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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 62-65

Percutaneous endoscopic gastrostomy: A prospective study


SIMS Institute of Gastroenterology, Hepatology and Transplantation, SRM Institutes for Medical Science, Chennai, Tamil Nadu, India

Date of Submission04-Sep-2020
Date of Decision21-Sep-2020
Date of Acceptance23-Sep-2020
Date of Web Publication23-Mar-2021

Correspondence Address:
Doraiswami Babu Vinish
No. 1, Jawaharlal Nehru Salai, Vadapalani, Chennai - 600 026, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_21_20

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  Abstract 


Introduction: Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure for establishing enteral access for nutrition. There is a paucity of literature on PEG from the Indian subcontinent. With the rate of complications in the literature showing a downward trend, we aimed to analyze the same in our institute following a standard procedure of PEG tube placement. Methods: The prospective study was conducted including patients referred for PEG placement from August 2017 to December 2019. Data were recorded on a proforma. The primary aim of the study was to determine the rate of complications in patients undergoing PEG, whereas the secondary aim was to determine whether early feeding was associated with increased rate of infection or other complications. Patients were reviewed after 3 days, 1 month, and every 3 months thereafter later with clinical examination. Results: Sixty-seven (83.75%) males and 13 (16.25%) females with a median age of 51 years (range 1–85) were included in the study. Forty-one (51.25%) patients had comorbidities with hypertension being the most common (n = 28). Postoperative placement of the PEG tube was done in 47 (58.75%) patients. Seventy-four patients had underlying neurological or neurosurgical conditions. At the time of PEG placement, 59 (73.75%) had tracheostomy. All procedures were performed in the endoscopic suite, of which two were performed as day care procedures. There were no intraprocedural complications. Feed was started within 2 h in 45 (56.25%) patients and all tolerated feed well. There were no major postprocedural complications. Thirteen patients had clinically suspected PEG site infection, of which 11 patients had a culture-positive organism. All responded to conservative management. Thirty-two patients were on follow-up at a median follow-up period of 2 years. Conclusion: The incidence of complications following PEG tube placement is low. With the standardization of the PEG technique, no major complications were seen in our study. Early PEG feeding was not associated with an increase in the rate of complications.

Keywords: Early feeding, infection, percutaneous endoscopic gastrostomy


How to cite this article:
Vinish DB, Krishnamurthy G, Sarangapani A, Rajini K, Ramakrishna BS. Percutaneous endoscopic gastrostomy: A prospective study. Gastroenterol Hepatol Endosc Pract 2021;1:62-5

How to cite this URL:
Vinish DB, Krishnamurthy G, Sarangapani A, Rajini K, Ramakrishna BS. Percutaneous endoscopic gastrostomy: A prospective study. Gastroenterol Hepatol Endosc Pract [serial online] 2021 [cited 2021 Apr 22];1:62-5. Available from: http://www.ghepjournal.com/text.asp?2021/1/2/62/311735




  Introduction Top


Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure for establishing enteral access for nutrition in patients who are not able to meet their daily nutritional requirement despite having a functional gastrointestinal tract.

Naso-enteric modality is preferred in patients in whom oral feeds can be started within a month. PEG placement should be considered in patients requiring or expected to require enteral feeding more than 2–3 weeks.[1]

Common indications for PEG are patients with degenerative neurological conditions (multiple sclerosis, Parkinson's disease, and dementia), loss of consciousness (head injury, postbrain surgeries, and prolonged coma), and head and neck malignancies.[2]

Patients undergoing PEG usually have multiple comorbidities, and the rate of complications varies from with 70% in earlier studies[3] and 4.9%–10.3%,[4] in later studies, thus showing a decreasing trend. PEG in India is an underutilized procedure for enteral accesses,[5] despite been showed to be a valuable procedure in providing nutrition for indicated patients. There is a paucity of literature on PEG in the Indian subcontinent. With the rate of complications in the literature showing a downward trend, we aimed to analyze the same in our institute following a standard procedure of PEG. We also wanted to study the impact of early initiation on complication rate.


  Methods Top


Data were collected in a preformatted proforma by the author or coauthors. The study included patients referred to the Institute of Gastroenterology, SIMS hospitals, for PEG placement. The primary aim of the study was to determine the rate of complications in patients undergoing PEG, whereas the secondary aim was to determine whether early feeding was associated with increased rate of infection or other complications.

All patients referred for PEG were included in the study. Exclusion criteria included the presence of gastrointestinal tract obstruction, ascites, uncorrected coagulopathy, and the inability to bring the anterior gastric wall in apposition with the abdominal wall to produce transillumination.

Patients were recruited from August 2017 to December 2019.

Methodology of the percutaneous endoscopic gastrostomy procedure

Antiplatelets and oral anticoagulants were stopped 5 days before the procedure, whereas heparin or low-molecular-weight heparin was withheld for 12 h before the procedure. An hour before the procedure, antibiotic prophylaxis was given, if the patient was already on an antibiotic, no prophylactic antibiotic was given. All procedures were performed under general anesthesia.

Steps included:

  1. Shaving the anterior abdominal wall in the endoscopy suite, the anterior abdominal wall was disinfected with povidone iodine
  2. Gastroscopy was done using a GIF HQ-190 Olympus Japan® gastroscope while keeping the insufflation at high which would give adequate insufflation to bring the luminal wall in apposition with the abdominal wall. Gastroscopy was done up to D2
  3. The intensity of the light source was increased with transillumination option. Transillumination was noted on the anterior abdominal wall which was marked with a needle cap
  4. Using the scalpel, a small incision was made on the anterior abdominal wall on the site of the mark and percutaneous placement of a tapered cannula into the stomach was made through the abdominal wall
  5. Guidewire was then introduced into the cannula which was brought out through the oral cavity with a snare
  6. PEG tube was knotted to the guidewire at the oral end and the guidewire pulled on to the abdominal wall, the skin was widened if the tube could not be easily pulled onto the anterior abdominal wall. The tube was then fixed with the external bolster
  7. Repeat endoscopy was done to confirm the position of the internal bolster.


Critical points for safe and successful placement of the feeding tube

  1. Ensuring adequate insufflation was obtained till distention causes flattening of the mucosal rugae in the body of the stomach. Good transillumination appearance including the intensity and the focal nature was confirmed
  2. We routinely performed second-look endoscopy to confirm the proper placement of the internal bumper immediately. In addition, one is to one movement of the internal bolster on rotating the tube externally. This ensures the internal bolster is snuggly fitting and not cause excessive pressure on the gastric wall that may lead to buried bumper after deflation. The point at which the tube was fixed on the anterior abdominal wall was noted and the same informed to the patient and attender.


Postprocedure

A dressing was placed over the bolster which was present for 24 h; post this dressing, the stoma was left open with no dressing or cleaning with antiseptic solutions. The timing of initiating feed was left to physician's discretion. Feed is started at a rate of 25 ml/h for 24 h and then gradually increased to achieve the patients' metabolic requirement. Bolus feeds are started after 1 week. Patients' attenders were instructed to keep the area clean with soap and water; attenders were educated regarding the need for a finger's space between the external bolster and the anterior abdominal wall. Tube care also included information regarding the nature of feed (liquid in consistency and cold) and flush the tube post feed with water. Patient and attenders were also instructed to give small amount of carbonated drinks every day to maintain the patency of the tube.

Definitions of complications

No consensus exists as to the precise nomenclature of complications following gastrostomy, we followed the hybrid classification as used by Grant et al.[6] [Table 1].
Table 1: Complications of percutaneous endoscopic gastrostomy

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Follow-up

Patients were reviewed after 3 days, 1 month, and every 3 months thereafter later with clinical examination. Follow-up information was recorded on a standard proforma which included information regarding possible complication of PEG tube. Patients were followed up PEG tube removal or death of the patient whichever is earlier.

Ethical committee

The study was conducted after approval from the institutional ethics committee.

Sample size calculation

The incidence of complications following PEG tube placement ranges from 4.9 to 10.8%.[4] Rabeneck et al.[7] reported incidence of PEG tube complications to be 5.17%. Minimal sample size of 75 patients was calculated with expected incidence of complications to be 5.17% using OpenEpi software version 3, with a confidence interval of 95%.

Statistical analysis

Data were collected on a specified proforma. Outcome variables were also recorded by the investigator. Categorical variables were compared by the Chi-square test and the Fisher exact test (two-tailed) when necessary. Continuous variables were compared by the Student's t-test or the Mann–Whitney U-test, depending on the distribution. All P values were two-sided. P < 0.05 indicated a statistically significant difference. All calculations were done with SPSS (version 10.0; SPSS Inc., Chicago, Ill., USA).


  Results Top


The study included 80 patients. There were 67 (83.75%) males and 13 (16.25%) females. The median age was 51 years (range 1–85). Hypertension was the most common comorbidity in the study group (n = 28, 35%). Diabetes mellitus, coronary artery disease, and chronic kidney disease were present in 26 (32.5%), 11 (13.75%), and 2 (2.5%) patients, respectively. Other comorbidities seen in the study group were aspiration pneumonitis and mitral stenosis. Thirty-nine patients (48.75%) had no comorbidities.

All procedures were performed in the endoscopic suite, of which two were performed as day care procedures. At the time of PEG placement, 59 (73.75%) had tracheostomy. Postoperative placement of the PEG tube was done in 47 (58.75%) patients. Seventy-four patients had underlying neurological or neurosurgical conditions. Among the rest, indications of PEG tube placement were oral cavity malignancy, poor oral intake, and post gastrectomy gastroparesis. Preexisting infective foci in the form of positive cultures were present in 55 (68.75%) patients. The sources of infective foci were urinary tract, respiratory tract, and wound in 27 (33.75%), 47 (58.75%), and 9 (11.25%) patients, respectively.

There were no intraprocedural complications. Feed was started within 2 h in 45 (56.25%) patients and all tolerated feed well.

Thirteen patients had clinically suspected PEG site infection, of which 11 patients had a culture-positive organism. There was no correlation of incidence of PEG site infection with preprocedural urine, blood, and endotracheal culture or timing of initiation of feed [Table 2]. Stoma site leak and stoma site bleeding were seen in two and one patient each. Four patients had persistent regurgitation of the PEG feeds and underwent PEG J placement.
Table 2: Univariate analysis of factors determining percutaneous endoscopic gastrostomy site infection

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There were no major complications in the study population.

Nine patients had expired due to the primary illness before PEG tube removal.

PEG tube of 3 diameters was used in the study, for the children (n = 3) below 5 years, a 14 Fr PEG tube was placed, for those < 15 years (n = 3), 20 Fr was placed, and for all other patients, 24 Fr PEG tube was placed. The diameters are all outer diameters of the PEG tube.


  Discussion Top


Percutaneous gastrostomy tubes can be placed endoscopically or radiologically. PEG is a minimally invasive procedure first described initially in children by Gauderer et al. in 1980 for providing nutrition[8] which in front of the coloured statement has now become a standard norm to establish enteral accesses in patients who are not able to have food orally due to various reasons. When the need for enteral accesses is expected to exceed 4 weeks and life expectancy of patients exceeds 2 months, PEG is the preferred choice over nasoenteral feeding.[9] There are three techniques for PEG tube placement: the peroral pull technique (Ponsky), the peroral push technique (Sacks-Vine), and the direct percutaneous procedure (Russell), of which the first is the most commonly used.[10] In our study, all the procedures were done by the pull method.

The rate of complications due to PEG has been varying with newer studies showing a declining trend. Twenty patients (16%) in this study had complications. There were no major complications. In a meta-analysis of 17 studies and 1281 patients, the incidence of minor complications was 4%–52%, whereas major complications varied between 0 and 15%.[6] The study also showed more complications in radiologically inserted PEG rather than endoscopically placed PEG.

The most common complication in our study was PEG site infection which was seen in 13 (10.4%). This is similar to reported rates by Rahnemai-Azar et al.[2] On the other hand, an Indian study by Vizhi et al.[11] reported complication rate of 21.9%. The lower rate of infection in our study is probably secondary to the high proportion neurological conditions compared to malignant conditions in the study by Vizhi et al., another reason could be that all patients who had infective foci in the form of a culture-proven organism in the blood, urine, or tracheal culture received atleast 2 days of antibiotics before the procedure. All the 13 patients with infection were managed successfully with conservative measures with antibiotics and wound care.

Stoma site leak was seen in 2 (1.6%) patients, which is similar to the 1%–2% as reported by Jain and Maple.[1] Of the two patients, one patient had a leak after 8 days after the insertion of the PEG tube. The patient also had peristomal infection. With conservative measures such as antibiotics and decreasing rate of feed, stomal leak subsided. One other patient presented after 4 months of PEG insertion, the PEG tube was removed, and a guidewire was placed in the wound site. Another PEG tube was reinserted in the same stoma after 72 h.[12]

Minor bleeding at the stoma site bleeding (peristomal) was seen in one patient. A superficial bleeding vessel was identified and ligated bedside. This is similar to the number of patients seen in the meta-analysis as reported by Grant et al. Four patients had regurgitation of the PEG feed, but none of these patients developed aspiration pneumonia. Immediately after a regurgitation of the feed was seen, the rate at which feed was given was reduced to 25 ml/h and prokinetics were added. All four patients did not respond to this course of management. All patients underwent jejunostomy tube insertion through the PEG tube. In all the patients, the PEG J was removed after a period of 15–25 days.

There are no set guidelines proposed on the starting of the timing of PEG feeds. In a meta-analysis, Szary et al. early feeding within 3 h was found to be safe and effective. We had started feeds after 2 h in 45 patients (56.25%), and there was no increase in complication rates compared to patients who had been started on feeds after 4 h.[13]

There were no major complications in the immediate postoperative period. Thirty-two patients had their PEG tube removed after obtaining adequate oral nutrition. Nine died before PEG tube removal due to underlying primary pathology. Our institute being a tertiary care center, patients are managed at their local place once the primary pathology is taken care adequately and do not report to our center, hence explaining our low follow-up rate.

Limitations of the study include the inability to draw conclusions on long-term complications given the low follow-up rate.


  Conclusion Top


The incidence of complications of PEG is similar or even decreasing. With the standardization of the PEG technique, no major complications were seen. Early PEG feeding was not associated with an increase in the rate of complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jain R, Maple JT, Anderson MA, Appalaneni V, Ben-Menachem T, Decker GA, et al. The role of endoscopy in enteral feeding. ASGE Standards of Practice Committee. Gastrointest Endosc 2011;74:7-12.  Back to cited text no. 1
    
2.
Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World J Gastroenterol 2014;20:7739-51.  Back to cited text no. 2
    
3.
Taylor CA, Larson DE, Ballard DJ, Bergstrom LR, Silverstein MD, Zinsmeister AR, et al. Predictors of outcome after percutaneous endoscopic gastrostomy: A community-based study. Mayo Clin Proc 1992;67:1042-9.  Back to cited text no. 3
    
4.
McClave SA, Chang WK. Complications of enteral access. Gastrointes Endosc 2003;58:739-51.  Back to cited text no. 4
    
5.
Verma S, Dutta U. Percutaneous endoscopic gastrostomy: An effective yet underutilized procedure in India. J Digest Endosc 2019;10:155-7.  Back to cited text no. 5
    
6.
Grant DG, Bradley PT, Pothier DD, Bailey D, Caldera S, Baldwin DL, 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;34:103-12.  Back to cited text no. 6
    
7.
Rabeneck L, Wray NP, Petersen NJ. Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. J Gen Intern Med 1996;11:287-93.  Back to cited text no. 7
    
8.
Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg1980;15:872-5.  Back to cited text no. 8
    
9.
Sartori S, Trevisani L, Tassinari D, Gilli G, Nielsen I, Maestri A et al. Cost analysis of long-term feeding by percutaneous endoscopic gastrostomy in cancer patients in an Italian health district. Support Care Cancer 1996;4:21-6.  Back to cited text no. 9
    
10.
Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: Techniques, problems and solutions. World J Gastroenterol 2014;20:8505-24.  Back to cited text no. 10
    
11.
Vizhi K, Rao HB, Venu RP. Percutaneous endoscopic gastrostomy site infections-Incidence and risk factors. Indian J Gastroenterol 2018;37:103-7.  Back to cited text no. 11
    
12.
Tsang TK, Eaton D, Falconio MA. Percutaneous ostomy dilation: A technique for dilating the closed percutaneous endoscopic gastrostomy sites and reinserting gastrostomies. Gastrointest Endosc 1989;35:336-7.  Back to cited text no. 12
    
13.
Szary NM, Arif M, Matteson ML, Choudhary A, Puli SR, Bechtold ML. Enteral feeding within three hours after percutaneous endoscopic gastrostomy placement: A meta-analysis. J Clin Gastroenterol 2011;45:e34-8.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2]



 

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