Drainage Percutaneous Endoscopic Gastrostomy Tube Placement in the Setting of Ascites

Abstract

Background: Drainage PEGs have been shown to be effective in palliating the symptoms associated with malignant bowel obstruction; a condition frequently associated with ascites. Ascites has been viewed as a relative contraindication to PEG tube placement. Aim: To analyze the safety of placing percutaneous endoscopic gastrostomy (PEG) tubes in cancer patients with both ascites and malignant bowel obstruction. Methods: A retrospective review identified all patients who underwent successful drainage PEG placement for malignant bowel obstruction at Memorial Sloan-Kettering Cancer Center. From this list, 100 consecutive patients who also had ascites were then identified. Both ascites and bowel obstruction were confirmed radiologically. The drainage gastrostomy tube used was a modified 28 Fr PEG tube, with a 15 cm intragastric portion and multiple drainage holes designed to optimize gastric drainage. All tubes were placed by the “pull method”. All patients received pre-procedure prophylactic antibiotics. The decision as to whether or not the ascites should be drained prior to the PEG procedure was a clinical decision made on a case-to-case basis. Results: Types of cancer included: ovarian (32), colorectal (17), gastric (15), pancreatic (11), uterine (9), small bowel (4), bladder (4), gallbladder (3), and miscellaneous (5). Ascites was characterized as small (16), moderate (35), large (44), or loculated (5). 40 patients underwent a pre-PEG paracentesis (mean, 2.62 L). The mean length of time for the procedure was 20 minutes. 95% of patients had relief of nausea and vomiting, with 5 patients continuing to have symptoms despite successful PEG tube placement. Patients were able to drink liquids and eat soft foods after the procedure. Five had complications, 1 major and 4 minor. Complications included: sepsis/death (1), incision infection (2), and leakage (2). Median survival after PEG placement was 46.5 days. Discussion: Previous studies looking at gastrostomy tube placement in the setting of ascites looked at radiologically-placed tubes, were limited by small size, and/or studied a narrow population. Our study looked at endoscopically-placed tubes in 100 patients with different cancers. The 5% complication rate seen compares favorably with previous feeding PEG studies. Conclusion: Drainage PEG tubes can be safely placed in patients with ascites, with a complication rate comparable to that of regular PEG tubes. They provide palliative relief of the symptoms associated with malignant bowel obstruction, without the discomfort associated with NG tubes. They can allow the patients to continue to drink clear liquids and eat soft foods.