Introduction

Percutaneous endoscopic gastrostomy (PEG) provides long-term enteral nutrition access in patients with a functional gastrointestinal tract and impaired swallowing. Population-based data on hospital admissions with long term PEG complications are lacking. This study examines the impact of nutrition support teams on admissions with PEG related complications and associated factors.

Aims & Methods

Adults undergoing first PEG insertion in England from 2007 to 2021 were identified in Hospital Episode Statistics. Long term complications (>30 days after PEG) were identified using ICD-10 codes and categorised into two groups: mechanical (PEG obstruction, displacement and leakage) and PEG site infection. Data on NHS trust nutrition support teams were available from GIRFT. The proportion of patients with hospital admissions associated with PEG related complications within 5 years of insertion was calculated. Cox proportional hazards models examined factors associated with both emergency and elective admissions with PEG complications.

Results

Of 108,515 patients (57.7% male; age 69(IQR 57-69)),10.8% had an emergency admission (with 84% for >48 hours) and 1.6% an elective admission due to PEG complication. Hospitals without a nutrition support team had 60.7(36.8-84.2)% emergency admissions due to PEG related mechanical complications compared with 49.5(22.5-90.6)% in hospitals with a nutrition support team.
Factors associated with any emergency admissions for PEG complications included: female (adjusted hazard ratio (aHR) 1.04(95% CI 1.01-1.08)); Asian ethnicity (aHR 1.10(1.02-1.19)); PEG insertion during an emergency admission (aHR 1.38(1.32-1.44)); dementia as PEG indication (aHR 1.27(1.08-1.49)); oesophageal cancer as PEG indication (aHR 2.28(1.99-2.62)); no trust nutrition support team (aHR 1.20(1.13-1.28)) and more recent years of PEG insertion (2021 aHR 1.75(1.52-2.00)). Factors associated with any PEG related complication admission included: PEG insertion during emergency admission (aHR 1.27(1.22-1.32)); oesophageal cancer as PEG indication (aHR 2.24(1.97-2.54)); dementia as PEG indication (aHR 1.24(1.06-1.44); other neurological conditions than stroke as PEG indication (1.16(1.10-1.23)); no trust nutritional support team (aHR 1.16(1.09-1.23)); increasing age (>82 years aHR 0.60(0.57-0.64)); the least deprived quintile (aHR 0.83(0.78-0.87)) and increasing comorbidity Charlson score >5 (aHR 0.86(0.82-0.91)).

Conclusion

10.8% of patients had an emergency admission with a complication within 5 years of PEG insertion, with 84% staying in hospital for >48hrs.The lack of a trust nutritional support team increased the risk of emergency admissions with complications.

Disclosure

No conflict of interest to declare

Introduction

Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition in dysphagic patients with a vast heterogeneous group of underlying conditions. Decision-making for gastrostomy placement requires careful consideration on a case-by-case basis, with the underlying condition, clinical status and prognosis taken into account. Although estimating prognosis is a critical factor in the decision-making of PEG tube placement, it remains challenging and heavily reliant on clinical judgement.

Aims & Methods

Retrospective study of adult patients who underwent PEG in a tertiary hospital from 2001 to 2023. This study aims to characterize conditions motivating PEG, assess nutritional status on the gastrostomy day, evaluate survival and search for survival predictors. 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 (35.3% with a potentially regressive course and 31.2% with a progressive course) and 31.3% head and neck or esophageal cancers (HNC/EC). The most frequent underlying conditions were post-stroke dysphagia (25.5%), dementia (11%) and amyotrophic lateral sclerosis (10.8%). The mean BMI was 20.9 kg/m2, with 49.8% underweight patients. Albumin, transferrin and total cholesterol were low at 43.2%, 62.2% and 50%, respectively. Median overall survival was 11.1 months, with a 1-, 3- and 5-year survival rates of 48.2%, 27.8% and 19.6%, respectively. 14.1% of deaths occurred within 4 weeks. These short survivors were significantly older and had lower mean albumin, transferrin and total cholesterol levels. Although BMI was also lower, this difference did not reach statistical significance. Potentially regressive neurological conditions presented higher survival than progressive ones (16.6 vs. 13.3 months, p = 0.004). HNC/EC patients presented a significantly lower survival (6.6 months) when compared to both of these groups (p < 0.001). Besides underlying condition, predictors of increased survival on the multivariable analysis included female gender (HR 0.396), younger age (HR 0.980), higher albumin (HR 0.687) and higher BMI (HR 0.963). The protective effect of BMI and albumin was more pronounced in males than in females.

Conclusion

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. The findings emphasize the complex interplay of clinical, demographic and nutritional factors influencing survival after PEG tube placement. By integrating these predictors of survival into clinical practice, patient selection can be tailored in order to optimize outcomes.

Introduction

Percutaneous endoscopic gastrostomy (PEG) is the standard method for providing long-term enteral nutrition and medication in patients with insufficient oral intake. However, data on the technical aspects of the procedure, adherence to published guidelines, and the decision-making process of endoscopists remain limited in certain countries.

Aims & Methods

The primary aim of this nationwide study was to assess the current practices among Greek gastroenterologists regarding PEG procedure, covering the entire spectrum of PEG, including initial clinical decision-making, technical aspects, periprocedural management, and long-term patient care. An anonymous web-based survey was distributed to every member of the Hellenic Society of Gastroenterology (HSG), including gastroenterology trainees. Participants electronically completed a 36-item questionnaire divided into five sections:
(1) demographics and professional background,
(2) general questions on PEG placement,
(3) specific procedural aspects,
(4) post-procedural management, and
(5) future perspectives.
Data analysis was performed using Stata statistical software, version 17.0 (StataCorp LLC, College Station, TX, USA).

Results

A total of 127 out of 766 members of the HSG responded (response rate: 16.5%). Regarding PEG placement, 66.7% reported involvement in up to two procedures per week. Multidisciplinary team meetings were rarely implemented, with 82.0% stating they “rarely” or “never” participate in such meetings. Neurological disorders were the leading indication for PEG (67.7%), followed by dementia (18.1%) and obstructive head, neck, or esophageal malignancies (11.8%). The primary indications differed significantly between the public and private sectors (P = 0.007), with neurological disorders being more frequently reported in the private sector (40.5% vs 26.1%), while obstructive tumors were less commonly cited as the main indication for PEG placement (1.6% vs 10.3%). The push-PEG technique in malignancy cases was used by 31.7% of respondents, whereas direct percutaneous endoscopic jejunostomy (D-PEJ) and percutaneous endoscopic gastrojejunostomy (PEG-J) were employed in 11.9% and 37.8%, respectively. Skin antisepsis and use of sterile instruments were consistently reported by 93.7% and 89.0% of the participants, while prophylactic antibiotics and surgical hand washing were routine for 58.3% and 45.7% of them. Regarding the reported incidence of serious adverse events, 17.3% of respondents had encountered at least one case of perforation or peritonitis, 12.6% reported severe bleeding, and 7.9% had experienced a PEG-related death. No statistically significant association was observed between the occurrence of adverse events and the variables age, years post specialization, trainee status, healthcare sector (public vs private), annual number of PEG procedures, or routine use of prophylactic antibiotics. After discharge, structured follow-up programs were reported by 15.1%, while 31.5% indicated that nutritional guidance was provided by a dedicated nutrition department.

Conclusion

This nationwide survey is the first to explore clinical practices related to PEG placement among gastroenterologists in Greece. The findings highlight areas of alignment with international standards, but also reveal important deviations, particularly in multidisciplinary collaboration, infection prevention measures, and postprocedural care. These results provide a valuable foundation for targeted training agendas and quality improvement initiatives.

References

1. Arvanitakis M, Gkolfakis P, Despott EJ, et al. Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2021;53(1):81-92. doi:10.1055/a-1303-7449
2. Bischoff SC, Austin P, Boeykens K, et al. ESPEN practical guideline: Home enteral nutrition. Clin Nutr. 2022;41(2):468-488. doi:10.1016/j.clnu.2021.10.018

Disclosure

Nothing to disclosure.

Introduction

Percutaneous endoscopic gastrostomy (PEG) is a relatively simple and safe therapeutic method of providing enteral access for patients with dysphagia and intact gastrointestinal (GI) tract. However, it is also associated with several complications, as well as a high morbimortality rate. The use of PEG as an ambulatory procedure in head and neck cancer (HNC) outpatients has not been well established in the literature so far.

Aims & Methods

The main objective of this study was to investigate the short and long-term complications of ambulatory PEG in a selected group of HNC outpatients. We performed a prospective clinical study involving HNC subjects who were in good clinical condition. Patients were included from September 2002 to December 2009 in a close long-term follow-up protocol of outpatient PEG by the pull technique.

Results

A total of 201 patients who underwent ambulatory PEG were included in the present study: 58 (28.9%) pretreatment, 48 (23.9%) during treatment and 95 (47.5%) after treatment for the underlying malignant disease. There was no procedure-related mortality. There were complications in 55.7% of patients in the long-term follow-up (16.9% early and 49.8% late, 6.5% major and 55.2% minor). The complications were: granulation tissue (43.3%), periostomal infection (11.4%), leakage (9%), BBS (6%), local pain (5.5%), persistent gastrocutaneous fistula (3.6%), gastric wall hematoma (3.5%), late tube dislodgement (3%), early tube dislodgement (0.5%), and respiratory failure (2.2%). The clinical-demographic variables (age, sex and timing of PEG) were not associated with significant statistical difference for complication rates (early or late, major or minor).

Conclusion

Ambulatory PEG is a viable and safe procedure in HNC outpatients who are in good clinical condition. Although PEG complication rates may be significant in the long-term follow-up, in most cases these complications are classified as minor. There were no deaths related to the procedure itself, and all complications were treated in an outpatient setting.

References

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2. Giacomini M, Conigliaro R, Tincani M, Benedetti G, Valent F. Complications of percutaneous endoscopic gastrostomy: results of a longitudinal prospective multicenter study. Nutr Ther Metab 2009; 27 (4): 193-202.
3. Grant DG, Bradley PT, Pothier DD, bailey D, Caldera S, Baldwin DL, Birchall MA. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and metaanalysis. Clin Otolaryngol 2009; 34: 103-12.
4. Mello GFS, Lukashok HP, Meine GC, Small IA, Carvalho RLT, Guimaraes DP, Mansur GR. Outpatient percutaneous endoscopic gastrostomy in selected head and neck cancer patients. Surg Endosc 2009, 23 (7): 1487-93.
5. Vujasinovic M, Marsk E, Tsolakis AV, Hynning B, Nordberg M, Lindblad M, Lindqvist C, Nordenvall LH, Bark R, Elbe P. Complications of gastrostomy tubes in patients with head and neck cancer. Laryngoscope 2022; 132 (9):1778-1784.
6. Ferraz-Gonçalves et al. Percutaneous gastrostomies in advanced cancer. Porto Biomed J 2023; 8 (6)