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Opinion
Percutaneous endoscopic gastrostomy (PEG): cui bono?
  1. Seamus O'Mahony
  1. Correspondence to Dr Seamus O'Mahony, Gastroenterology Unit, Cork University Hospital, Wilton, Cork, Ireland; Seamus.omahony{at}hse.ie

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Introduction

Percutaneous endoscopic gastrostomy (PEG) insertion became a routine and commonly performed procedure in the early 1990s. PEG feeding was enthusiastically adopted as a treatment for a wide variety of swallowing and nutritional problems. Compared with surgical gastrostomy, it was relatively non-invasive and low-risk, and endoscopists, in the early years of PEG, functioned primarily as technicians, acting on the instruction of physicians from other disciplines. Gradually, however, gastroenterologists began to be concerned about the appropriateness of PEG insertion in many patients referred for the procedure. The 2004 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report, Scoping our Practice,1 drew attention to the strikingly high mortality (6% at 30 days) in patients following PEG insertion. This report also concluded that nearly a fifth of PEG insertions were ‘futile’. In the decade since the NCEPOD report, endoscopists have become more involved in the decision-making process in PEG insertion, and many British acute general hospitals now have multidisciplinary nutrition teams, which enables better decision-making in this complex and emotionally-charged area. Detailed guidelines on PEG insertion have been produced by the British Society of Gastroenterology (BSG),2 and a thoughtful document on ethical and practical problems surrounding nutritional care has been published by a working party commissioned by the Royal College of Physicians and the BSG.3

Despite these welcome developments, decisions relating to PEG insertion continue to be challenging. Feeding has powerful symbolic, cultural and religious aspects, far beyond the provision of nutrition. Gastroenterologists continue to find themselves in difficult situations, under pressure from families, colleagues and other healthcare workers. For most endoscopists, PEG insertion is the commonest source of ethical difficulty in their clinical practice.

PEG and dementia

There is now a broad consensus that PEG feeding does not benefit patients with advanced dementia.4 ,5 Over the last 10 years, better education …

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