Maintenance of long-term nutrition poses a challenge in patients with medical disorders
with inadequate oral intake. Enteral nutrition is the preferred route in patients
with intact gastrointestinal tract and has multiple proven benefits over parenteral
nutrition including lower risk of sepsis, maintenance of gut barrier, and microbiota.[1] Stomach is the most commonly used site for long-term tube feeding when feasible.
Access can be maintained by using a nasogastric tube or a percutaneous gastrostomy
that may be placed surgically, radiologically, or endoscopically.[2] While nasoenteric tube may be used for short-term enteral feed (< 4 weeks), they
are associated with higher complications such as nasal/throat irritation, reflux esophagitis,
and aspiration pneumonia particularly in patients with impaired laryngeal reflexes
and thus not the preferred mode for long-term nutritional needs.[3] Percutaneous endoscopic gastrostomy (PEG) is the preferred mode for establishing
long-term tube feeding worldwide. A single-center experience from India is published
in this edition of the journal.
PEG was first described in 1980. The techniques and devices available have since further
evolved to become the most patient- and gastroenterologist-friendly method.[4]
[5] Compared with surgical feeding, gastrostomy/jejunostomy is of lower cost, requires
shorter hospital stays, induces lesser pain, and does not require general anesthesia.
Many of these debilitated patients are often poor candidates for general anesthesia.[6] Most common indications of PEG tube placement include neurological diseases (cerebrovascular
disease, motor neuron disease, dementia, prolonged coma) and malignancy (head and
neck cancer, esophageal cancer).[2] Expected survival of the patient should be preferably be over a month to justify
the procedure. Commonly encountered contraindications to PEG tube placement include
uncontrolled bleeding diathesis, hemodynamic instability, gross ascites, sepsis, peritonitis,
abdominal wall infections, gastroparesis, and gastric outlet obstruction and should
be excluded prior to the procedure.[3]
Among the three commonly available techniques: pull method, push method, and introducer
method; the “pull method” is the most preferred technique.[2] The procedure is usually safe. However, serious complications may occur rarely,
which include—bleeding, perforation peritonitis, local site infections and necrotizing
fasciitis, aspiration pneumonia, and buried bumper syndrome.[2]
[7] A single dose of preprocedure antibiotic (usually 1 g cefazolin) is recommended
as the standard practice to reduce infective complications.[8] Postprocedure stoma and tube care is equally important to prevent complications.
Stoma should be cleaned and examined for signs of infection and excoriation on a daily
basis. Thick feeds should be avoided and tube should be flushed with warm water before
and after each feed to prevent clogging.[3] Daily examination of the wound site is essential to detect complications promptly.
The caregivers need to be specifically educated about this.
While the procedure is being widely practiced globally, there is dearth of published
literature of its use from India. The paper published in current issue describes a
single-center experience with PEG placement in the form of a retrospective study of
data collected over a 3-year period. Standard “pull method” was utilized for placement
of a 24-Fr PEG tube. Overall, 76 patients underwent the procedure with a mean age
of 67 years. Most common indications were neurological disorders followed by malignancies.
High technical success (97.3%) was achieved; however, all the procedures were performed
by a single experienced gastroenterologist. A high disease-related mortality (56.16%)
was seen during follow-up with a short median time to death (65 days) postprocedure.
This probably reflects late referral of patients in India for PEG. Patients undergoing
PEG are thus having advanced disease, nutritionally depleted, and debilitated at the
time of procedure. This results in overall shorter survival as well as poses challenges
in conduct of the procedure. Sensitization of our neurology, oncology, and surgical
colleagues can improve the referral patterns and thereby improve the outcomes.
Local site infection remains one of the most common major postprocedure complications
(5–25%) despite the routine use of prophylactic antibiotics.[2]
[7]
[9] The reported rate was rather low (6.8%) in the current study. Possibly, some minor
infections and inflammation due to infection without culture positivity weren’t specifically
tracked/reported. Pus culture was positive in all cases and all were monomicrobial
(Gram-negative organisms). All but one patient (who required early removal of PEG)
could be managed conservatively. Caretaker and physicians should be sensitized for
optimal daily stoma care and early detection of infective complications facilitating
prompt management. Antibiotic protocols should be guided by local microbiological
profiles.[9] In our institution, we use 1 g cefazolin injection. Parenteral Augmentin, levofloxacin,
may also be used if patient is sensitive to cefazolin. Though the authors found Gram-negative
bugs on culture, infection by Gram-positive bugs is primarily prevented by the prophylactic
preprocedural antibiotic.
Inadvertent removal of PEG tube (three patients in the current study) remains a dreaded
complication in neurological patients who are often agitated, resulting in medical/surgical
emergency. While the early dislodgement rates have been reported to be low (0.6–4%),
the lifetime risk of inadvertent removal has been reported to be as high as 12%.[10] The risk can be mitigated with simple measures such as use of mittens. The tube
can be replaced through the same tract if the tract is mature (usually > 4 weeks post-PEG)
and patient presents within < 24 hours.[2] Otherwise, placement of a new tube requires a repeat endoscopic procedure by puncturing
the same site or a nearby site.
One patient developed pneumoperitoneum while replacing an inadvertently removed PEG
tube and required surgery for a feeding jejunostomy. Development of pneumoperitoneum
is a common, self-limiting postprocedural finding on abdominal X-ray and does not
necessitate surgical intervention unless there are features of peritonitis. It is
generally not considered a complication and is managed conservatively.[11] If features of peritonitis are present, cross-sectional imaging followed by radiological/surgical
intervention may be required apart from institution of parenteral antibiotics, parenteral
fluid infusion, keeping patient nil by mouth, and placing a nasogastric tube.
The authors have not highlighted some of the other commonly encountered complications
such as tube dysfunction, peristomal leak, bleeding, and aspiration, among others.
They have also not provided the number of patients who required tube replacements
during follow-up as a result of dysfunction. Moreover, it is a single-center experience
of a single trained gastroenterologist.
Despite its many advantages and safety, PEG remains an underutilized procedure in
India, primarily because of the lack of awareness and willingness on the part of primary
care physicians, neurologist, oncologists, and surgical colleagues. Moreover, due
financial constraints, fear of a major procedure, and lack of family support, some
patients’ caregivers may opt for nasogastric feeding alone. Thus, many of the patients
(primarily neurological and malignancies) who are candidates for long-term enteral
nutrition are maintained on nasogastric tubes or undergo feeding jejunostomy rather
than PEG placement. It is need of the hour to encourage timely screening and referral
of suitable candidates so that an optimal route of enteral nutrition can be established.
In the patients who undergo PEG placement, it is equally important to educate the
caretakers regarding the optimal feeding methods and tube care so that complications
such as infections, tube dysfunction, and inadvertent removal may be avoided and managed
promptly.
The procedure and techniques are still evolving, and recent developments include utilizing
ultrasonography, endosonography, laparoscopy, and fluoroscopy for gastrostomy tube
placement in patients where stomach is not accessible endoscopically due to pharyngeal
or esophageal malignancies. PEG-jejunostomy can be used to deliver postpyloric feed
in patients who are at high risk for aspiration (impaired laryngeal reflexes, vocal
cord palsy). A simple practical algorithm is shown in [Fig. 1].
Fig. 1 Approach to patients requiring enteral nutrition therapy.
In India, despite the procedure being shown to be effective and relatively safe, it
is underutilized. It is necessary that the procedure is taught actively in a structured
way to all gastroenterology trainees so that the procedure can be performed safely.
They could also undergo a certification course on the side of our major conferences,
to ensure competence in all aspects. Also, our neurology, oncology, and surgical colleagues
need to be sensitized regarding the safety and effectiveness of the procedure so that
more patients may benefit. To keep a check on cost, the accessories required could
be indigenously manufactured. However, quality control is essential to prevent procedural
failures. Patients and their relatives may be informed by educational videos about
care of the PEG tube to prevent complications. A multipronged intervention in these
lines is likely to benefit the ailing patients of the country who are often either
too ill to speak for themselves or cannot speak due to their neurological status.
