Unsedated Transnasal Percutaneous Endoscopic Gastrostomy Placement in Selected Patients

• Introduction
• Patients and Methods
• Results
• Discussion
• References

Background and Study Aims: The placement of a percutaneous endoscopic gastrostomy (PEG) is the procedure of choice for the long-term management of dysphagic patients with neurological disease or with trauma or tumors of the head and neck. It is not always possible to perform conventional upper gastrointestinal endoscopy in such patients due to stenosis and/or occlusion of the mouth or pharynx and/or partial or complete trismus. The aim of this study was to show whether transnasal esophagogastroduodenoscopy (EGD) offers a feasible and effective alternative method for PEG placement in these selected patients.
Patients and Methods: PEG placement was required for 155 patients at our institution during a 27-month period. In 12 patients oral access of an endoscope into the esophagus was not possible. Unsedated transnasal EGD (T-EGD) was then performed using an ultrathin video gastroscope, which had a distal-end diameter of 5.9 mm. A 16-Fr polyurethane PEG tube with a conical, flexible, soft distal end and a collapsible bumper was used in all cases. The Gauderer-Ponsky pull technique was used for PEG placement.
Results: T-EGD and perendoscopic transnasal placement of a PEG tube was successfully performed in all 12 patients. No patient required sedation during the procedure. No immediate or late-onset procedure-related complications occurred in any of the 12 patients.
Conclusions: In some dysphagic patients in whom the oral route is not accessible with a standard endoscope, a transnasal endoscopic approach allows the placement of a PEG tube. In these selected patients this technique has been shown to be safe and effective and does not require the use of sedation.

Introduction

Dysphagic patients with neurological disease, or with trauma or tumor affecting the head and neck, need adequate nutritional support. As long as the gastrointestinal tract is functioning, enteral feeding is preferable and the method of choice for long-term enteral nutrition in these patients is a percutaneous endoscopic gastrostomy (PEG) [1] [2]. However, conventional upper endoscopy is not possible in these patients when there is stenosis and/or occlusion of the mouth or pharynx and/or partial or severe trismus. Moreover, it is not possible to sedate these patients because of their general condition and because some strictures of the upper aerodigestive tract do not permit tracheal intubation [3].

There is some evidence in the literature that the use of the transnasal route may allow the placement of a PEG tube in these patients. A variety of endoscopes have been used for this, including pediatric and standard gastroscopes [3] [4] [5], though with some technical limitations. The passage of a standard gastroscope via the nasal route can be difficult and traumatic and requires the assistance of an otorhinolaryngologist [4]. Another limitation is the theoretical risk of bumper impaction in the nasopharynx [5].

The aim of this study was to demonstrate the feasibility and safety of atraumatic transnasal PEG tube placement (T-PEG) using an ultrathin video gastroscope in unsedated patients.

Patients and Methods

Between 1 April 2001 and 30 June 2003 PEG tube placement was required in 155 patients at our institution. In 12 patients (8 %; eight men, four women; average age 58, range 38-85) oral endoscopy using a standard gastroscope was not possible: three patients had severe trismus due to neurological disease; four patients had oropharyngeal obstruction, one having tonsillar cancer and three having tongue cancer; two patients with maxillofacial cancer had both severe trismus and oropharyngeal obstruction; three patients had a maxillofacial fracture.

Transnasal esophagogastroduodenoscopy (T-EGD) was performed without sedation in these 12 patients with local anesthesia (lidocaine spray in the nose), using an ultrathin video gastroscope (EVIS Exera GIF-XP 160 Slim Sight; Olympus Optical Co., Tokyo, Japan) which had a distal-end diameter of 5.9 mm and a working-channel diameter of 2.0 mm. One hour before the procedure an antibiotic was given prophylactically to all patients (ceftriaxone 1 g intravenously). Those patients who, for various reasons, were already receiving antibiotics continued their antibiotic therapy. Oxygen saturation was monitored before and during the procedure and oxygen was administrated if the saturation fell below 90 %.

The PEG was placed using the Gauderer-Ponsky pull technique (Figures [1], [2]). Local anesthetic was injected at the site of transillumination. A 16-Fr polyurethane PEG tube with a conical, flexible, and soft distal end and a collapsible bumper (Corflo-Max) was used in all cases. In this PEG tube the internal polyurethane bumper is maintained in its natural, expanded shape by a collapsible/expandable polyurethane foam (Figure [3]). This PEG tube contains an air lumen that connects the bumper with the outside atmosphere through a small hole near the end of the tube. During insertion, as always occurs when there is external pressure or obstruction, the bumper collapses to conform to the shape of the nasal canal (Figure [4]). When the bumper enters the stomach the polyurethane foam expands to return the bumper to its expanded shape. At the end of the PEG tube placement the bumper is held in its fully expanded retention shape by trapping air in a Y-adaptator. In all patients we checked that the bumper was fully expanded endoscopically. The patients were followed-up clinically and with respect to local and systemic infection for 30 days after the procedure.

Results

T-EGD and T-PEG were performed successfully in all 12 patients. No patient required sedation during the procedure. Oxygen saturations did not change during the PEG placement and no patient required oxygen supplementation. Transillumination was effectively obtained in all cases. No complications (bleeding and/or trauma to the nasopharynx, oropharynx or hypopharynx; trauma due to, or impaction of, the bumper) occurred during passage of the endoscope or the PEG tube via the nasal route. The internal bumper was effectively expanded in all cases without any sign of damage. The average duration of the procedure was 15 minutes. During the follow-up period no immediate or late-onset complications occurred in any of the 12 patients. None of the patients developed an inflammatory reaction at the stoma site and there were no cases of early dislodgment of the internal bumper.

Discussion

In around 6-9 % of malnourished patients, those with neurological disease, or trauma or tumors of the head and neck, it is not possible to place a PEG tube via the oral route [6]. However, some studies have shown that it may be possible to place a PEG tube or a feeding tube by using the transnasal route [3] [4] [5] [7].

A variety of endoscopes have been used for this, including pediatric and standard gastroscopes, with some technical limitations [3] [4] [5]. The placement of a PEG tube transnasally in unsedated patients is limited by several factors, one of which is the diameter of the endoscope. The passage of a standard gastroscope via the nasal route, as described by Taller et al. [4], though possible, is a difficult, traumatic, and painful procedure, requiring sedation and the assistance of an otorhinolaryngologist. Another limitation to T-PEG is the difficulty of passage of the PEG tube through the nasal canal and the theoretical risk of bleeding or of bumper impaction in the nasopharynx [5].

For these reasons we wanted to test the feasibility of placing a PEG tube transnasally using an ultrathin video gastroscope in 12 unsedated patients in whom conventional gastroscopy was not possible (8 % of the total number of patients requiring PEG at our institution during the study period).

Theoretically, endoscopy without sedation, as outlined by Sivak [8], represents a ”worthwhile goal” because it eliminates the morbidity and the mortality related to the use of narcotic and sedative drugs. In any case, in our 12 patients, performing an endoscopy without sedation was not a choice but a necessity dictated by the general condition of the patients and by the presence of strictures of the upper aerodigestive tract that would not permit tracheal intubation.

T-EGD, as demonstrated in many previous studies [9] [10] [11], fulfills the requirements of these patients. It is an easy, quick, and well-tolerated procedure for several reasons: gagging is minimal because of the absence of contact between the instrument and the back of the tongue, which reduces retching, vomiting and choking and thereby the risk of aspiration [10]. We found that the oxygen saturation of our patients did not change during the procedure and no supplemental oxygen was required, in contrast to the experience in another study [9].

Previous studies showed the small-diameter video endoscope to be deficient in terms of optical and aspiration/lavage capabilities, compared with a standard gastroscope. However, the most important characteristics of a gastroscope with regard to placement of a PEG tube are air insufflation and transillumination, which were both effectively obtained in all our patients. Moreover, we found the passage through the nasal canal and the subsequent execution of a complete gastroscopy easy and the duration of the whole procedure was similar to that of an oral gastrostomy.

In planning an atraumatic transnasal procedure we considered the characteristics of the PEG tube: we chose a 16-Fr PEG tube because its diameter is not larger than our ultrathin endoscope; and we chose a collapsible bumper because this meant that is was able to pass through the nasal canal and obviated the need for another gastroscopy later on for removal of the PEG tube. Usually, the bumpers of 16-Fr PEG tubes, even the collapsible ones, have a diameter of 3 cm, and certainly always larger than the diameter of the nasal canal. They collapse during their passage through a stricture under strong traction and, theoretically, this can cause bleeding or trauma during passage via the nasal route. For this reason we used a PEG tube with an internal air lumen which connects the bumper with the outside atmosphere and allows for complete collapse as the tube is passed through the nasal canal or any stricture. With these device characteristics, the intensity of traction applied to the PEG tube during insertion is highly reduced, making the procedure easier and less traumatic, and no bleeding or bumper impaction occurred in any of our patients during transnasal placement of the PEG tube. The procedure was conducted under endoscopic control, which showed that the internal bumper was effectively expanded in all patients and bumper dislodgment did not occur in any of the patients during the follow-up period.

The data regarding the benefit of antibiotic prophylaxis to prevent wound infections after PEG placement are controversial. In the literature, some prospective placebo-controlled studies found no benefit [12], whereas other trials showed a lower incidence of wound infections [13]. Furthermore, both the American Society of Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) recommend the use of antibiotic prophylaxis before PEG tube placement in all patients in their most recent guidelines [14] [15]. Considering the absence of data on antibiotic prophylaxis for transnasal PEG tube placement, we decided to give antibiotic prophylaxis to all 12 patients. It is interesting to note that none of the 12 patients developed a wound infection at the stoma site. We do not know if this promising preliminary result is due to the utilization of the nasal route, to the small number of patients included in our study, or to the antibiotic prophylaxis. A larger study would be required to establish if PEG tube placement by the transnasal route has a lower incidence of wound infections.

In conclusion, in some malnourished patients in whom the oral route is not accessible, transnasal endoscopy allows the placement of a PEG tube. We found this technique to be easy, safe, and nontraumatic, and it does not require sedation.

References

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  Search in Google Scholar
• 13 Akkersdijk W l, VanBerggeijk J D, VanEgmond T. et al . Percutaneous endoscopic gastrostomy (PEG): comparison of push and pull method and evaluation of antibiotic prophylaxis.  Endoscopy. 1995;  27 313-316
  Search in Google Scholar
• 14 American Society of Gastrointestinal Endoscopy (ASGE). Antibiotic prophylaxis for gastrointestinal endoscopy.  Gastrointest Endosc. 1995;  42 630-635
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  PubMedSearch in Google Scholar

M. A. Vitale, M.D.



Largo dell’ Artide 19 · 00144 Rome · Italy

Fax: +39-0677-055300·

Email: g.villotti@tiscali.it

References

• 1 Safadi A Y, Marks J M, Ponsky J L. Percutaneous endoscopic gastrostomy: an update.  Endoscopy. 1998;  30 781-789
  PubMedSearch in Google Scholar
• 2 Singh P, Kahn D, Greenberg R. et al . Feasibility and safety of percutaneous endoscopic gastrostomy in patients with subtotal gastrectomy.  Endoscopy. 2003;  35 311-314
  Thieme ConnectPubMedSearch in Google Scholar
• 3 Roman S, Pereira A, Caruso L. et al . Transnasal percutaneous endoscopic gastrostomy.  Gastroenterol Clin Biol. 2001;  25 106-107
  PubMedSearch in Google Scholar
• 4 Taller A, Horvath E, Ilias L. et al . Technical modifications for improving the success rate of PEG tube placement in patients with head and neck cancer.  Gastrointest Endosc. 2001;  54 633-636
  CrossrefPubMedSearch in Google Scholar
• 5 Lustberg A M, Darwin P E. A pilot study of transnasal percutaneous endoscopic gastrostomy.  Am J Gastroenterol. 2002;  97 1273-1274
  CrossrefPubMedSearch in Google Scholar
• 6 Gibson S E, Wenig B L, Watkins J L. Complications of percutaneous endoscopic gastrostomy in head and neck cancer patients.  Ann Otol Rhinol Laryngol. 1992;  101 46-50
  PubMedSearch in Google Scholar
• 7 Kulling D, Bauerfeind P, Fried M. Transnasal versus transoral endoscopy for the placement of nasoenteral feeding tubes in critically ill patients.  Gastrointest Endosc. 2000;  52 506-510
  CrossrefPubMedSearch in Google Scholar
• 8 Sivak M V, Jr. The nose: is this the route to improving esophagogastroduodenoscopy?.  Gastrointest Endosc. 1999;  49 395-398
  PubMedSearch in Google Scholar
• 9 Craig A, Hanlon J, Dent J, Schoeman M. Comparison of transnasal and transoral endoscopy with small-diameter endoscopes in unsedated patients.  Gastrointest Endosc. 1999;  49 292-296
  PubMedSearch in Google Scholar
• 10 Preiss C, Charton J P, Schumacher B, Neuhaus H. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD.  Endoscopy. 2003;  35 641-646
  Thieme ConnectPubMedSearch in Google Scholar
• 11 Birkner B, Fritz N, Schatke W, Hasford J. A prospective randomized comparison of unsedated ultrathin versus standard esophagogastroduodenoscopy in routine outpatient gastroenterology practice: does it work better through the nose?.  Endoscopy. 2003;  35 647-651
  Thieme ConnectPubMedSearch in Google Scholar
• 12 Sturgis T M, Yancy W, Cole J C. et al . Antibiotic prophylaxis in percutaneous endoscopic gastrostomy.  Am J Gastroenterol. 1996;  91 2301-2304
  Search in Google Scholar
• 13 Akkersdijk W l, VanBerggeijk J D, VanEgmond T. et al . Percutaneous endoscopic gastrostomy (PEG): comparison of push and pull method and evaluation of antibiotic prophylaxis.  Endoscopy. 1995;  27 313-316
  Search in Google Scholar
• 14 American Society of Gastrointestinal Endoscopy (ASGE). Antibiotic prophylaxis for gastrointestinal endoscopy.  Gastrointest Endosc. 1995;  42 630-635
  PubMedSearch in Google Scholar
• 15 Rey J R, Axon A, Budzynska A. et al . Guidelines of the European Society of Gastrointestinal Endoscopy (ESGE): antibiotic prophylaxis for gastrointestinal endoscopy.  Endoscopy. 1998;  30 318-324
  PubMedSearch in Google Scholar

M. A. Vitale, M.D.



Largo dell’ Artide 19 · 00144 Rome · Italy

Fax: +39-0677-055300·

Email: g.villotti@tiscali.it