ESPEN guidelines on artificial enteral nutrition ...

1 Clinical nutrition (2005)24, 848 861 CONSENSUS STATEMENTESPEN guidelines on artificial enteralnutrition percutaneous endoscopic gastrostomy (PEG)Chr. Lo sera, , G. Aschlb, buternec, Mathus-Vliegend,M. Muscaritolie, Y. Nivf, H. Rollinsg, P. Singerh, SkellyiaMedical Department, Rotes Kreuz Krankenhaus Kassel, 34121 Kassel, GermanybMedical Department, AKH Wels, 4600 Wels, AustriacGI nutrition , Archet 2 Hospital, 06202 Nice, FrancedDepartment of Gastroenterology, Academic Medical Centre, University of Amsterdam, The NetherlandseDepartment of Clinical Medicine, University La Sapienza , Rome, ItalyfDepartment of Gastroenterology, Rabin Medical Center, Tel Aviv University, IsraelgNutrition Nurse Specialist, Luton and Dunstable Hospital, Luton LU4 0DZ, UKhGeneral Intensive Care Department, Rabin Medical Center, Petah Tiqwa 49100, IsraeliDerbyshire Royal Infirmary.

2 Derby DE 1 2 QY, UKReceived 23 June 2005; accepted 23 June 2005 IntroductionSince the first published report of a percutaneousendoscopic gastrostomy (PEG) in 1980 by Gaudererand Ponsky,1the procedure has been modified andimproved several times. It has now replaced thesurgical gastrostomy (Witzel gastrostomy , Stammgastrostomy, Janeway gastrostomy ) which wasassociated with a markedly higher rate of ,3 Placement of a PEG/PEJ (percutaneousendoscopic jejunostomy) tube is simple, safe andwell-tolerated by ,5 There is a wide rangeof diets and nutrient preparations suitable for tubefeeding currently available. Modern PEG tubesystems made of polyurethane or silicone rubberare easy to insert and well-tolerated.

3 Clinicianshave a broad spectrum of low risk, practicable,patient-orientated forms of enteral nutritionaltherapy available. PEG-feeding, therefore, hasrapidly spread to become routine practice world-wide and is currently the method of choice formedium- and long- term enteral studies have provided new information onthe benefits and drawbacks of PEG-feeding. Wehave a clearer appreciation of ethical issuessurrounding artificial enteral feeding. Since westarted placing percutaneous enteral tube systemsby endoscopic techniques nearly 25 years ago1ourattitude towards this method has changed in manyways: in the early days PEG-tubes were often usedin patients in the advanced state of predominantlymalignant diseases; this is now regarded as aninappropriate indication in most cases being toolate to offer adequate clinical benefits to thepatients in terms of nutritional status and quality oflife.

4 Data from a large number of $ - see front Corresponding author. Tel.: +49 561 3086441;fax: +49 561 (Chr. Lo ser).published clinical studies has modified our views ona variety of issues: on the benefits and disadvan-tages of the PEG feeding; on more distinct clinicalindications with regard to important outcomeparameters ( maintenance and improvementof nutritional status and quality of life); on ethicalaspects; and on contraindications, for example inpatients with advanced dementia or during term-inal stages of incurable diseases. In many ways ourmodern point of view has shifted towards an earlierindividual consideration of additional supplemen-tary feeding via PEG tube in appropriate patients,when special nutritional advice and supplementarydrinks are not issued by various specialist authoritieshave been modified in the light of recentlypublished clinical studies and the recommendedprocedures have been markedly simplified in 9 With this background, ESPEN asked amultidisciplinary group (nutritionists, gastroenter-ologists, nurses, and medical practitioners)

5 Withspecial expertise in the field to prepare guidelinesand a consensus report on current clinical aspectsof artificial enteral nutrition via PEG-tubes in adultsand children. In the following, matters relevant toclinical practice are summarized and discussed onthe basis of the currently available tube systemsIn general, tube systems for artificial enteralnutrition can be placed by nasal insertion, guidedpercutaneous application, or surgical superiority of percutaneously placed gastros-tomies compared to former surgical gastrostomyprocedures ( Witzel, Stamm, Janeway techni-que) has been shown clearly in many ,3If it is to be expected that the patientwill require artificial enteral nutrition for a longerperiod after abdominal surgery, it is advisable toprepare for subsequent jejunal feeding by prepara-tion of a fine needle catheter jejunostomy (NCJ)towards completion of the surgical procedure.

6 Thisintraoperative technique enables the use of clini-cally effective early postoperative enteral nutritionin patients who are not able to eat sufficientamounts for a prolonged period after majorabdominal surgery. Today, various techniques andmodifications are 12 Several studies compared the various clinicaleffects of PEG tube feeding and feeding vianasogastric 17 While nasogastric tubefeeding was found to have a higher rate ofdiscomfort and complications (irritations, ulcera-tion, bleeding, dislocation, clogging), PEG feedingproved to have higher subjective and socialacceptance, being less stigmatizing, and hadreduced rates of oesophageal reflux and 17 Interestingly it was clearly shownthat with regard to nutritional efficacy PEG feedingwas superior ,17 Therefore, in our presentunderstanding.

7 Feeding via PEG should be preferredif it can be expected that the patient s nutritionalintake is likely to be inadequate and supplementaryartificial enteral nutrition is necessary for a periodexceeding 2 3 1shows the decisiontree that can be used in clinical practice to selectthe tube system for enteral nutrition most appro-priate to the requirements of the individual from research with parents suggests thatdecision making in children is difficult and emo-tionally laden; there is a special need for informa-tion and individual support in these , besides the standard endoscopicprocedure, many modifications and other techni-ques for adequate percutaneous placement ofenteral tube systems were established and provenin clinical practice.

8 In the hands of an experiencedendoscopist it should be possible to place percuta-neous tube systems in nearly all cases either byendoscopic, laparoscopic, sonographic, or fluoro-scopic means. The gastric and jejunal tube systemscurrently available for enteral feeding are outlinedinFig. 2. Artificial enteral nutrition should eitherbe given into the stomach or beyond the ligamentof Treitz, there are no medical reasons for any kindof duodenal feeding. In cases in which endoscopicinsertion of a tube is not technically possible,gastric (PLG) and jejunal (PLJ) enteral tubesystems can also be placed using laparoscopicARTICLEINPRESSno riskof aspirationriskof aspirationnasojejunaltubeno longer possibleno longer adequateshort - termunknown durationlong - term( > 2 - 3 weeks )no surgeryno surgerysurgeryPEGPEJJET-PEGprolonged requirementnasogastraltubeno riskof aspirationriskof aspirationORAL nutrition :NCJF igure 1 Decision tree for the selection of the appro-priate tube system for enteral nutrition (for explanation,see text).

9 ESPEN guidelines on artificial enteral 20In those rare situations in whichthere is a stenosis of the oesophagus which isresistant to bougienage and prevents passage of anendoscope, a gastric or jejunal feeding tube can beinserted with the aid of sonographic21,22or fluoro-scopic22 24guidance. Once a stable stoma hasformed at least 4 weeks after insertion of the PEGsystem, a changeover to use of a button systemmay be conducted for cosmetic reasons, at therequest of the 28 Although, primarilyplaced button procedures are published in theliterature,29,30it is generally recommended thatbuttons are placed secondarily after initial PEGplacement with a mature established stoma button systems are much more expensive andhave to be routinely exchanged approximatelyevery 6 months because of material fatigue whichis not necessary for PEG-tubes these systems areusually only indicated for cosmetic reasons insocially fully integrated younger patients.

10 In casesof gastroduodenal motility problems, pyloric ste-nosis or aspiration, a jejunal catheter can beplaced through the PEG and endoscopically guidedfurther into the jejunum beyond the ligament ofTreitz (JET PEG, jejunal tube PEG ) or a PEJ can beperformed as the initial 33 Tubedysfunction and the need for reinterventions aresignificantly lower in direct PEJ compared toJET PEG, therefore direct PEJ should be preferedif long-term jejunal feeding is indicated. There areconflicting data in the recent literature aboutwhether or not jejunal feeding via PEJ or JET PEGdefinitely reduces the rate of reflux and 35 IndicationsAs a general rule, PEG feeding should be consideredif it is expected that the patient s nutritional intakeis likely to be qualitatively or quantitativelyinadequate for a period exceeding 2 3 weeks.