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Tae CH, Lee JY, Joo MK, Park CH, Gong EJ, Shin CM, Lim H, Choi HS, Choi M, Kim SH, Lim CH, Byeon JS, Shim KN, Song GA, Lee MS, Park JJ, Lee OY. Clinical Practice Guideline for Percutaneous Endoscopic Gastrostomy. Gut Liver 2024; 18:10-26. [PMID: 37850251 PMCID: PMC10791499 DOI: 10.5009/gnl230146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/06/2023] [Accepted: 06/20/2023] [Indexed: 10/19/2023] Open
Abstract
With an aging population, the number of patients with difficulty swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. Long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach, aided endoscopically, which may be an alternative to a nasogastric tube when enteral nutritional is required for 4 weeks or more. This paper is the first Korean clinical guideline for PEG. It was developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tubes removal for PEG based on the currently available clinical evidence.
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Affiliation(s)
- Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Ju Yup Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyun Lim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyuk Soon Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Sang Hoon Kim
- Department of Gastroenterology, Dongguk University Ilsan Hospital, Goyang, Korea
- Korean College of Helicobacter and Upper Gastrointestinal Research–Metabolism, Obesity & Nutrition Research Group, Seoul, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Korean Society of Gastrointestinal Endoscopy–The Research Group for Endoscopes and Devices, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University College of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moon Sung Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jong-Jae Park
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea
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Martinovic D, Tokic D, Puizina Mladinic E, Usljebrka M, Kadic S, Lesin A, Vilovic M, Lupi-Ferandin S, Ercegovic S, Kumric M, Bukic J, Bozic J. Nutritional Management of Patients with Head and Neck Cancer-A Comprehensive Review. Nutrients 2023; 15:nu15081864. [PMID: 37111081 PMCID: PMC10144914 DOI: 10.3390/nu15081864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Dinko Martinovic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Daria Tokic
- Department of Anesthesiology and Intensive Care, University Hospital of Split, 21000 Split, Croatia
| | - Ema Puizina Mladinic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Mislav Usljebrka
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Sanja Kadic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Antonella Lesin
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Marino Vilovic
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
| | - Slaven Lupi-Ferandin
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Sasa Ercegovic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Marko Kumric
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
| | - Josipa Bukic
- Department of Pharmacy, University of Split School of Medicine, 21000 Split, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
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Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11020279. [PMID: 35203881 PMCID: PMC8868062 DOI: 10.3390/antibiotics11020279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 01/26/2023] Open
Abstract
Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.
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Oh J, Park SY, Lee JS, Park J, Lee SH. Clinical characteristics and pathogens in percutaneous endoscopic gastrostomy site infection in patients with head and neck cancer: A 16-year retrospective study. Laryngoscope Investig Otolaryngol 2021; 6:1325-1331. [PMID: 34938870 PMCID: PMC8665475 DOI: 10.1002/lio2.666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/11/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES Wound infection is the most common complication associated with percutaneous endoscopic gastrostomy (PEG) placement, with an incidence between 4% and 30%. In this study, we compared the characteristics of PEG site infection between the head and neck cancer (HNC) group and the non-HNC group. METHODS This study was conducted at Kangdong Sacred Heart Hospital at the Ilsong Head and Neck Cancer Center. We retrospectively collected and analyzed data on patients who underwent PEG insertion from October 2003 to May 2019 to evaluate the risk factors and microbiological etiologies of PEG site infection. RESULTS A total of 316 (HNC group [n = 129] and non-HNC group [n = 187]) patients undergoing PEG insertion were included in this study. Moreover, 67 episodes of PEG site infection were diagnosed, with an overall prevalence of 21.2%. PEG site infections were significantly higher in the HNC group than in the non-HNC group (32.6% vs 13.4%, P <.001). Pseudomonas aeruginosa is the most common pathogen associated with a PEG site infection. Multidrug-resistant (MDR) P aeruginosa was more frequent in the HNC group than in the non-HNC group (78.6% vs 25.0%, P = .006). CONCLUSIONS For appropriate treatment, P aeruginosa, especially MDR P aeruginosa, should be considered when selecting empirical antibiotics for PEG site infection in patients with HNC.Level of Evidence: 4.
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Affiliation(s)
- Jihyu Oh
- Department of Medicine, Graduate SchoolKyung Hee UniversitySeoulKorea
| | - So Yeon Park
- Division of Infectious Disease, Kangdong Sacred Heart HospitalHallym University School of MedicineSeoulKorea
| | - Jin Seo Lee
- Division of Infectious Disease, Kangdong Sacred Heart HospitalHallym University School of MedicineSeoulKorea
| | - Ji‐Young Park
- Department of Diagnosis and Examination, Kangdong Sacred Heart HospitalHallym University School of MedicineSeoulKorea
| | - Seo Hu Lee
- Division of Infectious Disease, Kangdong Sacred Heart HospitalHallym University School of MedicineSeoulKorea
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Antibiotic Prophylaxis for Percutaneous Endoscopic Gastrostomy in Children: A Randomised Controlled Trial. J Pediatr Gastroenterol Nutr 2021; 72:366-371. [PMID: 33148981 DOI: 10.1097/mpg.0000000000002981] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Paediatric studies on the role of antibiotic prophylaxis in the prevention of postoperative infections in children undergoing percutaneous endoscopic gastrostomy (PEG) are lacking. The aim of this study was to assess if a single dose of co-amoxiclav before PEG can decrease the rate of peristomal wound and systemic infection in children. METHODS In this prospective, randomised, double-blind, multicentre trial, children undergoing PEG were randomized to antibiotic prophylaxis with co-amoxiclav versus placebo and the rate of local and systemic infections were assessed. RESULTS Of the 106 patients considered for inclusion, 49 patients were randomized. In the per-protocol analysis, the occurrence of wound infection was 5% (1/20) in the antibiotic group and 21% (4/19) in the placebo group (P = 0.13, 16% difference in proportions, odds ratio [OR] 0.19, 95% confidence interval [CI] 0.02-1.9). The occurrence of systemic infection was 9% (2/22) in the antibiotic group and 27.2% (6/25) in the placebo group [P = 0.17, 18% difference in proportions, OR 0.32, 95% CI 0.06%-1.80%]. Similar results were obtained in intention-to-treat analysis. Interestingly, the overall infection rate was significantly higher in the placebo group as compared with the antibiotic group (40% vs 13.6%; P = 0.04) and the duration of hospital stay was significantly longer in the placebo group as compared with the antibiotic group (4.4 ± 1.6 vs 3.5 ± 1.05; P = 0.02). The number-needed-to-treat (NTT) to prevent 1 peristomal infection on average are 6.7 patients. CONCLUSIONS A preoperative dose of co-amoxiclav reduces the overall infection rate and the duration of hospital stay. Our data suggest that antibiotic prophylaxis should be recommended in every children undergoing PEG placement.
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Gkolfakis P, Arvanitakis M, Despott EJ, Ballarin A, Beyna T, Boeykens K, Elbe P, Gisbertz I, Hoyois A, Mosteanu O, Sanders DS, Schmidt PT, Schneider SM, van Hooft JE. Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:178-195. [PMID: 33348410 DOI: 10.1055/a-1331-8080] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Asuncion Ballarin
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Torsten Beyna
- Department of Gastroenterology and Therapeutic Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
| | - Kurt Boeykens
- Nutrition Support Team, AZ Nikolaas Hospital, Moerlandstraat 1, 9100, Sint-Niklaas, Belgium
| | - Peter Elbe
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Gisbertz
- Department of Gastroenterology, Bernhoven Hospital, Uden, the Netherlands
| | - Alice Hoyois
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ofelia Mosteanu
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital & University of Sheffield, United Kingdom
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Stéphane M Schneider
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Gastroentérologie et Nutrition, Nice, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Do Antibiotics Reduce the Incidence of Infections After Percutaneous Endoscopic Gastrostomy Placement in Children? J Pediatr Gastroenterol Nutr 2020; 71:23-28. [PMID: 32205769 DOI: 10.1097/mpg.0000000000002709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Percutaneous endoscopic gastrostomy (PEG) provides a long-term solution for tube dependency. Pediatric guidelines recommend prophylactic antibiotic treatment (ABT) based on adult studies. AIM To compare wound infection and other complications in children receiving a PEG with and without prophylactic ABT. METHODS Retrospective study including children 0 to 18 years undergoing PEG placement. Patients with (2010-2013) and without (2000-2010) ABT were compared with respect to the occurrence of wound infection and other complications. RESULTS In total, 297 patients were included (median age 2.9 years, 53% boys). Patients receiving ABT per PEG protocol (n = 78) had a similar wound infection rate (17.9% vs 21%, P = 0.625), significantly less fever (3.8% vs 14.6%, P = 0.013), leakage (0% vs 9.1%, P = 0.003) and shorter hospital admission (2 vs 4 days, P = 0.000), but more overgranulation (28.2% vs 8.7%, P = 0.000) compared with those without (n = 219). Patients receiving any ABT, per PEG protocol or clinical indication (n = 115), had similar occurrence of wound infection (19.1% vs 20.9%, P = 0.768), fever (7.8% vs 14.3%, P = 0.100) and leakage (3.5% vs 8.8%, P = 0.096), a significantly shorter hospital admission (3 vs 4 days, P = 0.000), but more overgranulation (21.7% vs 8.8%, P =0.003) compared with those without (n = 182). CONCLUSIONS Prophylactic ABT does not seem to reduce the occurrence of wound infection but it might be beneficial with respect to fever, leakage and duration of hospital admission, but not overgranulation. A randomized controlled trial is needed to confirm our results.
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Pih GY, Na HK, Hong SK, Ahn JY, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Clinical Outcomes of Percutaneous Endoscopic Gastrostomy in the Surgical Intensive Care Unit. Clin Endosc 2020; 53:705-716. [PMID: 32229800 PMCID: PMC7719425 DOI: 10.5946/ce.2019.196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/15/2020] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Percutaneous endoscopic gastrostomy (PEG) is usually performed on patients with chronic underlying diseases in the general ward (GW). This study evaluated the clinical outcomes of PEG performed on patients in the surgical intensive care unit (SICU) compared with those of PEG performed in the GW.
Methods The medical records of 27 patients in the SICU and 263 in the GW, who underwent PEG between January 2013 and July 2017, were retrospectively reviewed.
Results The median age of the 27 SICU patients was 66 years, and their median body mass index was 21.1 kg/m2. In the SICU group, the median baseline Sequential Organ Failure Assessment (SOFA) score was 4, and the median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 16. The median interval between surgery and PEG in SICU patients was 30 days, with a PEG failure rate of 3.7%. Acute complications in SICU patients included bleeding (7.4%) and ileus (11.1%), while chronic complications included aspiration pneumonia (7.4%) and tube obstruction (3.7%). The rates of acute and chronic complications did not differ significantly between the SICU and GW groups. The 30-day mortality rate was 14.8% in SICU patients and 5.3% in GW patients (p=0.073).
Conclusions PEG is a safe and feasible method of enteral feeding for critically ill patients who require ICU care after surgery.
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Affiliation(s)
- Gyu Young Pih
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Nutritional Support Team, Asan Medical Center, Seoul, Korea
| | - Suk-Kyung Hong
- Nutritional Support Team, Asan Medical Center, Seoul, Korea.,Division of Trauma and Surgical Critical Care, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Vujasinovic M, Ingre C, Baldaque Silva F, Frederiksen F, Yu J, Elbe P. Complications and outcome of percutaneous endoscopic gastrostomy in a high-volume centre. Scand J Gastroenterol 2019; 54:513-518. [PMID: 30905223 DOI: 10.1080/00365521.2019.1594354] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction: Percutaneous endoscopic gastrostomy (PEG) is the method of choice for long-term enteral feeding for patients with swallowing disorders and normal gut function. There is limited data regarding the demographics and clinical characteristics of patients from whom PEG was removed. Patients and methods: We performed a retrospective analysis of all consecutive adult patients who underwent first placement of PEG between 1 August 2013 and 31 December 2015 at Karolinska University Hospital in Stockholm, Sweden. Results: In total, 495 PEG were inserted in 495 patients during the study period, 56% male, mean age at insertion 67 years (range 19-95). Most patients belonged to the neurologic group (52%), followed by the oncologic (32%), another diagnosis (9%) and trauma (7%). Major complications occurred in 10 (2.0%) patients. There were no differences in the age or BMI of patients with either minor or major complications but both parameters were risk factors in terms of survival. PEG was removed from 165 (33.3%) patients, most of them from the oncology group, due to the improvement of general status of patients after specific oncologic treatment. Conclusion: Increased age and low BMI were identified as risk factors for mortality but did not correspond with the rate of complications. Antibiotic prophylaxis with sulfamethoxazole and trimethoprim provides good protection for patients with PEG.
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Affiliation(s)
- Miroslav Vujasinovic
- a Department for Digestive Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Caroline Ingre
- b Department of Neurology , Karolinska University Hospital , Stockholm , Sweden
| | | | | | - Jingru Yu
- d Department of Medical Epidemiology and Biostatistics , Karolinska Institute , Stockholm , Sweden
| | - Peter Elbe
- a Department for Digestive Diseases , Karolinska University Hospital , Stockholm , Sweden
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Duncan H, Painesi A, Buchanan E, McGrogan P, Gerasimidis K, Walker G, Haddock G, Russell RK. Percutaneous endoscopic gastrostomy placement in paediatric Crohn's disease patients contributes to both improved nutrition and growth. Acta Paediatr 2018; 107:1094-1099. [PMID: 29423918 DOI: 10.1111/apa.14268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 12/11/2017] [Accepted: 02/02/2018] [Indexed: 01/14/2023]
Abstract
AIM This paper describes the outcomes of gastrostomy feeding in patients with Crohn's disease (CD). METHODS Patients with CD who attended the Royal Hospital for Children, Glasgow and received gastrostomy feeding for at least two years between 2003 and 2010 were identified from the clinical database. The data recorded included the anthropometric data, CD phenotype, the surgical technique that was used, complications, medication, feed type, median feed, calories, volume and clinical outcomes. RESULTS The study identified 16 patients (14 male) who had a gastrostomy inserted using a pull technique at a median age of 12.6 years. Of these two required laparoscopic placement. Short-term complications lasting less than one month were experienced by nine (56%) patients and one (6%) experienced long-term complications. Anthropometry significantly improved at follow-up compared to baseline: at 12 months, the body mass index z-score was 1.11 (p = 0.005) and the weight z-score was 0.19 (p < 0.05). At 24 months, the height z-score was -1.03 (p = 0.04). The daily median volume and calories from feeds increased significantly from baseline to post-PEG insertion, from 400 to 738 mL and 705 to 860 kcal/day (p ≤ 0.01). CONCLUSION Gastrostomy feeding for paediatric patients with CD was associated with improved nutrition, weight gain and growth outcomes.
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Affiliation(s)
- H Duncan
- Department of Nutrition & Dietetics; The Royal Hospital for Children; Glasgow UK
| | - A Painesi
- Human Nutrition; School of Medicine; College of Medicine, Veterinary and Life Sciences; New Lister Building; Glasgow Royal Infirmary; University of Glasgow; Glasgow UK
| | - E Buchanan
- Department of Nutrition & Dietetics; The Royal Hospital for Children; Glasgow UK
| | - P McGrogan
- Paediatric Gastroenterology Department; The Royal Hospital for Children; Glasgow UK
| | - K Gerasimidis
- Human Nutrition; School of Medicine; College of Medicine, Veterinary and Life Sciences; New Lister Building; Glasgow Royal Infirmary; University of Glasgow; Glasgow UK
| | - G Walker
- Department of Surgical Paediatrics; The Royal Hospital for Children; Glasgow UK
| | - G Haddock
- Department of Surgical Paediatrics; The Royal Hospital for Children; Glasgow UK
| | - RK Russell
- Paediatric Gastroenterology Department; The Royal Hospital for Children; Glasgow UK
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Vizhi K, Rao HB, Venu RP. Percutaneous endoscopic gastrostomy site infections-Incidence and risk factors. Indian J Gastroenterol 2018; 37:103-107. [PMID: 29473130 DOI: 10.1007/s12664-018-0822-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) placement is the modality of choice for long-term enteral nutrition in view of technical ease and cost-effectiveness. Peristomal infection (PI) remains the most common complication following PEG tube placement. The aim of this study was to assess the incidence and risk factors for PI and outline a microbiological profile that can aid in prophylactic and therapeutic strategies. METHODS A retrospective study of 781 patients who underwent PEG placement (Cook PEG-Pull-S-20Fr/24Fr) from 2010 to 2015 at our tertiary care center were included. Relevant data were collected from the hospital electronic medical records. The incidence of PI was computed and potential risk factors were assessed using univariate analysis. The microbiological profile was created along with sensitivity patterns after reviewing the culture reports. Statistical analysis was performed using SPSS version 20.0. RESULTS PEG tube placement was performed in 781 patients (mean age 55.9 ± 36.1; M:F = 2:75). The major indication was oropharyngeal malignancies. PI was seen in 171 patients (21.9%). Diabetes mellitus, duration of hospital stay more than 7 days, and hypoalbuminemia were found to be significant risk factors for the development of PI (p < 0.05). Patients who had chemotherapy or radiotherapy before PEG placement had a higher incidence of peristomal infections (p 0.00). Pseudomonas and Klebsiella were the most common organisms causing infection. CONCLUSIONS PI remains a significant complication of PEG placement. Pseudomonas and Klebsiella are the most common organisms and prophylactic antibiotic protocols should be tailored accordingly. Elective PEG before the institution of chemotherapy/radiotherapy in patients with oropharyngeal malignancies is recommended.
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Affiliation(s)
- Kayal Vizhi
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, 682 041, India
| | - Harshavardhan B Rao
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, 682 041, India.
| | - Rama P Venu
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, 682 041, India
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12
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Value of Antibiotic Prophylaxis for Percutaneous Gastrostomy: A Double-Blind Randomized Trial. J Vasc Interv Radiol 2018; 29:55-61.e2. [DOI: 10.1016/j.jvir.2017.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/19/2017] [Accepted: 08/20/2017] [Indexed: 11/20/2022] Open
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13
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Teich N, Selig L, Liese S, Schiefke F, Hemprich A, Mössner J, Schiefke I. Usage characteristics and adverse event rates of the direct puncture and pull techniques for percutaneous endoscopic gastrostomy in patients with malignant tumors of the upper aerodigestive tract. Endosc Int Open 2018; 6:E29-E35. [PMID: 29340295 PMCID: PMC5766340 DOI: 10.1055/s-0043-121879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 09/12/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Patients with malignant tumors of the upper gastrointestinal tract are at risk of weight loss. Early supportive nutrition therapy is therefore recommended and usually requires placement of a percutaneous endoscopic gastrostomy (PEG). The aim of this study was to compare adverse events and usage characteristics of the direct puncture technique with those of the traditional pull technique when used in patients with endoscopically passable tumors. The primary endpoint was the rate of inflammatory adverse events (AEs) at the gastrostomy fistula. The secondary endpoint was the long-term rate of puncture-site metastases. PATIENTS AND METHODS One hundred twenty patients (median age 56; IQR 36, 86 years) were randomized and treated per protocol in this prospective open randomized single-center study. Follow-ups were conducted on the third and seventh post-interventional days, after 1, 3 and 6 months and the last follow-up 5 years after intervention. RESULTS Within the short-term follow-up period of 6 months after PEG placement, AEs were noted in 47 patients (39.2 %). These included 22 inflammations and 16 device dislocations and were mainly found in the puncture group (33 vs. 14 in the pull group) with a significantly increased incidence in the first month after PEG insertion ( P = 0.001). Evaluation of the 5-year data did not reveal any significant differences. The gastrostomy tube was used in 101 patients (84.2 %) (range 18 days to 5 years). CONCLUSIONS Our results favor the pull technique for patients with endoscopically passable tumors of the upper gastrointestinal tract due to less short-term adverse events. Both systems contributed equally to secure long-term use.
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Affiliation(s)
- Niels Teich
- Klinikum St. Georg, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany,Internistische Gemeinschaftspraxis für Verdauungs- und Stoffwechselkrankheiten, Leipzig, Germany,Medizinische Fakultät der Friedrich-Schiller-Universität Jena, Jena,Corresponding author Niels Teich, MD Internistische Gemeinschaftspraxis für Verdauungs- und StoffwechselkrankheitenNordstr. 21D-04105 LeipzigGermany+0049 341 60036560
| | - Lars Selig
- Universität Leipzig, Klinik und Poliklinik für Gastroenterologie und Rheumatologie, Leipzig, Germany
| | - Susanne Liese
- Universität Rostock, Klinik und Poliklinik für Mund-, Kiefer- und Plastische Gesichtschirurgie, Rostock, Germany
| | - Franziska Schiefke
- Universität Leipzig, Klinik für Mund-, Kiefer- und Plastische Gesichtschirurgie, Leipzig, Germany,Gemeinschaftspraxis für Mund-, Kiefer- und Gesichtschirurgie am Johannisplatz, Leipzig, Germany
| | - Alexander Hemprich
- Universität Leipzig, Klinik für Mund-, Kiefer- und Plastische Gesichtschirurgie, Leipzig, Germany
| | - Joachim Mössner
- Universität Leipzig, Klinik und Poliklinik für Gastroenterologie und Rheumatologie, Leipzig, Germany
| | - Ingolf Schiefke
- Klinikum St. Georg, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany,Gastroenterologie und Hepatologie am Johannisplatz, Leipzig, Germany
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Koc D, Gercek A, Gencosmanoglu R, Tozun N. Percutaneous Endoscopic Gastrostomy in the Neurosurgical Intensive Care Unit: Complications and Outcome. JPEN J Parenter Enteral Nutr 2017; 31:517-20. [PMID: 17947610 DOI: 10.1177/0148607107031006517] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Demet Koc
- From the Anesthesiology Unit, Marmara University
Institute of Gastroenterology, Istanbul, Turkey;
Anesthesiology Unit, Marmara University
Institute of Neurological Science, Istanbul, Turkey;
Department of General Surgery and
Sub-department of Gastroenterology, Marmara
University School of Medicine, Istanbul, Turkey; and the
Unit of Gastrointestinal Surgery and
Unit of Clinical Gastroenterology, Marmara
University Institute of Gastroenterology, Istanbul, Turkey
| | - Arzu Gercek
- From the Anesthesiology Unit, Marmara University
Institute of Gastroenterology, Istanbul, Turkey;
Anesthesiology Unit, Marmara University
Institute of Neurological Science, Istanbul, Turkey;
Department of General Surgery and
Sub-department of Gastroenterology, Marmara
University School of Medicine, Istanbul, Turkey; and the
Unit of Gastrointestinal Surgery and
Unit of Clinical Gastroenterology, Marmara
University Institute of Gastroenterology, Istanbul, Turkey
| | - Rasim Gencosmanoglu
- From the Anesthesiology Unit, Marmara University
Institute of Gastroenterology, Istanbul, Turkey;
Anesthesiology Unit, Marmara University
Institute of Neurological Science, Istanbul, Turkey;
Department of General Surgery and
Sub-department of Gastroenterology, Marmara
University School of Medicine, Istanbul, Turkey; and the
Unit of Gastrointestinal Surgery and
Unit of Clinical Gastroenterology, Marmara
University Institute of Gastroenterology, Istanbul, Turkey
| | - Nurdan Tozun
- From the Anesthesiology Unit, Marmara University
Institute of Gastroenterology, Istanbul, Turkey;
Anesthesiology Unit, Marmara University
Institute of Neurological Science, Istanbul, Turkey;
Department of General Surgery and
Sub-department of Gastroenterology, Marmara
University School of Medicine, Istanbul, Turkey; and the
Unit of Gastrointestinal Surgery and
Unit of Clinical Gastroenterology, Marmara
University Institute of Gastroenterology, Istanbul, Turkey
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Hucl T, Spicak J. Complications of percutaneous endoscopic gastrostomy. Best Pract Res Clin Gastroenterol 2016; 30:769-781. [PMID: 27931635 DOI: 10.1016/j.bpg.2016.10.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 09/18/2016] [Accepted: 10/02/2016] [Indexed: 01/31/2023]
Abstract
Percutaneous endoscopic gastrostomy (PEG) has become the method of choice for mid-to long-term enteral feeding. The majority of complications that occur are minor, but the rare major complications may be life threatening. Some complications occur soon after tube placement, others develop later, when the gastrostomy tract has matured. Older patients with comorbidities and infections appear to be at a greater risk of developing complications. Apart from being aware of indications and contraindications, proper technique of PEG placement, including correct positioning of the external fixation device, and daily tube care are important preventive measures. Adequate management of anticoagulation and antithrombotic agents is important to prevent bleeding, and administration of broad spectrum antibiotics prior to the procedure helps prevent infectious complications. Early recognition of complications enables prompt diagnosis and effective therapy.
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Affiliation(s)
- Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
| | - Julius Spicak
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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16
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Systemic Prophylactic Antibiotics for the Modified Introducer Method for Percutaneous Endoscopic Gastrostomy: A Prospective, Randomized, Double-Blind Study. J Clin Gastroenterol 2016; 50:727-32. [PMID: 26756107 DOI: 10.1097/mcg.0000000000000470] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is the most common method of enteral nutrition in patients who require long-term tube feeding. According to meta-analyses, administration of systemic prophylactic antibiotics for PEG reduces peristomal infection. However, with several recent developments in the procedure and instruments, the risk of infection might have been reduced. The aim of this study was to evaluate the use of systemic antibiotic prophylaxis for a modified introducer method of PEG. METHODS This prospective, randomized, double-blind trial assessed 278 patients undergoing PEG for inclusion. Ninety-one patients with an indication for PEG who gave informed consent to participate were randomized. Forty-six patients received prophylactic ampicillin and 45 patients received a placebo. A modified introducer method of PEG using a Seldinger PEG kit was performed. The primary outcome was the occurrence of clinically evident wound infection within 3 days after PEG. RESULTS Wound infection within 3 days was observed in none in the prophylaxis group and in 1 patient in the control group (P=0.4945). There was no significant difference between 2 groups in the other parameters, including peristomal infection within 7 days, overall infection, white blood cell counts, C-reactive protein level, and successive rate of finishing antibiotics. CONCLUSIONS For wound infection within 3 days, noninferiority of the placebo group to the antibiotics group was preliminarily suggested with our criteria, but not for peristomal infection within 7 days. More strict criteria for noninferiority should be examined in a further large sample study.
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17
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Mack RM, Staiger B, Langlois DK, Mehler SJ, Lam N, Moore T, Brown A, Beal MW. Development and characterization of a technique for percutaneous radiologic gastrojejunostomy tube placement in the dog. J Vet Emerg Crit Care (San Antonio) 2016; 26:646-53. [PMID: 27428382 DOI: 10.1111/vec.12506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 12/08/2014] [Accepted: 12/21/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To develop and describe a technique for percutaneous radiologic gastrojejunostomy tube placement in the dog. DESIGN Prospective technique development study. SETTING University teaching hospital. ANIMALS Six healthy adult male Beagles. INTERVENTIONS Following anesthetic induction, fluoroscopic and ultrasound guidance were used to identify an appropriate gastropexy site on the left lateral abdomen. Gastropexy was performed using gastrointestinal suture anchors. An over-the-wire catheter technique using fluoroscopic guidance was used to achieve jejunal access. An 18F/8F, 58 cm, dual-lumen gastrojejunal feeding tube was placed via serial over-the-wire dilation of the body wall using an 18F peel-away introducer kit. Tube location was determined radiographically immediately following placement and on days 2, 4, after emesis on day 4, and at time of gastrojejunal feeding tube removal (day 16-18). MEASUREMENTS AND MAIN RESULTS Percutaneous radiologic gastrojejunostomy (PRGJ) tube placement was successful in all dogs. Median time to pyloric passage with the guide wire was 23.5 minutes (range, 9-93 minutes). Median total procedure time was 53 minutes (range, 49-113 minutes). Significant tube migration was not observed at any point during the study. One dog developed linear foreign body obstruction secondary to the tube on day 5 that was relieved by release of the jejunal component. Other complications were minor and included mild-to-moderate peristomal inflammation in all dogs and removal of the feeding tube on day 3 by 1 dog. Feedings were well tolerated in all dogs. CONCLUSIONS PRGJ tube placement in the dog is a safe and minimally invasive technique that allows for jejunal feeding without surgery or endoscopy. The high success rates, acceptable procedural times, and minimal complications are appealing for use in critically ill patients. Although additional evaluations are needed, PRGJ tube placement may be considered for dogs that require postpyloric feeding with or without gastric decompression.
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Affiliation(s)
- Rebekah M Mack
- Upstate Veterinary Specialists, 393 Woods Lake Road, Greenville, SC, 29607
| | - Benjamin Staiger
- Red Bank Veterinary Hospital, 210 Route 206 S, Hillsborough, NJ, 08844
| | - Daniel K Langlois
- Department of Small Animal Clinical Sciences, Michigan State University, East Lansing, MI, 48824
| | - Stephen J Mehler
- Department of Small Animal Clinical Sciences, Michigan State University, East Lansing, MI, 48824
| | | | | | - Andrew Brown
- Animal Neurology & MRI Center, 1120 Welch Rd, Commerce Twp, MI, 48390
| | - Matthew W Beal
- the College of Veterinary Medicine, University of Edinburgh, Edinburgh, Scotland
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Lepore M, Marks DJ, Harbord MW. Percutaneous gastrostomy: troubleshooting complications. Br J Hosp Med (Lond) 2016; 77:C86-90. [PMID: 27269765 DOI: 10.12968/hmed.2016.77.6.c86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mario Lepore
- FY1 Doctor in the Department of Medicine, West Middlesex Hospital, Middlesex
| | - Daniel Jb Marks
- ST6 Registrar in Clinical Pharmacology and Therapeutics, University College London Hospital, London
| | - Marcus Wn Harbord
- Consultant Gastroenterologist in the Department of Medicine, Chelsea and Westminster Hospital, London SW10 9NH
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19
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Bernstein OA, Campbell J, Rajan DK, Kachura JR, Simons ME, Beecroft JR, Jaskolka JD, Ringash J, Ho CS, Tan KT. Randomized Trial Comparing Radiologic Pigtail Gastrostomy and Peroral Image-Guided Gastrostomy: Intra- and Postprocedural Pain, Radiation Exposure, Complications, and Quality of Life. J Vasc Interv Radiol 2015; 26:1680-6; quiz 1686. [PMID: 26316137 DOI: 10.1016/j.jvir.2015.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 06/12/2015] [Accepted: 07/15/2015] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Ondina A Bernstein
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada.
| | - Jennifer Campbell
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Dheeraj K Rajan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - John R Kachura
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Martin E Simons
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - J Robert Beecroft
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey D Jaskolka
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Chia S Ho
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Kong Teng Tan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
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Abstract
Placement of percutaneous endoscopic gastrostomy or jejunostomy is a safe procedure with low periprocedural mortality, but overall mortality rates are high because of underlying disease conditions. These procedures are also associated with postprocedure complications. The clinically significant adverse events related to the procedures include infection (at tube site and peritonitis), bleeding, and aspiration. More rare associated events include buried bumpers, injury to adjacent viscera with subsequent fistula formation, and tumor seeding. There is a lack of guidelines about these procedures other than those concerning the use of antibiotics and the management of antithrombotics and anticoagulation before the procedure.
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Affiliation(s)
- Ajaypal Singh
- Division of Gastroenterology, Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medical Center, 5700 Sought Maryland Ave, Chicago, IL 60637-1470, USA
| | - Andres Gelrud
- Division of Gastroenterology, Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medical Center, 5700 Sought Maryland Ave, Chicago, IL 60637-1470, USA.
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21
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Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure performed to maintain nutrition in the short- or long-term. During the procedure, a feeding tube that delivers either a liquid diet, or medication, via a clean or sterile delivery system, is placed surgically through the anterior abdominal wall. Those undergoing PEG tube placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression, or underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and to the debate surrounding antibiotic prophylaxis for PEG tube placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient's serum and tissues, via a brief course of an appropriate agent, by the time of PEG tube placement in order to prevent any peristomal infections that might result from the procedure. OBJECTIVES To establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomy tubes. SEARCH METHODS In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid Medline; Ovid Medline (In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials during PEG tube placement, with no restrictions regarding language of publication, date of publication, or publication status. Both review authors independently selected studies. DATA COLLECTION AND ANALYSIS Both review authors independently extracted data and assessed study quality. Meta-analyses were performed where appropriate. MAIN RESULTS One new trial was identified and included in this update, bringing the total to 13 eligible RCTs, with a total of 1637 patients. All trials reported peristomal infection as an outcome. A pooled analysis of 12 trials resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (1271 patients pooled: OR 0.36, 95% CI 0.26 to 0.50). The newly identified trial compared IV antibiotics with antibiotics via PEG and could not be included in the meta-analysis. AUTHORS' CONCLUSIONS Administration of systemic prophylactic antibiotics for PEG tube placement reduces peristomal infection.
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Affiliation(s)
- Allyson Lipp
- Department of Care Sciences, University of South WalesFaculty of Health, Sport and ScienceGlyn Taff CampusPontypriddUKCF37 1DL
| | - Gail Lusardi
- Department of Care Sciences, University of South WalesFaculty of Health, Sport and ScienceGlyn Taff CampusPontypriddUKCF37 1DL
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Erdogan A. Single endoscopist-performed percutaneous endoscopic gastrostomy tube placement. World J Gastroenterol 2013; 19:4172-4176. [PMID: 23864780 PMCID: PMC3710419 DOI: 10.3748/wjg.v19.i26.4172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 12/17/2012] [Accepted: 01/07/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether single endoscopist-performed percutaneous endoscopic gastrostomy (PEG) is safe and to compare the complications of PEG with those reported in the literature.
METHODS: Patients who underwent PEG placement between June 2001 and August 2011 at the Baskent University Alanya Teaching and Research Center were evaluated retrospectively. Patients whose PEG was placed for the first time by a single endoscopist were enrolled in the study. PEG was performed using the pull method. All of the patients were evaluated for their indications for PEG, major and minor complications resulting from PEG, nutritional status, C-reactive protein (CRP) levels and the use of antibiotic treatment or antibiotic prophylaxis prior to PEG. Comorbidities, rates, time and reasons for mortality were also evaluated. The reasons for PEG removal and PEG duration were also investigated.
RESULTS: Sixty-two patients underwent the PEG procedure for the first time during this study. Eight patients who underwent PEG placement by 2 endoscopists were not enrolled in the study. A total of 54 patients were investigated. The patients’ mean age was 69.9 years. The most common indication for PEG was cerebral infarct, which occurred in approximately two-thirds of the patients. The mean albumin level was 3.04 ± 0.7 g/dL, and 76.2% of the patients’ albumin levels were below the normal values. The mean CRP level was high in 90.6% of patients prior to the procedure. Approximately two-thirds of the patients received antibiotics for either prophylaxis or treatment for infections prior to the PEG procedure. Mortality was not related to the procedure in any of the patients. Buried bumper syndrome was the only major complication, and it occurred in the third year. In such case, the PEG was removed and a new PEG tube was placed via surgery. Eight patients (15.1%) experienced minor complications, 6 (11.1%) of which were wound infections. All wound infections except one recovered with antibiotic treatment. Two patients had bleeding from the PEG site, one was resolved with primary suturing and the other with fresh frozen plasma transfusion.
CONCLUSION: The incidence of major and minor complications is in keeping with literature. This finding may be noteworthy, especially in developing countries.
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Edwards-Jones V, Leahy-Gilmartin A. Gastrostomy site infections: dealing with a common problem. Br J Community Nurs 2013; Suppl:S8, S10, S12-3. [PMID: 23752296 DOI: 10.12968/bjcn.2013.18.sup5.s8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The most popular method of providing appropriate nutrition for large numbers of patients with swallowing difficulties is enteral feeding. However this treatment is not without complications, one of which is localized gastrostomy site infection. This is prevented initially by decolonisation of the oropharyngeal tract with antibiotic prophylaxis prior to insertion, and systemic antibiotics post insertion. Later complications include tracking infection, which is rare but can occur. Hypergranulation of the tissue can occur around the gastrostomy tube and this can become colonised or infected leading to further problems for the patient. A good gastrostomy site care pathway plan is required to maintain a healthy site and appropriate treatment required to minimize the infection risk.
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73-156. [PMID: 23461695 DOI: 10.1089/sur.2013.9999] [Citation(s) in RCA: 685] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Dale W Bratzler
- College of Public Health, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma 73126-0901, USA.
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. [DOI: 10.2146/ajhp120568] [Citation(s) in RCA: 1364] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Stayner JL, Bhatnagar A, McGinn AN, Fang JC. Feeding tube placement: errors and complications. Nutr Clin Pract 2012; 27:738-48. [PMID: 23064019 DOI: 10.1177/0884533612462239] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- James L Stayner
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah 84132, USA
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Fascetti-Leon F, Gamba P, Dall'Oglio L, Pane A, dé Angelis GL, Bizzarri B, Fava G, Maestri L, Cheli M, Di Nardo G, La Riccia A, Marrello S, Gandullia P, Romano C, D'Antiga L, Betalli P. Complications of percutaneous endoscopic gastrostomy in children: results of an Italian multicenter observational study. Dig Liver Dis 2012; 44:655-9. [PMID: 22541388 DOI: 10.1016/j.dld.2012.03.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 03/19/2012] [Accepted: 03/20/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy is the preferred way to achieve an artificial feeding route for patients requiring long-term enteral nutrition. Although the procedure is well-standardized, it carries early and late complications. AIM To establish the mortality and morbidity of this technique in a large cohort of children. METHODS A multi-centre prospective clinical data collection from children undergoing percutaneous endoscopic gastrostomy tube implantation has been conducted from January 2004 to December 2007. Previous abdominal surgery was the only exclusion criterion. Follow-up visits were carried out at 1, 3, 6, 12, and 24 months after the procedure. RESULTS 239 children (males, 55.2%; mean age 6.05±6.1years) were enrolled from nine tertiary Italian centres. Major complications occurred in 8 patients (3.3%). The cumulative incidence of complications was 47.7% at 24 months. The presence of thoraco-abdominal deformity was an independent predictor of complications at 12 months. No risk factors were identified in association to complications during the 1st tube replacement. CONCLUSION In children undergoing percutaneous endoscopic gastrostomy placement minor complications are common, while severe morbidities are rare. Accurate follow up is essential to recognize every complication, in particular when risk factors such as thoraco-abdominal deformity exist.
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Crnich CJ, Drinka P. Medical device-associated infections in the long-term care setting. Infect Dis Clin North Am 2012; 26:143-64. [PMID: 22284381 DOI: 10.1016/j.idc.2011.09.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Indwelling medical devices are increasingly used in long-term care facilities (LTCFs). These devices place residents at a heightened risk for infection and colonization and infection with multidrug-resistant organisms. Understanding the risk and pathogenesis of infection associated with commonly used medical devices can help facilitate appropriate therapy. Programs to minimize unnecessary use of indwelling medical devices in residents and maximize staff adherence to infection control and maintenance procedures are essential features of a LTCF infection prevention program. LTCFs that provide care for large numbers of residents with indwelling medical devices should routinely perform surveillance for device-related infections and develop systems for assessing the safety and efficacy of newly introduced device-related technology.
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Affiliation(s)
- Christopher J Crnich
- Division of Infectious Diseases, School of Medicine and Public Health, University of Wisconsin, 1685 Highland Avenue, 5217 MFCB, Madison, WI 53705,
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Onder A, Kapan M, Arikanoglu Z, Gul M, Bestas R, Palanci Y, Karaman H, Bac B. Percutaneous Endoscopic Gastrostomy: Mortality and Risk Factors for Survival. Gastroenterology Res 2012; 5:21-27. [PMID: 27785174 PMCID: PMC5051037 DOI: 10.4021/gr402w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2012] [Indexed: 01/01/2023] Open
Abstract
Background The present study evaluated long-term risk factors for survival in patients who have undergone Percutaneous endoscopic Gastrostomy, as well as morbidity and mortality rates. Methods The retrospective study included 44 patients who underwent placement of a percutaneous endoscopic gastrostomy tube at various departments at Dicle University Medical Faculty between April 2008-September 2010. Results The study evaluated 23 women (52.3%) and 21 men (47.7%), with a median age of 50 ± 20 (17 - 87) years. Median time for Percutaneous endoscopic Gastrostomy placement was 23 ± 8.3 (5 - 45) minutes per patient. Total morbidity was 15.9%, including wound infection (4), tube occlusion (1), peristomal leakage (1), and abdominal wall bleeding (1). Short-term complications were not associated with albumin level (P = 0.312).The median hospital stay was 49.34 ± 60.99 (1 - 314) days. The mean follow-up period was 13.07 ± 13.12 (1 - 41) months. The above-normal level of albumin was found to be effective on survival (P = 0.024). Mortality occurred in 18 (40.9%) patients during the follow-up. Conclusions Percutaneous endoscopic Gastrostomy is both safe and effective in that it does not require surgical operation and it can be performed under surface anesthesia. The serum albumin level with patients who have undergone percutaneous endoscopic gastrostomyis an effective factor for survival.
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Affiliation(s)
- Akin Onder
- Department of Surgery, Dicle University Faculty of Medicine, 21280, Diyarbakir, Turkey
| | - Murat Kapan
- Department of Surgery, Dicle University Faculty of Medicine, 21280, Diyarbakir, Turkey
| | - Zulfu Arikanoglu
- Department of Surgery, Dicle University Faculty of Medicine, 21280, Diyarbakir, Turkey
| | - Mesut Gul
- Department of Surgery, Dicle University Faculty of Medicine, 21280, Diyarbakir, Turkey
| | - Remzi Bestas
- Department of Gastroenterology, Dicle University Faculty of Medicine, 21280, Diyarbakir, Turkey
| | - Yilmaz Palanci
- Department of Public Health, Dicle University Faculty of Medicine, 21280, Diyarbakir, Turkey
| | - Haktan Karaman
- Departmant of Anesthesia and Reanimation, Dicle University Faculty of Medicine, 21280, Diyarbakir, Turkey
| | - Bilsel Bac
- Department of Surgery, Dicle University Faculty of Medicine, 21280, Diyarbakir, Turkey
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Percutaneous endoscopic gastrostomy using the direct method for aerodigestive cancer patients. Eur J Gastroenterol Hepatol 2012; 24:77-81. [PMID: 22081009 DOI: 10.1097/meg.0b013e32834dfd67] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND In esophageal or head and neck cancer patients, percutaneous endoscopic gastrostomy (PEG) by the pull method has higher complication rates than in noncancer patients. An introducer method is considered suitable for these patients, however, complications associated with deflation or rupture of the balloon-anchoring system are reported. AIM To investigate the efficacy of a modified introducer method, called direct method, for aerodigestive cancer patients. MATERIALS AND METHODS Between October 2007 and December 2010, direct-method PEG was performed in 160 patients with advanced-stage esophageal (59 patients) or head and neck (101 patients) cancer. Complications and postoperative course were retrospectively retrieved from charts. RESULTS An ultrathin endoscopy was used in 109 patients (72.7%), and 23 patients received previous endoscopic dilatation (14%) due to the stricture caused by the tumor. The success rate of tube placement was 98.8% (158/160). Major complications related to tube insertion, such as panperitonitis, gastrointestinal hemorrhage, and postoperative pneumonia occurred in five patients (3.2%). One patient died for panperitonitis due to late-onset tube dislodgement. There were no cases of tube blockade and no metastases in the PEG site during the median follow-up period of 153 days. CONCLUSION This was the first report of direct-method PEG in a number of esophageal or head and neck cancer patients. This method is optimal for its high success rate, acceptable safety profile, and little risk of stomal metastasis.
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Lozoya-González D, Pelaez-Luna M, Farca-Belsaguy A, Salceda-Otero JC, Vazquéz-Ballesteros E. Percutaneous endoscopic gastrostomy complication rates and compliance with the American Society for Gastrointestinal Endoscopy guidelines for the management of antithrombotic therapy. JPEN J Parenter Enteral Nutr 2011; 36:226-30. [PMID: 21868718 DOI: 10.1177/0148607111413897] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The American Society for Gastrointestinal Endoscopy (ASGE) has published recommendations in regards to anticoagulant (AC) and antiplatelet (AP) therapy management during endoscopic procedures. So far, no study has assessed either ASGE recommendation compliance during percutaneous endoscopic gastrostomy (PEG) placement or procedure-associated complication rates as related to the observance of these recommendations. The aims of this study were to compare the incidence and type of complications during PEG placement in patients receiving or not receiving AC and/or AP therapy and to determine the compliance with ASGE's AC and AP management guidelines. METHODS Medical files of patients who underwent PEG placement from January 2004 to December 2008 were reviewed. Clinical and procedure-related data were recorded. Patients were separated into 1 of 2 groups: patients under AP and/or AC therapy prior to PEG placement (n = 51) and a control group of patients (n = 40) not receiving any AP and/or AC treatment at least 6 months prior to the procedure. RESULTS A total of 91 patients (51 cases) were included. Groups were comparable in demographics and clinical characteristics. No differences in the frequency and type of complications were found between groups. ASGE's recommendations were not followed in any of these patients. CONCLUSIONS Overall PEG placement complication rate was 13.7%. AP therapy may be safely discontinued closer to the time of endoscopic procedure than the time currently recommended by the ASGE guidelines.
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Zarrinpar A, Kerlan RK. A guide to antibiotics for the interventional radiologist. Semin Intervent Radiol 2011; 22:69-79. [PMID: 21326676 DOI: 10.1055/s-2005-871861] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Antibiotics are among the most common pharmaceutical agents used by the interventional radiologist. This article updates some of the practical aspects of the use of antibiotics in interventional radiological practice and provides some general guidelines with respect to indications for and selection of antibiotics. In particular, the objectives of this article are to review the basic pharmacology of the common antibiotic agents, the interventional radiological procedures in which prophylactic antibiotics are usually administered, the specific antimicrobial agents recommended for prophylaxis before common interventional radiological procedures, the appropriate antibiotics for patients allergic to penicillins, and the indications for antibiotic prophylaxis to prevent bacterial endocarditis.
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Affiliation(s)
- Ali Zarrinpar
- Department of Radiology, University of California, San Francisco
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Kulvatunyou N, Joseph B, Tang A, O'Keeffe T, Wynne JL, Friese RS, Latifi R, Rhee P. Gut access in critically ill and injured patients: Where have we gone thus far? Eur Surg 2011. [DOI: 10.1007/s10353-011-0590-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
Many patients with advanced head and neck cancer are already in a poor nutritional status and need supportive nutritional therapy at the time of initial diagnosis. Malnutrition is associated with delayed recovery, prolonged hospital stay and unfavorable prognosis. By using percutaneous endoscopic gastrostomy (PEG), the social stigmatization for the patient resulting from the conspicuous nasal feeding tube is avoided. The PEG can be easily implemented at the time of diagnosis by head and neck surgeons in patients suffering from massive tumor-associated weight loss, when definitive or adjuvant radiochemotherapy is anticipated, or prior to tumor surgery likely to be followed by prolonged significant dysphagia and protracted swallowing rehabilitation. Analgesics can be administered via the PEG tube, thus simplifying adequate pain management, which plays a central role in the care of head and neck cancer patients.
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Blomberg J, Lagergren P, Martin L, Mattsson F, Lagergren J. Novel approach to antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): randomised controlled trial. BMJ 2010; 341:c3115. [PMID: 20601414 PMCID: PMC2896486 DOI: 10.1136/bmj.c3115] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate a new and simpler strategy of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG). DESIGN Single centre, two arm, randomised, controlled, double blind clinical trial. SETTING Endoscopy unit in Karolinska University Hospital, Stockholm, Sweden, between 3 June 2005 and 31 October 2009. PARTICIPANTS 234 patients with an indication for PEG who gave informed consent to participate. INTERVENTION A single 20 ml dose of the oral solution of sulfamethoxazole and trimethoprim (also known as co-trimoxazole or Bactrim; F Hoffmann-La Roche Ltd, Basel, Switzerland) deposited in the PEG catheter immediately after insertion. The control group received standard prophylaxis consisting of a single intravenous dose of 1.5 g cefuroxime (Zinacef; GlaxoSmithKline, London) administered before insertion of the PEG tube. MAIN OUTCOME MEASURE Primary outcome was the occurrence of clinically evident wound infection within 14 days after insertion of the PEG catheter. Secondary outcomes were positive bacterial culture and blood tests (highly sensitive C reactive protein and white blood cell count). All randomised patients were included in an intention to treat analysis. RESULTS Of the 234 patients included in this study, 116 were randomly assigned to co-trimoxazole and 118 to cefuroxime. At follow-up 7-14 days after insertion of the PEG catheter, wound infection was found in 10 (8.6%) patients in the co-trimoxazole group and 14 (11.9%) in the cefuroxime group, which corresponds to a percentage point difference of -3.3% (95% confidence interval -10.9% to 4.5%). The per protocol analysis, which comprised 100 patients in each group, gave similar results-10% and 13% infection in the co-trimoxazole and cefuroxime groups, respectively (percentage point difference -3.0%, 95% CI -11.8% to 5.8%). Both these analyses indicate non-inferiority of co-trimoxazole compared with cefuroxime because the upper bounds of the confidence intervals are lower than the pre-determined non-inferiority margin of 15%. Analyses of the secondary outcomes supported this finding. CONCLUSION 20 ml of co-trimoxazole solution deposited in a newly inserted PEG catheter is at least as effective as cefuroxime prophylaxis given intravenously before PEG at preventing wound infections in patients undergoing PEG. Trial registration Current Controlled Trials ISRCTN18677736.
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Affiliation(s)
- John Blomberg
- Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.
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Abstract
OBJECTIVES We sought to conduct an assessment of the practice of gastrostomy (G) tube placement across an entire city, which would reflect usual clinical care as compared with referral center practice. METHODS We reviewed and retrospectively extracted data from patient records for all percutaneous endoscopic G (PEG) and radiological percutaneous G (RPG) tube placements at six Winnipeg hospitals between 1 April 2005 and 31 March 2007. RESULTS A total of 418 patients had G tubes (376 PEG, 42 RPG) inserted during the study period. The most common indications were cerebrovascular accidents (25%), head and neck cancer (23%), and head trauma (10%). The position of the external bolster was not documented in 38% of patients. The median time to the first complication was 10 days, initiation of feeding was 48 hours, and tube removal was 40 days. Complications developed in 102 (24%) patients. Patients with RPG tubes had more infections and were less likely to receive prophylactic antibiotics (P<0.001). In multivariate analysis, complications were more likely to occur in patients with RPG tubes and after insertions by lowest procedure volume physicians. Overall mortality was 12% within 30 days of G-tube placement. Death of one patient was directly related to peritonitis after G-tube insertion. CONCLUSIONS In usual clinical practice, there is an underuse of prophylactic antibiotics and a delay in the institution of nutritional support after G-tube placement. A small but significant proportion of patients may develop major complications, with associated risk of mortality. The higher complication rate after procedures performed by lowest volume physicians needs further evaluation.
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‘How the introduction of a gastrostomy algorithm influenced the incidence of peristomal wound infection’. Proc Nutr Soc 2010. [DOI: 10.1017/s0029665109993880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Chuang CH, Hung KH, Chen JR, Chen CY, Kao AW, Chang WL, Wu JJ, Sheu BS. Airway infection predisposes to peristomal infection after percutaneous endoscopic gastrostomy with high concordance between sputum and wound isolates. J Gastrointest Surg 2010; 14:45-51. [PMID: 19816746 DOI: 10.1007/s11605-009-1058-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Accepted: 09/22/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Peristomal infection is common after percutaneous endoscopic gastrostomy. This study aims to evaluate the correlation between airway and peristomal infected pathogens. METHODS Before the procedure, sputum cultures were prospectively performed for the patients with airway symptoms. All the patients received prophylactic antibiotics. Once peristomal infection occurred, the wound cultures were obtained to analyze the antibiotic susceptibilities of the pathogens. The paired isolates, with concordance between sputum and wound cultures, were validated for their clone identity using pulsed-field gel electrophoresis. RESULTS One hundred twelve patients were enrolled, and 30 patients had peristomal infection. The 31 patients with airway pathogens had a 10-fold higher risk of peristomal infection than the other 81 without airway pathogens (95% CI, 3.85-26.4, p < 0.001). Among patients collected with paired isolates from wound and sputum, 85% had concordant microorganism species. In the paired concordant isolates, 94% had indistinguishable antibiogram, and nearly 90% were clonally identical in pulsed-field gel electrophoresis. CONCLUSIONS Patients with airway infection have an increased risk of peristomal infection after percutaneous endoscopic gastrostomy. Concerning the high concordance between infected wound and sputum isolates of such patients, the selection of appropriate prophylactic antibiotics could be individual to cover the microorganisms isolated from sputum.
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Affiliation(s)
- Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Medical Center, Tainan, Taiwan
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Hogan AM, Winter DC. Current practice in PEG placement: Pharmacologically illogical. MINIM INVASIV THER 2009; 18:369-70. [PMID: 19929301 DOI: 10.3109/13645700903381282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- A M Hogan
- Institute for Clinical Outcomes Research and Education, St. Vincent's University Hospital, Dublin, Ireland.
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Local infection after placement of percutaneous endoscopic gastrostomy tubes: a prospective study evaluating risk factors. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 22:987-91. [PMID: 19096738 DOI: 10.1155/2008/530109] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Due to its high efficacy and technical simplicity, percutaneous endoscopic gastrostomy (PEG) has gained wide-spread use. Local infection, occurring in approximately 2% to 39% of procedures, is the most common complication in the short term. Risk factors for local infection are largely unknown and therefore--apart from calculated antibiotic prophylaxis--preventive strategies have yet to be determined. OBJECTIVE To assess the potential patient- and procedure-related risk factors for peristomal infection following PEG tube placement. METHODS Potential patient-related (eg, age, sex, diseases, body mass index, concomitant antibiotic therapy) and procedure-related (endoscopist experience, institutional factors, findings on endoscopy) risk factors and their coincidence with local infection, defined as a positive peristomal infection three days after PEG tube placement, were evaluated at two institutions. A standardized antibiotic prophylaxis was not performed. The peristomal infection score was also evaluated in 390 patients. RESULTS Using a multivariate binary regression analysis, four risk factors were established as relevant for local infection after PEG: clinical institution (OR 6.69; P = 0.0001), size of PEG tubes (15 Fr versus 9 Fr; OR 2.12; P = 0.05), experience of the endoscopist (more than 100 investigations versus less than 100 investigations; OR 0.54; P = 0.05) and the existence of a malignant underlying disease (OR 2.28; P = 0.019). CONCLUSIONS Similar to other endoscopic interventions, local infection as a complication of PEG tube placement depends on the experience of the endoscopist. Institutional factors also play a significant role. Additional risk factors include PEG tube size and underlying diseases. These findings indicate that the local infection after PEG tube placement may be influenced by both endoscopy-associated factors and by the underlying disease status of the patient.
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Abstract
AIM To establish whether prophylactic systemic antimicrobials reduce the risk of peristomal infection in placement of percutaneous endoscopic gastrostomies. BACKGROUND Percutaneous endoscopic gastrostomies, placed surgically through the anterior abdominal wall, maintain nutrition in the short or long term. Those undergoing percutaneous endoscopic gastrostomy placement are often vulnerable to infection. The increasing incidence of methicillin-resistant Staphylococcus aureus contributes an additional risk to the debate surrounding antibiotic prophylaxis. The aim of antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient, during placement. DESIGN Systematic review. METHODS We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals, relevant conference proceedings and bibliographies of publications identified, and contacted manufacturers and distributors of percutaneous endoscopic gastrostomy products. Randomised controlled trials were selected evaluating the use of prophylactic antimicrobials for percutaneous endoscopic gastrostomy placement, with no restrictions for language, date or publication status. Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate. RESULTS Ten eligible randomised controlled trials were identified evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22-0.44). The relative reduction in risk of infection for those given antibiotics was 19% with the need to treat 5.8 patients to prevent one infection - NNT. CONCLUSIONS Administration of systemic prophylactic antibiotics for percutaneous endoscopic gastrostomy placement reduces peristomal infection. RELEVANCE TO CLINICAL PRACTICE The nurse's role in endoscopy is expanding rapidly and demands that practice is based on the best available evidence. This systematic review seeks to make a contribution to best practice in percutaneous endoscopic gastrostomy placement.
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Affiliation(s)
- Allyson Lipp
- Faculty of Health, Sport and Science, University of Glamorgan, Pontypridd, UK.
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Perger L, Watch L, Weinsheimer R, Fahl J, Azzie G. Laparoscopically Supervised PEG at Time of Nissen Fundoplication: A Safe Option. J Laparoendosc Adv Surg Tech A 2008; 18:136-9. [DOI: 10.1089/lap.2007.0084] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lena Perger
- Department of Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Libby Watch
- Department of Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Robert Weinsheimer
- Department of Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Jeffrey Fahl
- Department of Gastroenterology, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Georges Azzie
- Department of Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
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Crosby J, Duerksen DR. A prospective study of tube- and feeding-related complications in patients receiving long-term home enteral nutrition. JPEN J Parenter Enteral Nutr 2007; 31:274-7. [PMID: 17595434 DOI: 10.1177/0148607107031004274] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Percutaneous endoscopic gastrostomy tubes are frequently inserted to facilitate long-term enteral nutrition. There are few studies that address long-term complications related to feeding tubes. The purpose of this study is to examine the long-term complications related to tube malfunction and the effect these have on health care use. METHODS In this prospective study, 8 patients who were discharged home on long-term home enteral nutrition completed a diary that listed 17 potential complications related to enteral feeding devices. Subjects completed the diary on a weekly basis, noting which of the potential complications they were experiencing and the intervention related to that complication. RESULTS The 8 patients were followed for a mean of 10.5 months. Common tube-site complications included discharge from the tube site, red or tender stoma, and granulation tissue. Mechanical problems related to tubes plugging, breaking, and falling out were also common. Despite having a dedicated nurse and dietitian to follow these patients, unscheduled health care contacts were frequent and averaged 5.4 contacts over the mean follow-up time of 10.5 months. CONCLUSIONS In patients receiving long-term home enteral nutrition, tube and tube-feeding complications are frequent and result in significant health care use. Given the increasing use of long-term enteral nutrition, strategies and programs must be developed to assist patients and their families in managing these complications.
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Affiliation(s)
- Jason Crosby
- University of Manitoba, Winnipeg, Manitoba, Canada
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45
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Abstract
Intestinal failure refers to a condition in which inadequate digestion and/or absorption of nutrients leads to malnutrition and/or dehydration. Enteral access is occasionally used in patients with intestinal failure either for the purpose of providing nutrition or decompressing the gut. As a consequence, it is important that clinicians caring for these highly complex patients be knowledgeable in enteral access options and experienced in the subsequent care of these tubes. In this review, enteral access options and the potential complications associated with their use will be reviewed. Importantly, this information is relevant to both the pediatric and adult patient with intestinal failure.
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Affiliation(s)
- John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA.
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Tanswell I, Barrett D, Emm C, Lycett W, Charles C, Evans K, Hearing SD. Assessment by a multidisciplinary clinical nutrition team before percutaneous endoscopic gastrostomy placement reduces early postprocedure mortality. JPEN J Parenter Enteral Nutr 2007; 31:205-11. [PMID: 17463146 DOI: 10.1177/0148607107031003205] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of this study was to determine whether preassessment by a multidisciplinary nutrition team before percutaneous endoscopic gastrostomy (PEG) placement can reduce postprocedure mortality. This was a prospective single-center audit. METHODS Patients who had been referred to the Gastroenterology Department for consideration of PEG placement between 1995 and 2004 were included. In the index year, 2003-2004, where a formal nutrition team assessment was commenced, 79 patients were enrolled into our study group on a consecutive basis. These patients were subdivided into 3 groups; group A, PEG placed (51 patients); group B, PEG not placed due to severe comorbidity (19 patients); and group C, PEG not placed as deemed unnecessary (9 patients). Comparison was made with previous years where no formal preassessment had occurred. At Staffordshire General Hospital, a comparison of mortality post-PEG placement was made between the index group and previous years. Secondary measures included complication rates and frequency of biochemical monitoring. RESULTS One week post-PEG mortality fell from 10%-20% in previous years to 0% in the index year (p < .02). This improved survival extended to 3 months postprocedure (p < .016). Three patients (6%) had biochemical evidence of refeeding syndrome postplacement. Biochemical monitoring was inadequate, with only 27/51 (53%) patients being completely monitored. No complications pertaining to the endoscopy were reported. CONCLUSIONS This study demonstrates that early post-PEG mortality can be reduced by preassessment of patients by a multidisciplinary nutrition team and is evidence supporting the recommendations of the National Confidential Enquiry into Patient Outcome and Death report.
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Affiliation(s)
- I Tanswell
- Department of Gastroenterology, Staffordshire General Hospital, Stafford, United Kingdom.
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Toyama Y, Usuba T, Son K, Yoshida S, Miyake R, Ito R, Tsuboi K, Kashiwagi H, Tajiri H, Yanaga K. Successful new method of extracorporeal percutaneous endoscopic gastrostomy (E-PEG). Surg Endosc 2007; 21:2034-8. [PMID: 17404792 DOI: 10.1007/s00464-007-9270-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Revised: 12/14/2006] [Accepted: 01/08/2007] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although percutaneous endoscopic gastrostomy (PEG) has become popular for patients with swallowing disorders as a nutrition support or a decompressant of gastrointestine, perioperative complications associated with PEG have not decreased, especially peristomal infections. To reduce peristomal infections, we designed a new method of gastrostomy by extracorporeal approach under endoscopic observation, named as extra-corporeal PEG (E-PEG). METHODS Experimental studies for E-PEG were performed repeatedly using pigs under general anesthesia to confirm the safety of its procedure for human use. After approval of institutional ethics review board in our university, thirty patients with prior consent participated in this study. The operation time, the incidence rate of complications and the hospital stay were compared between E-PEG and ordinary pull-method PEG groups. RESULTS Two patients (6.7%) in E-PEG group had postoperative complications, i.e., aspiration pneumonia and surgical site infection. The operation time of E-PEG group was 5-16 (mean +/- SD: 10.3 +/- 2.96) min as compared to 14-37 (mean +/- SD: 26.9 +/- 8.39) min with pull-method PEG. The postoperative hospital day of E-PEG was within two days except for the two complicated cases. Significance differences of operation time, complication rate and postoperative hospital stay between those groups observed statistically. CONCLUSIONS These results indicate that E-PEG was safe, tolerable and speedy when compared ordinary pull-method PEG.
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Affiliation(s)
- Yoichi Toyama
- Department of Surgery, Jikei University School of Medicine, Kashiwa, Chiba, Japan.
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Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA, Galandiuk S. Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther 2007; 25:647-56. [PMID: 17311597 DOI: 10.1111/j.1365-2036.2007.03247.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite numerous guidelines recommending prophylactic antibiotics prior to percutaneous endoscopic gastrostomy, their use remains controversial. AIM To conduct a systematic literature review and performed meta-analyses to determine the benefit of antibiotic prophylaxis for percutaneous endoscopic gastrostomy placement. METHODS We performed a systematic literature review by searching healthcare databases and grey literature for randomized-controlled trials of antibiotic prophylaxis against wound infection after percutaneous endoscopic gastrostomy. Relative risks were calculated for individual trials and data pooled using fixed-effects model. Relative risk reduction, absolute risk reduction and number needed to treat were calculated and are reported with 95% confidence intervals. RESULTS Ten randomized-controlled trials met the inclusion criteria and 1059 cases were pooled. Overall findings indicated that antibiotic prophylaxis resulted in a relative risk reduction of 64% and an absolute risk reduction of 15%. Number needed to treat to prevent one wound infection was 8. Cephalosporin prophylaxis was associated with a relative risk reduction of 64%, absolute risk reduction of 10% and number needed to treat of 10, whereas penicillin-based prophylaxis was associated with a relative risk reduction of 62%, absolute risk reduction of 13% and number needed to treat of 8. CONCLUSIONS Antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy is effective in reducing the incidence of percutaneous endoscopic gastrostomy site wound infection. Based on sensitivity analyses, penicillin-based prophylaxis should be the prophylaxis of choice.
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Affiliation(s)
- N S Jafri
- Division of Internal Medicine, Department of Medicine, University of Louisville School of Medicine, Louisville, KY 40292, USA
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Abstract
BACKGROUND Percutaneous endoscopic gastrostomies (PEG) maintain nutrition in the short or long term. A PEG is a feeding tube, placed surgically through the anterior abdominal wall, which delivers a liquid diet, or medication, via a clean or sterile delivery system. Those undergoing PEG placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression and underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and also to the debate surrounding antibiotic prophylaxis for PEG placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patients serum and tissues, via a brief course of an appropriate agent, by the time of PEG placement. OBJECTIVES The review seeks to establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomies. SEARCH STRATEGY We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals relevant conference proceedings, and bibliographies of relevant publications identified by these strategies for further studies; and contacted manufacturers and distributors of PEG products. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials for PEG placement, with no restrictions for language, date or publication status. DATA COLLECTION AND ANALYSIS Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate. MAIN RESULTS We identified 10 eligible RCTs evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome, and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22 to 0.44). AUTHORS' CONCLUSIONS Administration of systemic prophylactic antibiotics for PEG placement reduces peristomal infection.
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Affiliation(s)
- A Lipp
- University of Glamorgan, School of Care Sciences, Glyntaff, Pontypridd, UK.
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Schulman AS, Sawyer RG. The safety of percutaneous endoscopic gastrostomy tube placement in patients with existing ventriculoperitoneal shunts. JPEN J Parenter Enteral Nutr 2006; 29:442-4. [PMID: 16224038 DOI: 10.1177/0148607105029006442] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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