The efficacy of a novel percutaneous endoscopic gastrostomy simulator using three-dimensional printing technologies.

BACKGROUND AND AIM: We developed a novel training simulator for percutaneous endoscopic gastrostomy (PEG) and determined its efficacy and realism in PEG insertion training. METHODS: The gastrostomy simulator was made using three-dimensional printing and silicone molding technology. The simulator is of two types: pull type and introducer type. We enrolled 20 participants, comprising 10 beginners with no experience of PEG insertion and 10 PEG-experienced endoscopists. Each participant underwent two training sessions for the two simulator types. We recorded the simulation time, self-evaluation, and difficulty score based on a 5-score scale for PEG insertion among the participants. Subsequently, simulator performance was assessed via a questionnaire based on a 7-point Likert scale. RESULTS: The mean time to completion of PEG simulation decreased from 11.9 (5.2) to 9.0 (4.0) min for the pull type and from 13.8 (7.0) to 12.0 (5.8) min for the introducer type in the beginner group. The mean self-evaluation scores of beginners increased from 2.2 (1.1) to 3.1 (0.7) (pull type) and from 2.2 (1.2) to 3.3 (0.8) (introducer type). The mean procedure difficulty scores of beginners decreased from 3.4 (1.1) to 2.7 (0.9) (pull type) and from 4.4 (0.5) to 3.0 (0.8) (introducer type). The improvement of skill score was 6.3 (1.2) for the beginner group. The general realism score of the simulator for handling was judged to be 6.0 (0.9) by the experienced group. CONCLUSIONS: The three-dimensional-printed simulator for PEG insertion can be useful for training of beginner endoscopists and shows good efficacy and realism.

Systematic review of qualitative and quantitative studies on the attitudes and barriers to percutaneous endoscopic gastrostomy feeding.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is now commonly used in long-term care and community settings. However, regional variations exist in the acceptability of PEG tube feeding with long-term nasogastric feeding still commonplace in many Asian nations. AIMS: To evaluate the evidence relating to attitudes towards PEG feeding and to determine potential barriers to the acceptance of PEG tube feeding. METHODS: We searched Ovid MEDLINE, EMBASE, the Cochrane Library, Web of Science and CINAHL databases. The search for the studies was performed without restrictions by using the terms "PEG", "percutaneous endoscopic gastrostomy", "enteral feeding", "attitude", "perception" and "opinion". Qualitative and quantitative studies were included. Quality of studies was assessed with the Alberta checklists. RESULTS: From 981 articles, 17 articles were included in the final analysis. Twelve qualitative and four quantitative studies were considered of good quality. Seven of the 14 studies reported positive attitudes towards PEG. Three major themes were identified in terms of barriers to PEG feeding: lack of choice (poor knowledge, inadequate competency and skills, insufficient time given, not enough information given, lack of guidelines or protocol, resource constraints), confronting mortality (choosing life or death, risk of procedure) and weighing alternatives (adapting lifestyle, family influences, attitudes of healthcare professionals (HCPs), fear and anxiety). CONCLUSIONS: Only half of the reviewed studies reported positive perceptions towards PEG feeding. The themes identified in our systematic review will guide the development of interventions to alter the current attitudes and barriers towards PEG tube feeding.

Gastric outlet obstruction: an unusual adverse event of percutaneous endoscopic gastrostomy

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Cumulative sum: a proficiency metric for basic endoscopic training.

BACKGROUND: As work hour restrictions increasingly limit some operative experiences, personalized evaluative methods are needed. We prospectively assessed the value of cumulative sum (Cusum) to measure proficiency with percutaneous endoscopic gastrostomy (PEG) among surgical trainees. MATERIALS AND METHODS: Nine postgraduate year 1 surgery residents each underwent a 1-month rotation dedicated to endoscopy. Procedure durations for all PEG insertions were recorded prospectively. Criteria for task failure included need for attending takeover or procedure duration >10 min. Cusum parameters were defined a priori, with acceptable and unacceptable failure rates of 5% and 15%, respectively. Concurrently, expert endoscopists blinded to Cusum results evaluated trainee proficiency weekly using a multicategory, five-point Likert-scale survey. RESULTS: Nine surgical residents performed an average of 21 PEGs each. Expert evaluations and Cusum analyses identified eight and seven participants who attained proficiency after a median of 11.5 and 12 cases, respectively. For four of the residents who achieved proficiency by Cusum criteria, eventual relapses to inadequate performance were identified. These relapses were not detected by expert evaluation. Six participants who attained proficiency by both metrics performed a combined 32 superfluous cases, which could have been redistributed to poor-performing trainees. CONCLUSIONS: Although lacking the granular insight of expert evaluations, Cusum analysis is more sensitive to relapses of subproficient performance. Adding Cusum analysis to expert evaluations can provide longitudinal, formative feedback and promote efficient redistribution of operative experiences.

Difficulties with percutaneous endoscopic gastrostomy (PEG): a practical guide for the endoscopist.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a widely used and effective means of providing long-term nutrition in patients with inadequate oral intake. The demand for this intervention has risen steadily since the early 1990s. Endoscopists who perform PEG insertion have become increasingly concerned about inappropriate use of this intervention. AIMS: This review addresses the particular areas of difficulty, namely, dementia, stroke, aspiration pneumonia and use of PEG to facilitate discharge from hospital. METHODS: A Pubmed literature search and the author's personal experience. CONCLUSIONS: Strategies for improving patient selection and a practical approach to difficult decisions are described.

Gastrostomía en la nutrición enteral domiciliaria / Gastrostomy in home enteral nutrition

La gastrostomía es el acceso enteral más considerado cuando se requiere una sonda de alimentación a largo plazo. Las técnicas de implantación de la sonda de gastrostomía pueden ser percutánea y quirúrgica. La alimentación por gastrostomía es generalmente bien aceptada en niños y adultos. La gastrostomía es un acceso de gran utilidad y de gran importancia a nivel clínico en la alimentación enteral a largo plazo tanto de niños como adultos.

Access gastrostomy is considered when more enteral feeding tube requires long term. The technical implementation of the gastrostomy tube can be percutaneously and surgically. Gastrostomy feeding is generally well accepted in children and adults. The gastrostomy is a useful access and important at the clinical level in the long-term enteral feeding both children and adults.

A novel approach for augmenting percutaneous endoscopic gastrostomy tube placement training.

INTRODUCTION: Surgical trainees routinely participate in percutaneous endoscopic gastrostomy (PEG) tube placement. Although simulation has gained widespread acceptance, novice trainees continue learning this procedure on real patients. We designed a novel hands-on training model for practicing PEG tube placement with minimal monetary investment (cost<$10). METHODS: Our portable low-fidelity bench model has a simulated upper gastrointestinal construct made of foam. Seventeen trainees used our model to acquire and practice skills necessary to perform PEG tube placement, for setting up and troubleshooting upper gastrointestinal endoscope, and for using endoscopic instruments in the state-of-the-art simulated operative room. Thirteen trainees completed the course evaluation, using a 5-point Likert scale (5=strongly agree). RESULTS: The training resulted in a self-reported increase in equipment familiarity (4.23±0.73) and troubleshooting real endoscope (4.69±0.48), and trainees felt better prepared (4.23±0.93) for performing PEG tube placement on real patients. Trainees agreed that this exercise has more educational value than using virtual reality simulator alone (4.38±0.52). CONCLUSIONS: Procedural training for PEG tube placement using a simple bench training model is perceived as valuable by trainees. Cost and commercial availability can be overcome by innovation in surgical simulation.

Care of the gastrostomy tube in the home.

Education is needed to reduce complications for the patient with a gastrostomy tube. Literature regarding education related to the gastrostomy tube in the home is not evidenced based, varies, and is confusing. The home care nurse needs to provide accurate and up-to-date information to assist the patient in managing care.

Gastrostomy tube feeding in the school setting skills for the school nurse.

The nurse is responsible for the safe delivery of care to every client. Before implementing any specialized procedure, the school nurse must follow steps in the nursing process to be sure the client will benefit from the procedure, and that the procedure is done correctly. These include: (a) reviewing written orders, (b) comparing these orders with standardized procedures, (c) determining if there are questions or concerns for the attending physician, (d) assessing the patient/client, (e) checking for all appropriate supplies, (f) deciding whether it is necessary to watch someone perform the procedure first, or have one's skills observed, and (h) assessing one's readiness to complete the task in order to benefit the client and not cause harm.

Evaluation of endoscopy training in a general surgery residency.

To evaluate the gastrointestinal endoscopy training program, a survey of the 33 former chief residents, who finished our program in 1981-1986, was conducted. All 33 graduates responded; 22 graduates are general surgeons, 11 completed or are completing training in a surgical specialty. Eighteen of the 22 general surgeons routinely perform endoscopy in their practice. Graduates in cities with a population greater than 250,000 are as likely to perform endoscopy as the surgeons who live in smaller communities. Ninety one per cent consider endoscopy training to have been an important part of their surgical training. Based on this assessment, endoscopy training is an important part of a general-surgery residency.