There are two methods commonly used to feed patients with swallowing disabilities; these are nasogastric tube (NGT) placement and percutaneous endoscopic gastrostomy (PEG). NGT feeding is non-invasive, but is associated with complications such as aspiration pneumonia, reflux esophagitis, esophageal mucosal damage caused by mechanical stimulation, sinusitis, and problems attributable to the need to change the tube every 3-4 weeks¹⁾. PEG feeding is employed if NGT feeding is likely to be required for more than 3 months²⁾. In the past, surgical gastrostomy was used, but this procedure is highly invasive and is associated with numerous potential complications³⁾. However, previous studies have shown that PEG is safe, effective over the long-term and associated with a low risk of complications⁴⁾. Thus, PEG is the preferred method for enteral nutritional support of patients who experience chronic problems with normal feeding4-⁶⁾.

PEG involves insertion of a feeding tube into the stomach via an endoscope. The procedure is associated with low mortality and is relatively easy to perform. Thus, the use of PEG has increased significantly since the time of introduction of the technique in 19817, ⁸⁾. An estimated 61,000 PEG procedures were performed worldwide in 1988 and an estimated 216,000 are performed annually today. PEG placement is currently the second most common indication for endoscopy of the upper gastrointestinal tract⁸⁾.

PEG is frequently used in neurologically impaired children to improve nutritional status, to reduce the amount of time needed for feeding, and to lower the prevalence rate of diseases that may result from poor nutrition1, ⁹⁾. Such patients may be diagnosed with hypoxic brain damage, leukomalacia, infantile spasms, epilepsy, or cerebral palsy.

Neurologically impaired children of poor nutritional status and suffering from immune deficiencies are at high risk of various PEG-related complications even though they are form the group that has most to benefit from PEG. Thus, it is necessary to carefully follow-up such patients after PEG procedures¹⁰⁾.

In the present study, we evaluated the effectiveness of PEG by analyzing the characteristics, complications, and outcomes of a group of neurologically impaired children who were treated with PEG at our hospital.

A total of 32 pediatric patients underwent PEG at the Bundang CHA Hospital (Gyeonggi-do, Korea), from March 2002 to August 2008. We reviewed the medical records of all patients, including clinical presentations, details of operative procedures, and postoperative complications.

NSAIDs and other oral medications were withheld from all patients for 1-7 days prior to the procedure, and oral food was withheld for 6-24 h before PEG tube feeding was initiated. Intravenous antibiotics, given either prophylactically or concurrently were given to reduce the incidence of peristomal wound infection after PEG placement.

With the consent of parents, patients were intravenously sedated using midazolam and/or fentanyl, and pethidine was administered intravenously during the procedure. PEG was performed using a commercial PEG kit (Bard Endoscopic Technologies, Billerica, MA) employing the Ponsky-pull technique¹¹⁾. A video endoscope of appropriate size was used. After the stomach was insufflated, transillumination and finger indentation were applied to confirm the puncture site. An insertion wire was passed into the stomach via the cannula, grasped by a wire snare, and withdrawn through the mouth together with the endoscope. The PEG tube was next attached to the end of the wire and pulled in an ante-grade manner through the esophagus and out of the abdominal wall. The final position of the dome was confirmed by a second endoscopic examination. Tube feeding with liquid food began 6-24 h after placement.

Early complications were defined as those occurring within 6 days after PEG insertion. Late complications were defined as those occurring after that time⁴⁾. To evaluate clinical outcomes, body weight was recorded 1 day before PEG and at least 6 months after PEG. Weight change was compared with the age-adjusted Z-score of weight before and after PEG. The Z-score of weight was calculated as: (actual weigh-mean weight)/SD. A retrospective study of clinical outcomes was performed with checking new aspiration event, aggravated GER, aggravated or new GI bleeding and removal of PEG⁴⁾.

SPSS version 17.0 (SPSS, Inc., Chicago, IL) was used for statistical analysis of data.

Gastrostomy feeding is preferred over NTG feeding if nutritional support is likely to be required for more than 3 months. PEG reduces morbidity, mortality, and costs associated with surgical gastrostomy. PEG also lessens the frequency of choking episodes, aspiration events, and chest infections; and improves nutritional status2, 12, ¹³⁾. In our experience, neurodisability is the main indication for PEG. A previous study noted that cerebral palsy was the single most important cause of PEG⁹⁾. Patient weight of less than 10 kg and a history of previous gastric surgery are no longer considered contraindications to PEG placement¹⁴⁾. In the present study, two patients weighed less than 10 kg and one had a history of previous gastric surgery, but none of these patients experienced complications.

Possible complications associated with PEG include aspiration, bleeding, perforation of the viscera, and prolonged ileus¹⁵⁾; as well as major complications such as peritonitis and necrotizing fasciitis9, 16-¹⁷⁾. In addition, PEG site infection, PEG site leakage, buried bumper syndrome, gastric ulceration, development of a gastro-colic fistula, tumor implantation at the PEG site, and GER, are all possible¹⁸⁾. Previous studies have reported that the rate of major complications was 3-17.5% and that of minor complications 2-25%4, 10, 13, ¹⁹⁾. Compared with other PEG studies, our complication rate (47%) was high. This may be attributable to our small sample size, among-study population differences (perhaps in body weight), and/or the use of different definitions of complications.

In our study, one patient had a gastro-colic fistula; this is a major complication. In the literature, the incidence of gastro-colic fistula caused by PEG has been reported to be 0.3-6.7%5, 10, 13, ²⁰⁾. This complication is typically treated by laparotomy. Changes in normal anatomy, such as occur in those with scoliosis and kyphoscoliosis, as in our patient, can predispose to development of a gastro-colic fistula. This can make it difficult to identify an appropriate puncture site for PEG insertion, because anatomical changes can displace the colon, small bowel, and stomach, as a result of over-inflation²¹⁾. In such patients, we suggest careful selection of a cutaneous puncture point using transillumination of the abdominal wall and clear visualization employing direct external palpation with digital pressure.

We found the Z-score of weight after PEG was larger than that before PEG. It indicated accelerated weight gain after PEG with catch-up growth⁴⁾. We also found a relationship between low body weight and the frequency of PEG complications, but no such association with any of gender, age, presence of underlying seizures, or tracheotomy. This suggests that the probability of complications associated to PEG rises if nutritional status is poor.

It has been suggested that PEG may exacerbate GER⁹⁾, and previous studies reported a GER rate after PEG of 14-47%22, ²³⁾. However, other workers found that GER frequency did not increase after PEG, so that concomitant anti-reflux procedures were not required²⁴⁾. No clear definitions of GER severity are available, and most GER complaints are subjectively reported. Thus, the reported association between PEG and GER has been debated²³⁾. In the present retrospective study, we did not assess GER severity before PEG, and we were thus unable to evaluate any association among GER, PEG, and nutritional status. However, in most children with histologically confirmed GER, vomiting and other symptoms seemed to resolve, and the need for anti-reflux medications fell. One patient had laryngomalacia and required anti-reflux medication, whereas another patient with severe scoliosis needed Nissen fundoplication. No new aspiration events occurred after PEG, and we thus recommend that fundoplication should not be routinely used²⁵⁾.

Various guidelines have been suggested to avoid the complications associated with PEG tube placement1, 13, ²⁶⁾. Based on our own experience and the results of the present study, we suggest additional measures to avoid major complications associated with PEG. First, the puncture site must be appropriately identified and prepared, especially in patients with severe anatomical abnormalities. Second, an abdominal supine x-ray should be obtained after feeding to guard against overinflation during PEG²⁰⁾. Third, nutritional support should include trace elements (zinc and iron) and multi-vitamins, to prevent wound infection. Finally, a longer PEG tube should be used, to allow of clear liquid flushing before and after PEG feeding.

Traditionally, enteral feeding was initiated 24 h after tube placement. However, it has been suggested that PEG tube feeding as early as 3 h after placement may be safe and effective. The maturation phase of wound healing is attained only after 20 days or more, so a 24 h wait would seem to allow of only minimal maturation of the gastrostomy tract. However, early feeding seems to be safe, and allows rapid administration of nutritional support, making the procedure less costly from a physiological viewpoint²⁷⁾.

The PEG tube replacement process is relatively simple and usually does not require any additional endoscopic procedure. Typically, the tubing is merely pulled out through the stomach site and replaced with a new catheter. In the present study, no complications were associated with PEG tube exchange, and most patients simply required larger PEG tubes because of increased body weight and expansion of puncture diameter²⁸⁾.

In conclusion, our results indicate that PEG is safe and effective when used to provide long-term nutritional support to severely handicapped children who require lifelong tube feeding. However PEG is associated with both minor and major complications. Therefore, we believe it essential to customize the PEG procedure for each patient, and we emphasize that post-procedural observation is imperative.