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Percutaneous enterostomy tubes are indicated when long-term enteral access of 4 weeks is necessary; these may be placed by endoscopic, fluoroscopic, or surgical techniques. The administration of a single dose of a broad-spectrum antibiotic pre-procedurally has been shown to reduce the risk of wound infection [60-68] and be cost-effective for percutaneous endoscopic gastrostomy. It is also recommended for other enterostomy placements as well [35] (Table 10.4).

3.1. Gastrostomy Tubes 3.1.1. Techniques for Placement

3.1.1.1. Endoscopically. The most common means of obtaining long-term gastric access is percutaneous endoscopic gastrostomy (PEG), the second most common indication for endoscopy of the upper gastrointestinal tract [69]. Typically performed under conscious sedation, it may also be performed at the bedside of critically ill patients [70]. Absolute contraindications to PEG placement are the same as those of upper gastrointestinal endoscopy as well as an inability to transilluminate the abdominal wall and appose the anterior gastric wall. Relative contraindications to PEG placement include coagulopathy, gastric varices, morbid obesity, prior gastrointestinal surgery, ascites, chronic ambulatory peritoneal dialysis, and neoplastic, infil-trative, or inflammatory disease of the abdominal wall [71].

Table 10.4

Randomized Controlled Trials Evaluating Efficacy of Antibiotic Prophylaxis in Percutaneous Endoscopic Gastrostomy

Table 10.4

Randomized Controlled Trials Evaluating Efficacy of Antibiotic Prophylaxis in Percutaneous Endoscopic Gastrostomy

I

—Treatment group-11—

—Control group—

I

Reference

Treatment

N

Wound

Control

N

Wound

P-value

infections

Infections

[60]

Cefoxitin 1 g IV

17

5

Placebo

16

5

N.S.

[61]

Cefazolin 1 g IV

27

2

Placebo

28

9

<0.025

[62]

Am 3 g/Clav 1.2 g IV

36

5

No treatment

60

21

0.05

[63]

Cefazolin 1 g IV

30

4

Placebo

31

6

N.S.

[64]

Cefotaxime 2 g IV or

201

1

No treatment

106

8

<0.01

Pip 4 g/Tazo 0.5 g IV

Am 1 g/Clav 1.2 g IV

41

6

Placebo

43

19

0.004

[65]

Ceftriaxone 1 g IV

69

4

No treatment

72

17

<0.05

[66]

Cefuroxime 750 mg IV

33

1

Placebo

33

6

0.03

[67]

Am 1 g/Clav 1.2 g IV

45

5

Placebo

38

18

0.001

or Cefotaxime 2 g IV

or Cefotaxime 2 g IV

IV = intravenous; N.S. = not significant; Am = amoxicillin; Clav = clavulanic acid; Pip = piperacillin; Tazo = tazobactam

Percutaneous endoscopic gastrostomy tubes are most commonly placed using the Ponsky ("pull") technique, first described in 1981 [20]. After advancement of the endoscope, the stomach is insufflated with air, and an optimal site for PEG placement is determined by simultaneously transilluminating the gastric/abdominal wall and indenting the abdominal wall with a finger while visualizing that indention endoscop-ically. After a small incision is made, a needle/trocar is inserted through the abdominal wall and into the stomach. A guidewire is passed through this needle/trocar and grasped endoscopically. The guide wire is then withdrawn through the mouth, and a gastrostomy tube is affixed to it. Finally, the guidewire is pulled back through the esophagus, stomach, and abdominal wall and held into place by an internal retention device and an external bumper.

Advantages of PEG for obtaining gastric enteral access are the avoidance of general anesthesia, travel to the radiology suite, and radiation exposure that are required by other techniques.

3.1.1.2. Fluoroscopically. First described in 1981 [72], fluoroscop-ically guided gastrostomy is performed in the radiology suite and may be performed with only local anesthetic. After insufflation of the stomach with a nasogastric tube, a puncture is created using a needle; the location of the needle is confirmed by injection of contrast medium or aspiration of air bubbles. Usually T-fasteners are inserted around the puncture site to maintain apposition of the stomach and anterior abdominal wall. The gastrostomy tract is created in the center of the T-fasteners with serial dilation. The gastrostomy tube is placed through a peelaway sheath and the nasogastric tube removed [73].

Fluoroscopic gastrostomy is an attractive alternative in that typically only local anesthesia or light sedation is required. It also remains an option for those patients with obstructive pharyngeal or esophageal pathology that renders upper GI endoscopy difficult or impossible.

3.1.1.3. Surgically. First performed in 1876, surgical gastrostomy was the only means of ensuring long-term enteral nutrition until the late 1970s. A gastrostomy tube placed using the open or laparo-scopic methods is typically performed in the operating room under general anesthesia; however, local anesthesia combined with conscious sedation may also be used. The most commonly used method, the Stamm technique, requires a small laparotomy in the medial upper abdomen. A small incision is made into the stomach, and the feeding tube is inserted and secured with purse-string sutures. The stomach is then affixed to the anterior abdominal wall, and the tube is often kept in place with an inflated balloon or by attachment to the abdominal wall [18, 74].

Laparoscopic gastrostomy placement likewise occurs in the operating room under general anesthesia or conscious sedation. A gastrostomy tube is placed over a guidewire into the stomach under direct visualization from outside the stomach. T-fasteners are used to affix the stomach to the anterior abdominal wall. The procedure then takes place similarly to fluoroscopic placement except monitoring occurs intraperitoneally [75-78].

Benefits of surgical gastrostomy over endoscopic and fluoro-scopic methods are limited. Gastrostomy tubes may be placed during other operative procedures, thus eliminating the need for additional sedation/anesthesia for a second procedure. Surgical gastrostomy also remains an option in patients with obstructive pharyngeal or esophageal pathology that renders endoscopy or nasogastric tube passage impossible.

Endoscopic and fluoroscopic methods are associated with less morbidity and cost than surgical methods, but the overall success rates are similar [16, 79-87], with published success rates typically greater than 90%. Factors that can lead to unsuccessful gastrostomy placement include unexpected obstruction of the pharynx or esophagus, deterioration of the clinical status of the patient intraprocedurally, incidental finding of gastric cancer, development of a hematoma at the gastrostomy site, and prior surgery that has altered esophageal, abdominal, or gastric anatomy [88].

3.1.2. Complications

As with nasal feeding tubes, complications of gastrostomy tubes can be divided into procedural and post-procedure complications (Table 10.5).

Table 10.5

Complications of Percutaneous Endoscopic Gastrostomy (PEG) Tubes

Table 10.5

Complications of Percutaneous Endoscopic Gastrostomy (PEG) Tubes

Procedural

Post-procedural

-Aspiration

-Peristomal infection

-Hemorrhage

-Stomal leakage

-Perforation of abdominal viscera

-Buried bumper syndrome

-Prolonged ileus

-Fistulous tracts

-Peritonitis

-Inadvertent removal

-Cardiopulmonary complications

-Gastric ulcer

related to sedation

-Tumor implantation

3.1.2.1. Procedural Complications. The procedural and long-term mortality rate directly related to gastrostomy placement is very low; however, the overall mortality of patients receiving gastrostomy tubes is up to 50% [89]. This high rate reflects the significant co-morbidities present in this population receiving PEGs rather than the procedure itself. Serious complications related to the procedure itself are comparable among methods of placement and range from 0.1-4% of cases. These include intraprocedural aspiration, hemorrhage, perforation of abdominal viscera, and prolonged ileus [84, 90, 91]. Risk factors for intraprocedural aspiration include supine position, advanced age, excessive sedation, and neurological impairment. The clinician can minimize the risk of intraprocedural aspiration by avoiding over-sedation, minimizing air insufflation of the stomach, and thoroughly emptying the gastric contents prior to the procedure [71].

Acute hemorrhage during gastrostomy placement is uncommon, but is likely increased in the setting of a coagulopathy, iatrogenic or otherwise. Checking coagulation studies prior to the procedure is recommended [81]. On the other hand, pneumoperitoneum as a result of percutaneous approaches is common and of no clinical consequence in the absence of signs of peritoneal irritation [92].

3.1.2.2. Post-Procedural Complications. The overall post-procedural complication rate of gastrostomy tubes ranges from 4.8-10.8% regardless of the method of placement [84, 93]. Peristomal infection is the most common complication of gastrostomy placement, but the vast majority of infections are mild and easily treated with oral antibiotics [64, 94]. To minimize morbidity and even mortality of peristomal infections, the administration of prophylactic antibiotics prior to placement, early recognition of wound infections, treatment with antibiotics, and local wound care are fundamental to the successful management of peristomal infections [61, 62, 64].

Leakage around the gastrostomy site is a common problem [95]. Peristomal infection, excessive cleansing with irritating solutions (e.g., full strength hydrogen peroxide and betadine), and excessive tension and side torsion on the external portion of the feeding tube all increase risk of leakage. Management of excessive leakage consists of treating infection if present, providing quality ostomy skin care, loosening the outer bumper to minimize tension, and stabilizing the external gastrostomy tube to prevent side torsion [47].

Buried bumper syndrome results from the partial or complete growth of gastric mucosa over the internal bumper of the gastrostomy tube and can result in migration of the bumper externally where it may lodge anywhere along the gastrostomy tract. Risk factors include excessive tension between the internal and external bumpers, poor wound healing, and significant weight gain [36]. Clinically, buried bumper syndrome leads to peristomal leakage or infection, abdominal pain, an immobile catheter, or resistance with infusion of formula. The buried bumper can be confirmed endoscopically when possible, or by gastrografin study with the patient in the prone position. Treatment consists of salvaging the stoma tract while returning the internal bumper back into the lumen of the stomach [96, 97].

Fistulous tracts connecting the stomach, colon, and skin are uncommon, but potentially life-threatening complications of gastrostomy tubes. If the colon is inadvertently punctured during endoscopic or fluoroscopic gastrostomy placement, or less commonly, if the tube erodes into the adjacent colon, patients may present acutely ill with colonic perforation. If the colon is traversed inadvertently during initial placement the patient may be asymptomatic until gastrostomy tube replacement when the replacement tube is inserted only as far as the colon. Then patients will present with leakage of stool around the gastrostomy site and diarrhea resembling feeding formula. Diagnosis can be made by infusion of gastrografin into the gastrostomy tube and observing the filling of the colon radiographically. Elevation of the head of the bed to displace the colon inferiorly and use of the safe track technique may minimize the risk of inadvertent puncture of the colon (Fig. 10.2) [98]. Treatment usually consists of gastrostomy tube removal, but surgical repair is indicated if peritoneal signs are present.

Inadvertent gastrostomy tube removal should be managed urgently. Gastrostomy tract maturation usually occurs within the first 7-10 days, but in the presence of malnutrition or poor wound healing it may be delayed as long as 4-6 weeks [90]. A gastrostomy tube that is inadvertently removed during this time period should be promptly replaced endoscopically or fluoroscopically as the tract may be immature and the stomach and anterior abdominal wall can separate, resulting in free perforation. If recognition is delayed, management includes nasogastric decompression, broad-spectrum antibiotics, and repeat gastrostomy after 7-10 days. Surgical exploration is indicated in patients with clinical evidence of peritonitis. Once maturation of the tract has occurred, a replacement tube may be placed at the bedside without endoscopic or fluoroscopic guidance if done without delay. Patients prone to pulling at tubes may receive benefit from an abdominal binder or placement of a low profile device (button) [90].

Peg Technique
Fig. 10.2. Safe tract technique.

3.2. Jejunal Tubes 3.2.1. Gastrojejunal Tubes

In the setting of impaired gastric motility, pancreatitis, risk for reflux and/or aspiration, gastric outlet obstruction or any time enteral feeding into the small bowel with simultaneous gastric decompression is desired, a gastrojejunal tube should be placed [22, 99].

3.2.1.1. Techniques for Placement. Endoscopically The jejunal arm of a percutaneous endoscopic gastrojejunostomy (PEG-J) tube is placed using an initially placed PEG tube. Most commonly, a guidewire is placed through an existing gastrostomy, and it is grasped endoscopically and carried into the jejunum. The guidewire is left in the jejunum and the endoscope withdrawn. The jejunal extension tube is then threaded over the guidewire into the small bowel [33, 100]. Advantages of PEG-J are similar to those of PEG; additionally, if a patient already has a PEG tube in place, conversion to PEG-J does not require an additional skin puncture. Success rates over 90% have been reported for PEG-J [101-104].

Fluoroscopically and Surgically Gastrojejunal tubes may be placed fluoroscopically or during laparotomy or laparoscopy. Fluroscopic technique is similar to endoscopic PEG-J. Using an existing gastrostomy, a guidewire is advanced through the stomach past the ligament of Treitz, and the jejunal extension tube is advanced over the wire into the jejunum under fluoroscopic guidance. Gastrojejunal tubes can be placed during laparotomy or laparoscopy methods using any of the above methods. Using manual and/or endoscopic methods the jejunal tube is positioned into the small bowel. The gastric component of the tube is left in the stomach. These modalities have success rates that are comparable to those of PEG-J [105].

3.2.2. Direct Jejunal Tubes

In patients without a need for gastric decompression, it may be desirable to place a enterostomy tube directly into the jejunum. Jejunostomy tubes are placed primarily endoscopically or surgically. Advantages and disadvantages of endoscopic vs. surgical methods are similar to those of gastrostomy placement.

3.2.2.1. Techniques for Placement. Endoscopically Direct percutaneous endoscopic jejunostomy (D-PEJ) is performed in a manner similar to that of the PEG 'pull' technique. A pediatric colonoscopy or enteroscope is advanced to the small bowel, and transillumination and finger indentation are performed over the jejunum rather than the stomach. A needle/trocar is inserted through the abdominal wall into the jejunum, and an insertion wire is passed through the trocar and grasped endoscopically. The remainder of the procedure is as described for the PEG 'pull' technique [106, 107]. In comparison studies, D-PEJ has been demonstrated to have greater longevity and decreased need for re-intervention compared PEG-J [101, 108, 109]. Therefore, in some cases it may be advantageous to place separate direct gastrostomy and jejunostomy tubes rather than a single combined gastrojejunal tube.

Surgically There are three basic types of surgical jejunostomy techniques in use: the Witzel technique, Roux-en-Y jejunostomy, and needle catheter jejunostomy. In the Witzel technique, the surgeon creates a submucosal tunnel in the small bowel through which the jejunostomy tube is threaded. In doing so, leakage of small bowel contents is minimized [19]. Needle catheter jejunostomy may be placed by laparotomy or laparoscopy; in this case a needle is threaded into the small bowel, and a guidewire is passed into the jejunum. A small jejunostomy catheter is passed over the guidewire into the jejunum. However, the smaller size of this catheter may lead to more frequent occlusion.

Jejunostomies may also be placed laparoscopically. After ports are placed in the left upper quadrant and medial lower abdomen, the jejunum is approximated to the anterior abdominal wall using T-fasteners. A guidewire is then passed into the jejunum, and a jejunostomy tube is advanced into the small bowel [76, 110]. Direct percutaneous endoscopic jejunostomy placement is successful in 68-100% of attempts [101, 106, 111, 112], while success rates approach 100% with surgical jejunostomy [76].

3.2.3. Complications

Complications of jejunal tubes are similar to those of gastrostomy tubes described above. It deserves mention that gastrojejunal feeding tubes have a higher incidence of malfunction (up to 70%), migration, and/or occlusion of the distal, smaller jejunal extension tube [103,113]. Additional complications of direct jejunostomy tubes include jejunal volvulus and small bowel perforation [112]. Despite expert opinion, the data are controversial as to whether more distal feeding with jejunal tubes decreases a patient's aspiration risk significantly [50, 114].

4. care of the feeding tube 4.1. Skin Care

The skin around tube enterostomies should be cleaned with mild soap and water, then rinsed and dried thoroughly. Use of irritant cleansers or full strength hydrogen peroxide should be avoided as they may lead to poor wound healing and leakage around the tube. Likewise, routine use of antibiotic ointments is not advised, and dressings at the tube insertion site are not necessary unless there is drainage at the site.

Skin care of the nasal area is important in patients with nasal tubes as the tubes can be irritating, and there is often prolonged exposure to adhesive products. Additionally, regular repositioning of the nasal tube reduces the risk of pressure necrosis.

Regardless of the method of placement, oral hygiene is appropriate for patients with feeding tubes. This is especially important in patients with a decreased level of consciousness or those on mechanical ventilation.

4.2. Prevention of Clogging

Tubes with smaller lumens are more prone to clogging, but maintenance of all sizes of tube is important to minimize clogging. Flushing with water regularly is paramount. Other causes of clogging include accumulation of pill fragments, frequent checking of residuals, and formulas containing high protein concentrations [115, 116]. Use of medications in liquid form is recommended, as is flushing after each medication administration [117].

4.3. Replacement Enterostomies

The external portion of gastrostomy and gastrojejunostomy tubes may be several centimeters long, requiring that caution be used to avoid traction or side torsion, which may promote tube leakage. In patients at high risk of pulling at the tube, or in patients desiring a more cosmetically acceptable option, a low-profile port ("button") may be used. The internal retention bolster of percutaneous tubes is constructed of either solid material (silicone or polyurethane) or a silicone balloon. Solid internal bolsters may last a year or longer and are most commonly used in initial endoscopic enterostomy tube placement. Balloon-type internal bolsters have a lifespan of 3-6 months and are more commonly used in radiological tube placements as well as replacement tubes due to the ease of placement [118].

5. conclusions

Enteral nutrition is the route of choice in patients with a functioning gastrointestinal tract. A number of enteral access options are available to patients in need of nutritional support. Consideration of the appropriate device, level in the gastrointestinal tract, and insertion method are critical to ensure optimal outcomes. In addition, appropriate aftercare and monitoring with early recognition and treatment of any complications are crucial to the success of enteral nutrition access.

references

1. Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 2001;74:534-542.

2. Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ 2001;6:773-776.

3. Jabbar A, Chang WK, Dryden GW, McClave SA. Gut immunology and the differential response to feeding and starvation. Nutr Clin Prac 2003;18:461-482.

4. Fink MP. Why the GI tract is pivotal in trauma, sepsis, and MOF. J Crit Illness 1991;6:253-269.

5. Doig CJ, Sutherland LR, Sandham JD, Fick GH, Verhoef M, Meddings JB. Increased intestinal permeability is associated with the development of multiple organ dysfunction syndrome in critically ill ICU patients. Am J Respir Crit Care Med 1998;158:444-451.

6. Peng YZ, Yuan ZQ, Xiao GX. Effects of early enteral feeding on the prevention of enterogenic infection in severely burned patients. Burns 2001;27:145-149.

7. Kudsk KA. Current aspects of mucosal immunology and its influence by nutrition. Am J Surg 2002;183:390-398.

8. Spiekermann GM, Walker WA. Oral tolerance and its role in clinical disease. J Pediatr Gastroent Nutr 2001;32:237-255.

9. Lebman DA, Coffman RL. Cytokines in the mucosal immune system. In: Handbook of mucosal immunology. San Diego: Academic, 1994, pp 243-249.

10. Windsor AC, Kanwar S, Li AG, Barnes E, Guthrie JA, Spark JI, Welsh F, Guillou PJ, Reynolds JV. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut 1998;42:431-435.

11. Deitch EA. Role of the gut lymphatic system in multiple organ failure. Curr Opin Crit Care 2001;7:92-98.

12. Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 1999;27:2525-2531.

13. Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ 2004;12:1407-1412.

14. Montejo JC, Zarazaga A, Lopez-Martinez J, Urrutia G, Roque M, Blesa AL, Celaya S, Conejero R, Galban C, Garcia de Lorenzo A, Grau T, Mesejo A, Ortiz-Leyba C, Planas M, Ordonez J, Jimenez FJ. Immunonutrition in the intensive care unit. A systematic review and consensus statement. Clin Nutr 2003;22:221-233.

15. Souba WW. Nutritional support. New Engl J Med 1997;336:41-48.

16. Levy H. Nasogastric and nasoenteric feeding tubes. Gastrointest Endosc Clin N Am 1998;8:529-549.

17. Vanek VW. Ins and outs of enteral access: Part 1: Short term enteral access. Nutr Clin Pract 2002;17:275-283.

18. Vanek VW. Ins and outs of enteral access: Part 2: Long term access-esophagostomy and gastrostomy. Nutr Clin Pract 2003;18:50-74.

19. Vanek VW. Ins and outs of enteral access: Part 3: Long term access-jejunostomy. Nutr Clin Pract 2003;18:201-220.

20. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 1981;27:9-11.

21. Ponsky JL, Gauderer MW, Stellato TA, Aszodi A. Percutaneous approaches to enteral alimentation. Am J Surg 1985;149:102-105.

22. Rombeau JL, Twomey PL, McLean GK, Forlaw L, Del Rio D, Caldwell MD. Experience with a new gastrostomy-jejunal feeding tube. Surgery 1983;93: 574-578.

23. Wills JS, Oglesby JT. Percutaneous gastrostomy. Radiology 1988;167:41-43.

24. Gray RR, St Louis EL, Grosman H. Percutaneous gastrostomy and gastro-jejunostomy. Br J Radiol 1987;60:1067-1070.

25. Ho CS, Gray RR, Goldfinger M, Rosen IE, McPherson R. Percutaneous gastrostomy for enteral feeding. Radiology 1985;156:349-351.

26. Barrett MK. A permanent gastrostomy. Gastroenterology 1950;16:764-767.

27. Metheny NA, Meert K. Monitoring feeding tube placement. Nutr Clin Prac 2004;19:487-496.

28. Araujo-Perez CE, Melhado ME, Gutierrez FJ, Maniatis T, Castellano MA. Use of capnography to verify feeding tube placement. Crit Care Med 2002;30: 2255-2259.

29. Rassias AJ, Ball PA, Corwin HL. A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Crit Care 1998;2:25-28.

30. Marderstein EL, Simmons RL, Ochoa JB. Patient safety: effect of institutional protocols on adverse events related to feeding tube placement in the critically ill. J Amer Coll Surg 2004;199:39-47.

31. Zaloga GP. Bedside method for placing small bowel feeding tubes in critically ill patients. A prospective study. Chest 1991;100:1643-1646.

32. Booth CM, Heyland DK, Paterson WG. Gastrointestinal promotility drugs in the critical care setting: a systematic review of the evidence. Crit Care Med 2002;30:1429-1435.

33. DiSario JA, Baskin WN, Brown RD, DeLegge MH, Fang JC, Ginsberg GG, McClave SA. Endoscopic approaches to enteral nutritional support. Gastrointest Endosc 2002;55:901-908.

34. Fang JC, Hilden K, Holubkov R, DiSario JA. Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients. Gastrointest Endosc 2005;62:661-666.

35. Kulling D, Sonnenberg A, Fried M, Bauerfeind P. Cost analysis of antibiotic prophylaxis for PEG. Gastrointest Endosc 2000;51:152-156.

36. McClave SA, Chang WK. Complications of enteral access. Gastrointest Endosc 2003;58:739-751.

37. McWey RE, Curry NS, Schabel SI, Reines HD. Complications of nasoenteric feeding tubes. Am J Surg 1988;155:253-257.

38. Odocha O, Lowery RC, Mezghebe HM, Siram SM, Warner OG. Tracheo-pleuropulmonary injuries following enteral tube insertion. J Nat Med Assoc 1989;81:275-281.

39. Roubenoff R, Ravich WJ. Pneumothorax due to nasogastric feeding tubes. Report of four cases, review of the literature, and recommendations for prevention. Arch Intern Med 1989;149:184-188.

40. Damore LJ, Andrus CH, Hermann VM, Wade TP, Kaminski DL, Kaiser GC. Prospective evaluation of a new through-the-scope nasoduodenal enteral feeding tube. Surg Endosc 1997;11:460-463.

41. Lee SS, Mathiasen RA, Lipkin CA, Colquhoun SD, Margulies DR. Endoscop-ically placed nasogastrojejunal feeding tubes: a safe route for enteral nutrition in patients with hepatic encephalopathy. Amer Surg 2002;68:196-200.

42. McClave SA, Sexton LK, Spain DA, Adams JL, Owens NA, Sullins MB, Blandford BS, Snider HL. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Criti Care Med 1999;27:1252-1256.

43. Brandt CP, Mittendorf EA. Endoscopic placement of nasojejunal feeding tubes in ICU patients. Surg Endosc 1999;13:1211-1214.

44. Bosco JJ, Gordon F, Zelig MP, Heiss F, Horst DA, Howell DA. A reliable method for the endoscopic placement of a nasoenteric feeding tube. Gastrointest Endosc 1994;40:740-743.

45. Patrick PG, Marulendra S, Kirby DF, DeLegge MH. Endoscopic nasogastric-jejunal feeding tube placement in critically ill patients. Gastrointest Endosc 1997;45:72-76.

46. Powell KS, Marcuard SP, Farrior ES, Gallegher ML. Aspirating gastric residuals causes occlusion of small-bore feeding tubes. J Parenter Enteral Nutr 1993;17:243-246.

47. McClave SA. Managing complications of percutaneous and nasoenteric feeding tubes. Tech Gastrointest Endosc 2001;3:62-68.

48. Marcuard SP, Stegall KL, Trogdon S. Clearing obstructed feeding tubes. J Parenter Enteral Nutr 1989;13:81-83.

49. McClave SA, DeMeo MT, DeLegge MH, DiSario JA, Heyland DK, Maloney JP, Metheny NA, Moore FA, Scolapio JS, Spain DA, Zaloga GP. North American Summit on Aspiration in the Critically 1ll Patient: consensus statement. J Parenter Enteral Nutr 2002;26:S80-S85.

50. Heyland DK, Drover JW, Dhaliwal R, Greenwood J. Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding. J Parenter Enteral Nutr 2002;26:S51-55.

51. George DL, Falk PS, Umberto Meduri G, Leeper KV, Wunderink RG, Steere EL, Nunnally FK, Beckford N, Mayhall CG. Nosocomial sinusitis in patients in the medical intensive care unit: a prospective epidemiological study. Clin Infect Dis 1998;27:463-470.

52. McClave SA, Chang WK. Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel. Nutr Clin Pract 2003;18:279-284.

53. Smith-Choban P, Max MH. Feeding jejunostomy: A small bowel stress test? Am J Surg 1988;155:112-117.

54. Kudsk KA. Proceedings from summit on immune-enhancing enteral therapy. JPEN 2001;25:S1-S62.

55. Bower RH, Cerra FB, Bershadsky B, Licari JJ, Hoyt DB, Jensen GL, Van Buren CT, Rothkopf MM, Daly JM, Adelsberg BR. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit Care Med 1995;23:436-449.

56. Bertolini G, Iapichino G, Radrizzani D, Facchini R, Simini B, Bruzzone P, Zanforlin G, Tognoni G. Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial. Intensive Care Med 2003;29:834-840.

57. Heyland DK, Novak F. Immunonutrition in the critically ill patient: more harm than good? JPEN 2001;25 (2Suppl):S51-S55.

58. Galban C, Montejo JC, Mesejo A, Marco P, Celaya S, Sanchez-Segura JM, Farre M, Bryg DJ. An immune-enhancing enteral diet reduces mortality rate and episodes of bactermia in septic intensive care unit patients. Crit Care Med 2000;28:643-648.

59. Zaloga GP, Siddiqui R, Terry C, Marik PE. Arginine: mediator or modulator of sepsis? Nutr Clin Prac 2004;19:201-215.

60. Jonas SK, Neimark S, Panwalker AP. Effect of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J Gastroenterol 1985;80:438-441.

61. Jain NK, Larson DE, Schroeder KW, Burton DD, Cannon KP, Thompson RL, DiMagno EP. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy. A prospective, randomized, double-blinded clinical trial. Ann Intern Med 1987;107:824-828.

62. Akkersdijk WL, van Bergeijk JD, van Egmond T, Mulder CJ, van Berge Henegouwen GP, van der Werken C, van Erpecum KJ. Percutaneous endoscopic gastrostomy: comparison of push and pull methods and evaluation of antibiotic prophylaxis. Endoscopy 1995;27:313-316.

63. Sturgis TM, Yancy W, Cole JC, Proctor DD, Minhas BS, Marcuard SP. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J Gastroenterol 1996;91:2301-2304.

64. Gossner L, Keymling J, Hahn EG, Ell C. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical trial. Endoscopy 1999;31:119-124.

65. Preclik G, Grune S, Leser HG, Lebherz J, Heldwein W, Machka K, Hostege A, Kern WV. Prospective, randomised, double blind trial of prophylaxis with single dose of co-amoxiclav before percutaneous endoscopic gastrostomy. Br Med J 1999;319:881-884.

66. Dormann AJ, Wigginghaus B, Risius H, Kleimann F, Kloppenborg A, Grunewald T, Huchzermeyer H. A single dose of ceftriaxone administered 30 minutes before percutaneous endoscopic gastrostomy significantly reduces local and systemic infective complications. Am J Gastroenterol 1999;94:3220-3224.

67. Ahmad I, Mouncher A, Abdoolah A, Stenson R, Wright J, Daniels A, Tillett J, Hawthorne AB, Thomas G. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy-a prospective, randomised, double-blind trial. Alim Pharmacol Therap 2003;18:209-215.

68. Saadeddin A, Freshwater DA, Fisher NC, Jones BM. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy for non-malignant conditions: a doubleblind prospective randomized controlled trial. Aliment Pharmacol Therapeut 2005;22:565-570.

69. Lewis BS. Perform PEJ, not PED. Gastrointest Endosc 1990;36:311-313.

70. Duszak RJ, Mabry MR. National trends in gastrointestinal access procedures: an analysis of Medicare services provided by radiologists and other specialists. J Vasc Intervent Radiol 2003;14:1031-1036.

71. Safadi BY, Marks JM, Ponsky JL. Percutaneous endoscopic gastrostomy. Gastro Endosc Clin N Am 1998;8:551-568.

72. Preshaw RM. A percutaneous method for inserting a feeding gastrostomy tube. Surg Gynecol Obstet 1981;152:658-660.

73. de Baere T, Chapot R, Kuoch V, Chevallier P, Delille JP, Domenge C, Schwaab G, Roche A. Percutaneous gastrostomy with fluoroscopic guidance: single-center experience in 500 consecutive patients. Radiol 1999;210:651-654.

74. Grant JP. Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy. Ann Surg 1988;207:598-603.

75. Lydiatt DD, Murayama KM, Hollins RR, Thompson JS. Laparoscopic gastrostomy versus open gastrostomy in head and neck cancer patients. Laryngoscope 1996;106:407-410.

76. Murayama KM, Johnson TJ, Thompson JS. Laparoscopic gastrostomy and jejunostomy are safe and effective for obtaining enteral access. Am J Surg 1996;172:591-594.

77. Peitgen K, von Ostau C, Walz MK. Laparoscopic gastrostomy: results of 121 patients over 7 years. Surg Laparosc Endosc Percutan Tech 2001;11:76-82.

78. Peitgen K, Walz MK, Krause U, Eigler FW. First results of laparoscopic gastrostomy. Surg Endosc 1997;11:658-662.

79. 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.

80. Laasch HU, Wilbraham L, Bullen K, Marriott A, Lawrance JA, Johnson JA, Johnson RJ, Lee SH, England RE, Gamble GE, Martin DF. Gastrostomy insertion: comparing the options-PEG, RIG, or PIG? Clin Radiol 2003;58: 398-405.

81. American Society for Gastrointestinal Endoscopy. ASGE guidelines for clinical application. Position statement on laboratory testing before ambulatory elective endoscopic procedures. Gastrointest Endosc 1999;50:906-909.

82. Taylor CA, Larson DE, Ballard DJ, Bergstrom LR, Silverstein MD, Zinsmeister AR, DiMagno EP. Predictors of outcome after percutaneous endoscopic gastrostomy: a community-based study. Mayo Clin Proc 1992;67: 1042-1049.

83. Wollman B, D'Agostino HB. Percutaneous radiologic and endoscopic gastrostomy: a 3-year institutional analysis of procedure performance. Am J Roent 1997;169:1551-1553.

84. Cosentini EP, Sautner T, Gnant M, Winkelbauer F, Teleky B, Jakesz R. Outcomes of surgical, percutaneous endoscopic, and percutaneous radiologic gastrostomies. Arch Surg 1998;133:1076-1083.

85. Moller P, Lindberg CG, Zilling T. Gastrostomy by various techniques: evaluation of indications, outcome, and complications. Scand J Gastroenterol 1999;34:1050-1054.

86. Stiegman GV, Goff JS, Silas D, Pearlman N, Sun J, Norton L. Endoscopic versus operative gastrostomy: final results of a prospective randomized trial. Gastrointest Endosc 1990;36:1-5.

87. Scott JS, de la Torre RA, Unger SW. Comparison of operative versus percutaneous endoscopic gastrostomy tube placement in the elderly. Am Surg 1991;57:338-340.

88. Stellato TA, Gauderer MW, Ponsky JL. Percutaneous endoscopic gastrostomy following previous surgery. Am Surg1984;200:46.

89. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282:1365-1370.

90. Lynch CR, Fang JC. Prevention and management of complications of percutaneous endoscopic gastrostomy tubes. Pract Gastroenterol 2004;28:66-76.

91. Kavic SM, Basson MD. Complications of endoscopy. Am J Surg 2001;181: 319-332.

92. Wojtowycz MM, Arata JA, Micklos TJ, Miller FJ. CT findings after uncomplicated percutaneous gastrostomy. Am J Roent1988;151:307-309.

93. Bankhead RR, Fisher CA, Rolandelli RH. Gastrostomy tube placement outcomes: comparison of surgical, endoscopic, and laparoscopic methods. Nutr Clin Prac 2005;20:607-612.

94. James A, Kapur K, Hawthorne AB. Long-term outcome of percutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke. Age Ageing 1998;27:671-676.

95. Lin HS, Ibrahim HZ, Kheng JW, Fee WE, Terris DJ. Percutaneous endoscopic gastrostomy: strategies for prevention and management of complications. Laryngoscope 2001;111:1847-1852.

96. Boyd JW, DeLegge MH, Shamburek RD, Kirby DF. The buried bumper syndrome: a new technique for safe, endoscopic PEG removal. Gastrointest Endosc 1995;41:508-511.

97. Ma MM, Semlacher EA, Fedorak RN, Lalor EA, Duerksen DR, Sherbaniuk RW, Chalpelsky CE, Sadowski DC. The buried gastrostomy bumper syndrome: prevention and endoscopic approaches to removal. Gastrointest Endosc 1995;41:505-508.

98. Foutch PG. Complications of percutaneous endoscopic gastrostomy and jejunostomy. Recognition, prevention, and treatment. Gastroint Endosc Clin N Amer 1992;2:231-248.

99. Mack LA, Kaklamanos IG, Livingstone AS, Levi JU, Robinson C, Sleeman D, Franceschi D, Bathe OF. Gastric decompression and enteral feeding through a double-lumen gastrojejunostomy tube improves outcomes after pancreaticoduodenectomy. Ann Surg 2004;240:845-851.

100. DeLegge MH, Patrick P, Gibbs R. Percutaneous endoscopic gastrojejunostomy with a tapered tip, nonweighted jejunal feeding tube: improved placement success. Am J Gastroenterol 1996;91:1130-1134.

101. Fan AC, Baron TH, Rumalla A, Harewood GC. Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension. Gastrointest Endosc 2002;56:890-894.

102. Simon T, Fink AS. Recent experience with percutaneous endoscopic gastrostomy/jejunostomy (PEG/J) for enteral nutrition. Surg Endosc 2000;14:436-438.

103. DeLegge MH, Duckworth PF, McHenry L, Foxx-Orenstein A, Craig RM, Kirby DF. Percutaneous endoscopic gastrojejunostomy: a dual center safety and efficacy trial. J Parenter Enteral Nutr 1995;19:239-243.

104. Hoffer EK, Cosgrove JM, Levin DQ, Herskowitz MM, Sclafani SJ. Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: a prospective, randomized comparison. J Vasc Interv Radiol1999;10:413-420.

105. Barkmeier JM, Trerotola SO, Wiebke EA, Sherman S, Harris VJ, Snidow JJ, Johnson MS, Rogers WJ, Zhou XH. Percutaneous radiologic, surgical endoscopic, and percutaneous endoscopic gastrostomy/gastrojejunostomy: comparative study and cost analysis. Cardiovasc Intervent Radiol 1998;21: 324-328.

106. Shike M, Latkany L, Gerdes H, Bloch AS. Direct percutaneous endoscopic jejunostomies for enteral feeding. Nutr Clin Pract 1997;12:S38-S42.

107. Varadarajulu S, DeLegge MH. Use of a 19-gauge injection needle as a guide for direct percutaneous endoscopic jejunostomy tube placement. Gastrointest Endosc 2003;57:942-945.

108. Krivian K, Peterson KP, DiSario JA, Fang JC. Comparison of percutaneous endoscopic gastrostomy with jejunal extension to combined direct percutaneous endoscopic gastrostomy/direct percutaneous endoscopic jejunostomy [abstract]. Gastrointest Endosc 2003;57:AB159.

109. DeLegge MH, Ginsberg GG, McClave SA, DiSario JA, Lehman GA, Fang JC. Randomized prospective comparison of direct percutaneous endoscopic jejunostomy vs. percutaneous endoscopic gastrostomy with jejunal extension feeding tube placement for enteral feeding [abstract]. Gastrointest Endosc 2004;59:AB158.

110. Duh Q, Senokozlieff-Englehart AL, Choe YS, Siperstein AE, Rowland K, Way LW. Laparoscopic gastrostomy and jejunostomy: safety and cost with local vs general anesthesia. Arch Surg 1999;134:151-156.

111. Shike M, Wallach C, Likier H. Direct percutaneous endoscopic jejunostomies. Gastrointest Endosc 1991;37:62-65.

112. Maple JT, Petersen BT, Baron TH, Gostout CJ, Wong Kee Song LM, Buttar NS. Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts. Am J Gastroenterol 2005;100:2681-2688.

113. DiSario JA, Foutch PG, Sanowski RA. Poor results with percutaneous endoscopic jejunostomy. Gastrointest Endosc 1990;36:257-260.

114. Guidelines for the Management of Adults with Hospital-Acquired, Ventilator-Associated, and Healthcare-Associated Pneumonia. Am J Respir Crit Care Med 2005;171:388-416.

115. Lord LM. Restoring and maintaining patency of enteral feeding tubes. Nutr Clin Pract 2003;18:422-426.

116. Sensibile JP, Leader JA, Griggs MR. Salvage of the clogged feeding tube: tricks of the trade. Nutr Clin Pract 2000;15:S74-S75.

117. Dickerson RN, Tidwell AC, Brown RO. Adverse effects from inappropriate medication administration via a jejunostomy feeding tube. Nutr Clin Pract 2003;18:402-405.

118. Heiser M, Malaty H. Balloon-type versus non-balloon-type replacement percutaneous endoscopic gastrostomy: which is better? Gastrol Nurs 2001;24:58-63.

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