europeman

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It's understandable that PEG's shouldn't be done w/ascites.

but what are your thought algorithms when you are trying to decide if it's a reasonable risk to put a surgically placed gastric tube (lap or open, whatever.. as long as it's nice and secure w/pexy) in patients with ascites. What if it's a lot of ascites? will that stop you? Does it depend on what the ascites is from (liver issue vs chf issue?).

I read a case report of a PEG done w/ascties whereby they placed pexy secured stitches... but lets not make this more complicated than it is.

thanks!
 

dpmd

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It's understandable that PEG's shouldn't be done w/ascites.

but what are your thought algorithms when you are trying to decide if it's a reasonable risk to put a surgically placed gastric tube (lap or open, whatever.. as long as it's nice and secure w/pexy) in patients with ascites. What if it's a lot of ascites? will that stop you? Does it depend on what the ascites is from (liver issue vs chf issue?).

I read a case report of a PEG done w/ascties whereby they placed pexy secured stitches... but lets not make this more complicated than it is.

thanks!

Why would you want to? If you have a patient that has ascites that can't be controlled and they can't eat, why put them through the risk of decompensation with surgery just to prolong things?
 

europeman

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Why would you want to? If you have a patient that has ascites that can't be controlled and they can't eat, why put them through the risk of decompensation with surgery just to prolong things?

That's why I'm asking.

I have a consult for a patient with really bad right sided CHF who is vent dependent, but mentally is totally with it and has full capacity to make decisions and she just can't stand her nasogastric tube. I don't blame her, I wouldn't want a feeding tube in my nose for weeks/months either.

She's sorta difficult situatation... obviously palliative care kind of patient, but not a patient who will be dying anytime soon. She's sick, but stable.

Thus, I think it's not unreasonable to do a surgical g-tube with a good pexy to prevent leak... I'm just not sure how much of a chance it has to work. If others have experience let me know. If there is like a 90% chance it won't, it will leak, get infected, blah blah, then I'll simply explain that to her and refuse I guess. But if the chances are more reasonable, and she understands those risks, then it starts to become more reasonable.

FYI her ascites from CHF not going away, ever.
 
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Miami_med

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I think it's a bad idea. Even if you do it laparoscopically, it's only a matter of time until you start leaking ascites from your port sites. Why don't you just trach the patient and then let her try and eat?
 

ESU_MD

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Whats the cause of r heart failure?

Maybe try a cuffed drain, like a PD catheter to drain the ascites prn for palliation then pace a g tube. Have alot of in/outs to keep up with, but with good nutrition maybe things will improve
 

Wustenfuchs

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That's why I'm asking.

I have a consult for a patient with really bad right sided CHF who is vent dependent, but mentally is totally with it and has full capacity to make decisions and she just can't stand her nasogastric tube. I don't blame her, I wouldn't want a feeding tube in my nose for weeks/months either.

She's sorta difficult situatation... obviously palliative care kind of patient, but not a patient who will be dying anytime soon. She's sick, but stable.

Thus, I think it's not unreasonable to do a surgical g-tube with a good pexy to prevent leak... I'm just not sure how much of a chance it has to work. If others have experience let me know. If there is like a 90% chance it won't, it will leak, get infected, blah blah, then I'll simply explain that to her and refuse I guess. But if the chances are more reasonable, and she understands those risks, then it starts to become more reasonable.

FYI her ascites from CHF not going away, ever.

Bloodletting is the cure!
bizarre-cures-bloodletting.jpg
 

MediCane2006

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I don't offer G- (or J-) tubes to these patients. In my experience they ALL eventually develop ascites leaks, and those are miserable to manage. I agree, it's a tough situation, but I think I'd try to get by with Letting the pt eat what she can, and making her comfortable otherwise. I think a g-tube would just make the situation worse.
 

Dr.LeoSpaceman

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Whats the cause of r heart failure?

Maybe try a cuffed drain, like a PD catheter to drain the ascites prn for palliation then pace a g tube. Have alot of in/outs to keep up with, but with good nutrition maybe things will improve

In the 2 or 3 times I've seen a g-tube placed in a patient with refractory ascites (all from carcinomatosis), this is what we've done as well. Keep everything drained until the g-tube has time to heal up.

I certainly would quote this person a significant risk of morbidity associated with pursuing that course. Yeah, an NG/NJ tube isn't comfortable, but I'd make sure they understand that you could actually make their condition significantly worse by trying to do anything about it.
 

Wustenfuchs

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"A fool may throw a stone into a well which a hundred wise men cannot pull out."
 

SLUser11

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I've yet to see it happen in all my years here. No one here does that.

But have you ever heard it specifically condemned? If so, what reason did they give?

What if it's a kiddo with ascites who needs a g-tube? What if it's an otherwise stable, non-ventilated adult?
 

Dr.LeoSpaceman

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I've yet to see it happen in all my years here. No one here does that.

I'm well aware it's outside the realm of the "norm". But our surgical oncology service does a lot of things that stretch the boundaries.

I've personally taken care a patient with a decompressive g-tube that was placed due to chronic obstruction in the setting of low volume carcinomatosis. She survived about 15 months on TPN. An NG for 15 months surely isn't an option, and I suppose you could try a pharyngostomy but the g-tube was certainly much more manageable for her.

I'm not saying it's something that you're going to do routinely or offer to a majority of patients, but in a very specific cases it can be an option assuming they are ok with all the attendant risks.
 
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