Q16. What are the complications from gastrostomy tube placement and is there a preferred method of placement?

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Q16. What are the complications from gastrostomy tube placement and is there a preferred method of placement?

Summary

Comparison of the studies in the literature in this area is limited due to the significant variation in definitions of major and minor complications.

There are six level III-2 neutral quality studies comparing different types of gastrostomy placement [1][2][3][4][5][6]. There appears to be higher procedure related mortality in the percutaneous radiological gastrostomy (PRG) group [2][1]. Complications are lower in percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy compared to laparoscopic placement overall [3]. Minor complications are higher in PEGs placed via the pull technique compared to PEGs inserted by the push technique [4]. Complication rates are higher in PRG compared to PEG [5]; minor complications appear to be greater in surgical tubes compared to PEG or PRG [1]; and complication rates are similar for PEG, radiologically inserted gastrostomy (RIG) and surgical tubes [2]. Complication rates and accidental removal was higher using the introducer PEG compared to the pull PEG[7] and mortality was higher although this did not reach statistical significance. No difference was seen for wound infections or perforations.

There are four level III-2 studies, two negative quality [8][9] and two neutral quality [10][11]. Amann reported a complication rate of 9.9% and that lower body mass index (BMI) is associated with more complications. Baschnagel et al. reported a major complication rate of 10%. Gibson reported that PEG placement may be more difficult in patients with head and neck cancer compared to neurology patients, but there are fewer complications. Sobani et al. found stromal leak (6.25%) and surgical site infection (12.5%) to be the only reported complications. There are four level III-3 studies, one positive quality [12] and three neutral quality [13][14][15]. One paper reported on outcomes with PRG with 0% major and 14% minor complications [13]. Two studies report on outcomes with a pull PEG with one documenting 8% major and 13% minor complications [14], and the other reporting 4.3% late complications with only one major infection (wall abscess) requiring chemotherapy discontinuation [15]. One study reporting on outcomes of patients receiving prophylactic PRG or PEG identified 0% major and 27% minor complications, with the most common being insertion site infection (44%) [12].

There was one level IV positive quality study [16], 26 level IV neutral quality studies [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42], and eight level IV negative quality studies [43][44][45][46][47][48][49][50]. Major complications range from 0% to 8%. Minor complications range from 0% to 40%. Procedure related mortality was reported with 10 papers reporting no mortality and five papers reporting rates from 0.7% to 5%. One study [19] reported increased risk of complications in gastrostomy placed during or after treatment compared to before treatment. One study has shown that for surgical treatment, PEG should be placed after surgical resection to reduce complications post PEG [33]. Patients who have an oral/throat infection are more likely to develop a stoma site infection post PEG [23].

There have been rare case reports in the literature of patients developing metastases at the gastrostomy site. Three theories have been proposed on the mechanism of this which includes either lymphatic spread, direct implantation with the pull technique using an endoscope or by swallowing of tumour cells. Cases have also been reported with radiological placement. A large series of 208 patients with active disease found an incidence rate of abdominal wall metastasis of 0.92% [24].

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Recommendation Grade
Procedure and associated choice of feeding tube should consider gastrostomy complications vary according to the tube type, insertion method and skill/expertise of those undertaking the procedure, as well as variations in the definitions of major and minor complications. Overall, there is a low procedure mortality rate (mean approx 1%).
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References

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