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I read with interest the article by Milanchi and Allins1 on early pneumoperitoneum after percutaneous endoscopic gastrostomy (PEG) as a predictor of possible bowel injury. The authors conclude that post-procedure radiography is essential. Although that is the ideal practice, it is neither practical nor cost-effective. In their study, Milanchi and Allins found only 1 significant (<1%) event (gastrocolic fistula) that required surgery. The pneumoperitoneum in this case should have been clinically evident based on the imaging shown.
The remaining 3 patients had transient self-limiting pneumoperitoneum. My colleagues and I recently reported our own experience with PEG.2 Our patients were examined daily for at least 3 days and we did not encounter any clinically evident pneumoperitoneum or bowel injury. The main complications were wound infections. We routinely give grace periods for patients to recover while they remain on nasogastric feeding and we do not routinely place PEG while patients are in the intensive care unit (ICU). Grace periods have been shown to provide better outcome.3 Properly used nasogastric tubes are equally effective and safe.
The authors did not state how long after admission to the surgical ICU the PEGs were placed. I agree with the authors that when a pneumoperitoneum is detected, it should always be taken seriously and followed up. However, instead of postprocedure radiography for all patients, it would be more cost-effective to monitor patients clinically and to follow up with radiography if required.
Raja Isteri Pengiran Anak Saleha Hospital Brunei Darussalam, Borneo
REFERENCES
We greatly appreciate your letter. You almost correctly quote our paper by noting that "<1%" of PEG patients developed operative complications of PEG placement (the actual number was 1.12%; we rounded for convenience). The important finding we tried to get across, however, was not the seemingly low frequency of operative complications, but the fact that the overall frequency of pneumoperitoneum in our series was significant: 4 of 89 patients. Of these, 1 (ie, 25%, but not statistically significant) required surgery or would likely have died of peritonitis. Our recommendation therefore is not to disregard the findings of the pneumoperitoneum, but to afford those patients with post-PEG pneumoperitoneum the benefits of appropriate clinical follow-up.
We’re not certain of the meaning of the "grace period" to which you refer. If our article gave the impression that all patients admitted to our surgical ICU receive PEGs on arrival, we assure you this is not the case. PEGs are reserved for patients who require long-term nutritional support most frequently due to chronically altered mental status (eg, closed head trauma, brain tumor debulking) or chronic respiratory failure requiring mechanical ventilatory support (eg, adult respiratory distress syndrome). Whereas most of these patients receive initial enteral supplementation via nasogastric tube, the nasogastric tube is changed to PEG if it becomes clear that a patient will remain debilitated for an extended period. Once the PEG is in place, we do not have a "grace period"; we initiate feeds within 24 hours of PEG placement.
As for cost-efficiency, we’ll reiterate a point from our article: findings associated with peritonitis (eg, fever, abdominal pain, tenderness, leukocytosis) are notoriously unreliable in many of our surgical ICU patients, most of whom have some or all of these conditions as part of their underlying clinical picture. Other patients, such as those with severe neurological impairment, do not have reliable abdominal exams. Under such circumstances we find upright portable films of the chest to be quick, cheap, and simple.
Cedars-Sinai Medical Center, Los Angeles, California
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