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Abstract

Introduction:

Obesity is reaching epidemic proportions in the United States, and as patients at the extremes of morbid obesity come under the care of surgeons, routine procedures may become increasingly complex in the face of greater body mass. We prospectively evaluated the success rate of percutaneous endoscopic gastrostomy (PEG) placement in a group of morbidly obese patients outside the current classification systems used to stratify obesity.

Methods:

Patients with a body mass index (BMI) greater than 60 kg/m² who presented for PEG over a one year period were prospectively enrolled. Each patient underwent attempted PEG placement using the pull method by a single surgeon. Outcome variables included: successful PEG, wound infection, tube dislodgement, or bleeding.

Results:

Six patients with BMI > 60 kg/m² presented for PEG. All patients were in a surgical critical care unit maintained on mechanical ventilation. All underwent successful PEG placement with standard techniques and sustained no post-procedural complications.

Conclusion:

In the hands of an experienced surgical endoscopist, percutaneous endoscopic gastrostomy can be safely performed in patients at the extremes of morbid obesity. Future studies are warranted to validate the results of our small series.

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INTRODUCTION

Obesity is reaching epidemic proportions in the United States. As this public health concern continues to grow, our hospitals and trauma centers are seeing an increasing number of critically ill patients with less than optimal body habitués. Recently, an expert panel convened by the National Heart, Lung, and Blood Institute (NHLBI) in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) identified a patient with a BMI of 25 kg/m² to 29.9 kg/m² as overweight, and those with a BMI of ≥30 kg/m² as obese. Defining over-weight as a BMI ≥25 is consistent with the recommendations of the World Health Organization and most other countries.

As more overweight, obese, morbidly obese, and super (mega) obese patients come under the care of ICU physicians, practices routine to the care of patients with ideal weights become a challenge in the face of greater body sizes. The long-term care of these patients requires a significantly greater amount of expertise in the performance of commonly performed invasive procedures. One procedure in particular is the placement of a percutaneous endoscopic gastrostomy (PEG) tube for long-term enteral access. We have recently reported that obese patients admitted to the ICU have a significantly greater number of ICU and hospital days as well as infectious complications.¹ The purpose of this study was to prospectively evaluate the success rate of PEG placement in a series of morbidly obese patients outside current classification schemes of obesity.

METHODS

The patient is placed on continuous oxygen saturation and cardiac monitoring. Before placement of the endoscope, intravenous Versed and Fentanyl are administered and titrated appropriately as per institutional conscious sedation guidelines. The endoscope is placed into the esophagus and a thorough evaluation of the esophagus, stomach, and duodenum is performed. After this is completed, the endoscope is pulled back into the stomach, and a careful evaluation of the anatomic position of the stomach is performed as the assistant applies digital pressure on the anterior abdominal wall. The endoscopist evaluates the level and intensity of each impression. In the super-obese patient, attention is focused exclusively in what we describe as the B Zone (Figure 1), as this area has the least amount of fat tissue density. The first step is to determine which “spot” finger impression is most significant. After this area is recognized, the lights are dimmed and transillumination is attempted. If unsuccessful, it is our practice in super-morbidly obese patients to apply significant transabdominal compression using the operating surgeon's fist, followed by repeat attempts at transillumination. It is important to note that in the super-obese patient, significant pressure is needed on the abdominal wall to obtain transillumination. If unsuccessful, the “spot” that is most impressive is marked. At this point, the abdomen is prepped and draped and local anesthesia is administered. A standard PEG kit is opened and an incision is made. A hemostat is gently placed into the incised area mimicking needle placement to visualize the optimal trajectory for the subsequent needle/catheter placement. The endoscopist introduces and opens the snare to encompass the stomach wall area in which the needle will most likely penetrate and thus facilitate the endoscopic snaring of the needle/catheter and wire. After the optimal trajectory is visualized and the snare location is set, the needle/catheter is slowly placed into the stomach under direct visualization. Because of the significant amount of abdominal wall tissue density that needs to be penetrated before piercing the peritoneum, the operator must continue to place a moderate amount of pressure on the abdominal wall area encompassing the incision to compress the tissue and allow for needle/catheter penetration of the gastric wall. In addition, a syringe is attached to the needle/catheter and simultaneous aspiration of the syringe is performed evaluating for air or potential bowel contents. The snare is manipulated to encompass the needle/catheter, and the wire is passed through the catheter and snared. The wire and endoscope are simultaneously pulled back out through the oral cavity, and a PEG catheter is fastened to the wire. The wire and PEG catheter are then pulled back through the oral cavity into the stomach and out through the abdominal wall until the button adheres to the abdominal wall. The endoscope is placed back into the stomach to assure that the proper position is obtained and that no evidence is present of bleeding or complications.

Bochicchio zone (B-zone) for percutaneous endoscopic gastrostomy placement in the Mega-morbid obese patient.

RESULTS

Over a 1-year period, 6 patients with a BMI >60 kg/m² underwent successful PEG placement utilizing the technique as described above (Table 1). Four patients were admitted for traumatic injury, and 2 were surgically treated for a necrotizing soft tissue infection. The mean age was 43±3 years with 4 of 6 (67%) being male. Three of the 6 patients had some type of prior abdominal surgery. All 6 patients were supported by mechanical ventilation for chronic respiratory failure and subsequently had a surgically placed tracheostomy. The mean day in which the PEG was placed was 19±5 days. Four of the 6 patients (67%) could be transilluminated with deep palpation, while the remaining 2 patients underwent successful placement based on finger impression alone. No procedural complications occurred for a placement success rate of 100%. Tube feeds were initiated after 24 hours of gravity drainage. Each patient was advanced to goal feeds within 48 hours of PEG placement. The mean hospital length of stay was 28±8 days. No postprocedural complications (ie, wound infections, bleeding, tube dislodgment) occurred as a result of the PEG placement.

Table 1.

DISCUSSION

Obesity has reached epidemic proportions in the United States, and we are continuing to see an increasing number of these patients in our critical care units. Results of the National Health and Nutrition Examination Survey (NHANES) (1999 –2000) indicate that an estimated 64% of United States adults are either overweight or obese. Estimates of obesity alone are generally over 18%, and in 18-to 29-year-olds obesity has increased from 12% to 19% between 1991 and 1999. A growing body of literature describes the higher mortality rates experienced by morbidly obese individuals. One study demonstrated that mortality rates in the morbidly obese are 12 times higher in men aged 25 to 34 years and 6 times higher in men aged 35 to 44 years compared with nonobese men of the same age. A prospective study documented increased risk of death from all causes, cardiovascular disease, and cancer across a range of BMI indicating overweight and obesity.

Classification systems have been developed to grade the level of obesity in a particular patient. An expert panel convened by the National Heart, Lung, and Blood Institute (NHLBI) in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has identified a patient as overweight with a body mass index (BMI) of 25 kg/m² to 29.9 kg/m² and as obese with a BMI ≥30 kg/m². The classification has been expanded by the World Health Organization Obesity Task Force, which defines overweight as a BMI ≥25, and further stratifies excess body mass with Class I obesity defined as a BMI of 30.0 to 34.9, Class II obesity as a BMI of 35.0 to 39.9; Class III, or extreme obesity is defined as a BMI ≥40. These widely used classification systems do not further stratify patients with a BMI >40 kg/m².

As the general population continues to push the limits of modern obesity classification schemes, it has become clear that the current upper limit of modern obesity classification systems may in fact be insufficient. As more of these patients outside of the modern classification systems come to require critical care for medical, surgical, and traumatic illness, practices routine to the care of patients with ideal weight become a challenge in the face of greater body sizes. One procedure in particular is the placement of a percutaneous endoscopic gastrostomy (PEG) tube for enteral access.

PEG placement in critically ill patients has become commonplace, as long-term enteral access for nutrition is essential in these compromised hosts who require long-term treatment due to the sequelae of their disease or illness. Numerous studies have shown the benefit of early enteral nutrition, with most advocating initiation of enteral nutrition within 24 hours of illness or injury in patients with an intact gastrointestinal tract.^– To meet this need in critically ill patients in the chronic stage of their disease who require long-term enteral access, percutaneous endoscopic gastrostomy (PEG) has been widely applied and has become the method of choice in critically ill and trauma populations.

Several recent studies have evaluated the placement of PEG in circumstances that were once considered contra-indications. For example, PEG in patients with prior abdominal surgery (once a contraindication to PEG placement) has become an accepted practice in experienced hands. Results from several studies^– have demonstrated similar safety and efficacy. Eleftheriadias et al evaluated PEG placement in 37 patients who had undergone previous abdominal surgery, with over half (22 of 37) undergoing PEG placement just 2 weeks postlaparotomy for a wide range of abdominal operations. PEG placement was successful in 36 of 37 patients compared with 286 of 291 in the nonoperative control group. In another recent report, patients with open abdomen and giant hernia following an abdominal catastrophe or abdominal compartment syndrome have also undergone safe PEG placement. Most recently, we reported in a prospective study of 117 patients that no difference occurred in complication rates between patients with prior abdominal surgery and those with a virgin abdomen.

A paucity of data, however, has evaluated the impact of body habitus on the efficacy of PEG placement. In 1992, Bender reported the successful placement of a single PEG in a 170-kg man in the operating room. During the procedure, ballottement was identified following insufflation of the stomach, but there was no light reflex and a spinal needle could not be passed into the stomach. A cut-down approach was utilized, in which an incision was made over the area where a finger impression had been visualized through the endoscope. The skin and subcutaneous fat were bluntly dissected to the level of the anterior rectus muscle, the PEG placement procedure completed, and the skin incision closed. The tube functioned well throughout a 13-month hospital and rehabilitation course.

Morbid obesity may have once been considered a relative contraindication to PEG placement, but our series represents the first and largest series evaluating PEG placement in morbidly obese patients outside the classification systems available today. The total absence of complications in this small number of procedures begins to challenge the notion that morbidly obese patients are poor candidates for PEG placement. Although small, this case series demonstrates the safety and efficacy of PEG placement even without full transillumination or use of a cut-down approach. We did not deviate from standard, routine placement techniques in any patient, nor did we utilize instruments outside those found in typical placement kits.

In addition, as a greater number of patients fall outside of the traditional obesity classification schemes, we propose expanding the current classification systems to stratify patients with a BMI >40 kg/m². At our institution, we typically classify patients with a BMI between 30 kg/m² to 40 kg/m² as obese, 40 kg/m² to 50 kg/m² as morbidly obese, 50 kg/m² to 60 kg/m² as super-morbidly obese, 60 kg/m² to 70 kg/m² as mega-morbidly obese, and those with a BMI >70 kg/m² as super-mega-morbidly obese. By revising and expanding this classification, we may better be able to evaluate risk of body habitus in a more defined and stratified fashion.

CONCLUSION

Current obesity classification systems are inadequate; obese patients who fall outside the current classification systems for obesity can have safe PEG placement in experienced hands. A larger, prospective study evaluating PEG placement in this challenging group of patients is currently under investigation utilizing an expanded obesity classification system that more appropriately stratifies this growing segment of our population.

References:

. (United States).

(Canada)Picture formatAudio formatOriginal releaseOctober 7, 2013 ( 2013-10-07) –April 23, 2018 ( 2018-04-23)External linksPeg + Cat is an / animated based on the children's book 'The Chicken Problem', which was published in 2012. The series, which featured the of and, was created by and and produced. It debuted on most stations on October 7, 2013, as part of the revamped brand, and aired 63 episodes through April 23, 2018.The show is targeted to children 3 to 5 years old. The goal is to 'inspire preschoolers’ natural curiosity about math and help them develop new skills and strategies for solving problems creatively in their daily lives.' In keeping with the math theme, the animation is presented as if it were drawn on.On March 3, 2015, PBS Kids renewed Peg + Cat for a second season, which started on April 4, 2016.

On March 28, 2016, a one-hour two-part film aired on PBS Kids. This new film, titled Peg + Cat Save the World, focused on the duo being called upon by the President of the United States (voiced by ), to prevent a global disaster. On March 14, 2016, PBS Kids released the first part of the film on its channel. Contents.Characters.

Peg – The main character, together with her talking cat, Cat. She is a young girl who wears a red hat and blue dress. She explains the situation in each episode directly to the 'camera', announces when they have 'a big problem', and reasons out solutions to math-related problems. During songs, she pulls out a and plays it. She has a special blue hidden under her hat. Her favorite crayon is 'little bluey'.

She is voiced by. Cat – An cat whose best friend is Peg.

He loves circles and accompanies Peg on her adventures. Cat often inspires Peg to realize a solution to a problem without being aware of it himself. Often helps to calm Peg when she is 'totally freaking out'. He was inspired by Jennifer Oxley's pet cat. He is voiced by.

Ramone – A boy who shows up to help Peg and Cat with their math problems. He is voiced by Thamela Mpumlwana in season 1 and Jaiden Lewis in season 2. Pig – A pig who is usually silent except when he sings in a rich operatic.

His favorite shape is the triangle. Voiced by Tommy Wazelle.

Neighbor Ladies – A female African American character named Viv and a female Asian American character named Connie that appear in several episodes. They often accidentally add to Peg and Cat's problems by trying to be nice. Viv is voiced by Angela Teek and Connie is voiced by. 100 Chickens – Chickens who play and live on farm and travel to space with Pig, Peg, and Cat. Voiced by Rob Morrison and Carys Casucci. The Pirates and their parrot – A quarrelsome quartet of pirates who live on an island. They like to sing in four-part harmony but sing 'really bad' when they get cranky.

They have had a sleepover with Peg and Cat. Voiced by Rob Morrison. Big Mouth – A blue, furry, horned space monster who likes to eat things that are little and yellow. Richard – A from the purple planet who plays with Peg and Cat in space. He often cries during tense situations. Voiced by Christian DiStefano.

The Teens – Three cool older kids who love pizza and texting on their phones, but can't stand getting dirt on their clothes. Tessa (voiced by ) is thirteen, Mora (voiced by ) is fourteen, and Jesse (voiced by Gabriel Giammaria) is fifteen. Giants – Peg and Cat's big friends who live up the beanstalk in Fairy Tale Land.

In The Giant Problem Peg and Cat think that the Giants are going to eat them. Voiced by Bryce Kulak (Giant) and Shoshana Sperling (Giantess). Mermaid – A swimming damsel who lives in the Magical Forest.

The Pig stole her Golden Pyramid's in The Golden Pyramid Problem. She is voiced by., - Nine Friends of Peg and Cat that get into bands like The Electric Eleven. Voiced by Kevin Brathwite (Papa Bear), Angela Teek (Mama Bear), Phatt Al (Baby Bear), and Rob Morrison (Three Little Pigs and Three Billy Goats Gruff).

The Blockettes – Five dancers that dance in the Radio City Music Hall. Voiced by Allie Hughes, Jennifer Wallis, and. Mac – A gruff-voiced man who works various jobs in different episodes.

Voiced by Kevin Del Aguila. Peg's Mom – Voiced by. Voiced by Rob Morrison.

Dragon – A mythical creature who lives in the Magical Forest. – A famous music composer who has problems writing music.

Voiced by Rob Morrison. – The first president of the United States. Voiced by Kyle McDonald.

– A famous scientist. Voiced by. Flat Woman – A supervillaness who likes to make things flat. Voiced by. Baby Fox – A young little fox who likes building his block tower and stays with Mrs. Sheep.

– Two young lovers from William Shakespeare's stage play of the same name. An adult blue dinosaur who talks. Randomly says 'Horn!' During conversation. Baby - A baby dinosaur with a voracious appetite who can't talk but instead shrieks.

Seen frequently with Triceratops. Peg + Cat's Queen of the Nile friend, along with her pet camel 'Epidermis'. Voiced by Patience Mpumlwana. Voiced by. Roxanne - A pink French cat. Voiced by Paula McNeil.

Grandmom and Granddad - Peg's grandparents who are obsessed with the 1960s. Voiced respectfully by Judy Marshack and Jim Codrington.

The President of the United States - Voiced by. Robin Hood - A robin loosely based on the.

Aki - A ninja in training. Voiced by Mika Shimozato. A famous jazz singer.Episodes Series overview SeasonEpisodesOriginally airedFirst airedLast aired40October 7, 2013 ( 2013-10-07)September 10, 2015 ( 2015-09-10)23April 4, 2016 ( 2016-04-04)April 23, 2018 ( 2018-04-23)Season 1 (2013–15) No.overallNo. This section needs additional citations for.

Unsourced material may be challenged and removed.Find sources: – ( January 2019) In Canada the show is broadcast on.Peg + Cat was also seen on from 2014, in Latin America and, and in the United Kingdom, with no plans to make more episodes. The series was widely known in Ireland for showing reruns on as part of its children's block. Child-oriented network showed episodes.

In South Korea, it ran on. It was shown by in Sweden, and by in Finland. It was also shown in Spain. It aired for some time on in UAE. It also aired on in Israel. Other airers have included (France), (Belgium), (MENA, Europe, Asia, Russia, Spain and Africa), and (Japan).AwardsPeg + Cat has won seven:, , Outstanding Individual Achievement in Animation (Jennifer Oxley, production designer), Outstanding Writing in a Pre-School Animated Program (includes Peg + Cat co-creators and Jennifer Oxley, Kevin Del Aguila, Dustin Ferrer, David Steven Cohen, Qui Nguyen, and writers), and Outstanding Music Direction and Composition (Steven Rebollido, music supervisor; J.

Walter Hawkes, music director; and Martin Erskine and D. Jackson, composers).

MerchandiseIn late 2016, and signed a deal with the -based toy manufacturer Imports Dragon to create an assortment of plush, arts-and-crafts sets, games and wooden puzzles based on the Peg + Cat characters.The toys join numerous books from, as well as from PBS Distribution in the U.S., eOne in Canada, ABC Commercial in Australia and Sony Music in Germany. Animation World Network. February 26, 2013. Retrieved December 25, 2017. January 14, 2013.

Retrieved December 25, 2017. 9 Story Entertainment. Retrieved December 25, 2017. August 7, 2013. Retrieved December 25, 2017.

Retrieved 2014-10-30. ^ (Press release). March 8, 2016. Retrieved December 25, 2017. Bibel, Sara; Baron, Steve (March 3, 2015). Archived from on 6 March 2015. Season two of the popular show will feature 25 engaging new episodes, including a hilarious one-hour special.

Retrieved December 25, 2017. Retrieved December 25, 2017. ^. Retrieved April 25, 2018. Retrieved December 25, 2017. Retrieved December 25, 2017.

Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017.

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Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017.

Archived from on April 2, 2015. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017.

Retrieved December 25, 2017. Retrieved December 25, 2017.

Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017.

Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017. Retrieved December 25, 2017.

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Berenz, Ryan (2013-10-07). Channel Guide Magazine. Retrieved 2019-12-13. Archived from on 2016-11-25. Retrieved 2016-12-05. CS1 maint: archived copy as title.

June 20, 2014. Retrieved December 25, 2017.

April 25, 2015. Retrieved December 25, 2017. June 20, 2015. Retrieved December 25, 2017.

^ (PDF). April 29, 2016. Retrieved December 25, 2017. ^. May 19, 2016.

Retrieved December 25, 2017.External links. on.