The relevance of systemic complications and the different outcomes of subgroups after percutaneous endoscopic gastrostomy (PEG)

Prevention and management of minor complications in percutaneous endoscopic gastrostomy

Background

Percutaneous endoscopic gastrostomy (PEG) was developed by Ponsky-Gauderer in the early 1980s. These tubes are placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition but can also be used for drainage or decompression. The tubes consist of an internal and external retention device. It is a generally safe technique but major or minor complications may arise during and after tube placement.

Method

A narrative review of the literature investigating minor complications after PEG placement.

Results

This review was written from a clinical viewpoint focusing on prevention and management of minor complications and documented with real cases from more than 21 years of clinical practice.

Conclusions

Depending on the literature the incidence of minor complications after gastrostomy placement can be high. To decrease associated morbidity, prevention, early recognition and popper management of these complications are important.

Percutaneous endoscopic gastrostomy (PEG) site infections: a clinical and microbiological study from university teaching hospital, India

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is used to provide enteral access in patients who are unable to swallow. Infection of the stoma is an important complication and there is little data from India on this problem, which can be used to inform infection prevention and prophylactic strategies.

AIM

The objective was to assess the prevalence and the role of contributory factors in PEG site infections.

METHODS

A total of 173 patients underwent PEG insertion from January 2011 to May 2012. Clinical and microbiological data were collected for culture-positive cases. Insertion was performed using a standard sterile pull-through technique. Infections were defined as two of: peristomal erythema, induration, and purulent discharge.

RESULTS

A total of 54 PEG infections occurred in 43 patients (28.85%). Seventy-seven organisms were isolated. Pseudomonas aeruginosa was the most common (n=29) followed by coliforms (n=21) and meticillin resistant Staphylococcus aureus (MRSA) (n=6). Thirty-one (72%) received amoxicillin-clavulanic acid as prophylaxis and 12 (28%) were receiving concomitant antibiotics for their underlying conditions. The occurrence of PEG site infections was statistically independent of the administered prophylactic antibiotics (p=0.3).

CONCLUSIONS

This study has demonstrated the importance of PEG sites as a cause of healthcare associated infections. Educating patients on wound care practices would play a significant role in prevention of PEG site infections.

A glycerin hydrogel-based wound dressing prevents peristomal infections after percutaneous endoscopic gastrostomy (PEG): a prospective, randomized study

BACKGROUND

Despite the use of prophylactic antibiotics, peristomal infection is the most common complication of percutaneous endoscopic gastrostomy (PEG). A new glycerin hydrogel (GHG) wound dressing has been proposed to possess more effective antimicrobial properties but has not been tested in a larger trial. The aim of the study was therefore to assess the superiority of GHG regarding the incidence of peristomal wound infections during a 30-day postprocedure follow-up.

METHODS

Sixty-eight patients with cancer undergoing PEG were recruited from 1 university and 2 general hospitals between January 2007 and December 2008. Patients were randomized to group 1 (34 patients), which received GHG, or group 2 (34 patients), which received a traditional wound dressing. Dressing changes were done at day 1 and weeks 1, 2, and 4 (group 1) vs daily changes during week 1 and at weeks 2 and 4 (group 2). The PEG site was assessed by using 2 different infection scores.

RESULTS

At the end of the first and second weeks, a statistically significant reduction of the mean infection scores was seen in patients with GHG wound dressings (first week: 1.64 ± 1.6 vs 3.12 ± 2.69, P < .008; second week: 1.37 ± 1.11 vs 2.53 ± 2.37, P < .02). After 7 days, wound reactions occurred in 14.7% in the GHG group vs 47.05% in the traditional group (p <0.005). The GHG wound dressing required 5 times less frequent dressing changes.

CONCLUSION

The GHG wound dressing significantly reduces peristomal wound infections and is a convenient, cost-effective alternative for wound management following PEG.

Local infection after placement of percutaneous endoscopic gastrostomy tubes: a prospective study evaluating risk factors

BACKGROUND

Due to its high efficacy and technical simplicity, percutaneous endoscopic gastrostomy (PEG) has gained wide-spread use. Local infection, occurring in approximately 2% to 39% of procedures, is the most common complication in the short term. Risk factors for local infection are largely unknown and therefore--apart from calculated antibiotic prophylaxis--preventive strategies have yet to be determined.

OBJECTIVE

To assess the potential patient- and procedure-related risk factors for peristomal infection following PEG tube placement.

METHODS

Potential patient-related (eg, age, sex, diseases, body mass index, concomitant antibiotic therapy) and procedure-related (endoscopist experience, institutional factors, findings on endoscopy) risk factors and their coincidence with local infection, defined as a positive peristomal infection three days after PEG tube placement, were evaluated at two institutions. A standardized antibiotic prophylaxis was not performed. The peristomal infection score was also evaluated in 390 patients.

RESULTS

Using a multivariate binary regression analysis, four risk factors were established as relevant for local infection after PEG: clinical institution (OR 6.69; P = 0.0001), size of PEG tubes (15 Fr versus 9 Fr; OR 2.12; P = 0.05), experience of the endoscopist (more than 100 investigations versus less than 100 investigations; OR 0.54; P = 0.05) and the existence of a malignant underlying disease (OR 2.28; P = 0.019).

CONCLUSIONS

Similar to other endoscopic interventions, local infection as a complication of PEG tube placement depends on the experience of the endoscopist. Institutional factors also play a significant role. Additional risk factors include PEG tube size and underlying diseases. These findings indicate that the local infection after PEG tube placement may be influenced by both endoscopy-associated factors and by the underlying disease status of the patient.

Reduced risk of peristomal infection of direct percutaneous endoscopic gastrostomy in cancer patients: comparison with the pull percutaneous endoscopic gastrostomy procedure

BACKGROUND

Although pull percutaneous endoscopic gastrostomy (Pull-PEG) is a commonly used procedure, peristomal infection and tumor implantation are considered unavoidable complications of this procedure as the instrument passes through the oral cavity. A novel extracorporeal PEG technique, Direct-PEG, has been developed to reduce the risk of peristomal infection and implantation.

STUDY DESIGN

The Direct-PEG procedure was performed on 87 patients from April 2006 to April 2007 in a single, high-volume cancer center in Japan. To compare the surgical outcomes of Direct-PEG and Pull-PEG, the clinical outcomes of Direct-PEG, such as peristomal infection, were retrospectively collected and compared with those of 64 patients having Pull-PEG procedures from April 2005 to March 2006.

RESULTS

The mean operation time for the Direct-PEG group (13+/-1 minutes) was comparable to that for the Pull-PEG group (12+/-1 minutes), and the mean visual analogue pain score during surgery was lower for the Direct-PEG group (3.5+/-1.7) than for the Pull-PEG group (24.6+/-3.6; p < 0.001). The incidence of peristomal infection was lower in the Direct-PEG group (1%) than in the Pull-PEG group (9%; p=0.001). Although the most common major underlying disease in the groups was oropharyngeal or esophageal tumor, tumor implantation was not observed in either group.

CONCLUSIONS

Direct-PEG may be superior to the Pull-PEG method for a high-volume cancer center because of reduced risks of infection.