Complications Associated with Percutaneous Endoscopic Gastrostomy Tubes

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Citation: 

Pages 36 - 41

Author(s): 

Vishal Ghevariya, MD, Vani Paleti, MD, Mojdeh Momeni, MD, Mahesh Krishnaiah, MD, and Sury Anand, MD

Percutaneous endoscopic gastrostomy (PEG) tube has now become a method of choice for long-term nutritional support, especially for the geriatric population. Technical advances during the past two decades have made this method a less expensive alternative to parenteral nutrition and more acceptable to patients. As literature demonstrating the benefits of enteral over parenteral nutrition mounts, we expect a continuous rise in the use of PEG tubes. Although considered safe, PEG tube placement can be associated with a diverse range of complications. This article describes a variety of PEG tube−related complications, preventive strategies, and treatment options for complications. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[12]:36-41)

Introduction

No disease process improves with prolonged starvation. Tube feeding has been practiced in various forms for more than 400 years, and technical advances during the past two decades have made this method a less expensive alternative to parenteral nutrition and more acceptable to patients.1 Since its introduction in 1980 by Gauderer and Ponsky2,3 use of percutaneous endoscopic gastrostomy (PEG) tubes has increased consistently. More than 200,000 PEG tubes are placed annually in the United States.4,5 As literature demonstrating the benefits of enteral over parenteral nutrition mounts, we expect a continuous rise in the use of PEG tubes. However, this procedure is not risk-free. The overall complication rate ranges from 4-24% of cases. Up to 4% of patients are affected by a major complication.6-10

A literature review was performed via the PubMed™ search engine, using the terms PEG, PEG tube, PEG tube complications, PEG morbidity, and PEG mortality. Cross-referenced non-PubMed™–listed articles were also reviewed. A total of 1318 articles were found, which were analyzed for relevance for and goals of this review. PEG tube−related complications were divided into specific groups: (1) upper endoscopy−related complications; (2) procedure-related complications; and (3) post-procedural complications, including PEG tube usage and wound care.

Complications of Upper Endoscopy

The most common complications of upper endoscopy include aspiration, hemorrhage, perforation, and cardiopulmonary complications related to sedation. Mortality associated with upper endoscopy is very low (0.005-0.01%).11,12 Risk of aspiration is low but significant (0.3-1.0%).13 Advanced age, altered mental status, chronic debilitating conditions, supine position, and sedation increase aspiration risk. Aspiration can be minimized by judicious use of sedation, optimizing air-insufflation of stomach, suctioning gastric contents before and after the procedure, and minimizing procedure time by performing the procedure efficiently. An unsedated transnasal approach using small-caliber endoscopy has been reported to lower aspiration rates.14,15

Mild, controllable bleeding is common during the procedure. Severe hemorrhage is rare (0.02-0.06%).11,12 Anticoagulation, antiplatelet agents, and anatomic anomalies increase such risk. Elective PEG placement should be deferred in presence of coagulopathy or thrombocytopenia.

Perforation of the esophagus is rare (0.008-0.04%).11,12 Common sites of iatrogenic perforation are cricopharyngeus, aortic knob, and diaphragmatic hiatus. Esophageal diverticulum, esophageal strictures, and tumors/mass lesions increase such risk. Treatment with broad-spectrum antibiotics and surgical debridement and repair are indicated. In patients without systemic evidence of sepsis, small contained perforations can be managed medically.

Prolonged ileus may follow PEG placement in up to 1-2% of cases,6 and it should be managed conservatively.

References: 

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