Search

Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery in the United States. RYGB is a successful and safe procedure that promotes weight loss, improves medical comorbidities and overall quality of life. Following RYGB, endoscopic access to the biliopancreatic limb and the excluded stomach is limited due to altered anatomy. Access to the excluded stomach maybe needed for management of complications following RYGB as gastric remnant decompression duo to biliopancreatic limb obstruction or nutritional support due to postoperative malnutrition. We report three cases of RYGB complications that necessitated percutaneous gastrostomy.

Background: To compare the safety and efficacy of percutaneous ultrasound guided gastrostomy (PUG) tube placement with traditional fluoroscopic guided percutaneous gastrostomy tube placement (PRG). Methods: A prospective, observational, non-randomized cohort trial was performed comparing 25 consecutive patients who underwent PUG placement between April 2020 and August 2020 with 25 consecutive patients who underwent PRG placement between February 2020 and March 2020. Procedure time, sedation, analgesia requirements, and complications were compared between the two groups in non-inferiority analysis. Results: Technical success rates were 96% in both groups (24/25) of procedures. Ninety-two percent of patients in the PUG cohort were admitted to the ICU at the time of G-tube request. Aside from significantly more COVID-19 patients in the PUG group ( P < .001), there was no other statistically significant difference in patient demographics. Intra-procedure pain medication requirements were the same for both groups, 50 micrograms of IV fentanyl ( P = 1.0). Intra-procedure sedation with IV midazolam was insignificantly higher in the PUG group 1.12 mg vs 0.8 mg ( P = .355). Procedure time trended toward statistical significance ( P = .076), with PRG being shorter than PUG (30.5 ± 14.1 minutes vs 39.7 ± 17.9 minutes). There were 2 non-device related major complications in the PUG group and 1 major and 1 minor complication in the PRG group. Conclusion: PUG is similar in terms of complications to PRG gastrostomy tube placement and a safe method for gastrostomy tube placement in the critically ill with the added benefits of bedside placement, elimination of radiation exposure, and expanded and improved access to care.

Drinking hydrogen (H2)-rich water is a common way to consume H2. Although many studies have shown efficacy of drinking H2-rich water in neuropsychiatric and endocrine metabolic disorders, their authenticity has been questioned because none examined the associated pharmacokinetics of H2. Therefore, we performed the first study to investigate the pharmacokinetics of H2 in pigs given an H2-rich glucose solution with the aim to extrapolate the findings to humans. We inserted blood collection catheters into the jejunal and portal veins, suprahepatic inferior vena cava, and carotid artery of 4 female pigs aged 8 weeks. Then, within 2 min we infused 500 ml of either H2-rich or H2-free glucose solution into the jejunum via a percutaneous gastrostomy tube and measured changes in H2 concentration in venous and arterial blood over 120 min. After infusion of the H2-rich glucose solution, H2 concentration in the portal vein peaked at 0.05 mg/L and remained at more than 0.016 mg/L (H2 saturation level, 1%) after 1 h; it also increased after infusion of H2-free glucose solution but remained below 0.001 mg/L (H2 saturation level, 0.06%). We assume that H2 was subsequently metabolized in the liver or eliminated via the lungs because it was not detected in the carotid artery. In conclusion, drinking highly concentrated H2-rich solution within a short time is a good way to increase H2 concentration in portal blood and supply H2 to the liver., Animal experimentation, translational medical research, catheterization, jejunal vein, portal venous blood sampling

Percutaneous gastrostomy tube placement is a commonly performed procedure to provide enteral alimentation to patients unable to tolerate oral feeds. Percutaneous gastrostomy is a relatively safe procedure, and serious complications like gastrointestinal bleeding, perforated viscus, and adjacent organ injury are rare. The most common complications after gastrostomy tube placement occur early and are usually minor. The purpose of this review article is to describe the techniques of percutaneous gastrostomy tube insertion and imaging protocol for gastrostomy tube evaluation, and describe the early, late, and anytime complications. The article will also illustrate very rare late complications of gastrostomy tube placement like gastro-hepatic fistula, gastro-colic fistula, buried bumper syndrome, and gastrostomy site hernia.

Percutaneous endoscopic gastrostomy tubes are placed when individuals are unable to orally consume adequate nutrition and require an alternative method to meet their daily nutritional needs. This decision is multifactorial and depends on the prognosis of the illness, patients' wishes, and weighing risks versus benefits. The recent movement toward patient-centered care supports open communication and shared decision-making that have the potential to mitigate decisional conflict. The aim of this literature review was to identify factors associated with the decision-making process for gastrostomy tube placement for adults. Three quantitative, 4 qualitative, and 1 Q-methodology study were analyzed. Social life, body image and intimacy, uncertainty and fear, complications, and burden to caregiver were central factors that influenced decision making. Social life and body image associated with intimacy were found to be the most prevalent themes in the review. This review indicates that decision making for gastrostomy tube placement is highly individualized. Patients need adequate information to make informed decisions that are congruent with their healthcare goals. Nurses should act as patient advocates and must have candid discussions to ensure that patients have received thorough and adequate information regarding gastrostomy tube placement and management.

Rationale and Objectives Historically, patients undergoing image-guided percutaneous gastrostomy tube placement have been admitted overnight with feeds commencing 12–24 hours postprocedure. With new expedited feeding protocols starting 3–4 hours postprocedure, same-day discharge is now possible. The purpose of this study was to evaluate the safety and cost of image-guided percutaneous gastrostomy tube placement as an outpatient procedure. Materials and Methods In this retrospective study, 131 patients (age 63.9 ± 11.6; 34% female) underwent gastrostomy tube placement as an outpatient procedure with expedited feeding protocol versus 40 patients (age 61.3 ± 12.6; 38% female) who were hospitalized overnight with feeds starting at 12–24 hours, primarily based on operator preference. The two groups were compared regarding complications within 90 days of procedure. Using a subgroup of 33 consecutive patients, procedural costs (total combined insurer and patient payments for professional and hospital services) for outpatients vs. hospitalized patients were compared. Results Complication rates were similar (p = 0.64) for gastrostomy tubes placed on outpatients (0.17 complications/procedure: 4 bleeding, 2 aspiration pneumonia, 1 abdominal abscess, 4 significant pain, 6 cellulitis, 1 surgical consult, 4 malpositioned/fractured tubes) and hospitalized patients (0.20 complications/procedure: 1 aspiration pneumonia, 1 significant pain, 3 cellulitis, 1 surgical consult, 2 fractured tubes). Total combined insurer and patient payments were similar ($2193/outpatient vs $2701/hospitalized patient; p= 0.52). Conclusion Outpatient image-guided percutaneous gastrostomy tube placement with an expedited feeding protocol is a safe and cost-comparable alternative to historic overnight hospitalization. Further prospective investigation with a larger sample is warranted.

Ataxia telangiectasia (A-T) is a rare genetic disease involving multiple organs, but, to our knowledge, data on long-term gastrointestinal and nutritional involvement are scarce. The aim of this study was to longitudinally review the nutritional and gastrointestinal aspects of A-T.This was a retrospective chart review of patients followed from 1986 to 2015 at one center. Demographic, laboratory, and nutritional data were retrieved. Body mass index (BMI) values were converted to BMI Z-score (BMI-Z). Caloric intake was estimated by food diaries and compared with estimated energy requirements for sex and age with a physical activity level factor for light physical activity.The study included 53 patients (28 males [53%], ages 14.6 ± 5.2 y). BMI-Z was inversely correlated with age (r = 0.48; P 0.004). A decline below minimal BMI percentiles was observed after the age of 4 y in boys and 7 y in girls. The relative percentage of caloric intake decreased with age (r = -0.5; P 0.002), and was positively correlated with BMI-Z (r = 0.35; P 0.05). Presence of cough during meals was associated with recurrent lower respiratory tract infections (Fisher exact test, P 0.01). Gastrostomy tubes were inserted in 12 patients, leading to improvement in BMI-Z from -5.1 ± 2.4 to -4 ± 2.9 (P 0.05).There is a progressive growth failure and low nutritional intake with age in patients with A-T, starting in early childhood in males, and more prominent in patients with cough and choking during meals. A proactive approach and insertion of a percutaneous gastrostomy tube as soon as the BMI-Z starts to decrease should be considered.

Sleeve gastrectomies have quickly become the most common bariatric weight loss surgery performed in the United States (U.S.). Given that hundreds of thousands of gastrostomy tubes (G tubes) are also placed each year, the number of patients with prior sleeve gastrectomies requiring a G tube will surely rise in the coming years. The case presented herein is a patient with prior sleeve gastrectomy who underwent percutaneous G tube placement.

PURPOSE We aimed to compare the antegrade transoral and the retrograde transabdominal approaches for fluoroscopy-guided percutaneous gastrostomy tube (G-tube) placement. METHODS Following institutional review board approval, all G-tubes at two academic hospitals (January 2014 to May 2015) were reviewed retrospectively. Retrograde approach was used at Hospital 1 and both antegrade and retrograde approaches were used at Hospital 2. Chart review determined type of anesthesia used during placement, dose of radiation used, fluoroscopy time, procedure time, medical history, and complications. RESULTS A total of 149 patients (64 women, 85 men; mean age, 64.4±1.3 years) underwent G-tube placement, including 93 (62%) placed via the retrograde transabdominal approach and 56 (38%) placed via the antegrade transoral approach. Retrograde placement entailed fewer anesthesiology consultations (P < 0.001), less overall procedure time (P = 0.023), and less fluoroscopy time (P < 0.001). A comparison of approaches for placement within the same hospital demonstrated that the retrograde approach led to significantly reduced radiation dose (P = 0.022). There were no differences in minor complication rates (13%-19%; P = 0.430), or major complication rates (6%-7%; P = 0.871) between the two techniques. CONCLUSION G-tube placement using the retrograde transabdominal approach is associated with less fluoroscopy time, procedure time, radiation exposure, and need for anesthesiology consultation with similar safety profile compared with the antegrade transoral approach. Additionally, it is hypothesized that decreased procedure time and anesthesiology consultation using the transoral approach are likely associated with reduced cost.

Severe bleeding requiring blood transfusions following endoscopic, percutaneous gastrostomy tube placement is a rare complication. We describe a case of severe recurrent haemorrhage with bright red blood from rectum from endoscopic, percutaneous gastrostomy tube placement, which ultimately required removal of the percutaneous endoscopic gastrostomy tube.

Ventriculoperitoneal (VP) shunt placement is one of the more common procedures in neurosurgery and has a variety of indications. However, shunt placement can be associated with multiple complications, one of which is proximal and distal shunt migration. There have been reported cases of migration of the distal end of a VP shunt from the intraperitoneal cavity into different organs resulting in a variety of complications. Most of the reported cases are the result of spontaneous migration. However, shunt catheter migration could be iatrogenic as well. We present a case of intragastric VP shunt migration in a patient following placement of a percutaneous endoscopic gastrostomy tube.

The purpose of this article is to evaluate the safety of T-fastener removal immediately after percutaneous gastrostomy tube placement by assessing difference in complication rates between early and delayed gastropexy removal.A retrospective review was performed of the electronic medical records of all patients who underwent percutaneous gastrostomy at our institution from January 2015 to June 2017. A total of 722 patients successfully underwent gastrostomy tube insertion during this period. Two hundred twenty-two patients were excluded from analysis on the basis of our exclusion criteria. Twelve patients were lost to follow-up. The remaining patients were divided into two groups: group 1 included 350 patients who had their T-fasteners released immediately after gastrostomy, and group 2 included 138 patients whose T-fasteners were left in place for 2 weeks. Electronic medical records were reviewed for postprocedure complications for up to 1 month. Complications were classified according to Society of Interventional Radiology classification. Statistical analysis was performed using a logistic regression model with calculation of odds ratios, power, p values, and 95% CIs.Seven (2.0%) major and 24 (6.8%) minor complications occurred in group 1. Two (1.4%) major and 11 (7.9%) minor complications occurred in group 2. There was no statistically significant difference in complication rates between immediate and delayed gastropexy removal.In our study, immediate removal of T-fasteners was not associated with a higher complication rate.

Fluoroscopic placement of gastrostomy tubes requires creation and dilation of a percutaneous tract through which the tube is placed. Given the relatively large caliber of these tubes, aggressive dilation of the percutaneous tract is necessary prior to their insertion. Tract dilation is most commonly performed via the use of several sequential dilators or a single telescoping serial dilator. These methods are cumbersome and relatively time-consuming, and as a result this portion of the procedure can result in considerable patient discomfort as well as technical complications. This chapter describes the use of a balloon catheter for gastrostomy creation. It describes clinical scenarios that would benefit from gastrostomy tube placement. The procedure is described in a step-by-step manner with a focus on gastrostomy tract dilatation.

Percutaneous Gastrostomy (PEG) tube is an endoscopic-guided procedure to provide enteral nutrition, medications and/or fluids to patients with oral or esophageal pathologies. PEG tubes are a relatively safe intervention but commonly known to have complications like insertion site infection, tube leakage, and tube blockage. This was an unusual case in which the PEG tube was discovered to be obstructing the third part of the duodenum after migration resulting in mechanical gastric obstruction with septic shock and severe hemodynamic instability. PEG induced gastric obstruction is often misdiagnosed during a triage due to the atypical presentation of this condition leading to aggressive management, testing and consultations. PEG dependent patients have rapidly increased over the years and a complete physical examination of the PEG site should be performed by all physicians in order to prevent related complications.

Background: Spontaneous intracerebral hemorrhage (sICH) is associated with substantial disability, accounting for considerable resource utilization among stroke survivors. Debate exists about the timing and utilization of tracheostomy (Trach) and percutaneous gastrostomy (PEG) tube placement in sICH patients. We hypothesized that sICH survivors with PEG and/or Trach would have higher odds of 30-day readmission. Methods: We analyzed the 2013 Nationwide Readmissions Database, a nationally representative sample of hospital discharges. Patients with a primary discharge diagnosis of sICH (ICD-9 code 431) were included in the analysis. Repeat, pediatric, same-day events, head trauma, AVM/fistula, and discharges occurring in December were excluded. Patients who received PEG and/or Trach were identified using published algorithms. We defined readmission as any admission within 30-days of index hospitalization discharge. Odds ratios for 30-day readmission comparing exposed versus unexposed were estimated with adjustment for demographics, risk factors, and concurrent illness. All analyses were performed using survey design variables. Results: Among the 32,715 sICH index hospitalizations, 3,480 (10.6%) received a PEG and 1806 (5.5%) received a Trach. Overall 4,320 (13.2%) were readmitted within 30 days (PEG 20.5%, trach 18.9%). In the fully adjusted models, sICH patients with PEG had higher odds of readmission (OR 1.43, 95% CI 1.14-1.80), while patients with trach did not (OR 0.77, 95% CI 0.54-1.11). Predictors of readmission among individuals with and without PEG and Trach will be presented. Conclusions: sICH patients who underwent PEG placement had higher odds of 30-day readmission while patients receiving Trach did not. This finding suggests that heightened post-discharge surveillance of individuals receiving PEG may be warranted.

Pancreas retransplantation, excluding immediate retransplantation for graft thrombosis, is a technically treacherous operation with the added challenges of adhesions from the prior transplant and difficulties identifying usable recipient vessels. The goal of this study was to review our single-center experience with late pancreas retransplantation. Charts for all pancreas transplant recipients between 01/2003 and 04/2013 were reviewed for demographics, graft and patient survival, length of stay (LOS), readmissions, and technical complications. Of 473 pancreas transplants, there were 20 late pancreas retransplants compared to 441 first transplants. There were no significant differences in donor or recipient demographics. There was no significant difference in graft or patient survival. The mean and median lengths of stay were 22 and nine d, respectively (range 5-175 d), and 11 recipients required readmission within the first three months post-transplant. Five patients were reexplored in the early postoperative period for an enteric leak at the site of the primary allograft (n = 1), complications of percutaneous gastrostomy tube placement (n = 1), hemorrhage (n = 1), and negative laparotomy for hyperglycemia (n = 2). Pancreas retransplantation is technically challenging but can be safely performed with graft and recipient survival comparable to primary transplants.

Objective: To evaluate the current indications, contraindications, and complications of percutaneous endoscopic gastrostomy tube insertion at the Endoscopy Department at King Hussein Medical center. Methods: A retrospective analysis of the records of all patients who underwent percutaneous endoscopic gastrostomy tube insertion between 2009 and 2012 was reviewed. Results: A total number of 149 cases (79 males, and 70 females) were performed over the study period. Age of patients ranged between 23 and 92 years with a median age 57.5 years. The most common indication in our series was neurological, mainly cerebrovascular accidents, accounting for around 60% of cases. The most common complication was infection at the site of insertion which accounted for about 70% of cases. Conclusions: Percutaneous endoscopic gastrostomy tube feeding is a safe, minimally invasive and effective procedure for providing nutritional support for those who cannot tolerate oral feeding.

e17540 Background: Prophylactic percutaneous gastrostomy tube (PEG) insertion reduces toxicity from chemoradiation to the head and neck but is thought to increase long term feeding tube dependence. This study retrospectively examines incidence and risk factors for treatment related complications of oropharynx cancer patients with and without prophylactic PEGs. Methods: Rush University Medical Center oropharynx cancer patients who received definitive chemoradiation treatment between 2007-2018 were included. Classifications were: “therapeutic” PEG (pretreatment for immediate use due to inability to swallow), prophylactic PEG, reactive PEG (patient/physician preference or 10% weight loss from baseline), and no PEG inserted on treatment. We compared patients with reactive or no PEG to (1) patients with prophylactic PEG, and (2) patients with prophylactic PEG and therapeutic PEG. Multivariate linear and logistical regression models were used to test PEG effect on weight loss, hospital admission, and incidence of acute kidney injury (AKI). Models were adjusted for covariates (age, gender, race, HTN, CAD, DM, other comorbidity). Acute kidney injury (AKI) was creatinine 1.5-2x above baseline. Results: In all, 104 patients were included with mean age 60.1 (SD = 8.65) and baseline BMI 29.6 (SD = 5.62). 53.4% (N = 55) had a prophylactic PEG, 38.8% (N = 40) had reactive or no PEG, 7.8% (N = 8) had a therapeutic PEG. 80 (76.9%) were treated with cisplatin. For all patients, analyses showed that reactive PEG or no PEG patients were more likely to develop AKI during treatment compared to patients with a prophylactic PEG (OR:3.2, p = 0.03), and to patients with prophylactic PEG and therapeutic PEG combined (OR:3.5, p = 0.02). There were no statistically significant differences between PEG groups for weight loss and hospital admission rate. In cisplatin treated patients, reactive PEG or no PEG patients were more likely to be admitted to the hospital compared to prophylactic PEG patients (OR:3.8, p = 0.04). Compared to patients with prophylactic and therapeutic PEG combined, however, there was no statistically significant difference. Patients with reactive or no PEG were more likely to have AKI than prophylactic PEG (OR:5.2, p < 0.01), and as compared to patients with therapeutic or prophylactic PEG (OR:4.4, p = 0.02). Conclusions: Reactive PEGs were associated with increased AKI and hospitalizations compared with prophylactic PEG. With a reactive PEG model, patients may need to have routine lab work and monitoring adjusted to reduce treatment complications.

OBJECTIVE. Radiologic percutaneous gastrostomy tube placement is a widely accepted method of enteral access for patients requiring long-term nutritional support for a variety of conditions. Although the safety of this procedure is well documented, complications do occur. The purpose of this article is to review the major and minor complications associated with gastrostomy tube placement and to present appropriate and effective management strategies. CONCLUSION. Familiarity with the potential complications, techniques for their prevention, and strategies for treatment will help practicing interventional radiologists successfully manage all possible outcomes.

There are numerous conditions and pathologies in which the patient's swallowing ability is diminished or prevented despite having working digestive system. These are the fundamental requirements for the placement of a percutaneous gastrostomy tube (PEG) as a method of choice to provide safe, effective, and prolonged enteral nutrition for the patient at home or when admitted to hospital. Due to its simplicity, safety and low cost, PEG offers several advantages over other feeding techniques, particularly nasogastric tube and parenteral feeding, although it does require simple and accurate knowledge and application of care that ensures low incidence of complications. The placement of a PEG tube should be contemplated in several clinical situations: a) for temporal use in those patients with potentially reversible diseases; b) in non-reversible diseases in which a long survival (of more than 6 months) is foreseeable, and c) in patients affected of terminal and debilitating illnesses in whom a relatively long survival is probable. In these last cases the indication and implementation for PEG should be individualized and agreed jointly. The appropriate training of care professionals and familiar supporters in charge of the patients carrying a PEG tube ensures its continuous functioning and reduces the risk of complications. This paper aims to review the indications and appropriate care for patients carrying a PEG tube and presents the most accurate care that should be provided by both the professional health carers and caregivers.

Fluoroscopically guided percutaneous gastrostomy tube placement is an uncommon but well-established interventional procedure. We present our experience of this procedure in a series of 23 patients, concentrating on the methodology, technique and pitfalls.

Purpose: To evaluate the safety, efficacy, and results of laparoscopically assisted placement of gastrostomy tubes (LAPGT) and compare the cost with that of percutaneous endoscopic gastrostomy (PEG). Patients and Methods: The medical records of all patients who underwent laparoscopic gastrostomy tube placement (N = 51) either alone (N = 8) or in conjunction with a fundoplication (N = 43) over a 2-year period (1998-1999) were evaluated for complications, length of procedure, and hospital charges. Hospital charges were compared with those of eight randomly selected patients who underwent PEG during the same period. We also reviewed the PEG database over this period to evaluate the percentage of children requiring a second procedure to convert a gastrostomy tube to a low-profile device. Results: There were no major complications related to gastrostomy tube placement in any of the 51 patients who underwent LAPGT. The operative time for LAPGT alone was 45 minutes. The initial hospital charges for LAPGT was $10...

Objectives:Compare functional and survival outcomes between patients with advanced stage head and neck squamous cell cancer (HNSCC) treated with primary transoral surgery versus primary chemotherapy and radiation.Methods:Retrospective case-control trial at an academic tertiary referral center. We identified a surgical group (SG) comprised of 37 patients with previously untreated stage III and IV HNSCC who underwent either transoral robotic surgery (TORS) or transoral laser microsurgery (TLMS) and a nonsurgical group (NSG) of 75 patients treated with primary chemotherapy and radiation between July 2007 and November 2011. NSG was matched to SG by age, sex, tumor location, stage, tobacco and alcohol use, and ECOG status. Tracheostomy and percutaneous gastrostomy tube (PEG) rates during treatment and at follow-up, as well as survival outcomes, were examined.Results:There were no statistically significant differences in the matched variables. Significantly fewer patients in the SG compared with the NSG still h...

Objective. To evaluate a newly developed method combining antegrade and retrograde techniques for percutaneous gastrostomy tube (PGT) insertion in the neonate and young infant. Materials and methods. From January 1994 to December 2000, 85 children (47 male, 38 female), mean age 4.5 months (range 0.44–9.13 months) underwent PGT insertion using the “push-pull” technique. With the addition, 57 children had a jejunostomy tube placed as well at or within 24 h of the PGT procedure. The mean weight was 3.74 kg, range 1.5–7.0 kg. The indications for the procedure included failure to thrive in 40 patients (25 %), static encephalopathy in 21 (25 %), neurological/congenital abnormalities in 12 (14 %), aspiration in 7 (8 %), and cardiac problems in 5 (6 %). Results. Eighty-five PGTs were successfully inserted in 85 children. One procedure was initially unsuccessful due to failed conscious sedation and was completed under general anesthesia. Four of 85 patients initially had attempted antegrade placement that failed, and the procedure was successfully completed using the “push-pull” method. One major complication occurred: a gastrocolic fistula at day 5 post-procedure, which was surgically repaired without sequelae. Tube-related problems included; tube dislodgement (n = 1) and procedure-related stomal infection (n = 3). Conclusion. The “push-pull” gastrostomy technique is a safe, effective method of percutaneous gastrostomy tube placement in neonates. It facilitates successful placement of the PGT in patients in whom the classic antegrade method is not possible. It has become the procedure of choice in this group.

Background Complications are possible following percutaneous enteral feeding in head and neck cancer patients and otolaryngologists should be aware of these as well as the possibility of liver metastases from these cancers. Case report A 53-year-old lady was treated by our service for metastatic squamous cell carcinoma of unknown primary origin. During radiotherapy treatment, a percutaneous endoscopic gastrostomy (PEG) tube was inserted to facilitate patient feeding. Severe abdominal pain developed and persisted around site of PEG tube insertion, the cause of which was discovered to be newly developed liver metastases from the tumor being compressed by the tube. Conclusion Liver metastases should be considered in patients developing persistent abdominal pain after PEG insertion.