THE AMERICAN JOURNAL OF GASTROENTEROLOGY
1, 2000
© 2000 by Am. Coll. of Gastroenterology
Published by Elsevier Science Inc.
Percutaneous Endoscopic Gastrostomy:
High Mortality Rates in Hospitalized Patients
Galia Abuksis, R.N., M.A., Melli Mor, R.N., Negba Segal, R.N., Ilana Shemesh, R.N., Shlomit Plout, R.N.,
Jaqueline Sulkes, Ph.D., Gerald M. Fraser, M.D., F.R.C.P., and Yaron Niv, M.D.
The Departments of Gastroenterology and Epidemiology, Beilinson Campus, Rabin Medical Center and
Sackler Faculty of Medicine, Tel-Aviv University, Petach Tikva, Israel
OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) is
a widely used method for insertion of a gastrostomy tube in
patients who are unable to eat but have a normally func-
tioning gut. Complications have been described, especially
in fragile, debilitated patients, and 30-day mortality rates of
4.1–26% have been reported. We assessed the outcome of
PEG tube placement for inpatients and outpatients, based on
morbidity, mortality, and long-term survival.
METHODS: We reviewed the medical records of all patients
who underwent PEG at our institution between January 1,
1995 and December 31, 1996. Four groups of patients were
compared: Group 1, patients from nursing homes; Group 2,
hospitalized patients; Group 3, hospitalized patients
matched to Group 2 for diseases, except mental disorder,
and not treated with PEG; and Group 4, the general hospital
population matched for age.
RESULTS: A total of 114 PEG tubes were inserted in 114
patients, 47 from Group 1, 67 from Group 2. Eighty-seven
percent of patients in Group 1 underwent PEG because of
dementia, versus 46% of Group 2 (p ⬍ 0.001). The mor-
tality rate was five times higher in Group 2 than in Group 3
(p ⬍ 0.001). The 30-day mortality was seven times higher
in Group 2 than in Group 1, twice that in Group 3, and five
times higher than in Group 4 (p ⫽ 0.002 and p ⬍ 0.001,
respectively). When intention-to-treat analyses were applied
to the data, 19/48 patients died (39.5%) in Group 1, and
60/83 (72.0%) died in Group 2, (p ⬍ 0.001).
CONCLUSIONS: Patients hospitalized with acute illness are
at high risk for serious adverse events after PEG insertion and
this procedure should be avoided. (Am J Gastroenterol 2000;
95:128 –132. © 2000 by Am. Coll. of Gastroenterology)
INTRODUCTION
Percutaneous endoscopic gastrostomy (PEG) is a widely
used method for introducing a gastrostomy tube to enable
enteral feeding in patients who are unable to eat but have a
normally functioning gut. In the United States, the number
of gastrostomy procedures for hospitalized patients has dou-
bled between 1988 and 1995 (1). Most of these patients are
elderly, debilitated, and chronically ill. The percutaneous
Vol. 95, No.
ISSN 0002-9270/00/$20.00
PII S0002-9270(99)00731-5
approach to gastrostomy tube placement was first described
by Gauderer et al. in 1980 (2). The indications for PEG
include patients with potentially reversible disease (e.g.,
stroke, Guillain-Barré syndrome), patients with incurable
disease with potential for extended survival (e.g., head and
neck cancer), or patients who are terminal or seriously
debilitated (e.g., head trauma or systemic malignancies)
(3– 8).
The use of PEG is associated with several complications.
Serious complications include pneumonia due to aspiration
of gastric contents, anesthetic adverse events, migration of
the tube, obstruction of the lumen, esophageal perforation,
hemorrhage, and wound infection (3, 9 –16). The 30-day
mortality rate has been reported to be between 4.1% and
26% (1, 17–19) and the major causes of death were pneu-
monia, urinary tract infection, and heart disease. Taylor et
al. found that the increased risk of death after PEG was
associated with older age, male gender, and diabetes mel-
litus (20). The incidence of gastroesophageal reflux and
esophageal motility abnormalities was increased in patients
with neurological diseases (21). Patients with urinary tract
infection, recurrent aspiration, hypoalbuminemia (serum al-
bumin ⬍3.0 g/day), and age ⬎75 yr are at high risk for an
invasive procedure such as PEG (19 –23). Wolfsen et al.
studied patients with a very short life expectancy (24): 36%
of their patients had cancer, 53% had benign mechanical
obstruction, and 11% could not maintain enteral nutrition
because of other causes. PEG shortened the hospitalization
time, but did not contribute to life expectancy. The ques-
tionable value of PEG in patients with a short life expect-
ancy was raised.
We investigated the outcome of PEG in a retrospective
study of patients referred as outpatients or during hospital-
ization. In addition, we compared the outcomes in the hos-
pitalized patients with those in a matched control group of
hospitalized patients who did not undergo PEG.
MATERIALS AND METHODS
Patients
We conducted a retrospective review of the medical records
of all patients who underwent PEG at Rabin Medical Center,
AJG – January, 2000 PEG Mortality in Hospitalized Patients 129

Table 1. Demographic Data for Patient Groups The following details were extracted from the patients’
Group 1 Group 2 Group 3 Group 4 charts: age, gender, referring institution, date of hospitaliza-
Number 47 67 67 1035 tion (if any), indication for PEG, medical history, date of
Age, yr PEG insertion, complications, date of death.
Mean ⫾ SD 84 ⫾ 11 80 ⫾ 16 80 ⫾ 9 79 ⫾ 8
Range 44–100 26–103 47–90 47–90 Statistical Analysis
Gender We used the ␹2 test or Fisher’s exact test to analyze the
Men 16 (34%)* 32 (48%) 32 (48%) 523 (51%) significance of differences between Groups 1, 2, 3, and 4
Women 31 35 35 512
and of category variables such as indications, complications,
* In comparison to Group 2, p ⫽ 0.195.
and mortality. The Student’s t test was used to analyze the
differences in the means of continuous parameters. Survival
Campus Belinson, Israel between January 1, 1995 and De- curves were estimated by the product limit method (Kaplan-
cember 31, 1996. The patients were divided into four Meier). Comparison of survival curves between Group 1
groups. (the ambulatory patients) and Group 2 (the hospitalized
patients) was calculated by the log-rank test; p values ⱕ0.05
Group 1: Outpatients, referred for PEG insertion from out-
were considered statistically significant.
side institutions such as nursing homes (from 15
different institutions);
Group 2: Inpatients, who underwent PEG during hospital- RESULTS
ization;
Group 3: Control group, matched for hospitalized patients Patients’ Characteristics
not treated with PEG insertion and hospitalized in Placement of PEG was performed in 48 outpatients who
one if the internal medicine departments at the were resident in geriatric institutions (Group 1) and in 83
same time; the control patients were matched for hospitalized patients (Group 2). One patient in Group 1 and
age, gender, and medical diagnosis, except for 16 patients in Group 2 died before PEG insertion, so that
mental state; and data were available for 47 outpatients and 67 hospitalized
Group 4: Hospital in-patients matched for age only; this patients, respectively. Thus, a total of 114 PEG tubes were
group was used to characterize our hospital pop- inserted. Group 3 was comprised of 67 hospitalized patients
ulation. matched to Group 2 for age, gender, and medical diagnosis,
except for mental state (Table 1). A large group of 1035
PEG hospital patients with a similar age and gender distribution,
The insertion of PEG was carried out under i.v. sedation hospitalized during the same period, served as a further com-
(midazolan 5 mg). All patients received prophylactic anti- parison to characterize our hospital population (Group 4).
biotics (1 g cejonicid i.m.) before and 24 h after the proce-
dure (25). Heart rate, blood pressure, and oxygen saturation Comorbidity
were recorded for each patient. A complete esophagogas- Comorbid diseases for each of the patient groups are shown
troduodenoscopy was performed in each patient to identify in Table 2. Mental disorders, such as dementia, were sig-
any mucosal lesion or obstruction. The gastrostomy site was nificantly more prevalent in both PEG-treated groups,
chosen by transillumination of the abdominal wall. Feeding, Group 1 (85%) and Group 2 (52%), than in control Groups
either continuous or bolus, was begun within 12 h after the 3 (19.4%) and Group 4 (6%). In addition, mental disorders
procedure if there was evidence of adequate bowel function were more common in Group 1 than in Group 2 (p ⬍ 0.001)
(26, 27). At the end of the procedure a verbal explanation and also more common in Group 2 than in Group 3 (p ⬍
and a standard instruction sheet were given to the patient’s 0.001). The percentage of patients with a medical history of
attendant or to the nurse from the patient’s institution. stroke (CVA) was higher in Group 1 than 2, but did not

Table 2. Clinical Spectrum of PEG Patients and Controls

Diseases Group 1 Group 2 Group 3* Group 4 p† p‡
Number 47 67 67 1035
Stroke 23 (49%) 20 (30%) 24 (35.8%) 196 (19%) 0.044 0.042
Ischemic heart disease 10 (21%) 18 (27%) 14 (20.8%) 132 (13%) NS 0.002
Diabetes mellitus 6 (13%) 18 (27%) 19 (28.3%) 412 (40%) NS 0.047
Hypertension 10 (21%) 17 (25%) 16 (23.8%) 648 (63%) NS ⬍0.001
Chronic renal failure 3 (6%) 6 (9%) 8 (11.9%) 105 (10%) NS NS
Mental disorder 40 (85%) 35 (52%) 13 (19.4%) 64 (6%) ⬍0.001 ⬍0.001
Parkinson’s disease 7 (15%) 5 (7%) 6 (8.9%) 62 (6%) NS NS
* Differences between Groups 2 and 3 did not reach statistical significance, except for mental disorder (p ⬍ 0.001).
† Comparison between Groups 1 and 2.
‡ Comparison between Groups 2 and 4.
130 Abuksis et al. AJG – Vol. 95, No. 1, 2000

Table 3. Cognitive and Functional Status of PEG Patients and Table 5. Complications of PEG
Controls
Complication Group 1 Group 2 p
Status Group 1 Group 2 p Number 47 67
Number 47 67 Local infection 6 (13.0%) 5 (7.0%) NS
Mental state Migration of tube 0 2 (3.0%) NS
Alert 1 (2%) 14 (21%) 0.004 Leakage 1 (2.0%) 0 NS
Confused 2 (4%) 4 (6%) NS Peritonitis 0 1 (1.5%)
Disoriented 44 (94%) 42 (62.7%) ⬍0.001 Total 7 (15.0%) 8 (11.5%) NS
Conscious state
Fully conscious 18 (38%) 27 (40%) NS
Partially conscious 29 (62%) 33 (49%) NS
Unconscious 0 7 (11%) 0.022 respectively; Table 6). Overall mortality for patients was
Functional state 38% in Group 1 and 66% in Group 2 (p ⫽ 0.006) during
Partial dependence 2 (4%) 14 (21%) 0.012 mean follow-up of 248 ⫾ 208 days and 105 ⫾ 117 days,
Bedridden 45 (96%) 53 (79%) 0.012
respectively. Differences in length of follow-up are due to
the high early mortality in hospitalized patients. When in-
reach statistical significant difference. Degenerative dis- tention-to-treat analyses was applied to the data, 19/48 pa-
eases such as CVA, ischemic heart disease (IHD), diabetes tients died (39.5%) in Group 1, and 60/83 (72.0%) died in
mellitus (DM), and arterial hypertension (HTN) were more Group 2 (p ⬍ 0.0001).
frequent in the PEG hospitalized patients in Group 2 than in
the general hospital population in Group 4. Reinsertion of PEG
The cognitive status of Group 1 and 2 patients is pre- During the study period, 23 patients underwent PEG rein-
sented in Table 3. There were more disoriented and bedrid- sertion: 16 (34%) patients in Group 1 after a mean follow-up
den patients in Group 1 than 2 (p ⬍ 0.001 and 0.012, of 12 ⫾ 6 months and seven (10%) patients from Group 2
respectively). after a mean follow-up of 7 ⫾ 4 months (p ⫽ 0.003).
Leakage around the PEG tube was the most frequent indi-
Indications for PEG cation for reinsertion.
The indications for performing PEG are shown in Table 4.
Dementia was a major indication in 87% of patients in DISCUSSION
Group 1, compared with 46% in Group 2 (p ⬍ 0.001).
Inability to eat due to malignancy was not an indication in Percutaneous endoscopic gastrostomy is an established
any patients in Group 1, compared with in 10% in Group 2 technique for providing long-term enteral feeding in patients
(p ⫽ 0.022). unable to take oral feedings. The factors that predict suc-
cessful long-term outcome have not been well studied, but
Complications the patient’s underlying physical and mental condition are
The frequency of complications in Groups 1 and 2 was likely contribute to the natural history. In our practice, the
similar (Table 5). Local wound infection was the most
common complication: six (13%) and five (7%) patients in
Groups 1 and 2, respectively. Intravenous antibiotics and
local care were needed for a complete recovery.
Mortality rates were higher in Group 2 than in Group 1 at
all times during a maximum of 2 yr follow-up. Using life-
table analysis (Fig. 1), we found survival in Group 2 to be
significantly lower than in Group 1 (p ⬍ 0.0002) and me-
dian survival was 4 months and 24 months, respectively.
The 30-day mortality after PEG insertion in Group 2 was
29% compared with 4% in Group 1, 13% in Group 3, and
6% in Group 4 (p ⫽ 0.002, p ⫽ 0.036, and p ⬍ 0.001,

Table 4. Indications for Performing PEG

Indication Group 1* Group 2† p
Number 47 67
Dysphagia 9 (19.0%) 21 (31.3%) NS
Aspiration 13 (27.6%) 20 (29.8%) NS
Dementia 41 (87.2%) 31 (46.2%) ⬍0.001
Malignancy 0 7 (10.0%) 0.022
Temporary nutritional support 0 4 (5.9%) NS Figure 1. Survival after insertion of PEG in outpatient (Group 1)
* In some patients there was more than one indication. and hospitalized patients (Group 2).
AJG – January, 2000
Table 6. Characteristics of the Patients Who Died
Group 1 Group 2
Number 47 67
Median follow-up 248 ⫾ 208 105 ⫾ 117
Age, yr 86 ⫾ 11 81 ⫾ 16
Range, yr 65–100 48–103
Gender
Men 5 20
Women 13 24
Died 18 (38%) 44 (66%)
30-day mortality 2 (4%) 20 (29%)
* Comparison between Groups 1 and 2.
† Comparison between Groups 2 and 3.
‡ Comparison between Groups 2 and 4.
NA ⫽ not available.
patients referred for this procedure are old, frail, demented,
and often have a poor prognosis.
To identify prognostic factors for poor outcome, we com-
pared two groups of patients referred for PEG insertion to
our department: outpatients from nursing home and inpa-
tients from the hospital wards. We used two control groups
for comparison: a group of patients with a similar disease
spectrum except for mental disorder and a group of hospi-
talized patients matched only for age. A mental disorder,
mainly dementia, was present in 85% of patients referred
from geriatric institutions and was present in 52% of hos-
pitalized patients, compared with 19.4% of matched con-
trols and 6% of the general hospital population. Thus, a
mental disorder is an important factor in deciding to perform
PEG probably because of difficulties in obtaining coopera-
tion from the patient in maintaining an adequate nutritional
state.
The combination of malnutrition, acute medical illness,
and mental disorder increases the mortality of PEG to un-
acceptable levels of 29% after 30 days in hospitalized pa-
tients (Group 2). Hospitalized patients are probably less able
to tolerate surgical procedures such as PEG because most of
them suffer from acute disease (or acute exacerbation of
chronic disease), which led to their hospitalization. A sim-
ilar phenomenon has been observed in other situations; for
example, upper gastrointestinal bleeding that begins in hos-
pitalized patients has a worse prognosis than for patients
admitted for gastrointestinal bleeding (28).
Malnutrition in hospital inpatients is common and is
associated with increased mortality (29). Physicians fre-
quently wish to improve the patient’s nutritional state but
are often unaware of the indications and complications of
PEG. In addition, the pressure from health providers to
reduce the length of hospitalization induces physicians to
discharge patients from the hospital as early as possible. In
Israel, feeding via a nasogastric tube requires the presence
of trained medical personnel, whereas gastrostomy tube-fed
patients can be cared for at home or in institutions without
certified trained staff. Thus, patients frequently cannot be
moved to nursing homes from the hospital ward unless they
have a PEG. These constraints increase the pressure for PEG
PEG Mortality in Hospitalized Patients 131
Group 3 Group 4 p* p† p‡
67 1035
NA NA 0.001
82 ⫾ 7 77 ⫾ 8 NS NS ⬍0.001
81–90 46–98
4 39
5 33
9 (13%) 72 (7%) 0.004 ⬍0.001 ⬍0.001
9 (13%) 67 (6%) 0.002 0.039 ⬍0.001
to be performed in a system where there is always a shortage
of acute medical beds.
In a large study of the Medicare population in the United
States, in which all types of gastrostomy placement were
included, the 30-day mortality was 23.9% and at 1 yr it was
63% (1). Mortality was highest for patients with acute
illness such as pneumonia or CVA and lowest when the
indication was malnutrition and a secondary diagnosis of
dementia. These data support the findings in our study.
However, in our study the conclusions were considerably
strengthened by the inclusion of control groups with which
to compare mortality rates. Thus we were able to show that
the 30-day mortality rate in the hospitalized PEG patients
was 29% compared with 13% in a control group matched for
age, gender, and disease, and 6% in a large group of patients
matched for age and gender. Demented patients without
acute disease and who were referred because of malnutrition
had a 30-day mortality of only 4%. The presence of acute
disease is therefore the most important negative prognostic
factor.
Rabeneck et al. (30) reviewed the indications for PEG
and recommended a decision making algorithm, in which
the physician should advise against the procedure in patients
in whom no positive change in health status could be ex-
pected in terms of quality or length of life (e.g., anorexia-
cachexia syndrome, permanent vegetative status). However,
this algorithm has been criticized as being too simplistic
(31).
The 30-day mortality rate for PEG has been reported to be
4 –26% (1, 17–19). Light et al. (19) suggested that there
should be a so-called “grace period” of 30 – 60 days during
which patients receive feeding through a nasogastric tube;
only if they survive this period should they be considered
candidates for PEG. We have demonstrated that hospitalized
patients represent a very high risk group and we recommend
that the proposal be adopted.
The type and frequency of complications of PEG in our
study were similar to those reported in the literature (3,
9 –16). Gastrostomy leakage was found in 2% of Group 1,
and wound infection in 13%, twice that of Group 2. As a
result of this study, we initiated steps to decrease the number
132 Abuksis et al.
of complications. We encouraged nurses from nursing
homes to accompany the patients and to increase their
familiarity with PEG feeding and care.
We conclude that hospitalized patients are at high risk for
PEG insertion and, if necessary, should be fed by nasogas-
tric tube until their acute illness has resolved.
Reprint requests and correspondence: Gerald M. Fraser, M.D.,
F.R.C.P., Department of Gastroenterology, Beilinson Campus,
Rabin Medical Center, Petach Tikva 49100, Israel.
Received May 18, 1999; accepted Aug. 17, 1999.
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