Elsevier

Gastrointestinal Endoscopy

Volume 50, Issue 6, December 1999, Pages 746-754
Gastrointestinal Endoscopy

Percutaneous endoscopic gastrostomy and gastrojejunostomy: a critical reappraisal of patient selection, tube function and the feasibility of nutritional support during extended follow-up,☆☆

https://doi.org/10.1016/S0016-5107(99)70153-7Get rights and content

Abstract

Background:  Percutaneous endoscopic gastrostomy (PEG) is a generally accepted procedure, but the appropriateness of patient selection and the justification of jejunal feeding have not been systematically investigated. Also, a critical appraisal of the applicability and tolerance of nutritional support in the immediate postinsertion period and during prolonged outpatient care is lacking. Methods:  Prospectively collected data in adult and pediatric patients during a period of 7 years were analyzed. Follow-up data were available at days 1, 7 and 28 and thereafter every 6 to 12 weeks until gastrostomy removal, death or the conclusion of the study. Results:  A PEG was successfully positioned in 268 of the 286 referred patients (94%). A jejunal tube through the PEG (JETPEG) was placed beyond the duodenojejunal ligament in 38 patients. Procedure-related mortality was 1%, 30-day outpatient mortality 6.7%. Total follow-up was 295 patient-years with an overall mortality of 53% (PEG 53%; JETPEG 50%). Both major (8.4%) and minor (24.0%) procedure-related complications in the first 28 days consisted merely of (infectious) wound problems. In prolonged follow-up, the complications were more tube-related. The durability of the tube in surviving patients with a PEG or JETPEG in situ was a median of 495 days (range 162 to 1732 days). Tube dysfunction because of clogging, porosity and fracture occurred after a median of 347 days (range 9 to 1123 days). Nausea, vomiting, bloating and dumping interfered with feeding during the first week and during extended follow-up. Intrajejunal feeding was associated with dumping and diarrhea. In retrospect, the anticipated need of 4 weeks of enteral nutrition was not met in 9.0%. The extension of a PEG into a JETPEG was thought inappropriate in 23.7%. In the remainder, a 91% reduction in aspiration justified its use. The tube life span was equal to or greater than that of a PEG, despite tube dysfunction in 26.8%. Conclusions:  Proper selection of patients for a PEG, i.e., those with an anticipated need of greater than 4 weeks of enteral nutrition, is a challenge. Notwithstanding an increased rate of tube dysfunction, well-selected patients may benefit from a JETPEG. Follow-up is mandatory because many patients might have become malnourished or underfed while on tube feeding, mainly because of GI intolerance. (Gastrointest Endosc 1999;50:746-54.)

Section snippets

Patients

All patients referred for PEG had an anticipated need for enteral nutrition of at least 4 weeks. The indication to extend the PEG into a JETPEG consisted of a documented history of reflux esophagitis or previous aspiration, the presence of gastric paresis or pancreatitis, diminished gag, swallow and cough reflexes in obtunded patients, intermandibulomaxillary fixation in trauma patients or artificial ventilation. The procedure was explained to outpatients and all materials to be used were shown

RESULTS

From November 1988 to December 1995, 286 patients, 147 male and 139 female, were referred for PEG. Patients were suffering from neurologic diseases such as ALS and cerebrovascular accident, mental-motor retardation because of cerebral palsy and metabolic diseases, and tumors of the head and neck. Some patients were admitted to the ICU for ventilatory support. The youngest patient was 6 weeks old, the oldest 85 years of age (Table 1).

. Descriptive characteristics of patients referred for

DISCUSSION

Short-term prospective studies have demonstrated the superiority of a PEG over nasogastric feeding tubes in patients with dysphagia due to chronic neurologic disease.14, 15, 16, 17 Our long-term follow-up study, covering 275 patient-years, corroborated the beneficial short-term data. A procedure-related death rate of 1.0%, unsuccessful positioning in 6% and a major complication rate of 8.4% were in agreement with data from other large series that reported short-term18, 19, 20, 21, 22 and

References (34)

  • VK Parasher et al.

    Successful placement of percutaneous gastrojejunostomy using steerable glidewire: a modified controlled push technique

    Gastrointest Endosc

    (1995)
  • JD Mellinger et al.

    Percutaneous endoscopic gastrostomy: an overview for 1996

    Endoscopy

    (1996)
  • JD Mellinger et al.

    Percutaneous endoscopic gastrostomy: state of the art 1998

    Endoscopy

    (1998)
  • DS Kaplan et al.

    Percutaneous endoscopic jejunostomy: long-term follow-up of 23 patients

    Gastrointest Endosc

    (1989)
  • JM Henderson et al.

    Limitations of percutaneous endoscopic jejunostomy

    JPEN

    (1993)
  • MH DeLegge et al.

    Percutaneous endoscopic gastrojejunostomy: a dual center safety and efficacy trial

    JPEN

    (1995)
  • S Sartori et al.

    Percutaneous endoscopic gastrostomy placement using the pull-through or push-through technique: is the second pass of the endoscope necessary?

    Endoscopy

    (1996)
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    Reprint requests: E. M. H. Mathus-Vliegen, MD, PhD, Department of Gastroenterology and Hepatology, C2-207, Academic Medical Center, Postbox 22660, 1100 DD Amsterdam, The Netherlands.

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