To PEG or Not to PEG


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To PEG or Not to PEG

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To PEG or Not to PEG

  1. 1. To PEG or Not To PEG This the Question ? Dr . Waleed Kh. Mahrous Consultant Internal Medicine Gastroenterologist F3
  2. 2. Percutaneous Endoscopic Gastrostomy  Physicians poorly inform patients and families regarding PEG tube benefits, burdens, and alternatives, often perform nonbeneficial PEG tube placements to avoid difficult discussions with patients, families, or colleagues
  3. 3. Percutaneous Endoscopic Gastrostomy  PEG tubes have a limited role in only a few conditions, that even in these conditions their advantage over nasogastric (NG) tubes or medical therapy is questionable, and that they are widely overused in current practice.
  4. 4. Percutaneous Endoscopic Gastrostomy Those who argue a PEG tube is not a medical intervention have likely never seen one placed.
  5. 5. Percutaneous Endoscopic Gastrostomy Creating a hole into the stomach through the anterior abdominal wall is surgery, regardless of who does the procedure.
  6. 6. Percutaneous Endoscopic Gastrostomy PEG is usually performed in patients with serious disease conditions who are usually elderly and closer towards the end of their life span.
  7. 7. PEG outcomes Making life longer (improving mortality) or 2. Better (improving quality of life). 1.
  8. 8. Mortality The overall mortality post- PEG placement is high due to underlying co-morbidity . Prevention and Management of Complications of Percutaneous Endoscopic Gastrostomy (PEG) Tubes PRACTICAL GASTROENTEROLOGY • NOVEMBER 2004
  9. 9. 30-Day Mortality  The rate of procedure- related mortality and 30-day mortality attributable to PEG placement itself are extremely low (0% to 2% and 1.5% to 2.1% respectively) Prevention and Management of Complications of Percutaneous Endoscopic Gastrostomy (PEG) Tubes PRACTICAL GASTROENTEROLOGY • NOVEMBER 2004
  10. 10. 30-Day Mortality In one study, the 30-day mortality after PEG tube placement rise to 8% and its use for non-evidence-based indications rise up to 16%
  11. 11. Percutaneous Endoscopic Gastrostomy  Such data led many to question the possible overuse and misuse of this procedure.  While safe and effective in the short term, it began to be recognized as an invasive artificial means of life support with multiple serious long-term complications
  12. 12. Burdens and Complications Associated with PEG
  13. 13. Poor prognostic indicators for PEG placement
  14. 14. DEMENTIA  Studies have documented a poor prognosis for hospitalized patients with advanced dementia (50% mortality at 6 months) that PEG failed to improve
  15. 15. DEMENTIA PEG “are generally ineffective in patients with advanced dementia in form of: 1. prolonging life, 2. preventing aspiration, and 3. providing adequate nourishment
  16. 16. CANCER No evidence support the role of PEG in nutrition support to most patients with cancer In Head and neck cancer, PEG can only improve QoL but not mortality
  17. 17. CANCER  In head and neck cancer, a recent study showed fatal or severe complications of PEG placement have occurred in 26% of cases  Theoretically, easy procedure could turn into a potentially dangerous operation
  18. 18. NEUROMUSCULAR DEGENERATIVE DISEASE  In Neuromuscular Degenerative Disease, PEG use has been shown to improve Qol scores and weight but not mortality
  19. 19. STROKE In multicenter trial found no benefit in early versus delayed PEG feeding and an increased risk of death or poor neurologic outcome with PEG compared to NG use
  20. 20. STROKE  Other studies have found high 30-day mortality and complication rates associated with PEG tube use after stroke.
  21. 21. 30 days after hospital discharge A waiting period also allows adequate time for recovery of swallowing function after a stroke or to assess any signs of improvement. Factors predicting early disc harge and mortality in post-percutaneous endoscopic gastrostomy patients - Annals of Gastroenterology (2014) 27, 1-7
  22. 22. 30 days after hospital discharge Studies indicate that 37% of patients with dysphagia after a stroke recover swallowing function within 8 days and 87% maybe swallowing normally by day 14 Factors predicting early disc harge and mortality in post-percutaneous endoscopic gastrostomy patients - Annals of Gastroenterology (2014) 27, 1-7
  23. 23. ASPIRATION PNEUMONIA Aspiration pneumonia is the most common cause of death after PEG placement
  24. 24. ASPIRATION PNEUMONIA All types of feeding (NG, PEG, jejunostomy, or post-pyloric tubes) in Neurogenic dysphagia patients have similar rates of aspiration pneumonia
  25. 25. SETTING OF PEG TUBE PLACEMENT  Inpatients have significantly higher 30-day mortality compared with outpatients PEG insertion.
  26. 26. TIMING OF PEG TUBE PLACEMENT  Stroke patients who received PEG placement 30 days after hospital discharge have significantly lower 30-day mortality than those who received PEG placement during their hospitalization
  27. 27. ETHICAL ISSUES  Our culture attaches great emotional symbolism to providing nutrition to loved ones.  Many physicians feel they cannot refuse PEG tube placement if it is requested by the patient or family.
  28. 28. ETHICAL ISSUES  Results from one study have shown that adequate procedurespecific benefits, burdens, and alternatives were only discussed with 0.6% of patients.
  29. 29. ETHICAL ISSUES  Most physicians would refuse a family request to repair a ventral hernia in an elderly demented patient, but many are willing to place a PEG tube in the same individual, even though both procedures are safe, effective, and nonbeneficial.
  30. 30. BARRIERS TO APPROPRIATE USE  Many physicians, including many gastroenterologists, are unfamiliar with the evidencebased indications for PEG tubes and continue to recommend them for aspiration, advanced dementia, and late-stage cancer
  31. 31. BARRIERS TO APPROPRIATE USE  Physicians in training often are taught not to question PEG placement decisions and to insert them even for inappropriate indications.
  32. 32. BARRIERS TO APPROPRIATE USE Physicians often find it easier to recommend a nonbeneficial procedure than to confront difficult endof-life issues.
  33. 33. Percutaneous Endoscopic Gastrostomy
  35. 35. PRACTICE GUIDELINES  Consideration of PEG placement in only four conditions: - Head and neck cancer - Acute stroke with dysphagia, 30 days after hospital discharge - Neuromuscular dystrophy syndromes - Gastric decompression.
  36. 36. Do not Offer  Aspiration  Dementia  Cancer short life expectancy  Cancer cachexia  Advanced progressive unresponsive cancer  Anorexia Cachexia Syndrome  Prognosis <2 months
  37. 37. INTERVENTIONS TO REDUCE INAPPROPRIATE USE  Use of hospital specific guidelines  Staff education  Mandatory palliative care consultations