Mathus-Vliegen L M, Koning H
Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Gastrointest Endosc. 1999 Dec;50(6):746-54. doi: 10.1016/s0016-5107(99)70153-7.
Percutaneous endoscopic gastrostomy (PEG) is a generally accepted procedure, but the appropriateness of patient selection and the justification of jejunal feeding have not been systematically investigated. Also, a critical appraisal of the applicability and tolerance of nutritional support in the immediate postinsertion period and during prolonged outpatient care is lacking.
Prospectively collected data in adult and pediatric patients during a period of 7 years were analyzed. Follow-up data were available at days 1, 7 and 28 and thereafter every 6 to 12 weeks until gastrostomy removal, death or the conclusion of the study.
A PEG was successfully positioned in 268 of the 286 referred patients (94%). A jejunal tube through the PEG (JETPEG) was placed beyond the duodenojejunal ligament in 38 patients. Procedure-related mortality was 1%, 30-day outpatient mortality 6.7%. Total follow-up was 295 patient-years with an overall mortality of 53% (PEG 53%; JETPEG 50%). Both major (8.4%) and minor (24.0%) procedure-related complications in the first 28 days consisted merely of (infectious) wound problems. In prolonged follow-up, the complications were more tube-related. The durability of the tube in surviving patients with a PEG or JETPEG in situ was a median of 495 days (range 162 to 1732 days). Tube dysfunction because of clogging, porosity and fracture occurred after a median of 347 days (range 9 to 1123 days). Nausea, vomiting, bloating and dumping interfered with feeding during the first week and during extended follow-up. Intrajejunal feeding was associated with dumping and diarrhea. In retrospect, the anticipated need of 4 weeks of enteral nutrition was not met in 9.0%. The extension of a PEG into a JETPEG was thought inappropriate in 23.7%. In the remainder, a 91% reduction in aspiration justified its use. The tube life span was equal to or greater than that of a PEG, despite tube dysfunction in 26.8%.
Proper selection of patients for a PEG, i.e., those with an anticipated need of greater than 4 weeks of enteral nutrition, is a challenge. Notwithstanding an increased rate of tube dysfunction, well-selected patients may benefit from a JETPEG. Follow-up is mandatory because many patients might have become malnourished or underfed while on tube feeding, mainly because of GI intolerance.
经皮内镜下胃造口术（PEG）是一种普遍接受的手术，但患者选择的恰当性以及空肠喂养的合理性尚未得到系统研究。此外，对于营养支持在置入后即刻及长期门诊护理期间的适用性和耐受性缺乏严格评估。
分析了7年间前瞻性收集的成人和儿科患者的数据。随访数据在第1天、第7天和第28天可获取，此后每6至12周获取一次，直至胃造口移除、患者死亡或研究结束。
286例转诊患者中有268例（94%）成功置入PEG。38例患者通过PEG置入了空肠管（JETPEG），其位置超过十二指肠空肠韧带。手术相关死亡率为1%，30天门诊死亡率为6.7%。总随访时间为295患者年，总死亡率为53%（PEG组53%；JETPEG组50%）。前28天的主要（8.4%）和次要（24.0%）手术相关并发症仅包括（感染性）伤口问题。在长期随访中，并发症更多与管道相关。PEG或JETPEG在位的存活患者中，管道的耐用时间中位数为495天（范围162至1732天）。管道堵塞、孔隙和断裂导致的功能障碍发生时间中位数为347天（范围9至1123天）。恶心、呕吐、腹胀和倾倒综合征在第一周及长期随访期间干扰喂养。空肠内喂养与倾倒综合征和腹泻相关。回顾性分析显示，9.0%的患者未达到预期的4周肠内营养需求。23.7%的患者认为将PEG扩展为JETPEG不合适。其余患者中，反流减少91%证明了其使用的合理性。尽管26.8%的患者出现管道功能障碍，但管道使用寿命与PEG相当或更长。
为PEG恰当选择患者，即预期需要超过4周肠内营养的患者，是一项挑战。尽管管道功能障碍发生率增加，但精心选择的患者可能从JETPEG中获益。随访是必要的，因为许多患者在管饲期间可能会出现营养不良或喂养不足，主要是由于胃肠道不耐受。
