Percutaneous endoscopic gastrostomy (PEG) is a well-established method for providing
long-term enteral nutrition in patients who are unable to maintain adequate oral intake.
Since its first description by Gauderer et al in 1980,[1] the procedure has become an integral part of nutrition management across neurological,
oncological, and postoperative settings. However, the demography of patients undergoing
PEG has changed substantially over the years. With increasing life expectancy, clinicians
now encounter a growing population of elderly and frail individuals with multiple
comorbidities, for whom the risk–benefit equation is less straightforward.
In this issue of the Journal of Digestive Endoscopy, Changela et al[2] report an important and timely study titled “Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Frail Patients: Exploring
Post-Procedural Outcomes and Readmissions using the National Readmission Database,
2018–2020.” Using a large, nationally representative data set of over 400,000 PEG placements,
the authors explored the association between frailty, procedural timing, and postprocedure
outcomes. Their findings provide new insights into how patient vulnerability influences
clinical results and health care utilization following PEG placement.
Frailty is a multidimensional clinical state characterized by reduced physiologic
reserve and increased susceptibility to stressors.[3] Its presence often predicts adverse outcomes independent of age or comorbidities.
The use of the Johns Hopkins Adjusted Clinical Groups (ACG) Frailty Indicator in this
study allowed objective quantification of frailty using diagnostic and utilization
data. The authors found that nearly two-thirds of PEG recipients were frail, highlighting
the procedure's growing use in this vulnerable population. The findings were striking:
frail patients had significantly higher in-hospital mortality, longer hospital stays,
and greater 30-day readmission rates compared with nonfrail patients.[2] The most common causes of readmission included sepsis, aspiration pneumonia, and
tube malfunction. These observations align with earlier reports that have identified
frailty as a major determinant of post-PEG morbidity and mortality.[4]
[5] It is increasingly clear that traditional risk factors, such as age or underlying
diagnosis, cannot fully capture procedural risk in this group. Frailty, rather than
age alone, determines resilience to physiological stress and recovery potential after
PEG.
Another issue highlighted by the analysis of this database concerns procedural timing.
Elective PEG placements were associated with markedly better outcomes, lower mortality,
fewer complications, and reduced readmissions than nonelective or emergency procedures.[2] This distinction reinforces the importance of procedure timing. Elective PEG allows
time for patient optimization, correction of metabolic derangements, and multidisciplinary
review. Nonelective PEG performed during acute illness, with metabolic instability,
infection, or critical debility, increases the likelihood of adverse outcomes. Similar
conclusions have been drawn from prospective analyses that demonstrated lower complication
rates and improved survival when PEG was performed after stabilization of acute disease.[6]
Sepsis and aspiration were the most common causes of readmission, consistent with
prior literature.[4]
[5] Frail patients are particularly predisposed to infection and aspiration due to impaired
immunity, poor mobility, and altered swallowing mechanisms. Aspiration pneumonia,
often underestimated, can have devastating consequences and remains one of the leading
causes of post-PEG mortality.[7]
The study findings reiterate that PEG placement must never be viewed solely as a technical
success. In many instances, the question is not whether the tube can be placed, but whether it should be placed. Evidence suggests that PEG does not confer
survival or quality-of-life benefits in certain settings, particularly in advanced
dementia, end-stage malignancy, or irreversible neurological decline.[8]
[9] The decision to perform PEG should therefore be grounded in a careful discussion
of goals of care, expected outcomes, and ethical considerations.
The present data make a compelling case for incorporating frailty assessment before
PEG placement. Institutions could consider implementing a “PEG readiness checklist”:
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Assess frailty and functional status using standardized tools.
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Determine reversibility of the underlying condition—whether the need for enteral feeding
is temporary or permanent.
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Optimize comorbidities and metabolic derangements before the procedure.
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Discuss prognosis and preferences with patients and families to ensure that PEG aligns
with the patient's overall care goals.
This large national analysis[2] underscores a crucial message—frailty fundamentally alters the risk–benefit balance
of PEG placement. Frail patients face higher mortality and readmission rates, but
careful timing, optimization, and patient selection can substantially mitigate these
risks. PEG should not be a reflexive intervention for feeding difficulty but a deliberate,
patient-centered decision based on comprehensive clinical assessment and multidisciplinary
consensus. Integrating frailty evaluation into standard PEG practice represents a
logical and necessary evolution toward safer and more ethical care. As the population
ages, the challenge before clinicians is not simply to perform more PEGs, but to perform
them wisely.
