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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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Park JW, Kim TG, Cho KB, Kim JS, Cho JW, Jeon JW, Lim SG, Kim CG, Park HJ, Kim TJ, Kim ES, Jeong SJ, Kwon YH. A Multicenter Survey of Percutaneous Endoscopic Gastrostomy in 2019 at Korean Medical Institutions. Gut Liver 2024; 18:77-84. [PMID: 38013476 PMCID: PMC10791510 DOI: 10.5009/gnl230174] [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: 05/14/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 11/29/2023] Open
Abstract
Background/Aims : This study aimed to review the indications, methods, cooperation, complications, and outcomes of percutaneous endoscopic gastrostomy (PEG). Methods : Questionnaires were sent to 200 hospitals, of which 62 returned their questionnaires, with a response rate of approximately 30%. Descriptive statistics were calculated to analyze the responses to the questionnaires. Results : In 2019, a total of 1,052 PEGs were performed in 1,017 patients at 62 hospitals. The main group who underwent PEG was older adult patients with brain disease, particularly stroke. Nutritional supply was an important purpose of the PEG procedure. "The pull method" was the most commonly used for initial PEG insertion. The complications related to PEG were mostly mild, with leakage being the most common. Patients who underwent PEG procedures were primarily educated regarding the post-procedure management and complications related to PEG. Preoperative meetings were skipped at >50% of the institutions. Regarding the cooperation between the nutrition support team (NST) and the physician performing PEG, few endoscopists answered that they cooperated with NST before and after PEG. Moreover, the rate of NST certification obtained by physicians performing PEG and the frequency of attendance at NST-related conferences were relatively low. Conclusions : This study shows a similar trend to that found in the previous PEG guidelines. However, it covers new aspects, including team-based work for PEG procedure, nutrition support, and education for patients and guardians. Therefore, each medical institution needs to select an appropriate method considering the medical environment and doctor's abilities.
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Affiliation(s)
- Jun Woo Park
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Tae Gyun Kim
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Kwang Bum Cho
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong Seok Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Jin Woong Cho
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Jung Won Jeon
- Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Chan Gyoo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Hong Jun Park
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Tae Jun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Sun Kim
- Department of Gastroenterology, Korea University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Department of Pediatric Gastroenterology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Yong Hwan Kwon
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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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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Akın M, Topaloğlu S, Özel H, Avşar FM, Akın T, Polat E, Karabulut E, Hengirmen S. Awareness and wound assesment decrease surgical site infections. Turk J Surg 2021. [DOI: 10.47717/turkjsurg.2021.5059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective: Various surveillance methods have been described for surveillance of surgical site infections (SSI). The aim of this study was to examine prac- ticality of SSI risk assessment methods (SENIC and NNIS) with a postoperative wound monitoring scale (ASEPSIS) as an outcome assessment measure and evaluation of the contribution of wound assesment to the reduction of wound infection.
Material and Methods: Patients were followed with a prospective data chart through four year. Correlation of SENIC and NNIS together with ASEPSIS were performed.
Results: During the study period, 275 SSI occurred. SSIs were determined within the 21 days-period after operations. Correlation between SENIC with ASEPSIS (rs= 0.41, p< 0.001) was found better than that for NNIS with ASEPSIS (rs= 0.37, p< 0.001). Type of operation (emergency vs. elective), body mass index, operation class and American Society of Anesthesiologists scores were found independently predictive factors for SSI. The forth year SSI rate was found to be significantly lower than the other years (p< 0.001).
Conclusion: This study indicates weak but significant correlation between preoperative risk assessment methods for SSI and ASEPSIS method. In addi- tion, surgical wound assesment and awarness of the wound infection rates, have decreased the SSI rates over the years.
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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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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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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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Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World J Gastroenterol 2014; 20:7739-7751. [PMID: 24976711 PMCID: PMC4069302 DOI: 10.3748/wjg.v20.i24.7739] [Citation(s) in RCA: 289] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 02/26/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the “pull” technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.
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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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Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26:231-54. [PMID: 23554415 DOI: 10.1128/cmr.00085-12] [Citation(s) in RCA: 288] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Flexible endoscopy is a widely used diagnostic and therapeutic procedure. Contaminated endoscopes are the medical devices frequently associated with outbreaks of health care-associated infections. Accurate reprocessing of flexible endoscopes involves cleaning and high-level disinfection followed by rinsing and drying before storage. Most contemporary flexible endoscopes cannot be heat sterilized and are designed with multiple channels, which are difficult to clean and disinfect. The ability of bacteria to form biofilms on the inner channel surfaces can contribute to failure of the decontamination process. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope and to prevent contamination and infection in patients after endoscopic procedures. This review presents an overview of the infections and cross-contaminations related to flexible gastrointestinal endoscopy and bronchoscopy and illustrates the impact of biofilm on endoscope reprocessing and postendoscopic infection.
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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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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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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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17
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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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Topaloglu S, Akin M, Avsar FM, Ozel H, Polat E, Akin T, Karabulut E, Hengirmen S. Correlation of risk and postoperative assessment methods in wound surveillance. J Surg Res 2008; 146:211-7. [PMID: 17644112 DOI: 10.1016/j.jss.2007.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Revised: 04/12/2007] [Accepted: 05/07/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Various surveillance methods have been described for surveillance of surgical site infections (SSI). The aim of this study was to examine practicality of SSI risk assessment methods (Study on the Efficacy of Nosocomial Infection Control [SENIC] and National Nosocomial Infections Surveillance [NNIS]) with a postoperative wound monitoring scale (ASEPSIS) as an outcome assessment measure. MATERIALS AND METHODS Patients were followed with a prospective data chart from January 1, 2003, to December 31, 2005. Correlation of SENIC and NNIS together with ASEPSIS were performed. RESULTS During the study period, 222 SSI occurred. SSIs were determined within the 21-d period after operations. Correlation between SENIC with ASEPSIS (r(s) = 0.47, P < 0.001) was found better than that for NNIS with ASEPSIS (r(s) = 0.41, P < 0.001). Type of operation (emergency versus elective), body mass index, operation class, and American Society of Anesthesiologists scores were found independently predictive factors for SSI. CONCLUSIONS This study indicates weak but significant correlation between preoperative risk assessment methods for SSI and ASEPSIS.
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Affiliation(s)
- Serdar Topaloglu
- First Department of Surgery, Ankara Numune Training and Research Hospital, Ankara, Turkey.
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19
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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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20
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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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21
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Thomas S, Cantrill S, Waghorn DJ, McIntyre A. The role of screening and antibiotic prophylaxis in the prevention of percutaneous gastrostomy site infection caused by methicillin-resistant Staphylococcus aureus. Aliment Pharmacol Ther 2007; 25:593-7. [PMID: 17305760 DOI: 10.1111/j.1365-2036.2006.03242.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Peristomal wound infections are common complications of percutaneous endoscopic gastrostomy (PEG), especially in hospitals where methicillin-resistant Staphylococcus aureus (MRSA) is endemic. Evidence suggests that antibiotic prophylaxis at PEG insertion may reduce infection rates. AIM To examine rates of peristomal MRSA infection before and after introduction of a screening, decontamination and antibiotic prophylaxis protocol. METHODS Retrospective case analysis detected new peristomal MRSA infections over a 33-month period. Prospectively from October 2004, patients requiring PEG were screened and, if MRSA positive, received decontamination (5 days) and prophylactic teicoplanin before insertion. Peristomal wound sites were monitored after insertion. RESULTS Peristomal MRSA infection was identified in 5/42 patients (12%) in 2002, 7/35 (20%) in 2003 and 7/24 (29%) in 2004 -- overall infection rate 19%. Of 47 patients undergoing new PEG insertions between October 2004 and August 2006 (four known MRSA and 10 identified by screening), one (2%) developed peristomal MRSA infection 14 days postprocedure. A significant reduction in MRSA peristomal infection has been demonstrated (P < 0.01). CONCLUSIONS Screening for MRSA before PEG insertion identifies MRSA colonization and subsequent decontamination and antibiotic prophylaxis reduces peristomal MRSA infection rates. Where MRSA is endemic, the risk of wound site infection may remain postprocedure unless high standards of wound care are maintained.
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Affiliation(s)
- S Thomas
- Department of Microbiology/Infection Control, Wycombe Hospital, High Wycombe, Buckinghamshire, UK
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22
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Radhakrishnan NV, Shenoy AH, Cartmill I, Sharma RK, George R, Foster DN, Quest L. Addition of local antiseptic spray to parenteral antibiotic regimen reduces the incidence of stomal infection following percutaneous endoscopic gastrostomy: A randomized controlled trial. Eur J Gastroenterol Hepatol 2006; 18:1279-84. [PMID: 17099376 DOI: 10.1097/01.meg.0000243871.48831.00] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To study the effectiveness of local antiseptic spray with or without a three-dose antibiotic regimen in the prevention of stomal infection following percutaneous endoscopic gastrostomy. METHODS Ninety-six patients were randomized into three groups: A, intravenous cefuroxime 750 mg just before the procedure followed by two further doses every 8 h; B, single application of povidone-iodine (Betadine) antiseptic spray; C, combination of A and B. The stomal site was examined at midweek and at the end of week 1 for evidence of infection using a validated scoring system. Fisher's exact test was used for analysis of primary end point, namely, stomal infection at midweek and at the end of week 1. Logistic regression models were used for secondary analysis to consider the effects of diabetes, acid suppressants, steroids, age and sex on outcome. RESULTS Group A had 34 patients, group B had 28 and group C had 34. Age, sex and indications in groups A, B and C are broadly comparable. Stomal infection was 32% in group B vs. groups A (6%) and C (9%) (P = 0.0114) at midweek, and 3% in group C vs. 32% each in groups A and B (P = 0.0013) at the end of week 1. Cumulative infections (n) at the end of week 1 were lower in group C (3) (9%) than in groups A (11) (32%) and B (12) (43%) (P = 0.003). No significant difference was observed between the three groups in terms of the number of patients who were given antibiotics for other indications (P = 0.363). By logistic regression only diabetes, but not other covariates, seems to have a significant effect on stomal infection (odds ratio, 33.34; 95% CI, 4.33-256.7). CONCLUSION A combination of cefuroxime and Betadine spray significantly reduces stomal infection following percutaneous endoscopic gastrostomy at the end of week 1. Both the antibiotic group (A) and the combined group (C) did well compared with the Betadine only group (B) at midweek.
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Affiliation(s)
- Nerukav V Radhakrishnan
- Department of Gastroenterology, Rochdale Infirmary, Pennine Acute Hospitals' NHS Trust, Rochdale, UK.
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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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24
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Abstract
PURPOSE OF REVIEW Critical to realizing increasing benefits of enteral nutrition are techniques for feeding tube placement. Feeding tubes can be placed by bedside, endoscopic, fluoroscopic, and surgical methods. This review encompasses noteworthy studies on endoscopic approaches to enteral feeding published from January 2005 to the present. RECENT FINDINGS Studies involving placement of nasoenteric feeding tubes include description of new methods for endoscopic nasoenteric feeding tube placement using a push technique with a stiffened tube, a modification of the 'drag and pull' method using a distal suture tie, and placement using an ultrathin transnasal endoscopic technique compared with fluoroscopic placement. Recent studies involving percutaneous endoscopic gastrostomy tube placement have demonstrated equivalent outcomes of endoscopic and fluoroscopic approaches, description of unsedated placement using transnasal technique, and risk of percutaneous endoscopic gastrostomy site metastasis in head and neck cancer patients. Studies on percutaneous jejunal feeding tubes demonstrate: high complication rate and short functional duration of percutaneous endoscopic gastrojejunostomy and reported outcomes of direct percutaneous endoscopic jejunostomy placement. SUMMARY Enteral nutrition access can be obtained by a variety of methods depending on local expertise and resources. Endoscopic approaches have equivalent or better outcomes than other methods; however, these methods may still have limitations and distinct complications.
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Affiliation(s)
- Kathryn R Byrne
- Division of Gastroenterology, University of Utah Health Sciences Center, School of Medicine, Salt Lake City, Utah, USA
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25
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Gencosmanoglu R. Percutaneous endoscopic gastrostomy: a safe and effective bridge for enteral nutrition in neurological or non-neurological conditions. Neurocrit Care 2006; 1:309-17. [PMID: 16174928 DOI: 10.1385/ncc:1:3:309] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly used methods for nutritional support in patients who are unable to take food orally. Traditional surgical gastrostomy, percutaneous radiologic gastrostomy, and laparoscopic gastrostomy are the alternatives. The most common indication is neurogenic dysphagia followed by obstructive causes such as head and neck tumors. Ethically justified and clinically comprehensive guidelines should be followed during the decision-making process for PEG tube placement. A limited life expectancy; technical difficulties, such as the inability to bring the anterior gastric wall in apposition to the abdominal wall; or pharyngeal/esophageal obstruction, which compromise tube insertion, peritonitis, and uncorrectable coagulopathy are absolute contraindications. The "pull method" is the first described and still the most performed technique of PEG tube placement. The procedure is simple, safe, and effective and fulfills all requirements to provide an ideal route for nutritional support. This article summarizes the reported experience on PEG in the current literature and discusses its utility in patients with neurological conditions.
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Affiliation(s)
- Rasim Gencosmanoglu
- Department of Gastrointestinal Surgery, Marmara University Institute of Gastroenterology, Istanbul, Turkey.
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26
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Maetani I, Sakai Y. REDUCING THE RISK OF PERISTOMAL INFECTION AFTER PEG PLACEMENT. Dig Endosc 2005. [DOI: 10.1111/j.1443-1661.2005.00546.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Saadeddin A, Freshwater DA, Fisher NC, Jones BJM. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy for non-malignant conditions: a double-blind prospective randomized controlled trial. Aliment Pharmacol Ther 2005; 22:565-70. [PMID: 16167973 DOI: 10.1111/j.1365-2036.2005.02578.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion has been encouraged following development of guidelines by a number of professional societies within the past few years. However, not all evidence supports routine prophylaxis, particularly in patients with 'benign' disease indications for percutaneous endoscopic gastrostomy insertion. AIM To identify whether prophylactic antibiotic usage is beneficial in patients undergoing percutaneous endoscopic gastrostomy insertion without malignant disease. METHODS Adult patients without malignant disease who were referred for percutaneous endoscopic gastrostomy insertion at our unit were assessed for participation in this prospective, double-blind, randomized controlled study. Patients were randomized to receive either placebo or 2.2 g co-amoxiclav (or 2 g cefotaxime if penicillin-allergic) at time of percutaneous endoscopic gastrostomy insertion. Clinical endpoints studies were percutaneous endoscopic gastrostomy site or systemic infection and death within 7 days of percutaneous endoscopic gastrostomy insertion. Results : Ninety-nine patients completed the study (51 antibiotics, 48 placebo). Outcomes in the antibiotic and placebo groups respectively were: percutaneous endoscopic gastrostomy site infection, 11% vs. 47% (P < 0.01); systemic infection, 16% vs. 38% (P < 0.05); and death, 8% vs. 15% (P = 0.5). CONCLUSIONS Antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion reduces both percutaneous endoscopic gastrostomy site and systemic infections in patients without malignant disease.
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Affiliation(s)
- A Saadeddin
- Department of Gastroenterology and Nutrition, Russells Hall Hospital, Dudley, West Midlands, UK
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29
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Baird R, Salasidis R. Percutaneous gastrostomy in patients with a ventriculoperitoneal shunt: case series and review. Gastrointest Endosc 2004; 59:570-4. [PMID: 15044902 DOI: 10.1016/s0016-5107(04)00004-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are few data on the safety of PEG in patients with a ventriculoperitoneal shunt. METHODS Medical records for patients seen in 3 tertiary care, university-affiliated hospitals between January 1, 1991, and January 1, 1999, were reviewed. OBSERVATIONS Six patients underwent PEG after ventriculoperitoneal shunt placement during the study period. There was no immediate complication. One patient died of pneumonia 2 months after PEG insertion. There was no instance of shunt malfunction, intra-abdominal complication, or wound infection in the study group. There was no long-term complication, with either the ventriculoperitoneal shunt or the PEG. CONCLUSIONS Although the number of cases was small, PEG placement with prophylactic administration of antibiotics appears to be safe in patients with a pre-existing ventriculoperitoneal shunt.
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Affiliation(s)
- Robert Baird
- Department of General Surgery, McGill University Health Center, Montreal, Canada
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30
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Hirota WK, Petersen K, Baron TH, Goldstein JL, Jacobson BC, Leighton JA, Mallery JS, Waring JP, Fanelli RD, Wheeler-Harbough J, Faigel DO. Guidelines for antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2003; 58:475-82. [PMID: 14520276 DOI: 10.1067/s0016-5107(03)01883-2] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.
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Affiliation(s)
- Douglas B Nelson
- Gastroenterology, Minneapolis VA Medical Center, Minnesota 55417, USA
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32
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Nelson DB. Infection control during gastrointestinal endoscopy. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2003; 141:159-67. [PMID: 12624597 DOI: 10.1067/mlc.2003.24] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Infection-control issues during gastrointestinal endoscopy, which are becoming increasingly important, can generally be divided into three major areas: (1) infectious complications resulting from a patient's own microbial flora (autologous), (2) infections transmitted from patient to patient by way of the endoscope (exogenous), and (3) infections transmitted between the patient and the health-care provider. The mean frequency of postprocedure bacteremia ranges from 0.5% for flexible sigmoidoscopy to 2.2% for colonoscopy, 4.2% for esophagogastroduodenoscopy, 8.9% for variceal ligation, 11% for endoscopic retrograde cholangiopancreatography, 15.4% for variceal sclerotherapy, and 22.8% for esophageal dilation. Although postprocedure bacteremia is not uncommon, it seldom results in infectious complications. Exogenous infections transmitted during endoscopy, which are extremely rare, generally result from failure to follow accepted guidelines for the cleaning and disinfection of gastrointestinal endoscopes, underscoring the importance of meticulous attention to endoscope reprocessing. Finally, although the risk of patient-staff transmission of infection is also rare, standard infection-control recommendations are important in protecting both patients and health-care providers.
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Affiliation(s)
- Douglas B Nelson
- Department of Gastroenterology, Minneapolis Veterans Affairs Medical Center, University of Minnesota, 55417, USA.
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33
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Scientific Surgery. Br J Surg 2003. [DOI: 10.1002/bjs.4109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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