Although PEG (Percutaneous Endoscopic Gastrostomy) probes have been around since the 1980s, there is a lot of variation in practice around PEG care. This has been shown by a recent survey from the MDL doctors who are working on a new guideline Enteral Access† “We do not yet know what the most efficient and safe placement process is,” says MDL doctor Dr Lennard Gilissen (Catharina Hospital, Eindhoven). He has a lot of experience with PEG probes.
The approximately 70 Dutch MDL departments were contacted for the survey with questions about various aspects of PEG care. The reason was that the MDL physicians in the guideline working group noticed major differences. The survey, to which 48 departments responded, confirmed this. For example, there were specific differences in antiseptic precautions (from only skin disinfection to complete sterility), prophylactic antibiotics (difference in time and form of administration), placement of the tube (2 MDL physicians versus 1 for both gastroscopy and puncture) and observation time after placement. (several hours of day care to overnight observation). Furthermore, it was found that 78% of MDL doctors place PEG tubes, but sometimes only 3 per year, and that a third of the centers do not have a PEG team.
To compare
“It is interesting to compare different aspects in studies, also in terms of costs,” Gilissen describes. “It is still unclear worldwide which placement method and which care and aftercare process is the most efficient. What is the best timing in, for example, the disease process of ALS, which sedation and supportive techniques are safe? And how do you remove a PEG probe as safely and patient-friendly as possible? This is usually done endoscopically, but sometimes by cutting the tube. These ways have never been properly compared either. However, comparative research requires several participating centers and sponsorship money, while PEG care is applied to a wide variety of diseases.”
The MDL department of the Catharina Hospital in Eindhoven specializes in placing these probes and variants thereof. The treatment has recently been included in the Top Clinical Care Register of the Cooperating Top Clinical Training Hospitals (STZ).
variants
There are different variants of the PEG probe, which are applied depending on the situation and anatomy. Gilissen, for example, places less and less the PEG-J, the ‘extended PEG’ with a second tube to the small intestine. “It is for, among others, people with gastroparesis, or Parkinson’s patients who receive Duodopa in the jejunum drop by drop. In addition, we increasingly place a direct PEJ: with a children’s colonoscope, the jejunum is punctured directly via the oral route. We also regularly perform a colostomy (PEC), where a connection is made to the right-sided colon for antegrade colonic lavage in persistent constipation. This flushing probe is also used on the left side in case of repeated volvulus, to fix and desuffle. Patients are referred from all over the Netherlands for PEC.”
The PEC is the last step before a possible surgical stoma. Gilissen is surprised that this is rarely used nationally. “We have been installing these for over 10 years. This probe can now prevent a surgical stoma in 60% of patients. Placement can be done fairly easily with a colonoscopy. If PEC doesn’t work or doesn’t work, the probe is easy to remove and the hole will close again within a day. This technique also has few complications.”
Closer to home
So there is a range of probes, for very different indications and different patients. “Just think of the changed anatomy in bariatric patients or after oncological surgery,” continues Gilissen. “The doctor discusses the options and alternatives with the patient. Being creative with probes is great to be able to offer a suitable solution for almost all patients. Referrers from all over the south of the Netherlands and beyond know where to find us. I’m glad we can help so many people, but also a little surprised that they’ve come this far. Even if there are problems with a probe, people now have to travel a long way. Good aftercare is just as important as the technical side of installations. That is why I hope that the expertise can be spread more widely across the country, so that people can come closer to home.”
For Duodopa administration via a PEG-J tube, Gilissen works closely with neurologists. For years it was customary to first set and test the medication via a nasogastric tube for a few days. If all went well, the PEG-J probe was placed. But in practice, almost all patients eventually received the PEG-J tube. Gilissen therefore wondered what the use of the nasogastric tube was. “If you skip that step, it saves patient inconvenience, time and costs. That is why, in consultation with the neurologists, we immediately started to place the PEG-J in these patients. We are very satisfied with that. Placing a nasogastric tube is often done out of habit, but it is not in the best interest of the patient and costs a lot more money.”
Due to the frequent problems with PEG-J inner probes, direct PEJs are increasingly used.
Complications and aftercare
Tube placement remains risky, just like surgery. Patient assessment and discussion of complications are essential. The main problem is wound infection, which occurs in 10 to 25% of patients. Gilissen: “That is why the new guideline states that an antibiotic is always necessary for prophylactic treatment. We use a local treatment with an antibiotic gauze that stays in place for three days. A chemical inflammation as a result of gastrointestinal juices probably also plays a role. My wish is to conduct national research into the most efficient preventive method. But that requires a lot of patients and inclusion time.”
Other complications include bleeding, peritonitis due to internal leakage, and mortality in certain groups. These complications occur in approximately 1% of patients. In the long run, skin problems can arise. “Most problems can be treated well, but it concerns vulnerable patients, so you always have to be alert and take action quickly if necessary,” says Gilissen.
Aftercare is also an important aspect. There are many questions about this among healthcare providers, patients and informal carers. Gilissen is therefore currently developing a PEG app for the mobile phone, together with Dr Linda Wanders, PhD student at MDL from Amsterdam. “It contains a lot of practical information, answers to questions and tips. The content of the app is ready and we hope it will become functional during the course of this year.”
New guideline
The Dutch Association of Gastrointestinal Liver Doctors (NVMDL) has taken the initiative for a new, modular guideline on gastrostomy placements. This guideline Enteral Access is almost ready and mainly deals with PEG and the radiological PRG probes. The directive had a long run, says Gilissen. “That is because it concerns different patient groups, such as people after a stroke, oncological patients, patients with neuromuscular disorders (NMA) and Parkinson’s patients. As a result, many professional groups are involved.” The guideline is expected to be released this summer.
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