Holt D Q, McDonald J F, Murray M L, Hair C, Devonshire D A, Strauss B J, Moore G T
Gastroenterology and Hepatology Unit, Monash Health, Melbourne, Australia.
Clinical Nutrition and Metabolism Unit, Monash Health, Melbourne, Australia.
Intern Med J. 2015 Jun;45(6):648-52. doi: 10.1111/imj.12705.
Percutaneous endoscopic gastrostomy (PEG) placement is performed in a patient group with high mortality in the short and medium term. For a significant proportion of patients, the procedure provides no increase in survival. There are no standardised assessment tools available to determine the clinical appropriateness of PEG placement, nor any to predict clinical outcome.
The study aims to determine whether clinical assessment, by a trained dietitian, of the appropriateness of PEG placement is predictive of mortality in the short and medium terms.
A prospective audit was undertaken of all requests for PEG placement at a single large, publicly funded Australian tertiary hospital. The clinical appropriateness of each request was assessed by a trained dietitian, and data on age, sex, reason for referral, comorbidities and satisfaction of assessment criteria were collected, and patient outcome and survival were compared for all patients according to whether a PEG was inserted or not. Main outcome measures were mortality at 30 and 150 days after referral.
During the period 2005-2008, 198 patients were referred for PEG; 94 were assessed as appropriate referrals, 104 as inappropriate. Eighty-four patients who underwent gastrostomy, after being assessed as appropriate, had significantly reduced mortality at 30 days (96.4% vs 74.6%, P < 0.0001) and 150 days (82.1% vs 57.9%, P = 0.0001) compared with all other patients. Patients who received PEG despite contrary advice had no significant survival advantage, at 30 days or 150 days, over patients who did not receive PEG.
The application of selection criteria by trained assessors improves patient selection for PEG insertion and predicts mortality at early and later time points, by identifying patients unlikely to benefit from PEG. The group of patients who received a gastrostomy despite an adverse assessment had no mortality benefit - in these patients, the procedure may have been futile.
经皮内镜下胃造口术（PEG）适用于一组短期和中期死亡率较高的患者群体。对于相当一部分患者而言，该手术并不能提高生存率。目前尚无标准化的评估工具来确定PEG置入的临床适宜性，也没有工具可预测临床结局。
本研究旨在确定由经过培训的营养师进行的PEG置入适宜性临床评估是否能预测短期和中期死亡率。
对澳大利亚一家大型公立三级医院所有PEG置入申请进行前瞻性审核。由经过培训的营养师评估每项申请的临床适宜性，收集年龄、性别、转诊原因、合并症及评估标准满意度等数据，并根据患者是否接受PEG置入，比较所有患者的结局和生存率。主要结局指标为转诊后30天和150天的死亡率。
在2005 - 2008年期间，198例患者被转诊接受PEG；94例被评估为适宜转诊，104例为不适宜。84例经评估适宜后接受胃造口术的患者，与所有其他患者相比，30天（96.4%对74.6%，P < 0.0001）和150天（82.1%对57.9%，P = 0.0001）时死亡率显著降低。尽管得到相反建议仍接受PEG的患者，在30天或150天时与未接受PEG的患者相比，并无显著生存优势。
经过培训的评估人员应用选择标准可改善PEG置入患者的选择，并通过识别不太可能从PEG中获益的患者，预测早期和晚期的死亡率。尽管评估不利仍接受胃造口术的患者群体并无死亡率获益——对这些患者而言，该手术可能是徒劳的。
