To PEG or Not to PEG

To PEG or Not To PEG

Dr . Waleed Kh. MahrousConsultant Internal Medicine

Gastroenterologist F3

This the Question ?

Percutaneous Endoscopic Gastrostomy

Physicians poorly inform patients and families regarding PEG tube benefits, burdens, and alternatives, often perform non-beneficial PEG tube placements to avoid difficult discussions with patients, families, or colleagues

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.

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

Percutaneous Endoscopic Gastrostomy

Creating a hole into the stomach through the anterior abdominal wall is surgery, regardless of who does the procedure.

Percutaneous Endoscopic Gastrostomy

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.

1. Making life longer (improving mortality) or

2. Better (improving quality of life).

PEG outcomes

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

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

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%

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

Burdens and Complications Associated with PEG

Poor prognostic indicators for PEG placement

DEMENTIA

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

DEMENTIA

PEG “are generally ineffective in patients with advanced dementia in form of:

1. prolonging life,2. preventing aspiration, and 3. providing adequate

nourishment

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

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

NEUROMUSCULAR DEGENERATIVE DISEASE

In Neuromuscular Degenerative Disease, PEG use has been shown to improve Qol scores and weight but not mortality

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

STROKE

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

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

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

ASPIRATION PNEUMONIA

Aspiration pneumonia is the most common cause of death after PEG placement

ASPIRATION PNEUMONIA

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

SETTING OF PEG TUBE PLACEMENT

Inpatients have significantly higher 30-day mortality compared with outpatients PEG insertion.

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

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.

ETHICAL ISSUES

Results from one study have shown that adequate procedure-specific benefits, burdens, and alternatives were only discussed with 0.6% of patients.

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 non-beneficial.

BARRIERS TO APPROPRIATE USE

Many physicians, including many gastroenterologists, are unfamiliar with the evidence-based indications for PEG tubes and continue to recommend them for aspiration, advanced dementia, and late-stage cancer

BARRIERS TO APPROPRIATE USE

Physicians in training often are taught not to question PEG placement decisions and to insert them even for inappropriate indications.

BARRIERS TO APPROPRIATE USE

Physicians often find it easier to recommend a nonbeneficial procedure than to confront difficult end-of-life issues.

Percutaneous Endoscopic Gastrostomy

PRACTICE GUIDELINES

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.

Do not Offer

Aspiration Dementia Cancer short life expectancy Cancer cachexiaAdvanced progressive unresponsive cancer

Anorexia Cachexia Syndrome Prognosis <2 months

INTERVENTIONS TO REDUCE INAPPROPRIATE USE

Use of hospital specific guidelines

Staff education Mandatory palliative care consultations

THANK YOU