Factors predicting major complications, mortality, and recovery in percutaneous endoscopic gastrostomy

Factors Predicting Major Complications and Mortality in Percutaneous Endoscopic Gastrostomy: 8 Years of Experience of a Tertiary Surgery Center

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a safe method of choice for patients who need long-term nutritional support. However, complications and high mortality rates have been reported. Based on 8 years of experience in tertiary care hospitals, we aimed to identify risk factors associated with major complications and 30-day mortality after PEG.

METHODS

Patients who underwent PEG in the General Surgery clinic of Tokat Gaziosmanpaşa University, Faculty of Medicine between January 2014 and March 2022 were included in the study. Data regarding patient demographics, comorbidities, laboratory data, drugs used together, and indications for PEG tube placement were collected.

RESULTS

There were 429 patients. The mean age of the patients was 66.9±16.75 years, and 180 (44%) patients were female. The mean follow-up period was 8.84±6.75 months. Twenty patients (4.9%) had major complications. Female sex [Odds Ratio (OR) 0.33, 95% CI, CI=1.23-8.87, P =0.02] and diabetes mellitus (DM) (OR=0.23, 95% CI=1.93-6, P =0.002) were the independent variables associated with major complications. The all-cause 30-day mortality rate was 5.9% (n=24). Malignancy, DM, corticosteroid use, low albumin, and platelet values were associated with increased mortality in multivariate analysis as indications for PEG.

CONCLUSIONS

Female sex and patients with DM may potentially face major complications. The patients with cancer, diabetes, and corticosteroid use were associated with higher mortality. In addition, low serum albumin and platelet levels were an effective factor for survival in patients undergoing PEG, and this should be taken into account in decision-making.

Percutaneous Endoscopic Gastrostomy in the 21st Century-An Overview of 1415 Consecutive Dysphagic Adult Patients

Background/Objectives: Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition in dysphagic patients. This study aims to characterize conditions motivating PEG, assess nutritional status on the gastrostomy day, evaluate survival and search for survival predictors. Methods: Retrospective study of adult patients who underwent PEG in a tertiary hospital from 2001 to 2023. Data collected included demographics, underlying disorders, nutritional status (anthropometry/laboratory evaluation) on the day of PEG and survival recorded until death or December 2023. Multivariable analysis was performed with Cox regression to search for survival predictors. Results: A total of 1415 patients were included (61.8% males, mean age 66.9 years); 66.4% presented a neurological disorder and 31.3% head and neck or esophageal cancers (HNC/EC). The mean BMI was 20.9 kg/m2, with 49.8% underweight. Albumin, transferrin and total cholesterol were low at 43.2%, 62.2% and 50%, respectively. Median overall survival was 11.1 months; 14.1% of deaths occurred within 4 weeks. HNC/EC patients showed lower survival than neurological patients. Potentially regressive neurological conditions presented longer survival than progressive ones. Predictors of increased survival included female gender, younger age, higher albumin and higher BMI. The protective effect of BMI and albumin was more pronounced in males than in females. Conclusions: Neurological disorders were the most frequent underlying conditions. Nearly half of the patients displayed malnutrition before PEG feeding. Although PEG-fed patients displayed a considerable median survival time, some died early without benefit from PEG. Patients with potentially regressive neurological conditions presented better outcomes. Female gender, younger age, higher albumin and higher BMI were associated with longer survival.

Association between the C-reactive protein/albumin ratio and mortality in older Japanese patients with dysphagia

Background

C-reactive protein-to-albumin ratio (CRP/ALB) has been proven to represent a biomarker for predicting prognosis in many groups of patients with severe diseases. However, few studies have investigated the association between CRP/ALB and mortality in Japan older people with dysphagia patients.

Objective

This retrospective cohort study aimed to assess the prognostic value of C-reactive protein/albumin ratio (CAR) in older Japanese patients with dysphagia.

Methods

We analyzed data from 253 patients diagnosed with dysphagia at a single center between January 2014 and January 2017. Cox regression analysis was used to compare the mortality rates across the CAR tertiles. Subgroup analyses were conducted, and Kaplan-Meier curves were used to determine the median survival times.

Results

The study included 154 female and 99 male patients, with a median age of 83 years. After adjusting for all covariates, the multivariable Cox regression analysis revealed a significant association between increasing CAR (HR = 1.19, 95% CI: 1.03-1.37, P = 0.022) and the risk of mortality. Compared to the reference group T1 (< 0.149), the adjusted hazard ratios for T2 (0.149-0.815) and T3 (> 0.815) were 1.75 (95% CI: 1.07-2.87, P = 0.027) and 2.15 (95% CI: 1.34-3.46, P = 0.002), respectively. Kaplan-Meier curves indicated median survival times of 864, 371, and 223 days for T1, T2, and T3, respectively.

Conclusion

The C-reactive protein/albumin ratio was positively related to mortality in Japan older people with dysphagia patients. There was no interaction for the subgroup analysis. The result was stable.

Time trends and outcomes of gastrostomy placement in a Swedish national cohort over two decades

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) and laparoscopically inserted gastrostomy have become the gold standard for adult patients and children, respectively, requiring long-term enteral nutrition support. Procedure-related mortality is a rare event, often reported to be zero in smaller studies. National data on 30-d mortality and long-term survival rates after gastrostomy placement are scarce in the literature.

AIM

To study the use of gastrostomies in Sweden from 1998-2019 and to analyze procedure-related mortality and short-term (< 30 d) and long-term survival.

METHODS

In this retrospective, population-based cohort study, individuals that had received a gastrostomy between 1998-2019 in Sweden were included. Individuals were identified in the Swedish National Patient Register, and survival analysis was possible by cross-referencing the Swedish Death Register. The cohort was divided into three age groups: Children (0-18 years); adults (19-64 years); and elderly (≥ 65 years). Kaplan-Meier with log-rank test and Cox regression were used for survival analysis.

RESULTS

In total 48682 individuals (52% males, average age 60.9 ± 25.3 years) were identified. The cohort consisted of 12.0% children, 29.5% adults, and 58.5% elderly. An increased use of gastrostomies was observed during the study period, from 13.7/100000 to 22.3/100000 individuals (P < 0.001). The use of PEG more than doubled (about 800 to 1800/year), with a corresponding decrease in open gastrostomy (about 700 to 340/year). Laparoscopic gastrostomy increased more than ten-fold (about 20 to 240/year). Overall, PEG, open gastrostomy, and laparoscopic gastrostomy constituted 70.0% (n = 34060), 23.3% (n = 11336), and 4.9% (n = 2404), respectively. Procedure-related mortality was 0.1% (n = 44) overall (PEG: 0.05%, open: 0.24%, laparoscopic: 0.04%). The overall 30-d mortality rate was 10.0% (PEG: 9.8%, open: 12.4%, laparoscopic: 1.7%) and decreased from 11.6% in 1998-2009 vs 8.5% in 2010-2019 (P < 0.001). One-year and ten-year survival rates for children, adults, and elderly were 93.7%, 67.5%, and 42.1% and 79.9%, 39.2%, and 6.8%, respectively. The most common causes of death were malignancies and cardiovascular and respiratory diseases.

CONCLUSION

The annual use of gastrostomies in Sweden increased during the study period, with a shift towards more minimally invasive procedures. Although procedure-related death was rare, the overall 30-d mortality rate was high (10%). To overcome this, we believe that patient selection should be improved.

Factors Associated With Short-Term Complications After Percutaneous Endoscopic Gastrostomy Tube Insertion: A Retrospective Cohort Study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tube placement is generally safe but is associated with a range of complications. Minor complications include infections, granuloma formation, leakage, and blockages, while major complications encompass aspiration pneumonia, hemorrhage, and more serious conditions such as necrotizing fasciitis and colonic fistula.

AIM

This study aimed to assess the rate of short-term complications within one month of endoscopic PEG insertion, focusing on their correlation with patient characteristics.

METHODOLOGY

This retrospective cohort study analyzed data from patients who underwent PEG insertion between January 2020 and December 2022. It evaluated the incidence of complications in relation to variables such as the indication for the procedure, the patient's immune status, albumin and CRP levels, and the setting of the procedure (inpatient vs. outpatient).

RESULTS

The study included 121 patients, with a mean age of 69.73 years, comprising 71 males (58.7%) and 50 females (41.3%). Neurological indications accounted for 64.5% of the cases. Notably, 67.8% of the patients were immunocompromised. Within 30 days of PEG insertion, 16.5% experienced complications, including GI bleeding (4.1%), infection at the PEG site (11.6%), and peritonitis (0.8%). Complications were significantly higher in immunocompromised patients and those with non-neurological indications. Higher serum albumin and lower CRP levels were associated with fewer complications, though the association was not statistically significant.

CONCLUSION

The study highlights that gastrostomy site infection is the most common short-term complication following PEG insertion. Immune status and the reason for PEG insertion emerged as key factors influencing the likelihood of complications.

Survival and factors affecting the survival of older adult patients in palliative care

PURPOSE

Investigate the survival and risk factors that affect the survival of aged patients in a palliative care center (PCC).

METHODS

A total of 180 inpatients (aged ≥ 65 years) who were admitted to a PCC from January 2018 to March 2020 were included. Information regarding patients' demographic characteristics, chronic diseases, length of hospital stay, nutrition provided at the first hospital stay, pressure wound, pain, and laboratory results were evaluated.

RESULTS

The patients 50% were women (n = 90). The mean age, mean comorbidity, and mean follow-up duration was 77.6 years, 3.4, and 115 days (median: 29 days), respectively. The mean NRS2002 score of patients was 4.0 ± 1.0 and the risk of malnutrition was 93%. The mortality rate of the patients was 91.7%. The life expectancy of patients without malignancy was higher than those with malignancy (p < 0.001). Enteral nutrition (EN) via percutaneous endoscopic gastrostomy (PEG) was associated with up to two-fold increase in the survival rates of patients with PCC (p = 0.049, HR: 2.029). High neutrophil/lymphocyte ratio (p = 0.002, HR: 1.017) and high ferritin (p = 0.001, HR: 1.000) and C-reactive protein (CRP) levels (p < 0.001, HR: 1.006) were adverse risk factors affecting life expectancy. Malignity reduced the survival rate of aged patients with PCC by 40% (p = 0.008).

CONCLUSION

EN via PEG was found to be a positive factor affecting survival rates of older adult patients in palliative care, whereas malignity, high neutrophil/lymphocyte ratio, high CRP and ferritin levels, and prolonged hospital stays were negative risk factors.

Preprocedural control of nutritional status score and prediction of early death after percutaneous endoscopic gastrostomy

Background and Aim

Percutaneous endoscopic gastrostomy (PEG) is often associated with early mortality. We therefore investigated factors associated with early death after PEG.

Methods

The present study comprised patients who had undergone PEG between April 2014 and March 2020. Patients were divided into two groups: an early mortality group who died within 1 month of PEG, and a non-mortality group whose clinical course could be followed for more than 1 month after the procedure. Patient background, hematological data, and procedural duration were compared between groups.

Results

Univariate analysis identified older age, high blood urea nitrogen (BUN), low prognostic nutritional index (PNI), and high controlling nutritional status (CONUT) score as factors associated with early death after PEG. In multivariate analysis, high CONUT score remained an independent prognostic factor (P = 0.0035).

Conclusion

A high CONUT score may be a prognostic factor for early mortality after PEG.

Mortality and complications after percutaneous endoscopic gastrostomy: a retrospective multicentre study

Background

Percutaneous endoscopic gastrostomy (PEG) is the method of choice for patients in need of long-term nutritional support or gastric decompression. Although it is considered safe, complications and relatively high mortality rates have been reported. We aimed to identify risk factors for complications and mortality after PEG in routine healthcare.

Methods

This retrospective study included all adult patients who received a PEG between 2013 and 2019 in Region Norrbotten, Sweden.

Results

389 patients were included. The median age was 72 years, 176 (45%) were women and 281 (72%) patients received their PEG due to neurological disease. All-cause mortality was 15% at 30 days and 28% at 90 days. Malignancy as the indication for PEG was associated with increased mortality at 90 days (OR 4.41, 95% CI 2.20–8.88). Other factors significantly associated with increased mortality were older age, female sex, diabetes mellitus, heart failure, lower body mass index and higher C-reactive protein levels. Minor and major complications within 30 days occurred in 11% and 15% of the patients, respectively. Diabetes increased the risk of minor complications (OR 2.61, 95% CI 1.04–6.55), while those aged 75 + years were at an increased risk of major complications, compared to those younger than 65 years (OR 2.23, 95% CI 1.02–4.85).

Conclusions

The increased risk of death among women and patients with malignancy indicate that these patients could benefit from earlier referral for PEG. Additionally, we found that age, diabetes, heart failure, C-reactive protein and body mass index all impact the risk of adverse outcomes.

Risk factors for postoperative bleeding and early death in percutaneous endoscopic gastrostomy: A multicenter retrospective study

BACKGROUND AND AIM

Comprehensive reports on the risk factors for bleeding and early death after percutaneous endoscopic gastrostomy (PEG) are limited. In this multicenter study, we retrospectively investigated the risk factors for bleeding and early death after PEG.

METHODS

Patients (n = 1234) who underwent PEG between 2015 and 2020 at Osaka Medical and Pharmaceutical University and its affiliated hospitals (11 institutions in total) were evaluated for postoperative bleeding and early death (within 60 days) after PEG according to patient characteristics, construction method, medical history, medications, preoperative hematological findings, and perioperative adverse events. Multivariate logistic regression was performed to identify independent predictors of bleeding and early death after PEG.

RESULTS

The risk factors for bleeding after PEG were PEG tube insertion using the modified introducer method (odds ratio [OR], 4.37; P = 0.0003), low platelet count (OR, 0.99; P = 0.014), antiplatelet therapy (OR, 2.11; P = 0.036), and heparinization (OR, 4.50; P = 0.007). Risk factors for early death were low body mass index (BMI) (OR, 0.89; P = 0.015), low serum albumin levels (OR, 0.50; P = 0.035), and comorbidity of active cancer (OR, 4.03; P < 0.0001). There was no significant association between bleeding and early death after PEG.

CONCLUSIONS

We identified several risk factors for bleeding and early death after PEG. Risk factors for bleeding were PEG tube insertion using the modified introducer method, low platelet count, antiplatelet therapy, and heparinization. Risk factors for early death were low BMI, low serum albumin levels, and comorbidity of active cancer.