PEG ESPEN Guidelines

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Clinical Nutrition (2005) 24 , 848 861

CONSENSUS STATEMENT

ESPEN guidelines on articial enteralnutrition Percutaneous endoscopic gastrostomy(PEG)

Chr. Loser a, , G. Aschl b , X. Hebuterne c , E.M.H. Mathus-Vliegen d ,M. Muscaritoli e , Y. Niv f , H. Rollins g, P. Singer h , R.H. Skelly i

a Medical Department, Rotes Kreuz Krankenhaus Kassel, 34121 Kassel, Germany b Medical Department, AKH Wels, 4600 Wels, AustriacGI Nutrition, Archet 2 Hospital, 06202 Nice, Franced Department of Gastroenterology, Academic Medical Centre, University of Amsterdam, The Netherlands e Department of Clinical Medicine, University La Sapienza, Rome, Italy f Department of Gastroenterology, Rabin Medical Center, Tel Aviv University, IsraelgNutrition Nurse Specialist, Luton and Dunstable Hospital, Luton LU4 0DZ, UK hGeneral Intensive Care Department, Rabin Medical Center, Petah Tiqwa 49100, IsraeliDerbyshire Royal Inrmary, Derby DE 1 2 QY, UK

Received 23 June 2005; accepted 23 June 2005

Introduction

Since the rst published report of a percutaneousendoscopic gastrostomy (PEG) in 1980 by Gaudererand Ponsky, 1 the procedure has been modied andimproved several times. It has now replaced thesurgical gastrostomy (Witzel gastrostomy, Stammgastrostomy, Janeway gastrostomy) which wasassociat ed with a markedly higher rate of compli-cations. 2,3 Placement of a PEG/PEJ (percutaneousendoscopic jejunostomy) t ube is simple, safe andwell-tolerated by patients. 4,5 There is a wide rangeof diets and nutrient preparations suitable for tubefeeding currently available. Modern PEG tubesystems made of polyurethane or silicone rubberare easy to insert and well-tolerated. Clinicians

have a broad spectrum of low risk, practicable,patient-orientated forms of enteral nutritionaltherapy available. PEG-feeding, therefore, hasrapidly spread to become routine practice world-wide and is currently the method of choice formedium- and long- term enteral feeding.

Recent studies have provided new information onthe benets and drawbacks of PEG-feeding. Wehave a clearer appreciation of ethical issuessurrounding articial enteral feeding. Since westarted placing percutaneous enteral tube sys t emsby endoscopic techniques nearly 25 years ago 1 ourattitude towards this method has changed in manyways: in the early days PEG-tubes were often usedin patients in the advanced state of predominantlymalignant diseases; this is now regarded as aninappropriate indication in most cases being toolate to offer adequate clinical benets to thepatients in terms of nutritional status and quality of life. Data from a large number of recently

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published clinical studies has modied our views ona variety of issues: on the benets and disadvan-tages of the PEG feeding; on more distinct clinicalindications with regard to important outcomeparameters (i.e. maintenance and improvementof nutritional status and quality of life); on ethicalaspects; and on contraindications, for example inpatients with advanced dementia or during term-inal stages of incurable diseases. In many ways ourmodern point of view has shifted towards an earlierindividual consideration of additional supplemen-tary feeding via PEG tube in appropriate patients,when special nutritional advice and supplementarydrinks are not effective.

Guidelines issued by various specialist authoritieshave been modied in the light of recentlypublished clinical studies and the recommendedprocedur es have been markedly simplied in manyrespects. 69 With this background, ESPEN asked a

multidisciplinary group (nutritionists, gastroenter-ologists, nurses, and medical practitioners) withspecial expertise in the eld to prepare guidelinesand a consensus report on current clinical aspectsof articial enteral nutrition via PEG-tubes in adultsand children. In the following, matters relevant toclinical practice are summarized and discussed onthe basis of the currently available scienticinformation.

Enteral tube systems

In general, tube systems for articial enteralnutrition can be placed by nasal insertion, guidedpercutaneous application, or surgical techniques.The superiority of percutaneously placed gastros-tomies compared to former surgical gastrostomyprocedures (i.e. Witzel, Stamm, Janeway techni-que) h as been shown clearly in many clinicalstudies. 2,3 If it is to be expected that the patientwill require articial enteral nutrition for a longerperiod after abdominal surgery, it is advisable toprepare for subsequent jejunal feeding by prepara-

tion of a ne needle catheter jejunostomy (NCJ)towards completion of the surgical procedure. Thisintraoperative technique enables the use of clini-cally effective early postoperative enteral nutritionin patients who are not able to eat sufcientamounts for a prolonged period after majorabdominal surgery. Today, various techniques andmodications are available. 10 12

Several studies compared the various clinicaleffects of PEG t ube feeding and feeding vianasogastric tubes. 13 17 While nasogastric tubefeeding was found to have a higher rate of

discomfort and complications (irritations, ulcera-tion, bleeding, dislocation, clogging), PEG feedingproved to have higher subjective and socialacceptance, being less stigmatizing, and hadreduced rat es of oesophageal reux and aspirationpneumonia. 13 17 Interestingly it was clearly shownthat with regard to nut ritional efcacy PEG feedingwas superior too. 14,17 Therefore, in our presentunderstanding, feeding via PEG should be preferredif it can be expected that the patients nutritionalintake is likely to be inadequate and supplementaryarticial enteral nutrition is necessary for a periodexceeding 2 3 weeks. Figure 1 shows the decisiontree that can be used in clinical practice to selectthe tube system for enteral nutrition most appro-priate to the requirements of the individual case.Evidence from research with parents suggests thatdecision making in children is difcult and emo-tionally laden; there is a special need for informa-

tion and individual support in these cases.Meanwhile, besides the standard endoscopicprocedure, many modications and other techni-ques for adequate percutaneous placement of enteral tube systems were established and provenin clinical practice. In the hands of an experiencedendoscopist it should be possible to place percuta-neous tube systems in nearly all cases either byendoscopic, laparoscopic, sonographic, or uoro-scopic means. The gastric and jejunal tube systemscurrently available for enteral feeding are outlinedin Fig. 2. Articial enteral nutrition should eitherbe given into the stomach or beyond the ligamentof Treitz, there are no medical reasons for any kindof duodenal feeding. In cases in which endoscopicinsertion of a tube is not technically possible,gastric (PLG) and jejunal (PLJ) enteral tubesystems can also be placed using laparoscopic

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no riskof aspiration

riskof aspiration

nasojejunaltube

no longer possibleno longer adequate

short - termunknown duration

long - term( > 2 - 3 weeks )

no surgery no surgery surgery

PEG PEJJET-PEG

prolonged requirement

nasogastraltube

no riskof aspiration

riskof aspiration

ORAL NUTRITION :

NCJ

Figure 1 Decision tree for the selection of the appro-priate tube system for enteral nutrition (for explanation,see text).

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gastrointestinal tract; PEG tubes may be usedpalliatively in inoperable cases or placed prior tosurgery, radiotherapy or chemotherapy andremoved when the patient has recovered andhas a reliable and adequate oral intake).

Neurological disorders (dysphagic states aftercerebrovascular stroke or craniocerebral trau-ma, and in patients with cerebral tumours,bulbar paralysis, Parkinsons disease, amyo-trophic lateral sclerosis, cerebral palsy).

Other clinical conditions (wasting in AIDS, shortbowel syndrome, reconstructive facial sur-gery, prolonged coma, polytrauma, Crohn 0s dis-ease, cystic brosis, chronic renal failure, con-genital abnormalities, e.g. tracheo-oesophagealstula).

Another indication for use of a PEG system is thepalliative drainage of gastric juices and secretions

in the small intestine in the presence of a chronicgastrointestinal stenosis or ileus. In non-selectedpatients less than 40% of patients wi th a PEG tubehave a malignant underlying disorder. 4 According tothe recent literature, the main therapeutic indica-tions are benign neurological disorders (almost 50%of cases) and ENT disorder susually malignant(approximately 30% of cases). 4

Aggressive cancer treatment (chemotherapy,radiotherapy) denitely requires an adequateindividual nutritional strategy. With the likelihoodof transient catabolic metabolism in this situationand the related increased risk of weight loss, PEGtubes can be used liberally; it has been demon-strated clearly that early and appropriate supple-mentary enteral nutrition via a PEG system is moreeffective than oral nutrition alone in those cases inwhich the patient undergo es several weeks of chemotherapy/radiotherapy. 44,45 In critically illpatients suffering from major head trauma, persis-tent or slow recovering vegetative state, or long-term intensive care stay: PEG should be consideredearly in order to ensure an adequate nutritionalsupport and to prevent the well-known drawbacksof prolonged nasogastric tube feeding. 46 Enteral

feeding can easily be terminated after such therapyif patients have recovered and have a stable,adequate oral food intake. Furthermore, prospec-tive clinical studies clearly reveal, that in mostcases supplementary PEG feeding can preventongoing weight loss and maintain nutritional statuswhile full reversal of wei ght loss is rare even inbenign diseases ( Fig. 3). 4,44 These clinical datahave led us to a more generous and a much earlierindividual discussion on the benets of additionalfeeding via PEG in appropriate patients. Figure 3from a prospective clinical study in 210 consecutive

patients depicts the two major problems: (I) onaverage adult patients lose about 12 kg body weightwithin the last 3 months before PEG placement isconsidered (and this is found for patients withmalignant as well as benign underlying disease inprecisely the same way!) and (II) this signicantdeterioration of nutritional status can be halted inmost cases but, even in patients with benigndiseases, it is very rare to fully regain lost wei ghtand return to the former nutritional status. 4,44

Though, a timely PEG placement is benecial inmost cases a general statement concerning optimaltiming is difcult and primarily depended on theindividual conditions.

HIV/AIDS

PEG placement may help to improve medicationcompliance in children and signicantly increasesnutritional sta tus in AIDS patients with wastingsyndrome. 47,48

Cystic brosis

There appears to be a consensus stating thatnocturnal PEG feeding of malnourished patientswith cystic brosis improves nutritional status,stabilizes lung function, is superior to the use of nasogas tri c tubes, and is without major sideeffects. 49 Since the long-term benet depends onpre-gastrostomy pulmonary function, with bett eroutcome observed with good pulmonary function, 50

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Figure 3 Time-course of body weight in all patients(n 210) and separately in patients with benign ormalignant underlying disease retrospectively for 3months before and prospectively 12 months after PEGplacement (Loser et al., Dig Dis Sci 1998; 43: 2549-2557;

for comments, see text).



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PEG insertion should be performed early in thecourse of the disease.

Crohns disease

Despite fears of complications such as stula

formation, recently published studies reveal thatPEG placement is safe with no higher rat e of complication in patients with Crohns disease. 51 54

Furthermore, supplementary feeding via PEGproved to be highly effective even in children withsevere growth retardation which nowadays makessupplementary feeding via PEG the most reliablenutritional measure available in malnourishedpatients with Crohns disease, where supplemen-tary nutritional drinks are not effective.

Small children

In experienced hands PEG-tubes can be placedsafely in low weight infants a nd neonates, even inthose weighing less than 3kg. 55

Mentally and physically retarded children

Feeding via PEG is able to substantially improvenutritional status and quality of life in mentallyretarded children and adults. 56 However, due tophysical deformities (severe kyphoscoliosis), place-ment is often complicated but feasible in experi-

enced hands. As the placement is sometimesimpossible, the procedure should be performedunder general anaesthesia in the operation room,and proceed with a minilaparotomy if the anato-mical situation prohibits endoscopic positioning.The surgeon punctures the stomach helped by theminilaparotomy, and the endoscopic procedurethen follows as usual.

Stroke, neurological dysphagia

Dysphagic states in neurological disorders are the

most common and established in dications forarticial enteral nutrition via PEG. 4,6,7,42,43 Theassessment of safe swallow and adequacy of nutritional assessment are crucial in determiningwhich patients with neurological dysphagia shouldbe referred for PEG. Especially in stroke patientswith dysphagia and inadequate oral food intakeearly feeding via PEG is helpful and highlyeffective, and in contrast to nasogastric tubefeeding allows in parallel adequate training to re-enable swallowing. In stroke patients PEG can beremoved when the ability to swallow recovers and

adequate oral food intake is possible withoutcomplications.

Amyotrophic lateral sclerosis

Most of these patients will receive a PEG. Thedecision for PEG placement should be made early inthe course of the disease as restricted pulmonaryfunction w ill reduce the chance of successfulplacement. 57 Pulmonary function with a vitalcapacity of more than 50% of the predictedcapacity is recommended, but in experiencedhands, PEG placement is feasible in patients witha VC of 1 l and a P CO2 of less than 45 mm Hg(6.5pKa). Sedation is critical and the stomachshould actively be desufated after the procedureas patients cannot lower the raised diaphragmthemselves.

Dementia

The most controversial area regarding PEG place-ment concerns patients with dementia. Stated aimsof tube feeding in advanced dementia includeimproving functional status, avoiding hunger, im-proving comfort, preventing nutritional decline andits consequences, preventing aspiration and redu-cing the incidence of pressure sores and infections.Although there are no randomized controlledstudies, recent reviews conclude that there is nopublished evidence that these aims are

achieved.58 61

Overall published data support anindividualized but critical and restrictive approachto PEG feed ing in elderly demented pa-tients. 36,37,39,41

Contraindications

Serious coagulation disorders (INR 4 1.5, Quick o 50%,PTT4 50 s platelets o 50,000/mm 3), interposedorgans (e.g. liver, colon), marked peritoneal carci-nomatosis, severe ascites, peritonitis, anorexia

nervosa, severe psychosis and a clearly limited lifeexpectancy are contraindications for the use of PEG/PEJ systems. 68 Though clinical studies are notavailable taking of low dose aspirin is not estab-lished as a contraindication for PEG-placement.Nowadays, the lack of diaphanoscopy (transillumi-nation of the endoscopic light through the abdom-inal wall) at the puncture area is no longer acontraindication; a negative needle aspiration test(using a syringe containing 5 ml saline solution,puncture under continuous aspiration towards theair-lled stomach without prior air aspiration)

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proved to be even safer than an adequatediaphanoscopy. 62 It has been shown in clinicalstudies that the presence of mild to moderateasci te s63 and/or a ventriculoperitoneal shunt sys-tem 64 are no longer contraindications for theinsertion of a PEG/PEJ tube, as an increased rateof complications has not been demonstrated underthese circumstances. Peritoneal dialysis treatmentis also not a contraindication for the use of a PEGtube. Particularly, in the paediatric eld, goodresults have been reported for the use of PEG tubesor button systems b eing placed prior to the start of peritoneal dialysis. 65,66 Case reports conrm thateven in pregnancy PEG tubes can be inserte dsuccessfully with no increased complication rate. 67

Oesophageal stenoses are not a contraindication,providing these can be passed by a very thinendoscope ( direct puncture technique ) or can betreated with endoscopic dilatation (pull techni-

que). It may be necessary to consider placing anoesophageal tube or stent (to improve quality of life by allowing swallowing of saliva, drinking atwill, tasting food, etc.), and to simultaneouslyinsert a PEG tube for adequate supplementarynutrition which is hardly possible in these casesjust by the oral route. In order to exclude thepossibility of local contraindications, gastroscopy isroutinely conducted prior to insertion of a PEG/PEJtube. Severe erosive gastritis or ulcer should behealed before an enteral feeding tube is inserted.Extensive tumour inltration in the area of thepuncture site also represents a local contraindica-tion. Previous gastrointestinal surgery (such asBillroth I or II resection or total gastrectomy) is nolonger considered a contraindication for the use of PEG/PEJ tube systems. Although, the primarysuccess rate for endoscopic placement of enteralfeeding tubes is somewhat lower in patients whohave undergone previous gastrointestinal surgery,the procedure can be carried out without asignicant increase in risk if diaphanoscopy issuccessful and/or the needle aspiration test isnegative.

Initial examination and informed consent

As the endoscopic insertion of an enteral feedingtube represents an elective invasive procedure andphysical injury from the legal point of vie w, it isessential to obtain legally valid consent. 41 Thenature and scope of the information to be given tothe patient and the related documentation shouldfollow the general guidelines for obtaining in-formed consent from patients prior to endoscopic

procedures and minimal invasive surgery. In thecase of patients with reduced legal capacity who asyet have no legal guardian, consent must beobtained from the local magistrates court prior toendoscopic placement of an enteral feeding tube inmost European countries, as is the case prior toother invasive, elective procedures. Nevertheless,in this regard the law is clearly different indifferent European countries and the special locallegal provisions have to be taken into account. Inthose cases in which there is no recent documenta-tion of the patients will to undergo the procedure,it is not sufcient from the legal point of view tomerely obtain consent from close relatives.

The preparatory measures required prior toendoscopic tube insertion are outlined in Table 1 .An indwelling venous catheter should rst beinserted. This allows for appropriate sedation forthe procedure with a short acting benzodiazepine

derivative (such as midazolam, 35 mg i.v.). Thepatient should be fasted for at least 8 h prior to the

PEG procedure. If there is extensive hair growth onthe abdomen, the epigastric region should beshaved above the umbilicus. It should be ensuredthat the current coagulation status is as follows:INR o 1.5, Quick 4 50%, partial thromboplastintime o 50 s and platelet count 4 50,000/mm 3 . Aspir-in can be stopped ve days prior to PEG-placement,but though it is not yet investigated in clinicalstudies clinical practice reveals that PEGs can beplaced in patients taking low dose aspirin medica-tion without increased risk of complications. Thereis no evidence that discontinuation of drugs whichinuence gastric acid secretion, such as H 2 receptorantagonists or proton pump inhibitors, is necessaryprior to insertion of a PEG tube. Children tend tohave a general anaesthetic and a shorter period of starvation.

Preparation, antibiotic prophylaxis

The adult patient should be fasted for at least 8 h

prior to the procedure for insertion of a PEGsystem, or longer in cases in which there isevidence of impairment of gastric motility. Cur-rently, there is a controversial debate in theliterature as to whether a single dose of anantibiotic (e.g. 2 g of a cephazolin i.v.), as ageneral prophylaxis, provides effective protectionagainst in ammatory complications (for an over-view, see). 68,69 At present, there are more pub-lished studies in which a clinical benet of asingle adminis trati on of an antibiotic has beendemonstrated, 70 75 while there are two studies in

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which no advantage in respe ct of the prevention of wound infection was found. 76,77 Additionally, onerecently published meta-analysis 69 conrmed theclinical benets of a single-shot antibiotic prophy-laxis. In view of the various criticized inadequaciesand obvious methodological aws of the publishedstudies, it is not possible to draw a deniteconclusion at present. There is no consensus as tothe general benet of prophylactic use of anti-biotics, so that in the late 1990s many experiencedcentres started to provide antibiotic prophylaxisonly in patients with a particularly high-risk prole.The German Association of Gastroenterology(DGVS) no longer recommends a general antibioticproph ylaxis in their revised new guidelines from2002. 78 On the other hand, ofcial guidelines of European and American Societies of Gastrointest-inal Endoscopy have recommended the use of asingle intravenous dose of anti bioti cs for allpatients undergoing PEG insertion, 79,80 which is inline with most of the published studies. 69 75

In summary we recommend that, in experiencedhands under established hygienic conditions, rou-

tine antibiotic prophylaxis is not mandatory for PEGplacement. However, in case of doubt or outsideexperienced centres a generous decision in favourof antibiotic prophylaxis is recommended. It is notnecessary to give a single, prophylactic dose of anantibiotic if the patient is already receivingantibiotic therapy.

A gastroscopy should be performed as a routinemeasure prior to insertion of the PEG tube. Theappropriate preparations for this procedure mustalso be taken. The examination should be con-ducted with the patient supine and the patients

head turned to the side. An aspirator should beavailable in cases where there is extensive forma-tion of mucus or other secretions. The PEGinsertion procedure is conducted using standardsurgical procedures under sterile conditions (skindisinfection, sterile surgical drapes, sterile glovesfor the PEG insertion, sterile dressing, etc.).

Technique

A variety of insertion techniques and a wide rangeof commercially available PEG systems, currentlyallow the experienced endoscopist to achieve asuccess rate greater than 99% for the procedureand a met hod-related mortality rate close to0%.4,31,81 83 Such success depends on meetingestablished technical standard s and observing thewell-known contraindications. 4,29,81 85 In patientswho have undergone prior gastric surgery (BillrothI- or II-resection, total gastrectomy , et c.) the

success rate is only slightly reduced.81,86

A PEGtube can be placed using either the pull throughmethod (pull technique), the Seldinger techni-que (push technique) or by direct puncture. Thethread pull through technique is the simplest andsafest technique and has become the most fre-quently used in clinical practice, followed by thedirect puncture method. As a general rule it isadvisable to use PEG tubes with a large lumen (atleast 15 Charrie re) even in children as smallerdiameter tubes are associated with higher rates of clogging.

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Table 1 Preparations and aftercare prior to and after endoscopic placement of an enteral tube system.

Preparation Aftercare

Exclusion of contraindications Allow external xation plate to adapt over night withlow traction (avoid tension!)

Current coagulation status (INR o 1.5, Quick o 50%,PTTo 50 s, platelets 4 50,000/mm 3)

Ensure tube has sufcient free movement 4 5 mmafter rst change of dressing next morning

Written informed consent (see text) Sterile Y-compress under the external xation plateIndwelling venous catheter Cleansing and sterile renewal of dressings initially on

a daily basis (later every 2 3 days) (see text)Patient fasting overnight (8h) Nutrients can be delivered via the tube 1h after

uncomplicated PEG placementAntibiotic prophylaxis (2 g cephazolin i.v.) (see text) Individual nutritional schedule (calories, uids, etc.)Shave the epigastric region above the umbilicus if necessary

Training of patients and relatives

Analgesia/sedation (e.g. midazolam i.v.), generalanaesthetic for children

Organization of further aftercare and nutritionalsupply

Placement of tube system under sterile surgicalconditions

Social support for patient and his family



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According to prospective studies PEG placementusing the standard pull through method takesapproximately 12 min. 4 In the thread pull throughmethod, the puncture site is marked with gastro-scopic monitoring of the anterior gastric wall in theregion of the distal corpus by means of diaphano-scopy or the needle aspiration test (see above) and,after adequate local anaesthesia (-in children longacting local anaesthetics e.g. bupivacaine shouldbe prefered to improve local pain relief postinsertion-) and an appropriate ( 8 mm, dependingon the tube size-) initial incision, the puncturecannula is inserted under endoscopic control intothe stomach which has been previously fully dilatedwith air. As stated above, lack of diaphanoscopy inthe region of the puncture site is no longerconsidered a contraindication for the procedure,assuming that there are no problems during needlepuncture (without prior air aspiration) using a

syringe containing 5 ml saline solution d uringgastric aspiration (needle aspiration test). 62 Asuture thread or guide wire is passed through thecannula sheath into the stomach, grasped using thebiopsy forceps by the endoscopist and drawn outthrough the mouth together with the gastroscope.The thread loop is fastened tightly to the externalend of the PEG tube and, while applying continuoustraction, is drawn down through the oesophagusand stomach and out through the puncture siteuntil the internal xation plate has drawn theanterior wall of the stomach against the abdominalwall. To avoid causing damage to the mucosa whilepulling the thread or wire, it must be ensured thatthe cannula sheath remains in the puncture canalduring the positioning phase until the conical tip of the tube is locked in its intragastric end. Providedthat positioning of the PEG tube has been con-ducted without complications, it is unnecessary toconrm appropriate placement by means of furthergastroscopy or X-ray. 87

In order to avoid the most commonly occurringcomplication, i.e. wound infection, it is impor-tant that the following general measures aretaken and these should be followed as a part of

routine practice: it should be ensured that theincision at the puncture site is sufciently large(8 mm) so that the tube does not cause pressure-related lesions in the skin area with subsequentischaemia; a Y-compress should be used to avoidthe formation of a moist cavity under the externalxation plate and, furthermore, to cushion move-ments; to ensure that local ischaemia is notinduced, the external xation plate should retainthe tube but not exert any tension on the stomacanal and allow free movement of the tube of atleast 5 mm.

Aftercare

On the basis of our current experience, there is nolonger any justication for the previously recom-mended procedure of application of traction to thefreshly inserted PEG system for the initial 24 h toachieve better adaptation of the gastric to theabdominal wall. On the contrary, if the tensionapplied is too great and is maintained for too long,there is the possibility of ischaemia and thus woundhealing complications and an increased risk of infection. In order to achieve appropriate adapta-tion, the external xation plate should be initiallysubjected to very low traction, without tension,overnight. It must thereafter be ensured that thetube has at least 5 mm of free movement when theY-compress is inserted under the external xationplate ( Table 1 ).

The rst change of dressing should be performed

the morning after PEG placement. Until granulationof the stoma canal has taken place it is advisable tochange the sterile dressing daily and provide localdisinfection (usually day 1 7). Dressings should beremoved and the xation plate opened and thetube removed from the groove. Then gloves aredisposed of, hands disinfected and new glovesapplied. The wound area is inspected (bleeding,erythema, secretion, induration, allergic skin reac-tion etc.), cleaned, disinfected and dried comple-tely. In order to avoid adhesions (buried bumpersyndrome, see below) the tube should be pushedapproximately 2 3 cm ventrally and carefullypulled back up to the resistance of the internalxation ange. Then a Y-compress is applied underthe tube and the external xation plate is securedwith free movement of at least 5 mm and a steriledressing is applied.

After initial wound healing wound cleansing anddressing should be performed every 2 3 days.Dressing with a simple plaster around the woundis possible. Washing with soap and water orshowering is possible after initial wound healing(12 weeks after insertion of PEG ); dressingsshould always be removed before washing, residual

soap rinsed away and the tube dried well before anew dressing is applied.After feed or medication administration the tube

should be ushed with about 40ml of drinking orstill mineral water.

As part of the further care of a patient with a PEGsystem, preparation of an individual nutrition plan(calculation of the patients daily calorie and uidrequirement, choice of the appropriate nutrientpreparations, etc.) is required, and, where neces-sary, the patient and his/her relatives may need tobe trained in care of the tube and administration of

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the feed. Meanwhile, measures for the futuretreatment and home care of the patient must beorganized and coordinated. For patients withcerebrovascular disease routine follow-up for ex-ample by speech and language therapists mightimprove the identication of patients whoseswallowing has improved sufciently to allow fulloral feeding and removal of the PEG tube, whichoccurs in about 25% of stroke patients requiringinitial PEG feeding.

To prevent material fatigue, the C-clamp shouldbe repositioned daily or preferably left open if notneeded. The tube tip should be cleaned daily usingwater and a small brush. Common errors madeduring enteral tube feeding that can cause con-siderable discomfort for the patient include toorapid build up of enteral nutrition in a patient whohas received total parenteral nutrition over aprolonged period, delivery of an excessive volume

as a bolus, delivery of the nutrient preparation attoo high or too low temperatures, uid deciency,insufcient supply of dietary bre and the use of nutrient preparations which are inadequate for theindividual patient.

Complications

The rate of complications after endoscopic place-ment of enteral feeding tubes is estimated in theavailable literature to be in the range 8 30%,depending on the very different denitions of whatactually constitutes a complication. Serious com-plications requiring tre atment occur in a pproxi-mately 1 4% of cases.4,29,34,43,81 83,85,88 90 Acuteand severe complications, such as perforation,serious abdominal haemorrhage or peritonitis,which require surgical intervention, occur in farfewer than 0.5% of cases, provided that the above-mentioned contraindications are observed.

The most frequent complication is the occur-rence of local wound infection (in approximately15% of cases). Less than 5 mm of reddening aroundthe outer stoma canal is frequent. It is largely

induced by movement and is not necessarily a signof wound infection. During initial daily change of dressing the wound should be inspected and red-dening should be carefully noted. Most of theperistomal forms of infection can be readily treatedby means of antiseptic measures and daily changeof dressings under sterile conditions. After taking aswab for microbiological examination, persistentlocal infections should additionally be treated byantibiotics. Radiological evidence of pneumoper-itoneum is very frequently observed after place-ment of a PEG system. It is reported in the

literature 91 93 that pneumoperitoneum after inser-tion of a PEG tube may occur in more than 50% of cases; nevertheless, a pneumoperitoneum is notregarded as a complication since there is no clinicalevidence of adverse consequences. Even in cases of pneumoperitoneum and abdominal pain the pa-tients rst should be treated conservatively sincesevere cases are denitely rare and many unneces-sary explorato ry investigations have been de-scribed. 43,91 93

In the initial days after endoscopic placement of an enteral feeding tube, patients may complain of peristomal abdominal pain, fever (in some in-stances with transient leukocytosis) or occasionallytransient leakage of the stomach contents from thegranulating puncture canal. If gastric contents areleaking skin protection for example using a hydro-colloid wafer as a keyhole dressing is an importantissue. The possible long-term complications after

placement of a PEG tube include occlusion of thetube, tube porosity and fracture with subsequentleakage from the tube or the tube connection,development of cellulitis, eczema or hypergranula-tion tissue (proud esh). The development of mostof these potential long-term complications isexclusively dependent on the quality of aftercaregiven to the tubing system, and can be effectivelyavoided if the proper measures are taken. Inassociation with the use of the thread pull throughmethod, 16 cases of contact cancer at the puncturesite due to the presence of occluding proximaltumours have been reported worldwide, althoughin none of these very rare cases did this prove to bea life-limiting factor. 94

Buried bumper syndrome is a rare complicationand to the best of our knowledge can be avoided byadequate aftercare treatment (see above). Never-theless, if a buried bumper syndrome occurs it isremovable in nearly all cases by endo scopic meansusing a needle knife sphincterotome. 89,95,96

Removal of a PEG system

We now frequently use PEG tubes as a prophylacticor temporary measure so the task of removing thetube is more common. In some c entres up to2030% of the PEG tubes are removed. 4 Although, ithas been demonstrated in clinical studies that PEGsystems can be removed by simply cutting away theexternal catheter and allowing the internal xationplate to pass from the body by th e na tural routewithout complications in adults, 97,98 it is stillrecommended to remove the xation plate endos-copically by catching it with a snare, since there

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are several reports of subsequent il eus, need foroperation, and even fatal outcome. 99,100 In chil-dren, PEG-tubes must be removed by endoscopicmeans in any way. Recent investigations haveshown that patients can ingest nutrients orallyimmediately after removal of a PEG system andthat the puncture canal heals rapidly, whencovered externally with a sterile compress. It isrecommended not to remove PEG tubes within therst ten days after initial placement because of apossibly higher risk of local complications as forexample peritonitis during this period.

In the meantime, there are now commerciallyavailable PEG systems with internal xation plateswhich can be released from the outside so thatthese tube systems can be simply removed percu-taneously without further endoscopy. Such PEGsystems are particularly suitable and clinicallyindicated in cases where it can be anticipated that

there will only be a temporary requirement foradditive enteral nutrition via a tube system, e.g. asis frequently the case during planned chemother-apy or radiation therapy in patients with criticalbaseline nutritional status.

The durability of a PEG tube system is primarilylinked to its careful handling. There is no need toexchange a tube system at regular intervals. In caseof adequate handling PEG tubes can stay in situ formany years exceeding even 10 years and more.

Clinical value, quality of life

PEG feeding has a distinct clinical value in thetreatment of patients with either malignant diseaseor benign conditions. In the case of patients whowill be able to ingest considerably less than theirfull daily uid and calorie requirement for theforeseeable future (for a period exceeding 2 3weeks), nutritional support by means of a PEGsystem provides the energy required for recoveryfrom the disorder and allows patients to feed orallyas far as they are able, but without the need to feel

forced to eat or drink without appetite or a safeswallow. In patients choking in their meals due tomuscle fatigue or weakness, additional PEG-feed-ing decreases the urgency to eat adequately. It isessential to provide an adequate nutritional regimefor patients with borderline or poor nutritionalstatus who are receiving radiotherapy/chemother-apy. In order to increase the patients tolerance of the treatment, reduce the complication and hospi-talization rate, and to maintain the patientsquality of life, temporary supplementary feedingvia an enteral tube should be considered in the

individual case. 44,45 For the patients who did notreach their nutritional requirements in the weeksbefore PEG insertion, nutritional support should beinitiated in a stepwise fashion together with amonitoring of biochemical parameters to preventrefeeding syndrome. Prospective clinical studiesclearly prove the inability to regain nutritionalstatus in most patients after severe loss of bodyweight even in those with benign underlyingdisorders ( Fig. 3)4,44 ; therefore, an early individualconsideration for supplementary enteral nutritionvia PEG is important.

Long-term prospective clinical studies havedemonstrated that the patients subjective accep-tance and tolerance o f enteral nutrition using a PEGsystem is excellent. 4,5 In a prospective study 3months after insertion of the PEG system, morethan 80% of patients gave the standard PEG tubemethod of nutrition the highest score on a four-

point scale.4

Prospective clinical studies have alsodemonstrated that enteral nutrition via a PEG tubesignican tly imp roves the quality of life of thepatients. 5,101,102 In a prospective long-term study in155 non-selected, consecutive patients, a signi-cant improvement in quality of life was found afternutrition via PEG for patients both with benign andmalignant underlying disord ers as well as consciousand unconscious patients. 5 On the other hand,studies from nursing homes and in older adultspaint a picture of frailty and dependency amongsttube fed patients. 101,103

As already pointed out earlier it is important tocarefully select patients being suitable for PEGfeeding on the basis of established medical andethical indications and contraindications. Theindividual benets with regard to quality of life isexpected to be lower in older patients and patientswith complex and severe co-morbidity and there-fore individual indications for feeding via PEG-tubes sho uld be considered more critically in thesepatients. 101,103

Recent developmentsIn addition to the routine endoscopic technique forpercutaneous placement of an enteral nutritiontube, there are now many alternative, well-standardized installation methods and techniques:laparoscopic (PLG, PLJ), sonographic (PSG, PSJ),uoroscopic (PFG, PFJ) and surgical (NCJ; Witzel orStamm stula) ( Fig. 2). Over the past few years,many of the different steps of the procedure havefortunately been simplied or even omitted on thebasis of results obtained in clinical studies: after

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complication-free placement of a PEG system,radiological or endoscopic control is no longerrequired on a routine basis; delivery of nutrientsvia the tube can commenc e with in 12 h afterplacement of a PEG system 104 107 ; routine anti-biotic prophylaxis is not obligatory in all cases;gastric acid secretion inhibitors do not necessarilyhave to be discontinued prior to placement of aPEG system; after endoscopic removal of a PEGtube, the patient can eat immediately; thedurability of a PEG system is primarily dependenton the quality of aftercare given to the tubingsystem; and routine removal and replacement of aPEG tube is not necessary as patients have used thesame PEG system for more than 10 years withoutcomplications.

Contraindications applicable to date such as lackof diaphanoscopy, mild to moderate ascites,Crohns disease, ventriculoperitoneal shunt, peri-

toneal dialysis or concomitant administration of immunosuppressants, can no longer be consideredcontraindications. On the contrary, Crohns diseasein young patients with malnutrition and retardationof growth is now an established indication fortargeted, long-term nutritional therapy via a PEGtube if oral measures are not successful.

Concluding remarks

Based on many recently published clinical studiesour earlier view of PEG being primarily linked toadvanced stages of mainly malignant diseases hasswitched to support for earlier decision making in alarge variety of potential patients with differentunderlying diseases. Patients with advanced can-cer, end-stage diseases or advanced dementia arenot usually considered appropriate candidates forarticial feeding via PEG tubes. Overall publisheddata support an individualized but critical andrestrictive approach to PEG feeding in suchpatients. In experienced hands PEG placementand feeding is a safe and highly effective procedure

if modern devices are used and established stan-dards are adhered to. Nevertheless, decisionmaking is still difcult in many cases having alwaysan individual character. Prospective clinical studieshave shown, that guidelines help to improve theappropriateness of patients selection and play aproactive role in the decision making for medicallyadequate PEG ins er tion with a consecutivelyimproved outcome. 108

Enteral nutrition via a tube system inserted withendoscopic guidance is an efcient, highly effec-tive and easy to use technique, associated with a

low rate of complications, which allows themaintenance of adequate enteral nutrition of patients who are unable to ingest sufcientnutrients orally. Clinical studies have demonstratedthe high level of acceptance by patients and themarked improvement in nutritional status andgeneral well being of such patients. In order toprevent deterioration of nutritional status and toimprove their overall quality of life, the decisionwhether or not to use an enteral tube system forfeeding should be taken at a much earlier stage andshould be more frequently positive in appropriatepatients who full the above mentioned anddiscussed criteria.

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