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Percutaneous Endoscopic Gastrostomy John P. Grant, MD Duke University Medical Center John P. Grant, MD Duke University Medical Center.

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Presentation on theme: "Percutaneous Endoscopic Gastrostomy John P. Grant, MD Duke University Medical Center John P. Grant, MD Duke University Medical Center."— Presentation transcript:

1 Percutaneous Endoscopic Gastrostomy John P. Grant, MD Duke University Medical Center John P. Grant, MD Duke University Medical Center

2 IF THE GUT WORKS – USE IT IF NOT – MAKE IT WORK IF YOU FAIL – TRY AGAIN! IF THE GUT WORKS – USE IT IF NOT – MAKE IT WORK IF YOU FAIL – TRY AGAIN! Nutritional Rule!

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 expensive Less risk of sepsis Less nursing time required

5 Enteral Access The Gastrostomy Tube

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 Enteral Access Percutaneous 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

9 Bard PEG Kit

10 Sherwood, Davis, & Geck PEG Tube

11 Inverta-PEG from Abbott Laboratories

12 PEG Gastrostomy

13 Optimal Exit Site for Gastrostomy Tube

14 PEG Gastrostomy

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19 Number of PEG’s Performed at Duke University Medical Center

20 PEG Insertion

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.

24 Chest X-ray

25 Pneumoperitoneum from endoscopy. Patient did well. Chest X-ray

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27 Leak from gastrostomy tube. Patient had an acute abdomen and required urgent surgery. Chest X-ray

28 Gastrografin Tube Check

29 Pneumoperitoneum but no leak from gastrostomy site. Patient did well. Gastrografin Tube Check

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31 Obvious leak from gastrostomy site. Patient had an acute abdomen. Gastrografin Tube Check

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33 False negative Gastrografin study. Patient had an acute abdomen. Gastrografin Tube Check

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) Hysterectomy147 Cholecystectomy87 Exploratory lap., lysis adhesions71 Appendectomy70 Subtotal gastrectomy (BI or BII)35 Abdominal Aortic Aneurysm30 Colectomy30 Ventriculoperitoneal shunt17 Cystectomy with ileal loop13 Small bowel resection13 Splenectomy9 Perforated duodenal ulcer8 Nissen fundoplication6 Aortobifemoral bypass graft5 Cesarian section4 Pancreatectomy3 Portocaval shunt1 Repair diaphragmatic hernia1 Total with prior surgery: failures, no complications

37 Duke Experience With PEG 1778 Patients 34Leakage about gastrostomy site 24Exit site infection (8 major) 12Peritonitis (12 major: 1 died, 6 exp lap, 5 antibiotics only) 3Colonic injury 2Aspiration pneumonia from endoscopy 6Bleeding at gastrostomy site 1Fracture of alveolar ridge opening mouth in OR 1Esophageal laceration on removal (major) 83Overall 4.7%Major 1.3% (23)

38 Complications of PEG Gastrostomy Ponsky Sangster Miller Saunders Gibson Total %3.3%7.3% Duke PEG %3.4%4.7% Stamm %8%18% Author # Years Major Minor All Duke PEG 1.3% 4.7%

39 Alternate Enteral Access Laparoscopic Gastrostomy

40 Ross Laparoscopic Gastrostomy Kit

41 Trocar Sites and Gastrostomy Exit Site 10-mm trocar

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44 Laparoscopic Gastrostomy Movie

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.

47 Enteral Access Button Gastrostomy

48 Stomate Button Gastrostomy – Abbott Labs Can replace standard G-tube after 3-4 weeks

49 PEG Tube Complications Necrotizing Fasciitis

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53 Occurs most commonly in settings of: –Concomitant infections, multiple antibiotics –Malnutrition, elderly, diabetics –Low output syndromes –Steroids, chemotherapy, or immunosuppression

54 Treatment of Necrotizing Fasciitis Ensure adequate nutrition continues. –Nasojejunal tube, jejunostomy, TPN Neutralize gastric acid. Give antibiotic (Keflex) via feeding tube.

55 Treatment of Necrotizing Fasciitis ± Give systemic antibiotics. Change dressing qid, antibiotic ointment. Protect skin (drainage bag). If all else fails – remove feeding tube.

56 Necrotizing Fasciitis

57 PEG Tube Complications Hypertrophic Granulation Tissue

58 Normal PEG Exit Site

59 Hypertrophic Granulation Tissue

60 Tissue Sharply Cut Away

61 Base Cauterized with Silver Nitrate

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.

65 Complications of PEG Patient Selection

66 32 patients received PEG following stroke. 9/14 (64%) died within 4 weeks Cost-benefit ratio favors PEG placement only in patients likely to survive and have dysphagia for > 4 weeks. Scolapio et al. NCP 15:36, 2000

67 Patient Selection Patients likely to regain swallow function < 4 weeks: –Age < 60 –Limited comorbidities –Nonhemorrhagic stroke –Mild oropharyngeal dysphagia Scolapio et al. NCP 15:36, 2000

68 Patient Selection 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 % Grant et al. J.A.M.A. 279:1973, 1998

69 Patient Selection Two groups of patients were compared: Group 1 - patients from nursing homes Group 2 - hospitalized patients 30-Day MortalityOverall Mortality Group 1 13%38% Group 2 29%66% Abuksis et al. Am. J. Gastroenterol., 95:128, 2000

70 Patient Selection They 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. Abuksis et al. Am. J. Gastroenterol., 95:128, 2000

71 Mortality Following PEG in ICU’s DUMC % 38% Days to Death: Ave = 16 Median = 13

72 Patient Selection All stable patients can be considered for early gastrostomy if feeding access anticipated to be needed for >30 days. Stable Patients

73 Patient Selection 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. Acutely Ill Patients

74 Percutaneous Endoscopic Gastrostomy John P. Grant, MD Duke University Medical Center John P. Grant, MD Duke University Medical Center

75 Loosen retention disk after 5 to 7 days Pull tube out and release If tube pulls back in:If tube does not pull Stomach probably notin: Stomach is attached. Retighten disk probably attached. and recheck in 3-5 days.


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