Presentation on theme: "Percutaneous Endoscopic Gastrostomy"— Presentation transcript:
1 Percutaneous Endoscopic Gastrostomy John P. Grant, MDDuke University Medical Center
2 Nutritional Rule! IF YOU FAIL – TRY AGAIN! IF NOT – MAKE IT WORK IF THE GUT WORKS – USE ITIF NOT – MAKE IT WORKIF YOU FAIL – TRY AGAIN!
3 Advantages of Enteral Nutrition Stimulates gallbladder emptying and reduces sludge and stone formation.Avoids steatosis by increasing release of enteroglucagon into portal circulation.Maintains gut-associated lymphoid tissue (GALT).Suppresses cytokine response.
4 Advantages of Enteral Nutrition Less expensiveLess risk of sepsisLess nursing time required
6 History of Gastrostomy 1837Egeberg proposed as possible.1839Sedillot performed gastrostomy in dog.1846Sedillot performed gastrostomy in 3 patients – all died of peritonitis.1876Verneuil performed first successful gastrostomy in man.
7 History of Gastrostomy 1891Witzel developed serosal tunnel.1894Stamm - concentric pursestring.1913Janeway - permanent gastrostomy. Beck-Jianu - gastric tube.1981Gauderer & Ponsky - PEG tube.
8 Percutaneous Endoscopic Gastrostomy (PEG) Enteral AccessPercutaneous Endoscopic Gastrostomy (PEG)A Simplified Technique for Constructing a Tube Feeding Gastrostomy Michael W.L. Gauderer, M.D., and Jeffrey L. Ponsky, M.D., F.A.C.S., Cleveland, Ohio Surgery, Gynecology & Obstetrics – January 1981 – Volume 152
21 Do’s and Don'ts of PEG Gastrostomy Do not place in patients with ascites.Do not place in patients with gastric varices.Do not attempt placement unless light is seen sharply through abdominal wall and/or indentation is clearly visible with external compression.
22 Do’s and Don'ts of PEG Gastrostomy Do give perioperative antibiotics.Do evaluate stomach and pylorus during endoscopy.Do make the exit site 1.5 x diameter of the feeding tube.Do loosen retainer after 5 to 7 days.
23 Do’s and Don'ts of PEG Gastrostomy Do NOT get a chest or KUB x-ray to evaluate postoperative abdominal pain.There will nearly always be free air and it will often be a considerable amount.Order a Gastrografin injection of the tube to evaluate proper tube placement.This test will not always detect a leak about the tube into the abdominal cavity.
33 Gastrografin Tube Check False negative Gastrografin study. Patient had an acute abdomen.
34 Do’s and Don'ts of PEG Gastrostomy Make decision on whether to explore the abdomen based on clinical examination and laboratory data.If leak is present, repair and tack stomach up to abdominal wall x 4.Thoroughly irrigate abdomen.Wrap omentum about gastrostomy site.
35 A PEG can be placed safely in patients with prior upper or lower abdominal surgery…. As long as finger indentation or light transillumination is satisfactory.
36 Placement of PEG in Patients with Prior Abdominal Surgery (1778 tubes) Hysterectomy147Cholecystectomy87Exploratory lap., lysis adhesions71Appendectomy70Subtotal gastrectomy (BI or BII)35Abdominal Aortic Aneurysm30ColectomyVentriculoperitoneal shunt17Cystectomy with ileal loop13Small bowel resection13Splenectomy9Perforated duodenal ulcer8Nissen fundoplication6Aortobifemoral bypass graft5Cesarian section4Pancreatectomy3Portocaval shunt1Repair diaphragmatic herniaTotal with prior surgery: failures, no complications
37 Duke Experience With PEG 1778 Patients 34Leakage about gastrostomy site24Exit site infection (8 major)12Peritonitis (12 major: 1 died, 6 exp lap, 5 antibiotics only)3Colonic injury2Aspiration pneumonia from endoscopy6Bleeding at gastrostomy site1Fracture of alveolar ridge opening mouth in OREsophageal laceration on removal (major)83 Overall 4.7% Major 1.3% (23)
38 Complications of PEG Gastrostomy Duke PEG % %Author # Years Major Minor AllPonsky307198324Sangster155198852529Miller330714Saunders13619913Gibson33419923237Total12624.0%3.3%7.3%Duke PEG17781.3%3.4%4.7%Stamm143810%8%18%
45 Advantages PEG Does not require general anesthesia. Minimal OR time (15-20 minutes).Prior surgery of little concern.Can evaluate gastric and duodenal mucosa.But: can injure colon or liver and poses serious problem if accidentally removed.
46 Advantages Lap G-Tube Avoid injury to colon or liver. Securely attach stomach to abdominal wall, less concern accidental removal.Gastrostomy tube easier to remove and replace.But: does require general anesthesia and up to 45 minutes OR time.
62 Complications of Enteral Nutrition Accidental Tube Withdrawal
63 Accidental Tube Withdrawal PEG Gastrostomy <72 hours: Emergent laparotomy (laparoscopy) to replace tube and secure stomach to abdominal wall.>3 to 7 days: Replace in radiology under fluoroscopy.>7 days: Replace at bedside checking placement with tube check in radiology.
64 Accidental Tube Withdrawal Laparoscopic Gastrostomy <72 hours: Replace in radiology under fluoroscopy.>72 hours: Replace at bedside with tube check in radiology.>7 days: Replace at bedside checking placement by aspiration of residuals.
66 Patient Selection Scolapio et al. NCP 15:36, 2000 32 patients received PEG following stroke.9/14 (64%) died within 4 weeksCost-benefit ratio favors PEG placement only in patients likely to survive and have dysphagia for > 4 weeks.
67 Patient Selection Scolapio et al. NCP 15:36, 2000 Patients likely to regain swallow function < 4 weeks:Age < 60Limited comorbiditiesNonhemorrhagic strokeMild oropharyngeal dysphagia
68 Patient Selection Grant et al. J.A.M.A. 279:1973, 1998 Mortality in 81,105 patients, 65 years or older, with Cerebrovascular disease, neoplasms, fluid and electrolyte disorders, and aspiration pneumonia.In-hospital mortality was 15.3 %30 day mortality was 23.9 %1 year mortality was 63.0 %3 year mortality was 81.3 %
69 Abuksis et al. Am. J. Gastroenterol., 95:128, 2000 Patient SelectionAbuksis et al. Am. J. Gastroenterol., 95:128, 2000Two groups of patients were compared:Group 1 - patients from nursing homesGroup 2 - hospitalized patients30-Day MortalityOverall MortalityGroup 113%38%Group 229%66%
70 Abuksis et al. Am. J. Gastroenterol., 95:128, 2000 Patient SelectionAbuksis et al. Am. J. Gastroenterol., 95:128, 2000They concluded:Patients hospitalized with acute illness are at high risk for serious adverse events after PEG insertion and the procedure should be avoided.Only stable patients benefit from early gastrostomy.
71 Mortality Following PEG in ICU’s DUMC 1998-1999 38%21%Days to Death: Ave = Median = 13
72 Patient Selection Stable Patients All stable patients can be considered for early gastrostomy if feeding access anticipated to be needed for >30 days.
73 Patient Selection Acutely Ill Patients All acutely ill patients should be nourished by nasoenteric tube for the first 30 days.If surviving 30 days, acutely ill patients can be considered for a gastrostomy on an individual basis.The tube should be placed about 1 week prior to discharge from the hospital.
74 Percutaneous Endoscopic Gastrostomy John P. Grant, MDDuke University Medical Center
75 Loosen retention disk after 5 to 7 days Pull tube out and releaseIf tube pulls back in: If tube does not pull Stomach probably not in: Stomach is attached. Retighten disk probably attached. and recheck in 3-5 days.