There’s More to a PEG Than Just Putting One In

We are no longer fascinated and amazed by the mere fact that a PEG can be done. First, blindly open a tract across multiple fascial planes and intentionally perforate hollow viscera, producing a pneumoperitoneum, and relying only on “sutureless approximation” for tract stability. Then (literally adding insult to injury) coat a foreign body with saliva and insert it into this fresh wound. In the 1980s, critics were sincerely convinced that this could lead only to disaster [1]. If it had not been conceived, developed, and tirelessly championed by well-respected academic surgeons [2], this counterintuitive shortcut technique, which seemingly violates every surgical principle, might have passed quietly into disreputable obscurity. Our view today is quite different, of course; now, we are only amazed that we ever regarded this simple procedure with suspicion.

As gastroenterologists and surgeons became more comfortable with the procedure, the threshold for its use dropped significantly. After a decade of gradual acceptance, PEG placement was enthusiastically embraced [3]. Every new medical technology cycles through phases of exploration, enthusiasm, realism, and, eventually, appropriate use. A recent plateau in the use of the procedure in the USA (Figure [1]) [4] [5] suggests that PEG is now entering this final phase. Questions of its “do-ability” faded away long ago. Contemporary debates focus on overuse of PEG in dementia [6] [7], its utility in anorexia nervosa [8], and such eternal conundrums as the ability of jejunal feeding to prevent aspiration [9] [10].

Figure 1 Gastrostomies carried out in the USA, 1989 - 2000 [4] [5].

In this issue of Endoscopy, Koulentaki et al. [11] address questions about what we do with feeding tubes once placed. The authors reflect on their extensive European experience to explore questions of efficiency and effectiveness in this difficult area. They correctly formulate the problem as involving “… patients are increasingly surviving the lifespan of the original tube.” We all understand that most patients requiring a gastrostomy tube die, a few get better, and many continue on - seemingly forever. And their need for care does not stop when they leave the gastroenterology department. Their care requirements are a continuum, without clear boundaries. Once the decision to consider a gastrostomy tube has been taken, a whole train of responsibilities and effects is set in motion (Table [1]). Koulentaki et al. attempt to address a few of the many issues involved by selecting discrete but generally applicable research questions.

Table 1 The PEG cascade Referral: Identifying and assessing the PEG candidate Consultation: Considering the unique clinical and ethical issues Informed consent: Preparatory education for patient and caregiver PEG placement In-patient: Acute post-insertion management Outpatient: Long-term management Feeding: Maximizing nutritional effectiveness Holistic care: Optimizing quality of life Impact: Modify disease outcome Survival: Prolonging life

What is the best replacement protocol for these tubes? The authors consider replacement costs and gastrostomy tube longevity in a simplified model unique to their environment. Although in the United States we deal with the same basic problems, differences between Milwaukee and Dundee make extrapolation of the European findings to our own practice difficult. For example, endoscopic replacement with an original PEG is rarely done here (less than 10 % of cases), but accounted for 62 % of the replacements in Dundee. Also, they replace their balloon tube every 2 - 3 months, as suggested by the European manufacturer. In the USA, the same MIC balloon gastrostomy tube (Ballard Medical Products, Draper, Utah, USA) comes with no such recommendation, and the instrument typically lasts 3 - 6 months before its need for replacement becomes evident. More formal cost accounting might take into account ambulance transportation and missed wages for the care-giver, etc., as a result of more frequent changes. This might change the cost-benefit ratio. Conversely, since the costs of hospitalization can dwarf the costs of tube maintenance [12], if scheduled gastrostomy tube replacement could prevent even a portion of the gastrostomy closures or pulmonary aspirations that occur, the approach might well prove to be more cost-effective. The issue, while important, is therefore not easily answered. The complexity of the problem is such that site-specific variations and other seemingly minor considerations can significantly affect the predicted best practice.

One of this study's most intriguing findings was the explicit value of care-giver education. The Dundee group showed that over a 2-year period, increasing care-giver education actually reduced demand on the service by 30 %, in spite of an increasing patient load. This result of their “multidisciplinary nutritional support team” illustrates its protocol-driven nature and the infrastructure support developed, including elements such as educational videotapes. The authors, however, appear to underemphasize this aspect, as many details of their practice are not spelled out in the paper. On inquiry, they stated that their protocols were undergoing continuous development and were thus difficult to specify. Our hospital administration refers to this type of ongoing and critical review of processes and developments “continuous quality improvement” (CQI) (of course, they also refer to any problems as “opportunities for improvement”). The point is that these teams are an important and often underappreciated adjunct to management, and they require ongoing management themselves.

Is an enteral nutrition team needed at every center? Many centers have inflammatory bowel disease (IBD) teams or protocols for hepatitis C management. Yet we care for gastrointestinal mastocytosis or Zollinger-Ellison syndrome on an ad-hoc basis, because such cases are too rare to justify developing group-specific infrastructure, such as care teams, protocols, and clinical pathways. Developing and maintaining this type of infrastructure requires resources; it is an investment. As the numbers of patients and complexity of cases requiring ongoing gastrostomy tube management continue to increase, many of us are indeed seeing an “opportunity for improvement.” Perhaps this opportunity should be embraced, especially at larger referral centers responsible for populations in the range of 250 000.

A brief survey of the recent literature and practices at other institutions shows that gastrostomy tube teams are often employed, but that their constitution and functioning can differ substantially. Tables [2] and 3 outline some common approaches, but as Koulentaki et al. [11] and others [13] [14] [15] [16] attest, the design needs to be tailored to each institution and its current needs. The arrangement at a pediatric hospital will differ significantly from that at a Veterans’ Administration hospital. But invariably, the clinical nurse specialist is the hub of the team [16] - both from the professional perspective and that of the patient. Designing and supporting the post of the clinical nurse specialist is as critical to the success of the team as recruiting the right person to fill it. Also, the team has to respond to challenges flexibly, including changes in technology and health-care delivery, as well as changes due to the impact of the team process itself. For instance, since referrals follow the path of least resistance, simplifying access may increase volume and also modify the patient population. Will your team handle gastrostomy tubes placed by outside radiologists and surgeons? Nasoenteric tube placement in the intensive-care unit? Changing referral patterns can even strain collegial relationships.

Table 2 Enteral nutrition team: one possible configuration Team members Duties of each Team as a unit 15 - Preprocedural assessment/selection- Clinical consent/education process- Developing protocols Clinical nurse specialist 16 (in-patient/outpatient) - “Anchor” - coordination and continuity- In-patient consultations, referral intake- Directing clinic, telephone triage- Most nonendoscopic replacements- Home and nursing-home visits Gastroenterologist Insertion and technical considerations Nutritionist/dietitian Designing and monitoring feedings Speech pathologist Selection and rehabilitation potential Pharmacist 18 Drug interaction and side effects

Table 3 Some potential opportunities for improvement Goals Tools Appropriate selection Protocols 11 Effective nutrition Telephone and home follow-up 9 Improved survival Integrated management protocols Remove intimidation Education: video, print, internet Maximize subjective quality of life Demonstration of tubes to show options 16 Reduce unneeded hospitalization Improve access to team for problems Control costs Proactive management Avoid complications Care-giver training and follow-up Provide resources and ad-hoc consultation Connections to lay support system 19

The endoscopist may no longer find PEG insertion intimidating, but the management of the gastrostomy tube is another matter. This growing and increasingly complex challenge is not only intimidating for patients and their primary-care physicians [17]; if the issues involved remain unaddressed, the resulting mismanagement and inconvenience can ultimately return to affect the endoscopist, health-care costs, and almost certainly the outcome for the patient. In the long run, many difficulties can be avoided by enhanced education, access, and oversight. As the numbers of patients needing this type of care expand, investment in an organized, proactive approach will become imperative. An integrated enteral nutrition service can respond to this challenge locally. The wider profession may also find that, as the systemic costs of the problem become more apparent, funding may develop to encourage research into the many critical questions that are still unanswered.

References

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