PERCUTANEOUS ENDOSCOPIC GASTROSTOMY: RESULTS OF 50 CASES

Rasim Gençosmanoğlu, M.D.* / Orhan Şad, M.D.* / Erol Avşar, M.D.** Hülya Över Hamzaoğlu, M.D.** / Osman Özdoğan, M.D.** Cem Kalaycı, M.D.** / Nurdan Tözün, M.D.**

* Surgical Unit, Institute o f , Marmara University, Istanbul, Turkey. * * Sub-department o f Gastroenterology, Department o f Internal Medicine, School o f Medicine, Marmara University, Istanbul, Turkey.

ABSTRACT 217.5 days (range 9 to 1669 days). In 9 patients the tube was removed with a median of 158.5 Objective: To present the results of days (range 35 to 427 days) and then oral percutaneous endoscopic gastrostomy (PEG), feeding was started. The tube was changed which has been an alternative method to in 7 patients who had tube dysfunction conventional surgical gastrostomy for the last 20 because of clogging, porosity or fracture with a years. PEG is one of the gastrostomy methods median interval of 122 days (range 35 to 1252 used for patients unable to take food orally. days). Of these patients, 2 needed replacement tube insertion twice and 3 three times. Two (4%) Patients and Methods: Between January 1996 cases had minor complications (wound infection) and July 2000, 50 consecutive patients in need of during the the first 30 days. During total follow­ enteral feeding for more than four weeks and up, two wound infections, one buried bumper undergoing PEG with 20 Fr tube by pull syndrome, and one aspiration pneumonia technique were retrospectively evaluated in developed. The last patient underwent JETPEG terms of indication, complications, durability of which was performed by introducing a 10 Fr tube, and mortality. The assessment of wound jejunal tube through the 20 Fr PEG opening. infection was conducted according to the criteria Total follow-up was 41.8 patient-years with a developed by Jain and Shapiro. procedure-related mortality of 0%, 30-day mortality of 8% (4/50), and overall mortality of Results: A PEG was successfully positioned in 32% (16/50). The mortality rate was 63.6% (7/11) 50 of the 52 referred patients (96%). Of the 50 for patients who had brain tumor and 23% (9/39) cases 26 (52%) were men and 24 (48%) women for the rest. with the median age of 63 years (range 2 to 88 years). Indications for PEG placement were Conclusion: PEG is a minimally invasive cerebrovascular accident in 20, brain tumors in gastrostomy method with low morbidity and 11, subarachnoidal hemorrhage in 9, several mortality rates, easy to follow-up, easy to replace neurologic disorders in 5 (2 infections, 2 when clogged. Parkinson’s disease, 1 Alzheimer’s disease), head injury in 3, iatrogenic in 1 (esophago- cutaneous fistula), and hypoxic encephalopathy Key Words: Percutaneous endoscopic in 1. The durability of the tube was a median of gastrostomy, Enteral feeding.

(Accepted 21 August, 2000) Marmara Medical Journal 2000;13(4):212-218

2 1 2 Percutaneous endoscopic gastrostomy: Results of 50 cases

INTRODUCTION PATIENTS AND METHODS

Percutaneous endoscopic gastrostomy (PEG) is Patients: an alternative to traditional surgical methods for Between January 1996 and July 2000, 52 creating a feeding gastrostomy. Since its first patients were referred from Marmara University description by Gauderer and Ponsky (1) in 1980, Institute of Neurologic Sciences to our PEG has become a widely accepted means of endoscopy unit for the placement of a PEG tube. providing enteral alimentation. The most Of the 52 patients, a PEG was successfully common indication for PEG tube placement is to positioned in 50. Patients, or in the case of provide access to a functioning gastrointestinal complete incapacitation, their legally responsible tract for long-term enteral nutrition (2). This term relatives, were informed about the possibilities is usually accepted as a minimum of 4 weeks (3). and risks associated with PEG and written Patients in this group often have neurologic informed consent was obtained from each of disorders and neoplasms of the head, neck, and them. . Other applications of PEG include decompression in patients with malignant The PEG Technique: carcinomatosis and intestinal obstruction, treatment of gastric , recirculation of bile, All patients received antibiotic prophylaxis, 1 g accessing the stomach for endoscopic or surgical ceftriaxone (Rocephin®, Roche) intravenously, instrumentation, administration of unpalatable 30 minutes before PEG placement and weight- medications to pediatric patients, and provision and age-adapted premedication (up to 100 mg of nutrition to patients in various hypercatabolic pethidine, or 5 mg midazolam). Local disinfection states (such as those with Crohn's disease and of the oropharyngeal cavity was not done. The severe burns) (2,4,5). Absolute contraindications patients’ abdomen was thoroughly disinfected to PEG tube placement include a limited life from the costal margin to the navel. expectancy, inability to pass the endoscope through the esophagus, and (6,7). PEG placement was applied using the “pull Relative contraindications include massive method” (16). After preparation of the abdomen, ascites, coagulopathy, , a complete upper gastrointestinal endoscopy peritoneal dialysis, hepatomegaly, large hiatal was performed. The stomach was then , prior subtotal gastrectomy, morbid insufflated, resulting in close opposition of the , anorexia nervosa, and infiltrative or stomach to the abdominal wall. A local anesthetic malignant disorders of the stomach (2,7-9). (Jetocaine®, Adeka) was infiltrated into the skin in the midepigastrium where there was maximum PEG can be performed by the pull method, the transillumination and indentation of the gastric introducer method, or the push method (2). lumen by an examining finger. After performing However, the “pull method” has changed little a 5 mm skin incision, a 16-gauge angiocath was since its original description and remains the inserted into the gastric lumen under direct most popular method of PEG tube placement endoscopic observation. A guidewire was (1,2,10). Major complications of PEG include threaded through the angiocath and grasped peritonitis, hemorrhage, aspiration, peristomal with a snare. After the endoscope and the wound infection, buried bumper syndrome, and snare grasping the guidewire were withdrawn gastrocolic fistula (2,11,12). The morbidity rate is from the mouth at the same time, the tapered end given as approximately 3% in large series of the gastrostomy tube was secured to the (13,14). These complications are uncommon, but guidewire and the PEG tube guidewire unit was when they occur they result in death in 25% of placed in the stomach by pulling the end of the patients. One of the most common the guidewire exiting the skin incision. The complications of PEG is aspiration especially in internal bumper remained in the gastric lumen. patients who have preexisting gastro-esophageal The external bumper was subsequently used reflux disease. JETPEG (introducing a thinner to secure the PEG tube in place. A control jejunal tube distally to Treitz’s ligament through endoscopy was done to be sure of the success of the PEG) has recently become more popularized the procedure and to check for any to avoid this complication (3,4,15). complications.

2 1 3 Rasim Gençosmanoglu, et al

After PEG tube placement, both the patient and Table III. Indications for PEG tube placement. the family members as well were instructed by nurses concerning the system of nutrition and the Cerebrovascular accident 20 use of the feeding pump. Patients were allowed Brain tumor 11 Subarachnoidal hemorrhage 9 to return home once they had mastered the Miscallaneous neurologic disorders 5 implementation of the system. Nutrition was Infectious 2 initiated 4-24 hours after complication-free PEG Parkinson’s disease 2 placement, and the level was increased Alzheimer's disease 1 continuously over several days up to individually Head injury 3 Iatrogenic (esophago-cutaneous fistula) 1 adequate feeding rate, in order to minimize the Hypoxic encephalopathy 1 side effects of tube-based nutrition.

Follow-up and Evaluation of Peristomal Wound Infection: or “safe tract” technique explained below. Of the All the patients were followed-up daily for the first 50 cases, 26 (52%) were men, 24 (48%) women week, then weekly for the first month, and with the median age of 63 years (range 2 to 88 monthly thereafter. Discharged patients were years). The indications for PEG tube placement also followed-up monthly by telephone inquiries. are shown in Table III. The durability of the tube For the first 7 days after PEG tube placement, was a median of 217.5 days (range 9 to 1669 the wound dressing at the site of puncture was days). In 9 (18%) patients the tube was removed renewed daily by the same team and checked for with a median of 158.5 days (range 35 to 427 possible infection. The assessment of wound days) because they were able to return to oral infection was conducted on a daily basis feeding. The tubes were changed in 7 (14%) according to the criteria developed by Jain et al. patients who had tube dysfunction due to (17) and Shapiro et al. (18), as shown in Table I. clogging, porosity or fracture with a median Patients were defined as having minor or major interval of 122 days (range 35 to 1252 days). Of complications according to their daily score those patients, 2 needed replacement tube (Table II). insertion twice, 3 three times. Minor complications (wound infection) developed in 2 (4%) patients during first 30 days. Neither RESULTS hemorrhage nor major complication was seen in all patients. During total follow-up 4 (8%) In 2 of 52 patients (4%), PEG placement was not complications (2 wound infections, 1 buried possible due to failure to achieve transillumination bumper syndrome, and 1 aspiration pneumonia) developed. The patients who had grade ll-lll wound infection were successfully treated by Table I. The scale for the assessment of local wound Infection. close wound care and antibiotics. Buried bumper 0 1 2 3 4 syndrome was recognized incidentally when the patient underwent tube replacement because of Erythema no <5 mm 6-10 mm 11-15 mm >15 mm porosity and clogging. Endoscopic finding was Induration no <10 mm 11-15 mm >15 mm mucosal dimpling to non-visualization of the Exudate no serous sero-sanguineous sanguineous purulent internal bolster. The problem was solved by dissecting the buried appliance from the Table II. Classification of Infectious complications according to abdominal wall under local anesthesia and a 15 the patients' dally score. Fr replacement tube inserted into the stomach Dally score from the same site. The patient who had aspiration pneumonia underwent JETPEG for the Grade I less then 2 solution of the problem. JETPEG was performed Grade II between 3 and 8 by introducing a 10 Fr jejunal tube through the 20 Grade III over 8 or manifest purulent exudate Fr PEG tube, and placing it distally to the Treitz’s Grade IV Peritonitis or had to have PEG removed ligament. Total follow-up was 41.8 patient-years. Procedure related mortality was 0%, 30-day Grade l-ll-lll minor complication mortality 8% (4/50), and overall mortality 32% Grade IV major complication

214 Percutaneous endoscopic gastrostomy: Results of 50 cases

(16/50). The mortality rate was 63.6% (7/11) for However, it became a relative contraindication patients who had brain tumors and 23% (9/39) with pioneering the “safe tract technique” by for the rest. Foutch et al. (33) and verifying in a retrospective series by Stewart and Hagan (34). When transillumination fails, we try the safe tract DISCUSSION technique with gastric mucosal indentation which can be achieved by simple palpation, and then Nutritional support can be quite challenging. The introduce 16-gauge angiocath into the stomach. advantages of enteral nutrition over parenteral This gives the safe way to gastric puncture. nutrition are well known and include lower cost, However, in our series, a PEG tube could not be increased safety, better patient tolerance, positioned in two patients, even though both maintenance of structural gastrointestinal transillumination and the safe tract technique integrity, and increased resistance against were used. In such circumstances, the other infection (19,20). Several advantages of the gastrostomy methods should be chosen instead percutaneous approach compared to operative of insisting on completion of the procedure. gastrostomy are the use of local anesthesia, decreased procedure time, ability to perform the The time interval between the PEG tube procedure in the endoscopy suite, decreased placement and feeding initiation is controversial. cost and earlier feeding after placement (3,21). Some authors recommend 12-24 hours before PEG for enteral nutrition has become widespread initiating the PEG feeding, whereas others prefer and offers distinct advantages with regard to cost 4 hours of rest after PEG tube placement (2,22). and a low level of complications compared with In a randomized prospective trial of early versus parenteral nutrition (22,23). PEG proved to be a delayed feeding after PEG, it has been very safe and reliable method in the scope of suggested that early initiation of PEG feeding is literature. On the other hand, short- and long­ safe, well tolerated, and reduces cost by term prospective studies have demonstrated the decreasing hospital stay (35). We allowed to superiority of a PEG over nasogastric feeding feeding 4-24 hours after PEG placement. tubes in patients with dysphagia due to chronic neurologic disease (3,24-27). Antibiotic prophylaxis is recommended as a general measure in PEG (22). It has been shown The performance of a full diagnostic upper that antibiotic prophylaxis significantly reduces endoscopy is imperative before PEG tube the risk of peristomal wound infection associated placement (2). Patients scheduled for PEG tube with PEG insertion (22). Dormann et al. (36) have placement may have endoscopic findings, such shown that a single dose of ceftriaxone as and gastric outlet administered 30 minutes before PEG obstruction that ultimately lead to major significantly reduces local and systemic infective modifications in management or abandonment of complications. We preferred ceftriaxone as a the procedure. Wolfsen et al. (28) gave this rate prophylactic antibiotic to avoid infectious as high as 36%. However, we did not find such complications. The wound infection rate of the endoscopic findings before starting the present study was as low as 4% when compared procedure in our patients. Although it has been to 5-30% of the studies in the literature (2,36). suggested that if a point of resistance is felt between the 3rd and 6th cm marking on the PEG Buried bumper syndrome occurs when excessive tube or if the internal bumper can be appreciated traction is applied to the PEG tube for an by finger palpation of the abdominal wall, repeat extended period. This results in ischemic endoscopy is not necessary; we preferred to necrosis of the gastric mucosa and migration of perform it in order to avoid any suspicion in the the internal bolster into the gastric or abdominal endoscopist's mind (29,30). Several of the early wall. It usually becomes apparent after 4 months papers describe transillumination of the stomach of use (2). This complication developed in one prior to gastric puncture as being integral to the case in our series, almost one year after the PEG procedure (21,31). Larson et al. (32) describe a tube placement. Treatment requires dissection of failure to transilluminate the stomach as being an the buried appliance from the abdominal wall, absolute contraindication to PEG tube insertion. and the same site can be used for placement of

2 1 5 Rasim Genposmanoglu, et at

a second PEG or replacement tube. To prevent 3. Mathus-Vliegen LMH, Honing H. Percutaneous buried bumper syndrome, it is advisable to allow endoscopic gastrostomy and gastrojejunostomy: for an additional 1.5 cm between the external a critical reappraisal o f patient selection, tube bumper of the PEG tube and the skin to minimize function and the feasibility of nutritional the risk of pressure necrosis (2). support during extended follow-up. Gastrointest Endosc 1999:50:746-754. Patients with and gastric atony, for 4. Scheidbach H, Plorbach T, Groitl fl, instance neurosurgical trauma or with gastric Hohenberger W. Percutaneous endoscopic outlet obstructions, are at risk of aspiration. gastrostomy / jejunostomy (PEG/PEJ) for decompression in the upper gastrointestinal Consistently, factors such as a history of tract. Initial experience with palliative aspiration (pneumonia), reflux , age treatment of gastrointestinal obstruction in older than 70 years, absent swallowing, gag and terminally ill patients with advanced cough reflexes and cerebrovascular accident carcinomas. Surq Endosc 1999:13:1103- emerge from published data as factors 1105. predisposing to aspiration (37,38). Despite many 5. Sheridan R, Schulz J, Ryan C, Ackroyd E, improvements in tube design and size, a Basha G, Tompkins R. Percutaneous tremendous controversy exists as to the use of a endoscopic gastrostomy in burn patients. JETPEG (39). Opponents argue that the Surg Endosc 1999;13:401-402. associated mortality and morbidity of a JETPEG 6. Gutt Cn, Held S, Paolucci V. et al. Experiences tube together with the inability to protect against with percutaneous endoscopic gastrostomy. pulmonary complications and the high incidence World J Surg 1996;20:1006-1009. of jejunal tube failure make its use unjustifiable 7. Marks JM, Ponsky JL. Access routes for (40,41). Those who advocated intestinal feeding enteral nutrition. Gastroenterologist. have observed a substantial reduction in 1995:3:130-139. aspiration pneumonia and have accepted a high 8. Stellato TA. Expanded applications of catheter failure (42). However, it has been shown percutaneous endoscopic gastrostomy. in a recent study that JETPEG may reduce the Gastrointest Clin N Am 1992;2:249-257. aspiration risk in the compliant high-risk patients 9. Sawyer AM, Ghosh S, Eastwood MA. and those with ongoing or previously Satisfactory outcome of percutaneous documented aspiration (3). In the same study, endoscopic gastrostomy in two patients with the catheter failure rate was 26.8% during and portal hypertension. Am J extended follow-up, which was significantly lower Gastroenterol 1995;90:826-828. than the reported 53% (3,40). In our series, we 10. Akkersdijk WL, van Bergeijk JD, van Egmond performed a JETPEG in one patient who had T, et al. Percutaneous endoscopic developed aspiration pneumonia during follow­ gastrostomy (PEG): comparison of push and up. pull methods and evaluation of antibiotic prophylaxis. Endoscopy 1995;27:313-316. To summarize, during the 20 years since its 11. Yamazaki T, Sakai Y, Hatakeyama R, introduction, PEG has remained the benchmark Hoshiyama Y. Colocutaneous fistula after percutaneous endoscopic gastrostomy in a for long-term enteral alimentation against which remnant stomach. Surg Endosc 1999; 13:280- all other such innovative methods must be 282. measured. JETPEG should be reserved for well- 12. Schapiro GD, Edmundowicz SA. Complications selected patients at risk of aspiration. of percutaneous endoscopic gastrostomy. Gastrointest Endosc Clin H Am 1996;6:409- 422. REFERENCES 13. Kohli H, Bloch R. Percutaneous endoscopic gastrostomy: a community hospital 1. Gauderer MWL, Ponsky JL, Izant RJ Jr. experience. Am J Surg 1995;61:191-194. Gastrostomy without laparotomy: A percutaneous technique. J Pediatr Surg 14. M ille r RE, C astlem an B, Lacqua EJ, e t al. 1980;15:872-875. Percutaneous endoscopic gastrostomy: results in 316 patients and review of 2. Vargo JJ, Ponsky JL. Percutaneous literature. Surg Endosc 1989;3:186-190. endoscopic gastrostomy: Clinical applications. Medscape Gastroenterology 2000:2(4).

216 Percutaneous endoscopic gastrostomy: Results of 50 cases

15. Leichus L, PateI R, Johlin F. Percutaneous 27. H orton B, H om er-W ard M, D o n n elly MT, Long endoscopic gastrostomy/jejunostomy RG, H olm es GET. A ra n d o m ize d pro sp e ctive (PEG/PEJ) tube placement: a novel approach. comparison of percutaneous endoscopic Gastrointest Endosc 1997:45:79-81. gastrostomy and nasogastric tube feeding 16. Ponsky JL, Gauderer MWL. Percutaneous after acute dysphagic stroke. BMJ endoscopic gastrostomy: a non-operative 1996;312:13-16. technique for feeding gastrostomy. 28. Wolfsen HC, Rozarek RA, Ball TJ. Value of Gastrointest Endosc 1981; 27:9-11. upper endoscopy preceding percutaneous 17. Ja in HR, Larson DE, S chroeder li, et al. gastrostomy. Am J Gastroenterol Antibiotic prophylaxis for percutaneous 1990;85:249-251. endoscopic gastrostomy. Ann Intern Med 29. Arsenberg J, Cohen L, Lewis BL. Marked 1987;107:824-828. endoscopic gastrostomy tubes permit one- 18. S hapiro M, M unoz 7,A, Tager ID, et al. Risk pass Ponsky technique. Gastrointest Endosc factors for infection at the operative site after 1991;37:552-553. abdominal or vaginal hysterectomy. Pi Engl J 30. Sartorl S, Trevisani L, Hielsen I. Percutaneous Med 1982;307:1661-1666. endoscopic gastrostomy placement using the 19. Lig h t VL, Slezak FA, P orter JA, Gerson LW, pull-through or push-through techniques: is McCord G. Predictive factors for early the second pass o f the endoscope necessary? mortality after percutaneous endoscopic Endoscopy 1996:28:686-688. gastrostomy. Gastrointest Endosc 3 1. StrodeI WE, Lemmer J, Eckhauser F. Early 1995;42:330-335. experience with endoscopic percutaneous 20. McArdle AH, Palmason C, Morency l, Drown gastrostomy. Arch Surg 1983; 118:449-451. RA. A rationale for enteral feeding as the 32. Larson DE, Burton DD, Schroeder RW, et al. preferable route for hyperalimentation. Percutaneous endoscopic gastroenterostomy. Surgery 1981;90:616-623. Indications, success, complications and 21. Russel TR, Drotman M, Horns F. Percutaneous mortality in 314 consecutive patients. gastrostomy. A new simplified and cost- Gastroenterology 1987,-93:48-52. effective technique. Am J Surg 33. Foutch PG, Talbert GA, Waring JP, et al. 1984; 14 8 :1 3 2 -1 3 7 . Percutaneous endoscopic gastrostomy in 22. Gossner L, Keymling J, Hahn EG, Ell C. patients with prior abdominal surgery: virtues Antibiotic prophylaxis in percutaneous of the safe tract. Am J Gastroenterol 1988; endoscopic gastrostomy (PEG): A prospective 83:147-150. randomized clinical trial. Endoscopy 34. Stewart JAD, Hagan P. Failure to 1999,31:119-124. transilluminate the stomach is not an 23. H e ym sfie ld SB, B ethel RA, A nsley JD. E nteral absolute contraindication to PEG insertion. hyperalimentation: an alternative to central Endoscopy 1998:30:621 -622. venous hyperalimentation. Ann Intern Med 35. M cC arter TL, C ondon SC, A g u ila r RC, G ibson 1979;90:63-71. DJ, Chen YR. Randomized prospective trial of 24. Park R11R, Allison MC, Lary J, et al. early versus delayed feeding after Randomised comparison of percutaneous percutaneous endoscopic gastrostomy endoscopic gastrostomy and nasogastric tube placement. Am J Gastroenterol 1998:93:419- feeding in patients with persisting 421. neurological dysphagia. BMJ 1992; 304:1406- 36. Dormann AJ, Wigginghaus B, Risius H. et al. A 1409. single dose of ceftriaxone administered 30 25. Wicks C, Gimbson A, Vlavianas P, et al. minutes before percutaneous endoscopic Assessment of the percutaneous endoscopic gastrostomy significantly reduces local and gastrostomy as part of an systemic infective complications. Am J integrated approach to enteral feeding. Gut Gastroenterol 1999:94:3220-3224. 1992;33:613-616. 37. Patel PH, Thomas E. Risk factors for 26. Panas MZ, Reilly H, Moran A, et al. pneumonia after percutaneous endoscopic Percutaneous endoscopic gastrostomy in a gastrostomy. J Clin Gastroenterol general hospital: prospective evaluation of 1990,12:389-392. indications, outcome, and randomized 38. Elperen EH. Pulmonary aspiration in comparison of the tube designs. Gut hospitalized adults. Hutr Clin Pract 1997; 12:5- 1994;35:1551-1556. 13.

2 1 7 Rasim Gençosmanoglu, et al

39. DeLegge MH, Patrick P, Gibbs K. Percutaneous 41. D iS ario JA, P outch PG, S a n o w ski RA. P oor endoscopie gastrojejunostomy with a tapered results with percutaneous endoscopic tip unweighted jejunal feeding tube: improved jejunostomy. Gastrointest Endosc placement success. Am J Gastroenterol 1990;36:257-260. 1996:91:1130-1 134. 42. Henderson JM, Strodel WE, Gilinsky HH. 40. W olfsen HC, R ozarek RA, B all TJ, Patterson Limitations of percutaneous endoscopic DJ, Botoman VA. Tube dysfunction following jejunostomy. JPEH 1993; 1 7:546-550. percutaneous gastrostomy and jejunostomy. Gastrointest Endosc 1990:36:261 -263.

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