Dilemmas in placing PEG tubes

Dr Clare Donnellan

Consultant Gastroenterologist, Leeds

December 2016

Overview

• What is the difference?

– PEGs

– RIGs

– Others

• What are the risks?

• Interactive dilemmas

Different tubes

• PEG

– Percutaneous Endoscopic Gastrostomy

Different tubes

• PEG

– Percutaneous Endoscopic Gastrostomy

Different tubes

• PEG

– Percutaneous Endoscopic Gastrostomy

Different tubes

• PEG

– Percutaneous Endoscopic Gastrostomy

Different tubes

• PEG

– Percutaneous Endoscopic Gastrostomy

Different tubes

• RIG

– Radiologically Inserted Gastrostomy

Different tubes

• RIG

– Radiologically Inserted Gastrostomy

Other gastrostomy tubes

• Different techniques

– Previous with modifications

• Surgical gastrostomies rare

Nomenclature

• ‘PEG’ only refers to endoscopic tube…

• In practice

– All gastrostomies termed ‘PEGs’!

Which tube??!

• After initial PEG, options:

– New PEG replaced

– Balloon gastrostomy

– Non-balloon gastrostomy

– Low profile devices

What are the risks of the initial

PEG?

1. 30 day mortality of 1%

2. 30 day mortality of 5%

3. 30 day mortality of 10%

4. 30 day mortality of 15%

Make your selection!

What are the risks?

1. 30 day mortality of 1%

2. 30 day mortality of 5%

3. 30 day mortality of 10%

4. 30 day mortality of 15%

PEG mortality

• Very variable 30 day mortality for PEGs

– n=7191

• 7 day mortality 43%

– n=7142

• 30, 60 & 365 day mortality 22%, 31% & 48%

– n=10413

• 30 day mortality of 5.8%

– n=5004

• 30, 90, 365 day mortality 11.3%, 28.3%, 46.8%

1NCEPOD, 2004 2Smith et al. (2008) Surg End, 22(1):74-80

3Richter-Schrag et al. (2011) Can J Gastro 25(4):201-6 4Kara et al. (2016) Nutr Clin Prac epub

What about RIGs?

• Better mortality rates?

– n=23791 (meta-analysis)

• 30 day mortality 1.8%

– n=6842

• 30 day mortality 1%

– n=10483 (meta-analysis of comparative papers)

• 30 day mortality 10.5%

• PEG 30 day mortality 5.5%, n=1135

1Grant et al. Clinical Otolaryngology, 2009;

2Lowe et al. Clinical Radiology, 2012; 3Lim et al. Intestinal Research, 2016

• Morbidity - 484 patients (51 failed insertions)

– Mean age 66, 58% male

• 45% neurological disorders

• 44% tumours

• 11% venting or head trauma

Blomberg et al. (2012) Scandinavian J Gastro, 47(6):737-42

What about RIGs? Morbidity

2 weeks - 453 2 months - 373

No complication 279 (61%) 271 (73%)

Leakage 43 (10%) 30 (8%)

Diarrhoea 50 (11%) 36 (10%)

Constipation 26 (6%) 18 (5%)

Abdominal pain 57 (13%) 16 (4%)

Fever 10 (2%) 5 (1%)

Peri-stomal

infection

50 (11%) 23 (6%)

Blomberg et al. (2012) Scandinavian J Gastro, 47(6):737-42

Morbidity Morbidity

• Increased risks if: – Radiotherapy

– Cirrhosis

– Altered anatomy

– Diabetes

– COPD

– High CRP

– Low albumin

– Age

Underlying

disease

factors

‘Current’

patient

factors

Blomberg et al. (2011) GI Endoscopy, 73(1):29-36

Leeds et al. (2011) GI Endoscopy, 74(5):1033-9

Enteral nutrition - PEGs

Sheffield Gastrostomy Score

Age >60 g/l 1 OR 5.4

Albumin 25-34 g/l 1 OR 4.6

<25 g/l 2 OR 10.0

Risk score Mortality %

0 0

1 7

2 21

3 37

Leeds et al. (2011) GI Endoscopy, 74(5):1033-9

Other ‘scores’

• CRP > 10 OR 3.47

• Alb < 30 OR 3.47

• Combination OR 7

Blomberg et al. (2011) GI Endoscopy, 73(1):29-36

Minimising risk factors

• Individual assessment

• MDT

• Defer if ongoing inflammation

• Good aftercare essential

– ICP

If there is prolonged or severe pain after the procedure, pain

on feeding, fresh bleeding, external leakage of stomach

contents or tube displacement

stop feed / medication delivery

immediately. Obtain senior

advice urgently and consider

CT scan, contrast study or

surgical review.

PEG decisions

• High mortality and morbidity

• Previously no formal training, with learning

‘on the job’

• Population growing older

– More co-morbidities

– Expectations changing

Cases

Case 1

• 65 year old man

– Stroke due to left MCA infarct

– Unsafe swallow

– NG fed for 4/52 with no improvement

– Referred for PEG

Case 1

• Would you insert a PEG?

1. Yes

2. No

Case 1 – evidence for PEG

insertion after strokes

• FOOD trials (Food or ordinary diet)

1. Normal vs. supplements

2. Tube feeding vs. not

3. NG vs. PEG

• Essentially NG feed for first 3 to 4 wks

• Then place PEG if swallow unsafe

Lancet 2005, 365: 755-763; Lancet 2005, 365: 764-772

Case 1

• On review

– Anterior resection 2003 (Rectal ca)

– Hb 9.6, MCV 74, ferritin 4

– OGD and CTC requested

– Transverse colon cancer

– He/family unkeen for surgery

Case 1

• Would you insert a PEG?

1. Yes

2. No

Case 1

• Further review/discussion

– Cancer limited to colon

– Patient preference to avoid further NG tubes

– CT reviewed to plan if safe

• PEG inserted 31/10/15

• Still alive!

Case 2

• 85 year old lady

– ‘Neuromuscular dysphagia’

– Gastric cancer diagnosed February 2014

– Mild dementia

– Referred for a PEG in August 2014

Case 2

• Would you insert a PEG?

1. Yes

2. No

Case 2

• Initial review

• OGD – stable tumour and cricopharyngeal

spasm

– No to PEG, on basis of:

• Unclear diagnosis ? Part of dementia

• Gastric carcinoma

Case 2

• But C of E consultant phoned…

– Pt hungry

– Good quality of life

– Neurological review – not related to dementia

– PEG placed 27/10/2014

– Died 14 months later

Case 3

• 78 year old man

– Gastrectomy in 1950s for PUD

– Pharyngeal carcinoma – surgical jejunostomy placed

– 2 admissions where jej fell out

• Jejunostomy resited under GA (v unwell post-op)

• NG placed through site – tract then dilated and

balloon tube placed

– Admitted as jejunostomy fell out….

Case 3

• How should he be fed?

1. PEJ

2. Surgical jejunostomy

3. Long-term naso-jejunal feeding

Case 3

• Pt and family unkeen on long-term NJ feed

• Attempted PEJ

• Actually gastric remnant – PEG sited 4/11/14

• Still alive!

Case 4

• 60 year old lady

– Admitted with aspiration pneumonia

– Referred for a PEG +/- PEG-J

Case 4

• On review

– Vaculopath

– Vascular dementia

– Weight loss

– Long history of progressive difficulty in eating

– Family concerned “she’s starving to death”

Case 4

• Would you insert a:

1. PEG

2. PEG-J

3. Neither

Case 4

• MDT review

– Family

– Consultant gastroenterologist

– 2nd opinion for C of E physician

– Progressive vascular dementia

– Clear deterioration over past 6 months

– Risks vs. benefits

– Palliative approach agreed

Case 4 – evidence for PEG

insertion if dementia

• Starting point should be NO!

– Failure of swallowing end-stage

– No evidence of benefit • 30 day mortality up to 54%

• 90% mortality at 1 year

– Ethical 2nd opinion useful

– End of life discussions…

NCEPOD, 2004; Sanders et al. Am J Gastro 2000

Other situations - evidence

• Chronic progressive neuromuscular

disease

– Improved nutritional parameters

– Improved function

– Prolonged survival

– But beware respiratory function

Other situations - evidence

• Other acute neurological injury

– LGI regional neurology centre

– Large numbers

– Good outcomes

– Beware ‘easier for placement’…..

Other situations - evidence

• Cystic fibrosis

– Stabilises lung function

– Evidence for benefit in children and adults

– Smaller size gastrostomy tubes

– Often low profile tubes

Other situations - evidence

• Anorexia nervosa

– No!

– No benefit

– Lots of complications

Summary

• Gastrostomy insertion

– High risk

– Low frequency

– Systematic approach

– MDT

– Robust aftercare

• Integrated Care Plan

What to do if a tube falls out?

• Put SOMETHING into tract

– Foley catheter

– Replacement gastrostomy

– NG tube

• If gastrostomy

– Wire

– Dilatation

– New tube