320
Journal of the Royal Society of Medicine Volume 85 June 1992
Percutaneous endoscopic gastrostomy in 41 patients: indications and clinical outcome
B J Moran MCh FRCSI' R A Frost FRCR2 Departments of 'Surgery and 2Radiology, Salisbury General Infirmary, Fisherton Street, Salisbury SP2 7SX Keywords: endoscopic gastrostomy; indications; outcome
Summary Percutaneous endoscopic gastrostomy, under local anaesthetic, was successfully used in 40 out of 41 patients referred for nutritional support. The indications were neurological disorders of swallowing in 32 patients, head and neck cancer in four patients and supplemental feeding in a miscellaneous group of five patients. The main complications of this procedure were one failed insertion and one peritubal infection. At prospective follow-up, the tube continued to function in 16 patients (seven at home) a mean of 184 days post-insertion (range 6-610 days). In 11 patients resumption of swallowing at a mean of 122 (20-390) days allowed tube removal. Thirteen patients died from their disease, a mean of 96 (12-320) days post-insertion. Patient tolerance and patient and carer satisfaction have been excellent and early results suggest that recovery of speech and swallowing in acute neurological disorders may be enhanced. Percutaneous endoscopic gastrostomy should be performed in all patients referred for a gastrostomy and should be considered in all patients requiring long-term tube feeding. Introduction Percutaneous endoscopic gastrostomy (PEG), under local anaesthetic, was described in 1980 for obtaining access to the stomach in patients requiring long-term tube feeding'. PEG is a safe technique, easy to perform and should be considered in all patients referred for a gastrostomy and in any patient who requires prolonged enteral feeding2-4. The majority of patients who require tube feeding suffer from neurological disorders of swallowing. Many are elderly, often generally unfit, and have, in the past, been condemned to a life of nasogastric intubation. Similarly, younger patients with chronic progressive neurological diseases, or severe head injury, have often not been considered for surgical gastrostomy which has many complications2A. PEG, with minimal complications, should have altered the management of the many patients needing prolonged enteral feeding. However, a recent review suggests that PEG is an underused technique5. Whilst many have noted the feasibility of the technique with very few insertion complications2-4 little has been reported concerning the outcome of patients who had PEG inserted. We report a consecutive series of 41 patients referred for a gastrostomy. We have prospectively followed these patients, looking in particular at the long-term outcome.
Table 1. Indications for percutaneous endoscopic gastrostomy Number Neurological disorders of swallowing Hemiplegia Severe head injury Multiple sclerosis Motor neurone disease Post craniotomy for a cerebellar tumour
Head and neck cancer Carcinoma of the tongue Postlaryngectomy fistula
18 9 2 2 1 2 2
Miscellaneous Severe head and neck burn Scleroderma Abdominal lymphoma Oesophageal stricture Nocturnal hypoglycaemia Total
1 1 1 1 1 41
Patients and methods Forty-one patients, with a mean age of 59 years (range 23-84 years), were referred for nutritional support. The indications are given in Table 1. At referral, all patients had nasogastric tubes and 38 were inpatients. The technique was performed under sedation as for gastroscopy. The gastroscope was passed and the stomach was insufflated with air. The patient was then rolled supine. The tip of the gastroscope was directed anteriorly to transilluminate the abdominal wall. A cannula was inserted percutaneously into the inflated stomach under local anaesthetic. A thread was passed through the cannula, grasped with a biopsy forceps or a snare and the gastroscope, forceps (or snare) and thread were retrieved out the mouth. The thread was tied to the gastrostomy tube and used to pull the tube into place (Figure 1). A number of commercial kits are now available and in this series we used the FRENTA set (Fresenius, Cheshire). Results The procedure was successful in 40 of the 41 patients (98%). The one failure was caused by an inability to transilluminate in a patient with a previous partial gastrectomy. Peritubal infection occurred in one patient prior to routine use of prophylactic antibiotics. Tube blockage occurred in two patients and aspiration pneumonia occurred in one patient.
01410768/92
060320-02/$02.00/0 © 1992
The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 June 1992
Figure 1. The thread has been retrieved out the mouth and is tied to the tapered end of the gastrostomy tube. The abdominal operator pulls the tube down the oesophagus and out through the anterior abdominal walL The flange maintains the end of the tube within the gastric lumen
the number who recovered allowing tube removal. A randomized prospective trial would be required to evaluate whether PEG speeds up recovery of speech and swallowing in those destined to recover. It would seem to be a reasonable hypothesis as the removal of a nasogastric tube ought to facilitate recovery. However, there is currently a reluctance to embark on prolonged enteral feeding in patients with neurological diseases. Despite this reluctance, a recent survey shows that a large number of patients are currently fed, both in hospital and in the community5. Careful selection of candidates for long-term nutritional support is called for. Once the decision has been made all should then be considered for PEG. Surgical gastrostomy as an isolated procedure should now be almost extinct as PEG is safer, easier to perform and both faster and cheaper2 . Surgical gastrostomy may still have a place as part of a procedure whereby the abdomen has been opened in the course of treatment or where there are no endoscopy facilities. PEG has been a major advance in nutritional support. Many patients currently maintained or supplemented by nasogastric tube feeding, often in the community, would benefit from this relatively simple procedure. Long-term follow-up confirms the safety and efficacy of the technique. Acknowledgments: We thank Mr C Johnson, Senior Lecturer, University Surgical Unit, Southampton General Hospital for his contribution.
At prospective follow-up, the tube continued to function in 16 patients (seven at home) a mean of 184 days post-insertion (range 6-610). In 11 patients resumption of swallowing at a mean of 122 (20-390) days allowed endoscopic tube removal. Thirteen patients died from their disease, a mean of 96 (12-320) days post-insertion. Communicative patients and all carers have expressed satisfaction with the gastrostomy. There is a suggestion that recovery of speech and swallowing in acute neurological disorders may be enhanced.
References 1 Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique for feeding gastrostomy. J Pediatr Surg 1980;15:872-5 2 Moran B, Taylor M, Johnson C. Percutaneous endoscopic gastrostomy: a review. Br J Surg 1990;77:858-62 3 Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: indications, limitations, techniques and results. World J Surg 1989;13:165-70 4 Grant JP. Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy. Ann Surg 1988;
207:598-602
Discussion PEG provides reliable long-term access to the gastrointestinal tract with few complications2-4. We found PEG safe and effective for nutritional support in a series of 40 patients. We were surprised with
5 Payne-James J, de Gara C, Grimble G, et aL Nutritional support in hospitals in the United Kingdom. Health Trends 1990;22:9-13
(Accepted 11 October 1991)
321
Journal of the Royal Society of Medicine Volume 85 June 1992
Percutaneous endoscopic gastrostomy in 41 patients: indications and clinical outcome
B J Moran MCh FRCSI' R A Frost FRCR2 Departments of 'Surgery and 2Radiology, Salisbury General Infirmary, Fisherton Street, Salisbury SP2 7SX Keywords: endoscopic gastrostomy; indications; outcome
Summary Percutaneous endoscopic gastrostomy, under local anaesthetic, was successfully used in 40 out of 41 patients referred for nutritional support. The indications were neurological disorders of swallowing in 32 patients, head and neck cancer in four patients and supplemental feeding in a miscellaneous group of five patients. The main complications of this procedure were one failed insertion and one peritubal infection. At prospective follow-up, the tube continued to function in 16 patients (seven at home) a mean of 184 days post-insertion (range 6-610 days). In 11 patients resumption of swallowing at a mean of 122 (20-390) days allowed tube removal. Thirteen patients died from their disease, a mean of 96 (12-320) days post-insertion. Patient tolerance and patient and carer satisfaction have been excellent and early results suggest that recovery of speech and swallowing in acute neurological disorders may be enhanced. Percutaneous endoscopic gastrostomy should be performed in all patients referred for a gastrostomy and should be considered in all patients requiring long-term tube feeding. Introduction Percutaneous endoscopic gastrostomy (PEG), under local anaesthetic, was described in 1980 for obtaining access to the stomach in patients requiring long-term tube feeding'. PEG is a safe technique, easy to perform and should be considered in all patients referred for a gastrostomy and in any patient who requires prolonged enteral feeding2-4. The majority of patients who require tube feeding suffer from neurological disorders of swallowing. Many are elderly, often generally unfit, and have, in the past, been condemned to a life of nasogastric intubation. Similarly, younger patients with chronic progressive neurological diseases, or severe head injury, have often not been considered for surgical gastrostomy which has many complications2A. PEG, with minimal complications, should have altered the management of the many patients needing prolonged enteral feeding. However, a recent review suggests that PEG is an underused technique5. Whilst many have noted the feasibility of the technique with very few insertion complications2-4 little has been reported concerning the outcome of patients who had PEG inserted. We report a consecutive series of 41 patients referred for a gastrostomy. We have prospectively followed these patients, looking in particular at the long-term outcome.
Table 1. Indications for percutaneous endoscopic gastrostomy Number Neurological disorders of swallowing Hemiplegia Severe head injury Multiple sclerosis Motor neurone disease Post craniotomy for a cerebellar tumour
Head and neck cancer Carcinoma of the tongue Postlaryngectomy fistula
18 9 2 2 1 2 2
Miscellaneous Severe head and neck burn Scleroderma Abdominal lymphoma Oesophageal stricture Nocturnal hypoglycaemia Total
1 1 1 1 1 41
Patients and methods Forty-one patients, with a mean age of 59 years (range 23-84 years), were referred for nutritional support. The indications are given in Table 1. At referral, all patients had nasogastric tubes and 38 were inpatients. The technique was performed under sedation as for gastroscopy. The gastroscope was passed and the stomach was insufflated with air. The patient was then rolled supine. The tip of the gastroscope was directed anteriorly to transilluminate the abdominal wall. A cannula was inserted percutaneously into the inflated stomach under local anaesthetic. A thread was passed through the cannula, grasped with a biopsy forceps or a snare and the gastroscope, forceps (or snare) and thread were retrieved out the mouth. The thread was tied to the gastrostomy tube and used to pull the tube into place (Figure 1). A number of commercial kits are now available and in this series we used the FRENTA set (Fresenius, Cheshire). Results The procedure was successful in 40 of the 41 patients (98%). The one failure was caused by an inability to transilluminate in a patient with a previous partial gastrectomy. Peritubal infection occurred in one patient prior to routine use of prophylactic antibiotics. Tube blockage occurred in two patients and aspiration pneumonia occurred in one patient.
01410768/92
060320-02/$02.00/0 © 1992
The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 June 1992
Figure 1. The thread has been retrieved out the mouth and is tied to the tapered end of the gastrostomy tube. The abdominal operator pulls the tube down the oesophagus and out through the anterior abdominal walL The flange maintains the end of the tube within the gastric lumen
the number who recovered allowing tube removal. A randomized prospective trial would be required to evaluate whether PEG speeds up recovery of speech and swallowing in those destined to recover. It would seem to be a reasonable hypothesis as the removal of a nasogastric tube ought to facilitate recovery. However, there is currently a reluctance to embark on prolonged enteral feeding in patients with neurological diseases. Despite this reluctance, a recent survey shows that a large number of patients are currently fed, both in hospital and in the community5. Careful selection of candidates for long-term nutritional support is called for. Once the decision has been made all should then be considered for PEG. Surgical gastrostomy as an isolated procedure should now be almost extinct as PEG is safer, easier to perform and both faster and cheaper2 . Surgical gastrostomy may still have a place as part of a procedure whereby the abdomen has been opened in the course of treatment or where there are no endoscopy facilities. PEG has been a major advance in nutritional support. Many patients currently maintained or supplemented by nasogastric tube feeding, often in the community, would benefit from this relatively simple procedure. Long-term follow-up confirms the safety and efficacy of the technique. Acknowledgments: We thank Mr C Johnson, Senior Lecturer, University Surgical Unit, Southampton General Hospital for his contribution.
At prospective follow-up, the tube continued to function in 16 patients (seven at home) a mean of 184 days post-insertion (range 6-610). In 11 patients resumption of swallowing at a mean of 122 (20-390) days allowed endoscopic tube removal. Thirteen patients died from their disease, a mean of 96 (12-320) days post-insertion. Communicative patients and all carers have expressed satisfaction with the gastrostomy. There is a suggestion that recovery of speech and swallowing in acute neurological disorders may be enhanced.
References 1 Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique for feeding gastrostomy. J Pediatr Surg 1980;15:872-5 2 Moran B, Taylor M, Johnson C. Percutaneous endoscopic gastrostomy: a review. Br J Surg 1990;77:858-62 3 Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: indications, limitations, techniques and results. World J Surg 1989;13:165-70 4 Grant JP. Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy. Ann Surg 1988;
207:598-602
Discussion PEG provides reliable long-term access to the gastrointestinal tract with few complications2-4. We found PEG safe and effective for nutritional support in a series of 40 patients. We were surprised with
5 Payne-James J, de Gara C, Grimble G, et aL Nutritional support in hospitals in the United Kingdom. Health Trends 1990;22:9-13
(Accepted 11 October 1991)
321
