- Email: [email protected]
Unsedated transnasal PEG placement
Unsedated transnasal PEG placement Je´roˆme Dumortier, MD, PhD, Marie-George Lapalus, MD, Adelino Pereira, MD, Jean-Pierre Lagarrigue, MD, Annick Chavaillon, MD, Thierry Ponchon, MD, PhD Lyon, France
Background: By using a small-diameter endoscope, EGD can be performed transnasally in adults. A prospective study was conducted to evaluate the feasibility of transnasal PEG placement without conscious sedation. Methods: Unsedated transnasal PEG was attempted in 23 patients by using a 5.9-mm-diameter videoendoscope. The indication for PEG insertion, success or failure, reason(s) for failure, and adverse effects of the procedure were recorded. During the first month, all patients were monitored by telephone contact for complications and to verify functionality of the PEG. Results: Transnasal PEG insertion was successful in 21 (91%) patients. The cause for failure was the inability to transilluminate the abdominal wall. Complications included epistaxis (n = 1), minor wound infection (n = 1), and soiling around the stoma (n = 1). Of the 21 patients in whom transnasal PEG placement was successful, all were alive, with a functional gastrostomy at the 1-month follow-up. Conclusions: Unsedated transnasal PEG tube insertion is minimally invasive, is feasible in daily practice in selected patients, and rarely is associated with complications. (Gastrointest Endosc 2004;59:54-7.)
Since the first description by Gauderer et al.1 in 1980, the minimally invasive PEG procedure has become the worldwide standard for direct gastric access.1 Initially developed for use in children, PEG has profoundly impacted nutritional management, particularly among adult patients. Over 216,000 PEGs are performed annually in the United States.2 Improved guidelines for its use and technical refinements have enhanced the safety of the PEG procedure. Conscious sedation is used routinely by most endoscopists during upper diagnostic and therapeutic endoscopy, including PEG.3-6 The associated cardiopulmonary risks, especially as a consequence of hypoxia, are well known.5,7-11 New methods that increase patient tolerance for EGD would reduce the need for conscious sedation. With the development of endoscopes with insertion tube diameters of 5.3 mm and 5.9 mm, unsedated transnasal EGD was shown to be feasible and to enhance patient tolerance compared with conventional peroral EGD.12 At present, unsedated transnasal EGD is used routinely for diagnostic upper endoscopy.13 Received February 24, 2003. For revision June 4, 2003. Accepted October 3, 2003. Current affiliations: Department of Digestive Diseases, Hoˆpital Edouard Herriot, Lyon, France. Reprint requests: Je´roˆme Dumortier, MD, Fe´de´ration des Spe´cialite´s Digestives, pavillon H, Hoˆpital Edouard Herriot, 69437 Lyon Cedex 03, France. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(03)02526-4 54
GASTROINTESTINAL ENDOSCOPY
The aim of this study was to prospectively assess the feasibility of transnasal PEG tube placement in selected patients, especially those with oropharyngeal neoplastic obstruction or with complications of stroke or dementia.
PATIENTS AND METHODS A forward-viewing ‘‘pediatric’’ videoendoscope was used for all procedures (GIF-XP160; Olympus Optical Co., Ltd., Tokyo, Japan). This endoscope has the following characteristics: outer diameter, 5.9 mm; air/water and accessory channel diameter, 2 mm; depth of field, 3 to 100 mm; working length, 1030 mm; field of view, 1208; and tip flexion, 1808 up, 908 down, 1008 left and right. All procedures were performed by senior endoscopists with experience in transnasal EGD. Topical anesthesia is induced in the nasal cavities by applying a solution of 5% lidocaine and 0.002% naphazoline (Astra France, Nanterre, France) with cotton pledgets and spraying of 5% lidocaine. The endoscope was inserted blindly (as for a nasogastric tube), or under visual control, through the more patent nostril to the pharynx. If it proved impossible to insert the instrument through one nostril, the other was used. The upper esophageal sphincter was passed under direct vision, and the esophagus, the stomach, and the first and second portions of the duodenum were examined in the usual manner. After infiltration of the subcutaneous tissue of the abdomen, a 20F gastrostomy tube with a soft retention dome (Bard Interventional Products Division, Billerica, Mass.) was placed, through the nose, by using the pull technique. To facilitate passage through the nostril, the retention dome was manually compressed by the operator. The ability to introduce the PEG bumper was VOLUME 59, NO. 1, 2004
Unsedated transnasal PEG placement
assessed by passage of the 5.9-mm-diameter endoscope at the beginning of the procedure; the diameter of the bolster, when manually compressed, was always less than that of the endoscope. The endoscope and gastrostomy tube were well lubricated before transnasal passage. All procedures were performed by two endoscopists assisted by a nurse. Duration of the endoscopic procedure was recorded. All procedures were conducted without administration of any sedative medication. All patients fasted for 6 hours before the procedure and were monitored by pulse oximetry and automated blood-pressure measurement during the procedure. Antibiotics (amoxicillin, clavulanic acid) were administered intravenously during the perioperative period (24 hours). Before the procedure, mupirocin was applied topically to the nasal mucosa (single dose) to eliminate Staphylococcus aureus (S aureus). A total of 91 adult patients were referred for PEG placement from February 1, 2000 to December 1, 2002. Exclusion criteria were the following: mechanical ventilation with sedation, stupor, and coma. Only patients in stable condition were included; those with an acute illness were excluded. Thus, transnasal insertion was attempted in 23 patients. Standard informed consent for PEG insertion was obtained from the patient or a relative. To evaluate the feasibility of transnasal PEG, the operator indicated whether the procedure was successful or unsuccessful (including the reason for failure) and recorded any adverse effect. During the first month, all patients were monitored by telephone contact for complications and to verify the functionality of the gastrostomy.
RESULTS Transnasal insertion of PEG was attempted in 23 patients (12 men, 11 women; median age, 63 years; range 46-91 years). The indications for PEG placement were stroke (n = 9, 39%); dementia, with refusal to eat (n = 8, 35%); and oropharyngeal obstructive malignancy, with or without trismus (n = 6, 26%). No patient was undergoing mechanical ventilation. Transnasal PEG placement was successful in 21 (91%). The reason for failure in two patients was the inability to transilluminate the stomach. A PEG was placed under fluoroscopic guidance without endoscopy in one patient. The duration of the endoscopic procedures ranged from 7.5 to 19.3 minutes (mean 9.5 minutes). Minor complications included epistaxis (n = 1), caused by endoscope trauma; minor wound infection, requiring systemic administration of antibiotics but not removal of the tube (n = 1); and soiling around the stoma that required local care and tightening of the discs holding the gastric wall to the abdominal wall (n = 1). There was no major complication, such as apnea, hypoxemia, peritonitis, hemorrhage, aspiration pneumonia, acute cardiovascular event, or severe wound infection. VOLUME 59, NO. 1, 2004
J Dumortier, M-G Lapalus, A Pereira, et al.
Of the 21 patients in whom transnasal PEG placement was successful, all were alive with a functional gastrostomy at the 1-month follow-up. Self-extubation was not observed during this period. DISCUSSION Transnasal EGD originally was regarded as an alternative procedure when transoral intubation was impossible or the patient was unable to tolerate transoral insertion of an endoscope.14,15 The feasibility of transnasal EGD with small-diameter endoscopes is well established, and this technique offers certain theoretical advantages. It was demonstrated by us that the increased patient tolerance is related to the transnasal route and not the smaller diameter of the endoscope.12 The patient can speak during the procedure, which probably reduces anxiety. Side effects, such as gagging, retching, vomiting, and choking, and, thereby, the risk of aspiration, also are minimized. The transnasal route improves patient tolerance and can reduce the need for administration of sedative drugs. At present, unsedated transnasal EGD can be considered as a well-tolerated method for routine diagnostic upper endoscopy. Moreover, the transnasal approach could probably be used for therapeutic purposes. Transnasal PEG had been described in a few patients.16-20 The results of the present study confirm that this method is feasible in selected patients and that complications are rare. The main limitation of transnasal PEG tube insertion is the need to pass the PEG device through the nostril. Factors that influence the feasibility of transnasal endoscopy in a prospective study of 1100 patients undergoing EGD were assessed by us.13 Transnasal EGD was possible in 93.9% of patients, similar to the success rate in the present study (21/23) for standard PEG placement. Feasibility was related to gender, age, and endoscope diameter. Thus, female gender, young age (#35 years), and larger endoscope diameter were significant predictive factors of failure: the failure rate was 8.5% in women vs. 3.2% in men, 10.5% in younger vs. 4.5% in older patients, and 4.7% with using the 5.3-mm-diameter endoscope compared with 16.7% with the 5.9-mm-diameter instrument. The high failure rate for transnasal PEG in the study of Lustberg and Darwin20 (50%) could be because of the use of a 7.9-mm-diameter endoscope (GIF-XP20; Olympus). Adverse effects related to transnasal PEG tube placement were rare in the present study. In our study of 1100 patients undergoing transnasal EGD, minor side effects included epistaxis (2.3%), nasal pain (1.6%), and vasovagal reaction (0.3%).13 Usually, epistaxis persisted for a few minutes and GASTROINTESTINAL ENDOSCOPY
55
J Dumortier, M-G Lapalus, A Pereira, et al.
resolved spontaneously. In our experience, it is essential that both a vasoconstrictor and anesthetic agent be applied to the nasopharynx. Transnasal PEG tube placement may be preferable to other methods that are potentially more invasive and carry a higher cost. The cost of transnasal PEG is difficult to determine accurately and was not evaluated in the present study. However, unsedated PEG insertion potentially could reduce costs. The cost of the drugs usually used for sedation is relatively unimportant, but transnasal PEG insertion may reduce procedure time and patient recovery time, the number of recovery beds needed, and the requirements for support personnel in the endoscopy unit. The risk of infection associated with transnasal insertion of a PEG is a particular concern. When using a standard peroral technique, it has been demonstrated that prophylactic administration of antibiotics significantly reduces the risk of peristomal wound infection, especially with the pull technique.21-24 Amoxicillin and clavulanic acid are the antibiotics most widely recommended for prophylaxis, and these were administered in the present study. However, the bacteriology of peristomal infection after PEG insertion has not been studied extensively, making the optimal choice of antibiotic for prophylaxis uncertain. Hull et al.25 studied peristomal infection after PEG tube insertion, including the contribution of methicillin-resistant S aureus. Nasal and pharyngeal swabs were taken from 31 consecutive patients before PEG insertion. Bacterial colonization and infection at the peristomal site were evaluated prospectively at days 2, 3, and 7 after insertion. Nasopharyngeal colonization by methicillin-resistant S aureus (35%) invariably led to peristomal colonization after PEG insertion. Peristomal infection occurred in 8 (26%) patients; 7 (88%) were caused by methicillin-resistant S aureus. Peristomal infection was significantly more likely to occur in patients in whom the nasopharynx was colonized with methicillin-resistant S aureus (odds ratio 10.8: 95% CI[1.6, 70.9]). These results strongly indicate that currently recommended antibiotic regimens for prophylaxis may be inappropriate in patients with significant methicillin-resistant S aureus colonization. With regard to transnasal PEG insertion, this led us to add prophylactic intranasal application of mupirocin, which has been shown to significantly decrease the rate of all nosocomial S aureus infections among the patients who were S aureus carriers.26 The rate of severe complications associated with PEG placement is 1% to 3%; the mortality rate is 1%.27,28 The low complication rate and absence of 56
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Unsedated transnasal PEG placement
mortality in the present small series may be related to the good status of the patients (none were being ventilated mechanically, and all were in stable condition) and that administration of sedative drugs was avoided. Probably for the same reasons, there was no death at the 1-month follow-up, in contrast to other studies in which the mortality rate was approximately 20%.29,30 Transnasal PEG insertion can be performed without conscious sedation in selected patients and has extremely low morbidity and mortality rates. This method may be useful in patients in whom a peroral approach is impossible (oropharyngeal malignant obstruction or trismus), as well as patients for whom sedation and general anesthesia are contraindicated. However, the promising results obtained in the present series must be confirmed in larger studies. REFERENCES 1. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5. 2. Gauderer MW. Percutaneous endoscopic gastrostomy 20 years later: a historical perspective. J Pediatr Surg 2001; 36:217-9. 3. Keeffe EB, O’Connor KW. 1989 A/S/G/E survey of endoscopic sedation and monitoring practices. Gastrointest Endosc 1990; 36:S13-8. 4. Daneshmend TK, Bell GD, Logan RF. Sedation for upper gastrointestinal endoscopy: results of a nationwide survey. Gut 1991;32:12-5. 5. Quine MA, Bell GD, McCloy RF, Charlton JE, Devlin HB, Hopkins A. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut 1995;36:462-7. 6. Froehlich F, Gonvers JJ, Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland. Endoscopy 1994;26:231-4. 7. Bell GD. Review article: premedication and intravenous sedation for upper gastrointestinal endoscopy. Aliment Pharmacol Ther 1990;4:103-22. 8. Hart R, Classen M. Complications of diagnostic gastrointestinal endoscopy. Endoscopy 1990;22:229-33. 9. O’Connor KW, Jones S. Oxygen desaturation is common and clinically underappreciated during elective endoscopic procedures. Gastrointest Endosc 1990;36:S2-4. 10. Arrowsmith JB, Gerstman BB, Fleischer DE, Benjamin SB. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc 1991;37:421-7. 11. Scott-Coombes DM, Thompson JN. Hypoxia during upper gastrointestinal endoscopy is caused by sedation. Endoscopy 1993;25:308-9. 12. Dumortier J, Ponchon T, Scoazec JY, Moulinier B, Zarka F, Paliard P, et al. Prospective evaluation of transnasal esophagogastroduodenoscopy: feasibility and study on performance and tolerance. Gastrointest Endosc 1999;49:285-91. 13. Dumortier J, Napoleon B, Hedelius F, Pellissier PE, Leprince E, Pujol B, et al. Unsedated transnasal EGD in VOLUME 59, NO. 1, 2004
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14.
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22.
daily practice: results with 1100 consecutive patients. Gastrointest Endosc 2003;57:198-204. Johnson DA, Cattau EL Jr, Khan A, Newell DE, Chobanian SJ. Fiberoptic esophagogastroscopy via nasal intubation. Gastrointest Endosc 1987;33:32-3. Gopal DV, Zaman A, Katon RM. A role for transnasal esophagogastroduodenoscopy in patients intolerant to the oral route: report of two cases. Gastrointest Endosc 1999; 49:379-81. Counihan T, Napolitano LM, Heard SO. Transnasal insertion of percutaneous endoscopic gastrostomy in a patient with intermaxillary fixation: case report. J Trauma 1996;41:530-2. Taller A, Horvath E, Harsanyi L, Balatoni Z, Ilias L. Transnasal percutaneous endoscopic gastrostomy [letter]. Endoscopy 1997;29:337. Lustberg A, Fleisher AS, Darwin PE. Transnasal placement of percutaneous endoscopic gastrostomy with a pediatric endoscope in oropharyngeal obstruction. Am J Gastroenterol 2001;96:936-7. Roman S, Pereira A, Caruso L, Sagnard P, Ponchon T, Dumortier J. Transnasal insertion of percutaneous endoscopic gastrostomy [letter]. Gastroenterol Clin Biol 2001;25: 106-7. Lustberg AM, Darwin PE. A pilot study of transnasal percutaneous endoscopic gastrostomy. Am J Gastroenterol 2002;97:1273-4. Jain NK, Larson DE, Schroeder KW, Burton DD, Cannon KP, Thompson RL, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy. A prospective, randomized, double-blind clinical trial. Ann Intern Med 1987;107: 824-8. Akkersdijk WL, van Bergeijk JD, van Egmond T, Mulder CJ, van Berge Henegouwen GP, van der Werken C, et al.
J Dumortier, M-G Lapalus, A Pereira, et al.
23.
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Percutaneous endoscopic gastrostomy (PEG): comparison of push and pull methods and evaluation of antibiotic prophylaxis. Endoscopy 1995;27:313-6. Gossner L, Keymling J, Hahn EG, Ell C. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical trial. Endoscopy 1999;31: 119-24. Preclik G, Grune S, Leser HG, Lebherz J, Heldwein W, Machka K, et al. Prospective, randomised, double blind trial of prophylaxis with single dose of co-amoxiclav before percutaneous endoscopic gastrostomy. Br Med J 1999;319: 881-4. Hull M, Beane A, Bowen J, Settle C. Methicillin-resistant Staphylococcus aureus infection of percutaneous endoscopic gastrostomy sites. Aliment Pharmacol Ther 2001;15:1883-8. Perl TM, Cullen JJ, Wenzel RP, Zimmerman MB, Pfaller MA, Sheppard D, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002;346:1871-7. Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987;93:48-52. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: indications, limitations, techniques, and results. World J Surg 1989;13:165-70. Grant MD, Rudberg MA, Brody JA. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA 1998;279:1973-6. Rimon E. The safety and feasibility of percutaneous endoscopic gastrostomy placement by a single physician. Endoscopy 2001;33:241-4.
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VOLUME 59, NO. 1, 2004
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57
Background: By using a small-diameter endoscope, EGD can be performed transnasally in adults. A prospective study was conducted to evaluate the feasibility of transnasal PEG placement without conscious sedation. Methods: Unsedated transnasal PEG was attempted in 23 patients by using a 5.9-mm-diameter videoendoscope. The indication for PEG insertion, success or failure, reason(s) for failure, and adverse effects of the procedure were recorded. During the first month, all patients were monitored by telephone contact for complications and to verify functionality of the PEG. Results: Transnasal PEG insertion was successful in 21 (91%) patients. The cause for failure was the inability to transilluminate the abdominal wall. Complications included epistaxis (n = 1), minor wound infection (n = 1), and soiling around the stoma (n = 1). Of the 21 patients in whom transnasal PEG placement was successful, all were alive, with a functional gastrostomy at the 1-month follow-up. Conclusions: Unsedated transnasal PEG tube insertion is minimally invasive, is feasible in daily practice in selected patients, and rarely is associated with complications. (Gastrointest Endosc 2004;59:54-7.)
Since the first description by Gauderer et al.1 in 1980, the minimally invasive PEG procedure has become the worldwide standard for direct gastric access.1 Initially developed for use in children, PEG has profoundly impacted nutritional management, particularly among adult patients. Over 216,000 PEGs are performed annually in the United States.2 Improved guidelines for its use and technical refinements have enhanced the safety of the PEG procedure. Conscious sedation is used routinely by most endoscopists during upper diagnostic and therapeutic endoscopy, including PEG.3-6 The associated cardiopulmonary risks, especially as a consequence of hypoxia, are well known.5,7-11 New methods that increase patient tolerance for EGD would reduce the need for conscious sedation. With the development of endoscopes with insertion tube diameters of 5.3 mm and 5.9 mm, unsedated transnasal EGD was shown to be feasible and to enhance patient tolerance compared with conventional peroral EGD.12 At present, unsedated transnasal EGD is used routinely for diagnostic upper endoscopy.13 Received February 24, 2003. For revision June 4, 2003. Accepted October 3, 2003. Current affiliations: Department of Digestive Diseases, Hoˆpital Edouard Herriot, Lyon, France. Reprint requests: Je´roˆme Dumortier, MD, Fe´de´ration des Spe´cialite´s Digestives, pavillon H, Hoˆpital Edouard Herriot, 69437 Lyon Cedex 03, France. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(03)02526-4 54
GASTROINTESTINAL ENDOSCOPY
The aim of this study was to prospectively assess the feasibility of transnasal PEG tube placement in selected patients, especially those with oropharyngeal neoplastic obstruction or with complications of stroke or dementia.
PATIENTS AND METHODS A forward-viewing ‘‘pediatric’’ videoendoscope was used for all procedures (GIF-XP160; Olympus Optical Co., Ltd., Tokyo, Japan). This endoscope has the following characteristics: outer diameter, 5.9 mm; air/water and accessory channel diameter, 2 mm; depth of field, 3 to 100 mm; working length, 1030 mm; field of view, 1208; and tip flexion, 1808 up, 908 down, 1008 left and right. All procedures were performed by senior endoscopists with experience in transnasal EGD. Topical anesthesia is induced in the nasal cavities by applying a solution of 5% lidocaine and 0.002% naphazoline (Astra France, Nanterre, France) with cotton pledgets and spraying of 5% lidocaine. The endoscope was inserted blindly (as for a nasogastric tube), or under visual control, through the more patent nostril to the pharynx. If it proved impossible to insert the instrument through one nostril, the other was used. The upper esophageal sphincter was passed under direct vision, and the esophagus, the stomach, and the first and second portions of the duodenum were examined in the usual manner. After infiltration of the subcutaneous tissue of the abdomen, a 20F gastrostomy tube with a soft retention dome (Bard Interventional Products Division, Billerica, Mass.) was placed, through the nose, by using the pull technique. To facilitate passage through the nostril, the retention dome was manually compressed by the operator. The ability to introduce the PEG bumper was VOLUME 59, NO. 1, 2004
Unsedated transnasal PEG placement
assessed by passage of the 5.9-mm-diameter endoscope at the beginning of the procedure; the diameter of the bolster, when manually compressed, was always less than that of the endoscope. The endoscope and gastrostomy tube were well lubricated before transnasal passage. All procedures were performed by two endoscopists assisted by a nurse. Duration of the endoscopic procedure was recorded. All procedures were conducted without administration of any sedative medication. All patients fasted for 6 hours before the procedure and were monitored by pulse oximetry and automated blood-pressure measurement during the procedure. Antibiotics (amoxicillin, clavulanic acid) were administered intravenously during the perioperative period (24 hours). Before the procedure, mupirocin was applied topically to the nasal mucosa (single dose) to eliminate Staphylococcus aureus (S aureus). A total of 91 adult patients were referred for PEG placement from February 1, 2000 to December 1, 2002. Exclusion criteria were the following: mechanical ventilation with sedation, stupor, and coma. Only patients in stable condition were included; those with an acute illness were excluded. Thus, transnasal insertion was attempted in 23 patients. Standard informed consent for PEG insertion was obtained from the patient or a relative. To evaluate the feasibility of transnasal PEG, the operator indicated whether the procedure was successful or unsuccessful (including the reason for failure) and recorded any adverse effect. During the first month, all patients were monitored by telephone contact for complications and to verify the functionality of the gastrostomy.
RESULTS Transnasal insertion of PEG was attempted in 23 patients (12 men, 11 women; median age, 63 years; range 46-91 years). The indications for PEG placement were stroke (n = 9, 39%); dementia, with refusal to eat (n = 8, 35%); and oropharyngeal obstructive malignancy, with or without trismus (n = 6, 26%). No patient was undergoing mechanical ventilation. Transnasal PEG placement was successful in 21 (91%). The reason for failure in two patients was the inability to transilluminate the stomach. A PEG was placed under fluoroscopic guidance without endoscopy in one patient. The duration of the endoscopic procedures ranged from 7.5 to 19.3 minutes (mean 9.5 minutes). Minor complications included epistaxis (n = 1), caused by endoscope trauma; minor wound infection, requiring systemic administration of antibiotics but not removal of the tube (n = 1); and soiling around the stoma that required local care and tightening of the discs holding the gastric wall to the abdominal wall (n = 1). There was no major complication, such as apnea, hypoxemia, peritonitis, hemorrhage, aspiration pneumonia, acute cardiovascular event, or severe wound infection. VOLUME 59, NO. 1, 2004
J Dumortier, M-G Lapalus, A Pereira, et al.
Of the 21 patients in whom transnasal PEG placement was successful, all were alive with a functional gastrostomy at the 1-month follow-up. Self-extubation was not observed during this period. DISCUSSION Transnasal EGD originally was regarded as an alternative procedure when transoral intubation was impossible or the patient was unable to tolerate transoral insertion of an endoscope.14,15 The feasibility of transnasal EGD with small-diameter endoscopes is well established, and this technique offers certain theoretical advantages. It was demonstrated by us that the increased patient tolerance is related to the transnasal route and not the smaller diameter of the endoscope.12 The patient can speak during the procedure, which probably reduces anxiety. Side effects, such as gagging, retching, vomiting, and choking, and, thereby, the risk of aspiration, also are minimized. The transnasal route improves patient tolerance and can reduce the need for administration of sedative drugs. At present, unsedated transnasal EGD can be considered as a well-tolerated method for routine diagnostic upper endoscopy. Moreover, the transnasal approach could probably be used for therapeutic purposes. Transnasal PEG had been described in a few patients.16-20 The results of the present study confirm that this method is feasible in selected patients and that complications are rare. The main limitation of transnasal PEG tube insertion is the need to pass the PEG device through the nostril. Factors that influence the feasibility of transnasal endoscopy in a prospective study of 1100 patients undergoing EGD were assessed by us.13 Transnasal EGD was possible in 93.9% of patients, similar to the success rate in the present study (21/23) for standard PEG placement. Feasibility was related to gender, age, and endoscope diameter. Thus, female gender, young age (#35 years), and larger endoscope diameter were significant predictive factors of failure: the failure rate was 8.5% in women vs. 3.2% in men, 10.5% in younger vs. 4.5% in older patients, and 4.7% with using the 5.3-mm-diameter endoscope compared with 16.7% with the 5.9-mm-diameter instrument. The high failure rate for transnasal PEG in the study of Lustberg and Darwin20 (50%) could be because of the use of a 7.9-mm-diameter endoscope (GIF-XP20; Olympus). Adverse effects related to transnasal PEG tube placement were rare in the present study. In our study of 1100 patients undergoing transnasal EGD, minor side effects included epistaxis (2.3%), nasal pain (1.6%), and vasovagal reaction (0.3%).13 Usually, epistaxis persisted for a few minutes and GASTROINTESTINAL ENDOSCOPY
55
J Dumortier, M-G Lapalus, A Pereira, et al.
resolved spontaneously. In our experience, it is essential that both a vasoconstrictor and anesthetic agent be applied to the nasopharynx. Transnasal PEG tube placement may be preferable to other methods that are potentially more invasive and carry a higher cost. The cost of transnasal PEG is difficult to determine accurately and was not evaluated in the present study. However, unsedated PEG insertion potentially could reduce costs. The cost of the drugs usually used for sedation is relatively unimportant, but transnasal PEG insertion may reduce procedure time and patient recovery time, the number of recovery beds needed, and the requirements for support personnel in the endoscopy unit. The risk of infection associated with transnasal insertion of a PEG is a particular concern. When using a standard peroral technique, it has been demonstrated that prophylactic administration of antibiotics significantly reduces the risk of peristomal wound infection, especially with the pull technique.21-24 Amoxicillin and clavulanic acid are the antibiotics most widely recommended for prophylaxis, and these were administered in the present study. However, the bacteriology of peristomal infection after PEG insertion has not been studied extensively, making the optimal choice of antibiotic for prophylaxis uncertain. Hull et al.25 studied peristomal infection after PEG tube insertion, including the contribution of methicillin-resistant S aureus. Nasal and pharyngeal swabs were taken from 31 consecutive patients before PEG insertion. Bacterial colonization and infection at the peristomal site were evaluated prospectively at days 2, 3, and 7 after insertion. Nasopharyngeal colonization by methicillin-resistant S aureus (35%) invariably led to peristomal colonization after PEG insertion. Peristomal infection occurred in 8 (26%) patients; 7 (88%) were caused by methicillin-resistant S aureus. Peristomal infection was significantly more likely to occur in patients in whom the nasopharynx was colonized with methicillin-resistant S aureus (odds ratio 10.8: 95% CI[1.6, 70.9]). These results strongly indicate that currently recommended antibiotic regimens for prophylaxis may be inappropriate in patients with significant methicillin-resistant S aureus colonization. With regard to transnasal PEG insertion, this led us to add prophylactic intranasal application of mupirocin, which has been shown to significantly decrease the rate of all nosocomial S aureus infections among the patients who were S aureus carriers.26 The rate of severe complications associated with PEG placement is 1% to 3%; the mortality rate is 1%.27,28 The low complication rate and absence of 56
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Unsedated transnasal PEG placement
mortality in the present small series may be related to the good status of the patients (none were being ventilated mechanically, and all were in stable condition) and that administration of sedative drugs was avoided. Probably for the same reasons, there was no death at the 1-month follow-up, in contrast to other studies in which the mortality rate was approximately 20%.29,30 Transnasal PEG insertion can be performed without conscious sedation in selected patients and has extremely low morbidity and mortality rates. This method may be useful in patients in whom a peroral approach is impossible (oropharyngeal malignant obstruction or trismus), as well as patients for whom sedation and general anesthesia are contraindicated. However, the promising results obtained in the present series must be confirmed in larger studies. REFERENCES 1. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5. 2. Gauderer MW. Percutaneous endoscopic gastrostomy 20 years later: a historical perspective. J Pediatr Surg 2001; 36:217-9. 3. Keeffe EB, O’Connor KW. 1989 A/S/G/E survey of endoscopic sedation and monitoring practices. Gastrointest Endosc 1990; 36:S13-8. 4. Daneshmend TK, Bell GD, Logan RF. Sedation for upper gastrointestinal endoscopy: results of a nationwide survey. Gut 1991;32:12-5. 5. Quine MA, Bell GD, McCloy RF, Charlton JE, Devlin HB, Hopkins A. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut 1995;36:462-7. 6. Froehlich F, Gonvers JJ, Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland. Endoscopy 1994;26:231-4. 7. Bell GD. Review article: premedication and intravenous sedation for upper gastrointestinal endoscopy. Aliment Pharmacol Ther 1990;4:103-22. 8. Hart R, Classen M. Complications of diagnostic gastrointestinal endoscopy. Endoscopy 1990;22:229-33. 9. O’Connor KW, Jones S. Oxygen desaturation is common and clinically underappreciated during elective endoscopic procedures. Gastrointest Endosc 1990;36:S2-4. 10. Arrowsmith JB, Gerstman BB, Fleischer DE, Benjamin SB. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc 1991;37:421-7. 11. Scott-Coombes DM, Thompson JN. Hypoxia during upper gastrointestinal endoscopy is caused by sedation. Endoscopy 1993;25:308-9. 12. Dumortier J, Ponchon T, Scoazec JY, Moulinier B, Zarka F, Paliard P, et al. Prospective evaluation of transnasal esophagogastroduodenoscopy: feasibility and study on performance and tolerance. Gastrointest Endosc 1999;49:285-91. 13. Dumortier J, Napoleon B, Hedelius F, Pellissier PE, Leprince E, Pujol B, et al. Unsedated transnasal EGD in VOLUME 59, NO. 1, 2004
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