Improving outcomes following percutaneous endoscopic gastrostomy (PEG) - a seven-day waiting policy is essential

Editor - We would like to congratulate Skitt et al for being the first group to demonstrate a reduction in mortality following gastrostomy tube insertion after a multi-faceted quality intervention approach was applied (Clin Med April 2011 pp 132–7). There have been three previous studies in this field which have shown improvements in patient selection for PEG insertion and/or a reduction in referral or insertion rate.^1–3

Our group have previously used a similar strategy, but with one additional intervention. As gastrostomy insertion is not an emergency procedure, a minimum one-week waiting list policy was initiated (Table 1). In 55% of the cases that we deferred or declined gastrostomy insertion, the patient succumbed within seven days (and for the rest within 30 days).¹ We wonder if the authors had seven day mortality data before and after their strategy for both the patients in whom a PEG was inserted or declined - and if there was any difference in seven day mortality between these two groups?

Table 1.

Percutaneous endoscopic gastrostomy referral strategy²

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report highlighted that of those individuals that died within 30 days of PEG insertion, 43% died within the first week.⁴ A seven-day waiting list policy has two functions. It serves to provide an opportunity to reflect on the implications of PEG tube insertion prior to undertaking the procedure (for all those involved in the decision making process). Secondly, in some cases patients may succumb during this ‘cooling off’ period.² Based on these observations we would encourage others to implement Skitt's excellent clinical practices but with the further addition of a one-week waiting list policy.