This presentation focuses on a procedure of enteral nutrition: Percutaneous Endoscopic Gastrostomy procedure, Common complications & Risk factors predicting complications

1. Journal Presentation
Dr. Aditi Sarker
Phase-B resident,
Dept. of Gastroenterology,
BSMMU

3. Background
• PEG is the most common method of enteral nutrition in patients who
are expected to require enteral feeding for longer than 2–3 weeks
• PEG is associated with superior outcomes with respect to
complication and mortality rates

4. • Most common PEG tubes for adult patients range in size from 16 to
20 Fr and are made of silicone.
• Requires replacement within 3 to 6 months.
• Replacement PEG tubes are broadly divided into 2 categories:
Replacement gastrostomy tubes
Low-profile devices

5. PEG tube
PEG was developed by Ponsky and Gauderer in the early 1980s.

6. Percutaneous endoscopic gastrostomy (PEG) using the pull (a–c) or the introducer (d–f) technique.
(a) A plastic sheath is inserted through the abdominal and gastric walls.
(b) Snare grasping guidewire through the endoscopic channel.
(c) PEG tube is placed by the pull technique using an internal bumper.
(d) Double-lumen gastropexy needle in the stomach.
(e) Penetration of the gastric wall using trocar and a peel-away sheath.
(f) Fixation by inflation of the balloon with saline

7. Common medical indications for PEG placement
• Cancer especially head , neck, oesophageal cancer, cerebral tumour
• Stroke
• Parkinson's disease
• MND
• Multiple sclerosis
• Dementia

8. Relative contraindications for PEG
the presence of gastric varices
major gastric resection
ascites
coagulopathy

9. The 30-day mortality after PEG has been reported to be 3.3–23.9%
The study aimed to identify potential risk factors associated with
• acute complications,
• chronic complications and
• 30-day mortality after PEG

10. Methods
• Total of 411 patients who underwent PEG at the Asan Medical Center
in Seoul, Korea
• Study period : January 2005 to December 2015
• Medical records of all patients were retrospectively reviewed for
investigating clinical characteristics of patients.

12. • Three hundred seventy seven (94.0%) patients received prophylactic
antibiotic 30 min before the procedure.
• Most of the prophylactic antibiotic regimen was 2 g of cefazolin.
• Before the procedure, all patients were sedated with intravenous
midazolam (0.05 mg/kg) and pethidine (25 or 50 mg).

13. Definitions
Post-procedural complications were classified into two groups :
1. Acute complications were defined as those developing ≤7 days
after PEG
2. Chronic complications included those that occurred > 7 days after
the procedure

14. •Bleeding
•Pneumoperitoneum
•Aspiration pneumonia
•Ileus
•Wound infection
•Mallory-Weiss tear
Acute
complications

15. Bleeding was
defined as an
• Event requiring intervention (such as
hemoclipping, embolization, or
epinephrine injection) to control bleeding
• Follow-up endoscopic examination to
check lesion healing
Bleeding
complications
included
• Mucosal tear bleeding
• Bleeding requiring compression during
and after the procedure

16. Aspiration
pneumonia
• Presence of a newly developed
symptom (cough, purulent sputum, and
fever)
• With indicative CXR change
Ileus
• Symptomatic and non-symptomatic
cases with indicative X-ray or computed
tomography (CT) image of ileus
• Decreased bowel sounds

17. •Tube leakage
•Tube obstruction
•Spontaneous tube removal
•Wound infection
•Buried bumper syndrome
•Recurrent aspiration pneumonia
Chronic
complications

18. Post-PEG management
On the day of the PEG
procedure
• All patients were kept
NPO with natural tube
drainage
On post-PEG day
• 1100 mL of clear water
was flushed via the
gastrostomy tube in
patients whose
abdomen was soft and
in those who showed
no abdominal
discomfort

19. • To check the position of the tube
• To detect any complications, such as
pneumoperitoneum, aspiration
pneumonia, and ileus
All patients underwent
routine abdominal and
chest X-ray on the same
day as the procedure or the
day after the procedure
If any complications were detected,
further imaging study or follow-up X-ray was performed

20. Able to receive tube feeding with 100–200 mL of fluid
Had no evidence of leakage at the site of PEG
Without abdominal pain or vomiting
Patients who tolerated the water flush

21. Baseline characteristics
Total (n = 401) Pull type (n = 139) Introducer type (n = 262)
Clinical characteristics
Age (median, IQR) 68 (57–77) 67 (55–76) 70 (57–77)
Gender, male (%) 262 (65.3) 82 (59) 180 (68.7)
BMI (median, IQR) 19.5 (17.2–21.7) 20.1 (17.3–23.0) 19.3 (17.1–21.2)
Indications for PEG, n (%)
Neurologic disease 240 (59.8) 85 (61.2) 155 (59.2)
Malignancy 70 (17.4) 29 (20.8) 41 (15.7)
Other 91 (22.7) 25 (18.0) 66 (25.2)
Comorbidities (%) 212 (52.9) 77 (55.4) 135 (51.5)
Antibiotic prophylaxis, n (%) 377 (94.0) 124 (89.2) 253 (96.6)

22. Total (n = 401) Pull type (n = 139) Introducer type (n = 262)
Concurrent medication, n (%)
Aspirin 63 (15.7) 26 (18.7) 37 (14.1)
Clopidogrel 26 (6.5) 10 (7.2) 16 (6.1)
Warfarin 12 (3.0) 4 (2.9) 8 (3.1)
Others 23 (5.7) 8 (5.8) 15 (5.7)
Laboratory values
WBC/μL 8243.0 ± 3580.2 8083.4 ± 3809.8 8324.6 ± 3461.6
Hemoglobin, g/dL 11.2 ± 2.0 11.2 ± 2.0 11.2 ± 2.0
Platelets, × 103/μL 266.1 ± 119.1 276.5 ± 137.7 260.8 ± 108.3
Albumin, g/dL 3.0 ± 0.7 3.0 ± 0.6 3.0 ± 0.7
Prothrombin time, INR 1.06 ± 0.27 1.03 ± 0.27 1.07 ± 0.27
CRP, mg/dL 3.0 ± 3.9 3.4 ± 4.4 2.9 ± 3.7

23. Clinical outcomes

24. Acute and chronic complications of PEG according
to the insertion type
Variable Pull type (n = 139) Introducer type (n = 262) p value
Follow-up, days 524 (100–1178) 269 (64–686) 0.001
Acute complications, n (%)
Bleeding 5 (3.6) 18 (6.9) 0.180
Pneumoperitoneum 9 (6.5) 29 (11.1) 0.135
Aspiration pneumonia 1 (0.7) 2 (0.8) 1.000
Ileus 4 (2.9) 22 (8.4) 0.033
Wound infection 1 (0.7) 1 (0.4) 1.000
Mallory-Weiss tear 0 4 (1.5) 0.303

25. Chronic complications, n (%) Pull type (n = 139) Introducer type (n = 262) p value
Wound infection 6 (4.3) 12 (4.6) 0.903
Leakage 7 (5.0) 22 (8.4) 0.216
Tube obstruction 5 (3.6) 37 (14.1) 0.001
Spontaneous removal 2 (1.4) 8 (3.1) 0.505
Buried bumper syndrome 1 (0.7) 1 (0.4) 1.000
Aspiration pneumonia 2 (1.4) 2 (0.8) 0.612
30-day mortality, n (%) 8 (5.8) 12 (4.6) 0.607

26. Risk factors for
complications

27. Univariate and multivariate logistic regression analysis of
predictors of acute complications associated with PEG
Predictor Univariate analysis Multivariate analysis
OR p value OR (95% CI) p value
Indication for PEG
Malignancy 2.003 0.017 2.205 (1.197-4.061) 0.011
Procedure time 1.031 0.037
No significant association: Clinical characteristics (Age, BMI, DM, HTN, CKD), Medications (Aspirin,
Clopidogrel, Warfarin), Indications (eg. Stroke Or other neurologic disease), Lab. Values (Anaemia,
WBC, Platelet, Prothrombin time, Albumin, CRP)

28. Univariate and multivariate logistic regression analysis of
predictors of chronic complications associated with PEG
Predictor Univariate analysis Multivariate analysis
OR(95% CI) p value OR (95% CI) p value
Clinical characteristic
Age ≥ 70 years 2.366 0.001 1.974 (1.186–3.285) 0.009
Diabetes mellitus 1.851 0.022 1.731 (1.007–2.977) 0.047
Hypertension 1.857 0.011
Aspirin 1.985 0.022
Indication for PEG
Malignancy 0.337 0.009 0.473 (0.199–1.082) 0.075
Diameter of PEG tube
15-Fr 0.031
20-Fr 0.143 (0.034–0.607) 0.008

29. Subgroup analysis between malignancy group
and neurologic disease group
Variable Malignancy Neurologic disease p value
Acute complication, n (%)
Bleeding 3 (4.3) 12 (5.0) 1.000
Pneumoperitoneum 12 (17.1) 18 (7.5) 0.016
Aspiration pneumonia 2 (2.9) 1 (0.4) 0.129
Ileus 5 (7.1) 15 (6.3) 0.784
Wound infection 0 1 (0.4) 1.000
Mallory-Weiss tear 0 3 (1.3) 1.000
Pull-type PEG, n (%) 29 (41.4) 85 (35.4) 0.359
Procedure time, minutes 14.5 (10.3–18.0) 16.00 (11.0–20.0) 0.128

30. Prognosis
• The 30-day mortality rate was 5.0%
• 20 patients died within 30 days of PEG insertion

31. Univariate and multivariate analysis for determining
factors associated with 30-day mortality after PEG
Predictor Univariate analysis Multivariate analysis
OR p value OR (95% CI) p value
Clinical characteristic
Chronic kidney disease 5.353 0.006 3.990 (0.993–17.072) 0.062
Indication for PEG
Stroke 0.094 0.022 0.125 (0.016–0.994) 0.049
Laboratory values
Platelet count < 100,000/μL 21.778 0.000 14.294 (3.358–60.851) 0.000
Hemoglobin < 11 g/dL 3.950 0.009
CRP ≥ 5 mg/dL 2.994 0.032 3.101 (1.021–9.414) 0.046

32. Discussion
• American Gastroenterological Association recommend that PEG is
performed only in patients who are expected to survive for more than
30 days after the procedure.
• Complication rate with PEG is reported to be 13.2–42.9%
• Older age and DM were risk factors associated with chronic
complications of PEG.

33. • Infection-related chronic complications (including wound infection
and recurrent pneumonia) comprised 21% of all chronic
complications after PEG.
• Wound infection in the chronic period following PEG occurred in 18
(4.5%) patients.

34. • As PEG is an invasive procedure with penetration from the skin to the
stomach, wound healing is crucial for the prevention of infection and
tube leakage.
• In addition, tube leakage was the second most common chronic
complication, developing in 29 (7.2%) patients.

35. Several risk factors
have been reported
to be associated with
early mortality after
PEG
•Elevated CRP level
•Low albumin level
•Older age
•Low BMI
•DM
30-day mortality was
associated with
•High CRP levels
•Low platelet count
•Stroke

36. Limitations
Because of the retrospective design of the study, some data were
missing from the medical records
The median follow-up period was relatively shorter than total
research periods
The present study was conducted at a tertiary referral hospital where
the disease severity is higher than that seen in general hospitals

37. Conclusion
PEG is a relatively safe and feasible procedure
Patients in neurologic diseases group including dementia, Parkinson’s
disease, neuromuscular disease and hypoxic brain damage showed
significantly lower early mortality rate than other diseases group
(including stroke and malignancy)
Platelet count < 100,000/μL or CRP ≥ 5 mg/dL were risk factors
associated with early mortality after PEG

38. Acute complications in patients with underlying malignancy &
chronic complications in patients aged ≥70 and those with DM should
be considered during and after PEG

40. Kaplan–Meier Curve of the proportion surviving within
90 days depending on the indication for the PEG
procedure

41. Results
The increased risk of death among women and patients with
malignancy indicate that these patients could benefit from earlier
referral for PEG
Older age, DM, heart failure, CRP and BMI impact the risk of adverse
outcomes

43. Results
• Gastrostomy site infection is the most common complication in the short
term
• Complications are higher in immunocompromised patients
• PEG insertion for a non-neurological indication, as opposed to a
neurological one, was associated with a more than 3X increase in the
likelihood of a poor postoperative outcome
• Low albumin & High CRP level were associated with more complications

44. Thank You