Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 51, Num. 1, 2005, pp. 28-29

Journal of Postgraduate Medicine, Vol. 51, No. 1, January-March, 2005, pp. 28-29

Expert's Comments

Percutaneous endoscopic gastrostomy

Lang Alon

The Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, University of Tel-Aviv, Ramat-Gan

Correspondence Address:The Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, University of Tel-Aviv, Ramat-Gan, alon.lang@sheba.health.gov.il

Code Number: jp05009

Percutaneuse gastrostomy has become the preferred method for providing long term enteral nutrition for patients who are unable to eat but have a functioning gut. Unfortunately, the short - term mortality following PEG is unacceptably high, ranging between 4- 54 %.[1] Moreover, in the manuscript by Janes and colleague in the current issue of The Journal of Postgraduate Medicine, the authors report a rise in the short- term mortality from 8 to 22% within 20 years. So what are we doing wrong? Clearly, the increased mortality is not due to a risky procedure, but is a consequence of a poor patient selection. To improve patients selection one should first clarify the indications based on the available data and than consider the risk factors for early mortality following PEG. As with any other medical care, when prescribing PEG, we should consider the benefit to the patient in terms of survival, quality of life, and improving the nutritional and the functional status. Currently, only patients with dysphagia due to acute cerbrovascular accident, patients with oropharyngeal malignancy, and patients with neuromuscular disease were proven to benefit from enteral feeding using PEG. PEG has no proven long term benefit in patients with dementia.[2] The issue of PEG for the patients with cancer is a controversial one. PEG has probably no place for the treatment of cancer cachexia, but it may be consider for patients undergoing chemo/radiation therapy with anticipated life span of more than 2 month, or as a mean for gastric decompression in certain cases.[3] After defining the indication, the next step would be to define the risk factors for early mortality following PEG. Factors such as old age (>75), recurrent aspirations, diabetes mellitus, low serum albumin and dementia are all risk factors for early mortality.[1] Furthermore, hospitalization for an acute illness is probably the most important risk factor. Frail elderly patients suffering from multiple diseases and often malnourished, have a grim prognosis while admitted for acute illness such as urinary tract infection or pneumonia. Abuksis et al. have shown that a policy of insertion of PEG 30 days after hospital discharge has reduced the 30-day mortality by 40%.[1] Therefore, it seems that PEG insertion should be performed only after the acute illness has resolved and the patient is stable. There is no rush to perform PEG in the acute phase of the disease, as adequate nutrition can be achieved with small bore naso-gastric tubes.

However, looking at the issue of PEG as merely medical one would be misleading. The decision to perform PEG is part of the general issue of artificial nutrition which is influenced by ethical, cultural, religious and legal issues. The physicians and nutritionist should offer PEG following the accepted indication, and considering the risk factors. PEG should not be performed unless the case was thoroughly discussed by the caring physician and, the gastroenterologist and the patient/caregivers regarding the indications and risk factors.

REFERENCES

1.	Abuksis G, Mor M, Plaut S, Fraser G, Niv Y. Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience. Clin Nutr 2004;23:341-6.   Back to cited text no. 1
2.	Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 2000;342:206-10.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.	Angus F, Burakoff R. The percutaneous endoscopic gastrostomy in tube placement medical and ethical issues. Am J Gastroenterol 2003;98:272-7.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]

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