Gastrostomy tubes are placed for motor neurone disease (MND) patients as a means of an alternative feeding route when they have dysphagia, are losing weight unintentionally, or as a pre-emptive placement if they have respiratory changes (Stavroulakis et al, 2013). The literature suggests that MND patients with dysphagia found that a gastrostomy feeding tube can enhance their quality of life due to reduced risk of aspiration and ensuring adequate nutritional intake (Ng et al, 2017; National Institute for Health and Care Excellence, 2019). However, some patients will choose to only use it for medication and hydration, which also improves quality of life and comfort care, without prolonging life.
A single-centre audit that the authors carried out in 2023 looked at the previous 3 years of gastrostomy data. This audit highlighted a high failure rate for percutaneous endoscopic gastrostomy (PEG) placements due to difficulties in transilluminating the stomach during gastrostomy placement, particularly in patients with advanced respiratory compromise. The data suggested that these patients were having a prolonged hospital stay while awaiting a next-step solution, which was usually a radiologically inserted gastrostomy (RIG).
There is no clear guidance on which procedure (PEG or RIG) is more beneficial for patients. A comprehensive literature search surrounding gastrostomy placements highlighted that there is no significant difference in mortality rate for either procedure (ProGas Study Group, 2015), although it revealed that RIGs have a higher dislodgement risk due to their being held in by a small water balloon. Sidhu et al (2024) and Miller et al (2009) emphasise that the decision of which gastrostomy to use should be addressing the concern of patients with compromised respiratory function (eg forced vital capacity <50%). They face higher risks with sedation, suggesting RIG is a safer alternative in such cases. RIG tubes need to be replaced every 3–6 months (NHS England, 2024), whereas a PEG can last up to 5 years with appropriate care. PEGs are usually our first tube of preference based on this.
The literature review investigated whether other areas or gastroenterology placement pathways use CT scans for their gastrostomy placement pathways. The main literature found suggests that CT scans offer superior anatomical detail compared to X-rays (Gutjahr et al, 2020). However, some studies, such as Thomson (2022), did not find CT scans significantly beneficial in general populations, although this may not reflect the changes that we are seeing with our MND patients – particularly those with respiratory changes.
PEGs are placed by our gastroenterology team in endoscopy, where the patient can mostly sit up for the procedure. Most MND patients struggle with breathing if lying flat and therefore RIGs have tended to be avoided as a first option. The other risk when considering a PEG or RIG placement, is thinking about when it is safe to do so, and the patient's respiratory function, as they would be requiring sedation. The ‘traffic light’ grading system (Thompson et al, 2017) was created within our practice to assess respiratory risk and guide gastrostomy decisions. ‘Green’ would present low risk, ‘amber’ moderate risk and ‘red’ high risk, representing patients with respiratory failure. As PEGs are our first choice, we work closely with the gastroenterology team and the list is consultant-led with precautions taken and awareness of the respiratory risk. There was a high trend of failure in ‘red’ patients undergoing a PEG placement; from the recent audit, ‘red’ patients typically have diaphragm weakness and altered stomach positioning.
From the audit, we thought a pre-procedure CT might provide the clinician with more information as to which procedure we should be suggesting, and developing a patient-centred approach.
This is the initial service evaluation from the first 6 months of collected data following the CT abdomen scan's implementation to our gastrostomy pathway.
Aims
The overall aim of the service evaluation was to explore the efficacy of the pre-procedural CT scan before a PEG placement. The CT scan itself was implemented, aiming to identify potential anatomical difficulties that might complicate gastrostomy placement. One of the major goals was to reduce the incidence of failed PEG placements, which can be distressing for patients and lead to prolonged hospital stays.
The service evaluation also took into consideration the cost-effectiveness of carrying out this pre-procedural CT scan and whether it should only be used for specific patient groups (likely referring to a risk-stratification system based on clinical or anatomical characteristics).
This service evaluation aims to provide valuable insight into the utility of CT scans in the gastrostomy pathway and help inform decision-making for clinicians regarding resource allocation.
Method and analysis
Patient data were gathered from our single-centre nutrition clinic documentation; this is a clinic that the authors run to discuss PEG placements with patients. Microsoft Excel spreadsheets are kept as a record on secure work computers, recording patients who attend the nutrition clinic and those who consented to a gastrostomy tube. The data used was from 1 February 2024 to 1 August 2024.
The findings from the CT reports were included in the spreadsheet data, indicating whether the report says a PEG is possible or not. To find the CT reports, it included searching the Electronic Patient Record (EPR), which again was through a secure work computer and only accessible if actively caring for that patient. The team started to record on the spreadsheet the outcome of the PEG procedure and if there were any complications or changes to the procedure plan. This spreadsheet was then stored on a password-protected work computer within the hospital network, to which others would not have access.
The sample of patients included in the service evaluation were only those with a diagnosis of motor neurone disease, as this is the specialty the lead author (JN) covers. There are multiple other neurological specialties referred to and reviewed in the nutrition clinic; these were excluded from this particular service evaluation.
Data from the MND nutrition clinic were collected and reflected on, to:
Ethical considerations
Ethical approval was gained from the trust to complete the service evaluation.
Findings
There was a mix of ‘traffic light colours’ for the patients recorded, meaning that there was a variety of CT results (9 green, 6 amber, 4 red). All 19 of the patients had a CT scan, 18 (94%) were reviewed by the multidisciplinary team (gastroenterology), 19 were reported formally by radiology. It was important that, even though they were formally reported by a radiologist, the scan results were then discussed within the multidisciplinary team and what the ongoing plan was going to be was communicated to the patient. Ordering a CT scan came with its own challenges, as most members of the team did not have the approval to do this, and so the responsibility fell to the clinicians.
Of the 19 patients, two were from out of area and had requested that they had a CT scan carried out at their local hospital so that they did not have any extra travel. The team agreed with this on a few occasions at the beginning; however, getting the CT scan report from another trust delayed the decision-making process and resulted in one of the scans not being reported entirely. We then insisted that patients had to have a scan carried out within our trust for PEG placement with us and we explained the rationale.
The CT abdomen report for one patient was normal and the report highlighted that the team should go ahead with PEG, but the PEG was still unsuccessful due to the patient's restricted throat anatomy. The patient could not tolerate the oesophagogastroduodenoscopy (OGD) procedure – which could not have been predicted from the CT scan. This patient then went on to have an RIG instead, which was successful.
For four (21%) of the patients, the CT reports changed the course of the planned PEG procedure and the patients were referred for a RIG instead based on radiology advice (2 green and 2 red). Unknown hiatus hernias, bowel overlaying the stomach and stomachs in the transthoracic space were the main CT-reported concerns that prevented a PEG placement. Although CT scans provided critical anatomical information, one of the red RIGs was still unsuccessful, due to extreme anatomical difficulties. This highlighted for our team that we were attempting very difficult anatomical placements and it signalled that we needed to reflect on these difficult cases and ensure we were using clinical assessment alongside protocols in place.
The complication rates that we were told of by patients for RIG insertions (especially site infections and balloon deflating) were more frequent than those for PEG procedures, emphasising the increased risk associated with the RIG procedure. It is unclear why skin site infections were more common with RIG procedures and highlighted that, following this, ongoing training for patients and carers would be required.
Given the above changes to the four patients’ gastrostomy plans, this saved the hospital and each of the patients four extra nights in hospital. This was an overall reduction of 16 nights in hospital, which is considered in the following cost-effectiveness calculations.
In terms of whether it was cost-effective to implement the CT scan: according to the figures from the NHS price workbook for 2024/2025 (NHS England, 2024), the total cost of the previous protocol (no pre-procedural CT) based on the patient's data would have been a total of £37 561 over the 6-month period. This took into consideration the cost of admissions and the cost of PEG procedures if successful; for those who did not have successful PEG placements, it then considered the cost of the extra hospital stays, CT scan and RIG procedure. However, the patients who were under the new protocol (pre-procedural CT and extensive procedure planning) the total cost now equated to £32 531 due to a reduction in hospital stays and the number of procedures required, resulting in total savings per patient of £5030 over 6 months for the hospital. These data demonstrated how the new protocol could make cost-effective savings for the NHS.
Conclusion
This service evaluation demonstrates that pre-procedural CT scans have potential benefits in optimising gastrostomy procedures, improving patient outcomes, and offering cost savings. Although there are logistical challenges to consider, the overall positive impact suggests that continuing and expanding the evaluation is a worthwhile endeavour.
The service evaluation has highlighted that the CT abdomen scan has changed the planned procedure for multiple ‘traffic light colour’ patients, not only patients with respiratory changes. Most of the pre-planned PEG patients who underwent the CT abdomen scan continued with their planned PEG placements. For those whose CT abdomen was reported as abnormal, this was mainly due to inaccessible stomach positioning.
These patients then underwent a RIG instead, following advice from radiology that it would be attempted. However, even then, one of the RIG placements still failed due to extremely difficult anatomy. The evaluation emphasised the importance of combining CT scan findings with clinical assessment, ensuring that patient risk factors and the benefits of different procedures be considered in a holistic, patient-centred decision-making process. This approach helped in selecting more anatomically suitable procedures, improving overall patient experience. The use of CT scans allowed for more accurate preoperative planning, which reduced unnecessary hospital stays and helped guide patients to more appropriate procedures, ultimately improving their overall experience.
Looking at the data from a cost-efficiency perspective revealed that the pre-procedural CT scan had saved £5030 per patient within 6 months and that we should continue it for a further evaluation.
Ordering a CT scan was challenging, but it was helpful to complete the radiology training so that members of our team could request the scans. A few issues with the scans having to be done included: the extra administrative implications; making sure that we were following up; that scans were done in a timely fashion; and making sure we discussed the reports. Another element was the patients having the extra journey to the hospital for the CT scan. As a few patients were out of area, this was challenging; however, they could get the scan done when convenient to them.
Given the promising results, it would be beneficial to extend the service evaluation to a longer period (eg one year). This extended data collection could provide more robust evidence for the continued use of CT scans in the gastrostomy pathway.
Incorporating qualitative data, such as patient surveys, would provide additional insights into the patient experience and satisfaction with their tube placements. This is something that we will be considering alongside the extended service evaluation.