Abstract
An 81-year-old woman who underwent percutaneous endoscopic gastrostomy (PEG) a year before, after cerebral infarction was receiving home medical care. The first accidental PEG tube removal occurred after clinic hours, and the home-care doctor visited her home to quickly reinsert the tube. After the narrowed fistula was dilated, the tube was reinserted with a guide wire. An X-ray taken with a CALNEO Xair, which is an easily portable X-ray system launched in 2018, confirmed that the tip of the PEG tube was successfully placed in the stomach. A similar accidental removal occurred 2 months later, and we managed it in the same way. Both events were resolved with a single radiograph without significant difficulty. With in-home medical care, PEG tube replacement can be performed easily and safely with a handy portable X-ray system.
Keywords: general practice / family medicine, long term care, healthcare improvement and patient safety, home care nursing
Background
Percutaneous endoscopic gastrostomy (PEG) is a widely used procedure for patients who need enteral feeding because of head and neck cancer or neurological disorders such as stroke and dementia.1 Since enteral feeding via nasogastric tube has more complications and less comfort than using PEG tube,2 PEG can be a better option for patients who need long-term continuous enteral feeding. However, the incidence of major complication including death was reported from 0.4% to 22.5% and minor complications including accidental tube removal was reported from 13% to 43%.3 4 In addition, there are some ethical issues in the decision to perform PEG, for example, indications for patients with difficulties in decision making.5 In Japan, the number of PEG procedures has been decreasing from 7 000 cases in 2011 to 4 500 cases in 2014.6
However, the number of PEG tube replacements, which is estimated to be approximately 30 000 times per year,6 has not decreased because life expectancy after PEG has been extended.7 Eighty percent of patients who undergo PEG are classified as grade C bedridden,8 meaning a score of ≥7 on the CSHA Clinical Frailty Scale.9 Furthermore, 50.6% of PEG patients reside in their own homes or in a nursing home.8 Using a handy portable X-ray system could help home-care doctors safely replace a PEG tube in a patient’s home, which would reduce the burden and costs for patients with low mobility and their families who would otherwise have to transport the patient to the hospital.
We report the first case in which a PEG tube was accidentally removed and replaced safely at a patient’s home using the handy portable X-ray system, CALNEO Xair (figure 1), after clinic hours.
Figure 1.
The exterior view of the CALNEO Xair. (A) The CALNEO Xair is small and sufficiently light weight to be carried easily by one person. (B) The CALNEO Xair is smaller than a 15-inch laptop PC.
Case presentation
An 81-year-old woman was receiving home medical care for the aftereffects of cerebral infarction, type 2 diabetes mellitus and hypertension. She suffered left hemiparesis, dysphagia and aphasia after cerebral infarctions at the ages of 75 and 79 years. She underwent PEG tube placement with a Cliny 14-Fr balloon-type tube a year before at the age of 80 years and then she became eligible to receive home medical care. Because she had visceral inversion, gastrostomy was installed in her right abdomen.
The home-care doctor visited the patient’s home because her husband called at 15:00 on a Saturday and stated that her PEG tube had been accidentally removed. This was the first accidental removal of the PEG tube, and the cause and time of the incident were unknown.
Her vital signs were normal on examination. Since the gastrocutaneous fistula was stenotic, the same diameter PEG tube as the previous tube could not be inserted even though the guidewire passed. Two options for PEG tube replacement were presented to the patient and her husband. The first option was to undergo replacement immediately at home, and the other was to undergo replacement 2 days later at the hospital, but with a higher possibility of requiring regastrostomy. The patient and her husband chose PEG tube replacement at home after the home-care doctor discussed the benefits and risks of the two options in detail.
Treatment
The narrowed fistula was incised crosswise with a scalpel under local anaesthesia with lidocaine. A new PEG tube with the same diameter was inserted without resistance. After the gastric fluid was suctioned out of the tube, amidotrizoic acid was injected through the PEG tube. Abdominal X-ray in the supine position using the CALNEO Xair showed normal gastric mucosal folds and confirmed that the tip of the PEG tube was in the stomach (figure 2). It took 5 min to take and review the X-ray image.
Figure 2.
Abdominal X-ray in the supine position taken with the CALNEO Xair after percutaneous endoscopic gastrostomy tube replacement during the first episode of accidental removal (visceral inversion syndrome). The image, which is of sufficiently high quality for use in home medical care, shows normal gastric mucosal folds and confirms that the tip of the PEG tube was in the stomach (arrow). PEG, percutaneous endoscopic gastrostomy.
Outcome and follow-up
The next day, the home-care doctor revisited the patient’s home and confirmed that the patient had no signs of infection, such as fever or redness around the PEG tube or bleeding from the wound. She experienced no problems after tube feeding was restarted.
Two months later, again after clinic hours, the patient’s PEG tube was accidentally removed. After the PEG tube was reinserted, the position of the tip of the PEG tube was checked quickly with an abdominal X-ray in the supine position using the CALNEO Xair, as in the previous episode.
Discussion
The handy portable X-ray system, CALNEO Xair, was invented and launched by Fujifilm in 2018. It weighs 3.5 kg and measures 144 mm high, 148 mm long and 258 mm wide and can be carried more easily by hand than traditional portable X-ray systems (figure 1). Because the system was developed for prehospital care, there are reports of using the CALNEO Xair for emergent patients in helicopters.10 However, there had been no reports of using the unit in the field of internal medicine or for in-home medical care.
To our knowledge, this is the first case report in which a PEG tube was accidentally removed and safely replaced at a patient’s home with the aid of the CALNEO Xair. After PEG tube replacement, the position of the tip of the PEG tube was checked quickly with an abdominal X-ray using the CALNEO Xair. There were no complications with the procedure and subsequent course after these two events. Although PEG tube replacement at a patient’s home is associated with a lower accuracy when checking the location of the tip of the tube than at the hospital, there may be many a need for PEG tube replacement at home, as in the present case. Furthermore, appropriate and quick resolution could avoid hospitalisation for regastrostomy, which would reduce the healthcare costs.
While PEG tube replacement at home has benefits, safety is essential. Since serious complications of PEG tube replacement are fistula injury and tube misplacement into the peritoneal cavity, which are reported to have a combined incidence of 0.2%–0.5%,11 correctly checking that the tip of the tube is located in the stomach is essential. In the hospital, endoscopy is the best way to check for complications; however, endoscopy is painful and invasive and can lead to aspiration and aspiration pneumonia.11 Therefore, contrast radiography is often used in clinical practice. Because sequential radiographic imaging cannot be performed with the CALNEO Xair compared with contrast radiography, the patient’s positioning and the timing of the X-rays should be carefully adjusted. In both events in the present case, one initial X-ray was sufficient to check the position of the tip of the PEG tube.
In PEG tube replacement at a patient’s home, the sky blue dye method and a PEG scope are useful to check the location of the tip of the tube.12 13 The sky blue method, which is not covered by the public medical insurance in Japan as of 2020, has a false-negative rate of 6%–10%,12 whereas the PEG scope, which has LED lights and does not require other light sources for the endoscope, can be passed through the PEG tube directly. Unfortunately, the PEG scope can be used only for PEG replacement, and no other endoscopic examinations can be performed.13 Although the PEG scope is lightweight and useful for PEG tube replacement at a patient’s home, the high purchase cost limits it usefulness and has made it difficult to popularise.13 Therefore, our clinic is not equipped with a PEG scope.
The CALNEO Xair, available for X-ray examination of the chest, abdomen and bones, is far more versatile than a PEG scope; however, its cost has never been published. We can diagnose pneumonia, heart failure, tuberculosis and bone fractures at a patients' home using this system. The quality of home medical care could be improved with this handy portable X-ray system.
In conclusion, we reported the first case in which a PEG tube was accidentally removed and safely replaced in a patient’s home with the aid of the handy portable X-ray system, CALNEO Xair. The system is expected to be a useful method for checking the location of the tip of a replaced PEG tube in a patient’s home.
Learning points.
Percutaneous endoscopic gastrostomy (PEG) tube replacement in a patient’s home was performed easily and safely with a handy portable X-ray system.
Because it takes 5 min to take and review the X-ray image, a handy portable X-ray system could make it easy to check the position of the tip of the PEG tube after replacement in a patient’s home.
PEG tube replacement in a patient’s home could reduce healthcare costs and patients’ costs of transportation.
Acknowledgments
We thank Choi S MD, the chairman of Budounoki Clinic for invaluable advice and kind support. We also thank Jane Charbonneau, DVM from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.
Footnotes
Contributors: HE was involved in concept, literature search, drafting and clinical care of the patient. NEK was involved in literature search and drafting. KY was involved in literature search and clinical care of the patient. MT was involved in concept, literature search and revision of article.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Parental/guardian consent obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
- 1.Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, et al. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World J Gastroenterol 2014;20:7739–51. 10.3748/wjg.v20.i24.7739 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Baeten C, Hoefnagels J. Feeding via nasogastric tube or percutaneous endoscopic gastrostomy a comparison. Scand J Gastroenterol 1992;27:95–8. 10.3109/00365529209096035 [DOI] [PubMed] [Google Scholar]
- 3.Figueiredo FAF, da Costa MC, Pelosi AD, et al. Predicting outcomes and complications of percutaneous endoscopic gastrostomy. Endoscopy 2007;39:333–8. 10.1055/s-2007-966198 [DOI] [PubMed] [Google Scholar]
- 4.Itkin M, DeLegge MH, Fang JC, et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of interventional radiology and American gastroenterological association (AGA) Institute, with endorsement by Canadian interventional radiological association (CIRA) and cardiovascular and interventional radiological Society of Europe (CIRSE). Gastroenterology 2011;141:742–65. 10.1053/j.gastro.2011.06.001 [DOI] [PubMed] [Google Scholar]
- 5.Rabeneck L, McCullough LB, Wray NP. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 1997;349:496–8. 10.1016/S0140-6736(96)07369-2 [DOI] [PubMed] [Google Scholar]
- 6.Ishizaki T. Health care resource use among older patients using insurance claim data. Jpn J geriatr 2016;53:4–9 https://www.jpn-geriat-soc.or.jp/publications/other/pdf/review_53_1_4.pdf(inJapanese) [Google Scholar]
- 7.Suzuki Y, Tamez S, Murakami A, et al. Survival of geriatric patients after percutaneous endoscopic gastrostomy in Japan. World J Gastroenterol 2010;16:5084–91. 10.3748/wjg.v16.i40.5084 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Gotoda T, Kusano C, Yamada N. Clinical impact of indications for percutaneous endoscopic gastrostomy in elderly patients. Gastrointest Endosc 2014;56:484–9. 10.11280/gee.56.484 [DOI] [Google Scholar]
- 9.Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489–95. 10.1503/cmaj.050051 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Omori K, Yanagawa Y, Muramatsu K-I, et al. Experience using a portable X-ray system at the scene transported by a physician-staffed helicopter. Acute Med Surg 2019;6:396–9. 10.1002/ams2.431 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kura T, Kusakabe T, Muramatsu M. Percutaneous endoscopic gastrostomy (PEG) placement andreplacement -the present state of PEG in Japan. Gastrointest Endosc 2013;55:3527–47. [Google Scholar]
- 12.Suzuki Y, Urashima M, Yoshida H, et al. The sky blue method as a screening test to detect misplacement of percutaneous endoscopic gastrostomy tube at exchange. Intern Med 2009;48:2077–81. 10.2169/internalmedicine.48.2598 [DOI] [PubMed] [Google Scholar]
- 13.Kusama R, Yoshino H. Clinical benefit of the use of the PEG scope during percutaneous endoscopic gastrostomy tube exchange. Gastrointest Endosc 2012;54:57–63. [Google Scholar]