PEG feeding is used where patients
cannot maintain adequate nutrition with oral intake. However, the simplicity of
PEG feeding has led to some to be concerned about its use when there is little
or no clinical benefit.
There are sometimes ethical factors to
consider (see 'Ethical dilemmas', below). Several court cases
have considered use of PEG feeding in patients who have lost the capacity for
self-determination.
Indications
In the past, it was considered that the lower limit of body weight to
insert PEG tubes should be 10 kg but PEG has been reported to be inserted
safely in infants with a weight as low as 2.3 kg. The use of PEG may be
indicated for children with:
· Neurological disorders with inability to
swallow or dysphagia.
· Craniofacial abnormalities.
· Oncology problems with malnutrition.
· Other clinical conditions that lead to
wasting and malnutrition - eg, chronic kidney disease, cystic fibrosis,
metabolic problems, chronic infection such as HIV, cardiac disorders, short
bowel syndrome and Crohn’s disease.
Contra-indications to
PEG
·Absolute contra-indications for using
PEG in children are bleeding disorders, severe
ascites, peritonitis, pharyngeal
or oesophageal obstruction and during periods of acute
severe illness.
·Relative contra-indications for use of
PEG include acute severe illness,
anorexia, previous gastric surgery,
peritonitis, ascites, and gastric outlet obstruction.
Cautions
·Infection: active systemic infection
increases the risk of early mortality and morbidity
post-PEG placement.
Elevation of serum CRP is the most accurate prognostic indicator of
poor
outcome.
·Other comorbidity: poorer outcome, with
increased PEG site and systemic infection
have been reported in patients with
diabetes mellitus, chronic obstructive pulmonary
disease and low albumin
levels.
·Ventriculo-peritoneal shunts: placement
of PEG tubes increases the risk of shunt
infection but this risk decreases with
increased time between shunt insertion and PEG
insertion. Prophylactic
antibiotics may further reduce the infection risk.
·
Anatomical considerations: in patients
with severe kyphoscoliosis, the stomach is often intrathoracic. This
particularly applies to patients with cerebral palsy. Radiological and
endoscopic approaches may be impossible. A combined laparoscopic and endoscopic
approach can be tried but this requires a general anaesthetic, which also
represents a considerable risk for the patient.
PEG insertion method
·
In children, PEG tube insertion is
performed under general anaesthesia. A single dose of intravenous antibiotic is
given.
·
After insertion of the gastroscope into
the stomach and a gentle insufflation of air, the most transluminant point of
indentation on the anterior abdominal wall is marked.
·
After sterilising the skin of the
anterior abdominal wall and infiltration of this point with local anaesthesia,
a skin incision is made and a trocar with a needle is pushed through into the
stomach under complete endoscopic visualisation.
·
A thread or a guide wire is inserted
through the trocar after removing the needle and this thread is then snared.
The endoscope is then withdrawn with the snare holding the thread.
·
A suitably sized PEG tube is then
connected to the thread and the thread is pulled from the skin incision pulling
the tube into the patient’s mouth through the oesophagus, to be retained in the
stomach by the internal bolster. An external bolster is placed loosely on the
skin.
·
The position of the inner opening of the
tube should be checked by endoscopy.
·
In the past, commencing use of the tube
has been delayed until 24 hours after insertion. There is now evidence that
delaying use of the tube has no advantage over early feeding.
Benefits of PEG
feeding
Benefits include:
·
It is well tolerated (better than
nasogastric tubes).
·
Nutritional status is improved.
·
Ease of usage over other methods
(nasogastric or oral feeding) reported by carers.
·
Satisfactory use by home carers.[9]
·
Low incidence of complications.
·
Reduction in aspiration pneumonia associated with swallowing
disorders.
·
Cost-effective relative to alternative
methods, particularly when reasonably long survival is expected.
Management after
insertion
·
Education of carers and patients is
essential to reduce tube problems and complications.
·
A number of studies indicate the support
and education of patients should be multidisciplinary, involving:
·
Nurses (wound care and ostomy
expertise).
·
Dietitians (nutritional advice and
support).
·
Ongoing care involves:
·
Inspection and maintainance of the
access device (see 'Care of PEG tube', below).
·
Wound care advice.
·
Nutritional support and advice.
Care of PEG tube
This routine care can be performed by the patient and/or the carers with
suitable training. After about 10 days following insertion asepsis is not
required.
·
Examine the skin for
infection/irritation around the site.
·
Note the measuring guide number at the
end of the external fixation device.
·
Remove the tube from the fixation device
and ease away from the abdomen.
·
Clean the stoma site with sterile
saline.
·
Dry the area with gauze.
·
Rotate the gastrostomy tube to prevent
adherence to sides of the track.
·
Re-attach the external fixation device
to the abdomen.
·
Attach the gastrostomy tube gently to
the fixation device and position as before according to the mark/number on the
tube.
·
Avoid use of bulky dressings.
Complications
Immediate
(within 72 hours):
·
Endoscopy-related:
·
Haemorrhage or perforation.
·
Aspiration.
·
Oversedation.
·
Procedure-related:
·
Ileus.
·
Pneumoperitoneum.
·
Wound infection.
·
Wound bleeding.
·
Injury to the liver, bowel, or spleen.
Delayed:
·
Gastric outlet obstruction.
·
Buried bumper syndrome (migration of the
internal bumper of the PEG tube into the gastric or abdominal wall).
·
Dislodged PEG tube.
·
Peritonitis.
·
Peristomal leakage or infection.
·
Skin or gastric ulceration.
·
Blocked PEG tube.
·
Tube degradation.
·
Gastric fistula after removal of the PEG
tube.
·
Granulation around site of insertion of
the PEG tube.
Prognosis
·
There have been few long-term follow-up
studies. Clearly the overall mortality rate after PEG insertion is high because
of the underlying medical problems.[13]
·
A five-year prospective study showed few
complications from the procedure itself and improved nutritional status.
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