Percutaneous endoscopic gastrostomy – Too often? Too late? Who are the right patients for gastrostomy?

Table 1 Basic considerations for percutaneous endoscopic gastrostomy implantation and typical access types

Basic considerations for PEG implantation
Is oral nutrition - for whatever reason - so inadequate that intervention is justified?
Is enteral nutrition likely to be necessary for at least 3 wk?
Is the intestine distal to the access path functional?
Are risk factors for complications absent?
Is the anatomy suitable for PEG?
Is compliance sufficient for PEG handling (feeding in (half) upright position, infection prophylaxis, mobilization of the PEG tube, etc.)?
Typical access types
Pull-PEG (Ponsky-Gauderer)	After diaphanoscopy, primary puncture with a trocar followed by pulling the tube with a thread through the esophagus
Push-/Introducer-PEG (Russell)	With diaphanoscopy, primary gastropexy followed by direct introduction of a balloon-fixed tube

PEG: Percutaneous endoscopic gastrostomy.

Table 2 Accepted and data-supported indications for percutaneous endoscopic gastrostomy (for references see text)

Main disease groups	Diagnosis/reason for dysphagia
Cancer	Head and neck cancer
	Pharyngeal cancer
	Esophageal carcinoma
	Cancer with functional bowel obstruction (percutaneous endoscopic gastrostomy used as a decompression measure)
Neurodegenerative disorders	Stroke
	Amyotrophic lateral sclerosis
	Multiple sclerosis
	Severe brain damage from various reasons (trauma, persistent vegetative state, psychomental retardation, etc.)

Table 3 Studies of enteral nutrition with dementia patients in recent years

Ref.	Design	Number of patients with dementia	Main results	Study problems/Appraisal
Higaki et al[15], 2008	Retrospective cohort study	311 (143 with and 168 w/o dementia)	No significant differences in survival	No controls w/o PEG
Suzuki et al[28], 2012	Observational study	1353	Significantly more benefit in patients with early dementia	Endpoint “Level of independent living of demented elderly” not validated, no controls
Ticinesi et al[34], 2016	Observational study	184 (54 with PEG, 130 w/o PEG)	Survival with PEG significantly worse	Selection bias, no basic data for PEG-group vs non-PEG-group, patients with advanced dementia had better results compared to those with early dementia
Nunes et al[35], 2016	Retrospective observational study	46 (only CDR 2 and 3)	Low albumin, transferrin and cholesterol as predictors for poor survival	No controls
Cúrdia et al[36], 2017	Prospective cohort study, uncontrolled	26 (out of 60 in the whole cohort)	Significant decrease in hospitalization and visits to ER, > 50% healing of pressure ulcers	Only internal controls, no dementia grading
Ayman et al[37], 2017	Retrospective cohort	165, control group with PEG for other reasons	Significantly shorter survival in dementia patients	No dementia control group, no dementia rating
Gingold-Belfer et al[38], 2017	Retrospective Cohort, uncontrolled	189	Albumin level associated with longer survival (at baseline as well as during observation)	No control group, no dementia rating
Van Bruchem-Visser et al[39], 2019	Retrospective cohort	42 (out of 303 in the whole cohort), no controls w/o PEG	Survival with PEG significantly shorter in patients with dementia	Selection bias, no dementia rating, PEG-indication partly unclear

w/o: Without; ER: Emergency room; PEG: Percutaneous endoscopic gastrostomy.

Table 4 Additional patient groups with a lack of data but potential benefit if the timing of gastrostomy is correct

Chronic pancreatitis

COPD with manifest or imminent undernutrition/cachexia

Severe eosinophilic esophagitis

Severe ulcerative reflux disease

Cancer with undernutrition syndrome

(Mild to) moderate dementia

COPD: Chronic obstructive pulmonary disease.