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Thinking Outside the Box of the Gastrostomy Kit: Stylet-Assisted Technique for Challenging Gastrostomy Tube Replacements
ELECTRONIC IMAGE OF THE MONTH Thinking Outside the Box of the Gastrostomy Kit: Stylet-Assisted Technique for Challenging Gastrostomy Tube Replacements Ana Ponte, Rolando Pinho, and João Carvalho Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia, Espinho, Portugal
n 84-year-old man with dementia presented with a 6-hour history of unintended dislodgement of a percutaneous endoscopic gastrostomy (PEG) tube (24 Fr Pull PEG; US Endoscopy, Mentor, OH), placed 4 months earlier. Physical examination showed a PEG stoma that was partially closed in the epigastrium, preventing insertion of the balloon gastrostomy tube (PEG24-BRT-S; Cook Medical, Inc, Bloomington, IN). After confirming the permeability of the gastrocutaneous tract with a nasogastric tube (Figure A), replacement using a stylet-assisted technique was planned (Figure B). The balloon gastrostomy tube was strengthened by passing a stylet inside (Satin-Slip 10Fr Intubating Stylet; Mallinckrodt Medical, St. Louis, MO), providing increased stiffness while retaining some flexibility, and leaving 2.5 cm of free stylet distal to the balloon gastrostomy tube tip for guidance (Figure C). This stylet is composed of an outer plastic layer and an inner malleable metallic wire that was left 2 cm behind the plastic layer, enhancing its safety (Figure C). The stylet was introduced into the gastric lumen carefully until a minor resistance was felt, indicating contact of the stylet with the opposite gastric wall. The balloon gastrostomy tube then was smoothly advanced over the stylet (Figure D). After replacement of the balloon gastrostomy tube, the stylet was removed, and the balloon was inflated. Adequate positioning was confirmed by prompt aspiration of gastric fluid contents through the gastrostomy tube. Since its advent in 1980, PEG now is recognized as an efficient and successful means of providing
A
long-term enteral nutrition.1–4 Despite its safety, PEG placement may result in complications, such as early and late unintentional removals, which occur in up to 5.3% of cases.3–5 Late dislodgements occur when the fistula has maturated, preventing peritoneal leakage, thus resulting in less morbidity and consequent underestimation in earlier studies when compared with early removals.2,3,5 A recent study reported a higher rate of late dislodgments of up to 12.8%.3 After tube displacement, the gastrocutaneous track is prone to closure within 12 to 24 hours.2,5 If the fistula has begun to close, insertion of the malleable PEG tube may be difficult, leading to bending of the tube when axial force is applied.1 The stylet-assisted technique appears to be a safe and useful approach for challenging gastrostomy tube replacements.
References 1.
Kumar S, Dreyer JS. Stylet reinforcement method for replacement of percutaneous gastrostomy tubes: a useful technique using endoscopic biopsy forceps. Endoscopy 2004;36:466.
2.
Westaby D, Young A, O’Toole P, et al. The provision of a percutaneously placed enteral tube feeding service. Gut 2010; 59:1592–1605.
3.
Rosenberger LH, Newhook T, Schirmer B, et al. Late accidental dislodgment of a percutaneous endoscopic gastrostomy tube: an underestimated burden on patients and the health care system. Surg Endosc 2011;25: 3307–3311.
Clinical Gastroenterology and Hepatology 2015;13:e137–e138
ELECTRONIC IMAGE OF THE MONTH, continued 4.
5.
e138
Gaines DI, Delegge MH. Semiurgent endoscopic PEG tube replacement as a treatment for early initial PEG tube dislodgement in the immune-compromised patient. Dig Dis Sci 2005; 50:2248–2250. ASGE Training Committee 2013-2014, Enestvedt BK, Jorgensen J, et al. Endoscopic approaches to enteral feeding and nutrition core curriculum. Gastrointest Endosc 2014;80:34–41.
Conflicts of interest The authors disclose no conflicts. Most current article © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.01.011
n 84-year-old man with dementia presented with a 6-hour history of unintended dislodgement of a percutaneous endoscopic gastrostomy (PEG) tube (24 Fr Pull PEG; US Endoscopy, Mentor, OH), placed 4 months earlier. Physical examination showed a PEG stoma that was partially closed in the epigastrium, preventing insertion of the balloon gastrostomy tube (PEG24-BRT-S; Cook Medical, Inc, Bloomington, IN). After confirming the permeability of the gastrocutaneous tract with a nasogastric tube (Figure A), replacement using a stylet-assisted technique was planned (Figure B). The balloon gastrostomy tube was strengthened by passing a stylet inside (Satin-Slip 10Fr Intubating Stylet; Mallinckrodt Medical, St. Louis, MO), providing increased stiffness while retaining some flexibility, and leaving 2.5 cm of free stylet distal to the balloon gastrostomy tube tip for guidance (Figure C). This stylet is composed of an outer plastic layer and an inner malleable metallic wire that was left 2 cm behind the plastic layer, enhancing its safety (Figure C). The stylet was introduced into the gastric lumen carefully until a minor resistance was felt, indicating contact of the stylet with the opposite gastric wall. The balloon gastrostomy tube then was smoothly advanced over the stylet (Figure D). After replacement of the balloon gastrostomy tube, the stylet was removed, and the balloon was inflated. Adequate positioning was confirmed by prompt aspiration of gastric fluid contents through the gastrostomy tube. Since its advent in 1980, PEG now is recognized as an efficient and successful means of providing
A
long-term enteral nutrition.1–4 Despite its safety, PEG placement may result in complications, such as early and late unintentional removals, which occur in up to 5.3% of cases.3–5 Late dislodgements occur when the fistula has maturated, preventing peritoneal leakage, thus resulting in less morbidity and consequent underestimation in earlier studies when compared with early removals.2,3,5 A recent study reported a higher rate of late dislodgments of up to 12.8%.3 After tube displacement, the gastrocutaneous track is prone to closure within 12 to 24 hours.2,5 If the fistula has begun to close, insertion of the malleable PEG tube may be difficult, leading to bending of the tube when axial force is applied.1 The stylet-assisted technique appears to be a safe and useful approach for challenging gastrostomy tube replacements.
References 1.
Kumar S, Dreyer JS. Stylet reinforcement method for replacement of percutaneous gastrostomy tubes: a useful technique using endoscopic biopsy forceps. Endoscopy 2004;36:466.
2.
Westaby D, Young A, O’Toole P, et al. The provision of a percutaneously placed enteral tube feeding service. Gut 2010; 59:1592–1605.
3.
Rosenberger LH, Newhook T, Schirmer B, et al. Late accidental dislodgment of a percutaneous endoscopic gastrostomy tube: an underestimated burden on patients and the health care system. Surg Endosc 2011;25: 3307–3311.
Clinical Gastroenterology and Hepatology 2015;13:e137–e138
ELECTRONIC IMAGE OF THE MONTH, continued 4.
5.
e138
Gaines DI, Delegge MH. Semiurgent endoscopic PEG tube replacement as a treatment for early initial PEG tube dislodgement in the immune-compromised patient. Dig Dis Sci 2005; 50:2248–2250. ASGE Training Committee 2013-2014, Enestvedt BK, Jorgensen J, et al. Endoscopic approaches to enteral feeding and nutrition core curriculum. Gastrointest Endosc 2014;80:34–41.
Conflicts of interest The authors disclose no conflicts. Most current article © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.01.011