Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
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Clinical practice guidelines for percutaneous endoscopic gastrostomy

  • Chung Hyun Tae (Department of Internal Medicine, Ewha Womans University College of Medicine) ;
  • Ju Yup Lee (Department of Internal Medicine, Keimyung University School of Medicine) ;
  • Moon Kyung Joo (Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine) ;
  • Chan Hyuk Park (Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine) ;
  • Eun Jeong Gong (Department of Internal Medicine, Hallym University College of Medicine) ;
  • Cheol Min Shin (Department of Internal Medicine, Seoul National University Bundang Hospital) ;
  • Hyun Lim (Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine) ;
  • Hyuk Soon Choi (Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine) ;
  • Miyoung Choi (National Evidence-Based Healthcare Collaborating Agency) ;
  • Sang Hoon Kim (Department of Gastroenterology, Dongguk University Ilsan Hospital) ;
  • Chul-Hyun Lim (Division of Gastroenterology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Jeong-Sik Byeon (Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Ki-Nam Shim (Department of Internal Medicine, Ewha Womans University College of Medicine) ;
  • Geun Am Song (Department of Internal Medicine, Pusan National University Hospital, Pusan National University College of Medicine and Biomedical Research Institute) ;
  • Moon Sung Lee (Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital) ;
  • Jong-Jae Park (Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine) ;
  • Oh Young Lee (Department of Internal Medicine, Hanyang University School of Medicine)
  • Received : 2023.02.27
  • Accepted : 2023.04.19
  • Published : 2023.07.30
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Abstract

With an aging population, the number of patients with difficulty in swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. However, the long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach that is aided endoscopically and may be an alternative to a nasogastric tube when enteral nutritional is required for four weeks or more. This paper is the first Korean clinical guideline for PEG developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tube removal for PEG based on the currently available clinical evidence.

Keywords

References

  1. Loser C, Aschl G, Hebuterne X, et al. ESPEN guidelines on artificial enteral nutrition: percutaneous endoscopic gastrostomy (PEG). Clin Nutr 2005;24:848-861.
  2. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-875.
  3. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 1981;27:9-11.
  4. Lee JM, Park Y, Park JM, et al. New sedatives and analgesic drugs for gastrointestinal endoscopic procedures. Clin Endosc 2022;55:581-587.
  5. Goudra B, Saumoy M. Anesthesia for advanced endoscopic procedures. Clin Endosc 2022;55:1-7.
  6. Pih GY, Na HK, Hong SK, et al. clinical outcomes of percutaneous endoscopic gastrostomy in the surgical intensive care unit. Clin Endosc 2020;53:705-716.
  7. ASGE Technology Committee, Kwon RS, Banerjee S, et al. Enteral nutrition access devices. Gastrointest Endosc 2010;72:236-248.
  8. Hull MA, Rawlings J, Murray FE, et al. Audit of outcome of long-term enteral nutrition by percutaneous endoscopic gastrostomy. Lancet 1993;341:869-872.
  9. Sarkar P, Cole A, Scolding NJ, et al. Percutaneous endoscopic gastrostomy tube insertion in neurodegenerative disease: a retrospective study and literature review. Clin Endosc 2017;50:270-278.
  10. ASGE Standards of Practice Committee, Jain R, Maple JT, et al. The role of endoscopy in enteral feeding. Gastrointest Endosc 2011;74:7-12.
  11. Arvanitakis M, Gkolfakis P, Despott EJ, et al. Endoscopic management of enteral tubes in adult patients. Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021;53:81-92.
  12. Gkolfakis P, Arvanitakis M, Despott EJ, et al. Endoscopic management of enteral tubes in adult patients. Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021;53:178-195.
  13. Higgins JP, Savovic J, Page MJ, Elbers RG, Sterne JA. Chapter 8: Assessing risk of bias in a randomized trial. Cochrane handbook for systematic reviews of interventions ver. 6.3 [Internet]. Cochrane; 2022 [updated 2022 Feb; cited 2023 Feb 27]. Available from: www.training.cochrane.org/handbook.
  14. Hinneburg I. ROBINS-1: a tool for asssessing risk of bias in non-randomised studies of interventions. Med Monatsschr Pharm 2017;40:175-177.
  15. Schunemann H, Brozek J, Guyatt G, Oxman A. GRADE handbook for grading quality of evidence and strength of recommendations [Internet]. [updated 2013 Oct; cited 2023 Feb 27]. Available from: https://gdt.gradepro.org/app/handbook/handbook.
  16. Geeganage C, Beavan J, Ellender S, et al. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev 2012;10:CD000323.
  17. Goldberg LS, Altman KW. The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clin Interv Aging 2014;9:1733-1739.
  18. Lee YF, Hsu TW, Liang CS, et al. The efficacy and safety of tube feeding in advanced dementia patients: a systemic review and meta-analysis study. J Am Med Dir Assoc 2021;22:357-363.
  19. Grant JP. Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy. Ann Surg 1988;207:598-603.
  20. Grant DG, Bradley PT, Pothier DD, et al. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis. Clin Otolaryngol 2009;34:103-112.
  21. Yuan Y, Zhao Y, Xie T, et al. Percutaneous endoscopic gastrostomy versus percutaneous radiological gastrostomy for swallowing disturbances. Cochrane Database Syst Rev 2016;2:CD009198.
  22. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009;2009:CD007209.
  23. Strijbos D, Keszthelyi D, Bogie RM, et al. A systematic review and meta-analysis on outcomes and complications of percutaneous endoscopic versus radiologic gastrostomy for enteral feeding. J Clin Gastroenterol 2018;52:753-764.
  24. Roveron G, Antonini M, Barbierato M, et al. Clinical practice guidelines for the nursing management of percutaneous endoscopic gastrostomy and jejunostomy (PEG/PEJ) in adult patients: an executive summary. J Wound Ostomy Continence Nurs 2018;45:326-334.
  25. George BP, Kelly AG, Albert GP, et al. Timing of percutaneous endoscopic gastrostomy for acute ischemic stroke: an observational study from the US nationwide inpatient sample. Stroke 2017;48:420-427.
  26. Malmgren A, Hede GW, Karlstrom B, et al. Indications for percutaneous endoscopic gastrostomy and survival in old adults. Food Nutr Res 2011;55.
  27. Bannerman E, Pendlebury J, Phillips F, et al. A cross-sectional and longitudinal study of health-related quality of life after percutaneous gastrostomy. Eur J Gastroenterol Hepatol 2000;12:1101-1109.
  28. Pih GY, Na HK, Ahn JY, et al. Risk factors for complications and mortality of percutaneous endoscopic gastrostomy insertion. BMC Gastroenterol 2018;18:101.
  29. Lodin D, Gupta AK, Rubay D, et al. The effectiveness of laparoscopic-assisted percutaneous endoscopic gastrostomy in patients with unfavorable anatomy: a single-center retrospective cohort study. Cureus 2020;12:e6647.
  30. Bender JS. Percutaneous endoscopic gastrostomy placement in the morbidly obese. Gastrointest Endosc 1992;38:97-98.
  31. Lucendo AJ, Sanchez-Casanueva T, Redondo O, et al. Risk of bleeding in patients undergoing percutaneous endoscopic gastrotrostomy (PEG) tube insertion under antiplatelet therapy: a systematic review with a meta-analysis. Rev Esp Enferm Dig 2015;107:128-136.
  32. Moon SY, Jung MK, Heo J. Endoscopic hemostasis using an over-the-scope clip for massive bleeding after percutaneous endoscopic gastrostomy removal: a case report. Clin Endosc 2022;55:443-446.
  33. Lim H, Gong EJ, Min BH, et al. Clinical practice guideline for the management of antithrombotic agents in patients undergoing gastrointestinal endoscopy. Clin Endosc 2020;53:663-677.
  34. Wollman B, D'Agostino HB, Walus-Wigle JR, et al. Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology 1995;197:699-704.
  35. Elliott LA, Sheridan MB, Denyer M, et al. PEG: is the E necessary? A comparison of percutaneous and endoscopic gastrostomy. Clin Radiol 1996;51:341-344.
  36. Bankhead RR, Fisher CA, Rolandelli RH. Gastrostomy tube placement outcomes: comparison of surgical, endoscopic, and laparoscopic methods. Nutr Clin Pract 2005;20:607-612.
  37. Jonas SK, Neimark S, Panwalker AP. Effect of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J Gastroenterol 1985;80:438-441.
  38. Jain NK, Larson DE, Schroeder KW, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy. A prospective, randomized, double-blind clinical trial. Ann Intern Med 1987;107:824-828.
  39. Akkersdijk WL, van Bergeijk JD, van Egmond T, et al. Percutaneous endoscopic gastrostomy (PEG): comparison of push and pull methods and evaluation of antibiotic prophylaxis. Endoscopy 1995;27:313-316.
  40. Sturgis TM, Yancy W, Cole JC, et al. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J Gastroenterol 1996;91:2301-2304.
  41. Gossner L, Keymling J, Hahn EG, et al. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical trial. Endoscopy 1999;31:119-124.
  42. Preclik G, Grune S, Leser HG, et al. Prospective, randomised, double blind trial of prophylaxis with single dose of co-amoxiclav before percutaneous endoscopic gastrostomy. BMJ 1999;319:881-884.
  43. Dormann AJ, Wigginghaus B, Risius H, et al. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): results from a prospective randomized multicenter trial. Z Gastroenterol 2000;38:229-234.
  44. Panigrahi H, Shreeve DR, Tan WC, et al. Role of antibiotic prophylaxis for wound infection in percutaneous endoscopic gastrostomy (PEG): result of a prospective double-blind randomized trial. J Hosp Infect 2002;50:312-315.
  45. Ahmad I, Mouncher A, Abdoolah A, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy: a prospective, randomised, double-blind trial. Aliment Pharmacol Ther 2003;18:209-215.
  46. Saadeddin A, Freshwater DA, Fisher NC, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy for non-malignant conditions: a double-blind prospective randomized controlled trial. Aliment Pharmacol Ther 2005;22:565-570.
  47. Radhakrishnan NV, Shenoy AH, Cartmill I, et al. Addition of local antiseptic spray to parenteral antibiotic regimen reduces the incidence of stomal infection following percutaneous endoscopic gastrostomy: a randomized controlled trial. Eur J Gastroenterol Hepatol 2006;18:1279-1284.
  48. Alessandri F, Strisciuglio C, Borrazzo C, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy in children: a randomised controlled trial. J Pediatr Gastroenterol Nutr 2021;72:366-371.
  49. Shastri YM, Hoepffner N, Tessmer A, et al. New introducer PEG gastropexy does not require prophylactic antibiotics: multicenter prospective randomized double-blind placebo-controlled study. Gastrointest Endosc 2008;67:620-628.
  50. Adachi Y, Akino K, Mita H, et al. Systemic prophylactic antibiotics for the modified introducer method for percutaneous endoscopic gastrostomy: a prospective, randomized, double-blind study. J Clin Gastroenterol 2016;50:727-732.
  51. Brown DN, Miedema BW, King PD, et al. Safety of early feeding after percutaneous endoscopic gastrostomy. J Clin Gastroenterol 1995;21:330-331.
  52. Choudhry U, Barde CJ, Markert R, et al. Percutaneous endoscopic gastrostomy: a randomized prospective comparison of early and delayed feeding. Gastrointest Endosc 1996;44:164-167.
  53. Unni M, Gumaste V, Dave P, Wasserman D. Percutaneous endoscopic gastrostomy (PEG): is it safe to begin feeding in three hours after insertion? Gastrointest Endosc 1996;43:360.
  54. McCarter TL, Condon SC, Aguilar RC, et al. Randomized prospective trial of early versus delayed feeding after percutaneous endoscopic gastrostomy placement. Am J Gastroenterol 1998;93:419-421.
  55. Stein J, Schulte-Bockholt A, Sabin M, et al. A randomized prospective trial of immediate vs. next-day feeding after percutaneous endoscopic gastrostomy in intensive care patients. Intensive Care Med 2002;28:1656-1660.
  56. Lee SW, Lee JH, Cho H, et al. Comparison of clinical outcomes associated with pull-type and introducer-type percutaneous endoscopic gastrostomies. Clin Endosc 2014;47:530-537.
  57. Campoli PM, de Paula AA, Alves LG, et al. Effect of the introducer technique compared with the pull technique on the peristomal infection rate in PEG: a meta-analysis. Gastrointest Endosc 2012;75:988-996.
  58. Kohler G, Kalcher V, Koch OO, et al. Comparison of 231 patients receiving either "pull-through" or "push" percutaneous endoscopic gastrostomy. Surg Endosc 2015;29:170-175.
  59. Maetani I, Tada T, Ukita T, et al. PEG with introducer or pull method: a prospective randomized comparison. Gastrointest Endosc 2003;57:837-841.
  60. Ohno T, Ogawa A, Yanai M, et al. The usefulness and safety of the introducer technique using a bumper-button-type device as compared with the pull method for percutaneous endoscopic gastrostomy. Surg Laparosc Endosc Percutan Tech 2015;25:e1-e4.
  61. Retes FA, Kawaguti FS, de Lima MS, et al. Comparison of the pull and introducer percutaneous endoscopic gastrostomy techniques in patients with head and neck cancer. United European Gastroenterol J 2017;5:365-373.
  62. Sartori S, Trevisani L, Nielsen I, et al. Percutaneous endoscopic gastrostomy placement using the pull-through or push-through techniques: is the second pass of the gastroscope necessary? Endoscopy 1996;28:686-688.
  63. Tucker AT, Gourin CG, Ghegan MD, et al. Push' versus 'pull' percutaneous endoscopic gastrostomy tube placement in patients with advanced head and neck cancer. Laryngoscope 2003;113:1898-1902.
  64. Van Dyck E, Macken EJ, Roth B, et al. Safety of pull-type and introducer percutaneous endoscopic gastrostomy tubes in oncology patients: a retrospective analysis. BMC Gastroenterol 2011;11:23.
  65. Fung E, Strosberg DS, Jones EL, et al. Incidence of abdominal wall metastases following percutaneous endoscopic gastrostomy placement in patients with head and neck cancer. Surg Endosc 2017;31:3623-3627.
  66. Siu J, Fuller K, Nadler A, et al. Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis. Gastrointest Endosc 2020;91:1005-1014.
  67. Burney RE, Bryner BS. Safety and long-term outcomes of percutaneous endoscopic gastrostomy in patients with head and neck cancer. Surg Endosc 2015;29:3685-3689.
  68. Wei MT, Ahn JY, Friedland S. Over-the-scope clip in the treatment of gastrointestinal leaks and perforations. Clin Endosc 2021;54:798-804.
  69. Macedo C, Almeida N, Alves AR, et al. Persistent peristomal leakage from percutaneous endoscopic gastrostomy successfully treated with argon plasma coagulation. GE Port J Gastroenterol 2021;28:210-214.
  70. Stanich PP, Sklaw B, Krishna SG. Persistent peristomal leakage from percutaneous endoscopic gastrostomy successfully treated with endoscopic suturing. Endoscopy 2013;45 Suppl 2 UCTN:E394.
  71. McClave SA, Chang WK. Complications of enteral access. Gastrointest Endos 2003;58:739-751.
  72. 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;141:742-765.
  73. Westaby D, Young A, O'Toole P, et al. The provision of a percutaneously placed enteral tube feeding service. Gut 2010;59:1592-1605.
  74. Toussaint E, Van Gossum A, Ballarin A, et al. Enteral access in adults. Clin Nutr 2015;34:350-358.
  75. Siau K, Troth T, Gibson E, et al. How long do percutaneous endoscopic gastrostomy feeding tubes last? A retrospective analysis. Postgrad Med J 2018;94:469-474.
  76. Bischoff SC, Austin P, Boeykens K, et al. ESPEN guideline on home enteral nutrition. Clin Nutr 2020;39:5-22.
  77. Metussin A, Sia R, Bakar S, et al. Foley catheters as temporary gastrostomy tubes: experience of a nurse-led service. Gastroenterol Nurs 2016;39:273-277.
  78. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis 2007;16:407-418.
  79. Anderloni A, Di Leo M, Barzaghi F, et al. Complications and early mortality in percutaneous endoscopic gastrostomy placement in lombardy: a multicenter prospective cohort study. Dig Liver Dis 2019;51:1380-1387.
  80. El AZ, Arvanitakis M, Ballarin A, et al. Buried bumper syndrome: low incidence and safe endoscopic management. Acta Gastroenterol Belg 2011;74:312-316.
  81. Cyrany J, Rejchrt S, Kopacova M, et al. Buried bumper syndrome: a complication of percutaneous endoscopic gastrostomy. World J Gastroenterol 2016;22:618-627.
  82. McClave SA, Jafri NS. Spectrum of morbidity related to bolster placement at time of percutaneous endoscopic gastrostomy: buried bumper syndrome to leakage and peritonitis. Gastrointest Endosc Clin N Am 2007;17:731-746.
  83. Casper M, Lammert F. How to improve success rates of endoscopic management for buried bumper syndrome. QJM 2018;111:467-472.
  84. Mueller-Gerbes D, Hartmann B, Lima JP, et al. Comparison of removal techniques in the management of buried bumper syndrome: a retrospective cohort study of 82 patients. Endosc Int Open 2017;5:E603-E607.
  85. Boeykens K, Duysburgh I. Prevention and management of major complications in percutaneous endoscopic gastrostomy. BMJ Open Gastroenterol 2021;8:e000628.
  86. Nishiwaki S, Araki H, Fang JC, et al. Retrospective analyses of complications associated with transcutaneous replacement of percutaneous gastrostomy and jejunostomy feeding devices. Gastrointest Endosc 2011;74:784-791.
  87. Lisotti A, Teci E, Cali A, et al. Percutaneous endoscopic gastrostomy (PEG) tube home replacement: prospective evaluation of a standardized protocol. Endoscopy 2019;51:S84.
  88. Jo IH, Kim HH, Choi MG, et al. Analysis of risk factors for early tube exchange in percutaneous endoscopic gastrostomy. Korean J Helicobacter Up Gastrointest Res 2014;14:261-267.
  89. Lee CG, Kang HW, Lim YJ, et al. Comparison of complications between endoscopic and percutaneous replacement of percutaneous endoscopic gastrostomy tubes. J Korean Med Sci 2013;28:1781-1787.
  90. Sbeit W, Kadah A, Shahin A, et al. Scheduled percutaneous endoscopic gastrostomy tube replacement did not reduce PEG-related complications. Scand J Gastroenterol 2021;56:1386-1390.
  91. Korula J, Harma C. A simple and inexpensive method of removal or replacement of gastrostomy tubes. JAMA 1991;265:1426-1428.
  92. Merrick S, Harnden S, Shetty S, et al. An evaluation of the "cut and push" method of percutaneous endoscopic gastrostomy (PEG) removal. JPEN J Parenter Enteral Nutr 2008;32:78-80.
  93. Pearce CB, Goggin PM, Collett J, et al. The 'cut and push' method of percutaneous endoscopic gastrostomy tube removal. Clin Nutr 2000;19:133-135.
  94. Kejariwal D, Bromley D, Miao Y. The "cut and push" method of percutaneous endoscopic gastrostomy tube removal in adult patients: the Ipswich experience. Nutr Clin Pract 2009;24:281-283.
  95. Agha A, AlSaudi D, Furnari M, et al. Feasibility of the cut-and-push method for removing large-caliber soft percutaneous endoscopic gastrostomy devices. Nutr Clin Pract 2013;28:490-492.
  96. Macchini F, Zanini A, Farris G, et al. Infant percutaneous endoscopic gastrostomy: risks or benefits? Clin Endosc 2018;51:260-265.
  97. Lim YJ, Yang CH. Technique, management and complications of percutaneous endoscopic gastrostomy. Korean J Gastrointest Endosc 2009;39:119-124.
  98. Gottfried EB, Plumser AB, Clair MR. Pneumoperitoneum following percutaneous endoscopic gastrostomy. A prospective study. Gastrointest Endosc 1986;32:397-399.
  99. Allen AI, Vaughan J, Cauthen A, et al. Evaluation of a trial of a desufflation technique to decrease the rate of postoperative pneumoperitoneum after percutaneous endoscopic gastrostomy. Am Surg 2017;83:e398-e399.
  100. Park WY, Lee TH, Lee JS, et al. Reappraisal of pneumoperitoneum after percutaneous endoscopic gastrostomy. Intest Res 2015;13:313-317.
  101. Blum CA, Selander C, Ruddy JM, et al. The incidence and clinical significance of pneumoperitoneum after percutaneous endoscopic gastrostomy: a review of 722 cases. Am Surg 2009;75:39-43.
  102. Nazarian A, Cross W, Kowdley GC. Pneumoperitoneum after percutaneous endoscopic gastrostomy among adults in the intensive care unit: incidence, predictive factors, and clinical significance. Am Surg 2012;78:591-594.
  103. Murphy CJ, Adler DG, Cox K, et al. Insufflation with carbon dioxide reduces pneumoperitoneum after percutaneous endoscopic gastrostomy (PEG): a randomized controlled trial. Endosc Int Open 2016;4:E292-E295.
  104. Nishiwaki S, Araki H, Hayashi M, et al. Inhibitory effects of carbon dioxide insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy. World J Gastroenterol 2012;18:3565-3570.