Endoscopic management of enteral tubes in adult patients – Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Main recommendationsESGE recommends the “pull” technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer (“push”) technique for PEG placement in cases where the “pull” method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed “blindly” at the patient’s bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 – 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 – 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

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Endoscopic management of enteral tubes in adult patients – Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopy ◽

10.1055/a-1303-7449 ◽

2020 ◽

Vol 53 (01) ◽

pp. 81-92

Author(s):

Marianna Arvanitakis ◽

Paraskevas Gkolfakis ◽

Edward J. Despott ◽

Asuncion Ballarin ◽

Torsten Beyna ◽

...

Keyword(s):

Percutaneous Endoscopic Gastrostomy ◽

Oral Intake ◽

Tube Placement ◽

Endoscopic Management ◽

Strong Recommendation ◽

Ulcer Disease ◽

Weak Recommendation ◽

Endoscopic Gastrostomy ◽

Percutaneous Endoscopic Jejunostomy ◽

Quality Evidence

Main recommendationsESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.

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Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopy ◽

10.1055/a-1397-3198 ◽

2021 ◽

Author(s):

Geoffroy Vanbiervliet ◽

Marin Strijker ◽

Marianna Arvanitakis ◽

Arthur Aelvoet ◽

Urban Arnelo ◽

...

Keyword(s):

Clinical Success ◽

Endoscopic Management ◽

R0 Resection ◽

En Bloc ◽

Strong Recommendation ◽

Moderate Quality ◽

Endoscopic Papillectomy ◽

Pancreatic Duct Stenting ◽

Ampullary Tumors ◽

Quality Evidence

Main Recommendations 1 ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2 ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence. 3 ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence. 4 ESGE recommends en bloc resection of ampullary adenomas up to 20–30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence. 5 ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence. 6 ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence. 7 ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence. 8 ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.

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Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopy ◽

10.1055/a-1442-2395 ◽

2021 ◽

Author(s):

Geoffroy Vanbiervliet ◽

Alan Moss ◽

Marianna Arvanitakis ◽

Urban Arnelo ◽

Torsten Beyna ◽

...

Keyword(s):

Endoscopic Resection ◽

En Bloc Resection ◽

Endoscopic Management ◽

Duodenal Adenoma ◽

En Bloc ◽

Strong Recommendation ◽

Delayed Bleeding ◽

Duodenal Adenomas ◽

Moderate Quality ◽

Quality Evidence

Main recommendations 1 ESGE recommends that all duodenal adenomas should be considered for endoscopic resection as progression to invasive carcinoma is highly likely.Strong recommendation, low quality evidence. 2 ESGE recommends performance of a colonoscopy, if that has not yet been done, in cases of duodenal adenoma.Strong recommendation, low quality evidence. 3 ESGE recommends the use of the cap-assisted method when the location of the minor and/or major papilla and their relationship to a duodenal adenoma is not clearly established during forward-viewing endoscopy.Strong recommendation, moderate quality evidence. 4 ESGE recommends the routine use of a side-viewing endoscope when a laterally spreading adenoma with extension to the minor and/or major papilla is suspected.Strong recommendation, low quality evidence. 5 ESGE suggests cold snare polypectomy for small (< 6 mm in size) nonmalignant duodenal adenomas.Weak recommendation, low quality evidence. 6 ESGE recommends endoscopic mucosal resection (EMR) as the first-line endoscopic resection technique for nonmalignant large nonampullary duodenal adenomas.Strong recommendation, moderate quality evidence. 7 ESGE recommends that endoscopic submucosal dissection (ESD) for duodenal adenomas is an effective resection technique only in expert hands.Strong recommendation, low quality evidence. 8 ESGE recommends using techniques that minimize adverse events such as immediate or delayed bleeding or perforation. These may include piecemeal resection, defect closure techniques, noncontact hemostasis, and other emerging techniques, and these should be considered on a case-by-case basis.Strong recommendation, low quality evidence. 9 ESGE recommends endoscopic surveillance 3 months after the index treatment. In cases of no recurrence, a further follow-up endoscopy should be done 1 year later. Thereafter, surveillance intervals should be adapted to the lesion site, en bloc resection status, and initial histological result. Strong recommendation, low quality evidence.

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A novel device for the endoscopic management of buried bumper syndrome

Endoscopy ◽

10.1055/a-0833-8516 ◽

2019 ◽

Vol 51 (07) ◽

pp. 689-693 ◽

Cited By ~ 4

Author(s):

Pieter Hindryckx ◽

Barbara Dhooghe ◽

Andreas Wannhoff

Keyword(s):

Abdominal Pain ◽

Gastric Mucosa ◽

Percutaneous Endoscopic Gastrostomy ◽

Endoscopic Management ◽

First Line ◽

Off Label ◽

Novel Device ◽

Endoscopic Gastrostomy ◽

Buried Bumper Syndrome ◽

Peg Tube

Abstract Background Buried bumper syndrome (BBS) is a complication of percutaneous endoscopic gastrostomy (PEG) in which the internal bumper is overgrown by the gastric mucosa. Apart from loss of patency of the PEG tube, the buried bumper may evoke symptoms such as abdominal pain or peritubular leakage. While the management of an incompletely buried bumper is fairly straightforward, this is not the case for a completely buried bumper. Different approaches to remove completely buried bumpers have been described, including endoscopic knife- or papillotome-based techniques. However, these devices are used off-label and the procedures can be laborious. Methods The Flamingo device has recently been introduced as the first tool specifically designed to remove a completely buried bumper. Results We describe the technique and our first experience in five patients with a completely (n = 4) or almost completely (n = 1) buried bumper. Fast and save removal of the buried bumper was obtained in all patients. Conclusion We believe that this device has the potential to become the standard first-line tool for the management of completely buried bumpers.

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Novel endoscopic management of buried bumper syndrome in percutaneous endoscopic gastrostomy: The Olympus HookKnife

World Journal of Gastroenterology ◽

10.3748/wjg.v23.i35.6546 ◽

2017 ◽

Vol 23 (35) ◽

pp. 6546-6548 ◽

Cited By ~ 4

Author(s):

Laura E Wolpert ◽

Dominic M Summers ◽

Andrew Tsang

Keyword(s):

Percutaneous Endoscopic Gastrostomy ◽

Endoscopic Management ◽

Endoscopic Gastrostomy ◽

Buried Bumper Syndrome

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UNUSUAL ENDOSCOPIC-LAPAROSCOPIC MANAGEMENT OF BURIED BUMPER SYNDROME AS COMPLICATION AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY PLACEMENT

10.1055/s-0040-1704425 ◽

2020 ◽

Author(s):

R DiMitri ◽

A Bonaccorso ◽

D Scimeca ◽

ML Mastro ◽

E Conte ◽

...

Keyword(s):

Percutaneous Endoscopic Gastrostomy ◽

Laparoscopic Management ◽

Percutaneous Endoscopic Gastrostomy Placement ◽

Endoscopic Gastrostomy ◽

Buried Bumper Syndrome

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Faculty Opinions recommendation of Effect of beta lactam antibiotic use in children on pneumococcal resistance to penicillin: prospective cohort study.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1003975.43808 ◽

2002 ◽

Author(s):

Marilyn Roberts

Keyword(s):

Cohort Study ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Antibiotic Use ◽

Beta Lactam ◽

Beta Lactam Antibiotic ◽

Lactam Antibiotic ◽

Resistance To Penicillin

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Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

Endoscopy ◽

10.1055/a-1369-5274 ◽

2021 ◽

Vol 53 (03) ◽

pp. 300-332

Author(s):

Ian M. Gralnek ◽

Adrian J. Stanley ◽

A. John Morris ◽

Marine Camus ◽

James Lau ◽

...

Keyword(s):

High Dose ◽

High Quality ◽

Peptic Ulcer Hemorrhage ◽

Strong Recommendation ◽

Epinephrine Injection ◽

Moderate Quality ◽

High Quality Evidence ◽

Mechanical Therapy ◽

Upper Gastrointestinal ◽

Quality Evidence

MAIN RECOMMENDATIONS 1 ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow–Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2 ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3–5 days.Strong recommendation, moderate quality evidence. 3 ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4 ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5 ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6 ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8 ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9 ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (a) PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (b) High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10 ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.

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