Latest / Behind The Knife: The Surgery Podcast / I’ve Got 99 Problems, and a G Tube is One
Transcript
- G Tube_ 99 Problems === [00:00:00] Welcome back to Behind The Knife, wherever you are, and whatever you're doing, we hope you're having a fantastic day. This is Patrick Geoff, acute care surgeon at Duke University, and today we are discussing G-Tubes Common Quick, easy. No problems. Right? Wrong. Look at the episode title. I've got 99 problems, and a G-tube is most definitely one. Like so many quote, easy procedures in the world of surgery, gastric access is fraught with nuanced considerations and sneaky complications. Look, no one's gonna high five you after an awesome PEG tube placement, but they will call you at 2:00 AM when grandma pulled out her tube on postoperative day number two. So let's get to the nitty gritty. Who needs a G-tube? What are the risks and how do we deal with the complications? Today I'm joined by Dr. Kerry Seymour, one of our minimally invasive and acute care surgeons at Duke University, and Chief Quality Officer for the Department of Surgery. And Dr. Joy love one of our [00:01:00] exceptional surgical residents and a member of our B-T-K-M-I-S team. And today we're gonna discuss the who, how, when, why, and where of gastrostomy tubes. Carrie, Joey, welcome. Thank you, Patrick. I'm excited to be here. So this is a consult that we see all the time, and like you said, it's fraught with more problems than initially meets the eye. Joey, let's say you're on a busy night shift and you get this consult, an 86-year-old female who had a stroke four days ago. She's in the neuro ICU and they're requesting enteral access, what do you need to know? Oh man. So many things. First, who is the patient age? Comorbidity, goals of care decision maker. A hundred percent. So a lot of these folks, like particularly the ones in the neuro ICU, they can't make their own decisions and it's really helpful and necessary at the time of the consult to know who you should be talking to and whether or not the primary team has made a good faith effort to [00:02:00] determine whether the tube is in the patient's best interest, and then any issues around goals of care. So sometimes we get stuck playing a much larger, but necessary role in these goals of care discussions. And oftentimes it's a bigger role than we might like. Ultimately, we should only be offering G-tubes to patients in whom it is safe, indicated and desired. But by definition, many of the patients who need a G-tube are not stellar operative candidates. So that often means we have to spend some time something we have such little of digging through the patient's chart, talking with family, and doing our due diligence. So Joey, you mentioned comorbidities. Which ones are you worried about when it comes to putting a g-tube in? Yeah, the first question is the same first question for any consult, which is the overall stability of the patient. Are they on rocket fuel? What are their ICU indications if they're in the unit, and how do we expect them to do over the next couple days? Are they febrile, bacter, remic fighting other battles? There's really no such thing as an emergent G-tube. So if the patient is tenuous, now is not the time. Then there's a set [00:03:00] of conditions that make placement more technically challenging, like an extensive abdominal surgical history cirrhosis with varice or ascites or bariatric surgery. So exactly all of these conditions, they require some special consideration. For example, if the patient has an extensive past surgical history, we may change our approach. Maybe it's a laparoscopic versus an open G-tube patient has liver failure or any ongoing ascites, then a G-tube or any enteral tube is usually contraindicated. And in my field, in bariatric surgery, a patient with a sleeve gastrectomy. It doesn't really have enough stomach for a gastrostomy tube, so you might have to place a G ostomy tube. And then for a patient with a gastric bypass, you can't access their remnant stomach, and so that needs a surgical tube. So a little bit more to think about. Yeah, absolutely. Okay. Alright Joey, so we're getting to know our patient but there's definitely other things that we want to hear about before committing to an operation or procedure. So what else are we thinking about? Yeah, we need to know [00:04:00] why they can't eat and are we sure they can't eat? Their trajectory is really important because we can't remove a G-tube safely for six weeks or so after placement. And if the patient's gonna be eating again in a week, this isn't the right option for them. So how do we determine when folks will be eating again? So depending on the etiology of the patient's dysphagia, we have some predictive capacity. The speech and language pathology team's gonna be our best resource. They can perform a swallow evaluation, additional studies like a fluoroscopic or video evaluation if they need to. And I'm not sure how many general surgeons know about this, but for stroke patients specifically, there is a well validated. Predictive model called press P-R-E-S-S, that integrates age stroke severity on admission, lesion location, initial risk of aspiration, and initial impairment of oral intake to predict who's most and least likely to be eating seven days later. And there's actually even an app for that model. Yeah, this is something that's new to me and it is quite handy. This is also a good time to talk about something that I deeply despise. And that's the consult for durable, enteral access for the sole purpose. [00:05:00] Of fulfilling a rehab or skilled nursing homes requirement that the patient not have a tube dangling from their nose, whether it's bridled or otherwise. Now, as we all know, many of these patients are doing just fine. They're progressing nicely. They're likely to regain swallow function. At some point, we can use that press model to maybe have more information about understanding exactly when, but they are stuck in the hospital until you, the friendly surgeon performs a procedure that is non-zero risk. And you move that tube from their nose to their abdominal wall, which really, has no apparent actual benefit to them. So , it can be pretty maddening. But you're stuck between a rock and a hard place here. And if you refuse on principle and hold up the patient's discharge, then you know that's gonna make people unhappy. Or you could go ahead and perform what may be an indicate. Procedure. And so in this circumstance, I think there's a few things that we can do. So number one, you wanna make triple sure that this is in fact the policy of the receiving facility. Because once you or the case manager [00:06:00] really look into it, it may not always be the case. And that's sometimes the experience that I've found, it may take a handful of extra phone calls, but you might be surprised what you find out. Second try to find another facility that'll take an NG tube. Three. If the patient is very low risk surgical candidate, then just place the tube and facilitate progression of care. Or four. If the patient is a high risk surgical candidate, then politely decline and explain why. So optimally, we'd wait a couple of weeks but our system isn't really designed to keep every patient in the hospital for a prolonged length of time. So we've also noted there's an administrative aspect. Yeah, so some have come up with unique interventions here. One hospital created a clinical care pathway utilizing a pm and r team, specifically a physiatrist, to evaluate patients with stroke. Basically just to justify prolonged nutrition via NG tube for appropriate candidates, and then facilitate their acceptance into the rehab facilities. There is this 2017 study of national nursing home acceptance rates for [00:07:00] NG tube that found that about 62% of nursing homes will take a patient with an NG tube. And it was a relatively small sample, but that's like a larger proportion than I would've anticipated based on the resistance. We often yeah, run up against. So utilization of bridals, might increase sniff comfort levels. It's definitely something to look into further. And then an important distinction is between those who will return to an adult care home where they live previously, because many of those folks don't have the right type of nursing staff to manage an NNG tube versus going to a skilled nursing facility where almost all of them should have the correct resources on board. But that said, a lot of adult care homes can't manage a G-tube either, so that patient has to go somewhere else anyway. Okay, so there's data to guide the timing of gastrostomy to placement in patients with gastric access is indicated. Can you tell us a little bit about that? Yeah. And this was alluded to earlier, but stroke guidelines advocate a two week trial of nasal gastric feeding, at least before placing a gastrostomy tube, because about 50% of people with dysphagia recover significantly by that time point. [00:08:00] In fact, for all comers with stroke, about 75% are unable to swallow a discharge, but 70% have. Oral intake 30 days later. And there's a small retrospective study from 2022 showing no difference in mortality or complication rate for patients that underwent early PEG two placement less than a week post-stroke as opposed to later PEG placement. And early peg placement did result in a significant reduction in length of stay. However, the study didn't comment on how many of the early patients actually needed the tube. We don't know if they were eating again a week or two later. , The other population is the trauma population that we often work with the TBI patients. Do we have any information about what we can expect in terms of their ability to recover yeah, so there's a retrospective cohort study in the Journal of Neurosurgical Anesthesia from 2018. It looks at almost a hundred thousand patients with TBI 3,300 of whom got pegs and they found higher mortality and worse outcome overall in peg placement less than seven days out and greater than 14. Days out suggesting this optimal seven to 14 day window. But interestingly, a small study on the natural history of dysphagia and TBI in 117 patients [00:09:00] showed 75% with oral intake at 17 days without additional supplementation needs by three weeks. By 22 days, 47% we're back to a regular diet. So we probably do too many G-tubes in this patient population as well. But risk stratification can be challenging and the best predictor they had in this study was if the patient was able to be evaluated for swallow within four days of admission. So at four days, the people who could not undergo bedside swallow evaluation, they were intubated or whatever else took twice as long to return to oral feeding. Makes sense. So Joey, tell us a little bit more about the patients that are still intubated and sedated, or even those that require a tracheostomy. Are those most likely to be the patients who are in that 25% who aren't eating a several weeks later? Yes, though contemporaneous gastrostomy and tracheostomy placement has also been studied. And the rates of inappropriate gastrostomy tube placement, which is defined as placement in those with oral intake at four to six weeks was up to 40%. However, it was no better in the patients that got tracheostomy first and peg later. [00:10:00] We also have to be aware of our biases. There's an a CS abstract that came out a few months ago looking at TBI and A level one trauma registry across five years that found that PEG placement was not correlated with dysphagia or TBI severity, but Troublingly was correlated with insurance status with an odds ratio of 10 for Medicaid and 40 for self pay. It's a troubling finding. I would say though, that I really never have a clue what my patient's insurance status is, which is the way I like it. So I'm not sure that this is a surgeon issue. And I guess it could be maybe it's related to the discharge destination as we talked about earlier. So Joey, let's switch gears. Is there anyone who definitely should not get a G tube? Patients with dementia, the data's pretty clear here. The nutrition doesn't prolong their life, and the complications can be serious. Yeah. So if you think the patient's at high risk of pulling out their tube definitely think twice before inserting anything. We also have to be cautious in our oldest old folks above 85, their rates of recovery from dysphagia are more or less equivalent to younger patients, but their rates of complications are higher. [00:11:00] Joey, that makes sense. But when you're evaluating the patient in the ICU. Some of the patients who've had an ischemic stroke are gonna be treated with sym anticoagulation. So what do we know about holding or stopping anticoagulation? Oh, in a trial of around 1500 patients on some form of uninterrupted antithrombotic therapy. So more for an aspirin, Plax, heparin, Lovenox. There were only six significant bleeding events. Interestingly, the only patients that bled were on subcu heparin. Another study found heparin infusion and duration of hospitalization to be the only predictors of significant bleeding with rate of bleeding. Still less than half a percent. So for patients with a high thrombotic risk who are on anticoagulation, consider operating without holding it, the risk of a clinically significant post peg placement bleed is really quite low. Got it. So a final consideration is that we need to know a little bit more about the patient's stomach and any dysmotility or whether they've had a gastric outlet obstruction. And they've only ever tolerated post pylori feeds. We don't wanna [00:12:00] put durable access into their stomach when it may not be functioning. So there still might be some benefit from something like a gastrojejunostomy or even a Degen ostomy tube placement. The exception, of course, is gonna be those malignant bowel obstructions with no other options or metastatic cancer patients with poor motility where we have to place a G-tube strictly for venting and symptom relief. Usually this is in transition to hospice, so we still have to ask all of our comorbidity and safety questions that you mentioned in the past, and I think that just helps give an indication for these tubes, makes it a little bit clearer. Yeah, absolutely. So we've hit the high points for patient selection and timing. Let's talk about technical consideration. So we can do an open gastrostomy tube, laparoscopic, percutaneous endoscopic, and GI and ir. Also place gastrostomy tube. So how do we choose who does the procedure and how it's. There are a couple populations that usually benefit from placement by ir. Those with oropharyngeal cancer or [00:13:00] severe trismus where we can't pass an endoscope but they can still pass an NG tube or a dobhoff to still contrast and place the G-tube percutaneously. Those with really high aspiration risk might also benefit from avoiding endoscopy. Patients that should have placement with surgery include anyone who might need a LAP assisted or fully lap G-tube, particularly if you don't think you have a window. Lap assisted can be great. Just a single port for insufflation and a camera so you can watch the G-tube. Go in and know you aren't hitting inter post colon or anything else. So when it comes to cross-sectional imaging, it's not really required before placement, but if there is imaging, you should always look right. You can always look for a window, and you can always determine the abdominal wall thickness. So if your G-tubes at seven centimeters of the skin and you only have two centimeters of abdominal wall thickness on a CT scan, then you definitely need to consider if there's some other organ in between the skin and your G-tube. And with that said, PEG two placement specifically is a dynamic procedure. And so as the stomach is insufflated [00:14:00] and the patient ideally positioned in the head up inberg position, the colon will often fall away from the stomach. So if you review a CT scan pre-op, and the colon is overlying the stomach, that does not automatically preclude the patient from getting a PEG tube. Now if the appropriate safety checks are performed, a tube can still be inserted in those patients. So remember, for all peg tubes, you want one-to-one blotting. So pushing your finger in and seeing about equal sized indentation. Internally with your scope, you want trans illumination where you can take your endoscope right up to the wall of the stomach where you had that one-to-one blotting. You can see light shining through externally and you wanna see that the depth of the needle should. Match with what you think of the patient's abdominal wall thicknesses or what you may have measured ideally on CT scan, if you have that. Beforehand, and if you don't have those safety checks, it's simply not safe to proceed. , There's other options for doing so safely. Oftentimes we'll consent patients who are getting a PEG tube for a lap assisted as well, or a laparoscopic G tube. So if we need to pivot [00:15:00] it's nice to think about that beforehand. Joey, when would we go to a laparoscopic or open tube specifically? As you mentioned it's all about safety. A patient with a ton of adhesions and no safe window will need adhesiolysis. Some of these folks can be done laparoscopically, but others won't tolerate insufflation or have such dense adhesions that an open G tube becomes the only option. So once we've been able to safely place this PEG tube can you talk a little bit more about what complications we're gonna worry about on the floor in post-op? Early dislodgement, buried bumper syndrome, bleeding, infection, late dislodgement and aspiration are the big ones. Yeah. Let's start with dislodgement. That's a big one. So Joey, does it matter when the tube gets dislodged and is there anything we can do to prevent that from happening? It def definitely matters. So the tract takes time to mature and the risk that gastric contents will leak into the abdomen, which would be a surgical emergency, is highest in those first seven, 10 days. So dislodgement in that period may require reoperation. If it's after seven [00:16:00] 10 days, the tube can often be replaced at the bedside with tube positioning confirmed. With a contrasted study, you can put an abdominal binder immediately post-op on patients you're concerned, may dislodge their own tubes. But those can also cause pressure injuries and we're not always the best at anticipating who's gonna pull their own tube out. Binders do help prevent the tube from snagging on things though, depending on patient risk for accidental dislodgement or for those who might need permanent gastric access like an A LS patient, you can also consider placing a permanent G-tube that cannot be removed by traction and has to be removed Endoscopically. Finally, and there's a recent paper in the American Journal of Surgery to attest to this. Early recognition is key, and having nursing care order sets requiring documentation of tube depth Q shift, along with protocols to notify the provider, helps to identify changes in tube depth much more quickly and prevent full dislodgement. So nursing and primary team education for these tubes is really important, and these patients are often not on a surgical service when these dislodgements happen. Intraabdominal sepsis is obviously a huge concern. You should have a high index of suspicion if the patient's febrile, [00:17:00] if they're not tolerating tube feeds, if they have a new leukocytosis or any change in their abdominal exam without any alternative explanation. These patients can also get necrotizing soft tissue infections when there's tube feed spillage into the soft tissue. This also can require some significant debridement in addition into even an X lap. The CT scan with a contrast injected in a tube is probably your best bet to get a rapid diagnosis. Yeah, we should take a step back too and just confirm again this patient we're talking about where the tube gets dislodged in that seven to 10 day window. It's most worrisome in patients who have undergone percutaneous endoscopic gastrostomy tube placements or peg where the stomach walls not fixated to the abdominal wall like we do in laparoscopic or open surgery, or even with t fasteners when ir places it percutaneously. Joey, let's walk through something here. You're on a call. A stroke patient underwent an uneventful peg tube, percutaneous endoscopic tube placement four days ago, and the tube was accidentally [00:18:00] dislodged during routine skincare. So you evaluate the patient, they look totally fine, their belly is soft and non-tender. What do you do next? Ideally, I would have a replacement tube, in this case, a tube with a balloon on it. Insert it really gently, carefully. You're not, you don't wanna make a false tract or push your way into any other space. But if you slide it into the same tract, aspirate gastric contents then you can get an injection study and confirm the location. What if there is an inappropriate tube around? What do you do? Yeah. The kind of MacGyver maneuver is to just take a Foley catheter and follow the same set of steps. So just slide it into the stomach and then you can exchange the Foley. For a proper tube once you're sure the tract is mature, so you can just wait out that last several days until you're in a safe replacement window. Yeah, before exchanging. Okay, so controversial topic here. What about securing a PEG tube specifically the tube or the flange itself to the patient with suture to prevent dislodgement? This seems to get surgeons all fired up. Yeah, [00:19:00] definitely. So to my knowledge this hasn't been explicitly studied but if you suture it too tight, you're at risk of skin necrosis and buried bumper syndrome without necessarily improving risk of dislodgment. The tube can move without the bumper moving or the bumper can move without the tube moving, regardless of how you try to suture it. Yeah. It oftentimes seems to cause more problems than it's worth, and I don't suture tubes for that reason. But everyone has their own opinion, some stronger than others. Carry. What do you do? So in the past I was trained to secure the bumper with suture, and I did that for several years. But when you consider the PEG tube and the fact that these are placed endoscopically and aren't always secured, I stopped securing these altogether. And look at the literature around the buried bumper. So I've drifted to, to your side of the fence, Patrick. Yeah, I don't think there's a, there's not a great answer to this and certainly, institutional and personal preference reign supreme in this space. And Joey did a great job of looking into the literature and there really is no strong literature [00:20:00] on that. So you'd mentioned a buried bumper syndrome. Joey, what is buried bumper syndrome? This is when the internal bumper has eroded into the abdominal wall instead of sitting in the stomach. So the tube might have to be repositioned or replaced or even just removed. So the primary issue at hand is often too much tension on the tube, which causes it to pull through. So when a patient presents with a buried bumper, the tube should be exchanged or removed depending on how far they out from placement. Typically, the buried bumper syndrome is something that can occur later in the game. So if the tract is relatively healthy, you can simply replace the tube and then pay attention to some local wound care, and then sometimes the tract will need to heal after removal and place a new G-tube in another location. Similarly, these patients can develop gastro cutaneous fistulas after tube removal. It's relatively rare, but it's clearly frustrating for patients. So how do we manage this? The chronic gastrostomy tube users greater than six months are most likely to have this rare complication. The mechanism is epithelialization of the [00:21:00] fistula tract. Management includes post pori or parenteral nutrition, PPI to reduce gastric acid along the tract treatment of any surrounding soft tissue infection and skincare. Yeah, , these are tough scenarios, so typically a gastro cutaneous fistula just needs time to heal and often you need to allow to heal before a tube can be placed and that tube is placed. at a different location, oftentimes a few centimeters away. Good wound care and treatment of cellulitis are really important as well. And oftentimes it's just a healthy dose of time, sometimes, many weeks before a fistula will heal. And that's oftentimes all you need is just a little bit of patience. And what if it doesn't close with a conservative approach? Endoscopists can use fibrin glue to plug the tract, sometimes multiple times, sometimes concurrently with or followed by endoscopic clip placement if endoscopy fails or as an alternative initial therapy surgery. Yeah. And these endoscopic aosis,, don't have a super high [00:22:00] success rate but there. Low risk in terms of giving it a whirl and seeing if it works. So when it comes to a surgical approach, this can be open, or MIS certainly MIS is preferred. If possible, the fistula tract can be taken down with an endoscopic stapler and the tract derided externally to help ensure heals quickly. This is typically all you need to get these to close up. Joey, what's the 99 problem? How do you unclog a G-tube? So there, there are clogs advocates but often power flushing or using soda like Coca-Cola works better. And flushing with a smaller syringe increases the pressure that you can actually apply into that tube. It has something to do with physics, which is beyond my simple brain. Five ml syringe, maybe better than a 20 ml syringe. And remind us, Joey, what are some of the relative contraindications to G-tube placement? We talked about 'em earlier. Clinical instability. Ascites can't tolerate gastric feeds. Terminal illness with poor prognosis and no indication to vent. Don't place [00:23:00] G-tubes in older patients with dementia. Yep. And what's the go-to study for someone not tolerating tube feeds through their new tube IR tube check so they squirt contrast down the tube and make sure it's intraluminal. If i's not available, you can get an abdominal x-ray at bedside and put contrast down just before shooting. Joey, do we hold anticoagulation for G-tube Placements? Management's individual, but particularly in high risk cardiac patients, no bleeding risk is very low. And how do we manage early G-tube Dislodgement if less than seven to 10 days and sick they're going to the OR if more than 10 days out or not sick, they may be appropriate for an attempt at bedside replacement. Great. There's a lot more we could say on internal nutrition, but that wraps us up for today. Go see some G-tube consults and dominate the day.