Title: Do you know Percutaneous Transesophageal Gastrotubing (PTEG) instead of PEG
Abstract:
Introduction:
Percutaneous Transesophageal Gastrotubing(PTEG) was developed in 1994 by Ohisi for the procedure to ease advanced cancer patients with bowel obstruction with a subsequent case series published in 20031).
I want to introduce PTEG as an elementary administration route and drainage tool of bowel obstruction situation, and more, by comparing with the other two methods, NG tube and PEG.
Methods:
Patients, 21 patients had been recruited, who had been treated by same doctor in three different private hospitals, Miyazu Takeda hospital, Otokoyama hospital, and Mukaijima Hospital in Kyoto, Japan, from July, 2015 to Novenber, 2021. All were suffered from pylorus stenosis due to advanced gastric cancer and contraindicate to operation because of several reasons. Six patients had already had PEG before finding gastric cancer. PTEG were performed for seven patients as a palliative method to decrease symptoms such as nausea, discomfort, vomiting and so on. Eight was set NG tube after refusing PTEG.
Technique for PTEG:
Before operation, CT should be performed essentially. CT can give us very important information, which side the esophagus lies. Fujiki et al. reported that five percent patients have their esophagus in the right side of their neck.
PTEG procedure will be shown in presentation.
Discussion:
PTEG is the excellent and elaborate procedure for both administration way of nutrition and drainage for gastrointestinal obstruction as a palliative care, however, as for now, have not been spread around the world widely. Some reasons prevent on-site doctors from performing operations of PTEG, for example, 1)the procedure of PTEG might be more difficult than that of PEG, 2)the criteria of the indication for PTEG might be stricter than those for PEG, or 3)clinical cost for PTEG might be higher than that of PEG. All of them can be said misunderstanding. Regarding for 1), using rapture free balloon (RFB catheter), this technique is proved as safe as, or safer than PEG. Regarding for 2), for instance, hypoalbuminemia is a contraindication for PEG, however, PTEG can be made under such malnutritional condition. Regarding for 3) understandings from now on.
This time, we have investigated about the best procedure as a palliative care method for the severe patients with gastroenteral obstruction due to advanced cancer, compared with nasa-gastric tube, PEG, and PTEG. As shown in results, PTEG might be validated the most excellent tool for drainage to placate their discomfort of terminal malignant patients.
Firstly, naso-gastric tube, in merit, does not need any surgical procedure so with no surgical complication. However, patients cannot avoid discomfort feelings in their nasal and laryngeal parts, and what is the worse, its placement for long period leads to occur aspiration pneumonia. ESPEN guide line also said if period of naso-gastric tube placement is going to reach over four weeks, PEG should be planed.
Secondly, PEG is a better procedure from the point of patients’ discomfortable feeling. However, from the point of effectiveness of drainage, PEG was validated to be poor than that of PTEG in this research. As you know, PEG is placed in anterior wall of stomach. When patients lie in bed on supine position, PEG cannot drainage until the stomach become to be full with large amount of fluid. Fig.1 shows the dose change over time of each procedure. We should have much attention to Day 1 and Day 2. The drainage dose of PEG might not be enough within 2days after starting to use. During this period, patients were likely to vomit and came to aspiration pneumonia. Such a situation might be caused from the position of PEG in the stomach. Before almost full stomach, little fluid is drainaged from PEG, so patients have likely vomited and aspirated some fluid from stomach to their lung unfortunately.
To the contrary, PTEG is placed at the fundic position, on the posterior side of stomach, so before their stomach becomes full, drainage will start naturally. Fig.1 shows enough dose of drainage from Day 1. As the result, aspiration pneumonia won’t occur. From this point, naso-gastric tube also could drainage enough from Day 1, however, Table 1 showed the same occurrence rate with PEG, 50.0%. We speculate naso-gastric tube in the throat causes the difficulty of swallowing adequately.
For above these reasons, we select PTEG to get rid of the pain of severe patients with bowel obstruction due to advanced cancer.
Conclusion:
PTEG could give us the best results to mitigate their discomfort and pain from bowel obstruction of advanced cancer patients, compared with naso-gastric tube and PEG. We should make more efforts to clear misunderstanding for PTEG to promote this excellent procedure known widely all over the world.
