a conserved breast, although the definition of local recurrence does depend on the extent and meticulousness of histopathological examination. Wide excision to ensure clear margins certainly compromises cosmetic results, particularly in small breasts, and the relative importance of cosmesis and local recurrence needs to be determined for each patient. Adequate radiotherapy minimises the risk of local recurrence, and if there is local recurrence survival does not seem to be affected adversely. The effect of a booster dose of radiation in relation to completeness of excision is currently the subject of a clinical trial by the European Organisation for Research and Treatment of Cancer. R D RUBENS Division of Oncology, United Medical and Dental Schools of Guy's and St Thomas's Hospitals, London SEI 9RT
Babies' sleeping position EDITOR,-Like Sarah Stewart-Brown, I am interested in the changes in infants' sleeping position over time.' I have looked at baby care manuals published in Britain since 1700 and have visited the Museum of Childhood in London. I have also looked at pottery babies in cradles in the Fitzwilliam Museum in Cambridge. I have found no evidence of babies sleeping other than on their backs from the fifteenth century to early this century, when they began to be placed on their sides to avoid the stated danger of inhaling vomit. I have not yet found the evidence on which this advice was based. They remained on their sides at least until the late 1940s and early 1950s. The earliest reference to babies being put on their fronts to reduce the risk of inhaling vomit that I have found in a British book on baby care dates from 1961. The first British edition of Spock's Baby and Child Care (1955) states, "It's considered a little safer for a baby to sleep on his back in the first six months...."3 I could not find why Spock thought that sleeping on the back was a little safer, but he thought that sleeping on the front was the alternative. He makes no mention of sleeping on the side. This could be the first suggestion in Britain that sleeping on the front was at least possible if not recommended. Stewart-Brown may be right that the doctors in special care baby units made a ghastly mistake, but the groundwork for such a shift in practice may have been made years earlier. The idea may have crossed the Atlantic by other routes. Recent Advances in Paediatrics (1954) contains a chapter on sudden infant death by the Cambridge pathologist A M Barrett. He quoted an American paper from 1944 and suggested that the higher incidence of death in the prone position was probably due to the higher prevalence of that sleeping position in the United States.4 The stated advantages of babies sleeping on their fronts had all the benefits of being reasonable, logical, and easy to understand that make a health message acceptable. Whatever the origins of the advice, a terrible mistake was made. The recent return to the recommendation that babies should sleep on their backs may be the first decision since the professionalisation of baby care to be based on a reasonably scientifically established principle rather than mere assertion. CHRISTINE HILEY
Department of Paediatrics, Cambridge University School of Clinical Medicine, Addenbrooke's Hospital, Cambridge CB2 2QQ I Stewart-Brown S. Cot death and sleeping position. B.M 1992; 304:1508. (6 June.) 2 Dally A. The A-Z of babies. London: Parrish, 1961. 3 Spock B. Baby and child care. London: Bodley Head, 1955. 4 Barrett AM. Sudden death in infancy. In: Gairdner D, ed. Recent advances in paediatnics. London: J and A Churchill, 1954: 301-20.
BMJ
VOLUME 305
11 JULY 1992
Percutaneous endoscopic gastrostomy feeding EDITOR,-R H R Park and colleagues have highlighted important advantages of percutaneous endoscopic gastrostomy feeding over nasogastric tube feeding.' Neurogenic dysphagia is the predominant indication for inserting percutaneous endoscopic gastrostomy tubes,2 and we have inserted 15 such tubes for neurogenic dysphagia out of a total of 22 tubes inserted over the past 18 months. We report the usefulness of percutaneous endoscopic gastrostomy in a particular subset of patients with neurogenic dysphagia: those who have difficulty in swallowing liquids but are able to swallow some solids. A 62 year old man sustained three episodes of cerebral infarction in 1984, 1988, and 1990. He regained his mobility but had disabling pseudobulbar palsy; he was able to swallow solids slowly but aspirated liquids. Despite spending seven hours a day over his meals he ingested only about 2 9 MJ a day and lost 5 kg in weight. A nasogastric tube was inserted with difficulty, but he found it uncomfortable and a social handicap. It also blocked repeatedly, and he suffered great distress when it was reinserted. Assessment of swallowing by videofluoroscopy showed impaired oral and pharyngeal phases of swallowing. A percutaneous endoscopic gastrostomy tube was inserted in March 1991, and the patient gained 12 kg in weight over the next eight months. He could also enjoy some of the pleasures of normal eating as he could swallow some solids. His energy intake had to be reduced as he was becoming overweight, and he was able to go away on holiday, finding this method of feeding a great social success. A 65 year old woman had a partially resolved right hemiparesis but virtually complete dysphagia after a brainstem stroke in December 1991. Her speech was intact, and videofluoroscopy showed persistent cricopharyngeal dysfunction. A fine bore nasogastric tube could not be passed despite repeated attempts and intervention by specialist ear, nose, and throat staff. A percutaneous endoscopic gastrostomy tube was inserted, and the patient was successfully rehabilitated at home; she considered the unobtrusiveness of the tube to be a great social benefit. After four months her swallowing started to improve: she was able to swallow some solids but remained unable to swallow liquid. In patients with neurogenic dysphagia affecting their ability to swallow liquid the preferred method of giving commercial liquid feeds may be through a percutaneous endoscopic gastrostomy tube; the energy intake should be adjusted according to volitional intake of solids. Patients retain the ability to enjoy the taste of some solids, and in mobile patients this method of feeding offers considerable social and cosmetic benefits. S GHOSH M A EASTWOOD Gastrointestinal Unit, Western General Hospital, Edinburgh EH4 2XU 1 Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ,etal. Randomised comparison of percutaneousendoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ 1992;304:1406-9. (30 May.) 2 Larson DE, Burton DD, Shroeder KW, DiM\agno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications and mortality in 314 consecutivre patients. Gasntrenterology 1987 ;93 :48-52 .
EDITOR,-R H R Park and colleagues report superior short term results in patients with persisting neurological dysphagia managed with percutaneous endoscopic gastrostomy compared with those managed with nasogastric tube feeding.' We agree that percutaneous endoscopic gastrostomy is the most appropriate management in such
patients. We have audited the long term outcome in 49 patients managed by percutaneous endoscopic gastrostomy, using an integrated team approach, in our unit over five years. All patients undergoing percutaneous endoscopic gastrostomy in this hospital are managed by a multidisciplinary home enteral nutrition team, consisting of a gastroenterologist, nutritionist, dietitian, and nurse. We have instituted a seven day training programme for patients and families before discharge and a telephone hotline for patients to the team to help to deal with problems that arise and to provide advice. Forty nine consecutive patients had percutaneous endoscopic gastrostomy. The main diagnoses were cerebrovascular accident (17 patients), motor neurone disease (13), malignancy (nine; mainly oropharyngeal), and others (10). The median duration of feeding was 175 days, and the total experience was 24 patient years. Thirty three patients were able to return home. Four patients died within 30 days, one from aspiration pneumonia two days after insertion of the gastrostomy tube. Of the 45 patients who survived more than 30 days, 22 experienced 41 complications. Twenty one of these complications were resolved without the need for a hospital visit, by a telephone discussion with the home enteral nutrition team and, in some cases, a home visit by the dietitian. The 41 complications observed were mechanical or blockage of the tube (21 cases), gastrointestinal symptoms (12), and local sepsis (eight), none of which was serious. Fifteen late deaths occurred, one due to gastric perforation related to the gastrostomy tube. Our results show that the long term results of percutaneous endoscopic gastrostomy are excellent, that the long term rate of complications is lower than that previously described, and that most complications are minor and do not require a hospital visit. We suggest that patients are best cared for by an integrated team of nutritionists and gastroenterologists. F E MURRAY M A HULL
J RAWLINGS C J HAWKEY S P ALLISON
Departments of Nutrition and Therapeutics, University Hospital, Nottingham NG7 2UH 1 Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ, etal. Randomised comparison ofpercutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with
persisting neurological dysphagia. BMJ 1992;304:1406-9. (30 May.)
EDITOR,-We question the ethics of R H R Park and colleagues' study comparing fine bore nasogastric tube feeding with percutaneous endoscopic gastrostomy feeding and the issue of informed consent. ' Despite Ian Forgacs and colleagues' reservations concerning overenthusiasm in adopting a technological advance,2 percutaneous endoscopic gastrostomy feeding is well established, has few complications, and has been recommended for any patient in whom informed clinical judgment suggests that enteral tube feeding will be required for at least a month.3 To randomise patients at four weeks (when they are presumably still being fed by nasogastric tube) and to inform them that the "potential advantages of gastrotomy tube feeding were untested against the standard method of tube feeding" is not, in our opinion, appropriate. One of us recently reported personal experience confirming the long term safety and efficacy of percutaneous endoscopic gastrostomy feeding and suggesting that, in patients with neurological disorders of swallowing, recovery seems to be enhanced when a nasogastric tube is replaced by a percutaneous endoscopic gastrostomy tube4; the presence of a nasopharyngeal tube is unlikely to help recovery of speech and swallowing. The complications of nasogastric feed-
115
ing (including fine bore tube feeding) have been well documented,5 but nasogastric feeding remains an essential part of nutritional support. Percutaneous endoscopic gastrostomy is a major technical advance in obtaining access for nutritional support, and though its safety is well. established, it is still an invasive procedure and not suitable for all. What has not been well established, and which neither Park and colleagues or Forgacs and colleagues addressed, is the indication for nutritional support in patients with disabling neurological conditions. Research and training in nutritional support are needed to define and outline the risks and benefits of nutritional intervention in such patients. Percutaneous endoscopic gastrostomy feeding is an advance for those who require long term tube feeding, and we would not have considered randomising patients who had already had four weeks of nasogastric tube feeding. We do not see percutaneous endoscopic gastrostomy feeding as a panacea for all, nor will its use "prevent the degrading spectacle of elderly, undernourished patients with their hands bandaged to the side of the bed."2 Let clinicians decide whether nutritional support is appropriate and then institute appropriate treatment using well proved technological advances such as percutaneous endoscopic gastrostomy. B J MORAN
Department of Surgery, Royal South Hants Hospital, Southampton S09 4PE H T KHAWAJA Department of Surgery,
King's College Hospital, London SE5 9RS I Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ, etal. Randomised comparison of percutaneousendoscopic gastrostomy and nasogastric tube feeding in patients with
persisting neurological dysphagia. BMJ 1992;304:1406-9. (30 May.) 2 Forgacs I, Macpherson A, Tibbs C. Percutaneous endoscopic gastrostomy. BMJ 1992;304:1395-6. (30 May.) 3 Moran Bj, Taylor MB, Johnson C. Percutaneous endoscopic gastrostomy: a review. BrJ Surg 1990;77:858-62. 4 Moran BJ, Frost RA. Percutaneous endoscopic gastrostomy in 41 patients: indications and clinical outcome. J R Soc Med
1992;85:320-1. 5 Payne-James J, Silk DBA. Enteral nutrition: background, indications and management. Baillieres Clin Gastroenterol 1988;2:815-47.
intravenous feeding continues to have a role in such circumstances. PETER A ANDREWS MICHELLE WEBB Department of Nephrology, Guy's Hospital, London SE1 9RT 1 Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ, et al. Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. B.j 1992;304: 1406-9. (30 May.) 2 Forgacs I, Macpherson A, Tibbs C. Percutaneous endoscopic gastrostomy. BMJ 1992;304:1395-6. (30 May.)
AUTHORS' REPLY,-It is a pity that B J Moran and H T Khawaja did not read our study more carefully. Patients were randomised to percutaneous endoscopic gastrostomy or nasogastric tube feeding at first contact and had not received enteral nutrition before randomisation. During the minimum four weeks of dysphagia to fulfil the criteria for entry to the study most patients could take a little oral nutrition with intravenous fluid supplements if necessary. Enteral nutrition was considered if the patient's dysphagia progressed or no improvement had occurred after at least four weeks. Patients who were unhappy about either method of tube feeding were treated outside the study. Those patients who failed with nasogastric tube feeding (mean 5 2 days) were immediately switched to percutaneous endoscopic gastrostomy
feeding. Our study did not attempt to address the difficult ethical problem of when to provide nutritional support to patients with severe neurological disability. We have found, however, that the quality of life and rehabilitation of patients have been greatly improved by percutaneous endoscopic gastrostomy feeding. The case described by Peter A Andrews and Michelle Webb illustrates the recognised danger of percutaneous endoscopic gastrostomy feeding in patients receiving continuous ambulatory peritoneal dialysis.' This method of dialysis is one of the few contraindications to insertion of a percutaneous endoscopic gastrostomy tube. RICHARD PARK PETER R MILLS
EDITOR,-We have used percutaneous endoscopic gastrostomy feeding on several occasions with excellent results but wish to add a caveat regarding its use in chronic renal impairment.' 2 A 63 year old woman started continuous ambulatory peritoneal dialysis in 1983 because of chronic renal failure secondary to polycystic kidney disease and atherosclerosis. In April this year the dialysis catheter was removed after persistent culture negative peritonitis and she was transferred to temporary intermittent haemodialysis. She. later developed gangrenous toes secondary to peripheral vascular disease and underwent amputation below the right knee. Because of poor oral intake, weight loss, and a low albumin concentration a percutaneous endoscopic gastrostomy tube was inserted under standard conditions. Six days later the patient developed severe abdominal pain, vomiting, absolute constipation, and peritonitis. At laparotomy the gastrostomy tube was found to lie in the peritoneal cavity, with leakage of enteral feed throughout the abdomen and an intense peritoneal reaction. The patient recovered well after lavage, repair of the gastrostomy wound, and a period of total parenteral nutrition but will be unable to have continuous ambulatory peritoneal dialysis in future. This case shows that percutaneous endoscopic gastrostomy feeding should be used with caution in chronic renal impairment as displacement of the catheter may have serious consequences for future dialysis and, hence, quality of life. Nasogastric or
116
Gartnavel General Hospital, Glasgow G12 OYN 1 Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: indications, limitation, techniques and results. WorldJ
Surg 1989;13:165-70.
EDITOR,-In their editorial Ian Forgacs and colleagues' refer to R H R Park and colleagues' study of percutaneous endoscopic gastrostomy compared with nasogastric tube feeding in patients with persisting neurological dysphagia2 and effectively argue the case for percutaneous endoscopic gastrostomy as opposed to long term nasogastric feeding. They state that "although most gastroenterologists should be able to learn the technique, it is far from universally available." The authors should have mentioned that percutaneous gastrostomy tubes can be easily and quickly inserted as a radiological procedure by one person. The stomach is inflated, usually with a fine bore nasogastric tube, then a needle is inserted percutaneously into the stomach so that a guidewire can be introduced. One or more dilating catheters are advanced over the wire into the stomach and then withdrawn, and a gastrostomy tube is introduced over the wire. The nasogastric tube can then be removed. The success rate and complication rate are similar to those of the endoscopic technique, although the incidence of wound sepsis is believed to be lower as the tube is not contaminated by oral flora before its passage through the abdominal wall.3
The endoscopic technique is indicated when the procedure must be performed at the patient's bedside. The radiological technique is indicated if endoscopic access to the stomach is prevented by an oesophageal tumour, when the radiologist may be able to gain access by using a catheter and shaped guidewire. Except in young children, exposure to radiation is not an issue as the fluoroscopy time can be kept to under five minutes. Tubes placed radiologically can readily be changed, and if reflux proves to be a problem the tube can easily be replaced by one that passes to the
jejunum. In summary, the radiological technique is quick, easily learnt, and, in my view, preferable for most patients to the endoscopic technique. Clinicians should ask their radiological colleagues to provide this service. A H CHAPMAN
Radiology Department, St James's University Hospital, Leeds LS9 7TF I Forgacs I, Macpherson A, Tibbs C. Percutaneous endoscopic gastrostomy. BMJ 1992;304:1395-6. (30 May.) 2 Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ, et al. Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with
persisting neurological dysphagia. BMJ 1992;304:1406-9. (30 May.) 3 Halkier BK, Ho C, Yee ACN. Percutaneous feeding gastrostomy with the Seldinger technique: review of 252 patients. Radiology 1989;171:359-62.
EDITOR, -Several statements and assertions in the editorial on percutaneous endoscopic gastrostomy demand comment.' It is commonly agreed that percutaneous endoscopic gastrostomy is a useful technique that may be appropriate to consider for any patient requiring long term (more than three or four weeks) enteral nutrition, and the study by R H R Parks and colleagues confirms this.2 The subtitle and tone of the editorial, however, are misleading as they seem to imply that nasogastric feeding has no place at all in enteral nutrition. This is of course untrue as most patients given enteral nutrition are fed for less than four weeks,3 4 when percutaneous endoscopic gastrostomy would be inappropriate. The main indication for enteral nutrition is not difficulty in swallowing due to neurological disease-that is the main indication for long term feeding. Medical and surgical patients and patients in intensive therapy units who cannot or will not eat on a short term basis make up most patients requiring enteral nutrition.4 Such patients tolerate fine bore nasoenteral tubes well with minimal complications. In the only randomised controlled trial of operative (surgical) gastrostomy versus percutaneous endoscopic gastrostomy the complication rates were the same, possibly because the operative gastrostomy was done when possible under local anaesthesia.5 That study confirmed that most of the morbidity associated with operative gastrostomy previously reported was probably related to general anaesthesia. Percutaneous endoscopic gastrostomy tubes were cheaper to place than operative gastrostomy tubes. A description of insertion of a percutaneous endoscopic gastrostomy tube is given, but it is not made clear that this represents only one example of several differing techniques. Percutaneous endoscopic gastrostomy has become widely used in the United Kingdom: in 1988 only 6% of centres replying to a national survey on nutrition practices used percutaneous endoscopic gastrostomy, compared with 74% in 1991.46 It is important to remember that percutaneous endoscopic gastrostomy is only one of many useful techniques for long term feeding. For example, radiologists are having considerable success in placing gastrostomy tubes under fluoroscopic control.7 Although most of us don't like the image of elderly patients with their hands bandaged to the
BMJ
VOLUME
305
11 JULY 1992
Babies' sleeping position EDITOR,-Like Sarah Stewart-Brown, I am interested in the changes in infants' sleeping position over time.' I have looked at baby care manuals published in Britain since 1700 and have visited the Museum of Childhood in London. I have also looked at pottery babies in cradles in the Fitzwilliam Museum in Cambridge. I have found no evidence of babies sleeping other than on their backs from the fifteenth century to early this century, when they began to be placed on their sides to avoid the stated danger of inhaling vomit. I have not yet found the evidence on which this advice was based. They remained on their sides at least until the late 1940s and early 1950s. The earliest reference to babies being put on their fronts to reduce the risk of inhaling vomit that I have found in a British book on baby care dates from 1961. The first British edition of Spock's Baby and Child Care (1955) states, "It's considered a little safer for a baby to sleep on his back in the first six months...."3 I could not find why Spock thought that sleeping on the back was a little safer, but he thought that sleeping on the front was the alternative. He makes no mention of sleeping on the side. This could be the first suggestion in Britain that sleeping on the front was at least possible if not recommended. Stewart-Brown may be right that the doctors in special care baby units made a ghastly mistake, but the groundwork for such a shift in practice may have been made years earlier. The idea may have crossed the Atlantic by other routes. Recent Advances in Paediatrics (1954) contains a chapter on sudden infant death by the Cambridge pathologist A M Barrett. He quoted an American paper from 1944 and suggested that the higher incidence of death in the prone position was probably due to the higher prevalence of that sleeping position in the United States.4 The stated advantages of babies sleeping on their fronts had all the benefits of being reasonable, logical, and easy to understand that make a health message acceptable. Whatever the origins of the advice, a terrible mistake was made. The recent return to the recommendation that babies should sleep on their backs may be the first decision since the professionalisation of baby care to be based on a reasonably scientifically established principle rather than mere assertion. CHRISTINE HILEY
Department of Paediatrics, Cambridge University School of Clinical Medicine, Addenbrooke's Hospital, Cambridge CB2 2QQ I Stewart-Brown S. Cot death and sleeping position. B.M 1992; 304:1508. (6 June.) 2 Dally A. The A-Z of babies. London: Parrish, 1961. 3 Spock B. Baby and child care. London: Bodley Head, 1955. 4 Barrett AM. Sudden death in infancy. In: Gairdner D, ed. Recent advances in paediatnics. London: J and A Churchill, 1954: 301-20.
BMJ
VOLUME 305
11 JULY 1992
Percutaneous endoscopic gastrostomy feeding EDITOR,-R H R Park and colleagues have highlighted important advantages of percutaneous endoscopic gastrostomy feeding over nasogastric tube feeding.' Neurogenic dysphagia is the predominant indication for inserting percutaneous endoscopic gastrostomy tubes,2 and we have inserted 15 such tubes for neurogenic dysphagia out of a total of 22 tubes inserted over the past 18 months. We report the usefulness of percutaneous endoscopic gastrostomy in a particular subset of patients with neurogenic dysphagia: those who have difficulty in swallowing liquids but are able to swallow some solids. A 62 year old man sustained three episodes of cerebral infarction in 1984, 1988, and 1990. He regained his mobility but had disabling pseudobulbar palsy; he was able to swallow solids slowly but aspirated liquids. Despite spending seven hours a day over his meals he ingested only about 2 9 MJ a day and lost 5 kg in weight. A nasogastric tube was inserted with difficulty, but he found it uncomfortable and a social handicap. It also blocked repeatedly, and he suffered great distress when it was reinserted. Assessment of swallowing by videofluoroscopy showed impaired oral and pharyngeal phases of swallowing. A percutaneous endoscopic gastrostomy tube was inserted in March 1991, and the patient gained 12 kg in weight over the next eight months. He could also enjoy some of the pleasures of normal eating as he could swallow some solids. His energy intake had to be reduced as he was becoming overweight, and he was able to go away on holiday, finding this method of feeding a great social success. A 65 year old woman had a partially resolved right hemiparesis but virtually complete dysphagia after a brainstem stroke in December 1991. Her speech was intact, and videofluoroscopy showed persistent cricopharyngeal dysfunction. A fine bore nasogastric tube could not be passed despite repeated attempts and intervention by specialist ear, nose, and throat staff. A percutaneous endoscopic gastrostomy tube was inserted, and the patient was successfully rehabilitated at home; she considered the unobtrusiveness of the tube to be a great social benefit. After four months her swallowing started to improve: she was able to swallow some solids but remained unable to swallow liquid. In patients with neurogenic dysphagia affecting their ability to swallow liquid the preferred method of giving commercial liquid feeds may be through a percutaneous endoscopic gastrostomy tube; the energy intake should be adjusted according to volitional intake of solids. Patients retain the ability to enjoy the taste of some solids, and in mobile patients this method of feeding offers considerable social and cosmetic benefits. S GHOSH M A EASTWOOD Gastrointestinal Unit, Western General Hospital, Edinburgh EH4 2XU 1 Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ,etal. Randomised comparison of percutaneousendoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ 1992;304:1406-9. (30 May.) 2 Larson DE, Burton DD, Shroeder KW, DiM\agno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications and mortality in 314 consecutivre patients. Gasntrenterology 1987 ;93 :48-52 .
EDITOR,-R H R Park and colleagues report superior short term results in patients with persisting neurological dysphagia managed with percutaneous endoscopic gastrostomy compared with those managed with nasogastric tube feeding.' We agree that percutaneous endoscopic gastrostomy is the most appropriate management in such
patients. We have audited the long term outcome in 49 patients managed by percutaneous endoscopic gastrostomy, using an integrated team approach, in our unit over five years. All patients undergoing percutaneous endoscopic gastrostomy in this hospital are managed by a multidisciplinary home enteral nutrition team, consisting of a gastroenterologist, nutritionist, dietitian, and nurse. We have instituted a seven day training programme for patients and families before discharge and a telephone hotline for patients to the team to help to deal with problems that arise and to provide advice. Forty nine consecutive patients had percutaneous endoscopic gastrostomy. The main diagnoses were cerebrovascular accident (17 patients), motor neurone disease (13), malignancy (nine; mainly oropharyngeal), and others (10). The median duration of feeding was 175 days, and the total experience was 24 patient years. Thirty three patients were able to return home. Four patients died within 30 days, one from aspiration pneumonia two days after insertion of the gastrostomy tube. Of the 45 patients who survived more than 30 days, 22 experienced 41 complications. Twenty one of these complications were resolved without the need for a hospital visit, by a telephone discussion with the home enteral nutrition team and, in some cases, a home visit by the dietitian. The 41 complications observed were mechanical or blockage of the tube (21 cases), gastrointestinal symptoms (12), and local sepsis (eight), none of which was serious. Fifteen late deaths occurred, one due to gastric perforation related to the gastrostomy tube. Our results show that the long term results of percutaneous endoscopic gastrostomy are excellent, that the long term rate of complications is lower than that previously described, and that most complications are minor and do not require a hospital visit. We suggest that patients are best cared for by an integrated team of nutritionists and gastroenterologists. F E MURRAY M A HULL
J RAWLINGS C J HAWKEY S P ALLISON
Departments of Nutrition and Therapeutics, University Hospital, Nottingham NG7 2UH 1 Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ, etal. Randomised comparison ofpercutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with
persisting neurological dysphagia. BMJ 1992;304:1406-9. (30 May.)
EDITOR,-We question the ethics of R H R Park and colleagues' study comparing fine bore nasogastric tube feeding with percutaneous endoscopic gastrostomy feeding and the issue of informed consent. ' Despite Ian Forgacs and colleagues' reservations concerning overenthusiasm in adopting a technological advance,2 percutaneous endoscopic gastrostomy feeding is well established, has few complications, and has been recommended for any patient in whom informed clinical judgment suggests that enteral tube feeding will be required for at least a month.3 To randomise patients at four weeks (when they are presumably still being fed by nasogastric tube) and to inform them that the "potential advantages of gastrotomy tube feeding were untested against the standard method of tube feeding" is not, in our opinion, appropriate. One of us recently reported personal experience confirming the long term safety and efficacy of percutaneous endoscopic gastrostomy feeding and suggesting that, in patients with neurological disorders of swallowing, recovery seems to be enhanced when a nasogastric tube is replaced by a percutaneous endoscopic gastrostomy tube4; the presence of a nasopharyngeal tube is unlikely to help recovery of speech and swallowing. The complications of nasogastric feed-
115
ing (including fine bore tube feeding) have been well documented,5 but nasogastric feeding remains an essential part of nutritional support. Percutaneous endoscopic gastrostomy is a major technical advance in obtaining access for nutritional support, and though its safety is well. established, it is still an invasive procedure and not suitable for all. What has not been well established, and which neither Park and colleagues or Forgacs and colleagues addressed, is the indication for nutritional support in patients with disabling neurological conditions. Research and training in nutritional support are needed to define and outline the risks and benefits of nutritional intervention in such patients. Percutaneous endoscopic gastrostomy feeding is an advance for those who require long term tube feeding, and we would not have considered randomising patients who had already had four weeks of nasogastric tube feeding. We do not see percutaneous endoscopic gastrostomy feeding as a panacea for all, nor will its use "prevent the degrading spectacle of elderly, undernourished patients with their hands bandaged to the side of the bed."2 Let clinicians decide whether nutritional support is appropriate and then institute appropriate treatment using well proved technological advances such as percutaneous endoscopic gastrostomy. B J MORAN
Department of Surgery, Royal South Hants Hospital, Southampton S09 4PE H T KHAWAJA Department of Surgery,
King's College Hospital, London SE5 9RS I Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ, etal. Randomised comparison of percutaneousendoscopic gastrostomy and nasogastric tube feeding in patients with
persisting neurological dysphagia. BMJ 1992;304:1406-9. (30 May.) 2 Forgacs I, Macpherson A, Tibbs C. Percutaneous endoscopic gastrostomy. BMJ 1992;304:1395-6. (30 May.) 3 Moran Bj, Taylor MB, Johnson C. Percutaneous endoscopic gastrostomy: a review. BrJ Surg 1990;77:858-62. 4 Moran BJ, Frost RA. Percutaneous endoscopic gastrostomy in 41 patients: indications and clinical outcome. J R Soc Med
1992;85:320-1. 5 Payne-James J, Silk DBA. Enteral nutrition: background, indications and management. Baillieres Clin Gastroenterol 1988;2:815-47.
intravenous feeding continues to have a role in such circumstances. PETER A ANDREWS MICHELLE WEBB Department of Nephrology, Guy's Hospital, London SE1 9RT 1 Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ, et al. Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. B.j 1992;304: 1406-9. (30 May.) 2 Forgacs I, Macpherson A, Tibbs C. Percutaneous endoscopic gastrostomy. BMJ 1992;304:1395-6. (30 May.)
AUTHORS' REPLY,-It is a pity that B J Moran and H T Khawaja did not read our study more carefully. Patients were randomised to percutaneous endoscopic gastrostomy or nasogastric tube feeding at first contact and had not received enteral nutrition before randomisation. During the minimum four weeks of dysphagia to fulfil the criteria for entry to the study most patients could take a little oral nutrition with intravenous fluid supplements if necessary. Enteral nutrition was considered if the patient's dysphagia progressed or no improvement had occurred after at least four weeks. Patients who were unhappy about either method of tube feeding were treated outside the study. Those patients who failed with nasogastric tube feeding (mean 5 2 days) were immediately switched to percutaneous endoscopic gastrostomy
feeding. Our study did not attempt to address the difficult ethical problem of when to provide nutritional support to patients with severe neurological disability. We have found, however, that the quality of life and rehabilitation of patients have been greatly improved by percutaneous endoscopic gastrostomy feeding. The case described by Peter A Andrews and Michelle Webb illustrates the recognised danger of percutaneous endoscopic gastrostomy feeding in patients receiving continuous ambulatory peritoneal dialysis.' This method of dialysis is one of the few contraindications to insertion of a percutaneous endoscopic gastrostomy tube. RICHARD PARK PETER R MILLS
EDITOR,-We have used percutaneous endoscopic gastrostomy feeding on several occasions with excellent results but wish to add a caveat regarding its use in chronic renal impairment.' 2 A 63 year old woman started continuous ambulatory peritoneal dialysis in 1983 because of chronic renal failure secondary to polycystic kidney disease and atherosclerosis. In April this year the dialysis catheter was removed after persistent culture negative peritonitis and she was transferred to temporary intermittent haemodialysis. She. later developed gangrenous toes secondary to peripheral vascular disease and underwent amputation below the right knee. Because of poor oral intake, weight loss, and a low albumin concentration a percutaneous endoscopic gastrostomy tube was inserted under standard conditions. Six days later the patient developed severe abdominal pain, vomiting, absolute constipation, and peritonitis. At laparotomy the gastrostomy tube was found to lie in the peritoneal cavity, with leakage of enteral feed throughout the abdomen and an intense peritoneal reaction. The patient recovered well after lavage, repair of the gastrostomy wound, and a period of total parenteral nutrition but will be unable to have continuous ambulatory peritoneal dialysis in future. This case shows that percutaneous endoscopic gastrostomy feeding should be used with caution in chronic renal impairment as displacement of the catheter may have serious consequences for future dialysis and, hence, quality of life. Nasogastric or
116
Gartnavel General Hospital, Glasgow G12 OYN 1 Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: indications, limitation, techniques and results. WorldJ
Surg 1989;13:165-70.
EDITOR,-In their editorial Ian Forgacs and colleagues' refer to R H R Park and colleagues' study of percutaneous endoscopic gastrostomy compared with nasogastric tube feeding in patients with persisting neurological dysphagia2 and effectively argue the case for percutaneous endoscopic gastrostomy as opposed to long term nasogastric feeding. They state that "although most gastroenterologists should be able to learn the technique, it is far from universally available." The authors should have mentioned that percutaneous gastrostomy tubes can be easily and quickly inserted as a radiological procedure by one person. The stomach is inflated, usually with a fine bore nasogastric tube, then a needle is inserted percutaneously into the stomach so that a guidewire can be introduced. One or more dilating catheters are advanced over the wire into the stomach and then withdrawn, and a gastrostomy tube is introduced over the wire. The nasogastric tube can then be removed. The success rate and complication rate are similar to those of the endoscopic technique, although the incidence of wound sepsis is believed to be lower as the tube is not contaminated by oral flora before its passage through the abdominal wall.3
The endoscopic technique is indicated when the procedure must be performed at the patient's bedside. The radiological technique is indicated if endoscopic access to the stomach is prevented by an oesophageal tumour, when the radiologist may be able to gain access by using a catheter and shaped guidewire. Except in young children, exposure to radiation is not an issue as the fluoroscopy time can be kept to under five minutes. Tubes placed radiologically can readily be changed, and if reflux proves to be a problem the tube can easily be replaced by one that passes to the
jejunum. In summary, the radiological technique is quick, easily learnt, and, in my view, preferable for most patients to the endoscopic technique. Clinicians should ask their radiological colleagues to provide this service. A H CHAPMAN
Radiology Department, St James's University Hospital, Leeds LS9 7TF I Forgacs I, Macpherson A, Tibbs C. Percutaneous endoscopic gastrostomy. BMJ 1992;304:1395-6. (30 May.) 2 Park RHR, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJZ, et al. Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with
persisting neurological dysphagia. BMJ 1992;304:1406-9. (30 May.) 3 Halkier BK, Ho C, Yee ACN. Percutaneous feeding gastrostomy with the Seldinger technique: review of 252 patients. Radiology 1989;171:359-62.
EDITOR, -Several statements and assertions in the editorial on percutaneous endoscopic gastrostomy demand comment.' It is commonly agreed that percutaneous endoscopic gastrostomy is a useful technique that may be appropriate to consider for any patient requiring long term (more than three or four weeks) enteral nutrition, and the study by R H R Parks and colleagues confirms this.2 The subtitle and tone of the editorial, however, are misleading as they seem to imply that nasogastric feeding has no place at all in enteral nutrition. This is of course untrue as most patients given enteral nutrition are fed for less than four weeks,3 4 when percutaneous endoscopic gastrostomy would be inappropriate. The main indication for enteral nutrition is not difficulty in swallowing due to neurological disease-that is the main indication for long term feeding. Medical and surgical patients and patients in intensive therapy units who cannot or will not eat on a short term basis make up most patients requiring enteral nutrition.4 Such patients tolerate fine bore nasoenteral tubes well with minimal complications. In the only randomised controlled trial of operative (surgical) gastrostomy versus percutaneous endoscopic gastrostomy the complication rates were the same, possibly because the operative gastrostomy was done when possible under local anaesthesia.5 That study confirmed that most of the morbidity associated with operative gastrostomy previously reported was probably related to general anaesthesia. Percutaneous endoscopic gastrostomy tubes were cheaper to place than operative gastrostomy tubes. A description of insertion of a percutaneous endoscopic gastrostomy tube is given, but it is not made clear that this represents only one example of several differing techniques. Percutaneous endoscopic gastrostomy has become widely used in the United Kingdom: in 1988 only 6% of centres replying to a national survey on nutrition practices used percutaneous endoscopic gastrostomy, compared with 74% in 1991.46 It is important to remember that percutaneous endoscopic gastrostomy is only one of many useful techniques for long term feeding. For example, radiologists are having considerable success in placing gastrostomy tubes under fluoroscopic control.7 Although most of us don't like the image of elderly patients with their hands bandaged to the
BMJ
VOLUME
305
11 JULY 1992
