Porter, R.J., McKinlay, A.W. and Metcalfe, E.L.
Gastropexy can be as safe as conventional percutaneous endoscopic gastrostomy (PEG), and biomarkers do not predict short-term or long-term outcomes: a 7-year follow-up audit. Frontline Gastroenterology. 2019 Nov 13.
http://dx.doi.org/10.1136/flgastro-2019-101306
Gastrostomy, the process in which the stomach is anchored to the abdominal wall and a gastrostomy tract then created using a dilator, is not a new process, having been performed since 1979. However, it remains a controversial area with both ethical and clinical challenges from the decision of whether to undergo gastrostomy to how it should be done. The National Confidential Enquiry into Patient Outcome and Death in 2003 showed a high 7-day mortality whilst other studies from across the world did not show the same results. In the UK, there is a lack of data to help guide clinical practice, this paper goes a good way towards answering this important clinical question.
This study of over 700 patients has compared the outcomes of pull-through percutaneous endoscopic gastrostomy and gastropexy procedures to facilitate gastrostomy. Perhaps surprisingly, the procedure was only unsuccessful in thirty five patients and reassuringly the complication rates very low with only 1 gastrointestinal bleed, 1 perforation and 1 peritonitis.
Crucially, there was no difference in mortality rates or complication between the two groups and this is both reassuring and good to know for clinical practice. However, discussing mortality with patients is not that simple. Clinical indication for gastrostomy was was associated with overall survival. The poorest survival was seen in mechanical obstructions to swallowing and best in long-term partial failure of intestinal function requiring supplementary intake. Patients with neurological diseases often have discussions about gastrostomy and the data provided on this was useful. Therefore, data on the differences between cerebrovascular events and motor neurone disease for example can be useful in discussions with patients.
Selecting appropriate and safe patients for gastrostomy is challenging. Therefore having more data to guide clinical decision making is useful. Patients having a PEG insertion have shown an increased hazard of death when older, with a higher alkaline phosphatase and depending on clinical indications. Similarly, in those having gastropexy, clinical indication was associated with mortality. There is more information in the article about this.
The overall 7-day mortality rate reported was 2.2%. This is significantly different to the previous NCEPOD and the authors go on to explain some of these reasons. Most importantly, it is reassuring when discussing and offering gastrostomy to patients.
Whilst gastropexy is more often offered when PEG is technically challenging or there are risks of seeding the authors suggest that perhaps it could also be used as a safe, alternative method to PEG insertion.
Ultimately, each case has to be considered on a case by case basis with input from the MDT and the patient but with more data this decision becomes easier and this paper provides a large dataset with useful clinical data. Therefore, anyone involved in nutrition or making these decisions, would benefit from reading the full paper at Frontline Gastroenterology or on the link here!