Introduction

​​​​In patients with indications for transnasal PEG tube placement, such as oral cavity, head and neck tumors where the conventional upper gastrointestinal endoscopic procedure to place a PEG tube through the oral cavity can be difficult due to complete or partial occlusion of mouth and/or pharynx.In such cases transnasal placement of a PEG tube is proven to be useful.

Aims & Methods

The aim of this study was to compare the efficacy, safety, procedure time, patient tolerance ,recovery time, immediate and late complication of transnasal PEG tube (T-PEG) placement with and without conscious sedation.A total of 150 patients had a successful PEG tube placement. Out of which 49 patients required transnasal PEG tube placement through ultra-thin video gastroscope with an external diameter of 5.9 mm. patients were selected randomly for sedation and without sedation. After all asceptic measures,transillumination18-Fr PEG tube was placed transnasally by the Gauderer-Ponsky pull technique. 25 of the patients underwent T-PEG without any sedation and the remaining 24 patients were placed under conscious sedation with 2 mg midazolam.
All patients were followed immediately and after 1 month of the procedure.

Results

T-PEG tube was placed successfully in all 49 patients.very surprisingly all patients for transnasal were male.all had history of tobacco chewing in the form of ghutka/mawa. mean age was 38 years. 24 patients had a transnasal-PEG tube placed under conscious sedation of 2 mg midazolam.2 patients in the sedated group had drop in oxygen saturation which was managed during procedure.one patient in sedated and one in unsedated group had minor nasal trauma during peg tube placement. procedure time, procedure tolerance in both groups were almost similar.while post procedure recovery,observation,monitoring and discharge time by the staff was shorter for unsadated group 10mins +-5 min as compared to the sadated group 60mins +-10mins.two patients in sedated group While only one patient in the unsedated group had stoma site infection which were treated according to c/s report. The overall tolerance and success rate was similar in both groups.

Conclusion

In patients with oral cavity obstructing mass or trismus where oral route of PEG tube placement cannot be done, a transnasal route can be considered for placement of PEG tube safely with no requirement of sedation.it decreases the patient hospital stay,staff nurse monitoring,risk of resuscitation tracheostomy.This method is especially useful if the procedure is done in remote settings where anesthesiologists are not available.

References

Unsedated transnasal percutaneous endoscopic gastrostomy placement in selected patientsM A Vitale et al. Endoscopy. 2005 Jan.
Unsedated transnasal percutaneous endoscopic gastrostomy carried out by a single physicianLian-Feng Lin et al. Dig Endosc. 2013 Mar.
Transnasal PEG tube placement in patients with head and neck cancerMoises I Nevah et al. Gastrointest Endosc. 2014 Apr.
Nasal unsedated seated percutaneous endoscopic gastrostomy (nuPEG): a safe and effective technique for percutaneous endoscopic gastrostomy placement in high-risk candidatesAdam McCulloch et al. Frontline Gastroenterol. 2018 Apr.
Nasal unsedated seated percutaneous endoscopic gastrostomy (nuPEG): a safe and effective technique for percutaneous endoscopic gastrostomy placement in high-risk candidatesNeil C Fisher et al. Frontline Gastroenterol. 2019

Introduction

​Percutaneous transesophageal gastrotubing (PTEG) was established as an alternative route to access the gastrointestinal tract for the patients that Percutaneous Endoscopic Gastrostomy was contraindicated. More than two hundred cases without indication of PEG were rescued by this ideal method.

Aims & Methods

The aim of this study is to evaluate the clinical usefulness of PTEG. A rupture-free balloon (RFB) catheter is inserted into the upper esophagus. Percutaneous balloon puncture with a specialized needle is then performed from the left side of patient’s neck under ultrasonographic control. A guide wire is inserted through the needle into the RFB, followed by a dilator and sheath. A placement tube is then inserted through the sheath, and the sheath is removed. Double Balloons equipped Over tube type RFB were used instead of primary RFB in fifty-seven cases that the puncture needle is punctured into the over tube trough the balloon. We perform PTEG in a total of 204 patients (124 men and 80 women, mean age 71.5 years) PTEG was performed for nutrition in 116 patients and for decompression in 88.Eighty-five patients had peritoneal carcinoma , 62 patients had prior gastrectomy , 30 patients had gastric herniation into the thoracic cavity.

Results

Satisfactory results were achieved in all 204 patients. Median follow-up was 65.0 days in patients who received decompression because of the obstruction due to mainly malignancies and 359.0 days in those who received nutrition. Nine patients who were started in the fluoroscopically assisted according to the original method needed endoscopic assistance to complete the procedure in first 30 cases.
Another 174 patients were performed in endoscopic assistance instead of fluoroscopy.
About the complications, there was 2 patient with severe bleeding requiring blood transfusion, Two patient had tracheal penetration, which was managed conservatively. Other complications were minor oozing bleeding in thirteen patients that did not require blood transfusion, subcutaneous emphysema in two patients, which were managed conservatively. Complication rate was 9.8%. No patient required surgical treatment or died after PTEG.

Conclusion

​PTEG is feasible, safe, and useful　for long-term nutrition and/or decompression for the patient who is contraindicated to PEG. PTEG may become the only procedure of the liberation from nasogastric tube for the patient who is contraindicated to PEG. PTEG is the ideal solution for the patients with PEG contraindicated.

Clinical Case Summary

Background: Percutaneous endoscopic gastrostomy (PEG) tubes are commonly used for long-term enteral nutrition in critically or chronically ill patients [1]. Buried bumper syndrome (BBS), a rare but serious complication, occurs when the internal bumper migrates along the stoma tract, leading to tissue ischemia, infection, and potential tube dysfunction [2,3]. BBS typically manifests around 18 months post-placement, with acute presentations exceptionally rare [4]. This case highlights an unusual early onset of BBS, emphasizing the importance of vigilant post-procedural care [5].
Case report: An 83-year-old male with multiple comorbidities, including progressive oropharyngeal dysphagia following cervical spine surgery, underwent PEG tube placement for enteral nutrition. Postoperatively, mild oozing was managed by tightening the bumper. Twelve days later, erythema and pressure necrosis were noted due to excessive tightness, prompting loosening. Three weeks post-placement, localized cellulitis developed and was treated with antibiotics. Two months postoperatively, the PEG tube became dysfunctional, and endoscopic evaluation revealed a partially buried bumper. A minimally invasive surgical approach, assisted endoscopically, was performed to extract the bumper and replace the tube with a balloon G-tube. The revised PEG tube functioned effectively, with no recurrence of complications.
Conclusion: This case underscores the importance of early recognition and management of BBS, even in the acute postoperative period [4,7]. Minimally invasive techniques, combined with proper bumper positioning and patient education, are crucial for preventing and managing this complication [3,6]. Vigilant monitoring of PEG sites and timely intervention can significantly reduce morbidity and improve outcomes in patients with BBS [2,7].

References

1. Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: Techniques, problems and solutions. World J Gastroenterol. 2014;20(26):8505–24.
2. Cyrany J, Rejchrt S, Kopacova M, Bures J. Buried bumper syndrome: A complication of percutaneous endoscopic gastrostomy. World J Gastroenterol. 2016;22(2):618–27.
3. Pérez R, De La Serna C. Buried bumper syndrome: A critical analysis of endoscopic release techniques. World J Gastrointest Endosc. 2019;11(9):611–7.
4. Pinho J, Libânio D, Pimentel-Nunes P, Dinis-Ribeiro M. The challenging acute buried bumper syndrome: A case report. GE Port J Gastroenterol. 2018;25(3):151–4.
5. Satiya J, Marcus A. The buried bumper syndrome: A catastrophic complication of percutaneous endoscopic gastrostomy. Cureus. 2019;11(3):e4275.
6. Maly O, Bichard P. Endoscopic management of buried bumper syndrome using a guidewire and external traction: a novel technique. Acta Gastro-Enterol Belg. 2023;86(1):13–6.
7. Venu RP, Brown RD, Pastika BJ, Erikson LW. The buried bumper syndrome: a simple management approach in two patients. Gastrointest Endosc. 2002;56(4):582–4.

Disclosure

Dear Editors,
I, Evelyn Inga, hereby declare that I have no financial, professional, or personal conflicts of interest.
I affirm that I have no affiliations, financial interests, personal relationships, or commitments that could influence my impartiality in reviewing, conducting, or overseeing our study. Additionally, I confirm that I will uphold the highest ethical standards in compliance with institutional and federal regulations.
If any potential conflict arises, I will promptly disclose it to the United European Gastroenterology Association. Please let me know if any further documentation is required.
Sincerely,
Evelyn Inga, MD

Introduction

Percutaneous transesophageal gastrotubing (PTEG) was established as an alternative route to access the gastrointestinal tract for the patients that Percutaneous Endoscopic Gastrostomy was contraindicated. PTEG will be an ideal method of tube feeding for the patients without indication of PEG.

Aims & Methods

The aim of this study is to evaluate the clinical usefulness of PTEG for the patients who need tube feeding. A rupture-free balloon (RFB) catheter is inserted into the upper esophagus. Percutaneous balloon puncture with a specialized needle is then performed from the left side of patient’s neck under ultrasonographic control. A guide wire is inserted through the needle into the RFB, followed by a dilator and sheath. A placement tube is then inserted through the sheath, and the sheath is removed. Double Balloons equipped Over tube type RFB were used instead of primary RFB in thirty-five cases that the puncture needle is punctured into the over tube trough the balloon. We perform PTEG in a total of 115 patients (78 men and 37 women, mean age 77.7 years) in whom PEG was not feasible for nutrition. Sixty-one patients had prior gastrectomy , 30 patients had gastric herniation into the thoracic cavity , 6 patients had there stomach located behind the colon , 4 patients had ventriculo-peritoneal shunt tube in front of the stomach and 4 patients had peritoneal carcinoma.

Results

Satisfactory results were achieved in all 115 patients. Median follow-up was 322.0 days. There were no patients who needed a nasogastric tube after PTEG. Seven of 115 patients were able to free from tube feeding due to PTEG tube feeding support. About the complications, there was 1 patient with severe bleeding requiring blood transfusion, one patient had tracheal penetration, which was managed conservatively. Other complications were minor oozing bleeding in seven patients that did not require blood transfusion, subcutaneous emphysema in two patients, which were managed conservatively. Complication rate was 10.4%. No patient required surgical treatment or died after PTEG.

Conclusion

PTEG is feasible, safe, and useful　for long-term nutrition for the patient who is contraindicated to PEG. PTEG may become the only procedure of the liberation from nasogastric tube for the patient who is contraindicated to PEG PTEG is the ideal solution for the patients with PEG contraindicated in the tube feeding.

Disclosure

Nothing to disclose

Clinical Case Summary

Percutaneous endoscopic gastrostomy (PEG) tube has been frequently placed for various indications in order to provide long term enteral nutrition support[i],[ii],[iii]. Approximately 160,000 to 200,000 PEG tubes are placed each year in United States[iv]. Advancements in surgical interventions of gastrointestinal tract has resulted in increased number of anatomically altered stomachs, and so anatomically changed on endoscopic examination as well; which makes endoscopic interventions a little different[v]. Multiple case series have been reported for PEG tube placement in patients with subtotal gastrectomy [vi], however, there is scarce data available for PEG tube placement in patients with history of sleeve gastrectomy. The case that is presented here is regarding 64 years old lady with history of sleeve gastrectomy and now referred for PEG tube placement as she was advised for radiotherapy for squamous cell carcinoma of right buccal mucosa. PEG tube was successfully placed and follow up to a month showed effectively functional PEG tube with no major complications.

References

[i] Powell-Tuck J, Van Someren N. Enterostomy feeding for patients with stroke and bulbar palsy. Journal of the Royal Society of Medicine. 1992 Dec;85(12):717-9.
[ii] Richards DM, Tanikella R, Arora G, Guha S, Dekovich AA. Percutaneous endoscopic gastrostomy in cancer patients: predictors of 30-day complications, 30-day mortality, and overall mortality. Dig Dis Sci. 2013;58:768–776. doi: 10.1007/s10620-012-2397-8.
[iii] Orphanidou C, Biggs K, Johnston ME, Wright JR, Bowman A, Hotte SJ, Esau A, Myers C, Blunt V, Lafleur M, Sheehan B. Prophylactic feeding tubes for patients with locally advanced head-and-neck cancer undergoing combined chemotherapy and radiotherapy—systematic review and recommendations for clinical practice. Current oncology. 2011 Aug;18(4):e191.
[iv] Wei M, Ho E, Hegde P. An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit. J Thorac Dis. 2021 Aug;13(8):5277-5296. doi: 10.21037/jtd-19-3728. PMID: 34527366; PMCID: PMC8411178.
[v] Morrell D, Pauli E, Juza R. Endoscopy in surgically altered anatomy. Annals of Laparoscopic and Endoscopic Surgery. 2019 Apr 24;4.
[vi] Singh P, Kahn D, Greenberg R, Indaram A, Pooran N, Bank S. Feasibility and safety of percutaneous endoscopic gastrostomy in patients with subtotal gastrectomy. Endoscopy. 2003 Apr;35(4):311-4. doi: 10.1055/s-2003-38156. PMID: 12664387.

Introduction

Since the report of Shaker in 1994, transnasal esophagogastroduodenoscopy (T-EGDS) has been reported worldwide as one technique to facilitate comfortable procedures avoiding sedation. From 1996 in our Centre, we routinely use this technique in all the patients for diagnostic and selected operative EGDS. This approach is also suitable for the placement of percutaneous endoscopy gastrostomy (PEG) but in the published papers it has been performed only when conventional upper gastrointestinal endoscopy was unusable (dysphagic patients with neurological disease or with stenosis and/or occlusion of the mouth or pharynx). On the contrary, since 2000 we have routinely used the transnasal approach for all patients requiring PEG, reserving the oral technique when the transnasal access route is impossible.

Aims & Methods

We performed a retrospective analysis of all patients who underwent PEG placement between January 2000 and March 2023 in the Unit of Gastroenterology of San Camillo De Lellis Hospital, Rieti, Italy, in order to demonstrate the feasibility and safety of T-PEG placement in routine practice. We used ultrathin gastroscope through a nostril after assessment and lubrification, and the pull technique was used for tube placement.

Results

PEG placement was required for 256 consecutive patients (male 49.4%; female 51.6%), the average age was 79 years, within a range from 26 to 104 years. Transnasal approach was used in 162 patients (nasal group: 63.3%) while oral approach was used in 94 (oral group: 36.7%). The failure of transnasal approach was related to impossibility of nasal intubation due to narrow nasal passages or to inability to transilluminate the stomach. In these cases we needed transoral route. 14 patients underwent transoral PEG placement due to unavailability of transnasal gastroscope. The duration of the procedures was similar in both approaches (12 ±3 minutes oral vs 13±4 minutes nasal).
The most common indications for PEG insertion were neurologic disorders (n=132, 51.6 %), cerebrovascular accident (n=73, 28.5 %), esophageal cancer or head and neck cancer (n=18, 7 %), other pathologies (n=33, 12.9 %). 167 procedures were performed without sedation: 77.8 % ( n= 130) in the nasal group and only 22.1% (n=37) in the oral group. Outpatient regimen PEG placement was also significantly higher in trans nasal group (79 % vs 58 % oral group). We registered 3 major complications, 1 in oral group and 2 in nasal group (one necessitated surgery). No procedure-related death was registered. There were no unplanned re-admissions of outpatients discharged from the gastroenterology unit for procedure-related complications.

Conclusion

The more than twenty years’ experience of our center demonstrates that the transnasal approach is safety, feasible and could be routinely used in daily endoscopic practice for PEG placement. The minimally invasive technique therefore reserves sedation to a few selected cases to reduce costs, improve logistic organization and avoid anesthesia related complications.

References

1. Campo R, Montserrat A, Brullet E. Transnasal gastroscopy compared to conventional gastroscopy: a randomized study of feasibility, safety, and tolerance. Endoscopy. 1998 Jun;30(5):448-52.
2. Schuldt AL, Kirsten H, Tuennemann J, Heindl M, van Bommel F, Feisthammel J, Hollenbach M, Hoffmeister A. Necessity of transnasal gastroscopy in routine diagnostics: a patient-centred requirement analysis. BMJ Open Gastroenterol. 2019 Apr 14;6(1):e000264.
3. Dumortier J, Lapalus MG, Pereira A, Lagarrigue JP, Chavaillon A, Ponchon T. Unsedated transnasal PEG placement. Gastrointest Endosc. 2004 Jan;59(1):54-7.
4. Dumortier J, Napoleon B, Hedelius F, Pellissier PE, Leprince E, Pujol B, Ponchon T. Unsedated transnasal EGD in daily practice: results with 1100 consecutive patients. Gastrointest Endosc. 2003 Feb;57(2):198-204
5. Preiss C, Charton JP, Schumacher B, Neuhaus H. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD. Endoscopy. 2003 Aug;35(8):641-6.

Introduction

Percutaneous transesophageal gastrotubing (PTEG) was established as an alternative route to access the gastrointestinal tract for the patients that percutaneous endoscopic gastrostomy was contraindicated. Over tube type method was developed especially for endoscopic support.

Aims & Methods

The aim of this study is to evaluate the clinical usefulness of PTEG using by specialized over tube for endoscopic support. Over Tube with puncture hole covered by double balloons type rupture free balloon (OT-RFB) is inserted into the upper esophagus. Percutaneous balloon puncture is performed into the over tube through the balloon with a specialized needle from the patient’s neck under ultrasonographic control. A guide wire is　inserted through the needle into the over tube. After inserting an over tube to the distal site of esophagus to release a guidewire, and removing an over tube followed by insert dilator and a sheath. A placement tube is then inserted through the sheath, and the sheath is removed. We perform PTEG using OT-RFB that were used instead of primary RFB in sixty-two cases. In a total of 62 patients (33 men and 29 women, mean age 72.5 years) PTEG was performed for nutrition in 41 patients and for decompression in 21. Twenty-three patients had peritoneal carcinoma , 13 patients had prior gastrectomy , 18 patients had gastric herniation into the thoracic cavity. For reliable puncture into the OT-RFB we pressed the LED pen light on the patients neck to adjust the puncture site hole of the over tube in the esophagus.

Results

Finally success of gastrotubing was achieved in all 62 patients . Follow-up days was 120 ±165.78 days in patients who received decompression because of the obstruction due to mainly malignancies and 491±633.99 days in those who received nutrition.
.About the complications, there was 1 patient with severe bleeding requiring blood transfusion, One patient had tracheal penetration, which was managed conservatively. Other complications were minor oozing bleeding in four patients that did not require blood transfusion, mediastinitis in one patient, which were managed conservatively. Complication rate was 11.2%. No patient required surgical treatment or died after PTEG.

Conclusion

PTEG is feasible, safe, and useful　for long-term nutrition and/or decompression for the patient who is contraindicated to PEG. PTEG using OT-RFB is safer with a little idea and the ideal solution for the patients with PEG contraindicated.