Dilemmas in placing PEG tubes
Transcript of Dilemmas in placing PEG tubes
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