Pull outdoes puncture technique for endoscopic gastrostomy
Using the pull technique over the puncture approach in the placement of a percutaneous endoscopic gastrostomy (PEG) resulted in fewer short-term adverse events (AEs) for patients with malignant upper gastrointestinal (GI) tract tumours, according to a study.
A total of 120 patients (median age 64 years, 85 percent male) with histologically confirmed, endoscopically passable (external diameter ≥8.7 mm) malignant epithelial tumours of the upper GI tract or larynx were randomized for PEG placement using either the conventional pull approach (n=58) or a novel direct puncture device (n=62). Follow-up for early AEs was done on days 3, 7, and 21 postintervention. For late AEs, follow-up was carried out after 1, 3, and 6 months, with a final follow-up 5 years postintervention.
At 1 month, there was a significantly higher incidence of rubor and pain at the placement site with the puncture vs the pull technique (18 vs 4; p=0.004 and 5 vs 0; p=0.059, respectively). [Endosc Int Open 2018;06:E29-E35]
Six months following PEG placement, inflammation and dislocation were more commonly observed with the puncture vs the pull arm (21.0 percent vs 15.5 percent; p=0.0011).
The findings were lower than that reported in a retrospective Korean study showing a high rate of PEG inflammation (81.1 percent) in all patients. [Surg Endosc 2013;27:3806-3815; Aliment Pharmacol Ther 2003;18:209-215] The researchers attributed this difference to the strict prophylactic antibiotic supplementation and standard protocol employed in the current study.
Patients with malignant upper GI tract tumours are at risk of weight loss due to impaired chewing and swallowing, with early supportive nutrition therapy recommended to mitigate malnutrition and improve prognosis, said the researchers. This would usually require PEG placement especially if low nutrient supply is expected to go beyond 3 weeks, [Clin Nutr 2006;25:245-259] with PEG favoured over nasoenteric systems given its sustainability and longer turnaround time.
The researchers initially postulated that direct puncture would fare better given the lack of direct contact between the PEG device and the upper GI tract microbiome. However, direct puncture entails a longer procedure time due to the additional gastropexies besides the PEG, noted the researchers.
Overall, the findings favoured the pull over the puncture technique for PEG application, with subgroup results illustrating a faster execution with the pull technique among low-weight patients with sparse visceral fat and less obstructive T1 tumours, said the researchers.
“Obstruction of the upper [GI] tract is a relevant factor for the pull technique as all tumours had to be passable by a standard gastroscope as per protocol,” they said.
Glucose tolerance, which was not evaluated in this trial, could be an important parameter that needs to be included in future trials as uncontrolled diabetes could also influence wound infection, they added.