| Abstract|| |
Background: Percutaneous endoscopic gastrostomy (PEG) is a widely used method for insertion of gastrostomy tube for patients with dysphagia due neuromuscular disorders. Aim : this article highlights the role of PEG for such patients, how safe, effective than standard gastrostomy in providing long -term nutritional support for patients with dysphagic stroke. Methods: Over a four-year period (1995-1998), 27 patients had percutaneous endoscopic gastrostomy performed for neuromuscular dysphagia. A Wilson Cook (24G) gastrostomy tube was used and it was inserted with Ponsky-Gauderer pull technique. Results: All the patients tolerated the procedure well. Stroke (81%) was the most common indication for PEG. Major gastroscopic finding was found in eight patients (29%). Minor complication was seen in only three patients (11%). Conclusion PEG Feeding is safe, simple and effective procedure with no serious side effects. Patients and their relatives accept PEG better than nasogastric tube feeding. However, the ideal timing at which to institute gastrostomy feeding after dysphagic stroke is still not clear.
Keywords: PEG, Dysphagic stroke, nutritional support and enteral route.
|How to cite this article:|
Bola KR. Use of percutaneous endoscopic gastrostomy in acute dysphagic stroke. Saudi J Gastroenterol 2001;7:59-61
Endoscopic positioning of feeding tube has received very little attention in the literature. This technique of percutaneous endoscopic gastrostomy was introduced in 1980 for long-term enteral nutrition and it is increasingly becoming the method of choice for patients with dysphagia due to neuromuscular disorder  . Percutaneous endoscopic gastrostomy (PEG) is performed under local anesthesia. It was developed as an alternative to surgically created gastrostomy, thus avoiding an operation under anesthesia in patients who are frail and old. Nasogastric tubes are least well tolerated by patients with stroke. They may require frequent reintubation, which is distressing for the patient with extra nursing time and occasional need for radiography when replacing tube feeding. Percutaneous endoscopic tubes make nursing these patients easy and simple by avoiding repeated change of nasogastric tube, which is associated with aspiration. Patients and their relatives accept percutaneous endoscopic gastrostomy better than nasogastric tube feeding. This paper describes our experience with this procedure done for acute dysphagic stroke at the Armed Forces Hospital, Sultanate of Oman (AFH).
| Patients and Methods|| |
Over a four-year period (1995-1998),27 patients (14 males and 13 females) had percutaneous endoscopic gastrostomy performed for neuromuscular dysphagia. They met the following criteria: dysphagia for more than two weeks due to stroke, a stable medical condition with likely survival of at least one month and the presence of a normal gastrointestinal tract . No patients were excluded for reasons of serious underlying disease. A-Wilson Cook (24G) gastrostomy tube was used. They were inserted with Ponsky-Gauderer pull technique. Mild sedation with Inj midazolam 3-5 mg IV and local anesthesia (1% lignocaine) was given. All patients received prophylactic antibiotic (Inj cefuroime 750 mg IV) 30 mins before the procedure. Also antiseptic mouthwash was given for two days before the procedure to minimize the postoperative infection. Heart rate and oxygen saturation was recorded for each patient. At the end of the procedure the endoscope was reintroduced to ensure proper placement of the internal rubber bolster flush with stomach wall and to exclude blanching of the gastric mucosa which would indicate excessive compression and traction. Dressings were not routinely applied unless there was leakage from the site. Dextrose solution was administered through the tube after 24 hours if bowl sounds were present and no pyrexia. Thereafter, feeding was commenced by bolus method. The tube was flushed before each feed. The patient remained in a semi-upright position during A60 minutes after the feeding to prevent aspiration.
| Results|| |
All the twenty-seven patients tolerated the procedure well. Feeding was restarted satisfactorily after 24 hours. Comorbid disease in patients who had PEG is shown in [Table - 1]. Majority of the patients had hypertension.
The indications for PEG included stroke, Parkinson's disease, head and tongue injury, in 22, three and two patients respectively. In one patient PEG was removed due hemataemisis. Endoscopy showed gastric erosion due to inner bolster. PEG tube was replaced with port gastrostomy device. PEG tube was changed in four patients due to damaged tube.
Complications encountered in the current study were local infection and gastric erosions in two and one patient respectively. Local wound infection was the most common complication (7%). Complete recovery was achieved with IV antibiotic and local wound care. Two patients died within two weeks after the procedure due to aspiration pneumonia. Fifteen patients were followed up for more than eight months and eleven for only two months. The tube was removed in four patients due to recovery of swallowing. The average hospital stay was seven weeks.
Coincidental upper gastric findings, duodenitis in six, gastric erosion in two and in one patient carcinoma in-situ of the stomach was diagnosed during removal of the PEG on recovery of swallowing. This patient subsequently had partial gastrostomy.
| Discussion|| |
The position of gastrostomy tube feeding by endoscopic technique proved to be a simple procedure taking on average 30 minutes and there were no serious side effects. The recognised complication of percutaneous endoscopic gastrostomy includes gastric perforation, hemorrhage, gastric fistula, benign pneumoperitonium, infection of stoma site and aspiration pneumonia  . Blind manipulation of the percutaneous endoscopic gastrostomy tube for early leakage should be resisted as may result in displacement of gastric bolster into the abdominal wall  . No dressing should ever be placed below the external bolster, which can cause excessive pressure on the anterior gastric wall with the internal bolster leading to gastric wall necrosis. When cleaning, the exit site was routinely checked for redness and leakage. Early leakage around a percutaneous endoscopic gastrostomy may indicate that the intragastric bolster has moved, in which case the enteral feeding was stopped immediately and endoscopy carried out to check the gastric wall and the position of gastric bolster corrected if indicated  .
The gastrostomy tube can remain in place for up to two years and it can be removed endoscopically and replaced externally through the stoma site but should be replaced within 24 hours. Once the gastrostomy tube is removed, the stoma tract should heal and close within 24 hours.
Up to 45% of all patients with cerebro-vascular accident are complicated by dysphagia 16) . The natural history of dysphagia after the stroke is variable and the time at which swallowing becomes irreversible is not clearly defined. The majority of these patient are fed initially through nasogastric tube. Norton and Homes have reported that early gastrostomy (14 days) tube feeding is acute dysphagic stroke is superior to nasogastric feeding and is associated with significant reduction of mortality and improved nutritional state compared to nasogastric tube feeding  .
A percutaneous endoscopic gastrostomy has definite advantages over nasogastric tube feeding; it causes less discomfort, the rate of displacement or blockage is reduced, the tube is concealed under the patients clothing, thus cosmetically acceptable, less likely to interfere with rehabilitation, the patients' relatives and nurses find it easier to feed and require less nursing time. This will also improve the prospects of early discharge from the hospital.
| Conclusion|| |
Percutaneous endoscopic gastrostomy is safe, simple and effective procedure with no serious side effects. It leads to significant improvement in nutritional status. The rapid application of this technique on a large scale serves as testimony to its superiority over nasogastric tube feeding. However, the ideal timing at which to institute gastrostomy feeding after dysphagic stroke is still not clear. Percutaneous endoscopic gastrostomy should be the procedure of choice for acute dysphagic stroke.
| Acknowledgement|| |
We thank the director of Forced Medical Services, Royal Army of Oman, for the permission to publish this article and Miss Julie for typing the manuscript.
| References|| |
|1.||Ian Forgaces, Andrew MacPerson, Christopher Tribbs. Percutaneous endoscopic gastrostomy. BMJ 1992; 504: 1395-6. |
|2.||Park R H R, Alison M C, Morris A J, et al. Randomized Comparison of PEG and NG tube feeding in patients with persisting neurologic dysphagia. BMJ 1992; 304: 1406-9. |
|3.||Foutch P. G. Complication of percutaneous endoscopic gastrostomy and jejunostomy: recognition, prevention and treatment. Gastrointest. Clin. N. Am 1992; 2: 231-48. |
|4.||Botteril I, Miller G, Dexter S, Martin I. Deaths after delayed recognition of PEG tube migration. BMJ 1998: 317: 524-5. |
|5.||Norton B, Homes-Ward M, Donnelly T M, Long R G, Holmes G K T. A randomized prospective comparison of PEG and NG tube feeding after acute dysphagic stroke, BMJ 1996; 312: 13-6. |
|6.||Peyers R A, Westby D. Percutaneous endoscopic gastrostomy. Indications, timing, and complications of the technique. Br. J. Care 1994; 14: 88-95. |
Kamath R Bola
Consultant Physician and Head of the department of medicine, Armed Forces Hospital, P.O. Box 726, post code 111, CPO Seeb, Sultanate of Oman
Source of Support: None, Conflict of Interest: None
[Table - 1]