| |
| Risk Factors for Complication Following Percutaneous Endoscopic Gastrostomy:
Acute Respiratory Infection and Local Skin Infection |
Jiro KANIE*, Hiroshi SHIMOKATA**, Hiroyasu
AKATSU,
Takayuki YAMAMOTO***, Akihisa IGUCHI*
* Department of Geriatrics, Nagoya University
School of Medicine.
** Department of Epidemiology, National Institute
for Longevity Sciences.
*** Department of Internal Medicine, Sawarabi-kai
Fukushimura Hospital.
|
|
| Digestive Endoscopy 1998; 10(3): 205-210
|
|
|
|
Background: Few studies of percutaneous endoscopic gastrostomy
(PEG) have evaluated the effects of antibiotic
prophylaxis, PEG placement technique and
early PEG feeding on acute postoperative
complications. In this study, we investigated
associations between postoperative management
of PEG and complications of infection.
Methods: The medical records of 271 patients were
included in this study. Administration of
antibiotics, early and delayed enteral feeding,
and PEG placement technique were analyzed
as risk factors for infectious complications.
Results: The rate of local skin infection correlated
with early PEG feeding, but there was no
difference in the rate of local skin infection
due to postoperative administration of antibiotics.
Early feeding with the usual enteral formula
was a strong risk factor for local skin infection.
The rate of local skin infection was higher
in the “Push/Pull” technique than the “Introducer”
technique. As for aspiration, the rate of
complication was lower in groups with postoperative
administration of antibiotics than in groups
without administration of antibiotics, but
there was no association between aspiration
and early feeding or PEG placement technique.
Conclusions: Local skin infection correlated with early
postoperative feeding and did not correlated
with antibiotic prophylaxis. However, for
the prevention of aspiration, administration
of antibiotics was recommended.
|
| Introduction |
Percutaneous endoscopic gastrostomy (PEG)
is a procedure for safe enteral
feeding in
patients with difficulty in swallowing,
and
is effective and easy to manage.
Patients
who need PEG placement are often
very sick,
and postoperative complications
are not rare.1,2
Various common complications
of PEG have
been documented.3,4,5 Such complications
include postoperative infections,
but the
risk factors for infection have
not been
well studied. Local skin infection
and aspiration
were the most frequent complications
among
the acute postoperative complications
related
to infection. We examined postoperative
PEG
management and its association
with these
complications.
|
| Materials and Methods |
Patients
Medical records of 295 patients who receive
PEG with informed consent between 1992 and
1997 were assessed. Six failed cases and
18 cases involving a second PEG were excluded.
And a total of 271 cases (male 104 and female
167) were analyzed (Table 1). Mean and standard
deviation of patient age were 76.7 ± 10.9
years (range: 35 to 99 years). The main purpose
of PEG placement was enteral feeding, but
in some cases the purpose of the PEG was
depressurization of irreversible intestinal
obstruction. Most primary diagnoses in these
patients were dementia and stroke, others
were degenerative diseases with difficulty
in swallowing and malignant tumors.
|
Table 1. The Profile of Patients
|
Group |
|
| Diseases |
I |
II |
III |
|
| Cerebral Infarction |
28 |
48 |
28 |
104 |
| Dementia |
23 |
41 |
27 |
91 |
| Cerebral hemorrhage |
8 |
10 |
9 |
27 |
| Subarachinoid hemorrhage |
1 |
4 |
6 |
11 |
| Gastrointestinal malignancy |
5 |
2 |
3 |
10 |
| Amyotrophic lateral sclerosis |
3 |
1 |
2 |
6 |
| Brain contusion |
1 |
2 |
2 |
5 |
| Parkinson's syndrome |
1 |
2 |
1 |
4 |
| Brain anoxia |
|
1 |
2 |
3 |
| Encephalitis |
|
2 |
|
2 |
| Brain tumor |
|
2 |
|
2 |
| Meningitis |
|
1 |
|
1 |
| Spinocerebellar degeneration |
1 |
|
|
1 |
| Spinal injury |
1 |
|
|
1 |
| Cerebral palsy |
|
1 |
|
1 |
| Multiple system atrophy |
1 |
|
|
1 |
| Adhesive intestinal obstruction |
1 |
|
|
1 |
| Sex |
Male |
33 |
37 |
34 |
104 |
| Female |
41 |
80 |
46 |
167 |
| Age |
75.6
(35-97) |
77.2
(39-99) |
77.4
(48-95) |
76.7 |
| H2 blocker |
used |
27 |
39 |
26 |
92 |
| not used |
47 |
78 |
54 |
179 |
| total |
74 |
117 |
80 |
|
|
PEG technique
The PEG tubes were placed using various
techniques including the “Pull” technique,
“Push” technique, and “Introducer” technique.
Ponsky and Gauderer technique6 was used as
the “Pull” technique and Suckes-VineTM
Gastrostomy Kit7 was used as the “Push”
technique. Either Malecot catheter by Russell8
or balloon catheter by Ueno and Kadota9 was
used as the “Introducer” technique. There
was no case receiving TGJ tube (Trance Gastro-Jejunal
tube) placement10 at the same time as PEG.
PEG technique was selected by the patient
or the attending physician.
The patient was placed on the endoscopy
table in a supine position and oral suction
was frequently applied to prevent aspiration
during endoscopy insertion. The abdominal
wall was sterilized with Popidon solution.
The mouth was swabbed with a gargle contained
Popidon Iodine solution to reduce oral bacteria
just before insertion of the endoscope in
the “Pull/Push” technique. Surgical duration
for PEG placement was determined from insertion
of the endoscope to removal of endoscope,
and all cases were performed in about 10
minutes.
Postoperative management
As for the time of starting nutrition,
patients were divided into three groups.
In the Group I, enteral feeding was not started
within the first five days. In the Group
II, sterilized enteral feeding (lactated
Ringer's solution for intravenous infusion)
using sterilized intravenous infusion kit
started within 24 hours after the procedure,
and in the Group III, feeding of the usual
enteral formula started within 24 hours after
the procedure. And as for the using of antibiotics,
they were divided into two groups, antibiotics
administered [AB(+)] and no antibiotics administered
[AB(-)]. Thus, the patients were divided
into six groups according to the time of
starting nutrition and the usage of antibiotics.
The method was determined by attending physician
of the patient. The best method in each case
was selected in the physician's judgment.
Antibiotics were administered in 175 cases
(Table 2). Most of the antibiotics were second
generation cephem administered intravenously
for 5 days postoperatively. In cases demonstrating
infection, administered antibiotics or its
duration was changed.
|
Table 2. Administered antibiotics by the method of
initiating enteral feeding
|
Group |
|
|
I |
II |
III |
Total |
| Cefotiam |
40 |
59 |
37 |
136 |
| Piperacillin |
2 |
9 |
0 |
11 |
| Cefazolin |
1 |
4 |
2 |
7 |
| Sefmetazole |
2 |
2 |
1 |
5 |
| Others |
9 |
5 |
2 |
16 |
| Total |
54 |
79 |
42 |
175 |
|
Group I；no infusion through the PEG tube
until 5 days after surgery
Group II；nutrition feeding started after
5-day-infusion of sterile lactose Ringer
solution
Group III；nutrition feeding started one
day after surgery |
|
Statistical analysis
Incidence of complications due to local
skin infection and aspiration were compared
by antibiotic prophylaxis, early enteral
feeding and PEG placement technique, and
tested by the Cochran-Mantel-Haenszel test
controlled for gender (male / female), age
(under 80 years / 80 years or over) and primary
diagnoses (dementia / others). On assessment
of the risk of complications by effects of
the interrelationship of antibiotic prophylaxis,
early enteral feeding and PEG placement technique,
the multiple logistic regression model with
gender, age and primary disease was used.
The FREQ(Frequency) procedure on SAS(Statistical
Analysis System) version 6.11 was used for
Cochran-Mantel-Haenszel test with CML (Cochran-Mantel-Haenszel)
option,11 and the LOGISTIC procedure on SAS
version 6.11 was used for multiple logistic
regression.12
In both the “Pull” technique and the
“Push” technique, catheters were inserted
through oral cavity, and only the technique
of catheter placement differed. Thus, the
“Pull” technique and the “Push” technique
were analyzed together as the “Push/Pull”
technique. The analyzed complications involved
local skin infection and aspiration which
were the most common infectious complications.
Local skin infection was defined as wound
infection with both redness and pus discharge
at the site of catheter insertion within
two weeks postoperatively. Number of aspirations
was also defined as the number of bronchitis
or pneumonia episodes. Bronchitis was counted
as cases involving fever and increase of
sputum volume without pneumonia on chest
x-ray film within one week postoperatively,
and cases that showed fever only were excluded.
|
| Results |
Tube placement and Post surgical management
Of 271 PEGs, the “Pull” technique
was
used in 68, the “Push” technique
in 99,
and the “Introducer” technique
in 104 (Malecot
catheter 81 and balloon catheter
23). As
for the initiation of postoperative
enteral
feeding, there were 74 in Group
I, 117 in
Group II, and 80 in Group III
(Table 3 and
4).
|
Table 3. Frequency of local skin infection
|
Push/Pull technique |
|
Introducer technique |
|
Total |
|
AB(+) |
AB(-) |
Total |
|
AB(+) |
AB(-) |
Total |
|
AB(+) |
AB(-) |
Total |
| Group I |
2/46* |
1/12 |
3/58 |
|
0/8 |
0/8 |
0/16 |
|
2/54 |
1/20 |
3/74 |
| Group II |
0/45 |
1/21 |
1/66 |
|
1/34 |
0/17 |
1/51 |
|
1/79 |
1/38 |
2/117 |
| Group III |
7/30 |
1/13 |
10/43 |
|
2/12 |
0/25 |
2/37 |
|
9/42 |
3/38 |
12/80 |
| Total |
9/121 |
9/46 |
14/167 |
|
3/54 |
0/50 |
3/104 |
|
12/175 |
5/96 |
17/271 |
|
Table 4. Frequency of aspiration
|
Push/Pull technique |
|
Introducer technique |
|
Total |
|
AB(+) |
AB(-) |
Total |
|
AB(+) |
AB(-) |
Total |
|
AB(+) |
AB(-) |
Total |
| Group I |
4/46* |
0/12 |
4/58 |
|
0/8 |
1/8 |
1/16 |
|
4/54 |
1/20 |
5/74 |
| Group II |
2/45 |
3/21 |
5/66 |
|
2/34 |
1/17 |
3/51 |
|
4/79 |
4/38 |
8/117 |
| Group III |
1/30 |
5/13 |
6/43 |
|
0/12 |
3/25 |
3/37 |
|
1/42 |
8/38 |
9/80 |
| Total |
7/121 |
8/46 |
15/167 |
|
2/54 |
5/50 |
7/104 |
|
9/175 |
1/96 |
22/271 |
*number of complication / number of PEG
Group I；no infusion through the PEG tube until 5 days after surgery
Group II；nutrition feeding started after 5-day-infusion of sterile lactose Ringer solution
Group III；nutrition feeding started one day after surgery
AB(+)；antibiotics administered after surgery
AB(-)；no antibiotics administered after surgery |
|
Complications
Acute postoperative complications after
PEG placement occurred 88 of 271 patients
(Table 5). Complications related to infections
occurred in 56; of these, aspiration including
bronchitis and pneumonia was noted in 22,
and local skin infection in 17.
|
Table 5. Post-surgical acute complications
| Infection |
|
Others |
| Complications |
frequency |
|
Complications |
frequency |
| Local skin infection |
17 |
|
Tube migration |
6 |
| Bronchitis |
16 |
|
Balloon burst |
6 |
| Fever |
13 |
|
Stomach wall injury |
6 |
| Pneumonia |
6 |
|
Catheter obstruction |
6 |
| Pan peritonitis |
2 |
|
Catheter extraction |
4 |
| Regional peritonitis |
2 |
|
Subcutaneous emphysema |
2 |
| |
|
|
Bleeding |
1 |
| |
|
|
Abdominal wall injury |
1 |
| Total |
56 |
|
|
32 |
|
Table 4 shows the frequencies of local skin infection after PEG placement.
For the comparison of the frequencies of local skin infection by initiation
of enteral feeding, Cochran-Mantel-Haenszel test controlled for gender,
age, and primary diagnosis was used. In Group I in whom enteral feeding
with the usual feeding formula was started after 5 days, 3 cases (4.1%)
of local skin infections were found among 74 patients. Two (1.7%) of 117
Group II patients in whom lactated Ringer’s solution was infused within
24 hours after the PEG placement showed local skin infection. There was
no significant difference in the frequency of the local skin infection
between these two groups. Group III in whom enteral feeding with the usual
enteral formula was started within 24 hours postoperatively showed high
rate of the local skin infections, that is, 12 cases (15.0%) in the 80
patients. This rate was significantly higher than the rate in Groups I
and Group II combined, 5 cases (2.6%) in the 191 patients (c2=14.7, df=1,
p<0.001). The rate of local skin infection was assessed by PEG placement
technique. Fourteen cases (8.4%) were found among 167 patients undergoing
the “Push/Pull” technique. This rate was marginally higher than the rate
with the “Introducer” technique, three (2.9%) of 104 patients (c2=3.3,
df=1, p=0.07).
As for antibiotic prophylaxis, 12 cases
(6.9%) of local skin infections occurred
among 175 patients with antibiotic administration,
and 5 cases (5.2%) were found among 96 patients
without antibiotic administration. There
was no significant difference due to antibiotic
prophylaxis for local skin infection. Whereas
there was no significant difference between
patients used and not used H2blockers for
local infection.
Twenty-two patients (8.5%) had complications
due to aspiration among of the total 271
patients (Table 4). Frequencies of aspiration
by antibiotic prophylaxis, initiation of
enteral feeding, and PEG placement technique
were analyzed using the Cochran-Mantel-Haenszel
test controlled for age, gender, and primary
diagnosis as well as local skin infection.
Based on introduction of gastrostomy feeding,
complications due to aspiration were found
in five (8.1%) of 74 Group I patients, eight
(6.8%) of 117 Group II patients, and nine
(11.3%) of 80 Group III patients. There were
no significant differences in the rate of
aspiration among these three groups. Fifteen
aspiration cases (9.0%) occurred among the
patients undergoing the “Pull/Push” technique
and seven aspiration cases (6.7%) occurred
among 104 patients undergoing the “Introducer”
technique. There was no difference in the
incidence of aspiration. As for antibiotic
prophylaxis, aspiration was found in 9 (5.7%)
of the patients receiving antibiotics, and
13 (13.5%) of 96 patients without antibiotic
administrations. The rate of aspiration was
significantly lower among the patients receiving
antibiotics than it was among patients without
antibiotics administration (c2=4.6, df=1,
p=0.03).
Risks of local skin infection and aspiration
by antibiotic administration, method of introducing
gastrostomy feeding, PEG placement technique,
gender, age, and primary diagnosis were assessed
by the multiple regression model (Table 6).
Significant risk factors for local skin infection
were early feeding and the “Pull/Push”
technique. Odds ratio of Group III in whom
enteral feeding with the usual formula was
started soon after surgery to Group I and
Group II was 8.66, and the 95% confidence
interval (CI) was 2.79 to 26.8. The odds
ratio of the “Push/Pull” technique to “Introducer”
technique was 3.95 (95% CI 1.00 to 15.6).
As for complications due to aspiration, antibiotic
prophylaxis was the only significant risk
factor. The odds ratio of the group with
antibiotic administration to the group without
antibiotics administration was 3.08 (95%
CI 1.21 to 7.83).
|
Table 6. Results of multiple logistic regression
| Variables |
Parameter
Estimate |
Standard
Error |
Wald
Chi-Square |
Probability
Chi-Square |
Odds
Ratio |
95% Conf.
Interval |
| Local skin infection |
|
|
|
|
|
|
|
| INTERCPT |
-5.23 |
2.13 |
6.05 |
0.01 |
- |
- |
- |
| Early feeding |
2.16 |
0.58 |
13.97 |
<0.01 |
8.66 |
2.79 |
26.86 |
| Antibiotics prophylaxis |
-0.40 |
0.60 |
0.43 |
0.51 |
0.67 |
0.21 |
2.20 |
| PEG technique |
1.37 |
0.70 |
3.84 |
0.05 |
3.95 |
1.00 |
15.62 |
| Gender |
-0.36 |
0.56 |
0.42 |
0.52 |
0.70 |
0.23 |
2.09 |
| Age |
0.01 |
0.03 |
0.18 |
0.67 |
1.01 |
0.96 |
1.07 |
| Primary diagnosis |
-0.37 |
0.61 |
0.36 |
0.55 |
0.69 |
0.21 |
2.29 |
| Aspiration |
|
|
|
|
|
|
|
| INTERCPT |
-4.03 |
1.76 |
5.24 |
0.02 |
- |
- |
- |
| Early feeding |
0.25 |
0.48 |
0.27 |
0.60 |
1.09 |
0.50 |
3.33 |
| Antibiotics prophylaxis |
1.13 |
0.48 |
5.59 |
0.02 |
3.08 |
1.21 |
7.83 |
| PEG technique |
0.66 |
0.50 |
1.71 |
0.19 |
1.94 |
0.72 |
5.20 |
| Gender |
0.68 |
0.46 |
2.15 |
0.14 |
1.97 |
0.80 |
4.89 |
| Age |
0.01 |
0.02 |
0.06 |
0.81 |
1.01 |
0.96 |
1.05 |
| Primary diagnosis |
-0.48 |
0.56 |
0.73 |
0.39 |
0.62 |
0.21 |
1.87 |
|
Discussion |
PEG was initially described by Ponsky and
Gauderer in 1980.13 Since then,
PEG placement
has been valued highly as a procedure
for
managing patients who need long-term
enteral
nutrition.14 However, we have
encountered
more frequent acute postoperative
complications,
that is 88 complications in the
271 PEG placement,
than indicated in previous reports.15-17
Local skin infection and aspiration
were
the most frequent complications.
Local skin
infection was usually intractable,
and sometimes
required surgical procedures
such as incision
and drainage. There were six
pneumonia cases
due to aspiration, and there
was one death
due to pneumonia. Aspiration
as a complications
of PEG placement should especially
be avoided.
There were some reports that
antibiotic administration
was effective in preventing local
skin infection.18,19
However, results of our study
were that local
skin infection did not correlate
with antibiotic
administration, but were related
with early
feeding and PEG placement technique.
On the
other hand, antibiotic prophylaxis
significantly
decreased the frequency of complications
due to aspiration.
Both pneumonia and bronchitis
were included
as complications of aspiration
in this study.
Aspiration was the most frequent
complication
we experienced. It is suspected
that aspiration
was directly associated with
the procedure
of endoscope insertion because
complications
occurred at almost the same rate
in the "Push/Pull"
and "Introducer" technique,
and
was not related with the early
feeding. Most
patients undergoing PEG had difficulty
of
swallowing. Endoscope was usually
inserted
in the supine position in these
high-risk
cases. Thus, accumulated saliva
in the oral
cavity would easily be aspirated.
Suctioning
of the oral cavity during insertion
of endoscope
was a routine procedure in this
study and
the oral cavity was cleansed
before the procedure
in the cases undergoing the "Push/Pull"
technique. There are no reports
showing the
effectiveness of these procedures.
However,
the insertion of endoscope is
so closely
related to aspiration, that we
should put
an enthasize on these procedures.
Moreover,
observation of these complications
during
postoperative management tends
to be focused
on abdominal symptoms since PEG
is a gastric
procedure, so it would be important
for symptoms
of the respiratory system to
be carefully
checked because aspiration is
a frequent
and serious complication.
Local skin infection was more
frequently
found in the cases managed by
the "Push/Pull"
technique than in those managed
by the "Introducer"
technique. The catheter is placed
at the
abdominal wall through the oral
cavity, esophagus,
and stomach by the "Push/Pull"
technique. Thus, it would be
expected that
the rate of local skin infection
is higher
in the "Push/Pull"
technique than
the "Introducer" technique.
The
results of this study confirmed
this assumption.
The rate of local skin infection
was also
significantly influenced by contents
and
timing of the start of enteral
feeding. It
is difficult to explain the difference
in
the rate of local skin infection
by contents
and starting time of enteral
feeding. Several
factors influencing the rate
of local skin
infection have been reported;
the rate was
decreased by antibiotic administration;18,19
the rate was decreased by sterilization
of
the oral cavity using Povidon
Iodine sterilization
or soaking of the catheter in
Povidon Iodine
solution;20 the rate was increased
by increased
intragastric pH in patients under
H2-blocker
treatment.21 There was a report
which showed
no difference in the rate of
local skin infections
between cases in which enteral
feeding started
three hours after surgery and
24 hours after
surgery.22
As for the time to start enteral
feeding,
various protocols have been proposed
based
on experiences with traditional
surgical
gastrostomies, such as the report
that enteral
feeding should start within 24
hours after
surgery19,22 and a report that
intravenous
hyperalimentation should be given
during
1 to 2 weeks after surgery.23
In our study,
all cases were divided into three
groups
according to the time of enteral
feeding
was started. The results showed
that the
Group I and II had significantly
lower rates
of local skin infection than
Group III, regardless
of antibiotic prophylaxis. The
method used
in Groups III is the usual method
of starting
enteral feeding. In this method,
even though
formula of the feeding is aseptic,
it is
soon contaminated by bacteria
after unsealing
the package, and the route of
enteral feeding
is not aseptic. Thus, it is logical
to assume
that the opportunity for local
skin infection
increases. As indicated above,
the incidence
of local skin infection is increased
by the
rise of intragastric pH.18. It
is also suspected
that the rising gastric pH caused
by enteral
feeding increases the frequency
of local
skin infection. In any case,
it is ideal
to wait to start enteral feeding
because
it takes 1 to 2 weeks for wound
healing,
prior to which, the wound has
inadequate
in fibrosis, and the adhesive
and anti-stretch
ability are quite weak during
healing.24
However, it is not reasonable
to give intravenous
hyperalimentation for a predetermined
period
in all PEG cases, because it
is sometimes
difficult to maintain an intravenous
route
in patients with dementia, and
surgical complications
caused by the route of intravenous
hyperalimentation
are not rare. Furthermore, intravenous
hyperalimantation
is a very expensive procedure.
From this
perspective, enteral feeding
with lactated
Ringer's solution for intravenous
infusion
within 24 hours after surgery
would be the
best method of starting feeding.
Antibiotic prophylaxis prevented
aspiration
but did not prevent local skin
infection
in this study. It could be debated
whether
antibiotic prophylaxis was not
effective
in preventing local skin infection
because
the infection was bacterial.
The reason for
ineffectiveness should be discussed
further.
The first issue is the time to
start the
antibiotic administration. Most
cases in
this study started receiving
intravenous
antibiotic administration after
returning
to the ward from the endoscopic
examination
room where PEG was performed.
If antibiotic
prophylaxis started before surgery
and the
maximal concentration of antibiotics
was
obtained during surgery, the
rate of infectious
complications would likely be
improved. The
second issue is the bacterial
cause of the
local skin infection. When bacterial
culture
could be obtained, methicillin
resistant
staphylococcus aureus and pseudomonas
aeruginosa
were sometimes the major bacterial
cause.
This was mainly because patients
undergoing
PEG placement were often immnocompromised
hosts. The antibiotics used in
this study
were mainly cefems, the second
generation
antibiotics, which might not
be sensitive
to opportunistic infection. These
opportunistic
infections were also observed
in complications
due to aspiration. Antimicrobial
agents must
be selected to be sensitive to
opportunistic
infection.
It is concluded that it is
desirable to
delay enteral feeding through
the PEG tube
for 5 days after surgery, but
in such delayed
cases, it is useful to start
enteral feeding
using lactated Ringer’s solution
used in
intravenous infusion kit. Antibiotic
prophylaxis
is effective especially for preventing
pulmonary
infections, and it is recommended
that antibiotics
sensitive to opportunistic infection
in the
immunocompromised host be selected.
|
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