients who had both devices placed, based on the timing between procedures. Methods We performed a retrospective database analysis using a multi-institutional database (TriNetX), looking at all patients diagnosed with gastrostomy tube with subsequent ventriculoperitoneal shunt placement and vice-versa. We also evaluated patients who had gastrostomy tubes and shunts placed at the same time. We categorized cohorts into patients with device placement after 1-10 days, 11-30 days, and after one month of the other. Our primary endpoints were shunt infection and shunt revision. Results Patients who had same-day gastrostomy tube and shunt placement had a shunt infection rate of 10.06% within five years, and 14.53% had a shunt revision. With prior shunting and subsequent gastrostomy tube placement within 1-10 days, 12.18% had shunt infections, and 17.88% had shunt revisions; for those who had subsequent gastrostomy tube placement within 11-30 days, shunt infections were seen in 10.57%, and shunt revisions in 19.41%; gastrostomy tube placement after one month or longer of shunt placement resulted in 15.39% of patients having shunt infections and 17.73% with shunt revision. Prior gastrostomy tube patients with subsequent shunt placement, within 1-10 days had shunt infection rates of 8.27% and revision rates of 14.39%; for shunt placement within 11-30 days, shunt infections were seen in 10.82%, and shunt revisions were done in 14.33% of patients; for shunt placement after one month or longer, shunt infection rate was 11.68%, and revision rate was 16.80%. Conclusions Our results demonstrate no significant difference in shunt infection rates and shunt revision rates between same-day gastrostomy tube and shunt placement versus placement within 1-10 days, 11-30 days, or any time after one month from one another.

Evaluation of Risk of Gastrostomy and Ventriculoperitoneal Shunt Placement in Pediatric Patients: A Systematic Review of the Literature

A subset of patients with neurologic deficits require ventriculoperitoneal shunt (VPS) placement in addition to gastrostomy tubes (GTs). At present, the literature is inconsistent with respect to the sequence and time period between procedures that yields the lowest risk profile for GT and VPS placement. The purpose of this systematic literature review was to determine if time elapsed between VPS and GT placement was associated with infection (peritoneal and/or CSF). A systematic literature review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. PubMEd/MEDLINE, Scopus, Ovid, Cochrane, and EMBASE databases were queried. Precise search terminology is available in the body of the manuscript. The initial database query yielded 88 unique articles. After abstract screening, 28 articles were identified and 6 met criteria for inclusion in the final analysis. The included studies were all retrospective analyses and reported data for 217 patients between the years of 1988 and 2016. Across all included studies, the infection rate after VPS and GT placement during the studies' surveillance period was 15.2% (n = 33/217). The cumulative rate of all reported complications in patients with both VPS and GT was 24.0% (n = 52/217). These studies suggest that placement of GT in patients with preexisting VPS does not significantly contribute to increased shunt or intraperitoneal infection. Future studies should determine the optimal time interval between VPS and GT placement and to identify the most appropriate prophylactic antibiotic regimen.

Optimal timing and sequence of ventriculoperitoneal shunt and gastrostomy placement

Background: The optimal timing of ventriculoperitoneal shunt (VPS) and gastrostomy placement, relative to the safety of simultaneous versus staged surgery, has not been clearly delineated in the literature.Objective: To study the optimal inter-procedural timing relative to distal VPS infection and pertinent reoperation.Methods: A fifteen-year, retrospective, single-center study was conducted on adults undergoing VPS and gastrostomy within 30-days. Patients were grouped according to inter-procedural interval: 0-24 hr (immediate), 24 hr-7 days (early), and 7-30 days (delayed). The primary endpoint of the study was VPS infection and distal shunt complications requiring reoperation. Potential predictors of the primary end point (baseline cohort characteristics, procedural factors) were examined with standard statistical methods.Results: A total of 188 patients met inclusion criteria. The average interval between procedures was 7 ± 6 days, with 43.1% undergoing VPS prior to gastrostomy. Primary endpoint was encountered in 5 patients (2.7%): 1 (5.9%) of 17 patients undergoing immediate placement, 3 (2.8%) of 107 with early placement, and 1 (1.6%) of 64 with delayed placement. Although not statistically significant, 3.7% of patients undergoing VPS first had the primary endpoint, compared to 1.9% of those with gastrostomy. There were no statistically significant associations between the primary outcome and peri-operative CSF counts, gastrostomy modality, hydrocephalus etiology, chronic steroid use, or extended antibiotic administration.Conclusion: Although the low overall event rate in this cohort precludes definitive determination regarding differential safety, the data generally support a practice of performing the procedures >24-hours apart, with placement of gastrostomy prior to VPS.

Safety of co-placement of ventriculoperitoneal shunt and percutaneous radiologic gastrostomy

Background

There is little evidence about the safety of co-placement of percutaneous radiologic gastrostomy in patients with ventriculoperitoneal shunt.

Purpose

To investigate the safety of co-placement of percutaneous radiologic gastrostomy tube and ventriculoperitoneal shunt.

Material and Methods

Between July 2006 and June 2018, 1015 patients underwent percutaneous radiologic gastrostomy placement at our institution. Those who had undergone both ventriculoperitoneal shunt and percutaneous radiologic gastrostomy placement were selected. Patient data, including baseline characteristics, percutaneous radiologic gastrostomy types, temporal relationship between the procedures, and ventriculoperitoneal shunt infection, were retrospectively reviewed.

Results

Nineteen patients received percutaneous radiologic gastrostomy and ventriculoperitoneal shunt co-placement. The percutaneous radiologic gastrostomy types were pigtail-retained gastrostomy (n = 12) and pull-type gastrostomy (n = 7). Ventriculoperitoneal shunt was placed before percutaneous radiologic gastrostomy in 15 patients (79%) and vice versa in four patients (21%). Mean interval between the two procedures was 361 days (range 3–1833 days). Only one case (5.3%) of ventriculoperitoneal shunt infection occurred and it was successfully managed conservatively. There was no significant difference in the incidence of complications between the ventriculoperitoneal shunt before percutaneous radiologic gastrostomy group and the opposite group ( P = 0.789). Moreover, there was no significant difference in complication rates between the two gastrostomy catheter types ( P = 0.368).

Conclusions

Co-placement of percutaneous radiologic gastrostomy and ventriculoperitoneal shunt seems safe and should not be considered a contraindication. Moreover, the percutaneous radiologic gastrostomy and ventriculoperitoneal shunt should be placed as far from each other as possible.

Gastrostomy tube placement increases the risk of ventriculoperitoneal shunt infection: a multiinstitutional study

OBJECTIVE

Gastrostomy tube placement can temporarily seed the peritoneal cavity with bacteria and thus theoretically increases the risk of shunt infection when the two procedures are performed contemporaneously. The authors hypothesized that gastrostomy tube placement would not increase the risk of ventriculoperitoneal shunt infection. The object of this study was to test this hypothesis by utilizing a large patient cohort combined from multiple institutions.

METHODS

A retrospective study of all adult patients admitted to five institutions with a diagnosis of aneurysmal subarachnoid hemorrhage between January 2005 and January 2015 was performed. The primary outcome of interest was ventriculoperitoneal shunt infection. Variables, including gastrostomy tube placement, were tested for their association with this outcome. Standard statistical methods were utilized.

RESULTS

The overall cohort consisted of 432 patients, 47% of whom had undergone placement of a gastrostomy tube. The overall shunt infection rate was 9%. The only variable that predicted shunt infection was gastrostomy tube placement (p = 0.03, OR 2.09, 95% CI 1.07-4.08), which remained significant in the multivariate analysis (p = 0.04, OR 2.03, 95% CI 1.04-3.97). The greatest proportion of shunts that became infected had been placed more than 2 weeks (25%) and 1-2 weeks (18%) prior to gastrostomy tube placement, but the temporal relationship between shunt and gastrostomy was not a significant predictor of shunt infection.

CONCLUSIONS

Gastrostomy tube placement significantly increases the risk of ventriculoperitoneal shunt infection.

Bowel Obstruction: Decompressive Gastrostomies and Cecostomies

Over the past 30 years, image-guided placement of gastrostomies and cecostomies for gastrointestinal decompression has developed into a safe and effective treatment for symptomatic bowel obstruction. Gastrostomies and cecostomies relieve patient symptoms, can prevent serious complications such as colonic perforation, and may bridge patients to more definitive treatment for the underlying cause of obstruction. This article will review the history of decompressive gastrostomies and cecostomies as well as the indications, contraindications, technique, complications, and outcomes of these procedures.

Systematic review of ventricular peritoneal shunt and percutaneous endoscopic gastrostomy: a safe combination

OBJECTIVE

Various international and national gastrointestinal guidelines take different positions on whether ventriculoperitoneal shunt (VPS) insertion is a contraindication to percutaneous endoscopic gastrostomy (PEG). The objective of this meta-analysis was to try to answer the question of whether VPS insertion is a contraindication to PEG.

METHODS

A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Electronic databases PubMed and Embase were searched using variations of the terms “ventriculo-peritoneal shunt” and “percutaneous (endoscopic) gastrostomy.” This search resulted in 70 studies, 9 of which were relevant. These were cross-referenced, and 1 additional study was found, resulting in 10 studies in this systematic review.

RESULTS

The 10 relevant studies in adult cohorts included 208 patients. All studies save one were retrospective and, in general, poor quality. Among the studies with relevant data, there were 26 (12.5% of 208 cases) VPS infections and 4 (4.4% of 90 cases) VPSs that malfunctioned. In 137 patients the VPS had been placed before the PEG tube, with a VPS infection rate of 4.4%. More VPS infections occurred among the 55 patients who first had a PEG and a subsequent VPS (21.8%) and in the 16 patients who had simultaneous PEG tube and VPS placement (50%). The heterogeneity of the studies in this analysis prohibited statistical comparisons of the timing of VPS and PEG tube placement.

CONCLUSIONS

This systematic review indicated that VPS placement in combination with a PEG has a high but acceptable VPS complication rate. Therefore, VPS insertion should not be considered a contraindication to the placement of a PEG tube. Preferably, a PEG tube should be placed after the VPS. Waiting 7–10 days between VPS insertion and a PEG seems reasonable, but this could not be corroborated in this review.

Feeding tube placement: errors and complications

Feeding tube placement for enteral nutrition (EN) support is widely used in both critically ill and stable chronically ill patients who are unable to meet their nutrition needs orally. Nasal or oral feeding tubes can be performed blindly at the bedside or with fluoroscopic or endoscopic guidance into the stomach or small bowel. Percutaneous feeding tubes are used when EN support is required for longer periods (>4-6 weeks) and are most commonly placed endoscopically or radiographically. Although generally safe and effective, there is a wide spectrum of known complications associated with feeding tube placement. Errors made at the time of feeding tube placement can result in a number of these procedural and postprocedural complications. In many cases, a single error at the time of placement can result in numerous complications. A thorough knowledge of these errors and avoiding them in practice will decrease iatrogenic complications in a vulnerable population. In addition, early recognition and management of complications will further minimize morbidity and even mortality in enteral feeding tube placement. This article reviews the common errors leading to complications of enteral feeding tube placement and their prevention and management.

Comparison of fluoroscopy-guided Pull-type percutaneous radiological gastrostomy (Pull-type-PRG) with conventional percutaneous radiological gastrostomy (Push-type-PRG): clinical results in 253 patients

OBJECTIVES

To analyze the clinical results and complications of fluoroscopy guided internal-external Pull-type percutaneous radiological gastrostomy (Pull-type-PRG) and conventional external-internal percutaneous radiological gastrostomy (Push-type-PRG).

METHODS

A total of 253 patients underwent radiological gastrostomy between January 2002 and January 2010. Data were collected retrospectively from radiology reports, Chart review of clinical notes, procedure reports, discharge summaries and subsequent hospital visits. Statistical analysis was performed to compare the two methods for gastrostomy with respect to peri-interventional aspects and clinical results.

RESULTS

128 patients received the Pull-type-PRG whereas the other 125 patients were served with the Push-type-PRG. Indications for gastrostomy were similar in these two groups. The most frequent indications for the both methods were stenotic oesophageal tumors or head/neck tumors (54.7% in Pull-type-PRG, 68% in Push-type-PRG). Gastrostomy procedures were successful in 98.3% in Pull-type-PRG compared to 92% in Push-type-PRG. There was no procedure-related mortality. Compared to Push-type-PRG, the peri-interventional complication rate was significantly reduced in Pull-type-PRG (14.8% versus 34.4%, P = 0.002).

CONCLUSIONS

Compared to the external-internal Push-type-PRG, the internal-external Pull-type-PRG showed a high primary success rate and a decreased incidence of peri-interventional complications.

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 transesophageal gastrotubing: alternative tube nutrition for a patient with a ventriculoperitoneal shunt

BACKGROUND

We report a patient who underwent percutaneous transesophageal gastrotubing (PTEG), that is, nonsurgical esophagostomy under ultrasonographic control, as an alternative to percutaneous endoscopic gastrostomy (PEG).

CASE DESCRIPTION

The PTEG was placed for shunt protection from inadvertent infection in a 29-year-old male patient in whom a ventriculoperitoneal (VP) shunt had previously been inserted. During the 3-year follow-up period, no complications associated with PTEG were experienced.

CONCLUSION

Percutaneous transesophageal gastrotubing is a good alternative to PEG in a patient with a VP shunt. Further investigation concerning the risk of infection related to PTEG and PEG in VP shunt patients is needed.

Complications of video-assisted gastrostomy in children with or without a ventriculoperitoneal shunt

The aim of the study was to test the hypothesis that the presence of a ventriculoperitoneal shunt (VPS) influences the frequency of postoperative complications after video-assisted gastrostomy (VAG) in children. When using a power of 80%, a critical value for significance of 5% and an assumed population-based standard deviation of 0.4, it will be required to have a sample size of at least 14 children to show that a difference of 0.6 is significant when using Student's t test for paired samples. Thus, 15 consecutive children with VPSs were included in the present study. All the children had nutritional problems and underwent a VAG operation at a tertiary care university hospital. After the operation, the children were prospectively followed up. Specially trained nurses documented all complications according to a protocol. For the purpose of comparison, we had a control group of neurologically disabled children without VPSs, matched for age and operated with VAG. The children did not present with any serious postoperative intra-abdominal complications or central nervous system infection. There was no significant difference in the frequency of minor complications between the studied group and the control group. This study did not reveal that children with VPSs who undergo a VAG button placement are at high risk for infection and subsequent shunt malfunction. They did not have more postoperative problems than a matched control group of neurologically disabled children.

Placement of gastrostomy tubes in patients with ventriculoperitoneal shunts does not result in increased incidence of shunt infection or decreased survival

The objective of this study was to examine if G-tube (G-tube) placement in patients with ventriculoperitoneal (VP) shunts results in shunt infection or impacts patient survival. We performed a retrospective cohort study. Patients underwent VP shunt and G-tube placement. Incidence of shunt infection and patient survival were calculated. Fifty-five patients qualified for the study. Shunt infection occurred in seven patients (12.5%). The incidence of shunt infection did not differ between surgically placed G-tubes (2/7=29%) and PEG tubes (5/7=71%; P=0.69). There was no difference in the risk of VP infection based on the order of placement (OR=0.61 [0.12-3.02]; P=0.69). No predictors for shunt infection were identified. Kaplan-Meier mortality estimates demonstrated a 21% 1-year mortality rate. There were no predictors of patient survival. We conclude that placement of G-tubes in patients with shunts is safe. The order of placement of G-tube and VP shunt does not affect the incidence of shunt infection or survival.

The safety of percutaneous endoscopic gastrostomy tube placement in patients with existing ventriculoperitoneal shunts

BACKGROUND

Because the insertion of percutaneous endoscopic gastrostomy tubes (PEG) involves disruption of the gastrointestinal tract with potential peritoneal contamination, patients with indwelling ventriculoperitoneal (VP) shunts could be at increased risk of meningitis, a potentially devastating infection. The safety of PEG placement in the presence of a VP shunt is unclear.

METHODS

A retrospective chart review was performed that included all adult patients with existing VP shunts requiring PEG placement at a single university medical center over an approximate 9-year period from July 1995 to March 2004.

RESULTS

Thirty-nine patients who underwent PEG placement 2-564 days after shunt placement were identified. Two patients (5%) subsequently developed meningitis. Cerebrospinal fluid cultures demonstrated Staphylococcus aureus and Enterococcus faecalis. These infections occurred 2 and 15 months after PEG placement, respectively. At the time of PEG placement, 17 patients (44%) were receiving antibiotics for reasons other than operative prophylaxis, and 11 patients (28%) received prophylactic antibiotics. Both infected patients had received antibiotics at the time of PEG placement.

CONCLUSIONS

These data constitute the largest series of patients with existing VP shunts undergoing PEG placement reported to date. When compared with the published 2%-5% infection rate for patients with VP shunts alone, our data do not suggest an increased risk of infection for patients after PEG placement. As the total number of adult patients requiring a PEG after VP shunt placement is low, multicenter studies should be carried out to better stratify this risk.

Risk of ventriculoperitoneal shunt infections due to gastrostomy feeding tube insertion in pediatric patients with brain tumors

OBJECTIVE

To determine the risk of ventriculoperitoneal (VP) shunt infections after percutaneous retrograde gastrostomy feeding tube (GT) placement in children with brain tumors.

PATIENTS AND METHODS

All children (age 0-18 years) with primary brain tumors diagnosed and treated at the Hospital for Sick Children, Toronto, Canada, were subjected to a retrospective analysis. Two groups were identified: the study group included children with a VP shunt and a GT; the control group included children with VP shunts only. Each study patient was matched with 2 controls to compare the rate of infections (cohort comparative study).

RESULTS

There were 1,167 children diagnosed and treated with primary brain tumors during the study period (1988-2003); 174 (15%) had a VP shunt and 23 (2%) children had both, a VP shunt and a GT. In the study group (n=17), GTs were inserted at a median time of 80 days (range 6-204 days) after VP shunts. VP shunt infection rate was 23.5% (4/17) compared to 8.8% (3/34) in the control group (OR 3.18; 95% CI 0.622-16.54, p=0.16). Three (75%) of the infection episodes in the study group presented with an ascending VP shunt infection directly related to the GT insertion or manipulation in the first 6 weeks. These GTs were inserted at 13, 47 and 49 days after VP shunt insertion.

CONCLUSION

Placement of percutaneous retrograde GTs, in the acute phase, in children with brain tumors and VP shunts may increase the risk of ascending meningitis especially if there are early GT-related complications.

Endoscopic approaches to enteral nutritional support

Enteral is preferred to parenteral nutritional support for acute and chronic diseases because it is more physiological and associated with fewer infection complications. Nasal tube feedings are generally used for 30 days or less and percutaneous access for the longer-term. Feeding by naso-gastric tubes is appropriate for most critically ill patients. However, trans-pyloric feeding is indicated for those with regurgitation and aspiration of gastric feeds. Deep naso-jejunal tube feeding is appropriate for patients with severe acute pancreatitis. There are several methods for endoscopic placement of naso-enteric tubes. Percutaneous endoscopic gastrostomy is used for most persons requiring long-term support. Long-term jejunal feeding is most often used for persons with chronic aspiration of gastric feeds, chronic pancreatitis intolerant to eating, or persons in need of concomitant gastric decompression. Percutaneous endoscopic gastrostomy with a jejunal tube extension is fraught with tube dysfunction and dislocation. Direct percutaneous endoscopic jejunostomy tubes may be more robust, but are less commonly performed.

Transient ventriculoperitoneal shunt dysfunction in children with myelodysplasia and urinary bladder infection. Report of three cases

The authors present three children born with myelomeningocele and hydrocephalus. Each presented with symptoms/signs of ventriculoperitoneal shunt malfunction. All patients at the time of presentation exhibited significant urinary bladder infections and were appropriately treated for their infection. No patient was found to have an underlying shunt infection. All patients without medically threatening symptoms were carefully observed and noted to have resolution of their shunt dysfunction symptoms/signs following treatment of their urinary bladder infections and thus did not undergo a shunt operation. Based on the courses of these patients, we believe that significant urinary bladder infection in patients with myelodysplasia in whom a shunt has been placed may often be enough to bring a subclinical shunt malfunction to clinical attention or even to be the cause of temporary distal peritoneal shunt malabsorption. Although the exact mechanism for this dysfunction is unclear, treatment of the bladder infection may address the symptomatic shunt dysfunction in some patients so as to avoid operative intervention. We emphasize, however, that careful observation of these patients should be performed during hospitalization because they often rely on adequate cerebrospinal fluid diversion. Only patients with mild symptomatology should be observed first as the initial line of treatment.

Gastrointestinal interventions--emphasis on children

Although the fundamental principles of interventional and minimally invasive image-guided techniques are the same in children as in adults, nonetheless the spectrum of diseases, the pediatric approach, and the devices used differ significantly from those in adults. The following is a general overview of image-guided gastrointestinal interventions in children and neonates, with emphasis on those aspects peculiar to children. Many of the facets and tips have been learned the hard way over the years, in a busy pediatric practice. Although there are several potential ways to do some of these procedures, the description below reflects our practice and experience. In general terms, minimizing radiation dose is a significant responsibility for the pediatric interventionalist. Reducing the number of exposures, reliance on last image hold, low-dose pulse fluoroscopy, and tight coning are all important. Protection for the radiologist is equally important, but sometimes difficult to achieve, given the small size of many of the patients.

Percutaneous gastrostomy in patients with a ventriculoperitoneal shunt: case series and review

BACKGROUND

There are few data on the safety of PEG in patients with a ventriculoperitoneal shunt.

METHODS

Medical records for patients seen in 3 tertiary care, university-affiliated hospitals between January 1, 1991, and January 1, 1999, were reviewed.

OBSERVATIONS

Six patients underwent PEG after ventriculoperitoneal shunt placement during the study period. There was no immediate complication. One patient died of pneumonia 2 months after PEG insertion. There was no instance of shunt malfunction, intra-abdominal complication, or wound infection in the study group. There was no long-term complication, with either the ventriculoperitoneal shunt or the PEG.

CONCLUSIONS

Although the number of cases was small, PEG placement with prophylactic administration of antibiotics appears to be safe in patients with a pre-existing ventriculoperitoneal shunt.

Percutaneous endoscopic gastrostomy in patients with ventriculoperitoneal shunts

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) may be required in neurosurgical patients with a persistently depressed neurological status or severe lower cranial nerve palsies. Such patients may have a coexisting hydrocephalus requiring cerebrospinal fluid (CSF) diversion. Despite the risk of infection resulting from exposure to oropharyngeal flora by the pull-through PEG technique and the secondary pneumoperitoneum seen in one-third of patients, simultaneous peritoneal placement of CSF shunt catheters with PEG is the current practice. The aim of the study was to determine the frequency of CSF diversionary procedures in neurosurgical patients undergoing PEG insertion and the occurrence of infective complications in patients with simultaneous placement of a PEG and a ventriculoperitoneal (VP) shunt.

METHODS

This was a retrospective review of all neurosurgical patients undergoing PEG. The presence of hydrocephalus, mode of CSF diversion and the development of subsequent infection in those having coexistent distal peritoneal catheter placement and PEG were determined.

RESULTS

PEGs were placed in 42 neurosurgical patients (9.3 per cent of all PEGs inserted), of whom 21 had a coexisting hydrocephalus. Eight of 16 shunts with distal catheter placement in the peritoneal cavity developed infection requiring revision. Infections occurred with greater frequency in patients with a tracheostomy. There were no shunt infections requiring revision in a second group of 21 patients who had a coexisting shunt and tracheostomy without PEG.

CONCLUSION

Simultaneous placement of a PEG and a VP shunt should be avoided in the acute phase of a patient's hospital admission.