Safety and feasibility of unsedated peroral percutaneous endoscopic gastrostomy placement in both outpatient and inpatient settings

Year 2024, Volume: 41 Issue: 2, 311 - 316, 19.05.2024

Kürşat Yemez Ahmet Burak Ciftci Hüseyin Eraslan Ömer Faruk Bük

Abstract

Percutaneous endoscopic gastrostomy (PEG) is traditionally performed under sedation. However, sedation is often associated with cardiopulmonary risks. Unsedated PEG placement may be an alternative in patients with a high anesthesia risk. However, there are only a few studies in the literature on the feasibility of oral unsedated PEG placements. Additionally, there are conflicting results in the literature regarding whether PEG placement increases mortality in hospitalized patients. The primary aim of this study was to investigate the safety and feasibility of peroral PEG placement without sedation in our surgical endoscopy unit. Secondly, we aimed to compare the mortality and morbidity results of unsedated PEG placements in inpatients (IP) and outpatients (OP). The medical records of patients who underwent peroral unsedated PEG placements in our surgical endoscopy unit between September 2019 and September 2022 were reviewed retrospectively. The patients were divided into two groups: inpatients (IP) and outpatients (OP). Demographic data, PEG indications, comorbidities, procedural success rate, PEG-related complications, and 30-day mortality data were analyzed. A total of 312 patients were included in the study, with a median age of 79 years (interquartile range (IQR): 70-86). The overall PEG-related complication rate was 9.2%, and the 30-day mortality rate was 5.1%. The procedure success rate was 99%. There were no statistically significant differences between the groups in terms of PEG indications, PEG-related complications, and mortality (p=0.430, p=0.384, and p=0.437, respectively). This study demonstrates that unsedated PEG placement using the conventional peroral route is a safe and feasible procedure, regardless of the indications. Also, the PEG procedures can be performed safely on outpatients without increasing complications. Furthermore, the study findings suggest that inpatient PEG placement does not lead to increased mortality rates compared to outpatient PEG placement.

Keywords

Percutaneous endoscopic gastrostomy, unsedated, peroral, inpatient, outpatient, mortality

Ethical Statement

ÇALIŞMAMIZIN ETİK KURUL ONAYI ALINMIŞTIR. PROTOKOL NUMARASI: GOKA/2021/6/3 TARİHİ: 24/03/2012

Supporting Institution

YOK

Project Number

2021/6/3

References

• Wilhelm SM, Ortega KA, Stellato TA. Guidelines for identification and management of outpatient percutaneous endoscopic gastrostomy tube placement. Am J Surg. 2010;199(3):396-9; discussion 9-400.
• Gauderer MW, Ponsky JL, Izant RJJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980;15(6):872-5.
• Moran BJ, Taylor MB, Johnson CD. Percutaneous endoscopic gastrostomy. Br J Surg. 1990;77(8):858-62.
• Barends CR, Absalom A, van Minnen B, Vissink A, Visser A. Dexmedetomidine versus Midazolam in Procedural Sedation. A Systematic Review of Efficacy and Safety. PLoS One. 2017;12(1):e0169525.
• Vargo JJ, 2nd. Sedation-related complications in gastrointestinal endoscopy. Gastrointest Endosc Clin N Am. 2015;25(1):147-58.
• Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World J Gastrointest Endosc. 2013;5(11):527-33.
• Dumortier J, Lapalus MG, Pereira A, Lagarrigue JP, Chavaillon A, Ponchon T. Unsedated transnasal PEG placement. Gastrointest Endosc. 2004;59(1):54-7.
• Lin LF, Shen HC. Unsedated transnasal percutaneous endoscopic gastrostomy carried out by a single physician. Dig Endosc. 2013;25(2):130-5.
• McCulloch A, Roy O, Massey D, Hedges R, Skerratt S, Wilson N, et al. Nasal unsedated seated percutaneous endoscopic gastrostomy (nuPEG): a safe and effective technique for percutaneous endoscopic gastrostomy placement in high-risk candidates. Frontline Gastroenterol. 2018;9(2):105-9.
• Sato Y, Goshi S, Kawauchi Y, Nishigaki Y, Mizuno KI, Hashimoto S, et al. Safety of unsedated PEG placement using transoral ultrathin endoscopy in patients with amyotrophic lateral sclerosis. Nutr Neurosci. 2017;20(1):71-5.
• Steed H, Barrett D, Emm C, Lycett W, O'Toole S, Evans K, et al. Unsedated percutaneous endoscopic gastrostomy insertion: a safe, effective, and well-tolerated method. JPEN J Parenter Enteral Nutr. 2012;36(2):231-4.
• Tsaousi G, Stavrou G, Kapanidis K, Michalopoulos A, Kotzampassi K. Unsedated Outpatient Percutaneous Endoscopic Gastrostomy in Stroke Patients: Is It Feasible and Safe? Surg Laparosc Endosc Percutan Tech. 2019;29(5):383-8.
• 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(3):341-6.
• Abuksis G, Mor M, Segal N, Shemesh I, Plout S, Sulkes J, et al. Percutaneous Endoscopic Gastrostomy: High Mortality Rates in Hospitalized Patients. THE AMERICAN JOURNAL OF GASTROENTEROLOGY. 2000;95(1):128-32.
• Anderloni A, Di Leo M, Barzaghi F, Semeraro R, Meucci G, Marino R, et al. Complications and early mortality in percutaneous endoscopic gastrostomy placement in lombardy: A multicenter prospective cohort study. Dig Liver Dis. 2019;51(10):1380-7.
• Dietrich CG, Schoppmeyer K. Percutaneous endoscopic gastrostomy - Too often? Too late? Who are the right patients for gastrostomy? World J Gastroenterol. 2020;26(20):2464-71.
• Committee ASoP, Early DS, Lightdale JR, Vargo JJ, 2nd, Acosta RD, Chandrasekhara V, et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2018;87(2):327-37.
• Loser C, Aschl G, Hebuterne X, Mathus-Vliegen EM, Muscaritoli M, Niv Y, et al. ESPEN guidelines on artificial enteral nutrition--percutaneous endoscopic gastrostomy (PEG). Clin Nutr. 2005;24(5):848-61.
• Vargo JJ, Zuccaro G, Jr., Dumot JA, Shermock KM, Morrow JB, Conwell DL, et al. Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial. Gastroenterology. 2002;123(1):8-16.
• ProGas Study G. Gastrostomy in patients with amyotrophic lateral sclerosis (ProGas): a prospective cohort study. Lancet Neurol. 2015;14(7):702-9.
• Blomberg J, Lagergren J, Martin L, Mattsson F, Lagergren P. Complications after percutaneous endoscopic gastrostomy in a prospective study. Scand J Gastroenterol. 2012;47(6):737-42.
• Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Gastroenterology. 1987;93(1):48-52.
• Schneider AS, Schettler A, Markowski A, Luettig B, Kaufmann B, Klamt S, et al. Complication and mortality rate after percutaneous endoscopic gastrostomy are low and indication-dependent. Scand J Gastroenterol. 2014;49(7):891-8.
• Shangab MOM, Shaikh NA. Prediction of risk of adverse events related to percutaneous endoscopic gastrostomy: a retrospective study. Ann Gastroenterol. 2019;32(5):469-75.
• de Souza e Mello GF, Lukashok HP, Meine GC, Small IA, de Carvalho RL, Guimaraes DP, et al. Outpatient percutaneous endoscopic gastrostomy in selected head and neck cancer patients. Surg Endosc. 2009;23(7):1487-93.
• Johnston SD, Tham TC, Mason M. Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death. Gastrointest Endosc. 2008;68(2):223-7.
• MacLeod CS, McKay R, Barber D, McKinlay AW, Leeds JS. Predicting 30-day mortality following PEG insertion: External validation of the Sheffield Gastrostomy Score and analysis for additional predictors. Clin Nutr ESPEN. 2021;42:227-32.
• Nicholson JP, Wolmarans MR, Park GR. The role of albumin in critical illness. Br J Anaesth. 2000;85(4):599-610.
• Friedenberg F, Jensen G, Gujral N, Braitman LE, Levine GM. Serum albumin is predictive of 30-day survival after percutaneous endoscopic gastrostomy. JPEN J Parenter Enteral Nutr. 1997;21(2):72-4.