Gastrostomy insertion: comparing the options--PEG, RIG or PIG?

Proportion of unplanned tube replacements and complications following gastrostomy: A systematic review and meta-analysis

AIMS

Gastrostomy feeding represents a vital component of supportive care provided to people with swallowing or feeding difficulties; however, the rate of specific long-term complications is currently unknown in the adult population. This study aimed to determine the prevalence of specific long-term gastrostomy-related complications and unplanned replacements in adults.

METHODS

A prospective systematic review of Medline, CINAHL and Embase databases was performed. Key complications of hypergranulation, infection and displacement among studies relevant to percutaneous endoscopic gastrostomy tubes, radiologically inserted gastrostomy tubes and balloon replacement tubes were critically appraised by two independent reviewers. Results were synthesised quantitatively in a meta-analysis using random effects where the population and condition were sufficiently homogeneous.

RESULTS

In total, 453 studies were identified, of which 17 met inclusion criteria. 8.5% of adults with a gastrostomy were found to have had an infection ≥42 days after initial tube insertion (p < 0.01), while 13% had hypergranulation (p < 0.01). Displacement occurred in 10.8% of adults (p < 0.01), with age (p < 0.001) and sex (p < 0.001) presenting as a risk factor (R2  = 75%) following meta-regression.

CONCLUSIONS

Approximately 1 in 10 people with a gastrostomy will experience a complication related to either hypergranulation, infection or dislodgement. Age, in combination with sex, may provide a guide for risk of displacement among adult female cohorts, though further studies reporting prevalence of gastrostomy-related complications along with participant demographics are required.

Endoscopic vs radiologic gastrostomy for enteral feeding: A systematic review and meta-analysis

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.

Compliance With Percutaneous Endoscopic Gastrostomy Tube Insertion Guidelines and Associated Complications in a Tertiary Care Setting: A Clinical Audit

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) tube insertion is a widely utilized enteral access technique offering long-term nutritional support for patients unable to tolerate oral intake. While the PEG tube provides numerous advantages, adherence to evidence-based guidelines is crucial to minimize complications. This study aims to evaluate adherence to PEG tube insertion guidelines and analyze associated complication rates in a tertiary care setting.

METHODS

A retrospective clinical audit was conducted at Quaid-e-Azam International Hospital, Islamabad. Data were collected over three years from patients undergoing PEG tube insertion by a single consultant gastrointestinal surgeon. Adherence to guidelines was evaluated using a 10-item checklist developed based on European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Complication rates and patient characteristics were analyzed.

RESULTS

The study included 70 participants (mean age = 72.21 ± 13.17). The PEG tube insertion rate was 100%. The mean checklist score was 8.34 ± 1.2. Laboratory investigations were performed for 98.6% of patients. 91.4% of patients had a life expectancy exceeding 30 days. 60% of patients received an anticoagulation hold. Prophylactic antibiotics were administered to 90% of patients. Psychological counseling and dietician consultation were offered to 38.6% and 64.2% of patients, respectively. Caregivers received specialized training in 98.5% of cases. 12.8% of patients experienced early complications post-procedure, and 14.2% experienced late complications. PEG tube removal occurred in 27% of patients, with only one patient experiencing complications after removal.

CONCLUSION

Adherence to PEG tube insertion guidelines was observed in various aspects of patient care, resulting in a low incidence of complications. Comprehensive auditing and guideline adherence are essential to ensure optimal patient safety and procedural outcomes.

A retrospective study of outcomes and the validation of the Sheffield Gastrostomy Score in PEGs, RIGs and PIGs

INTRODUCTION

There are limited studies comparing the safety and effectiveness of Radiologically Assisted Gastrostomies (RAGs) against Percutaneous Endoscopic Gastrostomies (PEGs). The Sheffield Gastrostomy Score (SGS) can be used to help predict 30-day mortality, more information is needed on its validity in RAGs. Our aim is to compare mortality between RAGs (Radiologically Inserted Gastrostomies (RIGs) and Per-oral Image Guided Gastrostomies (PIGs)) with PEGs and validate the SGS.

METHOD

Data on gastrostomies newly inserted in three hospitals from 2016-2019 were retrospectively collected. Demographics, indication, insertion date, date of death, inpatient status and blood tests (albumin, CRP and eGFR) were recorded.

RESULTS

1977 gastrostomies were performed: Gastrostomy mortality at 7 days was 1.3% and at 30 days was 6%. There was a 5% 30-day mortality for PEGs, 5.5% RIGs, 7.2% PIGs (p = 0.215). Factors increasing 30 day mortality were age ≥60 years (p = 0.039), albumin <35 g/L (p = 0.005), albumin <25 g/L (p < 0.001) and CRP ≥10 mg/L (p < 0.001). For patients who died within 30 days; 0.6% had an SGS of 0, 3.7% = 1, 10.2% = 2 and 25.5% = 3, with similar trends for RAGs and PEGs. ROC curves showed the area under the curve for all gastrostomies, RAGs and PEGs as 0.743, 0.738, 0.787 respectively.

DISCUSSION

There was no significant difference between 30-day mortality for PEGs, RIGs and PIGs. Factors predicting risk include age ≥60 years, albumin <35 g/L, albumin <25 g/L and CRP ≥10 mg/L. The SGS has been validated in this study for PEGs and for the first time in RAGs as well..

Nutritional Management of Patients with Head and Neck Cancer-A Comprehensive Review

While surgical therapy for head and neck cancer (HNC) is showing improvement with the advancement of reconstruction techniques, the focus in these patients should also be shifting to supportive pre and aftercare. Due to the highly sensitive and anatomically complex region, these patients tend to exhibit malnutrition, which has a substantial impact on their recovery and quality of life. The complications and symptoms of both the disease and the therapy usually make these patients unable to orally intake food, hence, a strategy should be prepared for their nutritional management. Even though there are several possible nutritional modalities that can be administrated, these patients commonly have a functional gastrointestinal tract, and enteral nutrition is indicated over the parenteral option. However, after extensive research of the available literature, it seems that there is a limited number of studies that focus on this important issue. Furthermore, there are no recommendations or guidelines regarding the nutritional management of HNC patients, pre- or post-operatively. Henceforth, this narrative review summarizes the nutritional challenges and management modalities in this particular group of patients. Nonetheless, this issue should be addressed in future studies and an algorithm should be established for better nutritional care of these patients.

Outcomes and Complications of Radiological Gastrostomy vs. Percutaneous Endoscopic Gastrostomy for Enteral Feeding: An Updated Systematic Review and Meta-Analysis

Background

Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) are commonly utilized to establish access to enteral nutrition. However, data comparing the outcomes of PEG vs. PRG are conflicting. Therefore, we aimed to conduct an updated systemic review and meta-analysis comparing PRG and PEG outcomes.

Methods

Medline, Embase, and Cochrane library databases were searched until February 24, 2023. Primary outcomes included 30-day mortality, tube leakage, tube dislodgement, perforation, and peritonitis. Secondary outcomes included bleeding, infectious complications, and aspiration pneumonia. All analyses were conducted using Comprehensive Meta-Analysis Software.

Results

The initial search revealed 872 studies. Of these, 43 of these studies met our inclusion criteria and were included in the final meta-analysis. Of 471,208 total patients, 194,399 received PRG and 276,809 received PEG. PRG was associated with higher odds of 30-day mortality when compared to PEG (odds ratio (OR): 1.205, 95% confidence interval (CI): 1.015 - 1.430, I² = 55%). In addition, tube leakage and tube dislodgement were higher in the PRG group than in PEG (OR: 2.231, 95% CI: 1.184 - 4.2 and OR: 2.602, 95% CI: 1.911 - 3.541, respectively). Perforation, peritonitis, bleeding, and infectious complications were higher with PRG than PEG.

Conclusion

PEG is associated with lower 30-day mortality, tube leakage, and tube dislodgement rates than PRG.

When Should the Appropriateness of PEG be Questioned?

PURPOSE OF REVIEW

This review aims to analyze the evidence regarding the appropriateness of PEG placement in the following clinical situations: short bowel syndrome, head and neck cancer, dementia and palliative use in malignant bowel obstruction.

RECENT FINDINGS

Percutaneous endoscopic gastrostomy (PEG) tubes are placed for a variety of clinical indications by numerous different specialties. First described in 1980, PEG tubes are now the dominant method of enteral access. Typically, PEG tubes are technically feasible procedures that can come with significant risk for both minor and major complications. Therefore, it is important to perform an in-depth, patient specific risk-benefit analysis when considering insertion. By analyzing the current evidence regarding benefits in these situations, superimposed by the lens of biomedical ethics, we make recommendations that are accessible to any provider who may be a consultant or proceduralist, helping to provide informed care that is in the patient's best interest.

Percutaneous Radiology Gastrostomy (PRG)-Associated Complications at a Tertiary Hospital over the Last 25 Years

OBJECTIVES

We aimed to describe and compare the complications associated with different percutaneous radiologic gastrostomy (PRG) techniques.

METHODS

A retrospective and prospective observational study was conducted. Patients who underwent a PRG between 1995-2020 were included.

TECHNIQUES

A pigtail catheter was used until 2003, a balloon catheter without pexy was used between 2003-2009 and a balloon catheter with gastropexy was used between 2015-2021. For the comparison of proportions, X² tests or Fisher's test were used when necessary. Univariate analysis was performed to study the risk factors for PRG-associated complications.

RESULTS

n = 330 (pigtail = 114, balloon-type without pexy = 28, balloon-type with pexy = 188). The most frequent indication was head and neck cancer. The number of patients with complications was 44 (38.5%), 11 (39.2%) and 54 (28,7%), respectively. There were seven (25%) cases of peritonitis in the balloon-type without-pexy group and 1 (0.5%) in the balloon-type with-pexy group, the latter being the only patient who died in the total number of patients (0.3%). Two (1%) patients of the balloon-type with-pexy group presented with gastrocolic fistula. The rest of the complications were minor.

CONCLUSIONS

The most frequent complications associated with the administration of enteral nutrition through PRG were minor and the implementation of the balloon-type technique with pexy has led to a decrease in them.

Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices

Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.

Radiology guided antegrade GASTROSTOMY deployment of mushroom (pull type) catheters with classical and modified methods in patients with oropharyngeal, laryngeal carcinoma, and anesthesia risk

OBJECTIVE

The aim of study is to evaluate the results of deployment of Percutaneous Radiological Gastrostomy (PRG), which is a good alternative to Surgical Gastrostomy (SG), with transoral approach in cases where Percutaneous Endoscopic Gastrostomy (PEG) is contraindicated, difficult or unsuccessful, in patients with high risk of American Society of Anesthesiologists with four scores. In addition, we aimed to demonstrate the advantages of mushroom pull type catheters over push type gastrostomy catheters.

METHODS

This retrospective study included a total of 40 patients (18 females and 22 males) aged 21-92 years who underwent PRG with the antegrade transoral approach. PRG was performed by retrograde passing through the esophagus or snaring the guidewire from the stomach and taking out of the anterior abdominal wall. Patients' demographic data, indications for PRG, procedural outcomes and complications were screened and recorded.

RESULTS

PRG was performed in 39 of 40 patients included in the study. Technical success rate was 97.5%. Procedure-dependent major complications such as death, aspiration, colon perforation, and deep abscess were not observed. Aspiration occurred in the first patient during the first feeding on the day after the procedure. Major complication rate was 2.5%. The total minor complication rate was 17.5% in 7 patients; parastomal leakage in 2 patients (5%), skin rash and infection in 3 (7.5%) patients, minor bleeding in 2 (5%) patients with oropharynx cancer, minimal bleeding from the gastrostomy catheter 1 week after the procedure in 1 (2.5%) patient. None of the cases had buried buffer. Tube functionality was preserved in all patients without any damage.

CONCLUSION

Mushroom tip (pull type) gastrostomy catheter is a safe treatment method for patients requiring prolonged feeding because of wide diameter, endurance, long staying opening duration, less excessive dilatation and parastomal leakage, and no need for gastropexy. Lower cost and easier access are advantageous for mushroom tip pull type catheters compared to push type gastrostomy catheters in our country. The less invasive PRG is an alternative option in patients who are difficult to administer PEG, are at high anesthesia risk and cannot be sedated.

ADVANCES IN KNOWLEDGE

This article is valuable in terms of its contribution to develop an alternative radiological method for the deployment of gastrostomy tubes in medical difficult patients. This method has shortened the duration of the procedure and increased the success rate in patients with difficulty in transition from the stomach to the esophagus or with difficulty in the upper gastrointestinal tract. Mushroom tip catheters can be placed successfully by radiological methods.

Laparoscopic-Percutaneous Combined Gastrostomy: Initial Experience and Description of a Technique

Background: Gastrostomy is a widely used procedure that aims to obtain access to the stomach. Its purpose may be feeding or gastric decompression. Currently, the most common techniques are endoscopic and radiologic. Sometimes, these accesses are not available due to technical or patient-specific factors. In these cases, laparoscopic and percutaneous approaches combined could be an option. The aim of this study was to describe a laparoscopic-percutaneous combined gastrostomy procedure, feasibility, and complications. Materials and Methods: Retrospective descriptive observational study. All patients underwent laparoscopic-percutaneous combined gastrostomy required for feeding or decompressive gastrostomy. We analyzed variables: demographics, surgical indication, operation time, hospitalization stay, success, and morbidity/mortality associated to the procedure. Results: A total of n = 17 patients were recruited (58.8% women and 41.2% men), with mean age of 53. Regarding the indications of laparoscopic-percutaneous combined gastrostomy, 47% were due to upper gastrointestinal/head and neck tumor, 29.4% stomach location in a retrocostal position, 17.7% colonic interposition, and 5.9% acute gastric dilation of remnant after Roux-en-Y gastric bypass. The mean time of the procedure was 25 minutes, and mean hospitalization stay was 1.2 days. The success of the procedure was 100%. No complications and mortality associated with the procedure were reported. Conclusion: Laparoscopic-percutaneous combined gastrostomy is fast, feasible, safe, and cost effective. It is an option in patients where it is not possible to perform standard minimally invasive approaches.

Percutaneous gastrostomy placement by intervention radiology: Techniques and outcome

Background

Interventional radiology (IR) has played an important role in the technical evolution of gastrostomy, from the first surgical, endoscopical to percutaneous interventional procedures.

Aim

This study is done to assess the technical feasibility and outcome of IR-guided percutaneous gastrostomy for patients requiring nutritional support for neuromuscular disorders or head and neck malignancies, as well as to describe simplified and newer technique for pull-type gastrostomy.

Materials and Methods

This is a retrospective study including 29 patients who underwent IR-guided percutaneous gastrostomy over a period of 8 years in a tertiary-level institution. Either pull or push-type gastrostomy was performed in these patients as decided by the interventional radiologist. The procedures were assessed by analyzing the indications, technical aspects, and complications.

Statistical Analysis

Descriptive summary statistics and frequencies were used to assess the techniques and related complications.

Results

The sample consists of 27 patients (93%) with pull technique and 2 patients (7%) with push technique. The technical success rate was 100%. Most of the complications were minor 24% (7/29), including superficial skin infections around the tube site, self-resolving pneumoperitoneum, tube-related complications such as block, leakage, deformation, and dislodgement. Three patients (10.3%) had major complications. One patient (3.4%) developed massive pneumoperitoneum and mild peritonitis due to technical failure in the first attempt and needed re-puncture for successful placement, and other two patients (6.9%) developed peristromal focal abscess. One patient died on the third postoperative day due to type II respiratory failure.

Conclusion

IR-guided percutaneous gastrostomy is a safe and effective procedure in selected patients.

Retrograde Radiological Gastrostomy Technique and Retrograde Stent Placement in a Completely Occluded Cervical Esophagus

Malignant obstruction of the cervical esophagus presents some anatomical and technical challenges when considering radiologic or endoscopic intervention. This case report describes the failure of antegrade access to place a gastrostomy tube and stent due to complete luminal occlusion from an esophageal tumor. The ultrasound-guided percutaneous gastric puncture was performed to achieve retrograde pneumodistension to allow radiologic gastrostomy insertion. Subsequently, the cervical esophagus was retrogradely cannulated via insertion of a guidewire from the gastrostomy site. A distal release esophageal stent was then inserted over the wire and deployed from the mouth in an antegrade manner.

However, due to the unpredictable proximal shortening of distal release stents, this stent was eventually shortened and displaced so that it no longer covered the top of the tumor stricture, and further antegrade access failed. Once more, a retrograde access approach was adopted via the gastrostomy stoma, a guidewire and catheter were passed retrogradely through the original stent and out through the mouth. A distal release stent system was then inserted in a retrograde manner via the gastrostomy stoma, effectively making it a proximal release stent which enabled more precise positioning of the stent above the tumor. Palliation was achieved until death, and beyond expected mean survival.

Image guided percutaneous gastrostomy catheter placement: How we do it safely and efficiently

Gastrostomy tube is an effective and safe long-term feeding access that is well-tolerated by patients. The typical placement routes include surgical, endoscopic and interventional radiologic placement. In particular, percutaneous interventional radiologic gastrostomy (PIRG) has increasingly become the preferred method of choice in many practices. Although many PIRG techniques have been developed since the 1980s, there is still a paucity of evidence supporting the choice of a most-optimal PIRG technique. Hence, there is a large variation in institutional approach to PIRG. We are a large, quaternary academic institution with an extensive experience in PIRG. Therefore, we aim to present the “push” PIRG technique utilized in our institution, to review the current literature, to discuss the optimal choice of PIRG technique and to generate further interests in comparison studies.

Modified percutaneous radiologic gastrostomy technique without endoscopic or nasogastric access

Background

The aim of this study is to evaluate the efficacy and safety of a modified percutaneous radiologic gastrostomy (MPRG) technique under ultrasound and fluoroscopic guidance without endoscopic or nasogastric access.

Results

The study included 24 patients: 10 males and 14 females whose ages ranged from 44 to 80 years old. Ten patients had esophageal cancer and 14 patients had neck cancer. Technical success was achieved in 23 out of the 25 procedures (92%). Two procedures failed (8%) and were converted to the conventional technique by using the nasogastric tube. No major complications were reported. Minor complications were observed in 5 patients (20%): intraperitoneal air and contrast leakage in 4 patients and focal mucosal dissection by the contrast in 1 patient.

Conclusion

The MPRG has high technical success rate, is safe with no major complications, and is most feasible when endoscopic or nasogastric access cannot be performed.

Percutaneous endoscopic versus radiologic gastrostomy for enteral feeding: a retrospective analysis on outcomes and complications

Background and study aims  Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are techniques used for long-term enteral feeding. Our primary aim was to analyze procedure-related and 30-day mortality and complications between PEG and PRG in relation to indications. Patients and methods  A single-center retrospective analysis was performed thath included all adult patients receiving initial PEG (January 2008 until April 2016) and PRG (January 2010 until April 2016). Outcomes were mortality (procedure-related, 30-day), complications (early (≤ 30 days) and late) and success rates. Results  A total of 760 procedures (469 PRG and 291 PEG) were analyzed. Most common indications were head and neck cancer (HNC), cerebrovascular accident (CVA) and amyotrophic lateral sclerosis (ALS). Success rates for placement were 91.2 % for PEG and 97.1 % for PRG ( P  = 0.001). Procedure-related mortality was 1.7 % in PEG and 0.4 % in PRG ( P  = 0.113). The 30-day mortality was 10.7 % in PEG and 5.1 % in PRG ( P  = 0.481 after multivariate logistic regression) CVA was associated with higher 30-day mortality, whereas ALS, higher body weight, and prophylactic placements in HNC were associated with lower rates. Tube-related complications were less frequent in PEG, both early (2.7 % vs. 26.4 %, P  ≤ 0.001) and late (8.6 % vs. 31.5 %, P  ≤ 0.001). The percentage of major complications and infections did not differ. Conclusions  With respect to procedure-related and 30-day mortality, PEG and PRG compare equally. PRG had a higher procedural success rate. Tube-related complications and pain are less frequent after PEG compared to PRG. The choice for either PEG or PRG therefore should primarily be based on local facilities and expertise.

Single-Step Method for Pull-Type Gastrostomy Tube Placement

Single-step pull-type gastrostomy tube (PGT) placement is a method involving gastric puncture with a curved 18-gauge trocar needle allowing retrograde cannulation of the gastroesophageal junction without use of a sheath or snare. This retrospective review of 102 patients who underwent single-step PGT placement demonstrated 91% success in advancing the wire up the esophagus using only the curved trocar. Successful placement of a gastrostomy tube was 100%. Two major and 2 minor complications occurred within 30 days, all unrelated to the single-step technique. Mean fluoroscopy time for all patients was 5.1 min (range, 1.5-19.2 min). Single-step PGT placement is an effective, safe, fast, and equipment-sparing method for gastrostomy placement.

[Percutaneous endoscopic gastrostomy]

Percutaneous endoscopic gastrostomy (PEG) was developed in 1980. Since that time this method has become preferable for long-term enteral nutrition. PEG is an effective and relatively safe procedure for enteral nutrition of patients with impaired enteral feeding. However, complications and mortality are also observed. Indications, contraindications and potential complications of PEG are reviewed in the article.

Retrospective comparison of outcomes and associated complications between large bore radiologically inserted gastrostomy tube types

PURPOSE

Multiple approaches to radiologically inserted gastrostomy (RIG) exist. The goal of this study was to compare 30-day outcomes and associated complications between large bore balloon-retained (BR), loop-retained (LR), and pull-type (PT) RIG devices.

METHODS

Data on 1477 patients who underwent RIG between January 1, 2005 and December 31, 2016 were collected retrospectively using a dedicated interventional radiology database and electronic medical record. Statistical analysis was performed to compare complication rates between BR, LR, and PT devices.

RESULTS

Ninety-eight percent (1477/1507) of the procedures were successfully performed. A total of 752 BR, 323 LR, and 402 PT gastrostomy tubes were placed. The overall complication rate for BR catheters was 5.7% (25 major [3.3%] and 18 minor [2.4%]). The overall complication rate for PT catheters was 3.7% (8 major [2.0%] and 7 minor [1.7%]). The overall complication rate for LR catheters was 1.6% (4 major [1.4%] and 1 minor [0.8%]). Compared to BR catheters, LR catheters had significantly fewer total complications (P = 0.01) but not minor complications (P = 0.052). There were no significant differences in the number of complications between LR and PT catheters or between BR and PT catheters.

CONCLUSIONS

Use of BR, LR, and PT devices for RIG is safe with a low incidence of complications. Compared to BR catheters, primary insertion of a LR gastrostomy was associated with significantly fewer overall complications within the first 30 days. Therefore, for initial tube placement, large bore LR catheters may be preferred over BR devices.

A Systematic Review and Meta-Analysis on Outcomes and Complications of Percutaneous Endoscopic Versus Radiologic Gastrostomy for Enteral Feeding

BACKGROUND

The optimal technique for long-term enteral feeding has not yet been established. Both percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are widely used. Aim was to extensively review outcomes of PEG and PRG.

MATERIALS AND METHODS

A systematic review using Medline, Embase, and Cochrane was performed, using standardized tools for assessing bias. Main outcomes were infectious and tube-related complications, procedure related and 30-day mortality. Pooled risk differences (RDs) with corresponding 95% confidence intervals (95% CIs) were calculated using random effects. Arcsine transformations were applied.

RESULTS

In total, 344 studies were identified, of which 16 were included, reporting on 934 PEGs and 1093 PRGs. No differences were found for infectious complications [RD, 0.03 (-0.05 to 0.11)], procedure-related mortality [RD, 0.01 (-0.04 to 0.06)], or 30-day mortality [RD, 0.06 (-0.01 to 0.13)]. Tube-related complications were higher in PRG [RD, 0.16 (0.06-0.26)]. Subgroup analysis was performed for head and neck cancer (HNC) and motor neuron disease. In HNC, this revealed significantly lower tube-related complications and procedure-related mortality after PEG. In motor neuron disease, no differences were seen. The level of evidence appears sufficient considering the low degree of heterogeneity.

CONCLUSIONS

No differences were found with regard to mortality or infectious complications. PEG showed lower risk of tube-related complications. Subgroup analysis revealed PEG to be favorable in HNC based on lower rates of procedure-related mortality and tube-related complications. Local experience and availability should be taken into account in the decision process.

Gastrostomy Tube Placement by Radiological Methods for Older Patients Requiring Enteral Nutrition: Not to be Forgotten

Background: The use of gastrostomy tubes for long-term nutritional support in older patients is frequent. Percutaneous gastrostomy tube placement may be performed using various techniques, including endoscopic, surgical, and radiologically-guided methods. While percutaneous endoscopic gastrostomy (PEG) placement is the most widely used and accepted approach, experience with the use of percutaneous radiological gastrostomy (PRG) is more limited.

Objective: To evaluate the safety and short-term outcomes of PRG in older patients requiring long-term enteral feeding.

Method: We performed a prospective study involving all patients aged 65 years and older who underwent PRG insertion at the Laniado hospital over a period of 2 years. Adverse events related to the gastrostomy tube insertion were recorded over a period of 3 months following the procedure.

Results: A total of 58 patients were included with a mean age of 78.1 years, and 48% were women. The most frequent indications for enteral feeding were stroke (47%) and dementia (41%). The technical success rate was 100% with no immediate procedure-related mortality or morbidity. One-month mortality was 3%, and overall mortality at 3-month follow-up was 16%. Complications were reported in 39 (67%) of patients, with 17 (29%) experiencing more than 1 complication. While most complications (88%) were minor, major complications occurred in 19 (33%) of the patients. Peritonitis was the cause of death in 2 patients, and tube dislodgment occurred in 17 subjects. During the follow-up period 17 (29%) of patients were re-admitted to hospital, with the cause for re-hospitalization being unrelated to the PRG in half of the cases. Neither bleeding nor deep wound infection was detected in the study group.

Conclusions: PRG is relatively safe and effective for gastrostomy placement in older patients, and this technique may be of value in patients with oral infections and those receiving anti-thrombotic therapy.

Which G-Tube to Use in Pullers: Assessment of Pull Pressures on Skin Models to Determine Optimal Catheter Choice in Patients with Recurrent Pulled Gastrostomy Tubes

INTRODUCTION

Pulled or dislodged gastrostomy catheters represent a common complication associated with percutaneous gastrostomy and are a common cause of recurrent visits in patients with altered mental status. We intended to perform an experiment to compare the pull forces required to dislodge different commonly used gastrostomy catheters.

MATERIALS AND METHODS

We used a digital force gauge device to measure the pull forces required to dislodge three types of 20 French gastrostomy catheters in double-layer skin models. These included the Flow 20 Pull Method (Cook Medical, Bloomington, IN, USA), Entuit Gastrostomy BR Balloon Retention feeding tube (Cook Medical, Bloomington, IN, USA), and Ponsky Non-Balloon Replacement Gastrostomy Tube (CR Bard Inc, Salt Lake City, Utah, USA). The catheters were inserted into the skin model using the same technique as would be utilized in a patient.

RESULTS

The mean forces measured to dislodge the per-oral Flow 20 Pull Method, Entuit Thrive Balloon Retention, and button-type retention Ponsky replacement catheters were 35.6, 22.8, and 20.6 Newtons, respectively. The pull method per-oral gastrostomy catheter required significantly more pull force to dislodge than both the Ponsky button-type retention catheter and the Entuit balloon retention catheters. There was no significant difference in the pull force required to dislodge the Ponsky replacement catheter and the Entuit balloon retention catheter.

CONCLUSIONS

Per-oral image-guided gastrostomy with pull-method button-type retention catheters may be the ideal choice in patients at high risk of tube dislodgment.

Push versus pull gastrostomy in cancer patients: A single center retrospective analysis of complications and technical success rates

PURPOSE

To compare the technical success and complication rates of push versus pull gastrostomy tubes in cancer patients, and to examine their dependence on operator experience.

MATERIALS AND METHODS

A retrospective review was performed of 304 cancer patients (170 men, 134 women; mean age 60.3±12.6 [SD], range: 19-102 years) referred for primary gastrostomy tube placement, 88 (29%) of whom had a previously unsuccessful attempt at percutaneous endoscopic gastrostomy (PEG) placement. Analyzed variables included method of insertion (push versus pull), indication for gastrostomy, technical success, operator experience, and procedure-related complications within 30 days of placement.

RESULTS

Gastrostomy tubes were placed for feeding in 189 patients and palliative decompression in 115 patients. Technical success was 91%: 78% after endoscopy had previously been unsuccessful and 97% when excluding failures associated with prior endoscopy. In the first 30 days, there were 29 minor complications (17.2%) associated with push gastrostomies, and only 8 minor complications (7.5%) with pull gastrostomies (P<0.05). There was no significant difference in major complications (push gastrostomy 5.3%, pull gastrostomy 5.6%). For decompressive gastrostomy tubes, the pull technique resulted in lower rates of both minor and major complications. There was no difference in complications or technical success rates for more versus less experienced operators.

CONCLUSION

Pull gastrostomy tube placement had a lower rate of complications than push gastrostomy tube placement, especially when the indication was decompression. The technical success rate was high, even after a failed attempt at endoscopic placement. Both the rates of success and complications were independent of operator experience.

Treatment approaches in motor neurone disease

PURPOSE OF REVIEW

Although there is no cure for motor neurone disease (MND), the advent of multidisciplinary care and neuroprotective agents has improved treatment interventions and enhanced quality of life for MND patients and their carers.

RECENT FINDINGS

Evidence-based multidisciplinary care, respiratory management and disease-modifying therapy have improved the outcomes of patients diagnosed with MND. Supportive approaches to nutritional maintenance and optimization of symptomatic treatments, including management of communication and neuropsychiatric issues, improve the quality of life for MND patients.

SUMMARY

Recent progress in the understanding of the clinical, pathophysiological and genetic heterogeneity of MND has improved the approach of clinicians to treatment. Notwithstanding improvement to care and quality of life, survival benefit has become evident with the advent of a multidisciplinary care framework, early treatment with riluzole and noninvasive ventilation. Weight maintenance remains critical, with weight loss associated with more rapid disease progression. The end-of-life phase is poorly defined and treatment is challenging, but effective symptom control through palliative care is achievable and essential. Encouragingly, current progress of clinical trials continues to close the gap towards the successful development of curative treatment in MND.

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.

Prospective experience of percutaneous endoscopic gastrostomy tubes placed by otorhinolaryngologist-head and neck surgeons: safe and efficacious

Percutaneous endoscopic gastrostomy (PEG) is often the treatment of choice in head and neck cancer (HNC) patients needing long-term nutritional support. Prospective studies on PEG tube placement in an otorhinolaryngologist service are lacking. At our hospital, otolaryngologist-head and neck (ORL-HN) surgeons-have performed PEG insertions for HNC patients since 2008. We prospectively analyzed 127 consecutive HNC patients who received their PEG tubes at the Department of Otorhinolaryngology-head and neck surgery, and evaluated the outcome of PEG tube insertions performed by ORL-HN surgeons. To compare time delays before and after, PEG placement service was transferred from gastrointestinal surgeons to ORL-HN surgeons, and we retrospectively analyzed a separate group of 110 HNC patients who had earlier received PEG tubes at the Department of Gastrointestinal Surgery. ORL-HN surgeons' success rate in PEG insertion was 97.6%, leading to a final prospective study group of 124 patients. Major complications occurred in four (3.2%): two buried bumper syndromes, one subcutaneous hemorrhage leading to an abscess in the abdominal wall, and one metastasis at the PEG site. The most common minor complication was peristomal granulomatous tissue affecting 23 (18.5%) patients. After the change in practice, median time delay before PEG insertion decreased from 13 to 10 days (P < 0.005). The proportion of early PEG placements within 0-3 days increased from 3.6 to 14.6% (P < 0.005). PEG tube insertion seems to be a safe procedure in the hands of an ORL-HN surgeon. Independence from gastrointestinal surgeons' services reduced the time delay and improved the availability of urgent PEG insertions.

Randomized Controlled Trial Comparing Radiologic Pigtail-Retained Gastrostomy and Radiologic Mushroom-Retained Gastrostomy

PURPOSE

To prospectively compare 2 different types of percutaneous fluoroscopic gastrostomy procedures (pigtail-retained gastrostomy [PG] vs mushroom-retained gastrostomy [MG]).

MATERIALS AND METHODS

Between March 2014 and February 2016, 100 patients were randomly assigned to receive 14-F PG or 20-F MG. Block randomization (block size 4) was performed, and sample size was calculated to assess the difference in minor complications. One patient withdrew from the study after allocation. Baseline characteristics were not significantly different between groups (P > .05). Technical success, defined as successful placement of gastrostomy tube, and procedural complications were evaluated. Procedural complications were divided into major and minor complications according to the Society of Interventional Radiology criteria.

RESULTS

Technical success rate was 100%. In the PG group, the major complication rate was 2% (1 of 50); 1 patient had a misplaced PG in the peritoneal cavity between the gastric and abdominal walls and developed peritonitis that had to be surgically treated. The minor complication rate was 34% (17 of 50) in the PG group. In the MG group, the major complication rate was 0%, and the minor complication rate was 12.2% (6 of 49). The most common minor complication was tube occlusion. Minor complication rate was significantly higher in the PG group (P = .016). Mean fluoroscopy time was significantly longer in the MG group (P = .013).

CONCLUSIONS

Both PG and MG demonstrated high technical success rates in all indications. MG had lower complication rates than PG at the cost of an increase in fluoroscopy times.

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy

There are a variety of techniques for gastrostomy tube placement. Endoscopic and radiologic approaches have almost entirely superseded surgical placement. However, an aging population and significant advancements in modern healthcare have resulted in patients with increasingly complex medical issues or postsurgical anatomy. The rising prevalence of obesity has also created technical challenges for proceduralists of many specialties. When patients with these comorbidities develop the need for long-term enteral nutrition and feeding tube placement, standard approaches such as percutaneous endoscopic gastrostomy (PEG) by endoscopists and percutaneous image-guided gastrostomy (PIG) by interventional radiologists may be technically difficult or impossible. For these challenging situations, laparoscopic-assisted PEG (LAPEG) is an alternative option. LAPEG combines the advantages of PEG with direct intraperitoneal visualization, helping ensure a safe tube placement tract free of intervening organs or structures. In this review, we highlight some of the important factors of first-line gastrostomy techniques, with an emphasis on the utility and procedural technique of LAPEG when they are not feasible.

Radiologically inserted gastrostomy: differences of maintenance of balloon- vs. loop-retained devices

PURPOSE

To compare outcome and associated complications of ballon- vs. loop-retained devices for radiologically inserted gastrostomy (RIG).

METHODS

From 2007 to 2011 233 patients (age 63.7 ± 10.6 years) were referred for a RIG because of pharyngeal stricture Intervention was performed with four different devices: balloon-retained - Freka^® GastroTube, Fresenius Kabi (n = 121); MIC^® Gastrostomy Feeding Tube, Kimberly-Clark (n = 34); Russell^® Gastrostomy Tray, Cook Medical Inc. (n = 17); and loop-retained - Tilma^® Gastrostomy Set, Cook Medical Inc. (n = 50). Follow-up was performed with regard to RIG-related complications, cause of removal and fatalities. Revision-free survival times after RIG were evaluated using Kaplan-Meier analysis and group differences by log-rank tests. For analysis of demographic and methodical variables multivariate Cox regression models were used.

RESULTS

With a primary technical success rate of 95.3% (222/233) a total of 92 instances of revisions were necessary in 66 patients (66/233, 28.3%) during follow-up (mean 182.8 ± 86.6 days). The most common complication was tube dislodgement (14.3%). There were no significant differences between the distinct devices (p = 0.098), but analyzing the data in subgroups of balloon-compared to loop-retained gastrostomy tubes we observed a significantly higher probability of minor complications for the latter (p = 0.023).

CONCLUSION

As it is significantly less prone to minor complications we recommend the use of balloon-retained gastrostomy tubes to improve the practicability and maintenance of RIG.

Thirty-day mortality after percutaneous gastrostomy by endoscopic versus radiologic placement: a systematic review and meta-analysis

Background/Aims

A percutaneous gastrostomy can be placed either endoscopically (percutaneous endoscopic gastrostomy, PEG) or radiologically (radiologically-inserted gastrostomy, RIG). However, there is no consistent evidence of the safety and efficacy of PEG compared to RIG. Recently, 30-day mortality has become considered as the most important surrogate index for evaluating the safety and efficacy of percutaneous gastrostomy. The aim of this meta-analysis was to compare the 30-day mortality rates between PEG and RIG.

Methods

Major electronic databases (MEDLINE, Embase, Scopus, and Cochrane library) were queried for comparative studies on the two insertion techniques of gastrostomy among adults with swallowing disturbance. The primary outcome was the 30-day mortality rate after gastrostomy insertion. Forest and funnel plots were generated for outcomes using STATA version 14.0.

Results

Fifteen studies (n=2,183) met the inclusion criteria. PEG was associated with a lower risk of 30-day mortality after tube placement compared with RIG (odds ratio, 0.60; 95% confidence interval [CI], 0.38–0.94; P=0.026). The pooled prevalence of 30-day mortality of PEG was 5.5% (95% CI, 4.0%–6.9%) and that of RIG was 10.5% (95% CI, 6.8%–14.3%). No publication bias was noted.

Conclusions

The present meta-analysis demonstrated that PEG is associated with a lower probability of 30-day mortality compared to RIG, suggesting that PEG should be considered as the first choice for long-term enteral tube feeding. Further prospective randomized studies are needed to evaluate and compare the safety of these two different methods of gastrostomy.

CIRSE Standards of Practice Guidelines on Gastrostomy

PURPOSE

Surgical Gastrostomy has been around since the 19th century but in 1980 the first successful percutaneous endoscopic gastrostomy was reported. A year later the first successful percutaneous gastrostomy was performed using fluoroscopic guidance. The technique for percutaneous insertion and the equipment used has been refined since then and it is now considered the gold standard for gastrostomy insertion. Here we present guidelines for image-guided enteral feeding tubes in adults.

MATERIAL AND METHOD

We performed a review and analysis of the scientific literature, other national and international guidelines and expert opinion.

RESULTS

Studies have shown fluoroscopic techniques have consistently higher success rates with lower rates of major complications than endoscopic techniques. However, the Achilles' heel of many fluoroscopic techniques is the requirement for smaller gastrostomy tube sizes resulting in them being more prone to blockages and thus requiring further intervention.

CONCLUSION

Radiological feeding tube insertion is a safe and effective procedure. Success rates are higher, and complication rates lower than PEG or surgical gastrostomy tube placement and innovative techniques for gastric and jejunal access mean that there are very few cases in which RIG is not possible. The principal weakness of radiologically inserted gastrostomies is the limitiation on tube size which leads to a higher rate of tube blockage. Per-oral image-guided gastrostomies have to an extent addressed this but have not been popularised. Currently many centres still consider endoscopic gastrostomies as the first line unless patients are too unwell to undergo this procedure or previous attempts have failed, in which case radioloically inserted gastrostomies are the technique of choice.

Radiologic Percutaneous Gastrostomy in Nondistended Stomach: A Modified Approach

INTRODUCTION

Gastrostomy tube placement for patients requiring long-term nutritional support may be performed using different techniques including endoscopic, surgical, and percutaneous radiologically guided methods. Radiologically inserted gastrostomy (RIG), typically performed when percutaneous endoscopic gastrostomy is not possible, requires proper gastric distension that is achieved by insufflating air through a nasogastric tube. We describe a simple technique to prevent air escape from the stomach during gastrostomy tube placement. To the best of our knowledge, this technique has not yet been described in the literature.

MATERIALS AND METHODS

Four patients with unsuccessful percutaneous endoscopic gastrostomy were referred for fluoroscopic-guided gastrostomy. One patient had a pyriform sinus tumor and three had an ischemic stroke causing dysphagia. Gastric distention was not achieved in the patients due to air escaping into the bowel during the standard RIG procedure. A modified approach using a balloon catheter inflated in the pylorus to avoid air passing into the duodenum permitted successful RIG.

RESULTS

The modified RIG procedure was successfully carried out in all cases without complications.

DISCUSSION

Inadequate air distension of the stomach is an unusual event that causes a failure of gastrostomy tube placement and an increased risk of both major and minor complications. The use of a balloon catheter inflated in the first part of the duodenum prevents the air passage into the bowel allowing the correct positioning of the gastrostomy.

Percutaneous endoscopic gastrostomy versus percutaneous radiological gastrostomy for swallowing disturbances

BACKGROUND

Gastrostomy has been established as the standard procedure for administering long-term enteral nutrition in individuals with swallowing disturbances. Percutaneous gastrostomy is a less-invasive approach than open surgical gastrostomy, and can be accomplished via endoscopy (percutaneous endoscopic gastrostomy or PEG) or sonographic or fluoroscopic guidance (percutaneous radiological gastrostomy or PRG). Both techniques have different limitations, advantages, and contraindications. In order to determine the optimal technique for long-term nutritional supplementation many studies have been conducted to compare the outcomes of these two techniques; however, it remains unclear as to which method is superior to the other with respect to both efficacy and safety.

OBJECTIVES

To compare the safety and efficacy of PEG and PRG in the treatment of individuals with swallowing disturbances.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, January 2016); MEDLINE (1946 to 22 January 2016); EMBASE (1980 to 22 January 2016); the reference lists of identified articles; databases of ongoing trials, including the Chinese Cochrane Centre Controlled Trials Register; and PubMed. We applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing PEG with PRG in individuals with swallowing disturbances, regardless of the underlying disease.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the search results and assessed the quality of the studies. Data analyses could not be performed as no RCTs were identified for inclusion in this review.

MAIN RESULTS

We identified no RCTs comparing PEG and PRG for percutaneous gastrostomy in individuals with swallowing disturbances. The large body of evidence in this field comes from retrospective and non-randomised controlled studies and case series. Based on this evidence, both PEG and PRG can be safely performed in selected individuals, although both are associated with major and minor complications. A definitive RCT has yet to be conducted to identify the preferred percutaneous gastrostomy technique.

AUTHORS' CONCLUSIONS

Both PEG and PRG are effective for long-term enteral nutritional support in selected individuals, though current evidence is insufficient to recommend one technique over the other. Choice of technique should be based on indications and contraindications, operator experience and the facilities available. Large-scale RCTs are required to compare the two techniques and to determine the optimal approach for percutaneous gastrostomy.

A Quality Improvement Initiative to Reduce Catheter Exchange Rates for Fluoroscopically Guided Gastrostomy Tubes

PURPOSE

To evaluate the effectiveness of a data-driven quality improvement initiative to reduce catheter exchange rates.

MATERIALS AND METHODS

A single-institution retrospective analysis of all percutaneous radiologic gastrostomy (PRG) placement and replacement procedures between January 2010 and July 2015 was conducted. A statistical model predicting the risk for catheter exchange for any reason and exchanges specifically for tube malfunction was created; a quality improvement plan to reduce catheter exchanges was designed and implemented in June 2014. The outcomes for subsequent PRG procedures from July 2014 through March 2015 were followed until July 2015.

RESULTS

Between 2010 and June 2014, 1,144 primary PRG procedures and 442 replacement procedures were performed in 1,112 patients. Of the 442 exchange procedures, 289 were "rescue" procedures secondary to catheter malfunction. A quality improvement plan was implemented in June 2014 that encouraged primary gastrojejunostomy catheter and balloon-retained PRG catheter placement and placement of skin sutures in patients considered high risk for catheter dislodgment. From July 2014 through March 2015, 229 PRG catheters were placed, and 71 exchange procedures were performed through July 2015. There was a statistically significant decrease in the number of rescue exchanges performed secondary to catheter malfunction (P = .036).

CONCLUSIONS

Procedural and patient-specific risk factors for PRG complications were identified, and a statistical model to predict rates of minor complications was created. These findings were used to implement a quality improvement program that resulted in a decrease in PRG exchanges secondary to catheter malfunction.

Randomized Trial Comparing Radiologic Pigtail Gastrostomy and Peroral Image-Guided Gastrostomy: Intra- and Postprocedural Pain, Radiation Exposure, Complications, and Quality of Life

PURPOSE

To prospectively compare radiologically created pigtail gastrostomy (PG), in which the tube is inserted directly through the abdominal wall, versus peroral image-guided gastrostomy (POG), in which the tube is inserted through the mouth. Pain profiles (primary outcome measure), fluoroscopy times, total room times, technical success, complications, and quality of life (QOL) were measured.

MATERIALS AND METHODS

Sixty patients were prospectively randomized to receive 14-F PG or 20-F POG tubes. All patients received prophylactically created gastrostomies before radiation therapy for head and neck squamous-cell carcinoma. Patients receiving palliative treatment were excluded, as were those with established pharyngeal obstruction. Pain was measured by numeric rating scale (NRS) scores for 6 weeks after the procedure and by intraprocedural fentanyl and midazolam doses and postprocedural 24-h morphine doses. Fluoroscopy times, total room times, technical success, complications up to 6 months, and gastrostomy-related QOL (using the Functional Assessment of Cancer Therapy-Enteral Feeding questionnaire) were determined.

RESULTS

Fifty-six patients underwent the randomized procedure. The POG group required significantly higher intraprocedural midazolam and fentanyl doses (mean, 1.2 mg and 67 μg, respectively, for PG vs 1.9 mg and 105 μg for POG; P < .001) and had significantly longer fluoroscopy times (mean, 1.3 min for PG vs 4.8 min for POG; P < .0001). NRS scores, morphine doses, total room times, technical success, complication rates, and QOL did not differ significantly between groups. The one major complication, a misplaced PG in the peritoneal cavity, followed a technical failure of POG creation.

CONCLUSIONS

Despite the differences in insertion technique and tube caliber, the measured outcomes of POG and PG are comparable.

Gastrostomy in patients with amyotrophic lateral sclerosis (ProGas): a prospective cohort study

BACKGROUND

Gastrostomy feeding is commonly used to support patients with amyotrophic lateral sclerosis who develop severe dysphagia. Although recommended by both the American Academy of Neurology and the European Federation of Neurological Societies, currently little evidence indicates the optimum method and timing for gastrostomy insertion. We aimed to compare gastrostomy insertion approaches in terms of safety and clinical outcomes.

METHODS

In this large, longitudinal, prospective cohort study (ProGas), we enrolled patients with a diagnosis of definite, probable, laboratory supported, or possible amyotrophic lateral sclerosis who had agreed with their treating clinicians to undergo gastrostomy at 24 motor neuron disease care centres or clinics in the UK. The primary outcome was 30-day mortality after gastrostomy. This study was registered on the UK Clinical Research Network database, identification number 9923.

FINDINGS

Between Nov 2, 2010, and Jan 31, 2014, 345 patients were recruited of whom 330 had gastrostomy. 163 (49%) patients underwent percutaneous endoscopic gastrostomy, 121 (37%) underwent radiologically inserted gastrostomy, 43 (13%) underwent per-oral image-guided gastrostomy, and three (1%) underwent surgical gastrostomy. 12 patients (4%, 95% CI 2·1-6·2) died within the first 30 days after gastrostomy: five (3%) of 163 after percutaneous endoscopic gastrostomy, four (3%) of 121 after radiologically inserted gastrostomy, and three (7%) of 43 after per-oral image-guided gastrostomy (p=0·46). Including repeat attempts in 14 patients, 21 (6%) of 344 gastrostomy procedures could not be completed: 11 (6%) of 171 percutaneous endoscopic gastrostomies, seven (6%) of 121 radiologically inserted gastrostomies, and three (6%) of 45 per-oral image-guided gastrostomies (p=0·947).

INTERPRETATION

The three methods of gastrostomy seemed to be as safe as each other in relation to survival and procedural complications. In the absence of data from randomised trials, our findings could inform clinicians and patients in reaching decisions about gastrostomy and will stimulate further research into the nutritional management in patients with amyotrophic lateral sclerosis.

FUNDING

Motor Neurone Disease Association of Great Britain and Northern Ireland (MNDA) and the Sheffield Institute for Translational Neuroscience (SITraN).

Radiologically Guided Placement of Mushroom-retained Gastrostomy Catheters: Long-term Outcomes of Use in 300 Patients at a Single Center

PURPOSE

To assess long-term outcomes including risk of complications and nutritional benefits of mushroom-retained (pull-type) gastrostomy catheters placed in patients by interventional radiologists.

MATERIALS AND METHODS

All patients who received pull-type gastrostomy tubes between 2010 and 2013 were retrospectively reviewed, including 142 men (average weight, 169.6 lb [76.32 kg]; mean age, 65.2 years; range, 22-92 years) and 158 women (average weight, 150.4 lb [67.68 kg]; mean age, 65.2 years; range, 18-98 years). Indications for placement were cerebrovascular accident (n = 80), failure to thrive (n = 71), other central nervous system disorder (n = 51), head and neck cancer (n = 47), and other malignancy (n = 51). Complications were recorded per Society of Interventional Radiology practice guidelines. Patient weight was documented at specific follow-up intervals. Statistical analysis was performed by using the Student t test and one-way analysis of variance for the effects of sex and indication for placement, respectively, on average weight change.

RESULTS

The technical success rate was 98.4% (300 of 305 patients). Major and minor complications occurred at a rate of 3.7% (n = 11) and 13% (n = 39), respectively. Follow-up weight during the early (≤45 days), intermediate (≤180 days), and long-term (>180 days) periods was available for 71% (n = 214), 36% (n = 108), and 15% (n = 44) of the 300 patients, respectively. Weight gain occurred in 77% (160 of 214), 60% (65 of 108), and 73% (32 of 44) of the patients, respectively. Patients who gained weight gained 6.7, 10.6, and 16.3 lb (3.02, 4.77, and 7.34 kg) during each follow-up period, respectively. Average weight gain at follow-up in all patients was 4.2, 0.6, and 5.4 lb (1.89, 0.27, and 2.43 kg), respectively. No significant differences in average weight change were seen among groups when they were classified according to sex or indication for placement.

CONCLUSION

Placement of mushroom-retained gastrostomy catheters is a viable long-term treatment option for enteral nutrition, with complication rates similar to those reported for other gastrostomy techniques. Improvement in nutrition status measured as weight gain was seen in most patients in both early and long-term periods.

Single port laparoscopic long-term tube gastrostomy in Göttingen minipigs

Oral dosing by gavage is often used to test compounds in minipigs. This method is also used for certain nutritional studies that require exact dosing. This procedure may be stressful for the animal and requires the assistance of more than one technician. We investigated whether a gastrostomy tube could be placed and maintained in Göttingen minipigs using a single port laparoscopic technique. As part of another study, laparoscopic gastrostomy tube placement was performed in 12 Göttingen minipigs (32 ± 2 kg) under general anesthesia. The procedure involved single port laparoscopic visualization of the stomach and placement of a locking pigtail catheter into the fundus region of the stomach. The minipigs were followed for three weeks after surgery and macroscopic and microscopic tissue reactions were evaluated at necropsy. All catheters were successfully placed and were easy to use. At necropsy it was evident that the catheter had entered the stomach in the fundus region in 11/12 of the animals. In one animal the catheter had entered the antrum region. None of the animals developed leakage or clinically detectable reactions to the gastrostomy tube. Histopathologically, only discrete changes were observed. Single port laparoscopic tube gastrostomy with a locking pigtail catheter is safe, simple and reliable and is an appropriate alternative to, for example, percutaneous endoscopic gastrostomy, when long-term enteral delivery of pharmacological or nutritional compounds is needed. The use of the gastrostomy tube was easy and, based on subjective assessment, feeding was minimally stressful to the animals.

Multidisciplinary Interventions in Motor Neuron Disease

Motor neuron disease is a neurodegenerative disease characterized by loss of upper motor neuron in the motor cortex and lower motor neurons in the brain stem and spinal cord. Death occurs 2-4 years after the onset of the disease. A complex interplay of cellular processes such as mitochondrial dysfunction, oxidative stress, excitotoxicity, and impaired axonal transport are proposed pathogenetic processes underlying neuronal cell loss. Currently evidence exists for the use of riluzole as a disease modifying drug; multidisciplinary team care approach to patient management; noninvasive ventilation for respiratory management; botulinum toxin B for sialorrhoea treatment; palliative care throughout the course of the disease; and Modafinil use for fatigue treatment. Further research is needed in management of dysphagia, bronchial secretion, pseudobulbar affect, spasticity, cramps, insomnia, cognitive impairment, and communication in motor neuron disease.

Predictive factors for early mortality after percutaneous endoscopic and radiologically-inserted gastrostomy

BACKGROUND

Gastrostomy insertion is of benefit to selected patients, but 30-day mortality is as high as 54% in some patient groups. The current study examines risk factors associated with 30-day mortality in a cohort of patients who underwent percutaneous endoscopic gastrostomy (PEG) or radiologically-inserted gastrostomy (RIG) in a district general hospital over a 2.5 year period.

METHODS

A retrospective review of case notes was performed for all patients who underwent a PEG (n=53) or RIG (n=40) insertion in the period January 2009-July 2011. PEG/RIG re-insertions were excluded. Demographic, clinical, and biochemical data were analysed. Multivariate regression analysis was used to identify risk factors for early mortality after gastrostomy insertion.

RESULTS

The indications for gastrostomy insertion were similar in the PEG and RIG groups and included mainly dysphagic stroke, chronic neuromuscular disease and head and neck cancer. The patients in the RIG group were older and had a higher incidence of cardiovascular co-morbidities. The overall 30-day mortality was 11% in the PEG and 40% in the RIG group. The multivariate regression analysis suggested that cardiovascular co-morbidities and RIG insertion were independent risk factors for early mortality. The main cause of death 30 days after gastrostomy insertion was pneumonia, which was significantly more common in the RIG group.

CONCLUSIONS

Our data suggest that PEG should be the procedure of choice when considering gastrostomy insertion and RIG should be reserved as a second-line approach for cases in which PEG is technically difficult or contraindicated.

Disc-retained tubes for radiologically inserted gastrostomy (RIG): not up to the job?

AIM

To assess the insertion procedure and performance of disc-retained gastrostomy tubes, recording complications and accidental displacements by prospective audit, and to determine whether primary placement of the tube off-licence was feasible.

MATERIALS AND METHODS

Disc-retained 12 F single-lumen Monarch gastrostomy tubes (Enteral UK, Selby, UK) were inserted by three gastrointestinal interventional radiologists in a supra-regional cancer centre. The 12 F tubes required a 20 F peel-away sheath with four-point gastropexy fixation and were placed under conscious sedation, using electrocardiogram (EEG) bispectral index monitoring. Follow-up was performed in an in-house gastrostomy drop-in clinic at 1 week and 1 month, supplemented with weekly telephone follow-up. Patients also had open access to the gastrostomy drop-in clinic for immediate advice and complication management.

RESULTS

Eighteen patients underwent primary insertion of a Monarch gastrostomy tube over 5 months. A total of 6/18 (33%) tubes displaced; 4/18 (22%) completely, 2/18 (11%) occult into the peritoneum. Four of 18 (22%) patients developed infection at the stoma site. Due to the unexpectedly poor performance of the tube, the study was terminated early.

CONCLUSION

Initial experience with the Monarch disc-retained gastrostomy tube demonstrates it unsuitable for primary placement with current protocols. In view of the potentially serious complications, the Medicines and Healthcare Products Regulatory Agency (MHRA) has been informed. A request has been made to the distributer to reassess the tube design and/or review the procedure promoted for primary placement.

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.