1. Karen Roberts Nutrition CNS RSCH
To PEG or not to PEG?
Karen Roberts Nutrition CNS RSCH
Karen Matthews Nutrition CNS RSCH/MARS team

2. Introduction Case study PEG RIG NGT Making a decision Discharging
Conclusion

3. Patient case Study 49 year old male unknown primary with TxN3
No significant past medical history
Treatment plan for:
Radical chemo/radiotherapy
6/52 30# RT with weekly cisplatin and 5FU chemo
Referred for feeding tube
Currently eating & Drinking

4. Percutaneous Endoscopic Gastrostomy – PEG (pull through method)

5. Peg tubes – Advantages Placed under heavy sedation, overnight stay
Tubes placed generally last for 2 years.
Less maintenance, plastic ends easily replaced
Less accidental dislodgements (Lees 1997 )
Easy to use , for feeds using bolus /pump or even gravity
Most patients happy with appearance of tubes and can be hidden underneath clothing, increased quality of life
Peg tubes placed since 1980s
How are peg tubes placed

6. Pegs-disadvantages
The risks of procedure itself: heavy sedation, peritonitis & perforation.
Other complications: pain, bruising, infection
Overnight stay and increased cost .
Psychological impact to patient of procedure its self.
Removal of tube, extra procedure needed at end of illness can cause extra stress, cost of removal and not same day as patient seen in clinic
Risk tumour seeding
Cos t of procedure and daily tarrif
contraindications; q

7. Radiologically Inserted Gastrostomy –RIG (push through method)

8. RIGS - advantages Generally less sedation required for patient
Easy to use , for feeds using bolus /pump or even gravity
Most patients happy with appearance of tubes and can be hidden underneath clothing, increased quality of life
Easily removed in timely manner usually done as needed for patient .
Method of choice if stomach in accessible through tumour or may be method of choice if patient has contraindications to peg from previous upper GI surgery or other co morbidities
How are rigs placed

9. RIG - disadvantages Need for NGT placement prior to procedure
Tube will need replacing after 3 months , thus patient will be needed to attend for further procedure .
Patients need to check and replace water in the balloon on a weekly basis
Further nursing time needed to remove stitches and teach balloon care
Increased risk of tube dislodgement , especially if patient / carer not confident with care of tube and risk of unscheduled hospital reviews

10. Contraindications to Peg/Rig
Absolute
Relative
Ascites
Neutropenia
Peritoneal dialysis
Megacolon
Unstable Angina
Recent Myocardial infarction
Morbid Obesity
Hiatus hernia
Previous total Gastrectomy
Previous subtotal/partial gastrectomy
Previous abdominal surgery
Presence large pharyngeal/Oesophageal tumour
Hepatosplenomegaly
Coagulopathy
Dementia
psychosis

11. Nasogastric tubes- advantages
Generally easy to insert , less cost approx. £10
per tube versus cost of endoscopic or RIG procedure.
Easy to remove when maintaining sufficient quantities of oral diet and fluids
Npsa, serious incidents and 12 deaths reported all directly due to misinterpretation of xrays (Toucher 2014)

12. Nasogastric tubes- disadvantages
Admission required
Difficult to manage in community, PH monitoring essential (NPSA guidelines)need for x-rays
Easily displaced even with nasal bridal.
Risk sinusitis/retropharyngeal abscess
May need repeated hospital visits to ensure safety of tube and increase compliance and reduce unscheduled treatment interruptions (beer 2005 )
Unsightly for patient and can be uncomfortable due laryngeal irritation and persistent gastroesophageal reflux (Baredes 2004 )(Eze et al 2006)
NGT Patient and carer may struggle with care, if feeding required in longer term i.e. more than 4 weeks ,

13. How do we make the decision?
Assessment
contraindications
Size & site tumour
Co-morbitities
Timing
Other alternatives
Availability slots
St Lukes Cancer Alliance

14. Patient Support Patient information leaflets on procedures
Patient information leaflets on care of tubes & feeding
Competency and discharge checklist
Alert advice For PEG/RIG
Registered on feed company/out of hours advice line
Referral to feed company Nurse
MARS

15. St Lukes Cancer Alliance – FPH,NHH,ESH
RSCH PEG
RSCH RIG
RSCH NG/NJ
RSCH
Surgical PEG
Surgical Jej
St Lukes Cancer Alliance – FPH,NHH,ESH
Total
Major complications 34 1 35 3 2 4
(PEG) 47 33 37 5 10
(PEG 9/RIG 1) 54 57 11 13
(PEG 12/RIG 1) 84 18 6
(PEG 25/ RIG 10)
108 43 28 36
(PEG 23/RIG 13)
113 32 7
(PEG 22/RIG10)
128 56 41
(PEG 15/RIG 3)
122 49 16
( PEG 7/RIG 8)
106
2014-jan 2015 39 27
(PEG 14/RIG 13)
105
total
477
206 30 9 26
189
(PEG 128/RIG 58/ jej 1)
937

16. Conclusion ‘Individual need’
Timing of procedures versus patient actual need for peg
( Nugent et al 2013 )
Consistent feeding will prevent on going weight loss and when inserted as a prophylactic measure during radiotherapy (Piquet 2002)
Long term reliance on enteral feeding v short term NGT tube …. Especially after treatment finishes (Corry 2008 ) , peg tubes may add to longer period of non oral-feeding secondary to deconditioning of muscles. (Baredes 2004)
RIG patient tend to be Sicker patient, therefore have more complications
‘Individual need’

17. Case study conclusion
Any Questions?