Published online: 2020-09-16 THIEME Research Article 193 Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG)—Single-Center Experience and Outcome Avinash Bhat Balekuduru1 Shruti Sagar Bongu1 Narendra Babu Mandalapu1 Gajendra Ramachandraiah1 Vinit Kumar Khemka1 Satyaprakash Bonthala Subbaraj1 1Department of Gastroenterology, M.S. Ramaiah Hospitals, Address for correspondence Avinash Bhat Balekuduru, DM, Bangalore, Karnataka, India Department of Gastroenterology, M.S. Ramaiah Hospitals, Bangalore 560054, India (e-mail: [email protected]). J Digest Endosc:2020;11:193–200 Abstract Background Gastrointestinal route is considered for feeding in subjects who are unable to swallow, either as a temporary or permanent option. Percutaneous endo- scopic gastrostomy (PEG) is the preferred mode for long-term enteral nutrition. The aim was to study the outcome of protocol-based PEG placement in a tertiary medical center. Materials and Methods All the patients who underwent PEG placement between January 2017 and December 2019 were included in the retrospective study. Study vari- ables were entered into a uniform structured proforma. The procedure was done by two people using Ponsky-Gauderer pull-technique. Fluoroscopy guidance was consid- ered for placement in special situations. Post-procedure, all the patients were regularly followed as per protocol to evaluate for adverse events. Results One hundred and eighteen patients with placement of PEG were included in the study. The mean age of the patients was 49.6 ± 7 years with 67.8% males. The most common indication of PEG was inability to swallow associated with head injury (43, 36.4%), followed by carcinoma esophagus (35, 29.8%) and stroke (24, 20.3%). Fluoroscopy was useful in 38 (32%) for PEG site identification. Tube dislodgement (16, 13.5%) and aspiration pneumonia (20, 16.9%) were the common adverse events. Age more than 60 years and dysphagia in neurologic disorders accounted for more Keywords than 60% of adverse events. Forty-nine (42%) of the PEG patients expired due to either ► percutaneous primary illness or due to sepsis after a median time of 139 days (range: 32–288 days). endoscopic There was no difference in the survival in patients with or without PEG-related compli- gastrostomy cations (p = 0. 74). ► fluoroscopy Conclusions Fluoroscopy assistance helps in accurate PEG placement in one third. ► complications Age > 60 years and dysphagia in neurologic disorders were independent risk factors ► F-PEG associated with PEG tube complications. Introduction radiological gastrostomy due to superior outcome both in terms of morbidity and mortality.2-4 For long-term nutrition Percutaneous endoscopic gastrostomy (PEG) was first in neurological dysphagia, PEG is preferred over nasogastric 1 reported by Gauderer et al. For enteral nutrition, PEG (NG) tube due to aesthetic appeal, avoidance of uncomfort- gained preference over the already established surgical or able oropharyngeal symptoms, less chance of oropharyngeal DOI https://doi.org/ ©2020 Society of Gastrointestinal 10.1055/s-0040-1716580 Endoscopy of India ISSN 0976-5042. 194 Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG) Balekuduru et al. candidiasis and respiratory infections, averting esophageal performed by the same endoscopic team under supervised ulcer and stricture, and reduced risk of clogging or dis- anesthesia. placement of tube.5-8 Also, overnight feeding is safer with a PEG tube.9 Inclusion Criteria In contrast to PEG, the placement of NG tube is relatively Patients presenting with neurological diseases having easy at the bedside by trained medical staff. The accuracy of reduced level of consciousness (e.g., cerebrovascular disease, NG tube position can be easily confirmed by auscultation motor neuron disease, head injury), cancer of head and neck over the upper abdomen on air insufflation through the tube or esophagus, and gastric volvulus were included. All patients or by aspiration of gastric contents and occasionally by radio- were on enteral feeds through a NG prior to PEG tube inser- graphic examination.10 tion. In gastric volvulus, fixation of anterior stomach wall to Although PEG placement is safe, it has both early and the abdominal wall was the primary aim to prevent recur- late complications like bleeding, peritonitis, bowel obstruc- rence. In patients on dual antiplatelets (aspirin and clopido- tion or perforation, and abscess at the operative site.7,11,12 grel), clopidogrel was stopped 7 days before the procedure The reported PEG-related morbidity and mortality are while continuing aspirin. Patients on warfarin were changed 9–17% and 0–10%, respectively.3,13 The American Society of over to low molecular weight heparin for 5 days before the Gastrointestinal Endoscopy recommends PEG insertion in procedure. The last dose of heparin was given 12 hours before patients who are expected to survive longer than 1 month procedure and restarted after 6 hours, post-procedure. after the procedure.14 The use of fluoroscopy at PEG tube placement (F-PEG) is Exclusion Criteria infrequently reported.15 In patients with ventriculoperitoneal Following are the exclusion criteria: Coagulopathy shunts, fluoroscopy assists in identifying and avoiding it, and (International Normalized Ratio > 1.5, partial thromboplas- helps select a suitable site for PEG placement. Fluoroscopy is tin time > 50 seconds, platelets < 50,000/mm3), hemody- also useful in patients having altered upper gastrointestinal namic instability, sepsis, gross ascites, peritonitis, peritoneal (GI) anatomy, kyphoscoliosis, gastric volvulus, or pseudo- carcinomatosis, history of total gastrectomy, gastric outlet obstruction. It can occasionally help in confirming accidental obstruction, and lack of informed consent for the procedure. colonic or small bowel injury during puncture and also aids Those with documented fever or significant leucocytosis in detection of any significant pneumo-peritoneum at the were excluded. time of procedure.16 PEG remains an underutilized procedure in India, mainly Technique due to lack of inclination or awareness among the treating All the patients received betadine oral gargle on the night physicians.17 The aim of our study was to study the outcome before procedure. After overnight fasting, oral cleansing of protocol-based PEG placement in a tertiary medical center. was performed in the morning on the day of procedure. Prophylactic antibiotic was given before the procedure (1 gm of ceftriaxone/vancomycin). Materials and Methods The procedure was performed in an endoscopy room Data was collected retrospectively for all the patients who having fluoroscopy facility. PEG procedure was done by two underwent a PEG tube placement between January 2017 and people using Ponsky-Gauderer pull-technique using standard December 2019 at our hospital. The study was approved by flexible endoscope (GIF–Q 150/H 180-Olympus, Tokyo, Japan) Institute Ethical Committee. and 24Fr gastrostomy tube (Wilson-Cook, Winston-Salem, The baseline data points captured included age, gender, North Carolina, United States).18 At endoscopy, luminal con- comorbidities, indications, and contraindications for PEG. tents were cleared including from hypopharynx (►Fig. 1). Also, regular follow-up data was maintained (especially A balloon replacement tube (BRT) was used for PEG looking for adverse events associated with PEG), includ- exchange when required. The BRT tube was inserted at previ- ing its removal. The patients underwent the procedure ous gastrostomy site and balloon was inflated to the capacity after required informed consent. All the procedures were with prefilled syringes. Fig. 1 (A) Pooling of secretions in the posterior pharyngeal wall; (B) Guidewire (GW) wire passed along side of existing percutaneous endo- scopic gastrostomy (PEG) tube that was held by snare as in image (C) for PEG exchange. In image (D), an Asepto pump was being used for home-based blenderized feeds. Journal of Digestive Endoscopy Vol. 11 No. 3/2020 Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG) Balekuduru et al. 195 Post-PEG Care the PEG tract was defined by bleeding from any side of the Patients were kept nil orally after PEG procedure for 8 hours. PEG tract that can present as external wound bleeding, sub- Prior to PEG feeding, the tube site was inspected and free cutaneous hematoma at PEG site, melena or other forms of GI rotation of tube and the external bolster was confirmed. Tube bleeding confirmed to be from PEG site on endoscopy and/or feeding was started with 100 to 200 mL of clear liquids, after drop in hemoglobin concentration.24 PEG tube obstruction was ensuring no abdominal pain, vomiting, or tube leakage as per identified by inability to pass feed or flush water down the protocol.19 After 4 hours, PEG feeds were initiated in boluses tube with no visible sign of tube kinking.24 of 250 mL in 20 minutes for every 4 hours. Flushing with The patients that recovered from primary illness and 20 mL of water was done after every feeding. At discharge, resumed oral intake had their PEG tube removed. the patients’ family were instructed about feeding, and made aware of potential PEG-related complications (mentioned Statistical Analysis below) and follow-up (either telephonically or physically) as Data were reported as mean ± standard deviation) for con- per clinical requirement. tinuous variables and frequencies (percentages) for categor- Aspiration pneumonia was defined by new development ical variables. All analyses were performed