Introduction

The use of endoscopy-assisted gastrostomy placement has become commonplace. The procedure Percutaneous Endoscopic Gastrostomy (PEG) was introduced about 20 years ago by Ponsky and others (₁). Among the technical improvements in the procedure have been the introduction of new tubes made of materials which are hoped to have greater durability and less prone to lead to complications. The advantages of new PEG sets have emphasized convenience of packaging, such as including a single-use snare, and/or single-use sufficient quantities of lidocaine for local anesthesia and/or iodine solutions for local disinfection. The evidence that any particular set will outlast another, and be less prone to tube breakdown, are lacking.

The American Society for Gastrointestinal Endoscopy (ASGE) has published guidelines for clinical application of PEGs, and regarding the role of PEGs. However, even in 2005, 25 years after the first PEGs were described, guidelines as to proper or suggested intervals at which PEGs should be re-examined or replaced are lacking.

The risks of PEG placement have been amply documented, and, in comparison to other endoscopic procedures, the PEG is a high-risk procedure, with mortality of 0.3-1%, serious morbidity of 3%, and overall morbidity of 17% (₂,₃,₄,₅). The risks involved in PEG replacement, which would seem intuitively to be probably less than of initial PEG placement, have not been published.

It has been our experience, and that of others, that patients in homes for the elderly who are sent to our hospital for PEG tube replacement have poor condition PEG tube which seem a likely source of morbidityy. A PEG which out-stays its durability tends to break down. The stopcock and tube become crumbly, and fungus develops in the tube. The site of entry may become inflamed, and infected as the skin breaks down from the non-smooth and infested tube. Local granulomas, infection and abscesses may be a portal of entry for systemic infections.

The literature in gastroenterology mentions the possibility of using Foley catheters and silicon replacement tubes instead of PEG tubes (₁₁). Only a few studies have objectively compared the durability of these tubes, which determine when they need be replaced, or compared them to PEG tubes. Blacka and coworkers found silicon tubes less durable than conventional PEGs (₁₂).

The current work was designed to evaluate the situation of patients with PEGs in our community and hope to encourage further prospective investigations in the future that may bring about more definitive results.

Subjects, Materials, and Methods

Statistical Methods

Subjects

Methods

Results

100 patients were examined who had PEGs in place for at least six months. 22 were hospital patients and 78 were in nursing homes. All patients were treated and fed by medical workers. Age of patients varied between 12 and 91 years of age.

Thrity-seven percent of patients had the originally implanted PEG and 63% had already had the PEG replaced at least once (see figure 1). Duration of use of the current PEG ranged from 1-27 months.

Figure 1

Figure 1: Patients classified by number of PEGs implanted

Indications for PEG placement were dysphagia from CVA (33%), dementia (42%), and trauma (25%). Different brand names of PEG were present in these patients. These were: Sandoz (8%), Bard (29%), Foley catheter (48%), non-Foley balloon (12%) (see figure 2).

Figure 2

Figure 2: Type of PEG

Skin breakdown became common, as was decayed PEG tube and stopcock, all beginning about eight months after PEG insertion, (Spearman's coefficient at p<0.01).

The skin condition around the PEG was divided into 4 categories: normal – 49%, inflamed – 40%, infected – 1%, with obvious discharge – 10% (see figure 3).

Figure 3

Figure 3: Skin condition surrounding PEG

The patency of the PEG was considered normal in 29% of patients, minimally occluded in 59% and at least 50% occluded in 12% of the patients (see figure 4). Note that occlusion was a visual estimate from the outside, and referred to rigidity and disfigurements of the tube. Valves were present in 56% of patients. The condition of the valve, when present, was normal in 35% of these patients.

Figure 4

Figure 4: Patency of the PEG

Figure 5

Figure 5: Skin condition around PEG as a function of patient's medical condition (CVA, Dementia, Trauma)

Approximately 51% of the patients had some level of visibly obvious fungus inside the PEG that was unrelated to the brand of PEG present. This was ascertained by inspection only – seeing lots of fungus discoloring the peg tube wall, and stopcock valve.

There was no significant correlation between the type of PEG used and the time before it was replaced. Most patients that had their PEGs replaced, had either a Foley catheter or balloon in its place. There was also no statistical difference between the brand name PEGs of Bard (n=29) and Sandoz (n=8) with respect to every parameter tested. We were unable to designate one brand as either better or worse with respect to any of the following parameters: time before replacement, quality of skin around PEG, tube status or the condition of the valve. Additionally, there was no difference between both tubes with regards to any visible fungal growth of any sort, nor did we find any association between the indications for PEG placement and the presence of fungus on the tube or valve.

Patients with gastrostomies placed after head trauma had significantly better skin condition around the PEG than CVA patients or patients with dementia (p<0.001)(see figure 5). In addition, the condition of the tube and the condition of the valve was also superior.

Discussion

The present cross-sectional study examined the condition of the PEG amongst patients who had PEGs for more than six months and were in chronic care hospitals or nursing homes. Patients who had PEGs for less than six months were excluded from this study.

The original PEG inserted among all the patients, both in the nursing home and hospital, was of a locally available brand: Sandoz or Bard. In contrast, the second and/or third PEG placed was most often a Foley catheter that was replaced by local caregivers, usually nursing staff for logistical and economical reasons.

Parameters considered in our survey included time since placement of PEG, quality of skin and PEG tube components. These were mostly subjective parameters that certainly may be regarded as limitations in our study design. To interpret our findings in an objectable manner we utilized scales determined in advance with comparison photos, used to determine how the skin and stopcock looked.

There were no differences between PEGs of the Sandoz or the Bard brands. The valve condition was similar regardless of the type of PEG. Frequency of finding fungi among the two types of PEGs was likewise similar.

There was a clear relationship between the time elapsed from PEG implantation and the quality of skin around it. The more time elapsed, the worse the skin condition. Patients who had the same PEG for more than eight months, had a tendency to have infected skin with discharge. We recommend replacing PEGs at eight month intervals. While eight months is arbitrary and has not shown to be superior to say seven or nine months, further investigation is sorely needed that may initiate guidelines for PEG maintenance and replacement. The results of this study suggest that manufacturers should recommend that PEG replacement be made no more than eight months after implantation, unless there is clear and documented evidence that the PEG that has been examined and may still be kept in place.

The quality of skin around the gastrostomy tubes of trauma patients was significantly better as compared to CVA or dementia patients. The condition of the tube and valve was also superior. We propose the following explanations for these findings: (1) CVA and dementia patients were considerably older and more prone to skin complications, (2) the differences in disease types (3) obtaining approval for tube replacement by a gastroenterologist in the hospital was easier for trauma patients. Consequently, most trauma patients had easy access to a gastroenterologist who is skilled and easily available resulting in better outcomes including better tube, valve, and skin around the implanted PEG.

Lack of physicians who are qualified to replace gastrostomy tubes in the hospital may indeed impose significant clinical concern for the prevention of long term complications of using PEGs. We recommend establishing mandatory tube replacement by a skilled physician in the hospital, and offering the same quality of care when dealing with replacing a tube as with placing one for the first time.

PEG mortality is among the highest of any gastroenterology procedure, at 1% in-hospital mortality with high morbidity rates. The complication rates for replacements of PEGs, while it seems logical to be lower, have not been published. As PEGs need periodic maintenance, the consideration as to whether a PEG should be implanted in the first place should also address these long term risks and added costs, including occasionally endoscopic replacements.

Conclusions

1. PEGs should be replaced after approximately eight months in order to prevent skin infection around the PEG, fungal growth and ensuing complications.

2. It is preferable to use the specifically approved PEG replacement tubes. The brand name PEGs were similar in quality and durability. Other types of PEGs may be better or worse. This subject should be further investigated in an attempt to maintain the quality of the skin around the PEG and the tube quality. This in turn may prevent long term complications due to PEG placement.

3. The quality of the skin around the PEG, the condition of the tube, and the condition of the valve was better for trauma patients than it was for patients with CVA or dementia. This may be explained by: differences in patient age, disease type, and quality of treatment and care.

Figure 6

Appendix A