Commentary (Lewis): Percutaneous Endoscopic Stomas for Enteral Feeding and Drainage

Endoscopically guided percutaneous gastrostomy tube placement was developed in 1980 by Jeffrey Ponsky [1].In the ensuing years, this procedure has evolved rapidly. The procedure began with a homemade kit consisting of urinary and intravenous catheters. Now the endoscopist has a choice of three different techniques and a host of commercially available kits from which to choose [2]. By 1989, percutaneous endoscopic gastrostomy became the preferred method of gastrostomy (over surgery), and presently is the second most common indication for EGD (esophago-gastro-duodenoscopy) in hospitalized patients in the United States (the most common indication is upper gastrointestinal bleeding). The long-term complication rate is extremely low [3,4], and both patients and nurses alike prefer percutaneous endoscopic gastrostomy to nasogastric tubes [3].

Over the years many misconceptions about this procedure have developed [5-7]. It was initially believed that only a gastrostomy sewn by a surgeon would provide a secure enough bond between the stomach and skin. We have learned that this is not true, and that the fibrous scar that joins the two with a percutaneous endoscopic gastrostomy is just as durable as a surgically sewn gastrostomy[8]. Percutaneous endoscopic gastrostomies last as long as surgical gastrostomies, and the tracts may be dilated to accommodate very large bore feeding tubes. It was also initially believed that endoscopically guided percutaneous gastrostomy tube placement was not appropriate for the postoperative patient, especially those who have undergone Billroth II resection. At present, the only requirements necessary to perform percutaneous endoscopic gastrostomy placement are 1) that the endoscope reach the stomach, and 2) that transillumination occurs.

The Dilemma

The decision to place a percutaneous endoscopic gastrostomy can be a moral dilemma. The effects of the procedure have to be judged against the longevity of the patient. A recent review of indications and outcome shows a high 30-day mortality rate in three different patient groups [9]. The mortality rate in neurologically impaired patients was 28%; patients with poor nutrition secondary to chronic pulmonary illness had a 90% mortality rate; and patients with cancer had a 37% mortality rate.

There are other considerations, particularly in the oncology patient. In patients with cancer, several useful functions can be served by this procedure. Some patients develop mucositis with their courses of chemotherapy, and are unable to eat for several days around their cycle. Percutaneous endoscopic gastrostomy intermittently provides nutritional support for these patients, and thus interrupts the cycle that often leads to weight loss and debilitation.

In patients who have had surgery for neck malignancies, return of swallowing ability can be delayed. Percutaneous endoscopic gastrostomy permits earlier hospital discharge, and can provide supplemental calories until swallowing ability returns. Use is indicated in cases of simple hydration or caloric supplementation, and in patients with carcinomatosis and obstruction. Gastrostomies in these cases improve patient comfort and allow some oral intake.

In a report from Mount Sinai Medical Center in New York [10], percutaneous endoscopic gastrostomy was successful in 83% (15/18) of insertions; 87% of patients were discharged to their homes or a hospice, with an average survival of 33.7 days in successful cases. However, transillumination was not achieved in 40% of even the successful cases.

Newer indications are also being developed. Recent studies have shown that when a patient is not fed, a decrease in gut weight along with villous atrophy occurs. These changes are associated with bacterial translocation in the gut and associated sepsis. It is thus no surprise that jejunal feeds have been associated with less ventilator/ICU days, less sepsis, less wound complications, less antibiotics, and shorter hospitalizations in the postoperative patient [11].

In this issue Dr. Shike has described the indications and techniques for percutaneous endoscopic gastrostomy. The relative ease and simplicity of the procedure should convert any remaining doubters as to its usefulness.

References:

1. Gauderer MW, Ponsky JL, Izant RJ Jr: Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg 15:842-845, 1980.

2. Kozarek RA, Ball TJ, Ryan JA Jr: When push comes to shove: A comparison between two methods of percutaneous endoscopic gastrostomy. Am J Gastroenterol 81:642-646, 1986.

3. Baeten C, Hoefnagels J: Feeding via nasogastric tube or percutaneous endoscopic gastrostomy. Scand J Gastroenterol 27 (suppl 194):95-98, 1992.

4. Hull M, Rawlings J, Murray F, et al: Audit of outcome of long-term enteral nutrition by percutaneous endoscopic gastrostomy. Lancet 341:869-872, 1993.

5. Steffes C, Weaver DW, Bouwman DL: Percutaneous endoscopic gastrostomy. New technique--old complications. Am Surg 55:273-277, 1989.

6. Grant JP: Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy. Ann Surg 207:598-603, 1988.

7. Stiegmann G, Goff J, VanWay C, et al: Operative versus endoscopic gastrostomy. Preliminary results of a prospective randomized trial. Am J Surg 155:88-92, 1988.

8. Ruge J, Vazquez RM: An analysis of the advantages of Stamm and percutaneous endoscopic gastrostomy. Surg Gynecol Obstet 162:13-16, 1986.

9. Stuart S, Tiley E, Boland S: Feeding gastrostomy: A critical review of its indications and mortality rate. South Med J 86:169-172, 1993.

10. Noyer C, Lewis B, Dottino P, et al: Percutaneous endoscopic gastrostomy (PEG): Gastric decompression in patients with carcinomatosis. Gastrointest Endosc 39:282, 1993.

11. Gentilello L, Cortes V, Castro M, et al: Enteral nutrition with simultaneous gastric decompression in critically ill patients. Crit Care Med 21:392-395, 1993.