Indications and contraindications for PEG/PRG

Percutaneous gastrostomy, either PEG or PRG, is usually indicated in individuals with disorders of swallowing that require long‐term nutritional support. Such individuals may suffer from head or neck cancer, oesophageal cancer, or neurological or muscular disorders (e.g. stroke, achalasia, multiple sclerosis, Parkinson's disease). Individuals with some systemic diseases, including Crohn's disease, scleroderma and radiation enteritis, may also benefit from gastrostomic feeding (Given 2005). In addition, percutaneous gastrostomy can also be used as a method of decompression, rather than nutritional support, in individuals with gastric outlet obstruction.

Contraindications to both PEG and PRG

A common contraindication to both PEG and PRG is uncorrectable coagulopathy.

Contraindications to PEG

Endoscopic gastrostomy can be contraindicated in conditions that make endoscopy difficult or impossible (e.g. neoplastic lesions of the upper gastrointestinal tract, large Zenker's diverticulum and severe oesophageal stenosis) (Thornton 2000). In addition, PEG may fail in individuals with a high subcostal stomach or obesity, because the optimal transillumination of the abdominal wall might be compromised (Laasch 2003; Thornton 2000). Other conditions, such as inflammatory or infiltrative diseases of the gastric and abdominal wall, are considered relative contraindications to PEG (Nicholson 2000).

Contraindications to PRG

Following recent technical innovations, there are fewer contraindications to PRG than to PEG. The presence of gastric varices and portal hypertension increases the risk of bleeding significantly, and these are seen as absolute contraindications to PRG. Percutaneous access to the stomach could be challenging if the individual has undergone colonic interposition; some authors regard this as a relative contraindication when using infracolonic methods (Mirich 1990). Similarly, the interposition of liver could be a relative contraindication with the use of computed tomography or ultrasound guidance (Given 2005). The presence of ascites has previously been regarded as an absolute contraindication to PRG, as leakage and infection of ascites may occur during this procedure. However, some authors consider ascites only a relative contraindication to PRG, as the technique can be safely performed by carrying out pre‐procedural paracentesis or gastropexy, or both (Shin 2010). In individuals who have undergone previous gastric or upper gastrointestinal surgery, the gastric remnant does not distend as normal stomach does, rendering gastric access more difficult. However, it is still possible to find an appropriate route for gastrostomy with the assistance of special techniques such as gastric distension using a balloon and computed tomography guidance (Foutch 1990; Sanchez 1992). As a result, a postoperative stomach does not preclude PRG even though more difficulties might be encountered.

Success rates for PEG/PRG

The success rates reported for PEG and PRG vary markedly among studies, and could be reasonably explained by differences in participant selection and operator experience. There are more contraindications to PEG than to PRG, and PEG is associated with more anatomical or technical limitations. In one study, individuals were usually converted to PRG when PEG was contraindicated or had failed, which may reflect the fact that PRG is superior to PEG in terms of technical feasibility (Thornton 2002). Some large series studies reported a higher success rate for PRG (99% to 100%) than for PEG (95.5 to 98%) (de Baere 1999; Laasch 2003; Leeds 2010; Rosenzweig 1994). In one study, which included 20 participants with amyotrophic lateral sclerosis, the success rate for PEG was reported to be as low as 55% (Thornton 2002). An historical meta‐analysis involving 5752 participants concluded that the rate of successful gastrostomy with PRG was higher than that with PEG (99.2% versus 95.7%, respectively). However, this study suffered a major limitation in that most studies included in the meta‐analysis were not comparative studies (Wollman 1995). The most commonly reported reasons for the failure of PEG were obstacles impeding the insertion of the endoscope (e.g. tumours in the upper gastrointestinal tract) and the difficulty of transilluminating the anterior abdominal wall (Desport 2005). On the whole, the current evidence favours a higher success rate for PRG than for PEG in the general population, but this needs to be validated in RCTs. Furthermore, the operator's experience and facilities available should also be taken into consideration when choosing the technique.

Major/minor complications with PEG/PRG

Based on the available evidence, most authors support PEG and PRG as safe procedures for enteral feeding; complications are generally infrequently encountered, although both techniques have the potential to cause mortality and morbidity. Documented major complication rates for PEG and PRG are 0% to 8% and 1.4% to 5.6%, respectively (Chandu 2003; Dwyer 2003; Hujala 2004; Möller 1999; Neeff 2003; Rimon 2005). Complication rates for PEG and PRG have been compared directly in some studies; however, results were contradictory (Eze 2007; Grant 2009; Lawrance 2003; Neeff 2003; Rustom 2006). Some studies found similar results in terms of complication rates for PEG and PRG (La Nauze 2012; Leeds 2010). However, a meta‐analysis of earlier studies, including 5752 participants, which assessed outcomes for PEG and PRG found that major complications were less frequently seen with PRG than with PEG (5.9% versus 9.4%, respectively), and that 30‐day mortality was higher in the PEG group than in the PRG group (0.53% versus 0.3%, respectively) (Wollman 1995). In contrast, another meta‐analysis that included 2379 individuals with head and neck cancer undergoing PEG or PRG found PRG to be associated with higher rates of major complications and mortality than PEG (Grant 2009). In a more recent systematic review that also assessed outcomes of PEG and PRG in individuals with head and neck cancer, evidence from four retrospective comparative studies favoured PEG over PRG with reference to mortality and peritonitis (Burkitt 2011). However, current meta‐analyses have some common limitations, making it difficult to draw a definitive recommendation as to the safety of either method. First, most studies included in these analyses were retrospective and not RCTs, and so are subject to significant reporting bias. Second, the majority of studies were characterised by a lack of detailed descriptions of participant selection criteria and the procedure studied; the heterogeneous nature of the population in whom percutaneous gastrostomy is indicated makes comparisons within the literature more difficult. Third, the small size of the samples in most studies could reduce the power to detect significant differences between groups. Finally, the means by which complications were reported were inconsistent among studies; different definitions for major and minor complications could have led to confusion. To date, no RCT has been reported that has compared outcomes between PEG and PRG; hence, the currently available evidence is far from sufficient to determine which procedure is safer than the other.

Long‐term results for PEG/PRG

As the ultimate goal of PEG/PRG is to provide nutritional support, it is necessary to evaluate the impact of these techniques on long‐term outcomes. For most individuals, tube feeding via gastrostomy is sustaining in the long term, but it is doubtful that all feeding techniques may impact equally on nutritional status, quality of life and long‐term survival. Assessing results over a long time frame (not only hospital stay, but also postdischarge) will give us more detailed information about the optimal feeding technique. Desport 2005 carried out a nutritional examination in 50 individuals with amyotrophic lateral sclerosis 364 (± 434) days after PEG or PRG and found a comparable improvement in nutritional status, as assessed by weight, triceps skinfold and mid‐arm muscle circumference, with both techniques. No significant difference in survival was found between groups (Desport 2005), consistent with the results of a previous study (Thornton 2002). Survival and nutritional status were also investigated in individuals with motor neurone disease following enteral tube feeding; again, no difference in survival between individuals undergoing PEG or PRG was detected (Rio 2010). In a mixed population, Leeds 2010 compared 170 PRGs with 233 PEGs and demonstrated similar 30‐day, 90‐day and 1‐year survival between groups. This conclusion has been confirmed by other authors who found no significant difference in 30‐day and 1‐year mortality rates between PEG and PRG within a median follow up of 405 days (La Nauze 2012). However, it was reported that tube function tended to be inferior with PRG within a median follow up of 17.2 months compared with PEG (PRG 58%; PEG 68%), but the difference did not reach statistical significance (Cosentini 1998).

Beyond clinical outcomes and nutritional status, the impact of treatment on individuals' quality of life should also be taken into account when evaluating a gastrostomy method. Unfortunately, few studies have compared quality of life following PEG or PRG. A study in 100 participants undergoing PEG assessed quality of life pre‐ and 6 months after PEG; a significant improvement from baseline in Quality of Life Index scores was achieved with PEG (19.25 ± 11.85 versus 30.08 ± 27.74) (Hossein 2011). More well‐conducted studies are required in order to evaluate long‐term results for PEG and PRG.

Summary of main results

Clinical reports have shown the feasibility and safety of PEG and PRG in selected individuals with swallowing disturbances; both techniques are effective options for administering enteral nutrition. However, the current evidence remains insufficient to draw any conclusion regarding which is superior to the other. Well‐designed and conducted RCTs are required to answer this question (summary of findings Table for the main comparison).