Complications of and Controversies Associated With Percutaneous Endoscopic Gastrostomy: Report of a Case and Literature Review

Abstract

Context

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly performed gastrointestinal procedures, despite absence of benefit in many patients and risks associated with the procedure. Increased education of primary care physicians about the shortcomings of PEG may allow for better selection of patients to be referred for PEG placement.

Evidence acquisition

We performed a comprehensive literature review by searching PUBMED using the search headings percutaneous enteral gastrostomy, PEG, complications, dementia, stroke, dysphagia, malnutrition, and complications. We identified English language articles from 1980 onward. The highest quality data were considered to be randomized controlled trials although given the paucity of trials in this area, we used all of the various types of literature.

Evidence synthesis

We based the major conclusions of this review, where possible, on the most robust literature, namely, controlled trials. However, the majority of the available literature in this field is based on case series. We attempted to maximize the use of larger case series with longer term follow-up. Case reports were used only to report on rare complications where no other literature was available.

Conclusions

Despite more than 30 years of experience with PEG, numerous questions remain regarding the utility of nutrition support in many of the clinical scenarios in which PEG placement is contemplated. There is a multitude of evidence that artificial nutrition does not improve outcome or quality of life in patients with dementia who have decreased oral intake. It is likely that ethical, moral, religious, and legal considerations of family members and caregivers play a role in the decision to place a PEG in a patient with dementia despite the medical evidence demonstrating lack of benefit.

Case Report

A 71-year-old man was admitted to the hospital for chest pain and rapid atrial fibrillation. His atrial fibrillation was rate controlled with calcium channel blockers and his electrocardiogram (ECG) and cardiac enzymes showed no evidence of myocardial infarction. During his hospital stay he had an episode of respiratory distress and tachycardia; chest radiograph revealed pneumonia, and the patient required mechanical ventilation. Subsequently, he failed several attempts at extubation due to high levels of secretions and an altered mental status. A tracheostomy was performed. A swallowing evaluation revealed evidence of severe aspiration. The gastroenterology (GI) service was consulted to place a PEG tube to establish access for long-term enteral nutrition.

Initial evaluation revealed an elderly man in no acute distress. His abdomen was slightly distended and without scars; nontender to palpation, and no masses or organomegaly were noted. Laboratory investigations revealed a normal white blood cell count, normal platelets, prothrombin time, and partial prothrombin time, as well as a normocytic anemia. Informed consent for PEG placement was obtained from the patient's next of kin.

The PEG was placed uneventfully the next day after IV administration of 1 g of cefazolin. The patient tolerated the procedure well. The nursing staff was instructed to administer medications through the PEG tube that evening but to hold feedings until postoperative evaluation by the GI team the next day.

The next morning the patient was noted to have increased abdominal distension and pain. He was normotensive and afebrile but had sinus tachycardia. Bowel sounds were absent and diffuse tenderness was elicited as well as voluntary guarding around the PEG site. The PEG site was without erythema, induration, or drainage. Laboratory studies revealed a leukocytosis of 25,000 cells/mm³ and stable hemoglobin. Empiric ciprofloxacin and metronidazole were initiated for the treatment of peritonitis. A computed tomography (CT) scan showed a large amount of free intraperitoneal air. The PEG tube was within the gastric lumen but was noted to course in proximity and perhaps even traverse through the transverse colon.

Exploratory laparotomy was performed; pneumoperitoneum and a small amount of purulent peritoneal fluid was noted. The bumper of the PEG tube was in the stomach but the tube was lacerated and was traversing the transverse colon adjacent to the greater curvature of the stomach. A small incision was made in the colon and the PEG tube was removed from the colon. The defect in the colon was closed with staples. The peritoneum was copiously irrigated and the PEG tube was left in situ in the stomach.

The patient had significantly less abdominal distension and pain on postoperative day 1, and his white blood cell count had decreased to 16,000 cells/mm³. By postoperative day 3, the leukocytosis had resolved. Enteral feeds were initiated on postoperative day 5 and advanced to meet his caloric needs by postoperative day 7. The patient was discharged to a long-term care facility.

Introduction

Since its introduction in 1979, PEG has become a widely performed medical procedure. It is estimated that 160,000–200,000 PEG procedures are performed each year in the United States; this makes PEG the second leading indication for upper gastrointestinal tract endoscopy.[1] PEG tube placement was originally devised as a technique for a sutureless gastrostomy in pediatric patients.[2] Over the past 3 decades, PEG has become the procedure of choice for providing enteral access for nutritional support in adults. The unproven efficacy of enteral nutrition in prolonging survival and improving quality of life in many clinical settings and the potential for multiple complications have reduced the “enthusiasm” for performing this procedure for nutritional support in many clinical situations. This article reviews common complications of PEG placement, discusses the evidence for enteral nutritional support in common clinical situations in which PEG is contemplated, and briefly addresses relevant ethical and legal issues.

Complications

Although success rates greater than 95% have been reported for PEG, procedure-related complications are common.[3–6] A large meta-analysis reported a procedure-related morbidity of 9.4% and mortality of 0.53%.[7] Most series report morbidity rates ranging from 9% to 17%, although major complications occur in only 1%-3% of cases.[8,9] Complications related to PEG placement are traditionally stratified as major vs minor (Table 1).

Table 1.

Percutaneous Endoscopic Gastrostomy Complications[3,13]

Major

Aspiration

Peritonitis

Hemorrhage

Buried bumper syndrome

Gastrocolocutaneous fistula

Wound infection

Necrotizing fasciitis

Inadvertent removal of PEG tube

Minor

Tube leakage

Tube blockage

Major Complications

Aspiration. Aspiration resulting in pneumonitis or pneumonia is one of the most frequently reported major complications of PEG placement.[10] Aspiration can occur either during or after the PEG placement procedure. Periprocedure aspiration of oropharyngeal contents occurs in 1% of patients undergoing PEG tube placement and carries a very high mortality.[3,11] There are no clear predictors of periprocedure aspiration risk, but this complication may be more likely to occur in patients undergoing PEG for neurologic etiologies.[3] The level of sedation, frequency of suctioning, and degree of elevation of the head of the bed may all contribute to aspiration risk. Postprocedure aspiration consists of either oropharyngeal contents or refluxed gastric contents and tube feedings. Although a frequently used justification for PEG placement is the prevention of aspiration, this is not supported by the available evidence. PEG has not been shown to prevent aspiration of oropharyngeal contents.[12] Furthermore, many patients have macroaspiration of gastric contents and tube feedings. Close monitoring of gastric residual volumes and holding feedings when high residuals are encountered may limit aspiration.[13] The presence of an abnormal swallowing evaluation and reflux esophagitis places patients at significantly increased risk for aspiration pneumonia within 1 month of PEG placement.[14]

Postpyloric or jejunal feeding may reduce the risk of aspiration. However, a systematic review of 8 trials compared gastric and postpyloric feeding and found similar rates of pneumonia, mortality, and length of ICU stay in both groups.[15] Jejunostomy tubes have been shown to decrease the reflux of nutrient solutions and thus may have a role in patients who have recurrent aspiration of feedings.[16,17] Placement of postpyloric tubes may be done endoscopically either via a transgastric approach or a direct percutaneous approach. The former technique has a high rate of early technical failure and the latter approach is associated with a higher rate of complications than PEG and requires technical expertise that is not widely available.[16] Durable enteral postpyloric access usually requires surgical jejunostomy.

Peritonitis. Peritonitis is a feared complication of PEG that often carries a high mortality rate. Peritonitis complicates up to 2.3% of procedures in large series.[18–21] Peritonitis manifests as abdominal pain, fever, and leukocytosis. The finding of pneumoperitoneum is not helpful in the diagnosis of peritonitis, as it can be found in up to 38% of patients after PEG.[22] Causes of peritonitis include removal or displacement of the tube prior to tract maturation, leakage from the PEG puncture site in the stomach, and perforation of another visceral organ.[23] A radiographic study with instillation of water-soluble contrast through the PEG tube is often helpful in ascertaining whether a disrupted PEG tract or gastric leak is the source of peritonitis. The study will also determine if the PEG tube has been placed correctly in the gastric lumen. If findings from the radiographic study are normal, an abdominal CT scan can be valuable in determining whether there has been damage to the small or large bowel or other organs during PEG tube placement. There are no guidelines for the management of peritonitis, but generally patients are treated with broad-spectrum antibiotics.[13] Perforation of bowel or leakage from the PEG tract almost always requires surgical repair.[13]

Hemorrhage. Hemorrhage occurs in up to 2.5% of PEG placements.[3,13] During the procedure hemorrhage may be caused by puncture of gastric wall vessels. The most common cause of hemorrhage post-PEG is due to the ulceration of the gastric mucosa underneath the internal bumper when applied in very tight approximation to the mucosa.[23] Esophageal trauma, gastric erosions, and unrelated peptic ulcer disease are less common etiologies of gastrointestinal bleeding after PEG.[13,23] Cutaneous bleeding from the skin incision is common and usually self-limited. Rarely, bleeding can be due to puncture of a large abdominal wall vessel and may require suturing for hemostasis; this is more common in patients with portal hypertension and coagulopathy.[23] Post-PEG hemorrhage is managed similar to other episodes of upper gastrointestinal bleeding. Diagnostic upper endoscopy is often performed. If endoscopy does not reveal a bleeding source it is useful to loosen the external bolster on the PEG tube to free it from the gastric mucosa and evaluate for underlying ulceration.

The American Society for Gastrointestinal Endoscopy has published guidelines for the use of anticoagulation and antiplatelet therapies for endoscopic procedures.[24] These guidelines consider PEG a high-risk procedure for bleeding. It is recommended that patients who are receiving warfarin stop taking the drug 3–5 days prior to PEG placement. If these patients are at high risk for a thromoboembolic event, they can be treated with unfractionated heparin, which is then stopped 4–6 hours prior to PEG and resumed 2–6 hours after procedure. Warfarin therapy is generally restarted the night of the procedure. The guidelines state that it is unnecessary to withdraw aspirin or nonsteroidal anti-inflammatory drugs prior to undergoing PEG.[24]

Tube migration and the buried bumper syndrome. The buried bumper syndrome is defined as migration of the PEG tube into the gastric wall and the subsequent epithelization of the ulcer site.[22] Buried bumper syndrome often manifests months to years after PEG placement (median duration was 35 months after PEG placement) as abdominal pain; difficulty feeding or flushing the tube; and inability to advance, withdraw, or rotate the tube.[25] Buried bumper arises from excessive traction on the tube causing it to burrow into the gastric wall. The incidence of this complication has decreased with newer tube designs that have a softer internal bumper.[13,19] Treatment involves removing the tube (which may require upper endoscopy), allowing the tract to close while an alternative method of feeding is established, and then placing a new PEG tube in a different location.[25]

Gastrocolocutaneous fistula. Although colonic perforation during PEG placement is a rare complication, there are at least 2 dozen case reports in the literature. This complication occurs more frequently in pediatric populations, at a rate of 2%-3.5%.[26,27] The transverse colon is apposed to the greater curvature of the stomach and if the stomach is not well insufflated during placement of the PEG tube, the colon may not be completely displaced out of the field, thus leading to puncture by the gastrostomy tube. The early presentation of this complication is that of peritonitis or large bowel obstruction, although many patients present months later with partial large bowel obstruction or diarrhea due to leakage of feedings into the colon.[13,19] Diagnosis is confirmed by barium enema examination, colonoscopy, or CT scan. Patients who do not manifest signs of obstruction or peritonitis can be managed by tube removal. In most cases, the fistula will close and a second gastrostomy can be performed.[13,19] If obstruction or peritonitis is present or the fistula does not close despite PEG removal; operative takedown of the fistula is necessary.[13,23,26] Anecdotal reports support the practice of using a fluid-filled syringe attached to the finder needle during PEG placement for reducing the risk of colonic perforation. Aspiration of air bubbles prior to visualizing the needle in the stomach suggests the presence of interposed bowel between the abdominal wall and stomach.

Wound infection and necrotizing fasciitis. These complications occur along a continuum, from simple peristomal infections to life-threatening necrotizing fasciitis. Peristomal wound infection is fairly common, occurring in 5%-25% of cases in cohort studies.[21,28,29] Infection rates are significantly higher among the placebo groups in recent randomized trials assessing the efficacy of prophylactic antibiotics for reducing the incidence of peristomal wound infection, ranging from 18% to 47%.[30,31] Both patient-related and technique-related factors have been linked to PEG site infections. Obesity, diabetes mellitus, malnutrition, and corticosteroid use represent patient-related factors. Small abdominal wall incisions and excessive traction on the PEG tube are technique-related factors.[32]

Early attempts at reducing wound infection using neomycin to sterilize the gastrointestinal tract or povidone-iodine to sterilize the oropharynx were ineffective.[22,33,34] Initial studies showed limited efficacy for prophylactic antibiotic therapy in reducing peristomal infections.[35,36] Multiple subsequent studies showed a significant decrease in the occurrence of wound infections with penicillin- or cephalosporin-based prophylactic regimens.[30,37–41] Several meta-analyses and a Cochrane database review have found that the use of prophylactic antibiotics leads to a reduction in the relative and absolute risk of wound infection by 64%-73% and 14%-17.5%, respectively; with a number needed to treat of 8–10.[42–44] Antibiotic prophylaxis has also been found to be a cost-effective strategy in this setting.[45]

The large majority of patients who undergo PEG are hospitalized and often severely ill and debilitated. These patients are at high risk for being colonized with resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA), for which conventional antibiotic prophylaxis is ineffective. A recent study has shown that among patients colonized with MRSA at the time of PEG placement, the rate of symptomatic MRSA peristomal wound infection is 57%.[46] Two studies have shown that MRSA screening and eradication are effective in reducing the rate of symptomatic MRSA peristomal infections.[47,48]

Necrotizing fasciitis is a very rare complication and the most aggressive type of PEG-related wound infection. Patients often present with progressive erythema and edema around the site, that then progresses to bullous lesions; septic shock can develop rapidly.[32] Despite the use of broad-spectrum antibiotics and multiple surgical procedures for debridement and reconstruction of the abdominal wall, mortality is greater than 50% in these cases.[49]

Inadvertent removal of PEG tube. Maturation of the PEG tract can occur as early as 1 week after tube placement.[22] Often maturation takes up to 3 weeks given that a majority of patients are severely ill, on corticosteroids, malnourished, and generally manifest poor wound healing.[50,51] Agitated or delirious patients who inadvertently pull out their PEG tube often can be successfully managed with nasogastric suction and PEG replacement.[52,53] Anecdotally, the PEG tract closes in 24–48 hours when the patient is treated with bowel rest with or without nasogastric suction. Subsequent placement of a PEG tube in a new site is often successful. Signs of peritonitis mandate treatment with antibiotics and a surgical consultation. If a PEG tube is inadvertently removed from a mature tract (> 3–4 weeks old), a Foley catheter can be inserted to maintain tract patency, but this should not be attempted if the PEG tract is immature.

Miscellaneous major complications. Other rare, but major complications of PEG tube placement include tumor seeding at the PEG stoma in patients with oropharyngeal squamous cell carcinoma,[54,55] aortogastric fistula,[56] intrahepatic PEG placement,[57] gastric volvulus,[58] subcutaneous emphysema,[59] and persistent pneumoperitoneum (Table 2).[60]

Table 2.

Rare Complications of Percutaneous Endoscopic Gastrostomy Tube Placement[3,13]

Tumor seeding

Aortogastric fistula

Intrahepatic PEG placement

Gastric volvulus

Subcutaneous emphysema

Persistent pneumoperitoneum

Minor Complications

Leakage is a common complaint and a major symptom that causes the patient, family, or caregiver to request a PEG tube change. PEG leakage is reported by 58%-78% of patients with long-term PEG tube placement and is described as very problematic by 12%-39% of these patients.[61] Factors that predispose to leakage include caustic agents (ascorbic acid) infused via the tube or used to clean the skin around the stoma (hydrogen peroxide) as well as local fungal or bacterial skin infections.[32] Leakage occurring due to tube failure may occur in as many as 25% of cases at 5 months, and generally requires tube exchange.[62] Leakage from the stoma usually occurs as the stoma dilates over time.[13] Removing the tube for a few days allows the stoma to narrow and permits an identically sized replacement tube to be re-inserted.[63]

Blockage of the tube is also a common problem seen in patients with long-term PEG placement. Indeed, 16%-31% of PEG tubes had at least 1 episode of significant blockage during 18 months of follow-up and 7% of tubes required removal due to irreversible blockage.[64] Silicone tubes had statistically significant higher rates of blockage that correlated with a higher rate of fungal colonization in the tubes.[64] Tube blockage can be minimized by frequent water flushes after feeding, only administering liquid medications or well-ground pills via the tube, and avoidance of materials likely to adhere to the inside of the tube. Blockages can often be removed at bedside either by flushing the tube with warm saline, infusing a phosphate-rich solution, or gently passing an endoscope cleaning brush through the tube.

Indications

Head and Neck Cancer

More than 40,000 new cases of head and neck cancer are reported in the United States each year, with more than 11,000 deaths occurring annually.[65] Malnutrition is common in this patient population and may be multifactorial in origin, being due to prior alcohol and/or tobacco use, dysphagia from the tumor, or treatment-related decreases in appetite and swallowing function.[65] Severe weight loss is seen in more than half of patients with head and neck cancer undergoing chemoradiation without concurrent nutritional support.[66,67] Weight loss and malnutrition cause interruptions in treatment, worsen local tumor control, and are predictors of decreased survival.[68,69]

Pre-treatment placement of a PEG tube has been shown to be effective in reducing weight loss, hospitalizations for dehydration, and treatment interruptions in these patients.[67,70] A substantial number of patients require long-term feeding; 1 study reported a median duration of enteral feeding of 7 months.[71] A significant number of these patients eventually regain the ability to consume oral intake, although approximately 10% remain dependant on enteral nutrition.[72,73] PEG has been shown to contribute to improved quality of life in those patients who remain dependent on enteral feedings.[74] Current practice includes pre-treatment PEG placement in the management of patients with head and neck cancer.[69] However, at present, no randomized trials have evaluated the use of enteral feedings vs oral intake or compared the various types of enteral access in this group of patients.

Stroke

Up to 16% of stroke patients have clinical or laboratory evidence of malnutrition at presentation, and because nutritional status declines rapidly after stroke, half of all surviving patients have evidence of malnutrition at the time of hospital discharge to a rehabilitation facility.[75,76] Indeed, 47% of these patients have dysphagia upon admission to a rehabilitation facility.[75,76] Dysphagia is a major risk factor for malnutrition in stroke patients.[77] Despite the high prevalence of malnutrition in these patients, nutritional supplementation in this population is controversial.

Small, single-center studies suggest that malnutrition is associated with poor outcome and an increased risk of death, poor functional outcome, infection, pressure sores, and increased hospital lengths of stay in stroke patients.[78] Another study showed that the level of serum albumin after stroke predicted survival, although the study did not control for stroke severity.[79] A third study showed that malnutrition at time of admission to a rehabilitation unit was associated with prolonged length of stay and worse functional outcome.[80]

Despite the association between malnutrition and poor outcome in stroke patients, there are very few trials examining nutritional supplementation in this population. One small randomized trial showed that oral supplementation after stroke improved nutritional parameters.[81] A retrospective study showed a decreased length of stay in patients who received early enteral nutrition after stroke.[82] Finally, a small single-center study demonstrated decreased case fatality rates in stroke patients who received PEG feeding rather than nasogastric tube feeding.[83]

The FOOD (Feed or Ordinary Diet) trials were 3 large multicenter prospective randomized trials designed to answer several questions about nutritional supplementation in hospitalized stroke patients. The first trial compared outcomes in stroke patients who were able to swallow who were randomized to either a regular diet or a regular diet and oral supplements.[84] At 6 months, there was no difference in survival or functional outcome between the 2 groups, although only 8% of patients were malnourished at baseline.[84] These findings suggest that routine nutritional supplementation is not necessary in adequately nourished stroke patients who can swallow. The second and third FOOD trials studied dysphagic stroke patients.[85] The second trial randomized 859 patients to either early enteral feeding via nasogastric tube or PEG within 7 days of stroke or to avoidance of early enteral feeding (ie, no feedings for more than 7 days). There were nonstatistically significant trends toward reductions in death or poor outcome in the early feeding group at 6 months.[85] The third trial randomized 321 stroke patients who could not tolerate oral intake, to either PEG or nasogastric feedings. There were nonstatistically significant trends toward increased rates of death or poor outcome in the PEG group compared with the nasogastric tube group at 6 months.[85]

Thus, early enteral feeding may be beneficial in dysphagic stroke patients, but the evidence is not definitive. Early feeding can be accomplished with a nasogastric tube and a change to a PEG placement only needs to be contemplated if long-term feeding is needed. However, a recent consensus statement by the European Society of Enteral and Parenteral Nutrition endorses PEG placement in dysphagic stroke patients without discussion of timing of feeding or type of enteral access.[86]

Dementia

PEG placement in patients with dementia continues to be a major area of controversy. Approximately 4 million individuals in the United States have dementia; this number will continue to rise as the population ages.[87] It is estimated that Alzheimer's disease affects approximately 50% of the population older than the age of 85.[88] Both malnutrition and dysphagia are very common in patients with dementia.[89,90] Dysphagia has been identified in up to half of institutionalized patients with dementia.[90] Not surprisingly, patients with dementia constitute a large group of patients undergoing PEG. In 1995, 40,000 patients with dementia received a PEG tube placement, which comprised 30% of all PEG placements that year.[91–93]

The decision by physicians and caregivers to place a PEG tube is often motivated by goals of providing nutrition and hydration, reducing the risk of aspiration pneumonia, improving pressure ulcers, improving nutritional parameters, and improving survival.[94] The evidence supporting the role of PEG in achieving these goals, however, is scarce. PEG is also often contemplated as a strategy to facilitate transfer of the patient from an acute care to a long-term care facility, to increase caregiver convenience, and to comply with long-term care facility policies that patients must maintain certain nutritional parameters.[94]

Given the difficult moral and ethical issues surrounding PEG placement in patients with dementia, there are no randomized trials comparing PEG placement with observation in this population. The majority of data on PEG outcomes in this population comes from retrospective case series or cohort studies.

Several studies have evaluated short-term (30 day) and long-term mortality in patients undergoing PEG. Some smaller studies exclusively comprise patients with dementia, whereas larger studies involve patients with multiple diagnoses, including dementia. Investigators reported a 22% 30-day mortality rate in a group of 150 patients undergoing PEG tube placement, 35% of whom had dementia.[95] Another study evaluated 350 hospitalized patients undergoing PEG and found a 30-day mortality of 28%, which increased to 54% in the subgroup of patients with dementia.[96] Other larger studies that involve more heterogeneous populations report 30-day mortality rates ranging from 9% to 31%.[94]

Long-term survival rates reported in larger studies of heterogeneous cohorts of PEG patients range from 39% to 66%.[94] A 1-year mortality of 63% was reported in a study involving >81,000 hospitalized Medicare beneficiaries who underwent PEG placement.[91] Long-term studies in dementia patients have shown either no survival benefit or even worse outcome with PEG placement. One study found a 6-month mortality of 44% in patients undergoing PEG, which was considerably higher than the 26% mortality observed in the control group.[97] Another study found no difference in overall mortality between nursing home residents with dementia undergoing PEG and comparable patients who were continued on oral nutrition.[98] Yet another study found that among nursing home residents with chewing and swallowing difficulty, mortality at 1-year was higher for those patients undergoing PEG placement.[99]

PEG placement has generally not been shown to improve nutritional parameters in patients with dementia.[95,97,100] Nor has PEG placement been shown to improve pressure ulcer healing or functional status in these patients.[94,95,100,101] There is also no evidence that PEG placement reduces the risk of infection and in fact some studies suggest higher rates of infections and bacteremia in patients with a PEG tube.[101]

Although difficult to evaluate, on the basis of the available evidence, PEG placement does not seem to improve the quality of life in patients with dementia. A questionnaire survey of caregivers found that 5 weeks after PEG placement, only 19% of caregivers thought the patients' quality of life had improved.[102] Tube placement has been associated with social isolation and denial of oral feeding.[94,101] PEG placement often leads to agitation and the frequent need to restrain the patient; 1 study found use of restraints in 71% of patients post PEG.[103]

Whether patients with dementia and decreased oral intake experience hunger and thirst has not been evaluated. However, studies involving other groups of patients with end-stage illness suggest this is not a major problem. A prospective study of mentally aware terminally ill patients, mainly with cancer, showed that 62% did not experience hunger or thirst.[104] Small amounts of fluid or ice chips were very effective in relieving hunger or thirst in patients with these symptoms.[104] Tube feeding has clearly been associated with adverse effects in patients with dementia, including increased abdominal discomfort, nausea, and vomiting.[105]

Current evidence suggests that PEG placement does not prolong survival, improve nutritional parameters, or prevent complications in patients with dementia. PEG placement does not improve and may in fact worsen the quality of life in this group of patients.

Ethical and Legal Issues

The decision to proceed with PEG placement is often based on the moral and ethical views of the patient, family, caregivers, or physician. Artificial nutrition and hydration, including PEG feeding, is considered a medical treatment. Generally it is thought to comprise a group of life-sustaining treatments, including mechanical ventilation and hemodialysis.[106] As with any medical treatment, the decision to place a PEG tube should be based on the patient's or surrogate's wishes and on whether it will provide any benefit to the patient in the context of an acceptable risk.[106] Despite the lack of clear evidence of medical benefit to PEG placement in many situations and the inherent risks, PEG placement continues to be a very common procedure.

Artificial nutrition and hydration are viewed by groups such as the American Medical Association and medical ethicists as medical treatments that can be withheld or withdrawn, but many physicians and patients/surrogates do not concur with this view.[94] Of 687 physicians and 759 nurses who were surveyed about a variety of end-of-life issues. 42% thought that food and water should be continued even if all other measures, including mechanical ventilation, were withdrawn.[107] Questionnaires were administered to either the patient or surrogate decision-makers for 100 patients over the age of 60 who received a PEG placement over a 16-month period.[108] In the majority of cases, the patient or surrogate perceived a great amount of stress and thus opted for PEG placement because they believed there was no alternative and they could not refuse.[108] Patients and/or surrogates also commonly rely on religious principles when making decisions regarding artificial nutrition and hydration. Many major religions tend to favor providing artificial nutrition and hydration in most scenarios.[94]

Legal precedents have been established in the United States regarding artificial nutrition and hydration. In 1976, the case of Karen Quinlan, a young woman in a persistent vegetative state after a drug overdose, established the precedent that surrogates have the right to withdraw extraordinary life-sustaining care. However artificial nutrition and hydration were not considered extraordinary measure and not explicitly considered in this case.[109] The Elizabeth Bouvia case in 1986 established the precedent that a patient with capacity has the right to refuse artificial nutrition and hydration.[109] The United States Supreme Court, in the case of Nancy Cruzan, ruled that surrogates could withdraw artificial nutrition and hydration.[109] However, the court indicated that the states could require surrogates to supply “clear and convincing evidence” that withdrawal of such support was in line with the patient's prior wishes. To date, New York and Missouri have enacted such laws that place this higher burden of evidence on the surrogate.[93]

Conclusion

PEG provides durable access for enteral nutrition, can generally be performed quickly and usually with only conscious sedation, and continues to be one of the most common procedures referred to gastroenterologists. It represents a dramatic improvement over surgical gastrostomy. However, a large number of PEG tubes continue to be placed in patients for whom the benefit is questionable or limited at best. These patients are exposed to a procedure with a procedure-related mortality of 0.5% and morbidity of 17% while they are unlikely to derive benefit. It is difficult to think of other medical procedures with as unfavorable risk-benefit ratios that are performed as commonly as PEG. The moral and ethical uncertainty facing patients, surrogates, and physicians when confronted with the choice to withhold artificial nutrition and hydration likely drives the decision to place PEG tubes in many patients who are unlikely to derive benefit. It remains to be seen if interventions such as improved physician education about the limitations of PEG tubes to improve outcome, the increased use of palliative care teams, the increased use of advanced directives, or overall education of physicians and the public about end-of-life issues, will lead to a decrease in the placement of PEG tubes in patients with end-stage illness.