REVIEW URRENT C OPINION

When is feeding via a percutaneous endoscopic gastrostomy indicated? Carthage Moran a and Seamus O’Mahony b

Purpose of review This review addresses current controversies regarding appropriate indications for percutaneous endoscopic gastrostomy (PEG) insertion. We address specific indications, namely, dementia, stroke, aspiration, motor neurone disease/amyotrophic lateral sclerosis, and head and neck cancer. We recommend practical strategies for improving patient selection. Recent findings There is now a general consensus in the United States that PEG feeding does not benefit patients with advanced dementia. ‘Early’ PEG insertion following stroke is similarly of no benefit. It is currently unclear whether patients with amyotrophic lateral sclerosis and head and neck tumors should have PEG or radiologically inserted gastrostomy. Summary Decisions relating to PEG insertion remain difficult. The gastroenterologist, working as a member of a multidisciplinary nutrition team, needs to take a lead role in this regard, rather than functioning as a technician. Keywords aspiration, dementia, gastrostomy, nutrition team, percutaneous endoscopic gastrostomy

INTRODUCTION Percutaneous endoscopic gastrostomy (PEG) is an effective means of providing long-term nutrition in patients with inadequate oral intake. The most common indications are dysphagia following stroke, chronic neurodegenerative conditions, and head and neck tumors. Decisions relating to PEG insertion are among the most common ethical dilemmas faced by gastroenterologists. Although PEG feeding can and does benefit many patients, there is growing evidence that for some patients, PEG insertion is futile and dangerous. When PEG feeding began in the 1980s, gastroenterologists functioned primarily as technicians, acting on the instruction of other physicians. Endoscopists, however, began to harbor concerns about the appropriateness of PEG insertion in some patients, for example, those with dementia. The 2004 UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report found that nearly a fifth of PEG insertions were ‘futile’, and drew attention to the high mortality in these patients [1]. A discussion document on oral feeding difficulties produced by the Royal College of Physicians (RCP) and the British Society of Gastroenterology (BSG) drew attention to the growing

problem of care homes making PEG insertion a condition for admission [2]. Over the last 10 years, gastroenterologists have played a much more active role in decisions about PEG insertion. We will address specific indications for PEG insertion where there is controversy and outline simple strategies for improving clinical decision making in this sometimes emotionally charged situation.

CONTROVERSAL INDICATIONS FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY We will discuss some of the more controversial indications for PEG below.

a Department of Medicine and bDepartment of Gastroenterology, Cork University Hospital, Wilton, Cork, Ireland

Correspondence to Dr Carthage Moran, Department of Medicine, Cork University Hospital, Wilton, Cork, Ireland. Tel: +353 21 492 22378; fax: +353 21 434 6494; e-mail: [email protected] Curr Opin Gastroenterol 2015, 31:137–142 DOI:10.1097/MOG.0000000000000152

0267-1379 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.

www.co-gastroenterology.com

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Nutrition

KEY POINTS  The multidisciplinary nutrition team can provide support when making difficult decisions regarding PEG insertion.  A gastroenterologist is a physician, not a technician.  The preferred method of gastrostomy insertion in MND and head and neck cancer is unclear; we recommend RIG.  There is no role for PEG in patients with advanced dementia.

Dementia There is now a broad consensus that PEG feeding does not benefit patients with advanced dementia [3,4 ,5]: there is no improvement in nutrition, comfort, or survival [6–8]. The use of PEG is associated with greater use of restraints, worsening pressure ulcers [9] and increased patient agitation. Hand-fed patients with advanced dementia are at lower risk of aspiration pneumonia and have lower mortality rate than those who are PEG fed. PEG feeding of patients with advanced dementia is associated with increased cost of inpatient hospital care [10]. Occasionally, some patients with dementia may benefit from PEG feeding: every case should be assessed on its own merits. Decision making regarding PEG feeding in advanced dementia is influenced by many factors other than clinical need. These include cultural norms, religious beliefs [11], expectations of families, and healthcare systems. Over the last 10 years, better education and widespread propagation of clinical guidelines has led, at least in Britain, to a marked decline in PEG feeding of patients with dementia. This is not the case in other countries such as the United States and Japan [12 ], where despite the lack of evidence of benefit, the practice is still widespread. Rates of tube feeding also locally vary [13]. Nursing home units with a home-like physical environment that promote the enjoyment of food and empower staff to value hand feeding and advanced care planning are more likely to hand-feed patients with advanced dementia [13]. The American Geriatrics Society advocates hand feeding rather than PEG in advanced dementia [14]. &&

&

Stroke Malnutrition is common in patients with acute stroke and during their rehabilitation, and is associated with poor outcomes [15]. Some early studies in the 1990s suggested that early (within a week) PEG 138

www.co-gastroenterology.com

feeding following stroke improved outcome [16]. The FOOD trial, however, found no such benefit [17]. This was a large, multicenter randomized controlled trial that assessed the benefit of tube feeding in stroke. Early feeding (via nasogastric tube or PEG) was associated with a modest reduction in mortality, but ‘at the expense of increasing the proportion surviving with poor outcome’. More significantly, PEG feeding, compared with nasogastric feeding, was associated with an increased risk of death or poor outcome. PEG feeding therefore should be reserved for those stroke patients who have persisting dysphagia at 2–3 weeks after the stroke [18–20]. In the early weeks, nasogastric tube feeding is appropriate for stroke patients with dysphagia. Scoring systems have been devised for early identification of patients who are likely to need PEG placement [21]. The following variables were associated with the requirement of PEG feeding in patients following stroke: high National Institute of Health Stroke Scale score, increasing age, and midline shift on imaging. A recent observational study in the United States found that institutions with a higher patient volume and for-profit status had higher rates of tube feeding poststroke [22 ]. &

Aspiration pneumonia This is the most difficult and controversial indication for PEG. Aspiration is commonly believed to be caused by laryngopharyngeal aspiration – food ‘going down the wrong way’. Videofluoroscopic studies are thought to predict the risk of aspiration pneumonia, although there is little evidence that this is the case. Hallenbeck [23] has eloquently summarized the problem: ‘It is worth noting that videofluoroscopy was never developed as a predictive test for aspiration pneumonia; it was developed for the purpose of assisting speech therapists in training patients in new ways of swallowing. Apparently, it works well for this purpose. Clinicians who perform videofluoroscopy found patients with evidence of food ‘‘going down the wrong way’’ and felt they had to do something’. PEG offers no significant protection against aspiration pneumonia [24]: indeed, aspiration pneumonia is the commonest cause of death in PEG-fed patients. How could this be? There are a number of possible explanations: PEG feeding does not prevent aspiration of colonized oral secretions; scintigraphic studies have shown evidence of aspiration of gastric contents in PEG-fed patients [25]; and ‘aspiration’ pneumonia in frail hospital inpatients may be multifactorial in origin, ‘a sign of often unrecognized global physiological decline’ [23]. Contributing factors include a compromised immune system, suppressed Volume 31  Number 2  March 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

When is feeding via a percutaneous endoscopic gastrostomy indicated? Moran and O’Mahony

cough reflex, and poor respiratory muscle function. None of these problems is corrected by PEG insertion. The belief, therefore, that bypassing the oropharynx will abolish aspiration pneumonia is largely incorrect. Increasingly, however, hospital inpatients are labeled as having ‘unsafe swallow’ and declared ‘nil by mouth’. This labeling inevitably increases the pressure for PEG insertion. A policy document on oral feeding difficulties by the RCP/ BSG working party concluded that ‘Coughing and spluttering are not necessarily an indication for ‘‘nil by mouth’’‘‘nil by mouth’’ should be a last resort, not the initial default option’ [2]. Options for patients with recurrent aspiration requiring enteral nutrional support include percutaneous endoscopic jejunostomy and PEG with a jejunal extension tube. These extension tubes are notoriously prone to displacement and blockage, and do not seem to reduce the incidence of aspiration pneumonia [26]. Percutaneous endoscopic jejunostomy is technically much more challenging than PEG, particularly in this high-risk population.

Motor neurone disease/amyotrophic lateral sclerosis PEG feeding is recommended by the European [27] and the American [28] guidelines, for patients with motor neurone disease (MND) and dsyphagia. Malnutrition can worsen muscle weakness, contributing to respiratory difficulties. Although rates of PEG feeding have increased in patients with MND [29], a low proportion of patients meeting criteria for PEG placement actually receive tube feeding [30]. Patients’ and carers’ perceptions of PEG feeding can delay timing of insertion, despite neurologists advocating early PEG insertion [31]. A recent meta-analysis and survey of clinical practice revealed variability of gastrostomy practices, and a paucity of high-quality evidence regarding optimal timing and method of gastrostomy insertion in this patient group [32 ]. The placement of PEG in MND patients with moderate-to-severe respiratory dysfunction has traditionally been considered hazardous because of the increased risk of respiratory compromise. Recent studies, however, challenge this. An Israeli study found no significant difference in complication rates or survival following PEG insertion in patients with forced vital capacity (FVC) less than 30% compared with those with greater FVC [33 ]. The use of noninvasive ventilation during PEG placement has been advocated in patients with moderate and severe respiratory impairment [34]. Placement of PEG using ultrathin endoscopy is well tolerated and can be performed without sedation [35]. &

&

An American study comparing the efficacy of radiologically inserted gastrostomy (RIG) to PEG in patients with MND found higher rates of successful placement and fewer episodes of postprocedure aspiration with RIG than PEG [36 ]. The PROGRAS trial (a prospective multicenter evaluation of gastrostomy in patients with MND) aims to assess efficacy of gastrostomy, and compare methods and timing of gastrostomy insertion, in patients with MND [32 ]. &

&

Oropharyngeal/esophageal cancer The most appropriate method of gastrostomy insertion in patients with head and neck cancer is unclear [37,38 ,39]. We recommend using RIG in patients with head and neck cancer because of the potential for metastatic seeding [40–43] and the technical difficulty of advancing the endoscope through the oral cavity and pharynx. PEG site metastasis in patients with squamous cell carcinoma of the head and neck is a rare but potentially grave complication of PEG insertion. Direct trauma to the tumor during endoscopy and subsequent implantation at the PEG site is thought to be the mechanism of tumor seeding. Although metastatic seeding by PEG is rare, brush cytology taken from PEG tubing and the transcutaneous incision site post-PEG insertion in patients with oropharyngeal and esophageal cancer had a positive yield of 22.5% for malignant cells [44]. &

STRATEGIES FOR IMPROVING PATIENT SELECTION Rates of inappropriate PEG insertion can be substantially reduced by the following strategies [45 ]. &

The nutrition team In their 2004 report, NCEPOD recommended that all patients referred for PEG should be assessed by a multidisciplinary team, and that there was need for more comprehensive national guidelines for patient selection [1]. The BSG published detailed guidelines in 2010 [19], and the report of the RCP/BSG working party was also published in 2010 [46]. Nutrition teams have become commonplace in British hospitals. These teams have a varying membership, but generally consist of a gastroenterologist, a specialist nurse, a dietitian, and a speech and language therapist [47]. All patients referred for PEG should be assessed by the nutrition team. There is some evidence that complications relating to tube feeding are less common in hospitals with nutrition teams [48]. Difficult decisions are better addressed by a

0267-1379 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.

www.co-gastroenterology.com

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

139

Nutrition

multidisciplinary team rather than an individual endoscopist [49,50]. Measures such as the Sheffield Gastrostomy Scoring System can provide objective support to clinicians when advising against PEG insertion [51].

The ‘cooling-off’ period This is a widely employed approach: having seen and assessed the patient, the nutrition team leaves a gap of at least a week before scheduling PEG insertion [52]. This allows the patient and their family to reflect on the many issues relating to PEG insertion. During this period, some patients (or their surrogate decision makers) may change their mind and decline PEG insertion. The ‘cooling-off’ period also allows the patient’s clinical condition to stabilize: NCEPOD cautioned against PEG insertion in patients who have active sepsis or other acute illness, such as decompensated heart failure. In the NCEPOD report, of those patients who died within 30 days of PEG insertion, 43% died within the first week: a 7-day waiting policy for PEG would allow the sickest patients to succumb without the added insult of PEG insertion.

Education and the percutaneous endoscopic gastrostomy referral form A well designed PEG referral form not only streamlines patient selection but also informs and educates other healthcare staff on appropriate use of PEG feeding. There is some evidence that education of healthcare staff regarding appropriate use of PEG improves patient selection and reduces mortality [53].

Better education of surrogate decision makers Most decisions regarding PEG insertion are made by surrogate decision makers. Discussion with relatives and surrogate decision makers is vital when making decisions about enteral feeding options. Families often feel that the decision to proceed with PEG insertion is made with too much haste and too little information [54,55]. Surprisingly, a recent American study showed that PEG insertion can negatively influence relatives’ perception of care that their relatives receive [56]. A randomized control trial demonstrated the benefit of decision aids when discussing feeding options in advanced dementia with surrogate decision makers. The use of decision aids leads to higher rates of hand feeding and less decisional conflict [57]. A Japanese study reported similar findings [58]. 140

www.co-gastroenterology.com

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY: NOT ALWAYS IN THE PATIENT’S BEST INTEREST Most patients benefit from PEG, but a substantial minority do not, and may even be harmed [59 ]. In many such cases, persons and agencies other than the patient himself may benefit. &&

(1) Families, who are reassured that the patient is not being ‘starved to death’. (2) Hospitals and nursing homes, for whom PEG feeding is less time consuming and labor intensive than hand feeding. There is a growing problem of care homes insisting on PEG insertion before accepting hospital patients requiring long-term care: PEG insertion may therefore save the hospital money by facilitating early discharge. (3) Speech and language therapists, for whom PEG, which by ‘by-passing’ the oropharynx, appears to be a neat and simple solution to ‘unsafe swallowing’. (4) Dietitians, for whom PEG enables daily caloric targets to be achieved and easily measured. (5) The patient’s physician, who by requesting PEG insertion satisfies the demands of the parties listed above. (6) The gastroenterologist, who realizes that proceeding to PEG insertion, although not in the patient’s best interest, will assuage parties (1)– (5), a much easier option than engaging in prolonged and difficult discussions around the appropriateness of the procedure. If a family has been advised by a confederacy of nurses, dietitian, speech and language therapist, and primary physician that PEG insertion is required, it becomes difficult, if not impossible, for the gastroenterologist to advise against it, particularly when the patient’s swallow has been designated ‘unsafe’. Difficult decisions, as in this case, are better addressed by a multidisciplinary nutrition team rather than the individual endoscopist, and might also lead to fewer patients being labeled as having an ‘unsafe swallow’.

THE GASTROENTEROLOGIST: PHYSICIAN OR TECHNICIAN? Writing in 1985, the late Sir Christopher Booth expressed a concern about the direction gastroenterology had taken as a specialty [60]: ‘there is a real danger that some gastroenterologists are allowing themselves to become technicians rather than professional colleagues to be consulted when their help Volume 31  Number 2  March 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

When is feeding via a percutaneous endoscopic gastrostomy indicated? Moran and O’Mahony

is needed. If another doctor asks for a technique such as endoscopy or liver biopsy to be carried out and the gastroenterologist simply responds by carrying out the technique, he is behaving not as a consultant but as a technician’. PEG was a new technique when Booth wrote this, and has become the prime example of what he had warned against.

CONCLUSION PEG feeding is useful for many, but not all, patients with feeding difficulties. Difficult decisions are best addressed by a multidisciplinary nutrition team rather than an individual endoscopist. Simple strategies such as the cooling-off period and a referral form derived from evidence-based guidelines improve patient selection. The hopes and fears of patients and families need to be addressed with sensitivity and tact. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. NCEPOD (2004). National confidential enquiry into patient outcome and death: scoping our practice. London, UK: NCEPOD. http://www.ncepod.org. uk/pdf/2004/Full_Report_2004.pdf. [Accessed 5 October 2014] 2. Royal College of Physicians (2010). Oral feeding difficulties and dilemmas: a guide to practical care particularly towards the end of life. London, UK: Royal College of Physicians. 3. Goldberg LS, Altman KW. The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clin Intervent Aging 2014; 9:1733–1739. 4. American Geriatrics Society Ethics Committee and Clinical Practice and && Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc 2014; 62:1590– 1593. Important position statement that should encourage a decline in PEG feeding of patients with advanced dementia. 5. Schwartz DB, Barrocas A, Wesley JR, et al. Gastrostomy tube placement in patients with advanced dementia or near end of life. Nutr Clin Pract 2014; 29:829–840. 6. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. J Am Med Assoc 1999; 282:1365–1370. 7. Hoffer LJ. Tube feeding in advanced dementia: the metabolic perspective. BMJ 2006; 333:1214–1215. 8. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009; (2):CD007209. 9. Teno JM, Gozalo P, Mitchell SL, et al. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med 2012; 172:697–701. 10. Hwang D, Teno JM, Gozalo P, Mitchell S. Feeding tubes and health costs postinsertion in nursing home residents with advanced dementia. J Pain Symptom Manage 2014; 47:1116–1120. 11. Greenberger C. Enteral nutrition in end of life: the Jewish Halachic ethics. Nurs Ethics 2014. [Epub ahead of print]

12. Nakanishi M, Hattori K. Percutaneous endoscopic gastrostomy (PEG) tubes are placed in elderly adults in Japan with advanced dementia regardless of expectation of improvement in quality of life. J Nutr Health Aging 2014; 18:503–509. Challenges belief that PEG benefits patients with advanced dementia. 13. Lopez RP, Amella EJ, Strumpf NE, et al. The influence of nursing home culture on the use of feeding tubes. Arch Intern Med 2010; 170:83–88. 14. Workgroup AGSCW. American Geriatrics Society identifies five things that healthcare providers and patients should question. J Am Geriatr Soc 2013; 61:622–631. 15. Yoo SH, Kim JS, Kwon SU, et al. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients. Arch Neurol 2008; 65:39–43. 16. Norton B, Homer-Ward M, Donnelly MT, et al. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ 1996; 312:13–16. 17. Dennis MS, Lewis SC, Warlow C, Collaboration FT. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet 2005; 365:764–772. 18. Wirth R, Smoliner C, Jager M, et al. Guideline clinical nutrition in patients with stroke. Exp Transl Stroke Med 2013; 5:14. 19. Westaby D, Young A, O’Toole P, et al. The provision of a percutaneously placed enteral tube feeding service. Gut 2010; 59:1592–1605. 20. Committee ASoP, Jain R, Maple JT, et al. The role of endoscopy in enteral feeding. Gastrointest Endosc 2011; 74:7–12. 21. Dubin PH, Boehme AK, Siegler JE, et al. New model for predicting surgical feeding tube placement in patients with an acute stroke event. Stroke 2013; 44:3232–3234. 22. George BP, Kelly AG, Schneider EB, Holloway RG. Current practices in & feeding tube placement for US acute ischemic stroke inpatients. Neurology 2014; 83:874–882. Variation in enteral tube feeding in patients poststroke associated with nonclinical factors. 23. Hallenbeck JL. Hydration, nutrition, and antibiotics in end-of-life care: tube feed or not tube feed? Chapter 6. In: Palliative care perspectives. New York: Oxford University Press; 2003. pp. 117–126. 24. Onur OE, Onur E, Guneysel O, et al. Endoscopic gastrostomy, nasojejunal and oral feeding comparison in aspiration pneumonia patients. J Res Med Sci 2013; 18:1097–1102. 25. Balan KK, Vinjamuri S, Maltby P, et al. Gastroesophageal reflux in patients fed by percutaneous endoscopic gastrostomy (PEG): detection by a simple scintigraphic method. Am J Gastroenterol 1998; 93:946–949. 26. Strong RM, Condon SC, Solinger MR, et al. Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study. JPEN J Parenter Enteral Nutr 1992; 16:59–63. 27. Andersen PM, Abrahams S, Borasio GD, et al. EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS): revised report of an EFNS task force. Eur J Neurol 2012; 19:360–375. 28. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidencebased review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2009; 73:1227–1233. 29. Katzberg HD, Benatar M. Enteral tube feeding for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Systemat Rev 2011; (1): CD004030. 30. Bradley WG, Anderson F, Gowda N, Miller RG. Changes in the management of amyotrophic lateral sclerosis since the publication of the AAN ALS practice parameter 1999. Amyotroph Lateral Scler Other Motor Neuron Disord 2004; 5:240–244. 31. Stavroulakis T, Baird WO, Baxter SK, et al. Factors influencing decisionmaking in relation to timing of gastrostomy insertion in patients with motor neurone disease. BMJ Support Palliat Care 2014; 4:57–63. 32. Stavroulakis T, Walsh T, Shaw PJ, McDermott CJ. Gastrostomy use in motor & neurone disease (MND): a review, meta-analysis and survey of current practice. Amyotroph Lateral Scler Frontotemporal Degener 2013; 14:96–104. Explains rationale for PROGRAS study. 33. Sarfaty M, Nefussy B, Gross D, et al. Outcome of percutaneous endoscopic & gastrostomy insertion in patients with amyotrophic lateral sclerosis in relation to respiratory dysfunction. Amyotroph Lateral Scler Frontotemporal Degener 2013; 14:528–532. Study showing potential for PEG use in MND patients with respiratory compromise (low FVC). 34. Czell D, Bauer M, Binek J, et al. Outcomes of percutaneous endoscopic gastrostomy tube insertion in respiratory impaired amyotrophic lateral sclerosis patients under noninvasive ventilation. Respir Care 2013; 58:838–844. 35. Sato Y, Goshi S, Kawauchi Y, et al. Safety of unsedated PEG placement using transoral ultrathin endoscopy in patients with amyotrophic lateral sclerosis. Nutr Neurosci 2014. [Epub ahead of print] 36. Allen JA, Chen R, Ajroud-Driss S, et al. Gastrostomy tube placement by & endoscopy versus radiologic methods in patients with ALS: a retrospective study of complications and outcome. Amyotroph Lateral Scler Frontotemporal Degener 2013; 14:308–314. Gastrostomy tube placement by RIG was more often successful and less often associated with aspiration. &

0267-1379 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.

www.co-gastroenterology.com

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

141

Nutrition 37. McAllister P, MacIver C, Wales C, et al. Gastrostomy insertion in head and neck cancer patients: a 3 year review of insertion method and complication rates. Br J Oral Maxillofacial Surg 2013; 51:714–718. 38. Nugent B, Lewis S, O’Sullivan JM. Enteral feeding methods for nutritional & management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy. Cochrane Database Systemat Rev 2013; 1:CD007904. Systematic review finding need for larger studies; no firm evidence to make a recommendation regarding enteral feeding in this patient population. 39. Wang J, Liu M, Liu C, et al. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for patients with head and neck cancer: a systematic review. J Radiat Res 2014; 55:559–567. 40. Zhang L, Dean SA, Furth EE, et al. Metastatic carcinoma to percutaneous endoscopic gastrostomy tube sites. A report of five cases. Am J Clin Pathol 2014; 141:510–514. 41. Nevler A, Gluck I, Balint-Lahat N, Rosin D. Recurrent metastatic spread to a percutaneous gastrostomy site in a patient with squamous cell carcinoma of the tongue: a case report and review of the literature. J Oral Maxillofacial Surg 2014; 72:829–832. 42. Sheykholeslami K, Thomas J, Chhabra N, et al. Metastasis of untreated head and neck cancer to percutaneous gastrostomy tube exit sites. Am J Otolaryngol 2012; 33:774–778. 43. Teh JL, Wong RK, Gowans M, et al. Gastric metastases of oral carcinoma resulting from percutaneous endoscopic gastrostomy placement via the introducer technique. Gastroenterol Rep 2013; 1:211–213. 44. Ellrichmann M, Sergeev P, Bethge J, et al. Prospective evaluation of malignant cell seeding after percutaneous endoscopic gastrostomy in patients with oropharyngeal/esophageal cancers. Endoscopy 2013; 45: 526–531. 45. O’Mahony S. Difficulties with percutaneous endoscopic gastrostomy (PEG): & a practical guide for the endoscopist. Irish J Med Sci 2013; 182:25–28. A practical guide for endoscopists to aid patient selection. 46. Royal College of Physicians. Oral feeding difficulties and dilemmas: a guide to practical care particularly towards the end of life. London: Royal College of Physicians; 2010. 47. Bischoff SC, Kester L, Meier R, et al. Organisation, regulations, preparation and logistics of parenteral nutrition in hospitals and homes; the role of the nutrition support team – Guidelines on Parenteral Nutrition Chapter 8. Ger Med Sci 2009; 7.

142

www.co-gastroenterology.com

48. Powers DA, Brown RO, Cowan GS Jr, et al. Nutritional support team vs nonteam management of enteral nutritional support in a Veterans Administration Medical Center teaching hospital. JPEN J Parent Enter Nutr 1986; 10:635–638. 49. Clarke G, Galbraith S, Woodward J, et al. Should they have a percutaneous endoscopic gastrostomy? the importance of assessing decision-making capacity and the central role of a multidisciplinary team. Clin Med 2014; 14:245– 249. 50. Clarke G, Harrison K, Holland A, et al. How are treatment decisions made about artificial nutrition for individuals at risk of lacking capacity? A systematic literature review. PloS One 2013; 8:e61475. 51. Kurien M, Leeds JS, Delegge MH, et al. Mortality among patients who receive or defer gastrostomies. Clin Gastroenterol Hepatol 2013; 11:1445–1450. 52. Kurien M, Sanders DS. Improving outcomes following percutaneous endoscopic gastrostomy (PEG): a seven-day waiting policy is essential. Clin Med 2011; 11:411. 53. Skitt LC, Hurley JJ, Turner JK, et al. Helping the general physician to improve outcomes after PEG insertion: how we changed our practice. Clin Med 2011; 11:132–137. 54. Van Rosendaal GM, Verhoef MJ, Kinsella TD. How are decisions made about the use of percutaneous endoscopic gastrostomy for long-term nutritional support? Am J Gastroenterol 1999; 94:3225–3228. 55. Golan I, Ligumsky M, Brezis M. Percutaneous endoscopic gastrostomy in hospitalized incompetent geriatric patients: poorly informed, constrained and paradoxical decisions. Israel Med Assoc J 2007; 9:839–842. 56. Teno JM, Mitchell SL, Kuo SK, et al. Decision-making and outcomes of feeding tube insertion: a five-state study. J Am Geriatr Soc 2011; 59:881–886. 57. Hanson LC, Carey TS, Caprio AJ, et al. Improving decision-making for feeding options in advanced dementia: a randomized, controlled trial. J Am Geriatr Soc 2011; 59:2009–2016. 58. Kuraoka Y, Nakayama K. A decision aid regarding long-term tube feeding targeting substitute decision makers for cognitively impaired older persons in Japan: a small-scale before-and-after study. BMC Geriatr 2014; 14:16. 59. O’Mahony S. Percutaneous endoscopic gastrostomy (PEG): cui bono? && Frontline Gastroenterol 2014. [Epub ahead of print] A polemical article that argues that PEG insertion is commonly carried out for reasons other than the patient’s best interests. 60. Booth CC. What has technology done to gastroenterology? Gut 1985; 26:1088–1094.

Volume 31  Number 2  March 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

When is feeding via a percutaneous endoscopic gastrostomy indicated?

This review addresses current controversies regarding appropriate indications for percutaneous endoscopic gastrostomy (PEG) insertion. We address spec...
205KB Sizes 0 Downloads 7 Views