Percutaneous endoscopic gastrostomy (PEG) feeding

What is a percutaneous endoscopic gastrostomy?

This is a procedure for placing a feeding tube directly into the stomach via a small incision through the abdominal wall. After aseptic preparation of the abdominal wall and prophylactic antibiotics, an endoscope is passed via the oesophagus into the stomach.^{w1 w2} A powerful light source within the endoscope and insufflation of air allows the position of the endoscope to be identified through the abdominal wall. Use of the finger invagination technique may also help identify the optimal site. After local anaesthetic infiltration, a needle is inserted through the abdominal wall (fig 1A⇓) into the stomach, along with a guide wire and grasped using a snare via the endoscope (fig 1B). The guide wire, the snare, and the endoscope are then retracted. The guide wire is attached to the end of a gastrostomy tube (fig 1C), pulled back down through the oesophagus and stomach, and brought out through the hole in the abdominal wall (fig 1D). The end of the PEG tube is retained within the stomach cavity, by a wide internal bumper (fig 1E). An external bumper is then fixed to the tube to prevent the internal bumper from moving distally in the alimentary canal. The procedure is usually performed under sedation and takes about 15-20 minutes. Gastrostomy feeding tubes may also be placed using radiological or surgical methods, depending on technical considerations or local availability.^{w3 w4}

Insertion of percutaneous endoscopic gastrostomy

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What are the benefits of gastrostomy feeding?

Malnutrition determines disease outcomes because it affects every system in the body, leading to both physical and psychological disability.^w5 Percutaneous endoscopic gastrostomy feeding aims to improve nutritional status. Gastrostomy feeding reduces mortality, length of hospital stay, and complications in carefully selected patients who are likely to be or later become nutritionally depleted for longer than four to six weeks.9 10 Clinical studies have shown clear benefits of PEG feeding after stroke6 7 (in terms of improving nutritional status and reducing mortality) and in patients with oropharyngeal cancer (in terms of improving nutritional status).11 12 When compared with other methods of enteral nutrition, such as nasogastric feeding, gastrostomy feeding caused less discomfort and had lower rates of complications such as bleeding, blockage, and dislodgment of the tube.13 14 Although gastrostomy feeding does not prevent reflux or aspiration, rates may be lower than in patients fed by a nasogastric tube.^w6

Who should have a percutaneous endoscopic gastrostomy?

Cohort studies have shown that 20-50% of hospital patients are malnourished.15 16 Box 1 provides a broad list of indications for which patients are currently being referred for percutaneous endoscopic gastrostomy. Although clinical studies have shown benefits for PEG feeding in stroke6 7 and oropharyngeal cancer,11 12 the appropriateness of gastrostomy insertion in other patient subgroups is controversial. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) undertook the largest study in the United Kingdom to date, which reviewed mortality after PEG insertion between April 2002 and March 2003. This study found a 6% mortality in a cohort of 16 648 patients. Of those who died, 43% died within one week of PEG insertion, and in 19% of patients PEG insertion was thought to have been futile.8 We believe that the decision making process for gastrostomy feeding should not be based solely on the referral indication, but that each patient must be considered according to their individual needs.

What are the contraindications to percutaneous endoscopic gastrostomy?

Few absolute contraindications to percutaneous endoscopic gastrostomy exist. Active coagulopathies and thrombocytopenia (platelets <50×10⁹/l) must be corrected before tube insertion. Anything that precludes endoscopy, such as haemodynamic compromise, sepsis, or a perforated viscus, would be an absolute contraindication to gastrostomy insertion. Relative contraindications include acute severe illness, anorexia, previous gastric surgery, peritonitis, ascites, and gastric outlet obstruction. Crohn’s disease used to be considered a contraindication to gastrostomy insertion because of concerns about possible fistula formation around the gastrostomy tract, but an observational study has shown percutaneous gastrostomy to be safe and without increased complications in patients with this disease.^w11

How are complications managed?

The rate of complications after percutaneous endoscopic gastrostomy has been reported as 8-30%.3 24 Box 2 lists these complications, which may be immediate or delayed. Most gastrostomy insertions are done in hospital, and immediate complications usually occur in hospital. Delayed complications are more often seen in the community setting. If favourable outcomes are to be achieved, prompt decisions should be made as to whether the problem can be managed within the community or whether it requires hospital admission.

What are the ethical and legal considerations in gastrostomy feeding?

PEG feeding raises ethical and legal considerations. Both the Royal College of Physicians and the General Medical Council in the UK have provided guidance on oral feeding and nutrition.26 27 Artificial feeding is considered a medical treatment in legal terms and requires valid consent before it is started. For consent to be valid the person giving consent must have the capacity to do so voluntarily after being given sufficient information to guide informed choice. When a patient has capacity their wish to consent to or refuse treatment should be upheld, even if that decision may lead to death. When a patient lacks capacity, an independent mental capacity advocate should represent that person. The multidisciplinary team caring for the patient is responsible for giving, withholding, or withdrawing treatment, including artificial feeding and hydration, and it should consider any advance directives, the patient’s prognosis, and the likely benefits of gastrostomy feeding when making decisions. A limited trial of feeding may sometimes be used, but strict criteria regarding what constitutes success should be determined before starting gastrostomy feeding.28 Where conflicts arise between healthcare professionals or between healthcare professionals and those close to the patient, it may be necessary to seek legal advice or resolution through a local clinical ethics committee.26

The National Institute for Health and Clinical Excellence guidelines on dementia highlight the importance of quality of life in advanced dementia and support the role of palliative care in these patients, from diagnosis until death.29 Best practice in these patients could be to encourage eating and drinking by mouth for as long as tolerated, to use good feeding techniques, to alter the consistencies of food, and to promote good mouth care. When disease progression is such that the patient no longer wants to eat or drink, then rather than inserting a gastrostomy tube, end of life care pathways might be considered. Views held by carers and medical staff may prevent progression to end of life care pathways. A questionnaire survey showed that allied healthcare professionals were more likely than doctors to consider PEG feeding when presented with patient scenarios relating to malnutrition.30

Conclusion

Percutaneous endoscopic gastrostomy feeding is an effective way to deliver nutritional support to people who are unable to meet their nutritional requirements orally. Improved nutritional status and survival have been demonstrated in selected subgroups of patients. Careful selection of patients on an individual case basis may improve outcomes.