Complication of Percutaneous Endoscopic Gastrostomy

Transcription

1 Complication of Percutaneous Endoscopic Gastrostomy Tube Ogori N. Kalu MD Morbidity & Mortality Conference General Surgery Service Kings County Hospital Center

2 ACGME Core Competencies 1. Medical knowledge 2. Patient care 3. Interpersonal and communication skills 4. Practice based learning 5. Systems based practice 6. Professionalism

3 Case Presentation 52 AA female on ENT service Medical history: locally invading, non obstructing squamous cell carcinoma of the left side of tongue No prior surgical history History of tobacco and alcohol consumption

4 Case Presentation Tentatively scheduled for primary tumor removal with free flap reconstruction Admitted to KCHC in July 2007 for preprocedure optimization: 1. tracheostomy 2. gastrostomy

5 Case Presentation - Hospital course xx : Tracheostomy done by ENT xx: General surgery consult for PEG xx: PEG placed in operating room Thin woman, all labs wnl Pull (Ponsky-Gauderer) technique endoscope passed into stomach, insufflation with air, puncture site located by transillumination i ti and external pressure 22Fr PEG tube placed with position confirmed endoscopically

6 Case Presentation - Hospital course 7/15: started t on tube feeds 7/18: called by primary service to reevaluate patient t for drainage around PEG tube. Exam: afebrile, VSS, WBC wnl soft abdomen with moderate distension, i tenderness around PEG site, drainage suspicious for stool CT abdomen/pelvis

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17 Case Presentation - Hospital course 7/19: exploratory laparotomy via small midline incision Findings: fully dislodged PEG tube, two holes in transverse colon adherent to anterior wall of stomach, with associated defect. Minimal stool spillage 6 cm transverse colon resected with primary anastamosis. Anterior stomach defect repair with new gastrostomy tube (20Fr foley) placed

18 Case presentation Hospital course 7/21 started on tube feeds, well tolerated 7/25 discharged home

19 Prevention and Management of Complications of PEG Tubes

20 Historical Perspective Dr. William Beaumont ( ) US Army surgeon, author of Experiments and Observations in Gastric Juice and Physiology of Digestion (1833) Based on the management of traumatic percutaneous gastrostomy of finjured dfur catcher Alexis St. Martin

21 Historical Perspective 1837 Norwegian surgeon Christian A. Egeberg initially described a surgical gastrostomy 1876 first successful gastrostomy done by Aristide Verneuil in France

22 Historical Perspective Open gastrostomy modified over time via the Stamm, Witzel, and Janeway techniques Morbidity and mortality rates of gastrostomy by laparotomy vary from 3% to 60%

23 Historical Perspective, cont d Drs. Michael Gauderer and Jeffrey Ponsky at the University Hospital of Cleveland described the first PEG intended for use in children 150 cases, no deaths, 10% minor complications easily treated J Pediatric Surg 1980; 15: Archives of Surgery 1983;118:

24 Historical Prespective, cont d. 1981: Canadian Preshaw described radiological approach of inserting gastrostomy tube via fluoroscopic guidance 1990s: laparoscopic approach

25 Epidemiology Over 200,000 PEG tubes are placed annually Up to 10% of nursing home residents and as many as 1.7% of Medicare patients over 85

26 Methods Comparison Measure Surgical Gastrostomy PEG PRG # of pts # of series Success rate 100% 95.7% 99.2% Procedural Mortality rate 2.5% 0.5% 0.3% Major complication i rate 199% 19.9% 94% 9.4% 59% 5.9% Minor complication rate 9% 5.9% 7.8%

27 Costs Comparison Procedure Surgical $ Endoscopic $ Radiologic$ i Gastrostomy Gastrojejunostomy Barkmeier JM, et al Cardiovasc. Intervent Radiol 1998 Jul-Aug; 21 (4) 324-8

28 Rt Retrospective ti Analysis 82 patients : 14 surgical, 24 PEG, 44 PRG Surgical PEG PRG Mortality Rate 0/14 0/24 1/44 Major complication i 2 (14%) 4 (17%) 5 (11%) Minor complication 6 (43%) 8 (33%) 16 (36%) Function at 1 year 67% 68% 58% Archives of Surgery Vol 133 No.10 October 1998

29 Indications Long term feeding: the American Gastroenterological Association endorses PEG tube placement for prolonged tube feeding (>30days). Replaces nasoenteric tube with decreased risk of aspiration, sinusitis Mechanical dysfunction near esophageal obstruction swallowing disorderd facial fractures

30 Indications Neurologic Impairment: stroke, closed head injury Permit transfer to long term facility Decompressive tube for palliation Gastric volvulus

31 Contraindications Terminal illness (except palliation) Inability to perform upper endoscopy obstructing esophageal tumor, stricture Ascites Inability to appose gastrostomy to anterior abdominal wall: previous subtotal gastrectomy, hepatomegaly

32 Relative Contraindications Coagulopathy Portal hypertension Peritoneal dialysis Large hiatal hernia

33 PEG Techniques The pull (Ponsky-Gauderer) technique vs the push (Sacks-Vine) technique No outcome difference Pull technique used more frequently Push technique used in radiologic and laparoscopic tube placement

34 Pull Technique Guide wire is placed in stomach Guide wire is brought retrograde through the patient s mouth PEG tube is pulled through abdominal wall

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43 Push Technique PEG tube advanced via modified Seldinger approach May involve dilators, peel away introducer

44 Major Complications Complication Frequency enc Aspiration up to 1.0% Hemorrhage 2.5% Peritonitis 1.3% Necrotizing fasciitis rare Death up to 2.1% Tumor implantation rare Gastroenterology 1987:93:48-52 Am. Surg, 2002;68: Practical Gastroenterology November 2004

45 Minor Complications Complication Frequency enc Ileus 1% - 2% Peristomal infection up to 30% Stomal leakage 1% - 2% Buried bumper 2.4% Gastric ulcer 1.2% Fistulous tracts up to 6.7% Inadvertent removal 1.6% - 4.4% Gastroenterology 1987;93;48-52 Gastrointest Endosc, 2002;56: Endoscopy, 2001;33:

46 Perforation of Viscera/Peritonitis Occurs in 0.5%-1.3% 13% of cases Abdominal pain, leukocytosis, ileus, fever Contrast studies Broad spectrum abx and surgical exploration

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48 Prevention Elevation of the head during placement to displace the colon inferiorly Use of an aspirating syringe filled with saline to identify intervening bowel between the skin and stomach if air bubbles appear in the syringe prior to endoscopic visualization of the needle in the gastric lumen. the safe track technique Fouch PG. Gastrointest Endosc Clin N Am, 1992;2:

49 Peristomal infection Most common complication Up to 30% with <1.6% needing aggressive debridement Increased risk in diabetics, obese, malnourished, steroids If early, oral abx Systemic signs, IV abx and local wound care

50 Buried Bumper Syndrome Partial or complete growth of gastric mucosa over the internal bumper Occurs 0.3% - 2.4% Presents as leakage, infection, immobile catheter, pain, resistance with feeds Risk factors excessive tension between bolsters, malnutrition, weight gain

51 Treatment of BBS Confirm endoscopically or radiographically Gastrograffin study with the patient prone Removal of PEG with any technique that t minimizes trauma to the PEG tract May need surgical removal

52 Practical Gastroenetrology November 2004