Percutaneous endoscopic gastrostomy during the covid-19 pandemic: To peg or not to peg

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a relatively easy and safe procedure that provides long-term enteral feeding for selected patients with dysphagia. Amid the COVID-19 pandemic, the European society of gastrointestinal endoscopy (ESGE) classified PEG insertion as a high priority procedure and advised to maintain services without disruption. Aims & Methods: This is a retrospective study of all consecutive adult patients who underwent PEG insertion between January 2019 and December 2020 at a district general hospital in the UK. The main aims were to assess the impact of COVID-19 on PEG insertion service and the clinical outcomes post PEG insertion in comparative cohorts. Data regarding patients' demographics, co-morbidities, laboratory findings and indications for PEG insertion were collected. 30-, 60- and 90-days post-PEG mortality data were assessed. Data of all procedures performed in 2020 (pandemic cohort) were compared with those in 2019 (pre-pandemic cohort). Continuous variables were compared using unpaired t-test, categorical variables were assessed using chi-square test or Fisher's exact test and factors associated with mortality were identified using multivariate logistic regression. Kaplan-Meier curves and log-rank tests were used to estimate mortality rates and compare survival post PEG insertion. Results: A total of 145 patients underwent PEG insertion using the pulltechnique (61.3% men, median age 68 years [IQR 59.5-77.5]). 60% of patients had WHO performance status 3 or 4 and 36.5% had two or more significant co-morbidities. The main indications for PEG were head and neck cancer (n= 64, 44.1%), cerebrovascular disease (n= 40, 27.5%) and neurological disorders (n= 27, 18.6%). There was a marked decline in PEG insertion in 2020 (n=55) compared to 2019 (n=90), mainly due to a 47.6% decline in prophylactic PEG insertion for head and neck cancer patients. There were no differences in patients' characteristics, co-morbidities and indications for PEG between the two study periods. Patients had longer hospital admissions in 2020 compared to 2019 (p=0.04). However, mortality rates were similar (p=0.11). 40/55 patients were screened for COVID-19, none of whom tested positive after two weeks of PEG insertion. The overall mortality was 7.5% at 30 days, 14.4% at 60 days and 18.6% at 90 days. Causes of death were sepsis (40.7%), pneumonia (37%) and COVID-19 (14.8%). Mortality was significantly higher for inpatient PEG insertion compared to outpatient (p<0.0001), but there was no procedurerelated mortality. At multivariate analysis, low serum albumin was independently associated with mortality (OR 1.2, 95% CI 1.07-1.37, p=0.002). 23/145 (15.8%) patients were successfully weaned off PEG in a mean period of 259 days (SD 170), the majority were head and neck cancer patients 19/23 (82.6%). Conclusion: PEG insertion during the COVID-19 pandemic was safe with a low risk of COVID-19 transmission and no significant difference in mortality compared to the pre-pandemic cohort. The decline in PEG insertion numbers was attributable to a significant reduction in elective cancer treatment.