Percutaneous endoscopic gastrostomypercutaneous endoscopic technique J Ped1atr Surg 1980; 15:872-5 2. Preshaw RM A percutaneous method for inserting a feedinr gastrostomy tuhe Surg

CLINICAL GASTROENTEROLOGY

Percutaneous endoscopic gastrostomy

RUNAI n J BR11x;1::-; MD. IRCl)C, Lw, PR SLJfllERI ANO MD, FRCPC. ',Y!)'-;l'Y 13ASS, MD. FRCPC. LOR:S.I M PRICE. MD. FRCPC

ABSTRACT: Sixty-five patients who had enJoscoptC placement of a fet•ding tube between April 1984 and November 1987, were reviewed . Mean follow-up was 245 days (rnngc one to 1191 days). The most common indication for gastrostomy insertion was a neurologic disorder (8 3°;.) Prophylactic antibiotic (cefoxitin) was gin-n to 55°'" of pauents (86'10 from one hospital). Minor complications (superficial wound infection, tuhe malfunctton, ileu" or localized abdominal pain) were seen m 55"oof patients Superfiwil wound infection, defined as local erythema and/or purulenr discharge. was tht• mo"t common wmplicatton ( 3 3'';,J No significant difference was found in the incidence of superficial wound infection between rhe group receiving prophylactic antibiotic and those who did not Major complications (gastm bleeding, aspiration. respiratory depress10n or abdominal absces,.,) occurred in 14"'o of patients The overall 30 day mortality was 2 3";,. In 60''., the cause of death was secondary to the underlying illness. No deaths occurred due to prolonged use of the feeding tube. F1\'e patten ts (8''.,) regained the ability to eat resulting in tube removal. The authors' expem•nce suggests that pt•rcutancous endoscopic gastrostomy (PEG). perhaps because of the patient population b associated wtth significant morb1d1ty and mortality. Prophylacnc antibiotics did not alter the incidence of wound infectiom associated with PEG However. this may bl' related to the use of a prophylactic antibiotic (cefoxttin) that has relatively poor coverage for Staphylococcus aureus, the most common organism cultured Careful consideration mmt be given to patienr selection prior to undertaking the procedure Can J Gastroneterol 1989;3( l ):26-28

Key Words: Nutritional therapy, Pl'TCU!llneous endoscop1<. !{mtrostomy, Sur!{1cal endo1copy

La gastrostomie endoscopique percutanee

RESUME: Le cas de 65 patients ayanr subi le placement endoscopique dune sonde aliment.lire entre avril 1984 Ct novembre 1987 a ere examine Le suivi etait en moyenne de 245 iour~ (er cou\'rait tl'un a 1391 iours). Dans la pluparr des cas, des troubles d'ordrc neurologiquL' just1fia1cnt l'inscrtton par gastrostomie (83%). Un antibiotique prophylactique (cefoxitin) a etc administre a 55°;, des patients (86~;, d'un hopital particulier). Des complications mincures (mfectmn superficielle de la plaie, malfonction de la sonde, ileus OU douleurs abdomina[es localisces) Ont etc relevces clans 550Jo des

D111.,wn of C,Nrocnr,:rnloi:~. Dcp,mmcnr o/ /nrnrwl Mdrcmt·. Fomhi//; Ho,f>u«I anJ C<1/g<1r'I Gcncwl Hm/>1kll, L'1111 rnu:i of C<1/1;a1 ), C<1/jlar:i. Al/,crw

Corm/>ondenrc <1nd H'/1r111r, Dr LR SurhcrlanJ, Rrn 1717. Heulch \ocm:e., Ccnrrc, !.l.lQ Hm/>1wl Dm.: :-.:W Ct1li:<1n Al/>1.·rr,.1 T 2l\ 4:,..1 Td.:phonc t-k)3122(\.4';l\l

Pm.:nwd dl thl' /inc \Vt'.llt:rn C<1nud<1 mccrmg, Canadll.ln Arnirll.ltlOn of G<1.1rrocnlt:rolo,1(:Y, Lake Loui1c, Albcrkl, A/ml 20 /9&'l

Rc.:e11ed for /n.l1li.:<111on \<.'/>r.:mht-r o. /988. Aw:/ited ,\,01·em/1i:r 2\ /Q&{

26

P I RCLTTANl:OUS EN[)O<;COPIC GAS·

trostomy (PEG) has become an accepted procedure to establish chronic enceral .1liml·ntation in patients who cannot swallow Since the procc<.lurc was first 1ntroduce<.l hy GauJerer and Ponsky ( l l in 198(), several other sruJ1es have reported on thl' procedure and associated wmplicat1ons ( 2-~ l Therl' han· been conflicting reports on the benefit of prophylautl an11b1or1c, for PEG (6,9-11) Most studies either fail ro define or poorly define the length of patient follow-up l:.xpenencc with PEG, including success rate. procedure related mortality, com plications and long rerm follow-up is rcportl'd

PATIENTS AND METHODS The recorJs of 65 pauents, from two

hosp1tab. who had endoscopic placement of a feeding tuhe hetwecn April 1984 and November 1987. were re · \ IL'\\"l'd Of the 65 ram·nts. H were female and >I were male, wnh a mean age of 62 7 (range two to 94) yea rs. Thirty-one patients \\Crc treated at the foothills Provincial Hospital and H patients ,It the Calgary General Hosp1· tal Inability to swallow due ro neurolog1c impairment was the primary ind1-catirn1 for the procedure (T.1ble I)

In each case, PEG was performed 111 hospital accorJmg to the procedure outlined by Ponsky ct al ( >) Intravenous sedation (d1azcpam) and local anesthenc were used 111 6 3 patients and general ,tncsthesia in two pauents. Five panents

CAN J GASTROENTEROL

cas. L'infection superficiellc de la plaie, definie com me erytheme local ctlou ecoulement de pus, constitue la complication la plus courante ( 3 3%). Aucune difference significacive n'a ere trouvcc pour ['incidence d'infection superficielle entre le groupe ayant m;u des ancibiotiques prophylacriques et les autres. Des complications graves (saignemenrs gastriques, aspiration, depression respiratoire ou abces abdominal) sont survenues chez 14% des patients. La morralire rorale sur 30 jours erair <le 23%. Dans 60% des cas, le deces etait du a la maladie sous-jaccnte. Aucun deces n'est attribuable a !'usage prolongc de la sonde alimentaire. Cinq patients (8%) ayant rccouvre la capacire de s'alimenter, la sonde leur a etc retiree. Selon notre experience, la gastrostomie endoscopique percuranee (GEP) est liee a un taux significarif de morbiditc et de morralitc, peut-etre a cause de la population de patients ams1 rraitee Les antibiotiques prophylactiques n'onr pas eu d'impact su r !'incidence d'infection des plaies associee avec la GEP. Toutefois, ceci est peut-etre du a !'usage d'un anrib1otique (cefoxitin) qui a peu de succcs centre le staphylocoque dore, l'organisme le plus communement cultive. Une arrenrion route particuliere doit etre accordee au choix du patient avant !'execution de cette procedure.

TABLE 1 Indications tor percutaneous endoscopic gastrostomy

Indication

Neurological disorders Oropharyngeal disorders Failure to lhrive Recurrent asplro1ion Esophageal cancer lnflammo1ory myopathy

Number of patients

54 4

3 2

at the Foothills Ho~pital and 31 patients at Calgary General Hospital received preoperative and postoperative antibiotics. generally cefoxitin. Feedings were started 24 to 48 h postoperatively. lnitially, a polymeric formula <lier was given by continuous infusion. Later this was changed to intermittent 'bolus' feeds. Patient followup ranged from one to 1391 days (mean

245 days). ln each case, at the time the review was conducted, the patient or, in event of death, a relative or the family physician, was interviewed regarding long term effects of the feeding gastrostomy. Statistical methods: Nonpaired l test and one-way analysis of variance were used for analysis of variables.

RESULTS There was no difference in patient age,

sex, underlying illness or indication for the procedure at the two hospitals. However. more patients at Calgary General Hospital received prophylactic antibiot1cs.

The gastrosromy tube was successfully placed in all 65 patients. In two cases the procedure was unsuccessful on the first

Vol. 3 No. I, February 1989

attempt due to technical difficulties. A repeat procedure was successful in both cases. Mortality: The 30day mortality was 2 3% ( 15 patients). Each death was reviewed by a su rgeon not associated with the study. Nine patients Jicd from a caw,e secondary ro underlying disease unrelated to che procedure Aspiration related deaths occurred in five cases. One procedure related death was thought to be due to respiratory depression following che procedure.

An additional 21 patients DI%) died from their underlying illness during the follow-up period of 30 days to 1391 days resulting in an overall one year mortality of 54'\,. No deaths were related to prolonged use of the feeding gastrostomy. Morbidity: Complications, which occurred in 45 of the 65 patients (69'\,). were determined to be major or minor based on the presence or absence of systemic manifestations. Nine major com-

TABLE 2 Complications following PEG

Major Aspiration Respiratory depression Upper gastrointestinal bleed Wound abscess

Minor Superficial wound infection Transient abdominal wall pain Tube leak/malfunction, dislodgement

lieus

Number of patients

6

22 7

5 2

Percutaneous endoscopic gastrostorny

plications occurred (Table 2). Aspiration occurred in six case:. with five resultant deaths; one pat1ent experienced respiratory depression and Jicd. One patient with a past history of peptic ulce r disease had an uppergastromtcstmal bleed requiring transfusion therapy three Jays after the procedure. Investigation regarding the b leeding source was declined by the patient. Emperic treatment with an H2 antagonise was scarred. No further bleeding occurred m two-and-one-half months of follow-up. One patient who had not received prophylactic antibiotics c.leveloped a penstomal abscess which was cultured for Staphlococcus c.rnreu.1 The gastrostomy feeJing tube was removed and the abscess wa:; succes~fully treated with drainage and systemic antibiotics. A repeat PEG was successfully performt'd three weeks later with no difficulty

TABLE 3 Organisms recovered at the exit site of the gastrostomy tube

Number of patients

Mixed 7 15 Staphylococcus oureus 10 Pseudomonos oeruginoso 6 Group D enterococcus 3 Staphylococcus epidermldis 2 Klebsiello pneumon,oe Hemolytic group B streptococcus Candido olbicons

Minor complications occurred in 36 patients ( 55°io) and included superficial wound infection (22 patients), transient localized abdominal wall pain (seven), tube malfunction or dislodgement (five) ,tnd ileus (two) (Table 2) Superficial wound infection, defined as local erythema and/or evidence of purulent discharge, was the most common minor complicanon ( 3 3'\,). Cultures were obtained in 15 of 22 patients (Table 3), seven cultures yielded multiple organisms. Most infections were ea:;ily created with local mca~urcs. ln four cases, treatment with systemic antib1oncs was required Of the 36 patients given antibiotic prophylaxis, 14 developed a supe rficial wound infection (39"i,), compared to

eight of 29 (280,:,) who were not given prophylaxis. Although more superficial

27

BRff)C,F<: er al

wound infections were seen at Calgary

General Hospital, this was not statisncally significant

Long term follow-up revealed the for

mation of granulanon tissue at the gasrrosromy site in some patient:,. However.

no adverse effects resulted from chis.

Eight patients had catheter exchange. thb was reportedly simple. Five patients (8°!,)

showed improvement in their wndicion rhat enahled removal of the feeding tube

In only one case wc1s the tube used for

less than one month prior to removal

The ruhc was removed hy pulling it out through the gascro~romy tract, or by cut

ting the tube and allowing the burmn to pass

DISCUSSION PEG has become an accepted proce

dure to ohtain access for chronic enteral

alimenrauon in patients who are unable

m ear hut haVl' an intact gastrointestinal

tract In the studies to date, PEG has been

found to be effective, generally safe and

to provide a favourable result when com

pared to surgical gastrosromy ( 5.12 ). Present data regarding complications

differ ~Jmewhm from previous reports ( 6,8.12.13 ). This is in part explained by

inclusion of symptoms such as transient

abdominal pain as a complication which

was nor reported in previous studies. In

addition, requirements for wound infec

tion may have heen more inclusive than

ACKNOWLEDGEMENTS: The authors acknowledge Mary Crowther and Nancy Rac1C()[ for their time spent interviewing patients, and to Dianr Buzan for her secretarial skills. Dr Bridges is a Gastroenterokigy Fellow at the University of Calgary.

REFERENCES I Gauderer MWL, Ponsky JL. lzart RJ Jr

Ga,rroscomy without laparotomy: A percutaneous endoscopic technique J Ped1atr Surg 1980; 15:872-5

2. Preshaw RM A percutaneous method for inserting a feedinr gastrostomy tuhe Surg Gynccol Ohstet 1981; I 52:6'i8-60

> Ponsky JL. Gauderer MWL Percutaneous cndo,nlpK gasmi,tomy: A nonopcr,Hive technique for feeding g,htm,ttlm) Gastniint<·,t En.lose 1981;27·9- I I

4 Larson DE. Flemm mg CR. Ott BJ, Schroeder KW. Percucam·ous endo·

28

previous studies. Maior complications

were seen in nine patients ( 14ci;,) and

included aspiration, gastrointesnnal hle..:d, respiratory depression and wound abscess.

Several minor complications, includ

ing wound 111fection, have been associated with PEG. Initial studies failed to

show that antibiotic prophylaxis altered

the incidence of wound infection follow

mg the rrocedure (6,9). However, the

studies were uncontrolled and nonran

d0mized. Jonas and colleagues ( JO), in a prospective randomized trial. found that

cefoxitin was n0 better than placebo in

prc\'cnting wound infections associated \\'Ith PEG. Rcccnrly.Jain and others ( 11) demonstrated that ccfozolin significantly reduced the risk for wound infection

,issociarcd with the procedure However,

the length 0f follow-up in this study was very short

Tcl explain these conflicting results,

Jain and others (II) suggested that cefa

:olin may he a better antihiotic than cefoxitin for chis situation. They found

StaJ1h aureus to be the most common organism cultured, as was the case in the

present study. Cefozolin has a l0nger halflife and better coverage for Gram-posi

tive wcci than cefoxitin. This may ex

plain the differing results between these

two studies and explain the present

results which failed to demonstrate significant benefit from antibtottcs.

scoptc gastroscomy: Simplified access for enreral nutrition. Mayo Clin Proc 1983;58.101-7

5. Tanker MS, Schemfcldt BD, Steerman PH, Goldstein M, Robinson G, Levine GM A prospective randomized study comparing surgical gastrostomy (SG) and percutaneous endo,cop1c gastroslomy (PEG) Gasm>mte,t Endosc 1986, 32· 144. (Abstl

6 Pom,ky JL, Gaudercr MWL, Stellam TA Percutaneous <'ndoscop1c gastr()stomy: Review of 150 cast's. Arch Surg L983;ll8:911-4.

7. Strode! WE, Lemmer J, !:ck ha user F, Botham M, Dent T. Early experience with endoscopic percut;:im•ous gastro,tomy Arch Surg 198 l.118.449-51.

l'i. h1utch PG. Haym·s WC, Bellapravalu S. S;inmvski RA Percutant'ous endoscopic gastro,tumy /PEG): A new procedure come, of age J Clin Gastroenteml 1986;/i 10-5

9 Thatcher BS, Ferguson DR, Paradis K

The present study indicates a 30 day

mortality of 23'\,. One death was directly

related to the placement of rhe tube and

five deaths occurred as a result o( aspiration o( feedings infused inro the stom

ach. In the remaining nine cases, the cause of death was attributed to the

patient's underlying illness and was not

related to the gastrostomy rube. Other

studies have reported similar results ( 13)

The rrescnt authors were unable to pre

dict from the data analysis which patients would have a better prognosis.

Lnng term follow-up in this study

sht)wcd none of the subsequent 21 deaths to he related to the prolonged use of the feeding gastrostomy tube Par,ents,

famtly members and/or family physicians

indicated satisfaction with little asSC1ciated difficulty in the long term use of the

tuhe It is not possible to draw definitive

conclusions about patienc nutrition as the study was uncontrolled

In summary, this experience suggests

that percurnneous endoscopic gastro

,tomy 1s easy to perform in di patients

hut is associated with significant morbid

ity and related mortality. Since patients arc critically ill prior to the pwccdurc,

the complicaritin rate is not unexpected. Careful consideration of patient selec

tion, increased physician experience and

refinement with the procedure. and

appropriate antibiotic prophylaxb may

further improve this effective technique.

Percutaneous endt)scopIC gastrostomy· A preferred method of focdmg rube gastrosromy Am J Gastrocntt·rol 1984;79·748-50.

I 0. )tlnas SK. Neunark MD, Pan walker AP. Effect ot antibl(ltic prophylax1, in percutaneous endoscopic gascrostomy. AmJ Gawoenterul 1985;80:438-41

11 lam NK, Larson DE. Schroeder KW. ~t al Annh1otte prophylaxis for pcrcu ta neous endoscopic gastrostomy: A prospecuve randomized. doublehlmd dimcal trial. Ann Intern Med 1987, 107.824-R.

I Z Rugue J. Vazquez RM An analysis of 1he advantages of Stamm and percutaneous endoscopic gastroscomy. Surg Gynecul Obstet 1986, 162: 13-6.

13. Larson DI:, Burton DD. Schucder KW. D1Magno EP Pcrcutaneou, cndmcopic . g~strustomy : lndicatl()ns. success, rnmplicanon, and mortality m 114 consecunve patients Gastroenterology 1987,93 48-52

CAN J GA:- fR()f-NTl:-IH)L

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Percutaneous endoscopic gastrostomypercutaneous endoscopic technique J Ped1atr Surg 1980; 15:872-5 2. Preshaw RM A percutaneous method for inserting a feedinr gastrostomy tuhe Surg