Relationship of early acute complications and insertion site in push method percutaneous endoscopic gastrostomy

Abstract

Percutaneous endoscopic gastrostomy (PEG), which is frequently used for nutrition management in patients having difficulty with oral intake, is considered a safe procedure. However, serious complications may occur depending on site of the puncture. This study aimed to clarify whether push method PEG construction at the posterior wall (PW) of the greater curvature (GC) had a higher risk of complications. We retrospectively investigated the relationship between puncture site at the PW of the GC and early acute complications in 540 patients receiving PEG. Early acute complications were defined as bleeding or perforation within 30 days after the PEG procedure. PEG-related complications were observed in 80 patients in total, with early acute complications detected in 42 patients. PEG construction at the PW of the GC in 12 cases exhibited a significantly higher occurrence of early acute complications versus PEG at other sites (41.7% vs. 7.0%, p = 0.001). Further, multivariate analysis revealed PW at the GC to be independently associated with early acute complications (OR 9.59, 95% CI 2.82–32.61; p = 0.0003). It may be desirable to avoid PEG at the PW of the GC. If performed, clinicians should pay careful attention to early acute complications.

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

“…Of course, just below the epigastrium is located the anterior gastric wall, which does not have large vessels; when excess air volume over-inflates the stomach, it can be twisted either clockwise or counterclockwise along its organ axis, thus exposing the great or the lesser curvature and their vessels, and more extremely, perhaps the posterior gastric wall - there were at least 5 cases of PEG performed in the posterior gastric wall[ 15 , 20 , 44 , 51 ]. This stomach rotation has been fully documented by Croaker et al [ 63 ], who inserted a laparoscopic camera into the abdomen in order to study the movement of the viscera when inflated[ 58 , 64 ].…”

“…However, to the best of our knowledge, few reports have addressed the relationship between PEG site and complications. Lee et al [ 13 ] found by a multivariate analysis that PEG tube insertion in the upper body of the stomach was a significant risk factor for complication occurrence, with the most obvious reason being the relatively long distance between the gastric and abdominal walls in the upper body as compared with the lower gastric body; this distance produces stronger tension between the abdominal and gastric walls during stomach contraction, inducing slow or incomplete adherence and thus fistula formation[ 64 ].…”

Percutaneous Gastrostomies: Associated Complications in PUSH vs. PULL Techniques over 12 Years in a Referral Centre

“…Koide's group [25] also associated PUSH-type PEG as a risk factor for bleeding compared to PULL PEG (OR: 5.236, 95% confidence interval: 1.040-26.316; p = 0.045). The use of gastropexy points in the PUSH technique could explain the tendency towards a higher frequency of minor bleeding, These bleedings seem to be associated with puncture of the posterior wall of the gastric greater gastric curvature or with bleeding of the gastroespiploic arteries during fixation of the gastropexy points of PUSH PEGs with the Russell technique or PRGs; however, the group of Suzuki et al [26] found no differences in bleeding when comparing three and four fixation points (the former being used in our study). The group of Kucha et al [20] also found a higher incidence of probe displacement in PUSH PEG (14.0% vs. 0.7%).…”

Radiologically inserted gastrostomy complications: A case series

“…Significant bleeds due to arterial injury during RIG or PEG insertion are rare (0.2%-1.5% of patients); 1,12 however, they can be initially undetected, as occurred in case 1, which emphasises the need for careful monitoring of haemodynamic stability for several hours in post-anaesthesia care units and day-stay units prior to discharge. Suzuki et al 14 found a significant relationship between introducer-type (Russell) method gastrostomy construction at the posterior wall of the greater curvature and the early acute complications of puncture and bleeding compared with PEG at other sites, indicating that the posterior wall of the greater curvature should be avoided to prevent these serious complications when there is rotation of the stomach on the long axis. This rotation, where the greater curvature sits close to the anterior abdominal wall, enables dilator puncture to occur tangentially to the posterior wall when it is vertically inserted through the abdominal wall, which can result in tearing and arterial damage on the greater curvature.…”