Stabilizing sutures for percutaneous endoscopic gastrostomy

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

AIM: To evaluate the inhibitory effects of carbon dioxide (CO₂) insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy (PEG).

METHODS: A total of 73 consecutive patients who were undergoing PEG were enrolled in our study. After eliminating 13 patients who fitted our exclusion criteria, 60 patients were randomly assigned to either CO₂ (30 patients) or air insufflation (30 patients) groups. PEG was performed by pull-through technique after three-point fixation of the gastric wall to the abdominal wall using a gastropexy device. Arterial blood gas analysis was performed immediately before and after the procedure. Abdominal X-ray was performed at 10 min and at 24 h after PEG to assess the extent of bowel distension. Abdominal computed tomography was performed at 24 h after the procedure to detect the presence of pneumoperitoneum. The outcomes of PEG for 7 d post-procedure were also investigated.

RESULTS: Among 30 patients each for the air and the CO₂ groups, PEG could not be conducted in 2 patients of the CO₂ group, thus they were excluded. Analyses of the remaining 58 patients showed that the patients’ backgrounds were not significantly different between the two groups. The elevation values of arterial partial pressure of CO₂ in the air group and the CO₂ group were 2.67 mmHg and 3.32 mmHg, respectively (P = 0.408). The evaluation of bowel distension on abdominal X ray revealed a significant decrease of small bowel distension in the CO₂ group compared to the air group (P < 0.001) at 10 min and 24 h after PEG, whereas there was no significant difference in large bowel distension between the two groups. Pneumoperitoneum was observed only in the air group but not in the CO₂ group (P = 0.003). There were no obvious differences in the laboratory data and clinical outcomes after PEG between the two groups.

CONCLUSION: There was no adverse event associated with CO₂ insufflation. CO₂ insufflation is considered to be safer and more comfortable for PEG patients because of the lower incidence of pneumoperitoneum and less distension of the small bowel.

Retrospective analyses of complications associated with transcutaneous replacement of percutaneous gastrostomy and jejunostomy feeding devices

BACKGROUND

Feeding device replacement is often required for long-term maintenance after initial percutaneous endoscopic gastrostomy or jejunostomy placement. Although there are several case reports on serious complications of gastrostomy device replacement, there are few reports of an overall analysis of the complications associated with feeding device replacement.

OBJECTIVE

To evaluate the frequency and variety of complications of transcutaneous replacement of feeding devices.

DESIGN

A retrospective study.

SETTING

Single center: Nishimino Kosei Hospital.

PATIENTS

This study involved 363 consecutive patients undergoing a total of 1265 percutaneous gastrostomy or jejunostomy device replacements from March 2000 to September 2010.

INTERVENTION

A new replacement device was inserted through the ostomy tract by using an obturator after traction removal of the previous device. Endoscopic treatments were performed in the cases of fistula disruption or hemorrhage.

MAIN OUTCOME MEASUREMENTS

Complications and their outcomes.

RESULTS

Gastrostomy and jejunostomy devices were replaced 1126 and 139 times, respectively. There were 16 complications (1.3% of total replacements) consisting of 10 cases of fistula disruption caused by misplacement of replacement devices into the peritoneal cavity, 4 cases of hemorrhage, and 1 case each of colocutaneous fistula and device breakage. Anticoagulation or antiplatelet medications were continued in all 4 hemorrhage cases but in only 27 of 347 (7.7%) complication-free cases (P < .0001). There were no replacement-related adverse events that required surgical repair.

LIMITATIONS

A single center, retrospective analysis.

CONCLUSION

Fistula disruption and hemorrhage were the most common complications associated with device replacement. In patients on anticoagulants, caution is necessary to avoid hemorrhage after replacement. It is also important to verify that the replaced device is located in the GI tract lumen before feeding.

Long-term results with a new introducer method with gastropexy for percutaneous endoscopic gastrostomy

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) using the pull-technique is the standard method for enteral feeding in patients with swallowing disorders. A different introducer technique with endoscopically controlled gastropexy is available avoiding oropharyngeal passage with the internal bumper. The aim of the study was to assess long-term safety of this technique.

MATERIAL AND METHODS

Between January 1999 and November 2001, 684 patients received a PEG in our prospective cohort trial. In 92.5% of cases a PEG was applied using the pull-through technique. In 6.7% of the patients (40 males, 6 females, mean age 60.6 yr) primary PEG application using the pull-through technique was not possible and an endoscopical controlled introducer PEG (Cliny PEG 13 CH (=13 F), AP Nenno, Germany) with two gastropexies was placed. Data collection criteria included application success, infectious complications (within 180 days), other complications (within 180 days), and mortality (within 180 days). Procedure, catheter change, and follow-up were standardized.

RESULTS

PEG placement was successful in all patients. During initial follow-up we saw a low rate of minor problems. In one case a peristomal peritonitis was seen due to detachment of two gastropexy sutures. During long-term follow-up only one local infection requiring antibiotic treatment occurred on day 14. We observed no treatment related mortality. In most of the patients the primary catheter was changed into a secondary system as scheduled. The average observation period was 131.8 days (range: 15-180 days).

CONCLUSION

The Cliny PEG 13 CH can be placed safely in an endoscopically controlled introducer procedure with dual gastropexy. Long-term follow-up of the patients revealed only minor complications. Primary indication is given in patients in whom PEG placement using the pull-through technique is not possible.