Jamie Wade David Leonard-Vidal Shannon Rosati Thoracic Surgery Jamie Wade David Leonard-Vidal Shannon Rosati

Cases PGY-4 Fellow (transition to care) Fellow (thoracic) Total 16 11 34 55

Complication Age/Sex: 84/F Attending/Res: Shah/Wade Diagnosis: esophageal cancer Operation: flexible bronchoscopy, EGD with PEG placement Complication: PEG Infection Assessments: A- ET (Error in Technique) B- 3 (Error with significant deleterious effect on patient outcome) Action: Diagnostic Laparoscopy, partial gastrectomy/wedge resection, incision and drainage abdominal wall abscess imaging

Complication 3/19: Pt referred to Thoracic surgery after presenting with a sore throat and dysphagia to pills, was found to have a proximal esophageal mass with lymphadenopathy, bx showed invasive squamous cell ca Pt to undergo chemo-XRT as therapy, however had weight loss and dysphagia, so it was decided to place a feeding tube prior to the start of chemo-XRT 3/23: OR for flexible bronchoscopy (no direct invasion noted), EGD with placement of 24 Fr PEG using Ponsky pull through technique Good translumination described during PEG placement, tube was described as being secured to the skin, with decompression of the stomach at EGD Patient discharged home the next day (chemoXRT started 3/24)

Complication 4/2: Pt seen for post op visit, was found to have blanching erythema and firmness around PEG site, admitted for concern for soft tissue infection Afebrile, normal vital signs Pt started on IV abx CT scan was obtained 8.9 7.0 172 25.5 imaging

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Complication CT read: PEG tube balloon is retracted with the inferior aspect of the balloon terminating within the anterior abdominal wall. There is surrounding subcutaneous air and stranding. No discrete abscess or drainable fluid collections are identified. HD 1: Decision made to send pt to IR for change out of PEG tube In IR, PEG tube removed, pus expressed from the gastrotomy site, US of soft tissue showed no fluid, new 24 French G tube placed using Seldinger technique and fluro imaging

Complication HD 4: pt taken to OR, underwent diagnostic laparoscopy, partial gastrectomy/wedge resection of stomach and incision and drainage of abdominal wall abscess Found to have necrotic abdominal wall 2 x 3 cm in size with purulent drainage Diagnostic lap performed, no sign of metastatic disease, site of prior gastrotomy resected with stapler, fascia closed and abd wall wound packed Patient discharged home POD 1 imaging

Complication Pt seen by heme/onc in follow up one week post op, noted to be healing well, plans to restart week 4 of chemo (weeks 2 and 3 missed due to infection) Currently patient has no nutritional access imaging

Cause-and-Effect diagram Medical Knowledge -Knowledge of need for nutritional access in esophageal cancer patients -Knowledge of affects of chemotherapy and radiation on wound healing Diagnostic Reasoning Therapeutic Choices Clinical assessment Communication -Discussion with Heme/onc on timing of chemo/XRT Personnel/Materials -Choice of suture to secure initial PEG Processes Environment Complication Error in technique -Evaluation of skin and soft tissue for persistent signs of infection -Workup of soft tissue infection -Management of abscesses and soft tissue infection -Patient initially sent to IR for replacement of PEG through infected site - PEG secured too tightly Error in judgment Error in systems

Percutaneous Endoscopic Gastrostomy Since 1980, endoscopically guided placement of a tube gastrostomy has been widely employed to provide access to the gastrointestinal tract for feeding or decompression. Indications for percutaneous endoscopic gastrostomy (PEG) include various disease processes that interfere with swallowing, such as severe neurologic impairment, oropharyngeal tumors, and facial trauma. PEG has also been employed to establish a route for recycling bile in patients with malignant biliary obstruction, to provide supplemental feeding in selected patients with inflammatory bowel disease, and to accomplish gastric decompression in patients with conditions such as carcinomatosis, radiation enteritis, and diabetic gastropathy.

Percutaneous Endoscopic Gastrostomy The tube should remain several millimeters from the skin to prevent excessive tension, which would cause ischemic necrosis of the underlying tissue. Complications Local wound infections are the most common complications of PEG. They can be minimized by administering preoperative antibiotics and ensuring that excessive tension is not applied to the crossbar at the end of the procedure (or making sure that the PEG is not secured too tightly). When such infections do occur, they can usually be treated via simple drainage and local wound care; sacrifice of the gastrostomy is rarely necessary. Several other complications, such as early extrusion of the tube, progressive enlargement of the tract, and separation of the gastric and abdominal walls with leakage of feedings into the abdominal cavity, are also most often attributable to excessive crossbar tension and subsequent ischemia. Gastrocolic fistula can occur after PEG. This problem may not be obvious for months afterward, but severe diarrhea after feedings is grounds for suspicion. Once the PEG tract is mature, gastrocolic fistulae usually close quickly after simple removal of the gastrostomy tube.

Percutaneous Endoscopic Gastrostomy- Pull vs. Push There are two common methods of PEG placement- the Ponksy-Gauderer pull method versus the Sachs-Vine push method

Results: 56.7% of pt were pull-throughs, 43.3% were push-PEGs Aim was to compare the final results deriving from both application methods Materials and Methods: 231 patients who underwent a PEG over a 3 year period (2009-2012) were reviewed and compared, using Clavien-Dindo classification and divided into early and late complications (before and after 10 days after PEG insertion) Results: 56.7% of pt were pull-throughs, 43.3% were push-PEGs 26.4% complication rate (60.6% Clavien-Dindo Grade I only, 2.2% Clavien-Dindo Grade IIIb) Overall complication rate significant increased by method used (push 33/100 vs pull 28/131= 21.4%, p=.047) Conclusion: Both techniques are safe and well established, Push-PEG showed significantly higher rate of complications, dislocations, and occlusions

Aim was to analyze complication rates and mortality with PEG and to identify subgroups with poor outcomes Materials and Methods: 401 patients who underwent a PEG in a single tertiary care center- cases reviewed for indications, characteristics, and causes of death Results: head and neck (34%), obstruction (18%), neurology (48%), f/u median 17 months, time PEG used for feeding 4 months 23% complication rate (8% early <30days, 12% major, 2 deaths) 30 day mortality 11% Multivariate analysis showed inc 30 day mortality associated with >75 yrs of age, ASA Class IV, Charlson comorbidity index >4, BMI <18.5 and ongoing abx usage Conclusion: The present predictive model may recognize patients with potential for poor outcome when referred for PEG

References Scientific American Surgery, Sec 5, Chp 18: Jeffrey Marks, MD, FACS, Jeffrey L. Ponsky, MD, FACS. Decker Intellectual Properties (SCORE)

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