Percutaneous endoscopic gastrostomy and gastrojejunostomy: a critical reappraisal of patient selection, tube function and the feasibility of nutritional support during extended follow-up

Background: Percutaneous endoscopic gastrostomy (PEG) is a generally accept ed procedure, but the appropriateness of patient selection and the justific ation of jejunal feeding have not been systematically investigated. Also, a critical appraisal of the applicability and tolerance of nutritional suppo rt in the immediate postinsertion period and during prolonged outpatient ca re is lacking. Methods: Prospectively collected data in adult and pediatric patients durin g a period of 7 years were analyzed. Follow-up data were available at days 1,7 and 28 and thereafter every 6 to 12 weeks until gastrostomy removal, de ath or the conclusion of the study. Results: A PEG was successfully positioned in 268 of the 286 referred patie nts (94%). A jejunal tube through the PEG (JETPEG) was placed beyond the du odenojejunal ligament in 38 patients. Procedure-related mortality was 1%, 3 0-day outpatient mortality 6.7%. Total follow-up was 295 patient-years with an overall mortality of 53% (PEG 53%; JETPEG 50%). Both major (8.4%) and m inor (24.0%) procedure-related complications in the first 28 days consisted merely of (infectious) wound problems. In prolonged follow-up, the complic ations were more tube-related. The durability of the tube in surviving pati ents with a PEG or JETPEG in situ was a median of 495 days (range 162 to 17 32 days). Tube dysfunction because of clogging, porosity and fracture occur red after a median of 347 days (range 9 to 1123 days). Nausea, vomiting, bl oating and dumping interfered with feeding during the first week and during extended follow-up. Intrajejunal feeding was associated with dumping and d iarrhea. In retrospect, the anticipated need of 4 weeks of enteral nutritio n was not met in 9.0%. The extension of a PEG into a JETPEG was thought ina ppropriate in 23.7%. In the remainder, a 91% reduction In aspiration justif ied its use. The tube life span was equal to or greater than that of a PEG, despite tube dysfunction in 26.8%. Conclusions: Proper selection of patients for a PEG, i.e., those with an an ticipated need of greater than 4 weeks of enteral nutrition, is a challenge . Notwithstanding an increased rate of tube dysfunction, well-selected pati ents may benefit from a JETPEG. Follow-up Is mandatory because many patient s might have become malnourished or underfed while on tube feeding, mainly because of GI intolerance.