Review

Authors: Ata A Rahnemai-Azar, Amir A Rahnemaiazar, Rozhin Naghshizadian...

Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the "pull" technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.

Topics: Device Removal; Enteral Nutrition; Equipment Design; Gastroscopy; Gastrostomy; Humans; Postoperative Complications; Risk Factors; Time Factors; Treatment Outcome

PubMed: 24976711
DOI: 10.3748/wjg.v20.i24.7739

Review

Authors: Kurt Boeykens, Ivo Duysburgh, Wim Verlinden...

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) was developed by Ponsky-Gauderer in the early 1980s. These tubes are placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition but can also be used for drainage or decompression. The tubes consist of an internal and external retention device. It is a generally safe technique but major or minor complications may arise during and after tube placement.

METHOD

A narrative review of the literature investigating minor complications after PEG placement.

RESULTS

This review was written from a clinical viewpoint focusing on prevention and management of minor complications and documented with real cases from more than 21 years of clinical practice.

CONCLUSIONS

Depending on the literature the incidence of minor complications after gastrostomy placement can be high. To decrease associated morbidity, prevention, early recognition and popper management of these complications are important.

Topics: Enteral Nutrition; Gastrostomy

PubMed: 35851280
DOI: 10.1136/bmjgast-2022-000975

Meta-Analysis Review

Authors: Alfredo J Lucendo, Ana Belén Friginal-Ruiz

BACKGROUND

Numerous disorders impairing or diminishing a patient's ability to swallow may benefit from a PEG tube placement. This is considered the elective feeding technique if a functional digestive system is present.

METHODS

A PubMed-based search restricted to the English literature from the last 20 years was conducted. References in the results were also reviewed to identify potential sources of information.

RESULTS

PEG feeding has consistently demonstrated to be more effective and safe than nasogastric tube feeding, having also replaced surgical and radiological gastrostomy techniques for long term feeding. PEG is considered a minimally invasive procedure to ensure an adequate source for enteral nutrition in institutionalized and at home patients. Acute and chronic conditions associated with risk of malnutrition and dysphagia benefit from PEG placement: Beyond degenerative neuro-muscular disorders, an increasing body of evidence supports the advantages of PEG tubes in patients with head and neck cancer and in a wide range of situations in pediatric settings.The safety of PEG placement under antithrombotic medication is discussed. While antibiotic prophylaxis reduces peristomal wound infection rates, co-trimoxazole solutions administered through a newly inserted catheter constitutes an alternative to intravenous antibiotics. Early feeding (3-6 hours) after PEG placement firmly supports on safety evidences, additionally resulting in reduced costs and hospital stays. Complications of PEG are rare and the majority prevented with appropriated nursing cares.

CONCLUSIONS

PEG feeding provides the most valuable access for nutrition in patients with a functional gastrointestinal system. Its high effectiveness, safety and reduced cost underlie increasing worldwide popularity.

Topics: Endoscopy; Gastrostomy; Humans; Postoperative Care; Postoperative Complications

PubMed: 25544410
DOI: No ID Found

Review

Authors: Christoph G Dietrich, Konrad Schoppmeyer

Percutaneous endoscopic gastrostomy is an established method to provide nutrition to patients with restricted oral uptake of fluids and calories. Here, we review the methods, indications and complications of this procedure. While gastrostomy can be safely and easily performed during gastroscopy, the right patients and timing for this intervention are not always chosen. Especially in patients with dementia, the indication for and timing of gastrostomies are often improper. In this patient group, clear data for enteral nutrition are lacking; however, some evidence suggests that patients with advanced dementia do not benefit, whereas patients with mild to moderate dementia might benefit from early enteral nutrition. Additionally, other patient groups with temporary or permanent restriction of oral uptake might be a useful target population for early enteral nutrition to maintain mobilization and muscle strength. We plead for a coordinated study program for these patient groups to identify suitable patients and the best timing for tube implantation.

Topics: Enteral Nutrition; Gastroscopy; Gastrostomy; Humans; Patient Selection; Practice Guidelines as Topic; Time Factors; Time-to-Treatment

PubMed: 32523304
DOI: 10.3748/wjg.v26.i20.2464

Meta-Analysis

Authors: Claudio A R Gomes, Régis B Andriolo, Cathy Bennett...

BACKGROUND

A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

OBJECTIVES

To evaluate the effectiveness and safety of PEG compared with NGT for adults with swallowing disturbances.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to January 2014, and contacted the main authors in the subject area. There was no language restriction in the search.

SELECTION CRITERIA

We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%.

MAIN RESULTS

We included 11 randomised controlled studies with 735 participants which produced 16 meta-analyses of outcome data. Meta-analysis indicated that the primary outcome of intervention failure, occurred in lower proportion of participants with PEG compared to NGT (RR 0.18, 95% CI 0.05 to 0.59, eight studies, 408 participants, low quality evidence) and this difference was statistically significant. For this outcome, we also subgrouped the studies by endoscopic gastrostomy technique into pull, and push and not reported. We observed a significant difference favouring PEG in the pull subgroup (RR 0.07, 95% CI 0.01 to 0.35, three studies, 90 participants). Thepush subgroup contained only one clinical trial and the result favoured PEG (RR 0.05, 95% CI 0.00 to 0.74, one study, 33 participants) techniques. We found no statistically significant difference in cases where the technique was not reported (RR 0.43, 95% CI 0.13 to 1.44, four studies, 285 participants).There was no statistically significant difference between the groups for meta-analyses of the secondary outcomes of mortality (RR 0.86, 95% CI 0.58 to 1.28, 644 participants, nine studies, very low quality evidence), overall reports of any adverse event at any follow-up time point (ITT analysis, RR 0.83, 95% CI 0.51 to 1.34), 597 participants, 6 studies, moderate quality evidence), specific adverse events including pneumonia (aspiration) (RR 0.70, 95% CI 0.46 to 1.06, 645 participants, seven studies, low quality evidence), or for the meta- analyses of the secondary outcome of nutritional status including weight change from baseline, and mid-arm circumference at endpoint, although there was evidence in favour of PEG for meta-analyses of mid-arm circumference change from baseline (MD 1.16, 95% CI 1.01 to 1.31, 115 participants, two studies), and levels of serum albumin were higher in the PEG group (MD 6.03, 95% CI 2.31 to 9.74, 107 participants).For meta-analyses of the secondary outcomes of time on enteral nutrition, there was no statistically significant difference (MD 14.48, 95% CI -2.74 to 31.71; 119 participants, two studies). For meta-analyses of quality of life measures (EuroQol) outcomes in two studies with 133 participants, for inconvenience (RR 0.03, 95% CI 0.00 to 0.29), discomfort (RR 0.03, 95% CI 0.00 to 0.29), altered body image (RR 0.01, 95% CI 0.00 to 0.18; P = 0.001) and social activities (RR 0.01, 95% CI 0.00 to 0.18) the intervention favoured PEG, that is, fewer participants found the intervention of PEG to be inconvenient, uncomfortable or interfered with social activities. However, there were no significant differences between the groups for pain, ease of learning to use, or the secondary outcome of length of hospital stay (two studies, 381 participants).

AUTHORS' CONCLUSIONS

PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT. There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration. Future studies should include details of participant demographics including underlying disease, age and gender, and the gastrostomy technique.

Topics: Adult; Deglutition Disorders; Enteral Nutrition; Gastrostomy; Humans; Intubation, Gastrointestinal; Malnutrition; Pneumonia; Randomized Controlled Trials as Topic; Treatment Failure

PubMed: 25997528
DOI: 10.1002/14651858.CD008096.pub4

Review

Authors: Sherwin P Schrag, Rohit Sharma, Nikhil P Jaik...

Percutaneous endoscopic gastrostomy (PEG) has become the modality of choice for providing enteral access to patients who require long-term enteral nutrition. Although generally considered safe, PEG tube placement can be associated with many potential complications. This review describes a variety of PEG tube related complications as well as strategies for complication avoidance. In addition, the reader is presented with a brief discussion of procedures, techniques, alternatives to PEG tubes, and related issues. Special topics covered in this review include PEG tube placement following previous surgery and PEG tube use in pregnancy.

Topics: Enteral Nutrition; Gastroscopy; Gastrostomy; Humans; Postoperative Complications

PubMed: 18193123
DOI: No ID Found

Authors: Kin Pan Au, Kenneth Siu Ho Chok

The article by Ker explores the treatment of peripancreatic fluid collection (PFC). The use of percutaneous drainage, endoscopy, and surgery for managing PFC are discussed. Percutaneous drainage is noted for its low risk profile, while endoscopic cystogastrostomy is more effective due to the wider orifice of the metallic stent. Surgical cystogastrostomy is a definitive treatment with a reduced need for reintervention, especially for cases with extensive collections and significant necrosis. The choice of treatment modality should be tailored to individual patient characteristics and disease factors, considering the expertise available.

Topics: Humans; Drainage; Treatment Outcome; Stents; Gastrostomy; Pancreatic Pseudocyst

PubMed: 38813046
DOI: 10.3748/wjg.v30.i17.2298

Authors: Marianna Arvanitakis, Paraskevas Gkolfakis, Edward J Despott...

ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.

Topics: Adult; Endoscopy, Gastrointestinal; Gastrointestinal Hemorrhage; Gastrostomy; Humans; Intestine, Small

PubMed: 33260229
DOI: 10.1055/a-1303-7449

Authors: Sapthagiri Gantasala, Peter B Sullivan, Adrian G Thomas...

BACKGROUND

Children with cerebral palsy can be significantly disabled in terms of their ability to suck, chew and swallow. This can lead to significant impairment in feeding and, eventually, to undernutrition. It can also result in aspiration of food into the lungs. Length of feeding time may be considerably increased and, instead of being an enjoyable experience, mealtimes may be distressing for both child and carer. For children unable to maintain a normal nutritional state feeding by mouth, gastrostomy or jejunostomy tubes are increasingly being used to provide the digestive system with nutrients. A gastrostomy tube is a feeding tube inserted surgically through the abdominal wall directly into the stomach. A jejunostomy feeding tube is inserted into the jejunum, part of the small intestine, either directly or via a previous gastrostomy. Although gastrostomy or jejunostomy placement may greatly facilitate the feeding of children with cerebral palsy, many carers find it very emotionally difficult to accept this intervention. Moreover, the intervention is costly and there is the possibility of complications. The effectiveness and safety of the treatment requires further assessment. This review is an update of one previously published in 2004.

OBJECTIVES

To assess the effects of nutritional supplementation given via gastrostomy or jejunostomy to children with feeding difficulties due to cerebral palsy.

SEARCH METHODS

For this update, we searched the following databases in July 2012: CENTRAL, MEDLINE , Embase, CINAHL, Science Citation Index, Conference Proceedings Citation Index, LILACS and Zetoc. We searched for trials in ICTRP and Clinicaltrials.gov, and for theses in WorldCat and Proquest Index to Theses. We also contacted other researchers and experts in this field.

SELECTION CRITERIA

We looked for randomised controlled trials that compared delivery of nutrition via a gastrostomy or jejunostomy tube compared with oral feeding alone for children up to the age of 16 years.

DATA COLLECTION AND ANALYSIS

Screening of search results was undertaken independently by two review authors. No data extraction was possible as there were no included studies.

MAIN RESULTS

No trials were identified that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

Considerable uncertainty about the effects of gastrostomy for children with cerebral palsy remains. A well designed and conducted randomised controlled trial should be undertaken to resolve the current uncertainties about medical management for children with cerebral palsy and physical difficulties in eating.

Topics: Adolescent; Cerebral Palsy; Child; Child, Preschool; Eating; Gastrostomy; Humans; Infant; Nutrition Disorders

PubMed: 23900969
DOI: 10.1002/14651858.CD003943.pub3

Authors: James Evans, Breeana Gardiner, Dan Green...

BACKGROUND

Nutrition support is essential in children with cancer, including those undergoing bone marrow transplant (BMT), to reduce the risk of malnutrition and associated deleterious outcomes. Enteral nutrition is more commonly provided via nasogastric than gastrostomy tubes because of safety concerns with the latter in immunocompromised children. This systematic review investigated the incidence and type of complications and outcomes in pediatric cancer patients fed by gastrostomy.

METHODS

Databases were searched for randomized and observational studies investigating the use of any gastrostomy device in children aged <18 years with any cancer diagnosis, including those undergoing BMT. Five cohort and 11 case series studies were included. Owing to clinical heterogeneity, meta-analyses were not performed.

RESULTS

Quality of evidence varied, with five studies judged at serious risk of bias and poor quality; however, the remaining 11 were considered to range from moderate to good quality. Across studies, 54.6% of children developed one or more complications, of which 76.6% were classified as minor, 23.4% major. The most frequent complications included inflammation (52% of episodes), infection (42.1%), leakage (22.3%), and granuloma (21%). Evidence regarding infection rates in cancer/BMT patients compared with other disease states was inconclusive. Gastrostomy feeding was associated with improvement or stabilization of nutrition status in 77%-92.7% of children.

CONCLUSION

Gastrostomy feeding in this population is relatively safe and effective in stabilizing or improving nutrition status throughout treatment. Complications are frequent but mostly minor. Placement requires careful consideration of the complications, benefits, nutrition risk and status at diagnosis, and quality of life.

Topics: Bone Marrow Transplantation; Child; Gastrostomy; Humans; Intubation, Gastrointestinal; Neoplasms; Quality of Life

PubMed: 34245471
DOI: 10.1002/ncp.10724