Abstract & Commentary
PEG and J-tube Placement Is Associated with High In-hospital Mortality
By Jennifer A. Best, MD
Associate Professor, University of Washington School of Medicine, Seattle, WA
Dr. Best reports no financial relationships in this field of study
Source: Sako A, Yasunaga H, Horiguchi H, Fushimi K, Yanai H et al. Prevalence and in-hospital mortality of gastrostomy and jejunostomy in Japan; a retrospective study with a national administrative database. Gastrointest Endosc 2014:80:88-96.
Percutaneous gastrostomy (PEG) and jejunostomy (J) tubes are utilized in hospital practice for medical or surgical patients in whom oral nutrition is either inadequate to meet caloric needs or unsafe as a result of structural or functional abnormality. Enteral feeding is always preferential to parenteral feeding, given lower costs and risks of morbidity. Though gastrostomy and jejunostomy placements are common, they are most often performed for complex, medically fragile patients that incur associated risks. Furthermore, placement may not benefit all patients.
Sako and colleagues in Japan performed a retrospective, cohort study to determine the prevalence of PEG and J-tube placement, demographic and clinical characteristics of patients undergoing the procedure, and associated risks of adverse events and mortality over the near term (in-hospital) and short term (to 30 days). In doing so, they utilized administrative data from a large national claims database — Diagnosis Procedure Combination (DPC). Participation in this database is mandatory for Japan’s university hospitals and voluntary for community hospitals. DPC represents inpatient claims data accounting for 45% of Japan’s acute care bed capacity. The investigators collected DPC data for all PEG and J-tube placements (both endoscopic and surgical) performed between 2007 and 2010. Patient-level data included hospital number, age, sex, clinical comorbidities (as determined by ICD-10 diagnoses and scores measured utilizing the well-validated Charlson Comorbidity Index) and condition at discharge. Procedure-level data included the type of tube placement and anesthesia utilization. Hospital-level data included admission and discharge dates and bed volumes at the hospital where each procedure was performed.
As a first step, researchers self-identified and classified major indications for PEG and J-tube placement as follows: 1) cerebrovascular disease, 2) malignancy (esophageal, head, neck), 3) neuromuscular disease, 4) dementia, 5) any combination of the previous four categories and 6) all other diseases. They then calculated the effect of each condition on in-hospital mortality, with and without pneumonia; pneumonia was also included as both a common indication for enteral feeding and the most common secondary adverse event. They also identified the effect of comorbidities (other malignancies, heart failure, renal failure, chronic liver disease, pressure ulcer and sepsis) and procedural complications (peritonitis, gastrointestinal perforation and intra-abdominal hemorrhage). The numbers of PEG and J-tube placements captured in the DPC database were used to estimate the prevalence of these procedures across acute care beds in all hospitals in Japan. The results were stratified by bed volume, as hospitals reporting to the DPC database were generally larger than those not reporting. Finally, mortality in the hospital and at 7, 14, and 30 days was calculated.
From a population of 11.6 million hospital discharges, 64,219 patients underwent PEG or J-tube placement. By authors’ estimates, this translates to an average of 96,000-199,000 placements in Japan yearly. The vast majority of study placements were PEG tubes (4.1% were J-tubes; 0.4% of patients had both placed). Patients undergoing these procedures were on average male (51.8%) and elderly (mean age 77.4 years). Placement was indicated most commonly as a result of cerebrovascular disease, pneumonia, neuromuscular disease and dementia. Median patient length of stay was 52 days, with a median of 22 days elapsing prior to tube placement. Adverse events were observed at low rates: GI hemorrhage (2.6%), wound infection (0.9%), peritonitis/perforation (0.8%) and intra-abdominal hemorrhage (0.03%). Observed in-hospital mortality was 11.9%, with subsequent mortality markedly lower, but increasing over the ensuing month: 7d (1.6%), 14d (3.3%) and 30d (6.2%). Factors found to be associated with in-hospital mortality included male sex, increasing age, urgent admission, J-tube, and lower hospital bed volume. Malignancy and other conditions were associated with higher mortality than cerebrovascular disease. Chronic heart, renal and liver disease, pressure sores and sepsis (including pneumonia) and procedural complications were all associated with higher mortality risk.
In summary, PEG and J-tube placement are common medical procedures associated with a high-degree of in-hospital morbidity, approaching 12%. For some physicians, this information may determine whether or not the procedure can be reasonably offered as an option. For some patients, this knowledge may dissuade them from proceeding, particularly when the ultimate benefit is felt to be equivocal or uncertain.
By way of commentary, this is a large study, though certainly limited by its retrospective design and the limitations of administrative data. Data concerning nutritional status (C reactive protein and albumin levels, for example) were not obtainable, despite being known to influence outcomes following enteral tube placement. Indication categories, though by my estimation reflective of clinical practice, were chosen arbitrarily by these researchers and may have missed other important disease processes. There may be significant overlap between these categories — between dementia and cerebrovascular disease, for example, rendering analysis less clean than would be ideal. Medical practices and patient cultural and medical preferences in Japan may not fully reflect patterns in other areas of the world, though it is believed that the prevalence of PEG placement is similar between Japan and the United States. Though it stands to reason that operators performing more of these procedures (perhaps at larger hospitals) may be more skilled and less prone to the complications which were shown to heighten mortality, the DPC database did not provide context on the cause of death, so the reader should not necessarily attribute higher mortality at lower-volume hospitals to operator inexperience. Certainly, as with all invasive procedures, PEG and J-tube should be avoided wherever possible. Many days elapsed prior to tube placement for most patients, providing a myriad of opportunities to optimize nutrition prior to the point at which a tube would be required and to explore other options. Additionally, for patients with risk factors identified to increase risk, thorough and candid discussion of risks and benefits is an essential step to informed consent and ultimate decision as to the best course of action.
