Successful new method of extracorporeal percutaneous endoscopic gastrostomy (E-PEG)

Hybrid percutaneous endoscopic gastrostomy (Hybrid PEG) improves patient safety by combining pull-through technique with gastropexy

Background and study aims

The direct puncture technique has been associated with a better safety profile compared with the classical pull-through technique for insertion of a percutaneous endoscopic gastrostomy (PEG). In this study, the safety of the hybrid PEG technique, combining gastropexy with the pull-through technique, was analyzed in a large retrospective patient cohort.

Patients and methods

Clinical data from patients undergoing PEG insertion in a high-volume center for endoscopy were included retrospectively between January 2016 and December 2021. Patient characteristics and complication rates were correlated in univariate and multivariate analyses.

Results

Data from 351 patients undergoing PEG insertion with the hybrid PEG technique were compared with 145 procedures with the direct puncture technique and 1073 procedures with the pull-through technique. In the group where gastropexy was performed (hybrid PEG and direct puncture), we could not find any significant differences in frequency of major and minor complications. Comparing the pull-through technique with the gastropexy group, we detected a five-fold higher major complication rate and a doubled minor complication rate for the pull-through technique. Multivariate analysis confirmed the protective role of gastropexy, with an odds ratio of 0.166 (0.084-0.329; P < 0.001) for major complications.

Conclusions

Hybrid PEG and direct puncture are equally safe PEG insertion techniques, with significantly better safety profiles than the pull-through technique. Despite the retrospective design of the study, these results suggest preferential use of hybrid PEG due to handling.

Complication rates of direct puncture and pull-through techniques for percutaneous endoscopic gastrostomy: Results from a large multicenter cohort

Background and study aims  Two different techniques for percutaneous endoscopic gastrostomy (PEG) have been developed: classical pull-through and direct puncture techniques. This study compared the complication rate for both techniques in a large retrospective patient cohort. Patients and methods  Clinical data from patients who received a PEG in four high-volume centers for endoscopy were included retrospectively between January 2016 and December 2018. Patient characteristics and complication rates were correlated in univariate and multivariate analyses. Results  Data from 1014 patients undergoing a PEG insertion by the pull-through technique were compared to 183 patients for whom the direct puncture technique was used. The direct puncture technique was associated with a 50 % reduction in minor and 85.7 % reduction in major complications when compared to the pull-through technique. Multivariate analysis of these data revealed an odds ratio of 0.067 (0.02-0.226; P  < 0.001) for major complications in the direct puncture group. Conclusions  Compared to the pull-through technique, the direct puncture technique resulted in a significant reduction in complications. Despite the retrospective design of this study, these results suggest that the direct puncture technique may be preferable to improve patient safety.

Comparison of Pull and Introducer Techniques for Percutaneous Endoscopic Gastrostomy

Objective

To compare indications, success rates and complications of pull [P] and introducer [I] techniques for percutaneous endoscopic gastrostomy (PEG).

Methods

In this retrospective study, inpatients who underwent primary PEG tube insertion between January 2015 and February 2020 at the Endoscopy Center of the First Affiliated Hospital of Fujian Medical University were included.

Results

A total of 103 inpatients were included in this study (P group, n = 67; I group, n = 36). The rates of tube replacement within first six months in the P and I groups were 1.5% and 11.1%, respectively (P = 0.049). The most common primary indication of PEG was malignancy. The proportion of patients with esophageal cancer was significantly lower in the P group (24.4% vs 54.2%, P = 0.015). No significant difference was found in the overall, major, or minor complications between the two groups. In patients with esophageal stenosis, the pull method was a risk factor for complications (P = 0.03; odds ratio [OR] = 12, 95% confidence interval [CI]: 1.164–123.684). Logistic regression analysis showed that the risk factors for major and minor complications were the admission-to-gastrostomy interval (OR = 1.078, 95% CI: 1.016–1.145, P = 0.014) and lack of antibiotic use (OR = 4.735, 95% CI: 1.247–17.979, P = 0.022), respectively.

Conclusion

Both PEG techniques have high clinical success rates. The introducer technique is more suitable for patients with esophageal stricture, which has lower minor complications, but higher rate of tube replacement compared to the pull technique. Use of antibiotics may reduce minor complications following PEG. Early PEG insertion may help to reduce post-PEG major complications.

Usage characteristics and adverse event rates ​of the direct puncture and pull techniques for percutaneous endoscopic gastrostomy in patients with malignant tumors of the upper aerodigestive tract

BACKGROUND AND STUDY AIMS

 Patients with malignant tumors of the upper gastrointestinal tract are at risk of weight loss. Early supportive nutrition therapy is therefore recommended and usually requires placement of a percutaneous endoscopic gastrostomy (PEG). The aim of this study was to compare adverse events and usage characteristics of the direct puncture technique with those of the traditional pull technique when used in patients with endoscopically passable tumors. The primary endpoint was the rate of inflammatory adverse events (AEs) at the gastrostomy fistula. The secondary endpoint was the long-term rate of puncture-site metastases.

PATIENTS AND METHODS

 One hundred twenty patients (median age 56; IQR 36, 86 years) were randomized and treated per protocol in this prospective open randomized single-center study. Follow-ups were conducted on the third and seventh post-interventional days, after 1, 3 and 6 months and the last follow-up 5 years after intervention.

RESULTS

 Within the short-term follow-up period of 6 months after PEG placement, AEs were noted in 47 patients (39.2 %). These included 22 inflammations and 16 device dislocations and were mainly found in the puncture group (33 vs. 14 in the pull group) with a significantly increased incidence in the first month after PEG insertion ( P  = 0.001). Evaluation of the 5-year data did not reveal any significant differences. The gastrostomy tube was used in 101 patients (84.2 %) (range 18 days to 5 years).

CONCLUSIONS

 Our results favor the pull technique for patients with endoscopically passable tumors of the upper gastrointestinal tract due to less short-term adverse events. Both systems contributed equally to secure long-term use.

Systemic Prophylactic Antibiotics for the Modified Introducer Method for Percutaneous Endoscopic Gastrostomy: A Prospective, Randomized, Double-Blind Study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is the most common method of enteral nutrition in patients who require long-term tube feeding. According to meta-analyses, administration of systemic prophylactic antibiotics for PEG reduces peristomal infection. However, with several recent developments in the procedure and instruments, the risk of infection might have been reduced. The aim of this study was to evaluate the use of systemic antibiotic prophylaxis for a modified introducer method of PEG.

METHODS

This prospective, randomized, double-blind trial assessed 278 patients undergoing PEG for inclusion. Ninety-one patients with an indication for PEG who gave informed consent to participate were randomized. Forty-six patients received prophylactic ampicillin and 45 patients received a placebo. A modified introducer method of PEG using a Seldinger PEG kit was performed. The primary outcome was the occurrence of clinically evident wound infection within 3 days after PEG.

RESULTS

Wound infection within 3 days was observed in none in the prophylaxis group and in 1 patient in the control group (P=0.4945). There was no significant difference between 2 groups in the other parameters, including peristomal infection within 7 days, overall infection, white blood cell counts, C-reactive protein level, and successive rate of finishing antibiotics.

CONCLUSIONS

For wound infection within 3 days, noninferiority of the placebo group to the antibiotics group was preliminarily suggested with our criteria, but not for peristomal infection within 7 days. More strict criteria for noninferiority should be examined in a further large sample study.

Comparison of the pull and introducer percutaneous endoscopic gastrostomy techniques in patients with head and neck cancer

BACKGROUND AND STUDY AIMS

Percutaneous endoscopic gastrostomy (PEG) in head and neck cancer (HNC) patients is associated with higher complication and mortality rates when compared to a general patient population. The pull technique is still the preferred technique worldwide but it has some limitations. The aim of this study is to compare the pull and introducer PEG techniques in patients with HNC.

PATIENTS AND METHODS

This study is based on a retrospective analysis of a prospectively collected database of 309 patients with HNC who underwent PEG in the Cancer Institute of São Paulo.

RESULTS

The procedure was performed with the standard endoscope in 205 patients and the introducer technique was used in 137 patients. There was one procedure-related mortality. Age, sex and albumin level were similar in both groups. However in the introducer technique group, patients had a higher tumor stage, a lower Karnofsky status, and presented more frequently with tracheostomy and trismus. Overall, major, minor, immediate and late complications and 30-day mortality rates were similar but the introducer technique group presented more minor bleeding and tube dysfunctions.

CONCLUSION

The push and introducer PEG techniques seem to be both safe and effective but present different complication profiles. The choice of PEG technique in patients with HNC should be made individually.

Interventions for dysphagia and nutritional support in acute and subacute stroke

BACKGROUND

Dysphagia (swallowing problems) are common after stroke and can cause chest infection and malnutrition. Dysphagic, and malnourished, stroke patients have a poorer outcome.

OBJECTIVES

To assess the effectiveness of interventions for the treatment of dysphagia (swallowing therapy), and nutritional and fluid supplementation, in patients with acute and subacute (within six months from onset) stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (February 2012), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), CINAHL (1982 to July 2011) and Conference Proceedings Citation Index- Science (CPCI-S) (1990 to July 2011). We also searched the reference lists of relevant trials and review articles, searched Current Controlled Trials and contacted researchers (July 2011). For the previous version of this review we contacted the Royal College of Speech and Language Therapists and equipment manufacturers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in dysphagic stroke patients, and nutritional supplementation in all stroke patients, where the stroke occurred within six months of enrolment.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, assessed trial quality, and extracted data, and resolved any disagreements through discussion with a third review author. We used random-effects models to calculate odds ratios (OR), 95% confidence intervals (95% CI), and mean differences (MD). The primary outcome was functional outcome (death or dependency, or death or disability) at the end of the trial.

MAIN RESULTS

We included 33 studies involving 6779 participants.Swallowing therapy: acupuncture, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation each had no significant effect on case fatality or combined death or dependency. Dysphagia at end-of-trial was reduced by acupuncture (number of studies (t) = 4, numbers of participants (n) = 256; OR 0.24; 95% CI 0.13 to 0.46; P < 0.0001; I(2) = 0%) and behavioural interventions (t = 5; n = 423; OR 0.52; 95% CI 0.30 to 0.88; P = 0.01; I(2) = 22%). Route of feeding: percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding did not differ for case fatality or the composite outcome of death or dependency, but PEG was associated with fewer treatment failures (t = 3; n = 72; OR 0.09; 95% CI 0.01 to 0.51; P = 0.007; I(2) = 0%) and gastrointestinal bleeding (t = 1; n = 321; OR 0.25; 95% CI 0.09 to 0.69; P = 0.007), and higher feed delivery (t = 1; n = 30; MD 22.00; 95% CI 16.15 to 27.85; P < 0.00001) and albumin concentration (t = 3; n = 63; MD 4.92 g/L; 95% CI 0.19 to 9.65; P = 0.04; I(2) = 58%). Although looped NGT versus conventional NGT feeding did not differ for end-of-trial case fatality or death or dependency, feed delivery was higher with looped NGT (t = 1; n = 104; MD 18.00%; 95% CI 6.66 to 29.34; P = 0.002). Timing of feeding: there was no difference for case fatality, or death or dependency, with early feeding as compared to late feeding. Fluid supplementation: there was no difference for case fatality, or death or dependency, with fluid supplementation. Nutritional supplementation: there was no difference for case fatality, or death or dependency, with nutritional supplementation. However, nutritional supplementation was associated with reduced pressure sores (t = 2; n = 4125; OR 0.56; 95% CI 0.32 to 0.96; P = 0.03; I(2) = 0%), and, by definition, increased energy intake (t = 3; n = 174; MD 430.18 kcal/day; 95% CI 141.61 to 718.75; P = 0.003; I(2) = 91%) and protein intake (t = 3; n = 174; MD 17.28 g/day; 95% CI 1.99 to 32.56; P = 0.03; I(2) = 92%).

AUTHORS' CONCLUSIONS

There remains insufficient data on the effect of swallowing therapy, feeding, and nutritional and fluid supplementation on functional outcome and death in dysphagic patients with acute or subacute stroke. Behavioural interventions and acupuncture reduced dysphagia, and pharyngeal electrical stimulation reduced pharyngeal transit time. Compared with NGT feeding, PEG reduced treatment failures and gastrointestinal bleeding, and had higher feed delivery and albumin concentration. Nutritional supplementation was associated with reduced pressure sores, and increased energy and protein intake.

Effect of the introducer technique compared with the pull technique on the peristomal infection rate in PEG: a meta-analysis

BACKGROUND

Peristomal infection is a main complication of PEG. The pull technique appears to be associated with higher infection rates compared with the introducer technique, although published results are controversial.

OBJECTIVE

To determine which technique is associated with a higher risk of infection.

DESIGN

Systematic review and meta-analysis.

SETTING

Studies reporting rates of peristomal infection after PEG performed by either the pull or introducer technique.

PATIENTS

This study involved 2336 patients from 6 comparative and 10 observational studies.

INTERVENTION

Public MEDLINE (National Library of Medicine journal articles database), Excerpta Medica Database, Cochrane Central Register of Controlled Trials, and Latin American and Caribbean Center on Health Sciences Information databases and proceedings of two meetings, Digestive Disease Week and United European Gastroenterology Week, were searched. Both comparative and observational studies were included and analyzed separately.

MAIN OUTCOME MEASUREMENTS

Effect measures from each comparative study were reported as the odds ratio (OR). The pooled effect was then calculated. The infection rate in each observational study was also calculated, and a summary effect was then determined.

RESULTS

In comparative studies, the risk of infection was significantly higher with the pull technique (OR 13.0; 95% confidence interval [CI], 4.6-36.8; P < .0001). Similarly, observational studies also reported higher infection rates with the pull technique (10.7%; 95% CI, 4.9-21.8 with the pull technique vs 0.9%; 95% CI, 0.2-4.5 with the introducer technique).

LIMITATIONS

Few studies were available for inclusion, and there was a high risk of bias among the comparative studies.

CONCLUSION

The pull technique appears to be associated with a significantly higher risk of infection compared with the introducer technique.

Successful control of peristomal infection by introducer-type percutaneous endoscopic gastrostomy: a retrospective historical control study

BACKGROUND

The techniques of percutaneous endoscopic gastrostomy are classified as the pull and introducer methods. Peristomal infection is the most common procedure-related complication in the pull method.

OBJECTIVES

The objective of this study was to compare procedure-related complications between the two methods and to assess the outcome of long-term use of the introducer method.

METHODS

Between January 1999 and November 2009, 116 patients received percutaneous endoscopic gastrostomy at Seoul St. Mary's Hospital in Korea. Before June 2006, the pull method was used for all patients; since then, every patient had been treated using the introducer method. We compared outcomes and complications within 180 days of gastrostomy placement for the two methods.

RESULTS

The pull method was performed on 63 patients and the introducer method on 53 patients. The occurrence of peristomal infection within 30 days was significantly lower in the introducer method group than in the pull method group (1.9% vs. 36.5%, P = 0.001). Methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the major organisms isolated from the peristomal infection. The requirement for catheter reinsertion because of displacement, obstruction, or damage to the catheter between 30 and 180 days was significantly higher in the introducer method group than in the pull method group (40.5% vs. 0%, P = 0.001).

CONCLUSIONS

Our results suggest the superiority of the introducer method in terms of infection control. However, the balloon-type catheter is associated with problems such as balloon insufficiency in long-term use.

Assessment of safety and feasibility of a new technical variant of gastropexy for percutaneous endoscopic gastrostomy: an experience with 435 cases

BACKGROUND

Percutaneous Endoscopic Gastrostomy (PEG) performed through the Introducer Technique is associated with lower risk of surgical infection when compared to the Pull Technique. Its use is less widespread as the fixation of the stomach to the abdominal wall is a stage of the procedure that is difficult to be performed. We present a new technical variant of gastropexy which is fast and easy to be performed. The aim of this study was to evaluate the safety and feasibility of a new technical variant of gastropexy in patients submitted to gastrostomy performed through the Introducer Technique.

METHODS

All the patients submitted to PEG through the Introducer Technique were evaluated using a new technical variant of gastropexy, which consists of two parallel stitches of trasfixation sutures involving the abdominal wall and the gastric wall, performed with a long curved needle. Prophylactic antibiotics were not used. Demographic aspects, initial diagnosis, indication, sedation doses, morbidity and surgical mortality were all analyzed.

RESULTS

Four hundred and thirty-five consecutive PEGs performed between June 2004 and May 2007 were studied. Nearly all the cases consisted of patients presenting malignant neoplasia, 79.5% of which sited in the head and neck. The main indication of PEG was dysphagia, found in 346 patients (79.5%). There were 12 complications (2.8%) in 11 patients, from which only one patient had peristomal infection (0.2%). There was one death related to the procedure.

CONCLUSION

Gastropexy with the technical variant described here is easy to be performed and was feasible and safe in the present study. PEG performed by the Introducer Technique with this type of gastropexy was associated with low rates of wound infection even without the use of prophylactic antibiotics.