Peg tube insertion: enhanced need for greater selectivity in patient referral.
Introduction: Percutaneous endoscopic gastrostomy (PEG) refers to insertion of a tube into the stomach percutaneously, aided by endoscope and was first described in 1980 by Gauderer. This was devised for feeding the patients who have swallowing problems due to any reason especially neurodisability. There is an enhanced need for greater selectivity in patient referral. Retrospective, single - institution case series. The study was performed in Waterford Regional Hospital, Water- ford, Ireland. Jan 2003 to Dec 2007.
Materials and Methods: A total of 203 consecutive patients referred for nutritional support under- went PEG tube insertion during this period. Written informed consent was taken from all the par- ticipants or their attendants and the procedure was performed with prophylactic antibiotic and under intravenous sedation. Standard PEG set was used for the procedure. Feeding was started 12 hours after tube placement and care instructions were given. The parameters of study included in- dications, annual frequency, and overall outcome.
Results: A total of 203 patients having a male to female ratio 1:0.7 underwent PEG tube insertion. The age ranged from 26 to 96 years (mean 79 + 5.17. The mean duration of PEG feeding was 93 (3-785) days. The annual frequency of insertion increased from 19 (9.3%) patients in 2003 to 64 pati- ents (31.5%) in 2007. The length of stay ranged from 1 to 350 days (median 93). In this cohort, 32 (15.7%) patients died during the same admission. A total of 79 (38.9%) were discharged for home, 92 (45.3%) were discharged back to nursing home care.
Conclusion: This study underscores the need for enhanced awareness and protocol - driven selec- tivity in patient referral for PEG tube insertion.
Key Words: Percutaneous endoscopic gastrostomy, PEG, Oesophagogastroduodenoscopy.
Percutaneous endoscopic gastrostomy (PEG) refers to insertion of a tube into the stomach percutane- ously, aided by endoscope and was first described in 1980 by Gauderer.1 This was devised for feeding the patients who have swallowing problems due to any reason especially neurodisability.2,3 Feeding thro- ugh nasogastric tube can be prolonged for several weeks but is inconvenient and cumbersome for such patients besides its mechanical adverse effects.4,5
Surgical gastrostomy is also not suitable for such patients as it requires general anaesthesia and such patients are usually frail and unfit for such anaes- thesia.6 PEG is one of the most common endoscopic procedures performed today, and an estimated 100,000 - 125,000 are performed annually in Uni- ted States.7 Currently, PEG enteral feeding is the most commonly used method of nutritional sup- port. However, the procedure is not without risks. However high morbidity and mortality after PEG in elderly patients are commonly attributed to the se- verity of their underlying diseases. On the other hand, procedure related mortality is highlighted as more than expected in the literature.8 We have sele- cted this topic with the aim to review our unit's ex- perience with PEG tube in relation to its indications, annual frequency, and overall outcome of the proce- dure.
MATERIALS AND METHODS
This retrospective study was conducted in Water- ford Regional Hospital, Waterford, Ireland, from Jan 2003 to Dec 2007. A total of 203 consecutive patients referred for nutritional care underwent PEG tube insertion during this period. The project was approved by the Hospital Ethics Committee and informed consent was taken from all the participa- nts or their attendants. The procedure was perfor- med with prophylactic antibiotic cover along with intravenous sedation. Oesophago-gastro-duodeno- scopy (OGD) was performed. The site for placement of PEG tube was positioned by transillumination on the abdominal wall and impression of finger pres- sure. With the gastroscope in the stomach maintain- ing distension, a small incision was made at the site and an 18 gauge needle catheter was pushed thro- ugh the anterior abdominal wall into the stomach. A guidewire was then passed through it into the sto- mach and grasped with a polyp snare.
The guide-wire was withdrawn through gastroscope with the free end of the wire remaining outside the abdomi- nal wall. The PEG tube was then tied to the wire at the mouth and pulled into the stomach by pulling on the free end of the wire at the abdominal wall. Position of the PEG tube was confirmed by check endoscopy. Feeding was started 12 hours after tube placement and care instructions were given. The pa- rameters of our study included indications, annual frequency, and overall outcome.
A total of 203 patients, male to female ratio 1:0.7 underwent PEG tube insertion. The age ranged from 26 to 96 years (mean 79 +- 5.17). The mean duration of PEG feeding was 93 (3-785) days. Indications of PEG tube insertion are shown in Table 1. The ann- ual frequency of insertion increased from 19 (9.3%) in 2003 to 64 patients (31.5%) in 2007. The length of stay ranged from 1 to 350 days (median 93). In this cohort, 32 (15.7%) patients died during the sa- me admission, one oesophageal perforation, one haemorrhage, and one aspiration pneumonia, 29 patients due to primary disease. Four patients deve- loped peritonism and ileus, which resolved after conservative treatment. Minor complications inclu- ded peristomal sepsis 13.6%, tube blockage 12%, and tube connector leak 5%. Whilst 79 (38.9%) were discharged for home, 92 (45.3%) were discharged back to nursing home care.
Table 1: Indications of PEG for insertion.
Head and neck cancer###24###11.8
The advancement in endoscopic procedures has led to the development of gastrostomy feeding tubes with the aim of improving the nutritional status of patients who are unable to take food orally. The in- dications are expanding with the better understand- ing of importance of nutritional support in critically ill and chronically debilitated patients. The adequa- cy of nutritional support should be the final out- come of successful PEG placement.9 There were 142 males and 61 females showing male preponderance requiring PEG intubation in this study. There are many studies which support this finding.10,11 This predominance in male persons is probably due to increased incidence of strokes in this group. In our study, the patients with neurological disorders out- numbered the candidacy for PEG. A number of stu- dies have shown the main indication for PEG tube insertion is neurological.10-12
Major complications resulting from PEG tube placement reported in the literature include peritonitis, haemorrhage, Buried Bumper syndrome and gastrocolic fistula.13 Only 3 patients (2.2%) in our study had PEG related major complications. We had 13.6% patients with peristo- mal infection which was treated with entered anti- biotics. The frequency of local sepsis was reported 16% by Sadik et al14 13% by Schurink et al15 and 3-15% by Anis et al.16
There are many studies advocating the positive role of PEG in the nutritional buildup of the chro- nically ill patient and according to them, PEG is considered to be the preferred technique for the patients who need long - term enteral nutritional support.17 The studies have shown adequate nutri- tional status obtained by PEG feeding, of patients with head and neck malignancies receiving radio- therapy.18 The medical literature has reported a con- siderable amount of experience which demonstrates its ease of placement and low incidence of complica- tions associated with placement.19,20
As with any surgical procedure, it is also not without complications especially when selection cri- teria for tube insertion is not observed properly.
Many geriatric diseases result in eating difficulties and a number of patients undergo PEG to meet the- ir nutritional requirement and for the medication purposes. Indications for selecting individuals for PEG are not yet precise and everybody may not be- nefit from the procedure. The high morbidity and mortality after PEG tube insertion especially in el- derly patients is commonly attributed to the severity of their underlying diseases but procedure related mortality is higher than expected. Old age should not be a contraindication for PEG. A high early mor- tality indicates that there is a need of better criteria for selection and timing of PEG insertion in the el- derly.14,21 A study conducted by Baltz et al, showed high percentage of mortality in patients with cirrho- sis liver who underwent PEG tube placement.
They recommended prior assessment and weighing of ris- ks against the benefits of PEG tube placement in patients with cirrhosis.22 Long term dependence on PEG may lead to adverse effects on swallowing in head and neck cancer patients in postradiotherapy period.23 In one study by Low, the patients and their attendants preferred to be treated in a hospital set- ting and most differed with the usage of artificial feeding.24
PEG tube feeding in severely and chronically ill elderly adults can be accomplished safely. However, there are important concerns associated with the PEG and there was limited evidence that the proce- dure improves functional, nutritional, or subjective health status in this group of older adults. The issue was raised by Callahan et al in their study in which they compared PEG tube feeding with alternative methods of patient care for elderly adults with diffi- culty in eating.25
In patients with poor renal function, poor car- diac function, severe malnutrition or exhaustion, the indications for PEG need to be very carefully in- vestigated.26 The opponents recommend the formu- lation of strict criteria for the selection of patients for the procedure.
Several questions remain unanswered regarding the utility of nutritional support in many clinical scenarios in which PEG placement is considered. There is a multitude of evidence that artificial nutri- tion does not improve outcome or quality of life in patients with dementia who have decreased oral in- take. Though in this regard, ethical, moral, religi- ous, and legal considerations of family members and caregivers play a role in the decision to place a PEG in such patients despite the medical evidence representing lack of benefit.
A single center, retrospective analysis.
In conclusion there is an increasing trend to- wards PEG tube insertion despite a generally poor outcome and prospect of quality of life. PEG tube insertion may be associated with considerable mor- bidity and even mortality. These finding underscore the need for enhanced awareness and protocol dri- ven selectivity in patient referral for PEG tube in- sertion.
1. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic tech- nique. J Pediatr Surg. Dec 1980; 15 (6): 872-5.
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1Departments of General Surgery and 2ENT, Shalamar Hospital, Lahore, 3Department of Obstetrics and Gynaecology, Fatima Memorial Hospital, Lahore
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|Author:||Khan, Rizwan A.; Khan, Babar H.; Khan, Fareeha K.|
|Article Type:||Clinical report|
|Date:||Dec 31, 2011|
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