Usage characteristics and adverse event rates ​of the direct puncture and pull techniques for percutaneous endoscopic gastrostomy in patients with malignant tumors of the upper aerodigestive tract

Abstract

Background and study aims Patients with malignant tumors of the upper gastrointestinal tract are at risk of weight loss. Early supportive nutrition therapy is therefore recommended and usually requires placement of a percutaneous endoscopic gastrostomy (PEG). The aim of this study was to compare adverse events and usage characteristics of the direct puncture technique with those of the traditional pull technique when used in patients with endoscopically passable tumors. The primary endpoint was the rate of inflammatory adverse events (AEs) at the gastrostomy fistula. The secondary endpoint was the long-term rate of puncture-site metastases. Patients and methods One hundred twenty patients (median age 56; IQR 36, 86 years) were randomized and treated per protocol in this prospective open randomized single-center study. Follow-ups were conducted on the third and seventh post-interventional days, after 1, 3 and 6 months and the last follow-up 5 years after intervention. Results Within the short-term follow-up period of 6 months after PEG placement, AEs were noted in 47 patients (39.2 %). These included 22 inflammations and 16 device dislocations and were mainly found in the puncture group (33 vs. 14 in the pull group) with a significantly increased incidence in the first month after PEG insertion ( P = 0.001). Evaluation of the 5-year data did not reveal any significant differences. The gastrostomy tube was used in 101 patients (84.2 %) (range 18 days to 5 years). Conclusions Our results favor the pull technique for patients with endoscopically passable tumors of the upper gastrointestinal tract due to less short-term adverse events. Both systems contributed equally to secure long-term use.

Complication rates of direct puncture and pull-through techniques for percutaneous endoscopic gastrostomy: Results from a large multicenter cohort

“…Subgroup analysis indicated that for the direct puncture technique, the decrease in complications was driven by a reduction in infections (severe wound infection, peritonitis, and subcutaneous abscess) as well as complications related to insufficient adherence of stomach and abdominal wall (peritonitis, acute abdomen, pneumoperitoneum, and dislocation requiring surgery). The reduction in infectious complications documented here for use of the direct puncture technique was previously reported in five of seven studies comparing the two techniques 4 5 6 7 8 9 11 . Most authors suggested that the increased infection rate in the pull-through technique group was mediated by the spread of bacteria from the oropharyngeal area 6 7 8 9 10 .…”

“…The subgroup analysis indicated that for the direct punction technique the decrease in complications was driven by a reduction of infections (severe wound infection, peritonitis und subcutaneous abscess) as well as complications related to an insufficient adherence of stomach and abdominal wall (peritonitis, acute abdomen, pneumoperitoneum, and dislocation requiring surgery). The here identified reduction in infectious complications by the introduction of the direct punction technique was previously reported in five out of seven studies comparing both techniques [4][5][6][7][8][9]11].…”

“…In 2011, different results were reported by van Dyck et al [11], who published a retrospective analysis of 57 patients, identifying the direct puncture technique to be associated with a significantly higher complication rate (11/24, 48 %) when compared to the pull-through technique (4/33,12 %, P < 0.05). Teich et al confirmed these data in a prospective randomized trial with 120 patients (per protocol treatment) with an early complication rate of 33 serious adverse events in 58 patients in the direct puncture technique group versus 14 of 62 patients in the pull-through technique group (P = 0.001) [4]. This thorough compilation of the complication rates with the pull-through and direct puncture techniques returned contradictory results.…”

“…The pullthrough technique has become the standard procedure for PEG over the years. The complication rate of this technique varies between 4.9 and 23.8% of the interventions in the literature [2][3][4].…”

“…The complication rate for this technique varies between 4.9 % and 23.8 % in interventions documented in the literature [2][3][4].…”