Percutaneous endoscopic gastrostomy (PEG) is a relatively new technique in South Africa. It is useful in the management of patients with neurological and oropharyngeal disorders in whom long-term feeding is necessary. The PEGs inserted in patients at Groote Schuur Hospital between June 1986 and March 1990 as part of an on-going study to evaluate this procedure are reported

Johnston, D.A.

Marks, I.N.

Newton, K.A.

Wright, J.P.

Zak, J

English

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•SAMJ VOL. 79 15 JUN 1991 725Percutaneous endoscopic gastrostomyIndications, technique and complication:s at Groote Schuur Hospital,J. ZAK, D. A. JOHNSTON, K. A. NEWTON, J. P. WRIGHT, I. N. MARKSSummaryPercutaneous endoscopic gastrostomy (PEG) is a relativelyI1ew technique in South Africa. It is useful in the managementof patients with neurological and oropharyngeal disorders inwhom long-term feeding is necessary. The PEGs inserted inpatients at Groote Schuur Hospital between June 1986 andMarch 1990 as part of an on-going study to evaluate thisprocedure are reported.S AIr Med J 1991; 79: 725-726.Percutaneous endoscopic gastrostomy (PEG) was first describedby Gauderer et af.! in 1980. Since then it has become theprocedure of choice in providing nutrition for patients withfunctional gastro-intestinal tracts who would otherwise requirenasogastric intubation. PEG may also be used for gastro-intestinal decompression and internalisation of biliary drainage.The procedure is relatively new in South Africa, the firstPEG being performed at Groote Schuur Hospital in 1986.Initial experience, and the resulting changes introduced, arereported.Patients and methodsTwenty-two of 25 patients referred for possible placement of aPEG were considered suitable candidates for the procedure.All 22 met the following criteria: (I) a functional gastro-intestinal tract with no anatomical impediment to gastrostomyor PEG insertion; and (il) a supportive family or nursinghome/hospital milieu.PEGs were inserted using the method of Gauderer et ai, 1with a few minor modifications. All PEGs were inserted inpatients in the Gastro-Intestinal Unit or in the Intensive CareUnit (ICU). The Caluso PEG was used (Superior BiosystemsInc., Cumberland, R.I., USA). It should be noted that theprocedure may be performed using a 12F De Pezzer catheterand a l'l gauge Medican cannula together with a length ofsurgical black silk at a much lower cost; however, it must benoted that the De Pezzer catheter will not last as long as thestandard PEG.PEG insertion was performed by 2 doctors and 2 trainednurses. An upper gastro-intestinal endoscopy was performedunder sedation by the first doctor to exclude any disease, andto facilitate the procedure. The abdomen was prepared and asterile technique was·employed for PEG insertion. The stomachGastro-intestinal Clinic, Department of Medicine, Univer-sity of Cape Town and Groote Schuur Hospital, CapeTownJ. ZAK Ill, M.D. (ROSS)D. A. JOHNSTON, M.R.C.P.K. A. NEWTON, F.C.P. (SA)J. P. WRIGHT, F.R.C.P.I. N. MARKS, F.R.C.P., F.A.C.G."'coepted 22 Nov 1990.SQwas insufflated with air to allow the anterior wall of thestomach to oppose the abdominal wall, and the anterior wallilluminated. An external site was chosen by the second doctor,and the area trans-illuminated by the endoscopist. A slightadjustment in the site was sometimes necessary. Inability totrans-illuminate through to the anterior abdominal wall was anabsolute contraindication to the procedure. Local anaestheticwas infiltrated and a 6 mm incision made. A Seldinger catheterwas ir.serted through this incision into the stomach and visua-lized by the endoscopist. A guidewire was passed via thecatheter into the stomach, grasped with biopsy forceps andpulled out through the mouth. The guidewire was attached tothe loop at the end of the PEG. The latter was lubricated andpulled through the mouth to the stomach (Fig: 1) and out viathe catheter tract until the internal bolster was flush againstthe anterior wall of the stomach. The external bolster was thenslipped over the PEG and placed flu h with the skin. A silksuture was tied around the bolster to prevent slippage of thePEG. The procedural part of the PEG was then cut off. Nosutures were required to secure the bolster to the skin. Patientswere usually started on feeds after 12 - 24 hours.Fig. 1. Diagram of the PEG procedure in progress.ResultsPEG insertion was successful in 21 of the 22 patients (15 men;age range 21 - 88 years, median 60 years) considered suitablefor the procedure. The 1 failure resulted from inability to passthe catheter into the stomach due to gross obesity. Themajority of insertions were carried out during the past 2 years.The majority of patients (19; 86,3%) had neurological indica-726 SAMJ VOL 79 15 JUN 1991tions, including 2 with malignant disease (Table 1). Five of the7 patients under 40 years old were involved in trauma!neurosurgery. Of the remaining 3 patients, 2 had non-neurological malignancies and I had swallowing problems asa result of severe mental retardation. Twenty-one patients(95,4%) had a PEG inserted for feeding purposes. One PEGwas placed for gastric decompres ion in a patient with ovariancarcinoma.TABLE I. INDICATIONSNeurologicalMotor vehicle accidentMotor neuron diseaseCerebral vascular accidentLateral medUllary syndromeHuntington's choreaPost-pneumococcal meningitisMeningiomaRecurrent posterior fossa ependymomaBulbar palseyTrauma to heaaLeft cerebellar infarctOropharyngeal malignancyCancer of larynxSevere mental retardation and hiatus herniaThe follow-up period was I month to 3 years. There wasonly one major complication, a haematemesi~ secondary to anulcer adjacent to the internal bolster of the PEG. The ulcerwas located on the anterior wall within the bolster's circum-ference. The suture securing the external bolster onto thePEG had come off resulting in increased mobility of thebolster. Minor complications occurred in 6 patients. Threepatients had PEG site infections unassociated with fever whichresolved without antibiotics. Two patients had a PEG siteinfection with abscess formation which necessitated drainageand antibiotics. The PEG fell out secondary to the resultantincrease in the size of the orifice in one of them and necessitatedreplacement with a larger Foley catheter. This was removed 19months later without further complication. The other patienthad also developed an ileus which resolved spontaneouslywithin 3 days. The sixth patient had an asymptomatic ulceradjacent to the PEG noted upon removal of the PEG after8 weeks. The ulcer was situated, again, within the bolster'scircumference.DiscussionPEGs offers several advantages over nasogastric tubes in thatthey decrease the rate of aspiration, are easier to maintain andare more socially acceptable. Liquidised, or even mashedfoods, are suitable with a PEG and patients do not necessarilyrequire commercial feeds. This is a most important cost/con-venience consideration.Our major complication rate of 4,5% (1/22 patients) is in the3 - 7% range quoted in the larger series. H The minor compli-cation rate was 27% bur the 30-day clinically significantcomplication rate was 9% (2/22 patients); this comparesfavourably with the IS - 20% incidence in other series. As ofMarch 1990, we have had only one long-term complication inthe group of patients followed up which continued untilremoval of the PEG or death of the patient. This was thehaematemesis, resulting from the ulcer described before, whichrequired an admission. The patient followed-up for 3 yearshad the same PEG in place until he died. One lCD patient,whose PEG was satisfactorily placed at 24 hours, died 3 dayslater of unrelated causes. One patient who survived for 18months had the original PEG replaced because of crackingafter II months. Complications as reported in other seriesare listed in Table 11. As more people learn of the PEG,referrals will increase and our knowledge of the possiblecomplications will expand. The procedure is now the methodof choice in most parts of the developed world for providingnutrition in patients with an intact gastro-intestinal tract whocannot ear. We conclude that PEG is a safe and practicalprocedure in the appropriate patient when performed byexperil:;nced personnel. .TABLE 11. COMPLICATIONSMajorDeath (aspiration, laryngospasm)2Gastric perforation2Gastric haemorrhage2Haematoma2Upper gastro-intestinal haemorrhageSFatal necrotising fasciitis6MinorWound infectionTube pUlled outlIeus/Ogilvie'sFeverAspirationStromal leakAnorexiaTube migrationHaematomaPneumoperitoneum7Benign subcutaneous emphysema8REFERENCESl. Gaurderer MWL, Ponsky JL, Izam RJ jun. Gastrostomy without laparo-tomy: a percutaneous endoscopic technique.] Pediacr Surg 1980; 15: 872-877.2. Larson DE, BUrlon DD, Schroeder KW, DiMagno EP. Percutaneousendoscopic gastrostomy: indications, success, complications) and mortality in314 consecuti,'e patients. Gastroenterology 1987; 93: 48-52.3. Ponsky JL, Gauderer MWL, Ste11ato TA. Percutaneous endoscopic gastro-stomy: review of 150 cases. Arch Surg 1983; llS: 913-914.4. Foutch PG, Haynes WC, Be11apravalu S, Sanowski RA. Percutaneousendoscopic gastrostomy (PEG): a new procedure comes of age. ] ClinGas/roenteroI1986; 8: 10-15.5. Pate1 PH, Hunter W, Willis M, Thomas £. Upper gastroimestinal hemor-rhage secondary to gastric ulcer complicating percutaneous endoscopicgastrostomy. Gaslroin/es/ Endosc 1988; 34: 88-89.6. Grief JM, Ragland 11, Ochsner MG, Riding R. Fatal necrotizing fasciitiscomplicating percutaneous endoscopic gastrostomy. Gas/roin/m Endosc 1986;32: 292-294.7. Plumser AB, Gornried EB, Clair MR. Pneumoperitoneum after percutaneousendoscopic gastrostomy. Am] Gas/roenceroI1984; 79: 440-441-8. Orchard JL, Barlow J. Benign subcutaneous emphysema after percutaneousendoscopic gastrostomy (Correspondence). Gas/roinresl EndosC' 1987; 33: 5 I-

Percutaneous endoscopic gastrostomy: Indications, technique and complications at Groote Schuur Hospital

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Percutaneous endoscopic gastrostomy: Indications, technique and complications at Groote Schuur Hospital

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