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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 13-17

Percutaneous endoscopic gastrostomy: The Benin experience


Department of Surgery, University of Benin Teaching Hospital, Benin, Nigeria

Date of Submission02-May-2019
Date of Decision04-Jul-2019
Date of Acceptance16-Jul-2019
Date of Web Publication23-May-2020

Correspondence Address:
Dr. Omorodion Omoruyi Irowa
Department of Surgery, University of Benin Teaching Hospital, Benin
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJGH.NJGH_11_20

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  Abstract 


Background: Percutaneous endoscopic gastrostomy (PEG), a gastrointestinal access, is one of the means of ensuring the sustenance of enteral feeding in patients who cannot swallow or eat. The procedure of PEG in the University of Benin Teaching Hospital (UBTH) is new with increasing acceptance by the clinicians and patients as it reduces morbidity and fosters early discharge home.
Aims/Objectives: The aim of this study is to identify the need and usefulness for PEG, audit the process in its initial introduction, and document patient outcomes.
Patients and Methods: This was a prospective study done over a 4-year period (2015-2018) and included all consecutive patient referred for PEG in the endoscopic suite of UBTH. Patient demographics, indication for PEG, outcome of the procedure, and complications were entered into a pro forma and the data analyzed.
Results: A total of 17 patients had PEG over a period of the study. The male-to-female ratio was 2:1. The age range was 35–94 years, with a mean age of 68.6 years. Cardiovascular accident was the most common indication for PEG (64%; 10 patients), whereas intracranial tumors were 12% (2 patients), and other indications, namely severe head injury, dementia, and sepsis were 6% (1 patient) each. All patients had a successful procedure. Surgical site infection occurred in one patient, whereas another patient had extrusion of the PEG tube 1 month after the procedure.
Conclusion: PEG is a safe procedure. The authors advocate the routine use of PEG in patient who cannot eat, especially in a subset of cardiovascular accident patients to sustain adequate nutrition while reducing the morbidity associated with nasogastric intubation and hospitalization.

Keywords: Enteral feeding, experience, gastrointestinal access, percutaneous endoscopic gastrostomy


How to cite this article:
Irowa OO, Nwashilli NJ. Percutaneous endoscopic gastrostomy: The Benin experience. Niger J Gastroenterol Hepatol 2020;12:13-7

How to cite this URL:
Irowa OO, Nwashilli NJ. Percutaneous endoscopic gastrostomy: The Benin experience. Niger J Gastroenterol Hepatol [serial online] 2020 [cited 2020 Oct 23];12:13-7. Available from: https://www.njghonweb.org/text.asp?2020/12/1/13/284719




  Introduction Top


Percutaneous endoscopic gastrostomy (PEG) is gastrointestinal access, which can ensure the sustenance of enteral feeding in patients who cannot swallow or eat. PEG procedure is the insertion of a tube (feeding tube) into the stomach through the anterior abdominal wall with the aid of a gastroscope. It is less traumatic compared to the open gastrostomy. This procedure is done in the endoscopic suite. PEG was first done in 1979 and presented to the world in 1980 at the annual conference of the America Pediatric Association by Guederer et al.[1],[2],[3] About 200,000 gastrointestinal access procedures, PEG inclusive, are done annually in the USA.[3] It was first performed in the pediatric age group but has since found its application in the adult population.[1],[3] The patients in whom PEG are indicated should not have obstructive oropharyngeal or esophageal lesions.

It has undergone a lot of modification over the past 38 years with the additional two other methods of percutaneous gastrostomy, namely radiologic percutaneous gastrostomy and Russell's type percutaneous gastrostomy (Seldinger's technique).[2],[4],[5],[6] The tube used has also undergone modifications over the years. The placement of the PEG tube is done with either the pull or push technique, but the pull technique is well established.

The advantage of PEG over the nasogastric tube (NGT) and the open surgical gastrostomy is well documented in the literature.[7],[8],[9],[10] It reduces morbidity and mortality in patient in whom they are indicated. It also facilitated early discharge from the hospital.

As in most procedures, it is not without its attendant complications. The major ones being aspiration pnuemonitis, intraperitoneal bleeding, injury to organs, and peritonitis.[11],[12],[13],[14],[15],[16],[17]

PEG tube removal is done once its indication has been achieved and could last for as long as 8 months or even more in some patients.[18] There may be need to replace the tube if it falls off, extrudes, get blocked, or causes gastric outlet obstruction.

Initial work on PEG in Nigeria done by Alatise et al. in Ile-Ife demonstrated the usefulness of PEG in the nutritional rehabilitation of chronically ill patients. The patients recruited in their study were mainly those with central nervous system impairment and a minor complication, peristoma infection, encountered during the study. No mortality was recorded.[19]

The University of Benin Teaching Hospital (UBTH) is the premier tertiary institution in South-South Nigeria, which was established in 1973. It is only in the past 4 year that PEG was introduced, though open surgical gastrostomy procedure has being in place virtually from its inception.

The procedure of PEG in our facility is new and has being attended by increasing acceptance by the clinicians and patients because of the reduce morbidity and early discharge from the hospital.

This study identifies the need and usefulness of PEG, audit the process in its initial introduction and document patients outcome.


  Patients and Methods Top


This was a prospective study done over a 4-year period (2015–2018). All consecutive patients referred for PEG in the endoscopy suite of UBTH were entered into a pro forma. Patient demographics, indication for PEG, outcome of the procedure, and complications were analyzed. There were no hepatoslenomegaly, ascites, upper abdominal masses, or bleeding diathesis in all the patients. Informed consent was obtained from the caregivers. All the patients had overnight fast or 6–8 h fast before the commencement of the procedure. Anesthesia consisted of topical xylocaine application to the oropharynx, local infiltration of the site of the PEG tube on the anterior abdominal wall, and mild sedation. All the patients had prophylactic antibiotics.

The placement of the PEG tubes was aided by the use of endoscopy machine which consisted of the gastroscope, the processor, the light source, the insufflator, and a suction machine. The pull technique was employed in the placement of the PEG tubes. The PEG kits (containing essentially of the PEG tube, trocar and cannular, a guidewire, a bolster, a disposable surgical blade and a drape, all sealed in a sterile pack) were sourced from local vendors of medical devices [Figure 1]. Different manufacturers and varying sizes of PEG tubes were used due to the challenges in sourcing the kit. All the PEG tubes used for the study were made of latex material. Sourcing the Kits took between 3 and 5 days.
Figure 1: The percutaneous endoscopic gastrostomy kit

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The site of the PEG tube was routinely prepared and draped [Figure 2]. These procedures were done over a 30 min period or under. The PEG tube feeding commenced 24 h after the procedure. All patients were on trial oral intake while on the PEG tube.
Figure 2:The percutaneous endoscopic gastrostomy tube being inserted

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These patients were followed up for a period of 6 months, noting the complications, resolution of dysphagia, and time of removal of the PEG tube.


  Results Top


A total of 17 patients were recruited for PEG over the period of the study. There were 11 males and 6 females. Male-to-female ratio was 2:1. The age range was 35–94 years, with a mean age of 68.6 years. The cluster age was from the seventh to eighth decades of life. No child was referred for PEG tube placement during this study.

Cardiovascular accident was the most common indication for PEG 64% (11 patients), Intracranial tumors – 12%, other indications included severe head injury, dementia, and sepsis were 6% (1 patient) each. All patients had successful procedure, and there was no reason to abandon any of the procedure. All patients but two had prior NGT insertion (88%). The mean duration of the NGT use was 3 weeks. All the patients with NGT were in-patient and insertion of PEG tube was a prerequisite for their discharge from the hospital. All the inpatients were discharged within 48 h of PEG insertion by their primary care physician after PEG placement. Only one PEG tube insertion was done on the outpatient basis. All patients on PEG tube were followed up after PEG insertion.

Surgical site infection occurred in one patient (5.9%). Extrusion of the tube occurred 2 months after PEG insertion in another patient (5.9%) at about the time he had already commenced oral intake. No mortality was recorded as a consequence of PEG tube insertion.

All patients were on trial oral intake while the PEG tubes were in situ. The PEG tubes were removed once the patients achieve satisfactory oral intake. Removal of the PEG tubes when indicated was done in the outpatient clinics and not an endoscopic procedure. PEG tube was removed within 6 months of insertion in 12 (70.6%) patients following resolution of dysphagia, 2 were on tube feeding, and 3 died of their primary disease while still on the tube.


  Discussion Top


The number of patients (17 patients) who had PEG in our study was similar to the work done by Alatise et al. in Ife.[19] The low volume of PEG procedure may not be unrelated to the newness of the procedure in our center and the challenges involved in procuring the PEG kits as demonstrated in our study. The finding [Figure 3] of more male in our study (M: F-2:1) may be as a result of the primary pathology for which PEG is indicated in our study being more in males.[20],[21] The mean age in our study was 68.6 years, with a cluster in the 7th and 8th decades of life [Figure 4], which tallies largely with the age incidence of the primary pathologies.[19],[20],[21],[22] This relationship of age to the use of PEG may be due to primary pathologies for which PEG is indicated in our study occurring with increasing age.
Figure 3: Sex distribution

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Figure 4: Age distribution

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The indications for PEG [Figure 5] in our study were all centered on pathologies of the central nervous system, comprising 94% (16 patient) of all the procedures.[15],[23] Only 1 (6%) was due to sepsis. These findings were similar to other studies on PEG in our environment and in other climes.[12],[14],[19],[23] Cardiovascular accident constituted 64% (11 patients) of indication for PEG in our study, which is similar to the work done in Ile-Ife, Nigeria,[19] but it constituted only 20% of the indication for PEG in Bosnia and Herzegovina.[23] Intracranial tumors were 12% (2 patients), which is in contrast with the work by Vanis, where a greater proportion were due to due to head-and-neck tumors.[23] Other indications such as severe head injury, Parkinson's disease, dementia, and sepsis were 6% each reflecting the relative low incidence of these disease conditions in the area of the study. No PEG was done for decompression, postoperative feeding, or fixation of the stomach. These indications may not be unrelated to the degree of acceptance of PEG (a relatively new procedure) by the primary care physician and, the cost and delays in procuring the PEG kit in our environment.
Figure 5: Indications for percutaneous endoscopic gastrostomy

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In our study, 88% (15 patient) had prior NGT for enteral feeding which is the initial option for the patient that will ultimately require PEG tube placement.[24],[25],[26] PEG tube placement was indicated for the sustenance of enteral feeding as it has being found to be superior to NGT in patient requiring enteral feeding for >30 days.[7],[8],[9] The superiority of PEG is in better feed tolerance, reduction in discomfort with repeated reintubation, and avoidance of esophageal ulceration with a long-term use among others. The average duration of NGT use [Figure 6] before instituting PEG was 3 weeks in our study which is similar to the already established 2–3 weeks in literatures.[24],[26] This period proposed for the use of NGT is said to allow time for the resolution of acute events, and that the dysphagia may resolve within this period in some patient.
Figure 6: Duration of nasogastric tube use

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All of our patients commenced tube feeding 24 h after PEG placement, which is a delayed/traditional option of commencing tube feeding, though tube feeding have been found to be safe if commenced within 3–4 h.[27],[28],[29]

A majority of our patients were inpatients 92% (15 patients), which is similar to the work in Ile-Ife.[19] We were able to demonstrate (6% of the patients) in this study that PEG placement can be done as day case procedure even in low resource setting.

Complications occurred in two patients (12%); a patient had surgical site infection and another the extrusion of the PEG tube; the tube was not reinserted because the patient had commenced oral feeds at about the time the tube extruded. These complications which were minor are comparable to other studies in the literature.[12],[20],[23]

Our study demonstrated that PEG tubes were discontinued in 12 (12%) patients who had resolution of their dysphagia within 6 months of their placement. This is agreeable with other studies where PEG tube could last for 8 months even longer.[18]


  Conclusion Top


PEG is a safe procedure. It ensures adequate nutritional support through the enteral route when there is no obstructive esophageal lesion in the patient in whom its indicated. The authors advocate the routine use of PEG tubes in patients who cannot eat, especially in a subset of cardiovascular accident patients, in order to sustain adequate nutrition. We also reaffirm the need to institute PEG tubes within 3 weeks of illness to reduce the morbidity associated with nasogastric intubation and hospitalization.

Limitations of study

The small number of patients involved in the study which resulted from the apparent low level of acceptance of the procedure by the primary physicians and the difficulty involved in sourcing the PEG kit.

Acknowledgment

The authors would like to thank all the nurses in the special investigation unit, endoscopy arm for their assistance while carrying out these procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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