Introduction Percutaneous endoscopic gastrostomy (PEG) placement is an established technique for nutritional support, with a procedural success rate around 95% in most case series.1 Failed procedures generally need alternative surgical or radiolofical approaches. In recent years we have adopted an algorithm for maximising PEG placement success rate and have now reviewed our outcomes.
Methods Referrals are vetted by the nutrition support team before selection and cases accepted for PEG are listed on a consultant gastroenterologist’s list. The preferred procedural algorithm is: 1 A standard PEG technique is used with finger indentation and a safe-track technique; transillumination not considered necessary. 2 Trochar insertion into the stomach is assisted by counter-traction on the surrounding mucosa with a snare if necessary. 3 If this doesn’t help then the PEG trochar +/- sheath are removed and a long drainage access (kellett) needle is passed to assist gastric puncture. 4 If the PEG is unsuccessful, then a further attempt on another day is considered with another endoscopist if necessary.
For this review, the nutrition team, endoscopy and clinical databases were reviewed for all patients accepted for PEG placement for 18 months from July 2014 onwards. Outcome measures included PEG success rates, techniques used, procedural complications and 30 day mortality.
Results 154 patients were accepted for first PEG placement. Five patients did not proceed to PEG attempt owing to death or swallowing recovery.
In the 149, all patients (100%) achieved successful PEG insertion at first or second attempt. Most cases (140/149, 94%) were done with the standard pull-through technique. In 6 cases (4%) a Kellett needle was used. In 3 cases (2%) a second endoscopy procedure was required for PEG completion: in 2/3 of these cases, initial failure was attributed to inadequate trans-illumination but successful completion was later done by another endoscopist. In the third case the oesophagus could not be intubated due to a large pharyngeal pouch; this was later overcome with the help of an oesophageal guidewire placed under fluoroscopic guidance. There were no identified procedural complications and overall 30 day mortality was 9%.
Conclusion The procedural algorithm we have described for PEG placement, which excludes the need for transillumination, includes optional usage of a long drainage access needle and considers a second endoscopy procedure if the first procedure fails, led to a 100% completion rate in this case series. Adoption of this approach may therefore minimise the need for other higher-risk alternatives.
Reference 1 Potack JZ, Chokhavatia S. Complications of and controversies associated with PEG: Report of a case and literature review. Medscape J Med 2008;10(6):142.
Disclosure of Interest None Declared