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• W2885347910 abstract "First described in 1980 by Gauderer et al,1Gauderer M.W. Ponsky J.L. Izant Jr., R.J. Gastrostomy without laparotomy: a percutaneous endoscopic approach.J Pediatr Surg. 1980; 15: 872-875Abstract Full Text PDF PubMed Scopus (1773) Google Scholar placement of a percutaneous endoscopic gastrostomy (PEG) tube has become an indispensable and routine procedure for providing enteral nutrition. The frequency of PEG tube placement has increased over the years based on Medicare claims data,2Duszak R. Mabry M.R. National trends in gastrointestinal access procedures: an analysis of Medicare services provided by radiologists and other specialists.J Vasc Interv Radiol. 2003; 14: 1031-1036Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar and is projected to increase given the increase in the elderly population. Minor complications range from 13% to 40%, and major complications vary from 0.4% to 4.4%.3Blumenstein I. Shastri Y.M. Stein J. Gastroenteric tube feeding: techniques, problems and solutions.World J Gastroenterol. 2014; 20: 8505-8524Crossref PubMed Scopus (200) Google Scholar In this review we describe the common complications associated with PEG tubes, their prevention, and management. Buried bumper syndrome (BBS) is a chronic, serious complication in which the internal bumper or bolster migrates into (incomplete BBS) or completely through the gastric wall and into the peritoneum (complete BBS). The incidence varies from 0.3% to 2.4%.4Cyrany J. Rejchrt S. Kopacova M. et al.Buried bumper syndrome: a complication of percutaneous endoscopic gastrostomy.World J Gastroenterol. 2016; 22: 618-627Crossref PubMed Scopus (76) Google Scholar It develops as a result of excessive external traction on the internal bumper, resulting in tissue ischemia and necrosis followed by granulation tissue formation. Other risk factors for buried bumper include rigid tubes, sharp short bumpers, malnourished patients with subsequent weight gain, systemic corticosteroids, and chemotherapy. Common presenting signs and symptoms include leakage around the PEG tube, an inability to rotate or insert the tube, difficulty administering tube feeds, and abdominal pain. Complications of BBS include local skin infection, necrotizing fasciitis, bleeding, peritonitis, and abscess formation. Prevention strategies are detailed in Table 1.Table 1Risk Factors, Prevention, and Management of PEG-Related ComplicationsComplicationsRisk factorsPreventionManagementBuried bumper syndromeExcessive traction on the internal bumperWeight gainUncooperative patients leading to inadvertent pulling of the tubeAllow >10 mm space between skin and external bumperAfter tract maturation, insert and rotate the tube 360° dailyAvoid gauze between skin and external bumperMittens, abdominal binders, low-profile devicesImmediately stop feeds through the tubeExtraction of the buried bumper by the new feeding tube using pull techniquePush–pull technique (see Figure 1)Endoscopic dissectionCut-and-leave approachSurgeryInfectionExcessive tractionLack of antibiotic prophylaxisNarrow incisionPoor wound careHost factors: malnutrition, diabetes, corticosteroid use, obesity, and malignancyProphylactic broad-spectrum antibiotic administrationIntroducer technique that does not require the tube to go through oropharynxBroad-spectrum antibiotics for 5–7 daysIV antibiotics if systemic signs are presentBroad-spectrum IV antibiotics and aggressive surgical debridement if necrotizing fasciitisPeristomal leakageExcessive cleaning with hydrogen peroxideExcessive gastric acid secretionLateral traction on the tubeAbsent external bolster Factors leading to poor wound healingAvoid excessive tractionClean with waterAvoid hydrogen peroxideProton pump inhibitorsAdhesive creams or zinc oxideRemove the tube for 2–3 daysPlace tube in a different locationColonic perforationExtremes of ages due to lax mesenteryPrior abdominal surgery leading to adhesionsImproper insufflation of stomachAdequate insufflation of stomachTransilluminationRaising the head end of bed because it pushes the colon downwardSafe tract techniqueConservative: remove the tube and allow the fistula to healSurgical if systemic signs are presentOver-the-scope clip for closing colocutaneous fistulaBleedingCoagulopathyPrior abdominal surgery Serotonin re-uptake inhibitorsHold antiplatelets, anticoagulants as per societal guidelinesPressure dressing at the PEG siteRepeat endoscopyRarely, angiographic or surgical interventionTube dislodgementCombative and confused patientsMittensAbdominal bindersLow-profile devicesEndoscopic replacement for PEG < 4 weeks oldBedside replacement for PEG > 4 weeks oldTube malfunctionSmall-caliber tubesUse of pancreatic enzymes through the tubePill form of medicationsAvoid bulking agents through the tubeFlushing with water before and after giving feeds and medicationsUse of only water-soluble or liquid medicationsWarm water flushesSodaPancreatic enzymes dissolved in bicarbonate solutionMechanical devices such as endoscopy channel cleaning brush or endoscopic cathetersNonhealing stomaDelayed gastric emptying Increased acid productionPoor wound healingOver-the-scope clipsEndoscopic suturing devicesEndoscopy-guided placement of external sutures (see Supplementary Movie)SurgeryIV, intravenous. Open table in a new tab IV, intravenous. Diagnosis usually is evident on external inspection and manipulation of the PEG tube, but can be confirmed by endoscopy. Endoscopy may show ulceration of gastric mucosa beneath the internal bumper, or complete disappearance of the bumper with only granulation tissue or residual fistula visible. A computed tomography scan and fluoroscopy can aid with location of the internal bumper if it has completely eroded out of the gastric wall. Once diagnosed, feedings should be withheld, antibiotics administered, and extraction even in asymptomatic patients should be attempted given the risk of progression. Various therapeutic procedures have been described based on the location of the internal bumper and the presence of concomitant complications. If the bumper is within the gastric wall then endoscopic removal techniques can be attempted. First, extraction of the buried bumper by a new feeding tube using a pull technique. Second, a push–pull technique in which a snare is inserted into the buried tubing, the external tubing is cut twice, and the distal cut portion is rotated to make a T on to the proximal end. The snare and T now are pushed into the stomach with the help of Kelly clamps. The endoscopist pulls the snare and endoscope from inside the stomach while the assistant pushes the T into the stomach, thus aiding the removal of the buried tube orally (Figure 1). Third, endoscopic dissection: a papillotome or endoscopic cautery-enhanced knife (hook, hybrid, needle knife) can be used to dissect the internal granulation tissue from around the buried bumper. Fourth, cut-and-leave approach in patients with poor outcome. When the internal bumper is beyond the gastric wall a surgical approach is recommended.4Cyrany J. Rejchrt S. Kopacova M. et al.Buried bumper syndrome: a complication of percutaneous endoscopic gastrostomy.World J Gastroenterol. 2016; 22: 618-627Crossref PubMed Scopus (76) Google Scholar Peristomal wound infection is the most common complication of PEG tube placement, with an incidence of 5% to 25%.5Rahnemai-Azar A.A. Rahnemaiazar A.A. Naghshizadian R. et al.Percutaneous endoscopic gastrostomy: indications, technique, complications and management.World J Gastroenterol. 2014; 20: 7739-7751Crossref PubMed Scopus (253) Google Scholar Risk factors include excessive traction on the internal bumper, lack of antibiotic prophylaxis, narrow skin incision at the time of placement, poor wound care, and host factors including malnutrition, diabetes, corticosteroid use, obesity, and malignancy. The push technique, which does not require the tube to go through the oropharynx, has been shown to have a lower rate of infection compared with the pull method. An adequate skin incision (1–2 mm wider than the tube) has lower rates of infection. With the advent of prophylactic antibiotic administration the rate of infection has decreased significantly. A meta-analysis of 13 randomized controlled trials including 1271 patients comparing antibiotic prophylaxis vs placebo or no intervention showed a lower rate of infection in patients receiving prophylactic antibiotics (odds ratio, 0.36; 95% CI, 0.26–0.50).6Lipp A. Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy.Cochrane Database Syst Rev. 2013; 11: CD005571PubMed Google Scholar A broad-spectrum antibiotic such as a third-generation cephalosporin 30 minutes before the procedure is recommended. With the increasing rate of methicillin-resistant Staphylococcus aureus–associated infections, preprocedural screening and decolonization of the nasopharyngeal mucosa has been shown to reduce the rate of this infection. Once diagnosed, a short course of broad-spectrum antibiotics for 5 to 7 days is recommended. If systemic signs are present, intravenous antibiotics may be required. Necrotizing fasciitis requires broad-spectrum intravenous antibiotics and aggressive surgical debridement. Peristomal leakage occurs in 1% to 2% of the patients. The incidence likely is underestimated because small-volume leakage may go unreported. Risk factors are included in Table 1. When leakage is present it is imperative to evaluate the site for infection and buried bumper, which also may present as peristomal leakage. First-line treatment includes antisecretory therapy (proton pump inhibitor) and application of adhesive creams or zinc oxide. If leakage persists and the tract is mature, the tube can be removed for 48 to 72 hours, allowing the stoma diameter to reduce followed by insertion of the same size or smaller replacement gastrostomy tube. Inserting a larger-diameter tube should be avoided because the stoma inevitably will enlarge, resulting in further leakage. If all else fails, the PEG tube should be placed at an alternative site with feeding started after more than 50% closure of the initial site. Colon perforation is a rare PEG tube complication (see part 1 of the Supplementary Movie). It can present acutely as peritonitis or chronically in the form of gastrocolic, colocutaneous, or gastrocolocutaneous fistulae. Risk factors include extremes of age owing to lax mesentery, prior abdominal surgery leading to adhesions, and improper insufflation of the stomach at the time of placement. Acutely, patients may present with abdominal pain and peritoneal signs. This subset will require immediate diagnosis and surgical management given the tract immaturity. Once the fistulous tract is formed, presentation may be subtle in the form of diarrhea during feed administration, poor weight gain, and peristomal leakage of fecal material. It also may manifest after tube replacement in which a pre-existing gastrocolocutaneous fistula is present but the replacement tube cannot be navigated into the stomach and now terminates within the lumen of the colon. Diagnosis can be made with water-soluble contrast injected through the PEG tube during fluoroscopy. Prevention includes the following: (1) adequate insufflation of the stomach; (2) transillumination; (3) raising the head end of bed because it pushes the colon downward; and (4) safe tract technique in which a needle is attached to a syringe with gentle negative pressure. As the needle is inserted, if air or fluid is withdrawn before endoscopic visualization, interposed bowel may have been punctured. Conservative management includes removing the tube and allowing the fistula to heal. If systemic signs or a persistent fistulous tract are present then surgical intervention is indicated. Endoscopic management has been reported using over-the-scope clips in closing colocutaneous fistulae. Bleeding is an uncommon complication of PEG tube placement, ranging from 1% to 2.5%.7Anderson M.A. Ben-Menachem T. Gan S.I. et al.Management of antithrombotic agents for endoscopic procedures.Gastrointest Endosc. 2009; 70: 1060-1070Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar Mild bleeding from the PEG tube tract can be treated with abdominal pressure and resolves within 48 hours. Severe bleeding from the gastric artery, splenic vein, or mesenteric vein, and rectal sheath hematomas, has been reported. Risk factors include coagulopathy, prior abdominal surgery, and serotonin re-uptake inhibitors. Antiplatelet and anticoagulant medications should be withheld per American Society for Gastrointestinal Endoscopy guidelines.7Anderson M.A. Ben-Menachem T. Gan S.I. et al.Management of antithrombotic agents for endoscopic procedures.Gastrointest Endosc. 2009; 70: 1060-1070Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar Repeat endoscopy for persistent intraluminal bleeding can confirm PEG tube–related bleeding as well as exclude alternative sources. Endoscopic therapy of PEG tube–associated bleeding also has been reported. It is important to visualize the mucosa obscured by the internal bumper at the time of endoscopy. In rare cases of retroperitoneal, peritoneal, and severe bleeding, angiographic or surgical intervention might be required. Tube dislodgement is a common reason for emergency room visits in patients with PEG tubes, with an incidence of 4% to 13%.8Rosenberger L.H. Newhook T. Schirmer B. et al.Late accidental dislodgement of a percutaneous endoscopic gastrostomy tube: an underestimated burden on patients and the health care system.Surg Endosc. 2011; 25: 3307-3311Crossref PubMed Scopus (53) Google Scholar It commonly occurs in combative and confused patients. Displacement could occur externally or internally. When displaced internally, the migrated internal bumper can lead to gastric outlet or intestinal obstruction. If displacement occurs before the tract has matured (<4 wk), a repeat endoscopy is recommended. Patients should be monitored for peritonitis in this situation. After 4 weeks, bedside placement of a replacement gastrostomy tube can be attempted. If there is concern for malposition after replacement, imaging with water-soluble contrast should be used to confirm intragastric placement before feed initiation. Clogging from medications or enteral formula is the most common cause of tube malfunction, with an incidence of 25% to 35%. Prevention strategies include the following: (1) avoid bulking agents through the tube, (2) flushing with water before and after administering feeds and medications, and (c) use of only water-soluble or liquid medications. If blockage occurs, warm water flushes are the best irrigant. Alternatives include soda and pancreatic enzymes dissolved in bicarbonate solution. Mechanical devices such as an endoscopy channel cleaning brush or endoscopic catheters also have been used. Over time the tube may pit, dilate, or crack. Fungal infections of the tubes have been recognized as the cause of tube degradation. No specific treatment is useful but polyurethane tubes are more resistant then silicone devices. Persistent gastrocutaneous fistulas can develop as a result of delayed gastric emptying, increased acid production, and poor wound healing. Various endoscopic techniques have been described including over-the-scope clips and endoscopic suturing devices. In cases of persistent or large fistulas, endocutaneous suturing techniques have been described (part 2 of the Supplementary Movie and Figure 2). Ultimately, in nonhealing fistulae, surgery should be offered. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0OTkwZTMzMzBkZWJlM2NlYTNkZGY1MzFmODkxYTBmYSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODMzMjA5fQ.c3NWYx9aC6rv1ZfDNBCyfAxhFQ81cYCKRWIsjWL-7vEMq2SDQZwtGMjwFFsOmBpzMYtwzAXVhDm4knQjLcra_OWd3cjnJuaTAXfEugGXCCKKYXL1jQnL8M6gAGTC_t3xCS8SIB-GBq8z6998HVWVpiYU-8ZfwuwK62bXqWk2SkBSORHQxmOlxwUAOuruim33U-DvqTVxU9r0e7s_HRhGj0UKQCScjlonqCRN2maL_C8X-Yxw7jG6-kWPZNeuq1vMWB5fADW7omP72v9jdA1B4oNTZ0LDXoku3da8WWvr_5U-XYroPT1vsJKXNT5rkc9Rs2IpgXOf7XnTmLomKPbg6A Download .mp4 (128.71 MB) Help with .mp4 files Supplementary MoviePart 1: PEG tube through the colon. Colonoscopy in a patient with recurrent partial bowel obstruction and a PEG tube shows the tube traversing across the lumen of the colon. (provided by Mohamed Othman, MD, Baylor College of Medicine). Part 2: Gastrocutaneous fistula repair. A long fistula is seen. Two 14G angiocaths are inserted adjacent to the fistula across from each other. A suture is inserted from an angiocath and with the help of microforceps withdrawn from the other angiocatheter. The angiocaths are removed and a knot is tied externally. Two knots can be tied across from each other for greater strength. Hemostatic clips are placed to close the residual small opening of the internal portion of the fistula (provided by Wasif Abidi, MD, Baylor College of Medicine)." @default.
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• W2885347910 date "2018-12-01" @default.
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• W2885347910 title "Common Gastrostomy Feeding Tube Complications and Troubleshooting" @default.
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