Dig Dis Sci (2014) 59:117–125 DOI 10.1007/s10620-013-2891-7
ORIGINAL ARTICLE
Risk Factors for Complications of Percutaneous Endoscopic Gastrostomy Sang Pyo Lee • Kang Nyeong Lee • Oh Young Lee Hang Lak Lee • Dae Won Jun • Byung Chul Yoon Ho Soon Choi • Seung Hyun Kim
• •
Received: 16 July 2013 / Accepted: 14 September 2013 / Published online: 19 October 2013 Ó Springer Science+Business Media New York 2013
stroke as an indication for PEG [OR 3.047 (95 % CI 1.174–8.882)], and PEG tube placement by an inexperienced endoscopist [OR 3.401 (95 % CI 1.073–10.779)] were significantly associated with early complications. Conclusions A PEG tube should not be inserted into the upper body of stomach to reduce complication risk, and PEG procedures should be performed by skilled endoscopists to prevent early complications. An abnormal leukocyte count can be a predictor of early complication, and care is needed when PEG is performed for patients with stroke.
Abstract Background Percutaneous endoscopic gastrostomy (PEG) is a commonly performed procedure for patients with severe dysphagia leading to malnutrition. Improved knowledge of risk factors for PEG-related complications might decrease patient discomfort and healthcare costs. Aim The aim of the present study was to investigate factors associated with complications after PEG. Methods A retrospective review was performed for all patients referred for PEG placement from December 2002 to December 2012 in single-tertiary care center. PEGrelated complications and risk factors were evaluated through chart reviews, endoscopic reports, and endoscopic and radiologic images. Results Among a total of 245 consecutive individuals (146 male, mean age 59.2 ± 12.6 years) enrolled, 43 major complications had developed. Multivariate analysis revealed that patients with an internal bolster of a PEG tube in the upper body of stomach were at significant risk for early [OR 6.127 (95 % CI 1.447–26.046)] and late complications [OR 6.710 (95 % CI 1.692–26.603)]. Abnormal leukocyte counts [OR 3.198 (95 % CI 1.174–8.716)],
Abbreviations PEG Percutaneous endoscopic gastrostomy ALS Amyotrophic lateral sclerosis BMI Body mass index SLE Systemic lupus erythematosis CRP C-reactive protein ASA American Society of Anesthesiology
S. P. Lee Department of Internal Medicine, Digestive Disease Centre, Konkuk University School of Medicine, Seoul, Korea
Introduction
K. N. Lee (&) O. Y. Lee H. L. Lee D. W. Jun B. C. Yoon H. S. Choi Department of Internal Medicine, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-792, Korea e-mail:
[email protected] S. H. Kim Department of Neurology, Hanyang University College of Medicine, Seoul, Korea
Keywords Gastrostomy Percutaneous endoscopic gastrostomy Complications Therapeutic endoscopy
Percutaneous endoscopic gastrostomy (PEG) is the most common method of providing enteral feeding to patients who cannot take adequate nutrition by mouth [1]. Since being introduced by Gauderer et al. [2], its use has increased to approximately 100,000–125,000 cases annually in the United States and continues to rise [3, 4]. PEG should be performed when a patient’s gastrointestinal tract is functionally normal and when there has been inadequate
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nutritional intake for more than 4–6 weeks [1]. An appropriate use of PEG may prevent further weight loss, correct nutritional deficiency, and arrest declining quality of life. Clinical studies have shown clear benefits of PEG feeding for patients after stoke (improved nutritional outcomes and reduced mortality) and in patients with oropharyngeal cancer (improved nutritional outcomes) [5–9]. Recent studies have shown that PEG had little effect on the overall quality of life for amyotrophic lateral sclerosis (ALS) patients, but increased survival rate [10, 11]. PEG tube placement has been proven to be a safe, effective procedure but sometimes complications can occur [12]. The frequency of complications depends upon definitions used and populations studied. Total complication rates vary from 16 to 70 % with major complication rates at 3–15 % [13–16]. Mitchell et al. [17] showed that old age, malignancy, male gender, and hypoalbuminemia were associated with increased mortality after PEG. In another study, Blomberg et al. [18] suggested that low albumin, high C-reactive protein (CRP), persons over age 65, and body mass index (BMI) less than 18.5 were associated with increased 30-day mortality after PEG. Although many studies have investigated risk factors for mortality, very little is known about risk factors for PEGrelated complications, which are important to patients because these complications can increase additional pain and healthcare costs. In previous studies, patients with cancer, AIDS, and thoraco-abdominal deformity were at significant risk of complications after PEG in children and young adults [19, 20]. Another study showed that cancer patients with American Society of Anesthesiology (ASA) scores of 4, 4E, or 5E were at increased risk of complication [21]. However, in several recent studies, there were no predictive factors for these complications [18, 22]. Accordingly, no factors have been clearly demonstrated to be associated with PEG complications. Therefore, this retrospective study was conducted to evaluate complications of PEG and to determine whether these can be predicted with patient-related or procedure-related risk factors.
Materials and Methods Patients and Study Design A retrospective review was performed to identify the records of patients referred for PEG or tube replacement at Hanyang University Hospital (Seoul, Korea) during the 10-year period between December 2002 to December 2012 (250 patients, 368 cases). Among these, patients were excluded for having undergone PEG more than once, including PEG exchange. Three patients were excluded due to poor record keeping and short follow-up period. Patients
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Dig Dis Sci (2014) 59:117–125 Table 1 Classification of complications Major (N = 43)
n
Minor (N = 27)
n
Early complication
21
Esophageal injury with minor bleeding
22
Mucosal laceration of esophagus with hemoclipping
6
Minor peristomal infection
4
Intramural hematoma of esophagus
1
Huge bezoar
1
Symptomatic pneumoperitoneum
9
Ileus
Not checked
Peritonitis
4
Aspiration pneumonia
Not checked
Necrotizing fasciitis
1
Tube blockage
Not checked
Bowel perforation
0
Injury of adjacent organ
0
Late complication Tube dislodgement
22 10
Buried bumper syndrome
7
Peristomal infection requiring tube removal
3
Necrotizing fasciitis
2
were included for review if they were followed up for at least a month after PEG. Patients who died within the investigated period were evaluated whether the death was related with the PEG procedure or not. When the inclusion and exclusion criteria were applied, 245 patients remained to be included in the analysis. We were able to obtain information regarding patients and procedures through review of medical chart, endoscopic report, and endoscopic and radiologic images. The study protocol was approved by the institutional review board at Hanyang University Hospital (HYUH 2013-02-012-003). Definitions of Complications Complications were classified into major and minor complications (Table 1). A complication was considered as major if required medical intervention, tube removal, or hospitalization, including post-PEG bleeding (requiring transfusion or endoscopic treatment), peristomal infection (need for PEG removal), necrotizing fasciitis, peritonitis, esophageal or gastric perforation, buried bumper syndrome, tube dislodgement, intramural hematoma of esophagus, pneumoperitoneum with symptoms, and injury to an adjacent organ (liver, bowel, or spleen). Minor complications were peristomal infection (for cases where the existing PEG was not removed or exchanged) and minor bleeding or injury (oral cavity, GI tract, skin wound). Major complications were further divided into early
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Table 2 Risk of major (early and late) complication after PEG among 245 patients Parameter
No. of patients
No. of patients with early complication (N = 21)
P valuea
No. of patients with late complication (N = 22)
P valuea
Age (C65 years)
85
9
0.411
9
Sex (female)
99
8
0.821
7
0.521 0.389
BMI (\18.5 kg/m2) Comorbidity
62
4
0.606
7
0.449
Diabetes
41
4
0.761
5
0.430
H/O aspiration pneumonia
46
3
0.773
6
0.285
Ischemic heart disease
19
3
0.191
4
0.064
142
10
0.315
13
0.910
Stroke
38
7
0.018
1
0.215
Cancer
17
1
1.00
1
1.00
Indication for PEG ALS
Medication Anti-platelet drug
42
4
0.765
3
0.775
6
0
1.00
0
1.00
Anti-coagulation drug Steroid
9
0
1.00
2
0.188
11
1
1.00
2
0.258
Hemoglobin (\10 g/dL)
61 38
11 5
0.002 0.276
12 6
0.001 0.113
Platelet (\150,000/mm3)
35
5
0.192
6
0.068
Prothrombin time (C1.2INR)
29
5
0.076
4
0.308
Creatinine (C1 mg/dL)
19
2
0.671
2
0.683
Albumin (\3 g/dL)
28
2
1.00
3
0.725
116
14
0.064
17
0.003
88
9
0.488
9
0.609
Deformed stomach Blood chemistry Leukocyte (\4,000 or C10,000/mm3)
CRP (C1 mg/dL) Procedure time (C10 min) Workmanship of endoscopist (beginner)
29
6
0.013
1
0.487
The position of internal bolster (upper body)
11
5
