Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Percutaneous endoscopic gastrostomy James DiLorenzo MD, Booker Dalton MD & Paul Miskovitz MD To cite this article: James DiLorenzo MD, Booker Dalton MD & Paul Miskovitz MD (1992) Percutaneous endoscopic gastrostomy, Postgraduate Medicine, 91:1, 277-281, DOI: 10.1080/00325481.1992.11701183 To link to this article: http://dx.doi.org/10.1080/00325481.1992.11701183
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [University of Saskatchewan Library]
Date: 27 June 2016, At: 14:51
--@CME credit article
Percutaneous endoscopic gastrostomy What are the benefits, what are the risks?
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
James DiLorenzo, MD Book.er Dalton, MD Paul Miskovitz, MD
Preview Placing a feeding tube directly into the stomach through a small incision with the aid of endoscopy is often preferable to surgical gastrostomy or the use of a nasogastric tube. However, the benefits, risks, and contraindications have to be carefully considered in the context of each patient's disease, needs, and prognosis. The authors describe patient selection, tube placement, and feeding techniques that minimize the risk of complications.
In the last decade, increased attention has been focused on ways to meet the nutritional needs of elderly, chronically ill, and dysphagic patients. In many institutions, the feeding of patients who have irreversible oropharyngeal dysphagia is discussed at the same time that other medical treatments (eg, use of antibiotics), cardiopulmonary resuscitative status, and candidacy for intensive care unit-based therapy are being decided. For dysphagic patients with intaa gastrointestinal function, use of nasogastric or nasoenteric feeding tubes, performance of surgical gastrostomy, and insertion of a percutaneous endoscopic gastrostomy and/or jejunostomy tube must be considered. 1 Small-caliber nasogastric and nasoenteric feeding tubes and commercially prepared, nutritionally complete feeding substrates have been welcome developments. Their use enhances long-term feeding (for weeks to months) of both hospitalized and ambulatory patients and causes minimal risk and tolerable discomfon if used in the
shon term. However, use of this type of nutritional suppon is limited in patients requiring extended care because of nasal and oral discomfon, the risk oflaryngeal penetration and tracheobronchial aspiration of the feeding solution (attributable in pan to compromise of the lower and upper esophageal sphinaers by the feeding tube), the tendency of small-caliber tubes to become occluded, and the undesirable appearance of patients outfitred with one of these devices. Surgical (Stamm) gastrostomy and jejunostomy have traditionally been used to gain access to the gastroinrestinal traa to meet the longterm nutritional needs of seleaed patients. However, as with any surgical procedure, these two operations are not risk-free; complications of general anesthesia and wound infections may develop. Also, consulting surgeons are ofi:en reluaant to perform these operations on severely ill or chronically debilitated patients (some of whom are anticipated to have a limited life expeaancy); ironically, these are of-
VOL 91/NO 1/JANUARY 1992/POSTGRADUATE MEDICINE • PERCUTANEOUS GASTROSTOMY
ten the patients who need the procedures. Gauderer and associat~ were the first to repon placing a feeding tube using percutaneous endoscopic gastrostomy and local anesthesia. Enthusiastic reports of modifications of and improvements in the techniqu~·4 have followed. This procedure has been widely embraced by the medical community as safe, cost-effective, and well tolerated by patients. Less well known is the faa that the medical literature is replete with case reports of complications attributable to percutaneous endoscopic gastrostomy. Also, rigorous comparison of percutaneous endoscopic gastrostomy and surgical gastrostomy in terms of optimal criteria for patient selection, avoidance of complications, and benefit has been difficult.
Patient selection The most common indication for percutaneous endoscopic gastrostomy is the presence of a neurologic disorder that results in impairment of deglutition (eg, cerebrovascular accident causing chronic aspiration) or alteration in consciousness to such a degree that patients cannot eat. The second most common indication is a pathologic condition of the oropharynx that affeas swallowing (ie, neoplasm of the head or neck). On rare occasions, percutaneous endoscopic gastrostomy may be of value for purposes other than feeding. For example, dual percutacontinued 277
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
The most common indication for percutaneous endoscopic gastrostomy is a neurologic disorder that impairs deglutition or alters consciousness.
Table 1. Contraindications to percutaneous endoscopic gastrostomy
Cutaneous edema involving anterior abdominal wall Massive ascites Need for peritoneal dialysis Portal hypertension (moderate or severe) with esophageal, gastric, or duodenal varices or portal gastropathy Sepsis Terminal illness and limited life expectancy Total or high-grade esophageal obstruction Unanticipated significant gastric pathologic condition discovered on endoscopy 6 Uncorrectable severe coagulation disorder Unstable cardiac arrhythmia Wound infection involving anterior abdominal wall
neous endoscopic gastrostomies may be used to anchor the stomach to the anterior abdominal wall in patients with recurrent gastric volvulus. The procedure may also be used to eliminate the need for chronic nasogastric suction in patients with abdominal carcinomatosis and bowel obstruction (as is sometimes seen with advanced ovarian carcinoma). The procedure, like conventional surgical gastrostomy, is generally contraindicated in any terminally ill patient with limited life expectancy.' It is also contraindicated when any of several other conditions, listed in table 1, is present. A past history of abdominal surgery does not preclude percutaneous endoscopic gastrostomy in an otherwise suitable candidate. The procedure has been performed without increasing morbidity rates in patients with a neurologic disorder 278
who have a ventriculoperitoneal shunt. In appropriately selected patients, the success rate of the procedure is universally high. 7
Placement technique
Patients are given standard topical oropharyngeal and intravenous sedative-analgesic medication in preparation for the procedure. Many clinicians advocate antibiotic prophylaxis during the procedure. 8 First, complete esophagogastroduodenoscopy, including retroflexed viewing of the cardia with a forward-viewing adult- or pediatric-sized gastroscope, is performed. Next, a sterile, controlled needle puncture of the insufflated stomach is completed under endoscopic guidance. 9 ' 10 A catheter is passed through the puncture site, and a guidewire is threaded through the catheter and into the stomach.
The endoscopist catches the guidewire with a grasping device, preferably an endoscopic retrieval baskd 1 because of its three-dimensional spatial configuration. A percutaneous endoscopic gastrostomy tube is then pulled, over the guidewire, through the oropharynx and esophagus, into the stomach, and out through the puncture wound. Newer videoendoscopic systems greatly facilitate coordination between the endoscopist, assistant, and nurse during the procedure. Proper functioning of the tube is confirmed endoscopically. A small bolus of sterile water is administered, and when the percutaneous endoscopic gastrostomy tube is functioning properly, the bolus is seen to flow through it and into the stomach. The tube is secured to the anterior abdominal wall with a retainer and/or sutures. The anticipated goal is that eventually a mature, stable fistula tract will form from the cutaneous aspect of the anterior abdominal wall to the mucosal aspect of the anterior gastric wall. After a 24-hour wait, during which the patient is observed for signs of change in clinical status (eg, fever, tachypnea, tachycardia, changes in abdominal or respiratory findings), feedings are usually initiated at reduced concentration and volume. Conversion to a percutaneous endoscopic jejunostomy tube may be accomplished with an adapter. This conversion may be appropri-
PERCUTANEOUS GASTROSTOMY • VOL 91/NO 1/JANUARY 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
Hydration status should be regularly assessed in patients receiving long-term enteral feedings.
ate in patients with docrnnented severe gastroesophageal reflux or known gastroparesis.
Feeding technique Before or shortly after placement of a percutaneous endoscopic gastrostomy tube, a dietitian should formally assess the patient's nutritional status and make specific formula recommendations. Feeding should be started with a commercially available formula chosen on the basis of the patient's specific needs. Available formulas include milkbased products; lactose-free products; elemental formulas; special formulas for patients with renal, pulmonary, and/or hepatic disease; and modular formulas that may be combined to meet unusual nutritional requirements. 12 High-fiber formulas are also available for patients who require extra dietary bulk to prevent constipation or watery diarrhea. Vitamin elixirs may be added when needed. Feedings may be administered by a nrnnber of techniques. 13 Boluses of250 to 600 mL of formula may be delivered by syringe into the stomach several times daily. Alternatively, formula may be infused by gravity drip (250 to 600 mL over 30 to 90 minutes) from an enteral feeding bag. In patients who cannot tolerate bolus or gravity drip feedings, an enteral prnnp may be used and formula infused continuously at a predetermined rate or cyclically (usually overnight) for 6 hours or more. Use of an en-
Table 2. Complications of percutaneous endoscopic gastrostomy Minor Hematoma at gastrostomy site Minor pulmonary aspiration Occlusion of tube lumen (necessitating replacement of tube through established, mature stoma) Persistent stomal leakage Transient fever Transient ileus Transient pneumoperitoneum Transient superficial wound infection Major Gastrocolic fistula Hemorrhage of upper gastrointestinal tract Migration of catheter Necrotizing fasciitis Peritonitis Respiratory complications of anesthesia (rare) Serious (often delayed) wound infection (rare) Tracheobronchial aspiration with severe pneumonia
teral feeding prnnp is mandatory in patients who have a percutaneous endoscopic jejunostomy tube. Although the precise method of initiating feeding is controversial, a conservative approach is to begin with half-strength formula diluted with water and progress to full strength as tolerated and necessary. The total amount of formula given per 24-hour period is determined by the estimated caloric and fluid needs of the patient. Patients receiving enteral feedings for a long period must be medically monitored. 14 Their hydration status (ie, mucous membrane moisture, tissue turgor, orthostatic blood pressure changes, urine output) should be regularly
VOL 91/NO 1/JANUARY 1992/POSTGRADUATE MEDICINE • PERCUTANEOUS GASTROSTOMY
assessed and may be corrected either by changing to a formula with a different water content or by changing the volrnne and/or frequency of fluid flushes of the percutaneous endoscopic gastrostomy tube. The patient's weight and bowel and bladder habits should be charted regularly, and routine laboratory blood evaluation should be performed several times per year. In patients with irregular bowel habits, periodic digital rectal examinations may be necessary to exclude the possibility of fecal impaction. Oral hygiene should be provided daily. The gastrostomy site should be inspected daily for erythema, swelling, and discharge; cleansed continued 279
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
If diarrhea persists and weight loss occurs in a patient receiving enteral feedings, evaluation for maldigestion and malabsorption should be considered.
be removed easily endoscopically, and the gastrocutaneous fistula usually closes spontaneously within 7 to 10 days. This is important because up to 14% of patients regain their ability to eat, making the gastrostomy tube unnecessary.4
Feeding complications
James Dilorenzo, MD Booker Dalton, MD Paul Miskovitz, MD Drs Dilorenzo (right) and Dalton (left) are senior clinical fellows in digestive diseases and Dr Miskovitz (middle) is associate professor of clinical medicine, Cornell University Medical College, New York.
with hydrogen peroxide; and dressed with a sterile bandage. Bacitracin ointment (Baciguent) may be applied regularly to the surrounding skin.
Tube-placement complications Placement of a percutaneous endoscopic gastrostomy tube may be accompanied by a variety of complications (table 2). The overall incidence is reported in the medicalliterature4 as 13% for minor complications and 3% for major complications. This incidence may be minimized, to some extent, by appropriate patient selection and proper care of the percutaneous en280
doscopic gastrostomy site after the institution of feedings. The mortality rate for the procedure is 1%.4The 30-d.ay overall mortality rate among patients who undergo the procedure is about 16%4; the majority of deaths are related to the underlying disease. The incidence and nature of complications are similar between percutaneous endoscopic gastrostomy and the standard Stamm gastrostomy. However, the former avoids the risks of general anesthesia, makes laparotomy unnecessary, can be performed at the bedside, and is less expensive. Also, a percutaneous endoscopic gastrostomy tube can
Diarrhea and dehydration are chronic and common problems in tube-fed patients. The exact cause of enteral feeding-associated diarrhea is unclear, but the condition can usually be managed by a few simple measures. Obvious causes, such as use of magnesium-containing antacids or stool softeners, should be sought and corrected. The rate of administration, volume, and water content of feedings should be reviewed. Digital rectal examination should be performed to exclude the possibility of fecal impaction with "overflow'' diarrhea. Stool specimens should be assessed for bacterial pathogens (eg, Clostridium di.fficile), ova, and parasites. Once all of these causes have been excluded, diarrhea may be treated empirically and symptomatically with such standard antimotility agents as deodorized tincture of opium and loperarnide hydrochloride (Irnodium). As previously mentioned, bulk-containing formulas may also be used to help control diarrhea. If diarrhea persists despite these measures, particularly if weight loss occurs despite adequate caloric intake, more
PERCUTANEOUS GASTROSTOMY • VOL 91/NO 1/JANUARY 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
definitive evaluation (eg, for maldigestion and malabsorption) should be considered. Electrolyte derangements should also be sought. Laryngeal penetration and pulmonary aspiration are more serious problems of enteral feeding. Standard preventive measures include elevating the trunk to at least 30° from horiwntal during feeding, monitoring gastric residual before infusing formula, and giving a prokinetic motility agent (eg, metoclopramide [Maxolon, Octamide, Reglan]) to facilitate gastric emptying. Use of a percutaneous endoscopic jejunostomy tube to infuse formula into the small bowel has been advocated as an antireflux measure; however, recent research questions the long-term effectiveness of this technique. 15 Maintenance of tube patency and tract integrity may be a problem with percutaneous endoscopic gastrostomy. The interior of the tube should be cleansed by flushing before and after feedings. Many fluids have been suggested for this purpose, but water is usually sufficient. Instillation of medications in the form of crushed pills, capsules, or highly viscous liquids through the tube should be avoided. Longacting oral medications whose timed-release characteristics depend on the pill matrix should never be crushed and given through a percutaneous endoscopic gastrostomy tube.
Summary One way to nutritionally support patients who aumot swallow is to administer fonnula directly into the stomach. Placing a gastrostomy tube percutaneously using endoscopy avoids the risks of general anesthesia and wound healing that accompany surgical gastrostomy. Although certain conditions (eg, sepsis, coagulation disorder, portal hypertension) are contraindications to the procedure, it can be done in patients who have had previous abdominal surgery and in those with severe illness.
A commercially available feeding fonnula is used. The type chosen and the frequency of ad-
ministration are based on the patient's specific needs. With regular medical monitoring and daily care of the gastrostomy site, appropriately selected patients may be safely maintained with enteral feeding for months. An advantage of the percutaneously inserted tube is that it is easily removed when the patient regains the ability to eat, and the fistula
heals rapidly. IVt'l
-®See
Earn credit on this article.
CME Quiz.
Address for correspondence: Paul Miskovitz, MD, Cornell University Medical College, 1300 York Ave, Box 422, New York, NY 10021-4885.
References I. Groher ME, Bukaunan R. The prevalence of swallowing disorders in two reaching hospitals. Dysphagia 1986; 1:3-6 2. Gauderer MW; Ponsky JL, lzant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediarr Sutg 1980;15(6): 872-5 3. Gauderer MW; Ponsky JL A simplified technique for constructing a tube feeding gastrostomy. Sutg Gynecol Obsrer 1981;152(1):83-5 4. Ponsky JL, Gauderer Mw. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gasrrointest Enclose 1981;27(1):9-11 5. Miskovitz P, Weg A, Groher M. Must dysphagic patients always receive food and water? Dysphagia 1988;2(3): 125-6 6. Miskovitz PF, Chen JP. Percutaneous endoscopic gastrostomy: incidence and significance of incidental endoscopic findings. Gasrrointesr Endose 1989;35(2): 155-6 7. Cantor MC, Miskovitz PF. Percutaneous endoscopic gastrostomy following ventriculoperitoneal shunting for increased intracranial pressure: preliminary report. Gasrrointesr Enclose 1988; 34(2):202-3
VOL 91/NO 1/JANUARY 1992/POSTGRADUATE MEDICINE • PERCUTANEOUS GASTROSTOMY
8. Jonas SK, Neimark S, Panwalker AP. Effect of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. AmJ Gastroenterol1985; 80(6):438-41 9. Weg A, Miskovitz PF. Percutaneous endoscopic gastrostomy: a critical reappraisal. Dysphagia 1987;1:227-31 10. Cantor M, Miskovitz PF. Percutaneous endoscopic gastrostomy. Infect Surg 1988;7(10): 643-52 11. Weg Al., Miskovitz PF. Percutaneous endoscopic gastrostomy: spiral retrieval basket versus snare technique. Gasrrointest Enclose 1987;33(2): 175 12. Ford DB, Bergerson SI.., Henderson P, et al. Establishing an enteral product formulary. J Am Diet Assoc 1989;89(5):681-3 13. McCrae JA, Hall NH. Current practices for home enteral nutrition. JAm Diet Assoc 1989; 89(2):233-40 14. American Dietetic Association. Nutrition monitoring of rhe home parenteral and enteral patient. JAm Diet Assoc 1989;89(2):263-5 15. DiSario JA, Foutch PG, Sanowski RA. Poor results with percutaneous endoscopic jejunostomy. Gasrrointest Enclose 1990;36(3):257-60
281
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Percutaneous endoscopic gastrostomy James DiLorenzo MD, Booker Dalton MD & Paul Miskovitz MD To cite this article: James DiLorenzo MD, Booker Dalton MD & Paul Miskovitz MD (1992) Percutaneous endoscopic gastrostomy, Postgraduate Medicine, 91:1, 277-281, DOI: 10.1080/00325481.1992.11701183 To link to this article: http://dx.doi.org/10.1080/00325481.1992.11701183
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [University of Saskatchewan Library]
Date: 27 June 2016, At: 14:51
--@CME credit article
Percutaneous endoscopic gastrostomy What are the benefits, what are the risks?
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
James DiLorenzo, MD Book.er Dalton, MD Paul Miskovitz, MD
Preview Placing a feeding tube directly into the stomach through a small incision with the aid of endoscopy is often preferable to surgical gastrostomy or the use of a nasogastric tube. However, the benefits, risks, and contraindications have to be carefully considered in the context of each patient's disease, needs, and prognosis. The authors describe patient selection, tube placement, and feeding techniques that minimize the risk of complications.
In the last decade, increased attention has been focused on ways to meet the nutritional needs of elderly, chronically ill, and dysphagic patients. In many institutions, the feeding of patients who have irreversible oropharyngeal dysphagia is discussed at the same time that other medical treatments (eg, use of antibiotics), cardiopulmonary resuscitative status, and candidacy for intensive care unit-based therapy are being decided. For dysphagic patients with intaa gastrointestinal function, use of nasogastric or nasoenteric feeding tubes, performance of surgical gastrostomy, and insertion of a percutaneous endoscopic gastrostomy and/or jejunostomy tube must be considered. 1 Small-caliber nasogastric and nasoenteric feeding tubes and commercially prepared, nutritionally complete feeding substrates have been welcome developments. Their use enhances long-term feeding (for weeks to months) of both hospitalized and ambulatory patients and causes minimal risk and tolerable discomfon if used in the
shon term. However, use of this type of nutritional suppon is limited in patients requiring extended care because of nasal and oral discomfon, the risk oflaryngeal penetration and tracheobronchial aspiration of the feeding solution (attributable in pan to compromise of the lower and upper esophageal sphinaers by the feeding tube), the tendency of small-caliber tubes to become occluded, and the undesirable appearance of patients outfitred with one of these devices. Surgical (Stamm) gastrostomy and jejunostomy have traditionally been used to gain access to the gastroinrestinal traa to meet the longterm nutritional needs of seleaed patients. However, as with any surgical procedure, these two operations are not risk-free; complications of general anesthesia and wound infections may develop. Also, consulting surgeons are ofi:en reluaant to perform these operations on severely ill or chronically debilitated patients (some of whom are anticipated to have a limited life expeaancy); ironically, these are of-
VOL 91/NO 1/JANUARY 1992/POSTGRADUATE MEDICINE • PERCUTANEOUS GASTROSTOMY
ten the patients who need the procedures. Gauderer and associat~ were the first to repon placing a feeding tube using percutaneous endoscopic gastrostomy and local anesthesia. Enthusiastic reports of modifications of and improvements in the techniqu~·4 have followed. This procedure has been widely embraced by the medical community as safe, cost-effective, and well tolerated by patients. Less well known is the faa that the medical literature is replete with case reports of complications attributable to percutaneous endoscopic gastrostomy. Also, rigorous comparison of percutaneous endoscopic gastrostomy and surgical gastrostomy in terms of optimal criteria for patient selection, avoidance of complications, and benefit has been difficult.
Patient selection The most common indication for percutaneous endoscopic gastrostomy is the presence of a neurologic disorder that results in impairment of deglutition (eg, cerebrovascular accident causing chronic aspiration) or alteration in consciousness to such a degree that patients cannot eat. The second most common indication is a pathologic condition of the oropharynx that affeas swallowing (ie, neoplasm of the head or neck). On rare occasions, percutaneous endoscopic gastrostomy may be of value for purposes other than feeding. For example, dual percutacontinued 277
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
The most common indication for percutaneous endoscopic gastrostomy is a neurologic disorder that impairs deglutition or alters consciousness.
Table 1. Contraindications to percutaneous endoscopic gastrostomy
Cutaneous edema involving anterior abdominal wall Massive ascites Need for peritoneal dialysis Portal hypertension (moderate or severe) with esophageal, gastric, or duodenal varices or portal gastropathy Sepsis Terminal illness and limited life expectancy Total or high-grade esophageal obstruction Unanticipated significant gastric pathologic condition discovered on endoscopy 6 Uncorrectable severe coagulation disorder Unstable cardiac arrhythmia Wound infection involving anterior abdominal wall
neous endoscopic gastrostomies may be used to anchor the stomach to the anterior abdominal wall in patients with recurrent gastric volvulus. The procedure may also be used to eliminate the need for chronic nasogastric suction in patients with abdominal carcinomatosis and bowel obstruction (as is sometimes seen with advanced ovarian carcinoma). The procedure, like conventional surgical gastrostomy, is generally contraindicated in any terminally ill patient with limited life expectancy.' It is also contraindicated when any of several other conditions, listed in table 1, is present. A past history of abdominal surgery does not preclude percutaneous endoscopic gastrostomy in an otherwise suitable candidate. The procedure has been performed without increasing morbidity rates in patients with a neurologic disorder 278
who have a ventriculoperitoneal shunt. In appropriately selected patients, the success rate of the procedure is universally high. 7
Placement technique
Patients are given standard topical oropharyngeal and intravenous sedative-analgesic medication in preparation for the procedure. Many clinicians advocate antibiotic prophylaxis during the procedure. 8 First, complete esophagogastroduodenoscopy, including retroflexed viewing of the cardia with a forward-viewing adult- or pediatric-sized gastroscope, is performed. Next, a sterile, controlled needle puncture of the insufflated stomach is completed under endoscopic guidance. 9 ' 10 A catheter is passed through the puncture site, and a guidewire is threaded through the catheter and into the stomach.
The endoscopist catches the guidewire with a grasping device, preferably an endoscopic retrieval baskd 1 because of its three-dimensional spatial configuration. A percutaneous endoscopic gastrostomy tube is then pulled, over the guidewire, through the oropharynx and esophagus, into the stomach, and out through the puncture wound. Newer videoendoscopic systems greatly facilitate coordination between the endoscopist, assistant, and nurse during the procedure. Proper functioning of the tube is confirmed endoscopically. A small bolus of sterile water is administered, and when the percutaneous endoscopic gastrostomy tube is functioning properly, the bolus is seen to flow through it and into the stomach. The tube is secured to the anterior abdominal wall with a retainer and/or sutures. The anticipated goal is that eventually a mature, stable fistula tract will form from the cutaneous aspect of the anterior abdominal wall to the mucosal aspect of the anterior gastric wall. After a 24-hour wait, during which the patient is observed for signs of change in clinical status (eg, fever, tachypnea, tachycardia, changes in abdominal or respiratory findings), feedings are usually initiated at reduced concentration and volume. Conversion to a percutaneous endoscopic jejunostomy tube may be accomplished with an adapter. This conversion may be appropri-
PERCUTANEOUS GASTROSTOMY • VOL 91/NO 1/JANUARY 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
Hydration status should be regularly assessed in patients receiving long-term enteral feedings.
ate in patients with docrnnented severe gastroesophageal reflux or known gastroparesis.
Feeding technique Before or shortly after placement of a percutaneous endoscopic gastrostomy tube, a dietitian should formally assess the patient's nutritional status and make specific formula recommendations. Feeding should be started with a commercially available formula chosen on the basis of the patient's specific needs. Available formulas include milkbased products; lactose-free products; elemental formulas; special formulas for patients with renal, pulmonary, and/or hepatic disease; and modular formulas that may be combined to meet unusual nutritional requirements. 12 High-fiber formulas are also available for patients who require extra dietary bulk to prevent constipation or watery diarrhea. Vitamin elixirs may be added when needed. Feedings may be administered by a nrnnber of techniques. 13 Boluses of250 to 600 mL of formula may be delivered by syringe into the stomach several times daily. Alternatively, formula may be infused by gravity drip (250 to 600 mL over 30 to 90 minutes) from an enteral feeding bag. In patients who cannot tolerate bolus or gravity drip feedings, an enteral prnnp may be used and formula infused continuously at a predetermined rate or cyclically (usually overnight) for 6 hours or more. Use of an en-
Table 2. Complications of percutaneous endoscopic gastrostomy Minor Hematoma at gastrostomy site Minor pulmonary aspiration Occlusion of tube lumen (necessitating replacement of tube through established, mature stoma) Persistent stomal leakage Transient fever Transient ileus Transient pneumoperitoneum Transient superficial wound infection Major Gastrocolic fistula Hemorrhage of upper gastrointestinal tract Migration of catheter Necrotizing fasciitis Peritonitis Respiratory complications of anesthesia (rare) Serious (often delayed) wound infection (rare) Tracheobronchial aspiration with severe pneumonia
teral feeding prnnp is mandatory in patients who have a percutaneous endoscopic jejunostomy tube. Although the precise method of initiating feeding is controversial, a conservative approach is to begin with half-strength formula diluted with water and progress to full strength as tolerated and necessary. The total amount of formula given per 24-hour period is determined by the estimated caloric and fluid needs of the patient. Patients receiving enteral feedings for a long period must be medically monitored. 14 Their hydration status (ie, mucous membrane moisture, tissue turgor, orthostatic blood pressure changes, urine output) should be regularly
VOL 91/NO 1/JANUARY 1992/POSTGRADUATE MEDICINE • PERCUTANEOUS GASTROSTOMY
assessed and may be corrected either by changing to a formula with a different water content or by changing the volrnne and/or frequency of fluid flushes of the percutaneous endoscopic gastrostomy tube. The patient's weight and bowel and bladder habits should be charted regularly, and routine laboratory blood evaluation should be performed several times per year. In patients with irregular bowel habits, periodic digital rectal examinations may be necessary to exclude the possibility of fecal impaction. Oral hygiene should be provided daily. The gastrostomy site should be inspected daily for erythema, swelling, and discharge; cleansed continued 279
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
If diarrhea persists and weight loss occurs in a patient receiving enteral feedings, evaluation for maldigestion and malabsorption should be considered.
be removed easily endoscopically, and the gastrocutaneous fistula usually closes spontaneously within 7 to 10 days. This is important because up to 14% of patients regain their ability to eat, making the gastrostomy tube unnecessary.4
Feeding complications
James Dilorenzo, MD Booker Dalton, MD Paul Miskovitz, MD Drs Dilorenzo (right) and Dalton (left) are senior clinical fellows in digestive diseases and Dr Miskovitz (middle) is associate professor of clinical medicine, Cornell University Medical College, New York.
with hydrogen peroxide; and dressed with a sterile bandage. Bacitracin ointment (Baciguent) may be applied regularly to the surrounding skin.
Tube-placement complications Placement of a percutaneous endoscopic gastrostomy tube may be accompanied by a variety of complications (table 2). The overall incidence is reported in the medicalliterature4 as 13% for minor complications and 3% for major complications. This incidence may be minimized, to some extent, by appropriate patient selection and proper care of the percutaneous en280
doscopic gastrostomy site after the institution of feedings. The mortality rate for the procedure is 1%.4The 30-d.ay overall mortality rate among patients who undergo the procedure is about 16%4; the majority of deaths are related to the underlying disease. The incidence and nature of complications are similar between percutaneous endoscopic gastrostomy and the standard Stamm gastrostomy. However, the former avoids the risks of general anesthesia, makes laparotomy unnecessary, can be performed at the bedside, and is less expensive. Also, a percutaneous endoscopic gastrostomy tube can
Diarrhea and dehydration are chronic and common problems in tube-fed patients. The exact cause of enteral feeding-associated diarrhea is unclear, but the condition can usually be managed by a few simple measures. Obvious causes, such as use of magnesium-containing antacids or stool softeners, should be sought and corrected. The rate of administration, volume, and water content of feedings should be reviewed. Digital rectal examination should be performed to exclude the possibility of fecal impaction with "overflow'' diarrhea. Stool specimens should be assessed for bacterial pathogens (eg, Clostridium di.fficile), ova, and parasites. Once all of these causes have been excluded, diarrhea may be treated empirically and symptomatically with such standard antimotility agents as deodorized tincture of opium and loperarnide hydrochloride (Irnodium). As previously mentioned, bulk-containing formulas may also be used to help control diarrhea. If diarrhea persists despite these measures, particularly if weight loss occurs despite adequate caloric intake, more
PERCUTANEOUS GASTROSTOMY • VOL 91/NO 1/JANUARY 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Saskatchewan Library] at 14:51 27 June 2016
definitive evaluation (eg, for maldigestion and malabsorption) should be considered. Electrolyte derangements should also be sought. Laryngeal penetration and pulmonary aspiration are more serious problems of enteral feeding. Standard preventive measures include elevating the trunk to at least 30° from horiwntal during feeding, monitoring gastric residual before infusing formula, and giving a prokinetic motility agent (eg, metoclopramide [Maxolon, Octamide, Reglan]) to facilitate gastric emptying. Use of a percutaneous endoscopic jejunostomy tube to infuse formula into the small bowel has been advocated as an antireflux measure; however, recent research questions the long-term effectiveness of this technique. 15 Maintenance of tube patency and tract integrity may be a problem with percutaneous endoscopic gastrostomy. The interior of the tube should be cleansed by flushing before and after feedings. Many fluids have been suggested for this purpose, but water is usually sufficient. Instillation of medications in the form of crushed pills, capsules, or highly viscous liquids through the tube should be avoided. Longacting oral medications whose timed-release characteristics depend on the pill matrix should never be crushed and given through a percutaneous endoscopic gastrostomy tube.
Summary One way to nutritionally support patients who aumot swallow is to administer fonnula directly into the stomach. Placing a gastrostomy tube percutaneously using endoscopy avoids the risks of general anesthesia and wound healing that accompany surgical gastrostomy. Although certain conditions (eg, sepsis, coagulation disorder, portal hypertension) are contraindications to the procedure, it can be done in patients who have had previous abdominal surgery and in those with severe illness.
A commercially available feeding fonnula is used. The type chosen and the frequency of ad-
ministration are based on the patient's specific needs. With regular medical monitoring and daily care of the gastrostomy site, appropriately selected patients may be safely maintained with enteral feeding for months. An advantage of the percutaneously inserted tube is that it is easily removed when the patient regains the ability to eat, and the fistula
heals rapidly. IVt'l
-®See
Earn credit on this article.
CME Quiz.
Address for correspondence: Paul Miskovitz, MD, Cornell University Medical College, 1300 York Ave, Box 422, New York, NY 10021-4885.
References I. Groher ME, Bukaunan R. The prevalence of swallowing disorders in two reaching hospitals. Dysphagia 1986; 1:3-6 2. Gauderer MW; Ponsky JL, lzant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediarr Sutg 1980;15(6): 872-5 3. Gauderer MW; Ponsky JL A simplified technique for constructing a tube feeding gastrostomy. Sutg Gynecol Obsrer 1981;152(1):83-5 4. Ponsky JL, Gauderer Mw. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gasrrointest Enclose 1981;27(1):9-11 5. Miskovitz P, Weg A, Groher M. Must dysphagic patients always receive food and water? Dysphagia 1988;2(3): 125-6 6. Miskovitz PF, Chen JP. Percutaneous endoscopic gastrostomy: incidence and significance of incidental endoscopic findings. Gasrrointesr Endose 1989;35(2): 155-6 7. Cantor MC, Miskovitz PF. Percutaneous endoscopic gastrostomy following ventriculoperitoneal shunting for increased intracranial pressure: preliminary report. Gasrrointesr Enclose 1988; 34(2):202-3
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8. Jonas SK, Neimark S, Panwalker AP. Effect of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. AmJ Gastroenterol1985; 80(6):438-41 9. Weg A, Miskovitz PF. Percutaneous endoscopic gastrostomy: a critical reappraisal. Dysphagia 1987;1:227-31 10. Cantor M, Miskovitz PF. Percutaneous endoscopic gastrostomy. Infect Surg 1988;7(10): 643-52 11. Weg Al., Miskovitz PF. Percutaneous endoscopic gastrostomy: spiral retrieval basket versus snare technique. Gasrrointest Enclose 1987;33(2): 175 12. Ford DB, Bergerson SI.., Henderson P, et al. Establishing an enteral product formulary. J Am Diet Assoc 1989;89(5):681-3 13. McCrae JA, Hall NH. Current practices for home enteral nutrition. JAm Diet Assoc 1989; 89(2):233-40 14. American Dietetic Association. Nutrition monitoring of rhe home parenteral and enteral patient. JAm Diet Assoc 1989;89(2):263-5 15. DiSario JA, Foutch PG, Sanowski RA. Poor results with percutaneous endoscopic jejunostomy. Gasrrointest Enclose 1990;36(3):257-60
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