Enteral Access:The Old and the New

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Enteral AccessThe Old and the New

• Klaus Gottlieb, MD, FACP, FACG
• 1-888-PEG-TUBE

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Who benefits from long-term enteral feedings?

• Those who unable to eat or cannot eat adequate
  diet for periods longer than 5 days and who are
  likely to be fed for periods more than 3 or 4
  weeks.
• Patients with swallowing difficulties e.g. after
  a stroke. Stroke patients often resume swallowing
  within 2-4 weeks, and during that period feeding
  through a NG-tube is more appropriate. They
  should be considered for PEG insertion if after 4
  weeks following the stroke swallowing problems
  still persist.
• Patients with neurological conditions such as
  head injury, motor neuron disease, multiple
  sclerosis, cerebral palsy, myotonic dystrophy.
• Head and neck malignancy.
• Gut dysmotility.
• Psychiatric patients with eating disorders.
• Patients unable to tolerate a nasogastric tube or
  patients that for certain reasons long -term
  nasogastric tube feeding is not appropriate.

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Gastrostomy Methods

• Percutaneous Endoscopic (PEG)
• Radiological
• Surgical
• Accidental

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First Gastrostomy

• Diagram of Alexis St. Martin's wound (from Dr.
  Beaumont's book, Experiments and Observations on
  the Gastric Juice and the Physiology of
  Digestion, 1833)"This engraving represents the
  appearance of the aperture with the valve
  depressed.A A A Edges of the aperture through
  the integuments and intercostals, on the inside
  and around which is the union of the lacerated
  edges of the perforated coats of the stomach with
  the intercostals and skin.B The cavity of the
  stomach, when the valve is depresed.C Valve,
  depressed within the cavity of the stomach.E E E
  E Cicatrice of the original wound."

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Percutaneous Endoscopic Gastrostomy
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Button-PEGs
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Radiologic Gastrostomy
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T-Fasteners to pull the stomach against the
abdominal wall
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Commonly used tubes
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Surgical gastrostomy Witzel or Stamm
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The methods compared
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PEG costs least

• Barkmeier JM, Trerotola SO, Wiebke EA, et al
  Percutaneous radiologic, surgical endoscopic, and
  percutaneous endoscopic gastrostomy/gastrojejunost
  omy comparative study and cost analysis.
  Cardiovasc Intervent Radiol 1998 Jul-Aug 21(4)
  324-8

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What Medicare Actually Pays for PEG in 2003

• To the Hospital 406.71 (APC 0141)
• To the Physician 232.04 (CPT 43246)
• Total Medicare cost for PEG 638.75
• If no Medigap insurance, patient responsible
  for 127.75

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Advantages of P.E.G.

• Direct endoscopic visualization of upper GI
  tract Why is that important?
• More likely to be successful in an operated
  stomach
• Allows larger caliber tubes
• Allows conversion with jejunal extension tube

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Special situations

• Obstruction of the esophagus. Not a
  contraindication to PEG. Endoscopic dilation
  followed by PEG insertion
• Concomitant surgery gastrostomy and jejunostomy
  at the time of major abdominal operations is
  routinely done

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Before I forgetWhen PEGs come out

• Put a Foley in
• Put a Foley in
• Put a Foley in
• Recommended size 20 Fr, 30 cc balloon

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Jejunostomy
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PEG/PEJ Conversion
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Problems with PEG/PEJ conversion(jejunal
extension tube) The tube that keeps coming
back

• Placement arduous, difficult and not always
  successful
• Small tubes prone to clogging
• Jejunal tube migrates back into the stomach
• Staff often does not understand the plumbing,
  tubes come out accidentally

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Tube Thrombosis Emergency Care

• Some use Voodoo (Mountain-Dew, Diet Coke)
• Some use wire brushes
• Enzyme solutions
• Commercial
• Home Brew

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Enzyme Solutions

• Have somebody order
• 2 tablets of sodium bicarbonate
• 2 capsules of pancreatic enzymes (Pancrease)
• Mix with 10 cc of tap water, grind in mortar
• Flush into tube and hold pressure up to 3 minutes
• If above not helpful call 1-888-PEG-TUBE

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Surgical (laparoscopic) jejunostomy Stamm type
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Witzel Modification
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Direct percutaneous endoscopic jejunostomy tube
placement
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Direct percutaneous endoscopic jejunostomy, the
early Mayo Experience

• In 26 (72) of 36 patients, DPEJ placement was
  successful.
• During the mean follow-up of 107 days, none of
  the patients with DPEJ required reintervention
  for tube malfunction or displacement.
• Two patients developed a persistent
  enterocutaneous fistula following the removal of
  the DPEJ tube. No other procedure-related
  complications were noted.
• Fifteen (78) of 19 patients who responded to
  follow-up questions reported an overall
  satisfaction rating of 8 or higher on a 10-point
  scale (1, completely dissatisfied, to 10,
  completely satisfied).

Mayo Clinic Proceedings 2000 75807-810
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DJ compared with PEG-J, more recent Mayo data

• 56 pts with DJ (20 F), 49 with PEG-J (9F)
• 6 months follow up
• Reinterventions
• DJ (direct percutaneous endoscopic jejunostomy)
  5 of 56 or 9
• PEG-J (PEG with J-tube extension) 19 of
  49 or 38.7
• Gastrointest Endosc 2002 Dec56(6)890-4

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DJ 85 successful

• The direct percutaneous endoscopic jejunostomy
  technique allows placement of tubes directly in
  the jejunum with a success rate of around 85 and
  a minimal complication rate which is comparable
  to that of PEGs.
• Shike M, Latkany L.Gastrointest Endosc Clin N
  Am 1998 Jul8(3)569-80

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Technical Improvements

• MicrovasiveEndoVive Direct PEJs
• Combines sounding needle with trocar

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Ideal candidate for DJ

• Reasonable life expectancy
• Not obese
• Prior abdominal surgeries no contraidication
• Good performance status

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Complications of Enteral Feeding
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Complications Specific to PEG
Exit Site Infection
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PEG Tube Exit Site Infection

• Frequent occurrence
• External retention device pulled too tight
  against abdominal wall (skin necrosis)
• Initial skin incision not long or deep enough
  (tube itself exerts pressure leading to
  necrosis/infection)
• Severely debilitated patients with impaired
  immune responsew

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How to deal with exit site infections

• Make sure PEG rotates easily, bumper is not too
  tight
• Meticulous local wound care (Betadine, diluted
  peroxide solution, light non-occlusive dressing
  frequently changed)
• Broad spectrum oral antibiotics (Bactrim has a
  surprisingly good activity against many skin
  organisms)
• If there is frank pus, obtain a culture

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The leaking PEG

• Most common reason
• Chronic low grade exit site infection
• The biggest mistake
• Exchanging existing tube for one with a larger
  diameter (the Plumbers Choice)
• The second most common mistake
• Attaching a Colostomy bag (creating the Petry
  dish environment, bacteria, molds and fungi LOVE
  THAT)

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The leaking PEG

• If it just leaks a little, it is possible to
  salvage it (see under exit site infections)
• If it looks like Alexis St. Martins gastrostomy,
  the tube needs to come out

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PEGsA Haven for Yeasts

• Gottlieb K, DeMeo M, Borton P, Mobarhan S.
• Gastrostomy tube deterioration and fungal
  colonization.
• Am J Gastroenterol 1992 Nov87(11)1683
• Gottlieb K, Leya J, Kruss DM, Mobarhan S, Iber FL
• Intraluminal fungal colonization of gastrostomy
  tubes.
• Gastrointest Endosc 1993 May-Jun39(3)413-5
• Marcuard SP, Finley JL, MacDonald KG.
• Large-bore feeding tube occlusion by yeast
  colonies.
• JPEN J Parenter Enteral Nutr 1993
  Mar-Apr17(2)187-90
• Gottlieb K, Iber FL, Livak A, Leya J, Mobarhan S.
• Oral Candida colonizes the stomach and
  gastrostomy feeding tubes.
• JPEN J Parenter Enteral Nutr 1994
  May-Jun18(3)264-7

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Iber FL, Livak A, Patel M.Importance of fungus
colonization in failure of silicone rubber
percutaneous gastrostomy tubes (PEGs). Dig Dis
Sci 1996 Jan41(1)226-31

• Silicone rubber PEG tubes or replacements were
  recovered from 111 patients and examined for
  blockage, dilatations, tears, breaks, or loss of
  elasticity. All irregularities were stained and
  examined for fungus using lactophenol cotton blue
  stain. The intraabdominal portion of the PEG
  failed from obstructions, loss of elasticity, or
  tears related to fungus colonies in 36 of cases.
  An additional 34 were colonized with fungi but
  did not fail. On frozen section, the fungus
  invaded the wall of the tubing. The
  extraabdominal PEG tubing failed from fungi in
  12, and 10 additional tubes had colonizations.
  Nine tubes had distal clogging with crystalline
  material that is believed to arise from
  medication. Fungus tube failure occurred in 37
  of the tubes in place 250 days and in 70 of
  tubes in place 450 days. Fungus is an important
  cause of PEG failure recommendations are
  provided to maintain tube patency.

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The deteriorating PEG

• Microbial deterioration of the silicone
• Candida species and other microorganisms can
  metabolize silicone/additives
• Can the tube be trimmed?
• If not Variety of replacement options
• Foley-type (with balloon)
• Ponsky type (with original style bumper)
• Button PEG

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Summary

• What should I remember from this talk?
• Enteral access options
• The advantages of endoscopic PEG
• Trouble shooting
• Direct jejunostomy as a major innovation
• The numbers 8-8-8