ESPEN-经皮内镜胃造瘘肠内营养指南英文(1)

ClinicalNutrition(2005)24,848–861CONSENSUSSTATEMENTESPENguidelinesonartificialenteralnutrition—Percutaneousendoscopicgastrostomy(PEG)Chr.Lo¨sera,
,G.Aschlb,X.He´buternec,E.M.H.Mathus-Vliegend,M.Muscaritolie,Y.Nivf,H.Rollinsg,P.Singerh,R.H.SkellyiaMedicalDepartment,RotesKreuzKrankenhausKassel,34121Kassel,GermanybMedicalDepartment,AKHWels,4600Wels,AustriacGINutrition,Archet2Hospital,06202Nice,FrancedDepartmentofGastroenterology,AcademicMedicalCentre,UniversityofAmsterdam,TheNetherlandseDepartmentofClinicalMedicine,University‘LaSapienza’,Rome,ItalyfDepartmentofGastroenterology,RabinMedicalCenter,TelAvivUniversity,IsraelgNutritionNurseSpecialist,LutonandDunstableHospital,LutonLU40DZ,UKhGeneralIntensiveCareDepartment,RabinMedicalCenter,PetahTiqwa49100,IsraeliDerbyshireRoyalInfirmary,DerbyDE12QY,UKReceived23June2005;accepted23June2005IntroductionSincethefirstpublishedreportofapercutaneousendoscopicgastrostomy(PEG)in1980byGaudererandPonsky,1theprocedurehasbeenmodifiedandimprovedseveraltimes.Ithasnowreplacedthesurgicalgastrostomy(Witzelgastrostomy,Stammgastrostomy,Janewaygastrostomy)whichwasassociatedwithamarkedlyhigherrateofcompli-cations.2,3PlacementofaPEG/PEJ(percutaneousendoscopicjejunostomy)tubeissimple,safeandwell-toleratedbypatients.4,5Thereisawiderangeofdietsandnutrientpreparationssuitablefortubefeedingcurrentlyavailable.ModernPEGtubesystemsmadeofpolyurethaneorsiliconerubberareeasytoinsertandwell-tolerated.Clinicianshaveabroadspectrumoflowrisk,practicable,patient-orientatedformsofenteralnutritionaltherapyavailable.PEG-feeding,therefore,hasrapidlyspreadtobecomeroutinepracticeworld-wideandiscurrentlythemethodofchoiceformedium-andlong-termenteralfeeding.RecentstudieshaveprovidednewinformationonthebenefitsanddrawbacksofPEG-feeding.Wehaveaclearerappreciationofethicalissuessurroundingartificialenteralfeeding.Sincewestartedplacingpercutaneousenteraltubesystemsbyendoscopictechniquesnearly25yearsago1ourattitudetowardsthismethodhaschangedinmanyways:intheearlydaysPEG-tubeswereoftenusedinpatientsintheadvancedstateofpredominantlymalignantdiseases;thisisnowregardedasaninappropriateindicationinmostcasesbeingtoolatetoofferadequateclinicalbenefitstothepatientsintermsofnutritionalstatusandqualityoflife.DatafromalargenumberofrecentlyARTICLEINPRESS:10.1016/j.clnu.2005.06.013
Correspondingauthor.Tel.:[phone];fax:[phone].E-mailaddress:[e-mail](Chr.Lo¨ser).publishedclinicalstudieshasmodifiedourviewsonavarietyofissues:onthebenefitsanddisadvan-tagesofthePEGfeeding;onmoredistinctclinicalindicationswithregardtoimportantoutcomeparameters(i.e.maintenanceandimprovementofnutritionalstatusandqualityoflife);onethicalaspects;andoncontraindications,forexampleinpatientswithadvanceddementiaorduringterm-inalstagesofincurablediseases.Inmanywaysourmodernpointofviewhasshiftedtowardsanearlierindividualconsiderationofadditionalsupplemen-taryfeedingviaPEGtubeinappropriatepatients,whenspecialnutritionaladviceandsupplementarydrinksarenoteffective.Guidelinesissuedbyvariousspecialistauthoritieshavebeenmodifiedinthelightofrecentlypublishedclinicalstudiesandtherecommendedprocedureshavebeenmarkedlysimplifiedinmanyrespects.6–9Withthisbackground,ESPENaskedamultidisciplinarygroup(nutritionists,gastroenter-ologists,nurses,andmedicalpractitioners)withspecialexpertiseinthefieldtoprepareguidelinesandaconsensusreportoncurrentclinicalaspectsofartificialenteralnutritionviaPEG-tubesinadultsandchildren.Inthefollowing,mattersrelevanttoclinicalpracticearesummarizedanddiscussedonthebasisofthecurrentlyavailablescientificinformation.EnteraltubesystemsIngeneral,tubesystemsforartificialenteralnutritioncanbeplacedbynasalinsertion,guidedpercutaneousapplication,orsurgicaltechniques.Thesuperiorityofpercutaneouslyplacedgastros-tomiescomparedtoformersurgicalgastrostomyprocedures(i.e.Witzel,Stamm,Janewaytechni-que)hasbeenshownclearlyinmanyclinicalstudies.2,3Ifitistobeexpectedthatthepatientwillrequireartificialenteralnutritionforalongerperiodafterabdominalsurgery,itisadvisabletoprepareforsubsequentjejunalfeedingbyprepara-tionofafineneedlecatheterjejunostomy(NCJ)towardscompletionofthesurgicalprocedure.Thisintraoperativetechniqueenablestheuseofclini-callyeffectiveearlypostoperativeenteralnutritioninpatientswhoarenotabletoeatsufficientamountsforaprolongedperiodaftermajorabdominalsurgery.Today,varioustechniquesandmodificationsareavailable.10–12SeveralstudiescomparedthevariousclinicaleffectsofPEGtubefeedingandfeedingvianasogastrictubes.13–17Whilenasogastrictubefeedingwasfoundtohaveahigherrateofdiscomfortandcomplications(irritations,ulcera-tion,bleeding,dislocation,clogging),PEGfeedingprovedtohavehighersubjectiveandsocialacceptance,beinglessstigmatizing,andhadreducedratesofoesophagealrefluxandaspirationpneumonia.13–17InterestinglyitwasclearlyshownthatwithregardtonutritionalefficacyPEGfeedingwassuperiortoo.14,17Therefore,inourpresentunderstanding,feedingviaPEGshouldbepreferredifitcanbeexpectedthatthepatient’snut