Decisions relating to Percutaneous Endoscopic Gastrostomy (PEG) are often complex. In 2006, a multi-professional committee was set up in Addenbrooke's Hospital chaired by a palliative care physician. Gastroenterology and elderly care medicine are represented at senior level, with speech and language therapists, dieticians, nutrition support and endoscopy nurses also present. This study aims to determine the effect of the Feeding Issues Multidisciplinary Team (FIMDT) on patient selection and outcome.
A retrospective analysis of patient records was performed for all patients receiving PEGs in the periods before and after the institution of the FIMDT. We reviewed all patients who have had PEGs for feeding purposes for a four and a half year period prior to and a three and a half year period after establishment of FIMDT. Reasons for patients not receiving PEG placement after discussion at the FIMDT were documented. Statistical significance was analysed by student t-test.
308 patients from the Pre-FIMDT period and 388 patients from the Post-FIMDT period were included. 261/388 patients (Male – 61%, Female – 39%; mean age – 60 years) from the post-FIMDT period (74/year) had PEGs compared to 308 patients (Male – 52%, Female – 48%; mean age – 63 years) in the Pre-FIMDT period (68/year). The commonest indications were stroke, neurodegenerative (ND) diseases and head and neck (H & N) cancers (Pre-FIMDT 33%, 22%, 18% vs. 16%, 18%, 32% in the post-FIMDT period respectively) (Figure 1).
The cumulative mortality at one, three, six and twelve months post-PEG was 7%, 19%, 27% and 40% in the pre-FIMDT period compared to 5%, 14%, 20% and 30% in the post-FIMDT period. The reduction in mortality at six and twelve months was statistically significant (p value 0.03 and 0.01 respectively). The reduction in cumulative mortality was highest for stroke patients (Pre-FIMDT 14%, 47%, 73%, 100% vs. Post-FIMDT 6%, 19%, 28%, 36% at one, three, six and twelve months respectively) (Figure 2).
Of the 127/388 patients referred to FIMDT who did not undergo PEG insertion, 55 were not indicated, 24 were unfit, 23 were referred on for Radiologically Inserted Gastrostomy (RIG) and 25 were appropriate but did not receive a PEG due to technical difficulty, refusal, or death. Therefore 102/388 (26%) patients originally referred to the FIMDT were deemed inappropriate for PEG placement.
The FIMDT resulted in a more selected population for PEG placement with an associated significant reduction in cumulative mortality at 6 months and 12 months. This was most pronounced among patients with stroke.
Figure 1. Common indications for PEG
Figure 2. Kaplan-Meier survival curves for Pre-FIMDT and Post-FIMDT patients with stroke
