The document discusses the use of percutaneous endoscopic gastrostomy (PEG) tubes. It notes that PEG tubes are often overused and placed for inappropriate reasons to avoid difficult conversations. PEG tubes only have a limited role in a few conditions and their benefits over other methods are questionable. The mortality rate after PEG placement is high due to underlying illnesses. Several conditions like advanced dementia and late-stage cancers show little benefit from PEG tubes. Guidelines recommend considering PEG only for specific conditions and not using them for situations like aspiration or short life expectancy. Hospitals need guidelines and education to reduce inappropriate PEG placements.

1. To PEG or Not To PEG
This the Question ?
Dr . Waleed Kh. Mahrous
Consultant Internal Medicine
Gastroenterologist F3

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. 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. Percutaneous Endoscopic Gastrostomy
Those who argue a PEG tube
is not a medical
intervention have likely
never seen one placed.

5. Percutaneous Endoscopic Gastrostomy
Creating a hole into the
stomach through the anterior
abdominal wall is
surgery, regardless of
who does the procedure.

12. 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.

13. PEG outcomes
Making life longer
(improving mortality) or
2. Better (improving quality
of life).
1.

14. 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

15. 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

16. 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%

17. 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

18. Burdens and Complications Associated with PEG

19. Poor prognostic indicators for PEG placement

20. DEMENTIA
 Studies have documented a poor
prognosis for hospitalized patients
with advanced dementia (50%
mortality at 6 months) that PEG
failed to improve

21. DEMENTIA
PEG “are generally ineffective
in patients with advanced
dementia in form of:
1. prolonging life,
2. preventing aspiration, and
3. providing adequate
nourishment

22. 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

23. 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

24. NEUROMUSCULAR DEGENERATIVE DISEASE
 In Neuromuscular Degenerative
Disease, PEG use has been shown to
improve Qol scores and weight but
not mortality

25. 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

26. STROKE
 Other studies have found high
30-day mortality and
complication rates associated with
PEG tube use after stroke.

27. 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

28. 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

29. ASPIRATION PNEUMONIA
Aspiration pneumonia is the
most common cause of
death after PEG placement

30. ASPIRATION PNEUMONIA
All types of feeding
(NG, PEG, jejunostomy, or
post-pyloric tubes) in
Neurogenic dysphagia patients
have similar rates of
aspiration pneumonia

31. SETTING OF PEG TUBE PLACEMENT
 Inpatients have significantly
higher 30-day mortality
compared with outpatients PEG
insertion.

32. 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

33. 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.

34. ETHICAL ISSUES
 Results from one study have shown
that adequate procedurespecific benefits, burdens, and
alternatives were only
discussed with 0.6% of patients.

35. 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.

36. 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

37. BARRIERS TO APPROPRIATE USE

Physicians in training often are
taught not to question PEG
placement decisions and to
insert them even for
inappropriate indications.

38. BARRIERS TO APPROPRIATE USE
Physicians often find it
easier to recommend a
nonbeneficial procedure
than to confront difficult endof-life issues.

39. Percutaneous Endoscopic Gastrostomy

40. PRACTICE GUIDELINES

41. 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.

42. Do not Offer
 Aspiration
 Dementia
 Cancer short life expectancy
 Cancer cachexia
 Advanced progressive unresponsive
cancer
 Anorexia Cachexia Syndrome
 Prognosis <2 months

43. INTERVENTIONS TO REDUCE
INAPPROPRIATE USE
 Use of hospital specific guidelines
 Staff education
 Mandatory palliative care
consultations