Unsedated transnasal percutaneous endoscopic gastrostomy carried out by a single physician

Nasal unsedated seated percutaneous endoscopic gastrostomy (nuPEG): a safe and effective technique for percutaneous endoscopic gastrostomy placement in high-risk candidates

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) tube placement is associated with a high risk of cardiorespiratory complications in patients with significant respiratory compromise. This study reports a case series of high-risk patients undergoing PEG placement using a modified technique-nasal unsedated seated PEG (nuPEG) placement.

DESIGN

Retrospective review of 67 patients at high risk of complications undergoing PEG placement between September 2012 and December 2016.

SETTING

UK specialist tertiary centre for clinical nutrition support.

INTERVENTIONS

Patients underwent 'push' PEG placement using nasal endoscopy without sedation in a seated position.

MAIN OUTCOME MEASURES

Procedural success and tolerability, short term (within 24 hours), medium term (24 hours to 30 days) complications and survival were recorded.

RESULTS

67 patients underwent 68 nuPEG placements. The majority had motor neuron disease (46/67). One patient developed a lower respiratory tract infection the following day. Two patients experienced accidental displacement of their PEG within 2 weeks. One patient died within 30 days of nuPEG insertion due to reasons unrelated to the procedure. Endoscopic comfort scores of 1 or 2 (98.0%) indicated good tolerance. A failure rate of 10.5% was attributed to intrathoracic displacement of the stomach, almost certainly due to the advanced stage of the neurological disease and associated diaphragmatic weakness.

CONCLUSIONS

Our experience with the nuPEG technique suggests that it is safe and well tolerated in high-risk patients. As a result, it has now entirely supplanted radiologically inserted gastrostomy insertion in our institution and we recommend it as the method of choice for gastrostomy tube insertion in such patients.

Unsedated transnasal esophagoscopy for monitoring therapy in pediatric eosinophilic esophagitis

BACKGROUND AND AIMS

Unsedated transnasal endoscopy (TNE) is safer and less costly than sedated EGD. The aim of this study was to evaluate the performance of TNE with biopsies in monitoring the esophageal mucosa of pediatric patients with eosinophilic esophagitis.

METHODS

Patients between 8 and 17 years of age with eosinophilic esophagitis and their parents were enrolled. Unsedated TNE was performed. A 2.8-mm (1.2-mm channel) or a 4-mm flexible bronchoscope (2-mm channel) was used, and esophageal biopsy specimens were obtained. Biopsy specimen analysis, duration, adverse events, and billing charges of TNE were assessed. Immediately after TNE and a minimum of 2 weeks later, a modified Group Health Association of America 9 survey and a preference questionnaire were completed, respectively.

RESULTS

Twenty-one of 22 enrolled patients underwent TNE. TNE was performed with no serious adverse events. Histopathological analysis revealed 0 eosinophils per high-power field (n = 12), fewer than 15 eosinophils per high-power field (n = 4), and more than 15 eosinophils per high-power field (n = 5). The total epithelial surface area of mucosal biopsy samples from either TNE Forceps (1.2 mm or 2 mm biopsy channel forceps) compared with those obtained during the subject's previous EGD by using standard endoscopic forceps was not statistically different (P = .308 [1.2 mm]/P = .492 [2 mm]). All parents and 76.2% of subjects would undergo the TNE again. TNE was preferred over EGD by 85.7% of parents and 52.4% of subjects. The modified Group Health Association of America 9 survey revealed a high degree of satisfaction (average, 43.19 ± 2.6; maximum score, 45). Charges associated with TNE were 60.1% lower than for previous EGDs.

CONCLUSIONS

Unsedated TNE is an effective, lower-cost procedure for monitoring the esophageal mucosa of children with eosinophilic esophagitis.

Improved method of gastrostomy tube replacement using a small-caliber transnasal endoscope

CONCLUSION

Gastrostomy tube replacement using a new approach through the abdominal-wall stoma with a small-caliber trans-nasal endoscope is feasible, fast, and safe compared with the trans-oral approach.

OBJECTIVES

To evaluate the feasibility of a new technique using a trans-nasal endoscope for gastrostomy tube replacement.

METHODS

Between June 2005 and December 2013 in the Peking University Third Hospital, 69 patients underwent gastrostomy tube replacement using the trans-oral approach (conventional method) or a small-caliber trans-nasal endoscope inserted through the abdominal-wall stoma (new method). A retrospective review was performed of the medical records of those patients, including demography and information about the surgical procedure and any complications. Patients were classified into the conventional group and the new method group. Descriptive statistics for all continuous variables were mean ± standard deviation and for categorical variables were number and percentage.

RESULTS

Gastrostomy tube replacement was achieved in 69 of 69 cases (100%); 23 of these procedures were performed using the new method. The surgery time with the conventional method (8.3 ± 2.0 min) was significantly longer than with the new method (6.0 ± 0.9 min, p < 0.001). With the conventional method, there was one patient (2%) with post-operative fever and skin infection; no complications occurred with the new method.

Transnasal PEG tube placement in patients with head and neck cancer

BACKGROUND

Head and neck cancer (H&NCa) patients have an increased risk of malnutrition and dysphagia because of their malignancy and the adverse events of therapy. Most of these patients require gastrostomies. Four percent to 7% of H&NCa patients are unable to undergo per oral percutaneous gastrostomies. Transnasal endoscopy is an option for gastrostomy placement in selected patients.

OBJECTIVE

Clinical, epidemiologic characteristics and outcomes of transnasal PEG (t-PEG) placement.

DESIGN

Retrospective analysis.

SETTING

Tertiary care hospital, The University of Texas MD Anderson Cancer Center.

PATIENTS

All patients who underwent t-PEG placement.

MAIN OUTCOME MEASUREMENTS

Epidemiology, adverse events, and outcomes of t-PEG placement.

RESULTS

Sixteen patients underwent t-PEG placement from January 2010 to May 2013. All patients had H&NCa and 56.3% had metastasis. Indications for the transnasal approach were airway compromise, malignant oropharyngeal obstruction, and trismus, among others. All procedures were successful using a 20F gastrostomy tube, push technique, anesthesiologist-guided propofol sedation, and/or nasotracheal intubation. Of all patients, 68.8% were white and 68.8% were men. Mean age was 54 years, and mean body mass index was 20.87. Two patients had a total of 2 adverse events: poor wound healing and wound site infection. Of all patients, 18.75% had leukopenia, 6.25% neutropenia, and 50% lymphopenia. Mean white blood cell count, absolute neutrophil count, and absolute lymphocyte count were 8.6 × 10(9)/L, 6.57 × 10(9)/L, and .93 × 10(9)/L, respectively. Eleven patients were alive, 2 were lost to follow-up, and 3 had died at the time of review.

LIMITATIONS

Retrospective analysis, small cohort, patient selection bias.

CONCLUSION

t-PEG placement is a viable and safe option for H&NCa patients when the standard endoscopic approach is not feasible.