Percutaneous Endoscopic Gastrostomy Complications
Enteral nutrition (EN) is defined as the administration of nutrients through the digestive tract. There are many options for digestive tract EN: oral, nasoenteric tubes, and enterostomies. For short-term (< 6 weeks) EN, nasogastric or nasoenteric tubes are the best choice. However, in long-term (> 6 weeks) EN, enterostomies are indicated, involving percutaneous endoscopic gastrostomy (PEG) or jejunostomy, fluoroscopic, image-guided gastrostomy, and surgical or laparoscopic gastrostomy.
The modality of choice for long-term enteral nutrition access is PEG, which was first described in 1980 by Gauderer and by Ponsky.1,2 Although a PEG is generally safe and requires minimally invasive surgery ( Fig. 17.1 ), it is associated with many potential complications related to both its insertion and the prolonged stay of a foreign body in the abdominal wall.
There are some absolute contraindications to PEG placement, which include pharyngeal or esophageal obstructions, coagulopathy, sepsis, and any other general contraindications to endoscopy. Obese patients, pregnancy, previous abdominal surgery, ascites, hepatosplenomegaly, and portal hypertension are relative contraindications.3
Perforation during upper endoscopy procedures, as an inadvertent puncture of the pharynx, esophagus, stomach, small bowel, colon, liver, or spleen, has an incidence rate of 0.008 to 0.04%.4,5 Anatomic anomalies such as the finding of a transverse colon over the anterior gastric wall and those produced by radiotherapy, or previous surgery, contribute to the perforation in up to 50% of patients.3 Patients typically present with tachycardia, fever, odynodysphagia, respiratory distress, or sepsis. Early (> 24 h) recognition is vital and its diagnosis is based on radiographic study. If diagnosed, broad-spectrum antibiotics, tube thoracostomy and a wide surgical procedure must be performed. In selected hemodynamically stable patients with small perforations, nonoperative management may be appropriate.
Pneumoperitoneum is seen in up to 56% of patients after PEG placement procedures,6 but is usually of no clinical importance7 and conservative management is required. If a patient with pneumoperitoneum shows signs of sepsis or peritonitis, then imaging studies and appropriate treatment are mandatory.
Peritonitis is a PEG complication that often carries a high mortality rate, and can be caused by removal or displacement of the tube before tract maturation, leakage from the PEG puncture site in the stomach or perforation of another visceral organ. It is manifested in post-PEG patients as abdominal pain, fever, leukocytosis, and ileus, and can result in significant morbidity if not identified and treated early with broad-spectrum antibiotics and surgical repair.3