Percutaneous endoscopic gastrostomies: are they being done for the right reasons?

PEG Insertion in Patients With Dementia Does Not Improve Nutritional Status and Has Worse Outcomes as Compared With PEG Insertion for Other Indications

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes are commonly utilized as a method of enteral feeding in patients unable to obtain adequate oral nutrition. Although some studies have shown improved mortality in select populations, the safety and effectiveness of PEG insertion in patients with dementia compared with those with other neurological diseases or head and neck malignancy remains less well defined.

OBJECTIVE

To evaluate the nutritional effectiveness, rate of rehospitalization, and risk of mortality among patients with dementia compared with patients with other neurological diseases or head and neck cancers who undergo PEG placement.

MATERIALS AND METHODS

We conducted a retrospective analysis from a prospective database of patients who underwent PEG placement at an academic tertiary center between 2008 and 2013. The following data were collected: indication for PEG, patient demographics, biochemical markers of nutritional status rehospitalization, and survival rates.

RESULTS

During the study period, 392 patients underwent PEG tube placement. Indications for PEG were dementia (N=165, group A), cerebrovascular accident (N=124, group B), and other indications such as oropharyngeal cancers and motor neuron disease (N=103, group C). The mean follow-up time after PEG was 18 months (range, 3 to 36 mo). No differences in baseline demographics were noted. PEG insertion in the dementia (group A) neither reduced the rehospitalization rate 6 months' postprocedure compared with groups B and C (2.45 vs. 1.86 and 1.65, respectively; P=0.05), nor reduced the mortality rate within the first year post-PEG placement (75% vs. 58% and 38% for groups A, B, and C, respectively, P=0.001), as well, it did not improve survival at 1 month after the procedure (15% vs. 3.26% and 7.76%, for groups A, B, C, respectively, P<0.01). The presence of dementia was also associated with shorter mean time to death (7.2 vs. 8.85 and 8 mo for groups A, B, C, respectively, P<0.05). The rate of improvement of the nutritional biomarker albumin was lower in the dementia group [3.1. to 2.9 vs. 3.2 to 3.3 and 3 to 3.3 g/dL for groups A, B, and C, respectively (P<0.02)]. Multivariate regression analysis showed that the presence of dementia was an independent predictor for mortality rate within the first year and 1-month mortality rate in patients undergoing PEG insertion with odds ratio 3.22 (95% confidence interval, 1.52-4.32) and odds ratio 2.52 (95% confidence interval, 1.22-3.67).

CONCLUSIONS

PEG insertion in patients with dementia neither improve both short-term and long-term mortality nor rehospitalization rate as compared with patients who underwent PEG placement for alternate indications such as other neurological diseases or head and neck malignancy and even was associated with shorter time to death. Furthermore, PEG insertion in patients with dementia did not improve albumin. Therefore, careful selection of patients with dementia is warranted before PEG placement weighing the risks and benefits on a personalized basis.

Mortality trend and predictors of mortality in dysphagic stroke patients postpercutaneous endoscopic gastrostomy

Background:

Percutaneous endoscopic gastrostomy (PEG) feeding is widely used in stroke patients suffering from persistent dysphagia; however, predicting the risks and benefits of PEG insertion in the individual patient is difficult. The aim of our study was to investigate if candidate risk factors could predict short-term mortality risk in poststroke patients who had PEG tube insertion for persistent dysphagia.

Methods:

This was a retrospective study of 3504 consecutive stroke patients admitted to two metropolitan hospitals during the period January 2005 to December 2013 and who also underwent PEG insertion for feeding due to persistent dysphagia.

Results:

A total of 102 patients were included in the study. There were 22 deaths in 6 months after insertion of PEG tubes and 20 deaths of those occurred within 3 months post PEG. Those who survived beyond 6 months showed significantly lower mean age (75.9 ± 9.0 years vs. 83.0 ± 4.9 years, P < 0.001), a lower mean American Society of Anesthesia (ASA) score (3.04 ± 0.63 vs. 3.64 ± 0.58, P < 0.001) compared to nonsurvivors. In multiple Logistic, age (P = 0.004, odds ratio [OR] = 1.144; 95% confidence interval [CI]: 1.044–1.255); ASA (P = 0.002, OR = 5.065; 95% CI: 1.815–14.133) and albumin level pre-PEG insertion (P = 0.033, OR = 0.869; 95% CI: 0.764–0.988) were the independent determinants of mortality respectively.

Conclusions:

We propose that age, ASA score and albumin level pre-PEG insertion to be included as factors to assist in the selection of patients who are likely to survive more than 3 months post PEG insertion.

Complication and mortality rate after percutaneous endoscopic gastrostomy are low and indication-dependent

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) is often used for the feeding of patients with malnutrition due to dysphagia, and despite more than 30 years experience, numerous questions on its benefit remain. This was a prospective observational study to assess the safety of PEG.

MATERIAL AND METHODS

One hundred and nineteen patients mean age 63 years (21-91 years) who were admitted to the Hannover Medical School between November 2010 and March 2012 and had an indication for PEG according to the German guidelines were included. Primary endpoints were the following: reason for indication, date of in-hospital mortality after PEG insertion, death within 3 months after PEG placement, and complications.

RESULTS

Most patients (54.6%) received PEG for dysphagia caused by tumors and second (29.4%) for neurologic diseases with a minor proportion of dementia (3%). About 73% of our patients had no complications at all and only 10% suffered severe effects. We saw only 1 case of aspiration, which did not lead to pneumonia. The 30-day mortality was 10%, and no patient died as a result of the PEG procedure. Significantly more patients with neurologic disorders died within 24 weeks of PEG placement than tumor patients (60% versus 27.7%, respectively, p = 0.002, n = 100).

CONCLUSION

It is important to select patients receiving PEG very carefully. The patients' indications, their primary disease, and their capability for mental cooperation are essential. If these aspects are taken into account, PEG is a safe method with few mainly mild complications.

Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure performed to maintain nutrition in the short- or long-term. During the procedure, a feeding tube that delivers either a liquid diet, or medication, via a clean or sterile delivery system, is placed surgically through the anterior abdominal wall. Those undergoing PEG tube placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression, or underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and to the debate surrounding antibiotic prophylaxis for PEG tube placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient's serum and tissues, via a brief course of an appropriate agent, by the time of PEG tube placement in order to prevent any peristomal infections that might result from the procedure.

OBJECTIVES

To establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomy tubes.

SEARCH METHODS

In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid Medline; Ovid Medline (In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials during PEG tube placement, with no restrictions regarding language of publication, date of publication, or publication status. Both review authors independently selected studies.

DATA COLLECTION AND ANALYSIS

Both review authors independently extracted data and assessed study quality. Meta-analyses were performed where appropriate.

MAIN RESULTS

One new trial was identified and included in this update, bringing the total to 13 eligible RCTs, with a total of 1637 patients. All trials reported peristomal infection as an outcome. A pooled analysis of 12 trials resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (1271 patients pooled: OR 0.36, 95% CI 0.26 to 0.50). The newly identified trial compared IV antibiotics with antibiotics via PEG and could not be included in the meta-analysis.

AUTHORS' CONCLUSIONS

Administration of systemic prophylactic antibiotics for PEG tube placement reduces peristomal infection.

High In-hospital mortality after percutaneous endoscopic gastrostomy: results of a nationwide population-based study

BACKGROUND & AIMS

It is important to carefully select patients who undergo endoscopic procedures, to optimize health care. Percutaneous endoscopic gastrostomy (PEG) is a frequently performed invasive endoscopic procedure that has been associated with high short-term mortality. We used a national database to determine the incidence of, and factors associated with, in-hospital mortality among patients undergoing PEG.

METHODS

We conducted a nested, case-control, retrospective study using the US Nationwide Inpatient Sample (NIS) to analyze data from all hospitalizations in 2006 with an International Classification of Diseases, 9th revision, procedure code for PEG. Bivariate and multivariate logistic regression analyses were performed using demographic and clinical variables to identify predictors of in-hospital mortality after the procedure. A separate analysis using a propensity score matching technique was conducted to compare mortality with a control cohort. Results were validated in an independent analysis of 2007 NIS data.

RESULTS

In-hospital mortality was 10.8% among 181,196 patients who underwent PEG in 2006 (95% confidence interval, 10.3%-11.3%). Odds of death increased with age (1%/y), congestive heart failure, renal failure, chronic pulmonary disease, coagulopathy, pulmonary circulation disorders, metastatic cancer, and liver disease. The indication for PEG was associated strongly with mortality. Women and patients with diabetes mellitus or paralysis had a lower risk of death. PEG was associated with slightly higher odds of in-hospital mortality compared with patients who did not undergo PEG. Qualitatively and quantitatively similar results were obtained when 2007 NIS data were analyzed.

CONCLUSIONS

The mortality rate is almost 11% among hospital inpatients after PEG. We have identified factors that increase and decrease the risk of death after PEG; these factors could improve patient selection for those most likely to benefit from this procedure.

Propofol-Based Sedation Does Not Increase Rate of Complication during Percutaneous Endoscopic Gastrostomy Procedure

Objectives. To evaluate and compare the complication rate of sedation with or without propofol regimen for percutaneous endoscopic gastrostomy (PEG) in a hospital in Thailand. Subjects and Methods. A total of 198 patients underwent PEG procedures by using intravenous sedation (IVS) from Siriraj Hospital, Thailand from August 2006 to January 2009. The primary outcome variable was the overall complication rate. The secondary outcome variables were sedation and procedure related complications, and mortality rate. Results. After matching ASA physical status and indications of procedure, there were 92 PEG procedures in propofol based sedation group (A) and 20 PEG procedures in non-propofol based sedation group (B). All sedation was given by residents or anesthetic nurses directly supervised by staff anesthesiologist in the endoscopy room. There were no significant differences in patients' characteristics, sedation time, indication, complications, anesthetic personnel and mortality rate between the two groups. All complications were easily treated, with no adverse sequelae. Mean dose of fentanyl and midazolam in group A was significantly lower than in group B. Conclusion. Propofol-based sedation does not increase rate of complication during PEG procedure. Additionally, IVS of PEG procedure is relatively safe and effective when performed by physicians in training. Serious complications are none.

A systematic review of prophylactic antimicrobials in PEG placement

AIM

To establish whether prophylactic systemic antimicrobials reduce the risk of peristomal infection in placement of percutaneous endoscopic gastrostomies.

BACKGROUND

Percutaneous endoscopic gastrostomies, placed surgically through the anterior abdominal wall, maintain nutrition in the short or long term. Those undergoing percutaneous endoscopic gastrostomy placement are often vulnerable to infection. The increasing incidence of methicillin-resistant Staphylococcus aureus contributes an additional risk to the debate surrounding antibiotic prophylaxis. The aim of antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient, during placement.

DESIGN

Systematic review.

METHODS

We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals, relevant conference proceedings and bibliographies of publications identified, and contacted manufacturers and distributors of percutaneous endoscopic gastrostomy products. Randomised controlled trials were selected evaluating the use of prophylactic antimicrobials for percutaneous endoscopic gastrostomy placement, with no restrictions for language, date or publication status. Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate.

RESULTS

Ten eligible randomised controlled trials were identified evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22-0.44). The relative reduction in risk of infection for those given antibiotics was 19% with the need to treat 5.8 patients to prevent one infection - NNT.

CONCLUSIONS

Administration of systemic prophylactic antibiotics for percutaneous endoscopic gastrostomy placement reduces peristomal infection.

RELEVANCE TO CLINICAL PRACTICE

The nurse's role in endoscopy is expanding rapidly and demands that practice is based on the best available evidence. This systematic review seeks to make a contribution to best practice in percutaneous endoscopic gastrostomy placement.

Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is an accepted method of placing a feeding tube to enable enteral feeding in patients with swallowing difficulties. However, the factors associated with complications and death after PEG have not been studied in detail. We describe the largest audit of deaths after PEG tube insertion.

OBJECTIVE

Our purpose was to determine the factors associated with death after PEG tube insertion.

DESIGN

Deaths occurring within 30 days after PEG tube insertion in the United Kingdom between April 2002 and March 2003 were identified and a questionnaire was sent to the consultant endoscopist for completion.

PATIENTS

A total of 719 patients (391 male, median age 80 years, range 26-98 years) who died within 30 days after PEG insertion were identified for this study.

SETTING

United Kingdom hospitals.

MAIN OUTCOME MEASUREMENT

Cause of death.

RESULTS

A total of 97% of the identified patients had coexistent neurologic disease. PEG tubes were inserted by specialized GI physicians in 522 cases (73%). Seventy-two patients (10%) required reversal agents after sedation. After PEG tube insertion, 309 patients (43%) died within 1 week. Death was due to cardiovascular disease (n = 175), respiratory disease (n = 508), central nervous system disease (n = 358), renal disease (n = 38), and hepatic failure (n = 11). In 136 cases (19%) the National Confidential Enquiry into Patient Outcome and Death expert panel regarded the procedure as futile.

LIMITATIONS

Retrospective review of case records.

CONCLUSIONS

Mortality and morbidity rates after PEG tube insertion are not insignificant. Selection of patients is paramount to good patient outcomes. Multidisciplinary team assessment should be performed on all patients being referred for PEG tube insertion.

Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomies (PEG) maintain nutrition in the short or long term. A PEG is a feeding tube, placed surgically through the anterior abdominal wall, which delivers a liquid diet, or medication, via a clean or sterile delivery system. Those undergoing PEG placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression and underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and also to the debate surrounding antibiotic prophylaxis for PEG placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patients serum and tissues, via a brief course of an appropriate agent, by the time of PEG placement.

OBJECTIVES

The review seeks to establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomies.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals relevant conference proceedings, and bibliographies of relevant publications identified by these strategies for further studies; and contacted manufacturers and distributors of PEG products.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials for PEG placement, with no restrictions for language, date or publication status.

DATA COLLECTION AND ANALYSIS

Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate.

MAIN RESULTS

We identified 10 eligible RCTs evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome, and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22 to 0.44).

AUTHORS' CONCLUSIONS

Administration of systemic prophylactic antibiotics for PEG placement reduces peristomal infection.

PEGs and Ethics Revisited

Percutaneous endoscopic gastrostomy is an accepted technique for long-term enteral feeding. The demand of percutaneous endoscopic gastrostomy placement continues to increase because of the increasing numbers of vulnerable patients with chronic diseases coupled with the relative ease of insertion, and societal ambivalence about such treatment. Despite the demand and improvements in placement technique, the issue of tube feeding in vulnerable patients remains an ethical minefield, leading to considerable discussion and debate. This contentious area of clinical ethics is further complicated by the recent papal allocution regarding artificial nutrition and hydration. The case of Terri Schiavo should serve as a timely reminder of those problematic clinical and ethical issues inherent in percutaneous endoscopic gastrostomy placement and feeding in vulnerable patients.

Preventing glycaemic excursions in diabetic patients requiring percutaneous endoscopic gastrostomy (PEG) feeding after a stroke

AIMS AND METHODS

Enteral feeding for diabetic patients with a stroke is often associated with hyperglycaemia and/or hypoglycaemia, which can adversely influence neurological recovery. We have developed a structured enteral feeding programme aimed at establishing 'normal' feeding patterns and avoiding marked glycaemic excursions.

RESULTS

Of 332 consecutive patients admitted to an acute stroke unit, 20 of 41 diabetic patients required PEG feeding. Over the initial 24-48 h, patients had 22- h feeds with continuous intravenous infusion of soluble insulin. Thereafter, they were established on three feeds per day. Soluble insulin was given prior to each feed with isophane insulin at 2200 h. Average duration of feed was 13 +/- 8 days with an achieved glucose level of 8.7 +/- 2.5 (mean +/- SD) mmol/l associated with 0.8 episodes of biochemical hypoglycaemia (< 3 mmol/l) each week.

CONCLUSIONS

A structured enteral feeding programme for PEG-fed diabetic patients can improve the quality of care with avoidance of marked glycaemic excursions.

Percutaneous endoscopic gastrostomy: a prospective audit of the impact of guidelines in two district general hospitals in the United Kingdom

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) is the accepted method for long-term enteral nutrition. Recent studies have suggested a higher mortality than was initially reported. The demands for gastrostomy insertion have risen, encompassing indications where the long-term outcomes are uncertain. We, therefore, constructed guidelines to try and improve the appropriateness of patient selection. Our aim was to prospectively assess the impact of guidelines for PEG insertion over a 1-yr period in a single center, Rotherham District General Hospital (hospital A) and compare against an adjacent center serving a similar population, Doncaster Royal Infirmary (hospital B) where guidelines had not been instituted.

METHODS

Data were collected from June, 1998 to May, 1999. Indication for PEG was documented and survival analysis performed using the Kaplan-Meier survival method.

RESULTS

The number of PEG insertions had been rising each year in both centers. After guidelines were introduced in hospital A, the number of procedures fell by 20, whereas in hospital B, the PEG insertion rate continued to rise (p = 0.02). There was a lower mortality observed in hospital A (at 1 month, 16%; at 3 months, 26%; at 6 months, 39%; and at 1 yr, 46%) than in hospital B (at 1 month, 26%; at 3 months, 44%; at 6 months, 58%; and at I yr, 68%), although this did not achieve statistical significance (log rank test, p = 0.1).

CONCLUSIONS

This is the first study to prospectively assess the impact of guidelines and a proactive role in the decision for PEG insertion. Fewer procedures were performed, and there was a trend toward a reduction in mortality.

Percutaneous endoscopic gastrostomy and the evolution of contemporary long-term enteral access

This paper is based on the opening lecture of the 23rd Congress of the European Society of Parenteral and Enteral Nutrition (ESPEN), given on September 9, 200l in Muenchen, Germany. The article relates the story of the origin and the evolution of the percutaneous endoscopic gastrostomy or PEG, based on the then-novel concept of sutureless approximation of a hollow viscus to the abdominal wall. It also provides a perspective of the clinical applications of PEG, in general, and the author's pediatric experience in particular. Additionally, it briefly describes the old and new expanded applications of the PEG concept. In this communication, the author of the procedure encourages young investigators to ask relevant questions in research and in clinical settings aimed at developing new ideas and concepts in the field of nutrition. He also stresses the need to carefully reflect upon the ethical and moral implications of new discoveries. The article contains pertinent illustrations and bibliographic references.

Day-case percutaneous endoscopic gastrostomy: a viable proposition?

The aim of our study was to evaluate the success rate, complications, and long term outcomes following day-case percutaneous endoscopic gastrostomy (PEG). This retrospective study was carried out in a 650-bed District General hospital in Northamptonshire, UK. Thirty-six patients, aged 28-90 years, were included in the study, 21 males (58%) and 15 females (42%). Indications for PEG insertion included head and neck cancer, dysphagia as a result of primary disease, and AIDS-related malnutrition. Data were collected from the medical and dietetic records. The PEG procedure was successful in 33 patients (92%). In 32 cases (97%) the patient was discharged home. Twenty five of the patients (76%) suffered no complications whilst seven (21%) suffered complications within a month of the procedure. No patient required further surgical intervention. Five patients (15%) died of their primary disease within a month of the procedure. Patients had had their PEG tubes in situ for up to 2.5 years at the end of data collection. We conclude that PEG can be performed as a day-case procedure in stable patients with no increase in complication rate, morbidity, or mortality.