Original Article www.jpgmonline.com

Percutaneous endoscopic gastrostomy: 30-day mortality

trends and risk factors
Janes SEJ, Price CSG, Khan S

Department of surgery, ABSTRACT

New Cross Hospital,
Background and Aims: 30-day Percutaneous endoscopic gastrostomy (PEG) mortality of 8% (1992). Recent
Wolverhampton,
England WV1 0QP concerns suggest that mortality may have increased, prompting a comparison of current practice with that
reported earlier.
Correspondence: Materials and Methods: Data regarding PEG insertion with relation to case mix, complications, 30-day mortality
Simon Janes, and associated risk factors, in 2002, in a British University Hospital was compared with that in 1992. Logistic
E-mail:
janessimon@hotmail.com regression analysis was used to determine factors independently predictive of 30-day mortality.
Results: In 2002, 112 patients (70% males, mean age 67.5 years; 1992: 63.6 years) underwent PEG. The 30-
day mortality increased significantly from 8% (1992) to 22% (2002), P= 0.03. During this time, PEG insertion
rate increased ten-fold, however, procedure-related mortality decreased from 2% to nil. In terms of percentage,
the indications for PEG in 1992 and 2002 respectively were: cerebrovascular disease (33/25), head and neck
tumours (16/24), motor neuron disease (27/11, P= 0.01). The proportion of PEGs for non-evidence-based
indications increased from 16% in 1992 to 31% in 2002, P= 0.048. The number of PEGs placed radiologically
increased (0/17, P= 0.02). Radiological patients received less antibiotic prophylaxis (P< 0.001) and had
more PEG site infections than standard placement, P= 0.04. Multivariate analysis identified nil by mouth 7
days or 11.4 (CI 3.2-41.7), albumin 30 g/L or 12 (2.2-66.7) and >1 cardiac factor or 5.1 (1.02-25.6) as
independent predictors of 30-day mortality.
Conclusions: The ten-fold rise in the PEG insertion rate has been accompanied by a three-fold rise in 30-day
Received : 05-10-04 mortality. This may reflect a lowered threshold of PEG insertion. The risk factors identified may help decision-
Review completed : 18-11-04
making in cases where the risk-benefit relationship is not clear-cut.
Accepted : 21-12-04
PubMed ID : 15793334
J Postgrad Med 2005;51:23-9 KEY WORDS: Percutaneous endoscopic gastrostomy, mortality, risk factors

ince its initial description over two decades ago, per- We also determined factors predictive of 30-day mortality, in
S cutaneous endoscopic gastrostomy (PEG) has become
the most widely employed method for long-term enteral nu-
order to help identify patients at high-risk of mortality.

trition. It is generally better-tolerated and causes less reflux or
aspiration than nasogastric tube feeding.[1] The benefit of PEG,
in terms of morbidity and mortality, is well-established in pa-
tients with cerebrovascular disease,[1] oropharyngeal malig-
nancy[2] and motor neuron disease (MND).[3] However, the de-
mands for PEG insertion have increased to include illnesses
where the long-term benefit of PEG feeding is less certain.[4]
Consequently, in Western countries the number of patients
on home enteral nutrition has doubled in the past five years.[5]
The growing number of gastrostomies may reflect a change in
patient selection or alternations in the clinicians attitudes to
enteral feeding, as the prevalence of disease conditions war-
ranting PEG has not changed two-fold during the same pe-
riod. Furthermore, recent evidence indicates 30-day mortality
has, in fact, increased,[6,7] paralleling the change in case mix.[7]
The aim of the study was to compare the case mix and mortal-
ity with a previously published audit from the our institution.[8]
Materials and Methods
The data of subjects who underwent PEG in a teaching hospital in
the UK during a 12-month period beginning April 2001 was analysed
after its retrieval using a hospital coding database and the Interna-
tional Classification of diseases 10th Edition (ICD-10) codes G448,
G341 and G342. The follow-up data for a period of six months was
also available. Referrals for gastrostomy were made from geriatricians,
neurologists, Ear, Nose and Throat (ENT) and maxillo-facial surgeons,
general physicians, the adult Intensive Care Unit (ICU), and
neurosurgeons.
An endoscopist or radiologist confirmed suitability for gastrostomy
and informed consent was obtained. Patients without the capacity to
give informed consent had a declaration signed by the responsible
consultant stating that the procedure was in the patients best inter-
est, in accordance with the United Kingdom Law.
The team responsible for the patients care rather than the
endoscopist decided the use of antibiotic prophylaxis. Routine in-
vestigations before the procedure included: full blood count, clot-

J Postgrad Med March 2005 Vol 51 Issue 1 23


Janes et al: Percutaneous endoscopic gastrostomy

ting time, urea, electrolytes, and liver function tests. Xylocaine Six patients (5%) died within the first week. Thirty-day mor-
throat spray was used for anaesthesia and intravenous midazolam tality was 22% (25 patients, 20 endoscopic PEG, five radio-
administered for sedation. Nine or 15 gauge FrekaTM gastrostomy logical), 90-day mortality 30% and 180-day mortality 39%. The
tubes were inserted via the pull technique, or under fluroscopic
mean time from admission until PEG was similar for those
guidance by a radiologist. Patients who underwent fluoroscopic
guided PEG insertion by a radiologist formed the 'Radiological
who died within 30 days (17.6) and those who lived for over 30
Group'. Patients received intravenous fluids for 24 hours, and un- days (20.6), P>0.5.
less there were complications, water was passed down the PEG six
hours after insertion. Enteral feeding generally began the following Post-procedure complications occurred in 37 (33%) patients.
day. Patients undergoing laparoscopic, open or CT-guided gastros- PEG site infections occurred in 13 (12%) subjects with three
tomy were excluded from the analysis. patients having methicillin-resistant Staphylococcus aureus
infections. Twenty-two patients developed chest infections
A standardised proforma was used to record patient age, gender, Glas- (20%), 11 (10%) of which followed aspiration. Five patients
gow Coma Score (GCS) on admission, number of medications on
(4%) developed diarrhoea, two (2%) of which were due to
admission, main presenting complaint, past medical history includ-
ing detailed cardiovascular history (myocardial infarction, ischaemic Clostridium difficile.
heart disease, congestive cardiac failure, atrial fibrillation, hyperten-
sion), Oxford Community Stroke Project Classification (for stroke Univariate analysis showed that patients presenting with a GCS
patients), referring speciality, consecutive days nil by mouth from <10, receiving at least 5 medications on admission, age over
admission until peg placement, total days nasogastric feeding prior 75 years or more than one cardiac risk factor had an increased
to PEG, time from admission until PEG, history of pneumonia or risk of death within 30 days (Table 3). Patients with the fol-
aspiration pre-peg, catheterisation or Urinary Tract Infection (UTI) lowing risk factors identified between admission and PEG also
pre-PEG, type of antibiotic prophylaxis (if used), routine blood tests,
had an increased risk of 30-day mortality: history of pneumo-
date of procedure, and pre-procedure pulse, blood pressure and oxy-
gen saturation. Complications and post-procedure infections were
nia or aspiration, serum albumin concentration 30 g/L, urea
noted if they were documented in the medical or nursing notes. 9 mmol/L, withholding of oral feeds for at least 7 days and
haemoglobin concentration lower than 10 g/dL (Table 3). Of
The following conditions were considered evidence-based PEG re- five patients with pneumonia as main diagnosis on admission,
ferrals: cerebrovascular disease, ENT tumours, MND, and multiple three (60%) died within 30 days, indicating a clinically impor-
sclerosis (MS).[1-4] Risk factors for 30-day mortality were analysed sta- tant but not statistically significant trend, [OR 5.8 (0.6-71.8)].
tistically using odds ratios (OR). Categorical data were compared Use of antibiotic prophylaxis or male gender did not affect
using the chi-square test or Fishers exact test, and the students t mortality (Table 3).
test was used to compare the means of normally distributed continu-
ous variables. OR are expressed with 95% confidence intervals (CI),
When these factors were entered into a multivariate model
P< 0.05 was considered significant throughout. Logistic regression
analysis was used to determine factors independently predictive of the independent predictors of 30-day mortality were: withhold-
30-day mortality. Kaplan-Meier survival curves were plotted to deter-
Table 1: Main presenting complaint in patients referred for
mine factors affecting survival and the log rank test was applied to
compare differences in survival between groups. Factors significantly PEG
affecting survival were entered into a stepwise Cox regression model Diagnosis Number %
to determine independent predictors of survival. Data was analysed
Cerebrovascular disease:
using the Statistical Package for the Social Sciences version 10.
Acute Ischaemic stroke 28 25
Intracerebral bleed 2 2
Results Subarachnoid haemorrhage 2 2
Multi-infarct disease 1 1
The study population in 2002 consisted of 112 patients with Head and Neck tumours 27 24
Chronic neurological conditions:
mean age of 67.5 years (1992: 63.6 years). Seventy per cent of
Motor neuron disease 12 11
the subjects were male. A significant cardiovascular history was Multiple sclerosis 5 4
present in 44 (39%) patients (range 1-4 factors) (Table 1). Sixty- Parkinsons disease 4 4
three per cent received nasogastric feeding before PEG, and Alzheimers disease 1 1
26 (23%) were nil by mouth for 7 consecutive days before Miscellaneous:
gastrostomy. Of these patients, the majority had suffered ei- Pneumonia 5 4
Others 25 22
ther a substantial CVA (with GCS <8) or were in the ICU for
treatment of sepsis. The mean number of medications received
on admission was 3.9 per patient (SD 2.7) with as many as 47 Table 2: PEG referral by speciality
(42%) patients taking 5 or more drugs. Over 60% of the pa- Speciality Number %
tients were referred from the geriatric or neurological services Healthcare of the Elderly 42 38
(Table 2). Neurology 27 24
Ear, Nose and Throat 15 13
Antibiotic prophylaxis was given to 58 (52%) patients. A vast General Medicine 11 10
Maxillary and facial 9 8
majority received cefuroxime (48 patients, 42%). However there
Intensive Care Unit 6 5
was no evidence that this reduced the infection rates (OR 0.6, Neurosurgery 2 2
95% CI 0.3 1.4).

24 J Postgrad Med March 2005 Vol 51 Issue 1

 Janes et al: Percutaneous endoscopic gastrostomy

Table 3: Univariate analysis of factors predicting 30-day mortality in 112 patients undergoing PEG
% Dead Within 30 Days Odds Ratio & 95% confidence interval
Age > 75 years 57 6.4 (1.7-24.9)
75 years 17
Gender Male 25 1.8 (0.6-5.9)
Female 16
Nil by mouth pre-PEG 7 days 69 25 (7-91.8)
< 7 days 8
Main Diagnosis Cerebrovascular disease 26 1.5 (0.5-4.1)
ENT tumours 15 0.5 (0.1-1.8)
Chronic neurological conditions 9 0.3 (0.03-1.4)
Pneumonia 60 5.3 (0.6-71.8)
Cardiovascular history > 1 factor 55 6.8 (2.1-22.1)
1 factor 15
Glasgow coma scale < 10 62 7.7 (1.9-33)
10 17
Medications on admission 5 40 6.7 (2.2-22.3)
<5 9
History of pneumonia or aspiration pre-PEG Present 44 6.7 (2.3-20.3)
Absent 11
Albumin 30 g/L 37 7.4 (2.2-31.8)
> 30 g/L 7
Urea 9 mmol/L 48 5.7 (1.9-17.2)
< 9 mmol/L 14
Anaemia Haemoglobin < 10 g/dL 47 4.3 (1.3-13.9)
Haemoglobin 10 g/ dL 17
Radiographic PEG Yes 26 1.3 (0.3-4.4)
No 22
History of diabetes Present 23 1.2 (0.4-3.3)
Absent 21
Urinary tract infection pre-PEG Present 20 0.9 (0.1-4.9)
Absent 29
Catheterised pre-PEG Yes 26 1.3 (0.5-3.6)
No 21
Antibiotic prophylaxis No 16 0.5 (0.2-1.3)
Yes 30

ing of oral feeding for at least 7 days [OR 11.4 (3.2-41.7)],
serum albumin 30 g/L OR 12 (2.2-66.7) and >1 cardiac fac-
tor, OR 5.1 (1.02-25.6) (Table 4).
The following factors independently affected survival during
follow-up (Cox regression analysis): withholding feeds for at
least 7 days, [hazard ratio (HR) 2.3 (1.4-3.4, P< 0.000)], se-
rum albumin concentration 30 g/L [HR 2.8 (1.4-5.6, P=
0.004)] and history of pneumonia [HR 2.1 (1.13.8, P= 0.017)].
Kaplan-Meier curves for these factors are represented in Fig-
ures 1-3 respectively.
59% respectively, P<0.001, 2 11.9, df 1) and had more PEG
site infections (five vs. eight patients, P= 0.04, Fishers exact
test). Despite this, rates of post-procedure complications were
almost identical (32% radiological group, 33% standard group).
Home discharge was achieved more often in the radiological
group (68% vs. 38%, P=0.01, 2 6.1, df 1).
Forty-nine patients (44%) achieved home discharge. Eighteen
patients (16%) were discharged to nursing homes and 23 (21%)
died in the hospital during the index admission. Thirteen pa-
tients (12%) had their PEG removed after 6 months.

The mean age was similar in the radiological group (67.3 years, Comparison between 1988-92 and the current project
SD 13.6) and the standard group (67.5 years, SD 14.4). Al- The 30-day mortality increased from 8% in 1992 to 22% in
though proportionately more patients died after radiological 2002, P= 0.03, 2 4.6, df 1. Table 5 summarises the indications
PEG placement (26%), the trend was not significant, OR 1.3 for PEG in 1992 and 2002. The number of PEGs for non-evi-
(0.3-4.4), P>0.5. The radiological group had more patients with dence-based conditions rose from 16% in 1992 to 31% in 2002,
head and neck tumours (47%), or MND (32%) than the stand-
ard group (19% and 6%), P= 0.02 and P= 0.003 respectively Table 4: Independent predictors of 30-day mortality on
(Fishers exact test). Only one (5%) patient in the radiological multivariate analysis
group had cerebrovascular disease as a main diagnosis, com-
Variable P value OR 95% CI
pared to 33 (35%) in the standard placement group, P= 0.009,
2 6.8, df 1. Nil by mouth 7 days <0.001 11.4 41.7-3.2
Albumin 30 g/L 0.004 12 2.2-66.7
>1 cardiovascular risk factor 0.047 5.1 1.02-25.6
Radiological PEG patients received less prior antibiotic prophy-
laxis when compared to standard placement patients (16% and OR= odds ratio, CI= confidence interval

J Postgrad Med March 2005 Vol 51 Issue 1 25


Janes et al: Percutaneous endoscopic gastrostomy

P= 0.048, 2 3.9, df 1 (Figure 4, Table 5). A similar proportion

had cerebrovascular disease (29% 1992, 33% current study).
However, less patients had MND in the current study (11% vs.
27%, P= 0.01, 2 6.0, df 1). Home discharge rates were lower in
the present study than in 1988-92 (43% vs. 69%) P= 0.002, 2
9.6 df 1. Patients in the present study tended to be older, mean
age 67.5 vs. 63.6 years, P=0.08. There were no radiological
PEGs in the original study compared to 19 in the current study.

Discussion

During the last ten years, PEG placement has increased ten-
fold whereas the procedure-related mortality has decreased
from 2% to nil Thus although technical skill improved, the
threshold for PEG insertion and the ability to select patients
who would survive 30 days has decreased significantly. Patients
in the recent cohort had more coexisting medical problems
Figure 1: Kaplan-Meier survival curve comparing patients nil by mouth <7 before PEG placement, which had a substantial impact on
days pre-PEG (dashed line), and those nil by mouth 7 days (solid line), mortality.
P<0.001
Ten years ago, more than 80% of PEGs were placed in patients
with CVD, MND, ENT tumours or MS. This proportion fell
to 69% in the current series, due to an increase in PEG place-
ment for acute medical conditions where the long-term ben-
efits of PEG are unproven. Patients admitted for pneumonia
illustrate this point: of the five patients with pneumonia as
primary diagnosis, three died within 30 days. No patient in the
Table 5: Characteristics of patients undergoing PEG in 1992
and 2002
Variable 1992 2002 Probability, P
Total number of patients 49 112 NR
Mean age 63.6 67.5 0.08
Male gender (%) 32 (65) 78 (70) >0.5
Cerebrovascular disease (%) 16 (33) 33 (29) >0.5
Motor neuron disease (%) 13 (27) 12 (11) 0.01
Ear nose and throat disorders (%) 8 (16) 27 (24) 0.27
Multiple sclerosis (%) 4 (8) 5 (4) 0.35
Figure 2: Kaplan-Meier survival curves for albumin concentration in serum Other (non-evidence-based) 8 (16) 35 (31) 0.048
30 g/L (solid line) and serum albumin level >30 g/L (dashed line) conditions (%)
P=0.004 Procedure-related mortality (%) 1 (2) 0 (0) 0.30
30-day mortality, % 8 22 0.03

40
35 P = 0.048
30
% of patients

25 P = 0.03
20
15
10
5
0
30-day Non- 30-day Non-
mortality evidence mortality evidence
1992 based 2002 based
PEGs 1992 PEGs 2002
Figure 3: Kaplan-Meier survival curve for patients with pneumonia or Figure 4: Comparison of 30-day mortality and percentage of PEGs inserted
aspiration pre-PEG (solid line) and those without (dashed line), P=0.017 for non-evidence-based procedures, 1992 and 2002

26 J Postgrad Med March 2005 Vol 51 Issue 1


previous study had pneumonia as the main reason for admis-
sion. Furthermore, of the six patients referred from the ICU in
the current series, only two survived 30 days whereas 10 years
previously there were no ICU patients. Comparison of the two
studies is partly limited because the original study was pro-
spective and the current study was retrospective. However, this
should not have affected mortality rates, as our follow-up was
complete except for one set of case notes.
To date no study has demonstrated a survival benefit in pa-
tients with pneumonia undergoing PEG. In the largest study
to date Grant et al[4] retrospectively reviewed 81,000 Ameri-
can medicare beneficiaries who underwent PEG. The most
common primary diagnoses were CVD and neoplasia, with a
30-day mortality of 25%. They found that 30-day mortality was
highest among those with non-aspiration pneumonia. Others
have found that aspiration pneumonia was a risk factor for 30-
day mortality[9] and it is suggested that patients with pneumo-
nia gain no improvement in nutritional or functional status
when treated with PEG.[10] Our data support these conclusions
and shows an adverse effect on overall survival in addition to
30-day mortality.
The significant reduction in the home discharge rate in the
current series is further evidence of a change in patient selec-
tion, and has considerable cost implications for healthcare pro-
viders. Ten years ago PEG was perceived as cost-effective as it
allowed early domiciliary discharge for dysphagic patients and
had low post-procedure complication rates.[8]
The issue of when to start enteral feeding remains controver-
sial. Abuksis et al[11] recently reported a 40% reduction in PEG
mortality by delaying PEG insertion until 30 days after dis-
charge, when compared with standard insertion. In a review of
161 consecutive elderly PEG patients, Raha et al[12] found high
mortality rates using PEG for elderly malnourished patients,
suggesting that earlier nutritional intervention may help pro-
long life. A study of 55 patients with dementia and inadequate
oral intake showed that PEG was an ineffective treatment for
hypoalbuminaemic patients, suggesting that enteral feeding
should commence before hypoalbuminaemia develops.[13] In
that study serum albumin <28 g/L was an independent pre-
dictor of six-month mortality. Our data support these findings
as serum albumin 30 g/L and nil by mouth for 7 days were
independent predictors of both 30-day mortality and survival.
Withholding oral feeding for at least seven days has not previ-
ously been described as a marker for 30-day mortality and prob-
ably reflects the severity of underlying disease. However, poor
nutritional status may not be a true independent predictor
because the underlying disease process may be associated with
both malnutrition and poor outcome. Although malnourished
patients fair worse, the limitation of retrospective analysis is
that we are unable to conclude whether PEG prolongs sur-
vival, or is an exacerbating factor in an inevitable downhill
course. Wolfsen et al[14] followed patients with very short life
expectancy, showing that PEG reduced hospital stay but did
not contribute to life expectancy. There is a consensus that
mortality is high when acutely ill patients undergo PEG,[4,5,10,14]
J Postgrad Med March 2005 Vol 51 Issue 1
Janes et al: Percutaneous endoscopic gastrostomy

leading some to suggest that PEG should be delayed in this
group until the acute illness has resolved.[6,10,15] Others advo-
cate a trial of nasogastric feeding until recovery from the acute
illness when PEG could be reconsidered.[7,11]
The dilemma we face is in trying to differentiate patients who
benefit from early PEG feeding from those who would not
survive for 30 days. For patients clearly in the later category,
PEG is an expensive and invasive procedure that should be
avoided. For those in the former, consideration of risk factors
may help predict those with a poor prognosis. However, whilst
poor prognostic indicators may be valid for a large patient co-
hort, they may not apply to separate cases and each patient
should be treated individually. The balance of benefit and harm
related to PEG is difficult to determine in patients with mul-
tiple co-morbidities. The risks associated with PEG should be
made clear to the patient and their family, and any decision
reached should be ethically justifiable.
Improving the quality of life is one long-term goal of PEG feed-
ing although there is little data on the quality of life after PEG.
Two recent studies assessing the quality of life after PEG were
limited by response rates of 7-14%,[16,17] due to many patients
having communication difficulties or due to loss to follow-up.
Of those who responded 83% had no improvement in func-
tional disability (Modified Rankin Scale) and only 45% thought
PEG had a positive effect on their quality of life.[17] Assessing
the quality of life is beyond the scope of this study, however, it
was interesting to note that one in three patients suffered post-
PEG complications that would have adversely affected the
quality of life.
Various risk factors for 30-day mortality have been identified,
including age over 75 years,[4,10] urinary tract infection,[10] de-
mentia,[18] diabetes mellitus[19] and severe functional impair-
ment.[7] Grant et al found that a secondary diagnosis of con-
gestive cardiac failure in PEG patients adversely affected 30-
day mortality.[4] Our results show that multiple cardiac pathol-
ogy also strongly predicts both 30-day mortality and overall
survival. These patients need careful risk-benefit evaluation
before invasive procedures such as PEG. Many of the cardiac
patients had five or more medications on admission, which
may explain why receiving five or more medications was not a
significant factor using multivariate analysis. Polypharmacy is
an established predictor of hospital mortality in patients in a
general geriatric ward,[20] but has not previously been associ-
ated with PEG mortality.
Although antibiotic prophylaxis was associated with a reduc-
tion in PEG site infections in the standard group when com-
pared to the radiological group, this study was not designed to
detect such a difference, and these findings should be inter-
preted with caution. Nonetheless, it is disappointing that only
half the patients received antibiotic prophylaxis, despite good
evidence of its benefit.[21]
Conclusions
Thirty-day PEG mortality has increased significantly since
27


Janes et al: Percutaneous endoscopic gastrostomy
1992. The ten-fold increase in PEGs reflects increased demands
for PEG, encompassing conditions where the long-term ben-
efits are uncertain. Increasing PEG placement combined with
decreased home discharge rates has important cost implica-
tions. The risk factors identified may help decision-making in
cases where the risk-benefit relationship is not clear-cut. Fu-
ture research should identify patients who will benefit most
from PEG, hence avoiding unnecessary procedures in patients
with a short life expectancy.
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Percutaneous endoscopic gastrostomy
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
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28
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neous endoscopic gastrostomy. BMJ 1999;319:881-4.
place for the treatment of cancer cachexia, but it may be con-
sider 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). Fur-
thermore, 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 prog-
nosis while admitted for acute illness such as urinary tract in-
fection or pneumonia. Abuksis et al. have shown that a policy
of insertion of PEG 30 days after hospital discharge has re-
duced 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
J Postgrad Med March 2005 Vol 51 Issue 1