Is percutaneous ultrasound gastrostomy (PUG) tube placement a cost-effective option for patients requiring long-term enteral nutrition?

Cost-Effectiveness of Percutaneous Ultrasound Gastrostomy (PUG) Tube Placement

Percutaneous ultrasound gastrostomy (PUG) tube placement is a cost-effective option for patients requiring long-term enteral nutrition, offering advantages similar to PEG with potentially lower costs in certain clinical scenarios. While specific cost-effectiveness data on PUG is limited, we can draw conclusions based on established guidelines for similar percutaneous gastrostomy techniques.

Comparison of Enteral Access Options

PEG vs. Surgical Gastrostomy

• PEG is strongly preferred over surgical gastrostomy for long-term enteral nutrition due to:
  • Lower complication rates
  • Better cost-effectiveness
  • Shorter operating time 1, 2

PEG vs. Nasogastric Tubes

• For long-term feeding (>4-6 weeks), PEG offers:
  • Fewer intervention failures
  • Better nutritional status improvement
  • Improved quality of life (less discomfort, inconvenience)
  • Lower incidence of tube dislodgement 1
  • Better tolerance and lower aspiration risk in elderly patients 1

Cost-Effectiveness Considerations for PUG

Advantages of PUG

• PUG provides an alternative when endoscopic placement is not possible 3
• Avoids costs associated with endoscopy equipment and personnel
• Can be performed at bedside with portable ultrasound
• Minimally invasive procedure with good safety profile 3
• Allows rapid placement in patients with upper GI obstruction 3

Clinical Scenarios Where PUG May Be More Cost-Effective

• Patients with upper GI obstruction where endoscopic access is limited 3
• Settings with limited endoscopy resources but available ultrasound equipment
• Patients who cannot tolerate endoscopy
• Critically ill patients who benefit from bedside procedures 4

Decision Algorithm for Enteral Access Method

1. Short-term feeding needs (<4-6 weeks): Consider nasogastric tube 1, 2

2. Long-term feeding needs (>4-6 weeks):

   • First choice: PEG - established cost-effectiveness and lower complication rates 1, 2
   • If PEG not feasible: Consider PUG - especially with upper GI obstruction 3
   • If neither PEG nor PUG feasible: Consider PLAG (percutaneous laparoscopic assisted gastrostomy) 1
   • Last resort: Radiologically inserted gastrostomy (RIG/PRG) - higher complication rates 1

Special Considerations

• For patients with gastroduodenal motility disorders, gastric outlet stenosis, or high aspiration risk, consider PEJ (percutaneous endoscopic jejunostomy) or PEG with jejunal extension 1, 2

• PUG has been shown to help stabilize nutritional parameters in patients with malignant diseases 3

Potential Pitfalls

• Limited long-term data specifically on PUG compared to PEG
• Operator dependency - requires ultrasound expertise
• May be challenging in obese patients or those with unusual anatomy
• Requires initial stomach filling with water through a nasal tube in most cases 3

While more direct comparative studies between PUG and other gastrostomy techniques are needed, current evidence suggests that PUG represents a cost-effective alternative to PEG in specific clinical scenarios, particularly when endoscopic access is limited.