Percutaneous endoscopic gastrostomy and the evolution of contemporary long-term enteral access

Understanding the Best Nutritional Management for Creutzfeldt-Jakob Disease Patients: A Comparison Between East Asian and Western Experiences

(1) Background: Creutzfeldt-Jakob disease (CJD) is a rare and fatal neurodegenerative disorder caused by the accumulation of an altered prion protein, which usually leads to death within one year after clinical onset. CJD patients usually present with rapid cognitive impairment associated with declines in cerebellar, motor, visual, behavioral, and swallowing functions. Moreover, CJD patients lose their ability to eat and take medications orally very early on in treatment; nevertheless, there are no specific nutritional guidelines for this disease shared worldwide. (2) Methods: This review aims to describe the nutritional outcomes of CJD patients in Western countries to compare them with those described in East Asian countries and then aims to explore the most recent trends in the nutritional management of CJD patients, including some dietary compounds that present neuroprotective effects. (3) Results: In Japan's, Taiwan's, and China's healthcare systems, CJD patients receive intensive life-sustaining treatment that prolongs their survival (i.e., artificial feeding); conversely, in Western countries, intensive life-sustaining treatments like tube feeding are not commonly provided to CJD patients. (4) Conclusions: It is difficult to pinpoint the reasons for these discrepancies around CJD palliative care supply, but it is clear that specific nutritional guidelines may directly improve the nutritional management of CJD patients and thus allow their families and caregivers to ensure the best end-of-life care for these patients.

Factors Associated With Short-Term Complications After Percutaneous Endoscopic Gastrostomy Tube Insertion: A Retrospective Cohort Study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tube placement is generally safe but is associated with a range of complications. Minor complications include infections, granuloma formation, leakage, and blockages, while major complications encompass aspiration pneumonia, hemorrhage, and more serious conditions such as necrotizing fasciitis and colonic fistula.

AIM

This study aimed to assess the rate of short-term complications within one month of endoscopic PEG insertion, focusing on their correlation with patient characteristics.

METHODOLOGY

This retrospective cohort study analyzed data from patients who underwent PEG insertion between January 2020 and December 2022. It evaluated the incidence of complications in relation to variables such as the indication for the procedure, the patient's immune status, albumin and CRP levels, and the setting of the procedure (inpatient vs. outpatient).

RESULTS

The study included 121 patients, with a mean age of 69.73 years, comprising 71 males (58.7%) and 50 females (41.3%). Neurological indications accounted for 64.5% of the cases. Notably, 67.8% of the patients were immunocompromised. Within 30 days of PEG insertion, 16.5% experienced complications, including GI bleeding (4.1%), infection at the PEG site (11.6%), and peritonitis (0.8%). Complications were significantly higher in immunocompromised patients and those with non-neurological indications. Higher serum albumin and lower CRP levels were associated with fewer complications, though the association was not statistically significant.

CONCLUSION

The study highlights that gastrostomy site infection is the most common short-term complication following PEG insertion. Immune status and the reason for PEG insertion emerged as key factors influencing the likelihood of complications.

Impact of Scoliosis Severity on Gastrostomy-Related Complications in Children

OBJECTIVES

This study aimed to determine the relationship between scoliosis and risk of developing complications in patients who underwent gastrostomy.

METHODS

Patients who underwent percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy (SG) between 2012 and 2022 were included. Leakage, discharge, granuloma, and hyperemia were considered minor complications, while visceral injury, ileus, and re-do surgery were considered major complications. The degree of scoliosis was calculated using the Cobb angle. The SG and PEG groups were compared by evaluating the complications and their correlation with scoliosis.

RESULTS

A total of 104 patients with a mean age of 5.0 ± 5.3 were included; 58% of patients were treated with SG. Patients in the SG group were younger ( P < 0.001). Minor complications were significantly more common in the PEG group ( P = 0.018). There was no difference between the groups in terms of major complications ( P = 1.000). Scoliosis was observed in 32.7% of the patients (n = 34). In the SG group, no correlation was found between the Cobb angle and the frequency of minor ( P = 0.173) or major complications ( P = 0.305). There was no significant difference between the Cobb angles of patients with and without minor complications in the PEG group ( P = 0.478); the Cobb angles of patients with major complications (75°) were significantly higher than those without (36°) ( P = 0.030).

CONCLUSION

Gastrostomy is important for weight gain and nutritional needs of children. This study showed that the risk of complications in SGs did not correlate with the degree of scoliosis and that the risk of major complications in PEGs increased in patients with a high degree of scoliosis.

Advances and challenges of gastrostomy insertion in children

When oral feeding cannot provide adequate nutritional support to children, enteral tube feeding becomes a necessity. The overall aim is to ultimately promote appropriate growth, improve the patient's quality of life and increase carer satisfaction. Nasogastric tube feeding is considered appropriate on a short-term basis. Alternatively, gastrostomy feeding offers a more convenient and safer feeding option especially as it does not require frequent replacements, and carries a lower risk of complications. Gastrostomy tube feeding should be considered when nasogastric tube feeding is required for more than 2-3 wk as per the ESPEN guidelines on artificial enteral nutrition. Several techniques can be used to insert gastrostomies in children including endoscopic, image guided and surgical gastrostomy insertion whether open or laparoscopic. Each technique has its own advantages and disadvantages. The timing of gastrostomy insertion, device choice and method of insertion is dependent on the local expertise, patient requirements and family preference, and should be individualized with a multidisciplinary team approach. We aim to review gastrostomy insertion in children including indications, contraindications, history of gastrostomy, insertion techniques and complications.

Biochemical and Microbiological Aspects of the Oral Cavity of Children and Young People with Neurological Impairment and Oropharyngeal Dysphagia

The components and the salivary flow have a direct influence on the composition of the oral microbiota of children and young people with oropharyngeal dysphagia, and studies have already demonstrated the excessive accumulation of supragingival dental calculus in individuals with enteral nutrition. This study aimed to compare the oral hygiene, biochemical, and microbiological aspects of the oral cavity of children and young people with neurological impairment and oropharyngeal dysphagia. Forty children and young people with neurological impairment and oropharyngeal dysphagia were enrolled and divided into two groups: group I, encompassing 20 participants fed via gastrostomy; and group II, encompassing 20 participants fed via the oral route. Oral hygiene and salivary pH and flow were assessed, and a polymerase chain reaction was performed to evaluate the messenger RNA expressions of Porphyromonas gingivalis, Tanerella forsythia, and Treponema denticola. In groups I and II, the mean Oral Hygiene Index-Simplified scores were 4 and 2, respectively, showing a significant difference; the mean Calculus Index scores were 2 and 0, respectively, showing a significant difference; and the mean pH was 7.5 and 6.0, respectively, showing a significant difference. Bacterial analysis indicated no association between the two groups. It can be concluded that children and young people who use gastrostomy had a poorer oral hygiene, greater dental calculus deposition, and higher salivary pH. The saliva of patients in both groups contained Porphyromonas gingivalis, Tanerella forsythia, and Treponema denticola.

Technology-Dependent Children

There are a growing number of medically complex children with implanted devices. Emergency physicians with a basic knowledge of these devices can troubleshoot and fix many of the issues that may arise. Recognition of malfunction of these devices can reduce morbidity and mortality among this special population. In this article, we review common issues that may arise in children with gastrostomy tubes, central nervous system shunts, cochlear implants, and vagal nerve stimulators.

Endoscopic Enteral Access

Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed.

Early versus Delayed Feeding after Percutaneous Endoscopic Gastrostomy Placement in Children: A Meta-Analysis

Early feeding after percutaneous endoscopic gastrostomy (PEG) placement is an accepted practice in the treatment of adult patients and the knowledge is clinically extrapolated in the treatment of children. To verify this treatment in children-as there are some specific features of PEG-related practices in children-the present study aimed to review meta-analyses of early feeding (within 4 h) after PEG placement in children. We searched the PubMed database for articles published until July 2020. A quality assessment was performed using the Grading of Recommendations, Assessment, Development, and Evaluation method. Three randomized controlled trials (208 patients) were eligible for inclusion. No patients died within 72 h. Early feeding resulted in little to no difference in the length of hospital stay (mean difference [MD] -7.47, 95% confidence interval [CI] -25.16 to 10.21; I2 = 95%) and vomiting events (risk ratio 0.84, 95% CI 0.55 to 1.31; I2 = 0%). In a subgroup analysis, early feeding without antibiotics reduced the length of hospital stay in one study (MD -21.60, 95% CI -22.86 to -20.34) but early feeding with antibiotics did not affect the length in two studies (MD 0.28, 95% CI -6.49 to 7.06; I2 = 0%). Overall, the certainty of the evidence was not very high. In summary, early feeding after PEG placement may be a safe alternative to delayed feeding in children. The findings in children seemed similar to those in adults, while there is a need for further studies that specifically investigate PEG placement-related practices in children.

Post cricoid tumours; a limiting factor for percutaneous endoscopic gastrostomy insertion in cancer patients: Results from a tertiary care hospital

BACKGROUND AND STUDY AIMS

The aim of this study was to review all episodes of PEG insertion in patients with head and neck cancer (HNC) at a cancer specialist centre.

PATIENTS AND METHODS

Using a structured data extraction form, we abstracted patients' demographic data and clinical information including the primary site of tumour, TNM staging, whether PEG tube was inserted successfully, any complications resulting from PEG tube insertion and duration the tube was in place.

RESULTS

We identified a total of 339 HNC patients who had received at least one attempted PEG tube insertion. The mean age of patients was 49.5 ± 14.5 years and 66% (n: 233/339) were males. 151/ 339 (44.5%) patients had a tumour in the pharynx and nasopharynx, 103/ 339 (30.4%) in oral cavity, 81/ 339 (23.9%) in post-cricoid region and 4 (1.1%) of the patients had a laryngeal carcinoma. Histopathologically, most tumours (75.8%) were squamous cell carcinoma presenting at a T4 (52.6%), N0 (38.3%) and M0 (91.7%) stage. PEG tube was successfully inserted in 303/339 (89.4%) patients. There were 36 PEG failures; 24 (66.6%) in postcricoid and laryngeal tumours, 8 (22.3%) in pharynx/nasopharynx and 4 (11.1%) in oral cavity tumours. Of the 81 patients with post-cricoid tumour, PEG tube was successfully inserted in 57/ 81 (70.3%) of the patients. Age, gender or T stage of the tumour was not found to be statistically significant predictors of PEG failure. The only significant factor was presence of post-cricoid or laryngeal tumours that increased the risk of PEG failure 12 times (95% confidence interval: 3.4 to 42.3).

CONCLUSION

PEG tube should be used as a first line feeding option in patients with all type of head and neck cancers, however, the attending clinicians should have this foresight of higher failure rates in patients with post-cricoid tumour.

Insights into paediatric tube feeding dependence: A Speech-language pathology perspective

Purpose: To explore possible factors contributing to paediatric tube feeding dependency from the speech-language pathology perspective. Tube feeding dependency can have serious repercussions for children and their families with failed or slow weaning/transitioning from tube to oral feeding, more likely after the age of five.Method: A mixed methods approach was conducted. During the first quantitative phase, an online national survey of speech-language pathologists (SLPs) from the health and non-health sectors was carried out followed by interviews with a subset of the respondents. Forty-three SLPs completed the survey. In the second qualitative phase, 10 participants from the survey were interviewed in depth as to their opinions about why tube dependency occurs. Survey data from phase one were analysed using descriptive statistics and chi square comparisons. Interview data were categorised using thematic analysis. Findings from both methodologies were combined to report the results.Result: Two interlinking meta-themes were identified from the combined data sets. These were: (1) Medicalisation of tube fed children in infancy as a root cause of tube feeding dependency and (2) Fragmentation of the tube fed child's continuity of care. The specific results indicated several possible reasons for tube feeding dependency including medical emphasis on weight gain, prolonged nasogastric tube feeding and waiting too long for transition from tube to oral feeding. A lack of integrated care and clinician confidence in non-health settings also appeared to be a factor contributing to tube feeding dependency.Conclusion: Early and ongoing biomedical focus on weight gain affected long-term goals for transitioning leading, subsequently, to tube feeding becoming normalised by school age.

Gastrointestinal feeding access - From idea to application

In this Festschrift communication, the author of two novel approaches to long-term enteral access: the gastrostomy without laparotomy (Percutaneous Endoscopic Gastrostomy or PEG) and the skin-level feeding device (Gastrostomy "Button"), relates the history of these innovations, describes the initial and extended applications, and comments on the implications of these developments.

Comparison of the Laparoscopic and Open Methods of Gastrostomy at Neonates and Infants Up To Three Months of Age

Background: An open surgical intervention is a common approach for gastrostomy tube placement in neonates and infants. Also available, however less often used, is a laparoscopic technique for low-profile gastrostomy tube (button) placement. In this study we compare the pre-, intra-, and post-procedural outcomes of each technique. Methods: We retrospectively evaluated all open and laparoscopically inserted gastrostomies at our department from January 2002 to December 2016 and compared them in terms of operative parameters and outcomes. Results: In the study interval, 44 open and 90 laparoscopically placed low-profile (button) gastrostomies were performed. There were no significant differences in gender distribution, mean age (42.54 versus 34.16 days), and mean weight (3311 versus 3476 g). The frequency of concomitant Nissen fundoplication was higher in the laparoscopy group (18% versus 47%; P < .05). The duration of G-tube placement by laparotomy was significantly longer (mean difference 16 minutes), than by laparoscopy, as were time periods between G-tube insertion and the onset of first feeding (mean differences 8.4 and 19.6 hours, respectively). Children in the laparoscopy group spent nearly 15 fewer days in the hospital than those who received a G-tube by laparotomy (29.0 versus 13.9; P < .05). Major complications were observed in 3 (6.82%) patients in the laparotomy group in the form of gastric content leak into the abdominal cavity and resulting peritonitis; complications were lower in the laparoscopy group (68.18% versus 13.33%; P = .03). Conclusions: Compared with open gastrostomy, the laparoscopic approach appears to be advantageous with respect to procedural duration, initiation of feedings, hospitalization duration, and rate of complications. Another difference was the frequency of concomitant Nissen fundoplication. Further prospective studies may determine the role of these patient-specific factors regarding who benefits most from the laparoscopic technique.

Fluoroscopy-guided jejunal extension tube placement through existing gastrostomy tubes: analysis of 391 procedures

PURPOSE

We aimed to evaluate the safety and efficacy of fluoroscopically placed jejunal extension tubes (J-arm) in patients with existing gastrostomy tubes.

METHODS

We conducted a retrospective review of 391 J-arm placements performed in 174 patients. Indications for jejunal nutrition were aspiration risk (35%), pancreatitis (17%), gastroparesis (13%), gastric outlet obstruction (12%), and other (23%). Technical success, complications, malfunctions, and patency were assessed. Percutaneous gastrostomy (PEG) tube location, J-arm course, and fluoroscopy time were correlated with success/failure. Failure was defined as inability to exit the stomach. Procedure-related complications were defined as adverse events related to tube placement occurring within seven days. Tube malfunctions and aspiration events were recorded and assessed.

RESULTS

Technical success was achieved in 91.9% (95% CI, 86.7%-95.2%) of new tubes versus 94.2% (95% CI, 86.7%-95.2%) of replacements (P = 0.373). Periprocedural complications occurred in three patients (0.8%). Malfunctions occurred in 197 patients (50%). Median tube patency was 103 days (95% CI, 71-134 days). No association was found between successful J-arm placement and gastric PEG tube position (P = 0.677), indication for jejunal nutrition (P = 0.349), J-arm trajectory in the stomach and incidence of malfunction (P = 0.365), risk of tube migration and PEG tube position (P = 0.173), or J-arm length (P = 0.987). A fluoroscopy time of 21.3 min was identified as a threshold for failure. Malfunctions occurred more often in tubes replaced after 90 days than in tubes replaced before 90 days (P < 0.001). A total of 42 aspiration events occurred (OR 6.4, P < 0.001, compared with nonmalfunctioning tubes).

CONCLUSION

Fluoroscopy-guided J-arm placement is safe for patients requiring jejunal nutrition. Tubes indwelling for longer than 90 days have higher rates of malfunction and aspiration.

Trends in the use of gastrostomies at a tertiary paediatric referral centre

OBJECTIVES

The aims of this study were to describe the population of paediatric patients undergoing gastrostomy placement at a Norwegian tertiary referral centre and to investigate trends over time in patient characteristics and operative technique.

MATERIALS AND METHODS

Patients <15 years of age getting a primary gastrostomy from 1994 to 2012 were included in this retrospective observational study. Patient data were collected from medical records and the National Registry.

RESULTS

Six-hundred forty-nine patients with a median age of 1.2 years [gestational week 30-14.9 years] were included. Neurological disorders (ND) was the most common underlying group of diagnosis (n = 311, 48%), followed by cardiac disease 104 (16%), congenital anomalies 85 (13%), respiratory disease 43 (7%), malignancy 29 (5%), and others 77 (12%). At follow-up, 162 (25%) patients were dead. A percutaneous endoscopic technique (PEG) was used in 401 (62%) patients, open surgery (OPEN) in 201 (31%) and laparoscopy (LAP) in 47 (7%). The number of gastrostomies per year more than doubled during the period (p < 0.001). More patients with cardiac disease and congenital anomalies were given a gastrostomy during the last years (all p < 0.05), whereas the number of patients with ND remained stable. Furthermore, there has been a decrease in median age and an increase in the number of PEG and LAP (p < 0.05).

CONCLUSION

The number of gastrostomy insertions has increased from 1994 to 2012. NDs is the most common underlying diagnosis in patients receiving a gastrostomy, PEG is the most common technique and patient characteristics have changed during the study period.

Guidelines for the diagnosis, treatment and clinical monitoring of patients with juvenile and adult Pompe disease

ABSTRACT Pompe disease (PD) is a potentially lethal illness involving irreversible muscle damage resulting from glycogen storage in muscle fiber and activation of autophagic pathways. A promising therapeutic perspective for PD is enzyme replacement therapy (ERT) with the human recombinant enzyme acid alpha-glucosidase (Myozyme®). The need to organize a diagnostic flowchart, systematize clinical follow-up, and establish new therapeutic recommendations has become vital, as ERT ensures greater patient longevity. A task force of experienced clinicians outlined a protocol for diagnosis, monitoring, treatment, genetic counseling, and rehabilitation for PD patients. The study was conducted under the coordination of REBREPOM, the Brazilian Network for Studies of PD. The meeting of these experts took place in October 2013, at L’Hotel Port Bay in São Paulo, Brazil. In August 2014, the text was reassessed and updated. Given the rarity of PD and limited high-impact publications, experts submitted their views.

Comparison of Two Laparoscopic Techniques for Gastropexy in Children

BACKGROUND

Laparoscopic gastrostomy is a widely used interventional procedure in pediatric surgery. We report comparative data for two endosurgical methods for the fixation of the stomach against the abdominal wall, using the U-stitches technique and the Saf-T-Pexy® (Halyard Health Inc., Alpharetta, GA) system.

MATERIALS AND METHODS

Within the period from January 2012 to June 2014 we performed 24 operations involving laparoscopic placement of a gastrostomy tube using U-stitches (Group I) and 24 operations using the Saf-T-Pexy system (Group II). The two groups of patients were compared in terms of demographics and intraoperative and postoperative results.

RESULTS

No statistical difference (P > .05) was found while comparing the patients' demographics and intra- and postoperative results. The mean duration of the surgical procedure in Group I was 23.75 minutes; in contrast, the mean duration of surgery in Group II was 22.71 minutes (P > .05). The time to first feeding (9.96 hours versus 10.63 hours) and time to full enteral feeding (23.13 hours versus 24.5 hours) were consistent for patients from both groups (P > .05). A similar postoperative duration of stay was recorded for the patients from the comparison groups (7.25 days versus 7.21 days; P > .05). Statistical analysis of the two groups demonstrated a significant difference in the parameters of minor postoperative complications (41.67% versus 8.33%; P < .05).

CONCLUSIONS

Use of the Saf-T-Pexy system is a simple and efficient method for gastropexy involving placement of gastrostomy tubes that significantly reduces the number of postoperative complications.

Feasibility and results of pull-percutaneous endoscopic gastrostomy for enteral nutrition in adults with severe cerebral palsy

BACKGROUND & AIMS

Eating and swallowing impairments often get worse as patients with severe cerebral palsy (CP) get older, creating increased demand for percutaneous endoscopic gastrostomy (PEG) tube placement. Here we investigated the feasibility, safety, adverse events (AEs) and outcomes of PEG in adult CP.

METHODS

We performed a retrospective study of 26 consecutive severe adult (age: 28 [19-48] yrs) CP patients who underwent pull-PEG tube placement under general anesthesia between 2005 and 2012 (median follow-up: 23 [6-64] months) at the same tertiary hospital centre.

RESULTS

The procedure was a technical success for 19 patients (BMI: 13.8 [10.7-21.4]) with (n = 11) or without (n = 8) previous respiratory disorder. Indications were mainly swallowing disorders (n = 14) and inadequate oral intake (n = 8). Early AEs were 7 transient oxygen needs, 3 local wound infections and 2 transient ileus. Long-term AEs were 9 non-severe gastrostomy incidents. There was no significant improvement in neurological status but respiratory function was improved in 6 patients and enteral nutrition enabled a significant median weight gain of 4.2 [1-8.8] kg (P < 0.01). Quality-of-life assessed by relatives and the healthcare team was improved in 13/16 and 13/15 cases respectively. AEs and outcomes did not differ significantly with previous respiratory disorder or nutritional status.

CONCLUSIONS

PEG tube placement is feasible in adult CP, although the risk of failure is increased by anatomical specificities. Previous respiratory disorders and undernourishment did not increase AE rates or modify outcomes. There were positive changes over time for nutritional status and perceived quality-of-life, but no neurological improvement.

[Button gastrostomy in children]

For the period January 2002 to December 2013 it was performed 84 interventions for introduction of gastrostomy tube. The first group included 24 open operations and the second group had 60 laparoscopic operations by using of button devices MIC-KEY (Kimberly-Clark, Roswell, USA) in neonates and infants. Statistically significant difference was not observed during comparison of demographic data of patients. Differences in groups were found in statistical analysis of intra- and postoperative parameters (p<0.05). Mean duration of surgery in the first group was 37.29 min, in the second group - 23.97 min. Time to start of feeding and transition to complete enteral nutrition was less in patients who underwent laparoscopic surgery than after open intervention (10.5 and 19.13 hours, 23.79 and 35.88 hours respectively; p<0.05). It was revealed augmentation of hospital stay in the 1st group in comparison with the 2(nd) group (11.71 and 7.09 days respectively; p<0.05). Frequency of postoperative complications was 18.33% in the 2(nd) group and 24% - in the 1st group (p<0.05). The authors consider that button devices are simply and effective technique of gastrostomy establishment in children. It is associated with minimal surgery duration and allows to start early enteral nutrition in comparison with open techniques.

National trends and outcomes of pediatric gastrostomy tube placement

OBJECTIVES

National outcomes data regarding surgical gastrostomy tube (G-tube) and percutaneous endoscopic gastrostomy (PEG) tube procedures are lacking. Our objectives were to describe trends in G-tube and PEG procedures, examine regional variation, and compare outcomes.

METHODS

This was a retrospective study using pediatric admissions during 1997, 2000, 2003, 2006, and 2009 from the Kids' Inpatient Database. Length of stay and cost were adjusted for demographics, complexity, setting, year, and infection or surgical complication.

RESULTS

G-tubes were placed during 64,412 admissions, increasing from 16.6 procedures/100,000 US children in 1997 to 18.5 in 2009. Surgical gastrostomy rates increased by 19% (0.17 procedures/100,000/year, P < 0.002) and, among children <1 year, they increased by 32% (2.56 procedures/100,000/year, P < 0.01). PEG rates did not increase (0.02 procedures/100,000/year, P = 0.47) in the study years. The West had an 18% higher rate than the national average for surgical G-tubes and a 10% higher rate for PEGs. When the sole procedure during the admission was gastrostomy, the G-tube was associated with a 19% (confidence interval 9.7-57.5) longer length of stay, and a 25% higher cost (confidence interval 16.4-34.5) compared with PEG.

CONCLUSIONS

Surgical gastrostomy insertion rates have increased whereas PEG rates have not, despite evidence of better severity-adjusted outcome measures for PEG tubes. Surgical gastrostomy insertion in children <1 year of age yielded the greatest increase, which may relate to a changing patient population; however, regional variation suggests that provider preference also plays a role. Our data underline the need for more robust collection and analysis of surgical outcomes to guide decision making.

Gastroenteric tube feeding: techniques, problems and solutions

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.

Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy

AIM: To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy (PEG) could be a valuable option for patients with complicated anatomy.

METHODS: A retrospective analysis of twelve patients (seven females, five males; six children, six young adults; mean age 19.2 years) with cerebral palsy, spastic quadriparesis, severe kyphoscoliosis and interposed organs and who required enteral nutrition (EN) due to starvation was performed. For all patients, standard PEG placement was impossible due to distorted anatomy. All the patients qualified for the laparoscopy-assisted PEG procedure.

RESULTS: In all twelve patients, the laparoscopy-assisted PEG was successful, and EN was introduced four to six hours after the PEG placement. There were no complications in the perioperative period, either technical or metabolic. All the patients were discharged from the hospital and were then effectively fed using bolus methods.

CONCLUSION: Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.

A simple method for percutaneous endoscopic gastrostomy tube removal: "tie and retrograde pull"

BACKGROUND/PURPOSE

Various techniques have been presented to remove the percutaneous endoscopically placed gastrostomy tube in children, but tubes with semi-rigid internal retaining discs are difficult or impossible to remove by external traction. We describe a simple and effective endoscopic removal technique that should be applicable to any type of percutaneous endoscopic gastrostomy tube.

METHODS

Percutaneous endoscopic gastrostomy tube removal was performed with the "tie and retrograde pull" technique. After a polypropylene suture was placed and tied 1cm over the skin level, the percutaneous endoscopic gastrostomy tube was cut 0.5 cm over the knot. The suture was cut from the connection point between the needle and the suture. The distal end of the suture was pushed through the stoma into the stomach. Then a forceps was inserted through the gastroscope. The suture was caught, and the residual percutaneous endoscopic gastrostomy portion was retrieved via retrograde traction on the suture.

RESULTS

The causes of exchange were determined to be planned tube replacement in 9, buried bumper syndrome in 1, and tube occlusion in 3 patients. The mean tube dwell time was 10.8 ± 3.9 months. Esophageal mucosal tear developed in 1 patient with epidermolysis bullosa during removal. No other complications occurred during PEG tube exchanges.

CONCLUSION

This is a rapid and useful technique that does not require any complex endoscopic devices.

Peristomal infection after percutaneous endoscopic gastrostomy: a 7-year surveillance of 297 patients

CONTEXT

Healthcare-associated infection represents the most frequent adverse event during care delivery. Medical advances like percutaneous endoscopic gastrostomy have brought improvement on quality of life to patients but an increased risk of healthcare-associated infection. Predictive risk factors for peristomal wound infection are largely unknown but evidence suggests that antibiotic prophylaxis and preventive strategies related to infection control may reduce infection rates.

OBJECTIVES

The primary aim was to evaluate the global prevalence rate of peristomal infection. Secondary objectives were to characterise the positive culture results, to evaluate the prophylactic antibiotic protocol and to identify potential risk factors for peristomal infection.

METHODS

Retrospective study of 297 patients with percutaneous endoscopic gastrostomy performed at a general hospital between January 2004 and September 2010. Patients received prophylactic cefazolin before the endoscopic gastrostomy procedure. Medical records were reviewed for demographic data, underling disease conditions to percutaneous endoscopic gastrostomy and patient potential intrinsic risk factors. Statistical analysis was made with the statistical program SPSS 17.0.

RESULTS

A total of 297 percutaneous endoscopic gastrostomy tubes were inserted. Wound infection occurred in 36 patients (12.1%). Staphylococcus aureus methicillin resistant was the most frequently isolated microorganism (33.3%) followed by Pseudomonas aeruginosa (30.6%). The incidence rate had been rising each year and differ from 4.65% in 2004/2007 to 17.9% in 2008/2010. This finding was consistent with the increasing of prevalence global infection rates of the hospital. Most of the infections (55.6%) were detected in the first 10 days post procedure. There was no significant difference in age, body mass index values, mean survival time and duration of percutaneous endoscopic gastrostomy feeding between patients with and without periostomal infection. Institutional factors, namely global prevalence infection rates and the endemic character of Staphylococcus aureus methicillin resistant, play an important role in peristomal infection rates. Traditional antibiotic prophylaxis with cefazolin is not adequate due to the prevalence of resistant organisms.

CONCLUSIONS

Peristomal infection is a frequent problem with clinical impact in percutaneous endoscopic gastrostomy patients and should be considered a healthcare associated infection. The antimicrobial prophylaxis regimens using cephalosporins are not adequate and need to be reviewed due to the high prevalence of Staphylococcus aureus methicillin resistant and other resistant organisms in hospitals and nursing homes.

[Aspiration pneumonia after spinal cord injury. Placement of PEG tubes as effective prevention]

BACKGROUND

Pulmonary infections are dreaded complications in acute spinal cord injuries. The prevention of pneumonia is essential for reducing mortality and the period of hospitalization. Swallowing disorders occur frequently in patients with cervical cord injuries and are accompanied by aspiration with a high risk of pneumonia.

PATIENTS AND METHODS

In this study the identification and analysis of patients with newly acquired cervical cord injuries were carried out with respect to respiratory complications, treatment and prevention.

RESULTS

A total of 27 patients with a cervical cord injury (tetraplegia) were identified. Of these 20 patients (74%) were identified with a swallowing disorder and a high risk of aspiration. Of these patients 11 (PEG group) received a percutaneous feeding tube (PEG tube), 9 patients (non-PEG group) with diagnosed dysphagia were treated without PEG tube. A total of 6 patients in the non-PEG group (67%) acquired pneumonia compared to 3 patients (27%) in the PEG group.

CONCLUSION

A swallowing disorder is a major risk factor for a pulmonary infection after a cervical cord injury. An early placement of a PEG tube has a preventive effect with respect to aspiration pneumonia in patients with dysphagia.

Abdominal plain film before gastrostomy tube placement to predict success of percutaneous endoscopic procedure

OBJECTIVES

Percutaneous endoscopic gastrostomy (PEG) tube feeding is a convenient method for children requiring long-term enteral nutrition. Preoperative fitness of the majority of pediatric PEG candidates is graded as American Society of Anesthesiologists physical status ≥ III, indicating increased risk for peri- and postoperative morbidity. The success rate of endoscopic insertion is high, but variations in the anatomy may lead to failure of PEG placement and repeated exposure to anesthesia for surgical gastrostomy. We evaluated the efficiency of using abdominal plain film with gastric insufflation in the preparatory phase to predict a successful PEG insertion and avoid rescheduling.

METHODS

A single-center cohort of candidates for PEG underwent abdominal plain film with gastric insufflation in the preparatory phase before tube insertion. The x-ray film was considered normal when the stomach projected distal to the costal margin. Primary endpoint was the success rate of PEG insertion. Multivariate logistic regression analysis was used to identify factors associated with PEG insertion failure.

RESULTS

A total of 303 candidates for PEG underwent abdominal plain film (age range 0.3-18.1 years). PEG tube insertion succeeded in 287 cases (95%). In case of an abnormal abdominal film, the probability of successful PEG insertion dropped to 67% (95% confidence interval 46%-87%). In a multivariate logistic regression model, significant predictors for PEG insertion failure were spinal deformities (odds ratio [OR] 12.1), previous abdominal surgery (OR 8.5), neurological impairment (OR 4.1), and abnormal plain abdominal film (OR 10.3).

CONCLUSIONS

Assessment of the gastric anatomy by abdominal plain film in PEG candidates with spinal deformities, previous abdominal surgery, or neurological impairment may help to identify children with a high likelihood of PEG insertion failure. This strategy enables the endoscopist to notify the surgeon in advance for a potential conversion and avoids repeated exposure to anesthesia.

Tolerance and efficacy of preventive gastrostomy feeding in pediatric oncology

BACKGROUND

Malnutrition in pediatric oncology remains underestimated, although having a negative impact on outcome. Enteral nutrition (EN) using percutaneous endoscopic gastrostomy (PEG) may prevent or reverse malnutrition consequences. We aimed to evaluate both efficacy and safety of early EN during tumors treatment in children.

PROCEDURES

Medical records of pediatric patients having a PEG tube inserted between 1995 and 2009 were retrospectively reviewed. We compared type and incidence of complications in Group 1, including 74 patients suffering from cancer, and control Group 2, including 57 patients with neurological impairment. Efficacy of EN was evaluated through nutritional parameters [Z-scores weight for height (W/H) and height for age (H/A)], post-operative complications and relapse rates. Statistical significance was set for P < 0.05.

RESULTS

PEG tolerance was similar in both groups, as shown by comparable complication rates (62% vs. 76%, NS). EN allowed improvement or stabilization of Z-score W/H in 76% of oncologic patients. The final height loss was lower (-0.5 vs. -1.2 SD of Z-scores H/A) when EN was started at the beginning of the oncologic treatment. In bone tumors, EN prevented weight loss during chemotherapy, and tended to lessen surgical complications, relapses and deaths.

CONCLUSIONS

Early gastrostomy feeding represents a relatively safe way to prevent malnutrition in children with cancer, and might play a role in bone tumors oncological outcome. Further prospective studies are needed to confirm these results and assess the impact of EN and PEG on quality of life.

Patients' perspectives of living with a percutaneous endoscopic gastrostomy (PEG)

BACKGROUND

Since enteral nutrition therapy is the preferred nutritional support for dysphagic patients with a range of diagnoses, PEG has become part of traditional care. However, enteral nutrition with PEG transfers treatment responsibility and activity to the patients and their carers, so the advantages should be discussed. The aim of this study was therefore to investigate patients' experience of living with a percutaneous endoscopic gastrostomy (PEG) in order to increase the understanding of patients' need for support.

METHOD

In a prospective study at Karolinska University Hospital in Sweden, data were collected consecutively at the time of PEG and two months later using a study-specific questionnaire about each patient's experience of living with a PEG. Fishers exact test was used to test for statistically significant difference at five per cent level.

RESULTS

There were 104 responders (response rate of 70%). Women felt more limited in daily activity compared to men (p = 0.004). Older patients experienced a more limited ability to influence the number of feeding times compared to younger (p = 0.026). Highly educated patients found feeding more time-consuming (p = 0.004). Patients with a cancer diagnosis reported that the PEG feeding interfered with their oral feeding more than patients with a neurological disease (p = 0.009). Patients mostly contacted the PEG outpatient clinic with problems regarding their PEG, and were mainly assisted by their spouse rather than district nurses.

CONCLUSIONS

PEG feeding is time-consuming and interferes with daily life. Although 73% was satisfied, patients' experiences of living with a PEG may be dependent on age, sex, education and diagnosis. Spouses are the main carers for PEG patients at home, and patients prefer to go to the PEG outpatient clinic for help if problems occur.

Laparoscopy-assisted percutaneous endoscopic gastrostomy using a "Funada-kit II" device

We aimed at assessing the effect of using a "Funada-kit II" device during laparoscopy-assisted percutaneous endoscopic gastrostomy (Lap-PEG), by reviewing 29 cases of Lap-PEG we performed from 2001 to 2011. We started using the "Funada-kit II" (CREATE MEDIC CO., Kanagawa, Japan) device with two parallel needles to puncture the stomach and assist suturing the anterior gastric wall to the anterior abdominal wall during Lap-PEG in 2011 (F-PEG). By introducing a loop through the lumen of one needle which allows placement of a suture introduced through the lumen of the other needle. Once repeated, the stomach can be pexied at two points, approximately 2 cm apart. We compared Lap-PEG (n = 23) with F-PEG (n = 6) where the mean ages and weights at surgery and sex ratios were similar. All cases were uneventful without intraoperative complications, although one postoperative wound infection occurred in a Lap-PEG case. There were no differences in the duration of analgesia, time taken to commence tube feeding, and return to full feeding. However, mean operating time was significantly shorter in F-PEG (28.1 min) versus Lap-PEG (46.1 min) p < 0.05. As per results F-PEG would appear to be as safe as Lap-PEG, but much quicker.

Indications, complications and long-term follow-up of patients undergoing percutaneous endoscopic gastrostomy: A retrospective study

INTRODUCTION

Gastroenterology units have faced a major increase in referrals for PEG insertion over the last decade. For this reason we decided to review our PEG insertion procedures with regard to indications, complications and follow-up.

MATERIALS AND METHODS

The indications, success of procedure, complications, long-term results of PEG in patients of Gulhane Military Medical Academy, Haydarpasa Training Hospital between October 2002 and April 2009 were retrospectively evaluated.

RESULTS

81 patients had undergone PEG insertion and follow-up information has been available for 77 patients. 40 were men with the mean age of all patients 70.74 ± 20.82 (range 20 to 104 years). PEG was successfully placed in all patients except in one patient who had gastric bleeding during the procedure. There was only one mortality related with the placement procedure. The most common indication for PEG was neurologic disorders in 71 (92%) patients. Other indications were head and neck cancers in 6 (8%) patients. Median follow-up period was 12 months (range, 3 days to 78 months). PEG related complications were seen in only 14 patients (18.2%) in 16 events with a total complication rate as 21%.

CONCLUSIONS

PEG placement is a safe procedure and well-tolerated with a low mortality and complication rate even in older patients who have multiple co-morbidities under adequate precautions.

Gastrostomy tube insertion in children: the Edmonton experience

BACKGROUND

Although gastrostomy tube insertion - whether endoscopic or open - is generally safe, procedure-related complications have been reported.

OBJECTIVE

To compare gastrostomy tube insertion-related complications between percutaneous endoscopic gastrostomy and open gastrostomy at a single pediatric centre.

METHODS

The charts of children (younger than 17 years of age at the time of tube insertion) who underwent endoscopic or open gastrostomy tube insertion from January 2005 to December 2007 at the Stollery Children's Hospital (Edmonton, Alberta) were examined.

RESULTS

A total of 298 children underwent gastrostomy tube insertion over a period of three years. After excluding patients with incomplete charts, 160 children (91 boys, mean [± SD] age 3.18 ± 4.73 years) were included. Eighty-five children (mean age 4.50 ± 5.40 years) had their gastrostomy tube inserted endoscopically, while the remaining 75 (mean age 1.68 ± 3.27 years; P<0.001) underwent an open procedure. The overall rate of major complications was 10.2% for the endoscopic technique and 8.6% for the open technique (P=0.1). Major infections were higher in the endoscopic technique group, while persistent gastrocutaneous fistulas after tube removal were more common in the open technique group.

CONCLUSION

Although the rate of major complications was similar between the endoscopic and open tube insertion groups, major infections were more common among children who underwent endoscopic gastrostomy. The decision for gastrostomy tube insertion was primarily based on clinical background.

Outcomes of percutaneous endoscopic gastrostomy in children

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe and minimally invasive surgical method for providing enteral access in children. In pediatrics, the indications for PEG placement frequently include malnutrition or failure to thrive, as well as oropharyngeal dysphagia, especially in children with neurological impairment (NI). The risk for postoperative complications is low. However, among children with NI, gastroesophageal reflux disease (GERD) may necessitate fundoplication prior to gastrostomy tube placement. Preoperative pH probe testing has not been shown to be an effective screening tool prior to PEG placement among patients with GERD. Laparoscopic gastrostomy tube insertion was introduced in pediatric patients in an attempt to decrease complications associated with PEG. Although outcomes were reported to be similar to or better than PEG alone, future comparative studies are needed to better define the optimal patient demographic for this technique.

Current microbiology of percutaneous endoscopic gastrostomy tube (PEG tube) insertion site infections in patients with cancer

PURPOSE

Percutaneous endoscopic gastrostomy (PEG) is frequently used to provide enteral access in cancer patients who are unable to swallow. Infection is an important complication in this setting. Current microbiological data are needed to guide infection prevention and treatment strategies.

METHODS

The microbiological records of our institution (a 550-bed comprehensive cancer center) were retrospectively reviewed over an 8-month study period in order to identify patients who developed PEG tube insertion site infections, and review their microbiological details and susceptibility/resistance data.

RESULTS

Fifty-eight episodes of PEG tube insertion site infections were identified. Of these, 31 (53%) were monomicrobial, and the rest were polymicrobial. The most common organisms isolated were Candida species, Staphylococcus aureus, and Pseudomonas aeruginosa. All infections were local (cellulitis, complicated skin, and skin structure infections including abdominal wall abscess) with no cases of concomitant bacteremia being documented. Most of the organisms isolated were susceptible to commonly used antimicrobial agents, although some quinolone-resistant and some multidrug-resistant organisms were isolated.

CONCLUSIONS

This retrospective study provides descriptive data regarding PEG tube insertion site infections. These data have helped us update institutional guidelines for infection prevention and treatment as part of our focus on antimicrobial stewardship.

Clinical trial: a randomized study comparing the durability of silicone and latex percutaneous endoscopic gastrostomy tubes

BACKGROUND

The use of percutaneous endoscopic gastrostomy (PEG) for nutrition support is increasing worldwide, but few studies have evaluated the durability of and complications related to the different materials used to manufacture gastrostomy tubes. Latex PEG tubes are widely used in our clinical setting, but no studies have compared their durability with silicone PEG tubes. The aim of the present study was to compare the durability of latex tubes with the durability of silicone tubes.

PATIENTS AND METHODS

A randomized clinical trial was conducted in patients with head and neck cancer with indications for PEG. Sixty patients were randomized to receive either latex or silicone PEG tubes and followed up for 90 days. The analyzed outcomes were duration, peristomal infection, granulated tissue formation, and leakage around the tube.

RESULTS

The durability of silicone PEG tubes was significantly greater than the durability of latex PEG tubes. The survival curves showed that silicone PEG tubes lasted twice as long (hazard ratio = 2.0, 95% confidence interval = 1.1-3.7, P = 0.01). No differences were found with regard to rate of peristomal infection, granulated tissue formation, or leakage.

CONCLUSION

Silicone PEG tubes are associated with a reduced need for replacement (attributable to higher durability) compared with latex PEG tubes.

Possibility of oral feeding after induction of percutaneous endoscopic gastrostomy

BACKGROUND AND AIM

Although percutaneous endoscopic gastrostomy (PEG) has become established as a useful enteral nutrition technique, the associated risks must always be kept in mind. Recently, we experienced several patients who could orally ingest after PEG. To avoid unnecessary PEG, we investigated patients who could orally ingest after PEG, and analyzed predictive factors of postoperative oral feeding.

METHODS

We retrospectively analyzed data of 302 patients who underwent PEG at our hospital. After all patients were divided according to postoperative oral feeding status, we assessed factors of patients' backgrounds. In patients who could orally ingest after PEG, we investigated the course of oral feeding status. We attempted to identify predictive factors for postoperative oral feeding using logistic regression analysis.

RESULTS

Mean age was high in both groups, and overall condition was markedly poor. Forty-four patients (15%) were able to ingest orally after PEG. Enteral nutrition could be avoided during our observation period in 15 cases, because sufficient oral intake was achieved. Conversely, oral feeding was reduced or discontinued in 14 cases. Multivariate analysis identified the following independent predictive factors for postoperative oral feeding: (i) absence of dysphagia or aphagia; (ii) younger age; (iii) favorable performance status; (iv) presence of post-traumatic encephalopathy; and (v) preoperative swallowing training.

CONCLUSIONS

A total of 15% of PEG cases were able to ingest orally after PEG. In patients showing positive predictive factors, indications for PEG should be carefully considered.

Assessment of safety and feasibility of a new technical variant of gastropexy for percutaneous endoscopic gastrostomy: an experience with 435 cases

BACKGROUND

Percutaneous Endoscopic Gastrostomy (PEG) performed through the Introducer Technique is associated with lower risk of surgical infection when compared to the Pull Technique. Its use is less widespread as the fixation of the stomach to the abdominal wall is a stage of the procedure that is difficult to be performed. We present a new technical variant of gastropexy which is fast and easy to be performed. The aim of this study was to evaluate the safety and feasibility of a new technical variant of gastropexy in patients submitted to gastrostomy performed through the Introducer Technique.

METHODS

All the patients submitted to PEG through the Introducer Technique were evaluated using a new technical variant of gastropexy, which consists of two parallel stitches of trasfixation sutures involving the abdominal wall and the gastric wall, performed with a long curved needle. Prophylactic antibiotics were not used. Demographic aspects, initial diagnosis, indication, sedation doses, morbidity and surgical mortality were all analyzed.

RESULTS

Four hundred and thirty-five consecutive PEGs performed between June 2004 and May 2007 were studied. Nearly all the cases consisted of patients presenting malignant neoplasia, 79.5% of which sited in the head and neck. The main indication of PEG was dysphagia, found in 346 patients (79.5%). There were 12 complications (2.8%) in 11 patients, from which only one patient had peristomal infection (0.2%). There was one death related to the procedure.

CONCLUSION

Gastropexy with the technical variant described here is easy to be performed and was feasible and safe in the present study. PEG performed by the Introducer Technique with this type of gastropexy was associated with low rates of wound infection even without the use of prophylactic antibiotics.

Percutaneous endoscopic gastrostomy (PEG) in children is not a minor procedure: risk factors for major complications

Percutaneous endoscopic gastrostomy (PEG) provides for enteral nutrition in children with feeding problems. PEG, however, is not without complications. The present study has a twofold aim: (1) comparing our incidence of major complications after PEG with the incidence in other centers, and (2) identifying risk factors for major complications. All patients receiving a PEG or laparoscopic-assisted PEG (lap PEG) in the period 1992-2008 were reviewed. Primary outcome was the occurrence of major complications, defined as the need for surgery, non-prophylactic antibiotics, or blood transfusion, and procedure-related death. Potential risk factors, eg, age under 1 year, mental retardation, scoliosis, constipation, hepatomegaly, upper abdominal surgery, ventriculoperitoneal shunt, peritoneal dialysis, esophageal stenosis, and coagulopathy, were analyzed. Of the 467 patients (448 PEG, 19 lap PEG), 12.6% developed major complications. The complication rate significantly decreased (P = 0.003) over the years. A significantly higher complication rate of 32% (P = 0.02) occurred in children with a ventriculoperitoneal shunt. None of the lap PEG procedures was associated with a major complication, but the difference was not significant, perhaps because of the small numbers in the latter group. The major complication rate after PEG in children is high. Preexisting ventriculoperitoneal shunt is a significant risk factor. Laparoscopically assisted PEG procedures seem to be associated with a lesser major complication rate.

Clostridium difficile-associated enteric disease after percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has become established as a useful enteral nutrition technique. Although various adverse events related to PEG are known, few reports have described Clostridium difficile-associated enteric disease (CDED) after PEG. We encountered several cases of CDED with onset soon after PEG. The present study examined these cases in detail and analyzed potential risk factors.

METHODS

A total of 239 patients underwent PEG at our hospital from 1999, and the subjects comprised 233 patients for whom data could be statistically analyzed. CDED with onset soon after PEG was defined for cases with symptoms within 1 month after PEG. We investigated features and prognosis of these cases. A total of 19 predictors were chosen, and logistic regression analysis was performed using CDED with onset soon after PEG as a dependent variable.

RESULTS

Mean patient age was high, and about 65% were men. Their body weights were low and their general condition was markedly poor. CDED with onset soon after PEG was shown in 15 patients (6.4%). Although oral administration of vancomycin resulted in prompt recovery in most cases, enteral nutrition was interrupted for a long period, and the general condition deteriorated markedly in two patients. Logistic regression analysis identified "past history of CDED" and "antibiotic dosing period at PEG" as risk factors for CDED onset soon after PEG.

CONCLUSIONS

CDED occurred with onset soon after PEG at a comparatively high rate. Our analysis suggested "past history of CDED" and "antibiotic dosing period at PEG" as risk factors for CDED after PEG.