The technique for PEG placement has evolved since is original description and there is a large volume of literature describing the evolution of the technique [1–13]. PEGs have become the procedure of choice for enteral access in patients requiring long-term tube feedings after trauma [5–11]. PEGs are a relatively straightforward procedure that can often be performed at the bedside, in the Intensive Care Unit or Intermediate Care Unit. Feedings can be started soon after PEG placement, thus minimizing the risk of malnutrition. PEGs are relatively safe with an accepted complication rate of <6–30%. [8, 11].
While many series exist concerning the use of PEG placement, most of these series contain a paucity of trauma patients. Trauma patients may be different for a number of reasons. Trauma creates a catabolic state with marked increase in nutritional needs. Infection is a common occurrence in the Intensive Care Unit following injury. Patients with major torso trauma may be unable to tolerate enteral nutrition early on, condemning them to TPN or even worse, no nutritional support at all. The high stress ulceration rate following injury could predispose trauma patients to a significant incidence of incidental death or upper gastrointestinal pathology despite routine use of gastrointestinal prophylaxis.
Unsuspected gastrointestinal pathology can be seen at the time of PEG placement. Several studies have described unsuspected pathologic findings in 10 to 60% of patients. Scott et al reported medical treatment changes based on EGD findings in approximately 38% of patients. In 5% of these patients, pathologic ulceration and pyloric stenosis was found, requiring duodenal feeding due to gastric outlet obstruction. A prior study from this institution described unsuspected pathologic findings in 38% of surveyed patients. This occurred in the esophagus 7% of the time, stomach 24% and duodenum 7%. In that series however, the patients studied included trauma patients and those with head and neck cancer and/or stroke. In our series of only trauma patients, we found only an eight percent incidence of duodenal pathology and no unsuspected gastric outlet obstructions. As we require that patients scheduled for PEG tolerate gastric feedings, no patients with unsuspected obstruction were scheduled for PEG placement.
We retrospectively reviewed 210 patients who underwent attempted PEG placement with survey endoscopy over a 2-1/2 year period. Our rate of unsuspected gastrointestinal pathology was 37%, not different from many other reports. The majority of these patients had non-specific mucosal changes and/or inflammatory injury consistent with stress pathology. It is perhaps not surprising that stress gastritis and/or ulceration would be the most frequent finding as over two-thirds of our patients sustained spinal cord injury or traumatic brain injury, presumably placing them at high risk for bleeding. All patients at our institution undergo routine GI prophylaxis at the time of admission. While the rate of unsuspected pathology is not substantially different than the literature, it is not clear from those studies, what percent of those patients underwent routine prophylaxis.
It is perhaps reassuring to note that although there was a substantial incidence of unsuspected GI pathology, the majority were controlled or healing with standard stress prophylaxis. In those patients, the prophylaxis was simply continued. Approximately half of the patients had acute changes at the time of EGD. These patients were changed to proton pump inhibitor therapy. Only one failed medical management with an upper GI bleed, which was successfully treated endoscopically.
It would seem then that there is a real role for surveillance endoscopy at the time of PEG placement. These unsuspected lesions are clinically significant and in 90% of patients, therapy was altered in some manner.
The overall complication rate in our series was 4.5%. There were no iatrogenic complications at the time of PEG placement. Only two patients required open therapy. One patient who inadvertently pulled their PEG out required laparotomy, gastric repair and jejunal feeding tube replacement. A second patient had an unsuspected PEG leak repaired at the time of laparotomy for unrelated hemorrhage. Other complications were relatively minor. We were concerned about the fact that three PEGS were pulled out by the patient and have modified our protocol since. We now currently routinely place abdominal binders over the PEG site and have the tube exit laterally out of the binder. If a patient with brain injury or multi-system trauma gets agitated and grabs the feeding tube, they merely pull the adapter out of the PEG rather than removing the PEG. Other centers have described the use of T-fasteners for agitated patients to maintain the PEG tract if inadvertently removed. Unfortunately many of these products have been recalled and are not currently available.
General surgeons specializing in trauma and critical care seem to be able to safely place tubes. In our series, PEG placement was successful in 98% of patients and full endoscopic survey was successful 99% of the time. This is not different than the 97% successful PEG placement and 99% successful endoscopic survey reported from our own institution when PEGs were performed by the surgical endoscopy service. EGD and PEG placement are basic skills and should be able to be mastered by any well-trained surgeon. Adding full surveillance endoscopy to the examination at the time of PEG placement should only add a few additional minutes to the procedure and requires basic endoscopic maneuvers most of the time. This does not require advanced endoscopic skills or intervention, which almost certainly should be performed by a specially trained endoscopist.