Push vs Pull Percutaneous Endoscopy Gastrostomy tube insertion and peristomal site infections: a meta-analysis

Vicente Porciuncula II

Background: Percutaneous endoscopic gastrostomy (PEG) insertion provides long-term enteral access. The Pull-type method is the usual procedure which requires passing the feeding tube through the mouth into the stomach and through the abdominal wall. It has been proposed that there is an increased risk of peristomal infections because the device passes through the oropharynx. An alternative method, the Push-type procedure, entails pushing the gastrostomy tube through the abdominal wall and entering the stomach bypassing the oropharynx. This procedure is particularly useful when tumors obstruct the upper aerodigestive tract that prevents passage of the PEG device via the Pull-type method. Since the Push-type method bypasses areas with high bacterial content, it is proposed that it has lesser risk of peristomal infections.

Several studies have investigated the incidence of complications after pull-type and push-type methods. However, no meta-analyses have been done comparing these two methods in terms of peristomal infections. This meta-analysis aims to determine the rate of peristomal infection of the Pull-type versus the Push-type methods of PEG insertion.

Methods: A systematic search of relevant studies was done through the Cochrane Central Register of controlled trials, Medline, Embase, Medscape, Clinical Trails and Pubmed. Two reviewers independently reviewed the studies retrieved and analyzed the data of relevant studies through Review Manager 5.2.6 software.

Results: Five studies were included in the analysis with moderate heterogeneity (I2=56%). The risk of peristomal infection was not conclusive between the Push-type and Pull-type methods (RR 2.75; 95% CI 0.67 to 11.27).

Conclusion: The difference of the rate of peristomal infection between the Push-type and the Pull-type method of PEG insertion was not conclusive. Further studies with larger sample sizes are recommended.