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Lots of Variation in Practice in PEG Care |  mednet

Lots of Variation in Practice in PEG Care | mednet

Although PEG (percutaneous endoscopic gastrostomy) probes have existed since the 1980s, there is great variance in practice around PEG care. This is proven by a recent survey of MDL doctors working on new guidelines Intestinal access† “We don’t yet know what is the most effective and safe deposit procedure,” says Dr. Leonard Gillesen (Kathrina Hospital, Eindhoven). He has significant experience in PEG investigations.

Approximately 70 Dutch MDL departments were contacted for the survey with questions about various aspects of PEG care. The reason is that MDL clinicians in the guideline working group noticed significant differences. This was confirmed by the poll, to which 48 constituencies responded. For example, there were specific differences in antiseptic precautions (from skin cleansing only to complete sterility), prophylactic antibiotics (difference in time and form of administration), tube placement (two MDL physicians versus 1 each for gastroscopy and paracentesis) and monitoring time after placement ( Several hours from day care until night observation). Furthermore, it was found that 78% of MDL physicians place PEG tubes, but sometimes only 3 per year, and a third of centers do not have a PEG team.

to compare

“It is interesting to compare the different aspects in the studies, also in terms of costs,” Gillesen describes. “Worldwide it remains unclear which method of placement and the most efficient aftercare and aftercare process. What is the best timing, for example, in an ALS operation, which anesthesia and supportive techniques are safe? And how can you remove the PEG probe as safely and patient-friendly as possible? Possible? This is usually done endoscopically, but sometimes by tube cutting. These methods have not been properly compared either. However, comparative research requires several participating centers and care money, while PEG care is applied to a variety of diseases” .

The MDL department at Catharina Hospital in Eindhoven specializes in the placement of these probes and variants. The treatment was recently included in the Top Clinical Care Registry of Top Collaborating Clinical Training Hospitals (STZ).


There are different types of PEG probe, which are applied depending on the condition and anatomy. Gilissen, for example, is putting less and less PEG-J, the ‘PEG stretching’ with the second tube into the small intestine. “It is intended, among others, for people with gastroparesis, or patients with Parkinson’s who receive Duodopa in the jejunum drop by drop. In addition, we are increasingly introducing direct PEJ: using a pediatric colonoscope, the jejunum is punctured directly via the oral route. We also perform regular colostomy (PEC), in which contact is made to the right colon for continuous anti-constipation colonic lavage. This rinse probe is also used on the left side in case of repeated inversion, for fixation and removal. Patients from all over the Netherlands are referred to PEC” .

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PEC is the last step before a potential surgical stoma. Jellison was surprised that this is rarely used nationally. “We installed these devices over 10 years ago. This probe is now able to prevent a stoma in 60% of patients. Placement can be done fairly easily with colonoscopy. If PEC does or does not work, it is easy to remove the probe and it will be Closing the opening again within a day. This technique also has a few complications.”

closer to home

So there is a set of probes, for very different indications and for different patients. “Just think of the altered anatomy in obese patients or after oncological surgery,” continues Gillesen. The doctor discusses options and alternatives with the patient. The creativity in sensors is great for offering a solution that works for nearly all patients. Referrals from all over the south of the Netherlands and beyond know where to find us. I’m glad we can help so many people, but I’m also a little surprised that they’ve come this far. Even if there were problems with the probe, people now have to travel long distances. Good aftercare is just as important as the technical aspect of fixtures. That’s why I hope the experience will spread more widely across the country, so that people can get closer to their homes.”

To administer Duodopa via a PEG-J tube, Gilissen is working closely with neurologists. For years, it has been the norm to adjust medication and first test it via a nasogastric tube for a few days. If all goes well, the PEG-J probe will be placed. But in practice, almost all patients eventually received a PEG-J tube. So Gillesen questioned the use of a nasogastric tube. “If you skip this step, it will save patient inconvenience, time and costs. For this reason, in consultation with neurologists, we immediately began placing PEG-J in these patients. We are very satisfied with it. A nasogastric tube is often placed out of habit, but it is It is not in the best interest of the patient and costs a lot of money.”

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Due to frequent issues with internal PEG-J probes, direct PEJs are increasingly being used.

Complications and aftercare

Tube placement remains risky, just like surgery. Patient assessment and discussion of complications is essential. The main problem is wound infection, which occurs in 10 to 25% of patients. Jellison: “That’s why new guidelines state that antibiotics are always necessary for preventive treatment. We use a topical treatment with antibiotic gauze that stays in place for three days. Chemical inflammation from gastric juices may also play a role. My wish is to do national research on the most common method.” Preventive is efficient. But this takes a lot of patients and time to include.”

Other complications include bleeding, peritonitis due to internal extravasation, and deaths in certain groups. This complication occurs in about 1% of patients. In the long run, skin problems can appear. “Most issues can be treated well, but they are for patients at risk, so always be careful and take action quickly if needed,” says Gillesen.

Aftercare is also an important aspect. There are many questions about this among health care providers, patients, and informal caregivers. Therefore, Gilissen is currently developing a mobile PEG app, with Dr Linda Wanders, an MDL PhD student from Amsterdam. “It contains a lot of practical information, answers to questions and tips. The content of the application is ready and we hope to work during this year.”

New guidelines

The Dutch Association of Gastrointestinal Hepatologists (NVMDL) has taken the initiative to develop new standard guidelines on gastrostomy sites. This guide Intestinal access Almost ready and mainly deals with PEG and PRG radiometer probe. Jellison says the guidance has had a lasting impact. “This is because it concerns different groups of patients, such as people after stroke, oncology patients, patients with neuromuscular disorders (NMA) and Parkinson’s patients. As a result, many professional groups are involved.” The guide is expected to be released this summer.