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Percutaneous Endoscopic Gastrostomy (PEG) Tubes: Medical, Legal and Ethical Considerations for Patients and Physicians

Course Authors

David E. Milkes, M.D.

Dr. Milkes is Fellow, Gastroenterology and Hepatology, Stanford University Medical Center, and reports no commercial conflict of interest.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 
Learning Objectives

Upon completion of this Cyberounds®, you should be able to:

  • Identify the major indications and contraindications to PEG tube placement

  • Discuss the complications associated with PEG tube placement

  • Discuss the major legal, ethical and medical issues surrounding PEG tube placement.

 

Percutaneous endoscopic gastrostomy (PEG) tubes have become the most common method of providing patients with long-term enteral nutrition. Since 1980, when the procedure was introduced, the number of PEGs placed has risen dramatically. Between 1988 to 1995, placement doubled among elderly hospitalized patients undergoing the procedure, from 61,000 to 121,000.(1) Indeed, most patients receiving PEGs are elderly and as the population ages physicians will increasingly face decisions regarding PEG placement.

Although PEGs are a common and seemingly routine procedure, there are many complex issues surrounding their placement. Decisions regarding PEGs can be particularly complicated and challenging in patients near the end of life, when legal and ethical questions about the provision of food and water are concerns.

Furthermore, several studies have called into question the lack of medical benefit of PEGs in elderly demented patients, while other analyses have revealed a relatively high mortality rate in certain patients within one month of PEG placement. These findings have alerted us to the need for widely accepted clinical guidelines to assist physicians in selecting patients for PEG but, unfortunately, such guidelines are not currently available. Moreover, the roles of the primary physician and the gastroenterologist are not well-defined; the gastroenterologist may be perceived as merely a technician performing the procedure.

Physicians are primarily responsible for initiating discussions with the patient and family about PEG placement and once the topic is introduced the procedure usually takes place.(2) Therefore, before even discussing the procedure with patients, physicians should have a clear understanding of their motivations and goals for pursuing PEG placement. In this way, physicians will be best able to select patients for PEG placement in a medically, legally and ethically responsible manner until such time as clinical guidelines can be fully developed.

Indications and Contraindications

In general, PEGs are placed to provide enteral nutrition for patients who cannot or will not eat, and who have a normally functioning gastrointestinal tract.(3) Common etiologies of dysphagia in this group of patients include head trauma, stroke, collagen vascular disorders and neurological diseases.(4),(5) Mechanical obstruction secondary to head and neck cancers, as well as esophageal cancers, are also common causes in this group of patients.(5)

Depressed patients may refuse to eat and may benefit from tube feedings as their underlying psychiatric condition is being treated. PEGs have been used to provide supplemental nutrition for patients with high catabolic conditions such as cancer cachexia or AIDS cachexia,(5) but the benefit of enteral nutrition for these patients is unclear and continues to be debated. PEGs are commonly placed to provide palliative stomach drainage in patients with gastric or intestinal obstruction secondary to advanced cancers.

There are some rare indications for PEG -- treatment of gastric volvulous, delivery of unpalatable medications and recirculation of bile drained exteriorly from the biliary tract.(4) It should be emphasized that prevention of aspiration pneumonia is not an indication for PEG.(6) Patients undergoing PEG may still be prone to aspirate oral secretions or refluxed gastric contents.

Patients undergoing PEG should require enteral feeding for greater than 30 days.(6) Patients with a life expectancy of less than 30 days or patients who will only require short-term enteral feeding of less than 30 days may be fed via a nasoenteric feeding tube.(6),(7) This recommendation, endorsed by the American Gastroenterological Association, spares patients with a grave prognosis or limited need for tube feedings the expense, risks and potential burdens of an invasive procedure.

Absolute contraindications to PEGs include the inability to pass the endoscope through the esophagus and peritonitis.(4),(5) Patients with esophageal cancer who are surgical candidates for curative resection should not undergo PEG with the feeding tube either pushed or pulled past the tumor because this may risk metastatic seeding of the gastrocutaneous tract. Relative contraindications include massive ascites, peritoneal dialysis, coagulopathy, gastric varices, portal hypertension, anorexia nervosa, large hiatal hernia, hepatomegaly, morbid obesity, prior subtotal gastrectomy and neoplastic diseases of the gastric wall.(4),(5)

Complications

The complications occurring with PEG placement can be divided into minor and major categories (see Table 1).

Table 1. Complications from PEG.

Minor (7-10% incidence)
  • Local skin infection
  • Tube obstruction
  • Inadvertent removal of the tube
  • Restraining the patient
  • Self-limited bleeding
  • Self-limited abdominal pain
Major (1-2% incidence)
  • Death
  • Necrotizing fasciitis
  • Aspiration pneumonia
  • Severe bleeding
  • Infectious peritonitis
  • Gastrocolonic fistula
  • Buried bumper syndrome
  • Perforation
  • Tumor seeding

Most complications are minor and occur in approximately 5-10% of cases, although rates as high as 30-40% have been reported.(8) Easily treatable and uncomplicated wound infections, bleeding and abdominal pain secondary to a chemical peritonitis represent the majority of minor complications.(8)(9) Pneumoperitoneum is a common occurrence post-PEG and has no clinical significance in the absence of peritoneal signs.(6)

PEGs can become clogged thereby preventing delivery of feedings and medications. Inadvertent or patient mediated removal of the tube is another common complication. Patients may require restraining in order prevent them from pulling on the tube, and some practitioners consider requirement for such restraints to be an undesirable outcome.(10)

Minor complications are responsible for considerable healthcare utilization and cost. One study documented that 7% of emergency room visits by nursing home patients in a single community were for gastrostomy tube complications with an average charge per visit of $1,000.(11)

Major complications are rare, occurring in 1-2% of cases.(12) The overall mortality rate associated with PEG is 0.3-1%.(5) The risk of mortality is likely associated with the advanced age and co-morbidities in the elderly patient population undergoing PEG, rather than simply being attributable to the procedure itself.

Necrotizing fasciitis is a severe, rare infectious complication. A more common and also life-threatening infectious complication is procedure related aspiration pneumonia.(8) Other rare complications limited to case reports include severe bleeding, infectious peritonitis, gastrocolonic fistulas caused by anomalous interposition of the colon between the stomach and abdominal wall, bumper penetration into the gastric wall (so-called buried bumper syndrome) and intestinal obstruction.(5)(8)(9)

There is evidence to support the use of prophylactic intravenous antibiotics to reduce the incidence of wound infections and necrotizing fasciitis. Indeed, a recent meta-analysis concluded that prophylactic use of antibiotics to reduce wound infections is cost effective, and the American Society of Gastrointestinal Endoscopy endorses this practice.(13)

Legal Considerations

Starting with the case of Karen Ann Quinlan in 1976, the United States courts have established legal precedents concerning life-sustaining treatments and artificial nutrition and hydration. Repeatedly, the courts have upheld the principle that competent patients may refuse or withdraw any medical treatment, even if that treatment is life-sustaining. The right to refuse life-saving medical therapies is upheld whether or not the patient has a terminal illness. In the Nancy Cruzan case in 1990, the majority ruling of the U.S. Supreme Court held the position that there is no difference between the termination of artificial nutrition and hydration and other forms of treatment.(14) Furthermore, the American Medical Association, a President's Commission and essentially every appellate court case have held that artificial nutrition and hydration is a medical procedure.(14)(15) Therefore, competent patients can legally refuse tube feedings, just as they can refuse any other medical treatment.

Medical decision-making for incompetent patients who cannot express their own wishes was addressed in the Quinlan case. The court determined that family members may refuse life-support on behalf of the incompetent patient.(16) Only two states, New York and Missouri, have strict requirements that surrogate decision-makers present "clear and convincing" evidence that the patient, while competent, would not have wished artificial nutrition and hydration in the setting of their present medical condition. Courts have recognized written statements and conversations with family and friends to constitute forms of "clear and convincing" evidence.

To assist physicians and families in making medical decisions for incompetent patients, the majority of state legislatures have passed statues to honor advance directives. An advance directive is a statement that a person makes, while competent, expressing their desire regarding treatment in the future, should they lose the capacity to make decisions.(14) It may provide written instructions about treatment (a living will) or may designate another person to make treatment decisions (a proxy or durable power of attorney).

Physicians should discuss advance directives with all their patients, not just geriatric patients or those with severe medical problems. In fact, all health care facilities receiving Medicare or Medicaid are legally obligated to provide patients with written information about their rights to accept or refuse medical treatments, and patients admitted to these facilities must be provided the opportunity to complete advance directives.(15) In rare cases, where no family member or legal instrument is available to determine the wishes of an incompetent patient, physicians should err in the direction of preserving life as long as the anticipated benefits of treatment outweigh the burdens.

Although each state has its own set of laws about terminating life-support, certain general principles apply across the United States. The courts have made no legal distinction between withholding and withdrawing life-sustaining treatments. Therefore, tube feedings can legally be withdrawn after they have been initiated. With the exception of Illinois, no state requires a physician to have a court order to withhold or withdraw tube feedings.(14) Rather, the courts overwhelmingly favor that such personal and emotional issues be dealt with directly through the physician-patient relationship and family interactions.

Although physicians may fear litigation, only 60 court cases were reported from 1975-1990 that involved decisions about terminating life-sustaining care, and most of these cases sought permission to terminate care.(14) None of those 60 cases resulted in criminal liability against a physician. In other words, when patients or surrogate decision makers properly refuse tube feedings, physicians are not legally obligated to provide artificial nutrition and hydration, nor should they fear litigation because they respect the decision to withhold or terminate such feedings.

Although legal, withholding or withdrawing tube feeding can be emotionally wrenching. There are strong cultural factors which associate caring and nurturing the sick by providing them with food and water. The instinctual response to feed the sick may lead some to question the ethical integrity of existing laws and, therefore, an exploration of the ethical issues is warranted.

Ethical Issues

Patient autonomy is a strongly accepted and protected principle of medical ethics. The principle was widely adopted into clinical practice after the drafting of the Nuremberg Code in 1947 which sought to protect patients from unwanted medical procedures. According to the principle of autonomy, patients have the right to decide their medical treatment; in other words, medical treatments cannot be imposed on the individual.

To protect patient autonomy, informed consent must be obtained prior to performing an invasive procedure. Informed consent insures that the patient understands the risks, benefits and alternative options of a procedure prior to undergoing the procedure. The concept of autonomy is important in discussions regarding PEG placement because it necessitates that the individual patient's values be respected and preserved prior to proceeding with the procedure.

In situations where the patient lacks capacity to make medical decisions, physicians need to direct families and health care proxies to make decisions based upon the patient's values and not their own. Physicians may therefore ask, "If your father could tell us whether or not he would want a PEG, what would he say?" or "Did your father ever express an opinion about life-support or artificial food and hydration?" The goal of such directed questioning should be to elucidate the patient's individual values and wishes. Because patients have different value systems, decisions regarding PEG placement will differ accordingly.

In a simplified model, there are two basic value systems regarding artificial food and hydration to which a patient may ascribe. Some patients, perhaps based on their religious beliefs, will regard all life as valuable and worth preserving. Accordingly, they regard the quantity of life preserved to be more important than the quality of life preserved. With this understanding in mind, they may choose to receive artificial food and hydration no matter what their clinical condition because without food and water they would surely die. They could argue that not providing food and water to a person results in that person dying of starvation.

Conversely, some patients will favor the quality of life preserved rather than the quantity of life preserved. They may regard certain clinical conditions, such as a permanent vegetative state, to lack sufficient quality of life to be preserved. They may view the provision of artificial food and hydration as merely prolonging their suffering in an undesirable condition. When artificial feedings are withheld in these patients, it can be argued that they die naturally as a result of their underlying medical condition and not from starvation. Because the intent of withholding artificial food and hydration is to relieve suffering, the action is justified they feel.

For the primary care giver, the central ethical issue is to determine the patient's individual value system and then make a medical decision consistent with those values. The physician's role is to provide perspective, clarification of uncertainties and reassurance that an ethically sound decision has been made.

Once there has been a decision to place a PEG tube, patients and family members may further question the ethics of stopping tube feeding after it has been initiated. Most ethicists believe that the distinction between withdrawing and withholding life-sustaining treatment is a matter of semantics rather than a matter of ethics.(16) If the benefits of providing artificial nutrition and hydration are unclear, then treatment may be started on a trial basis. Should the treatment become ineffective or too burdensome, it may be discontinued. By using this approach, one avoids withholding a potentially beneficial treatment because of a preconceived notion that the treatment could not be stopped once it was started.(16) In regard to PEG placement and feedings, it is important for patients and families to realize prior to the procedure that the feeding tube can ethically be withdrawn in the future. These ethical issues may be included with the information provided by the physician during an informed consent session.

The informed consent discussion, in addition to insuring patient autonomy and allowing the exploration of ethical issues, also provides an opportunity for the physician to examine his/her own motivations for pursuing PEG placement. Some experts have cautioned that PEG placement may be pursued for reasons other than for the primary health benefit of the patient. For example, a physician may perceive PEG placement to be a pre-requisite to nursing home placement or an expedient hospital discharge. If PEG placement is being pursued for a primary reason other than to benefit the patient, then the action may be unethical, especially if it violates the patient's autonomy.

Patients and families need to be aware that there are alternatives to PEGs. Patients can receive long-term enteral feedings via nasogastric tubes or they can be hand-fed.(17)(18) The most uncertain element physicians must address in obtaining informed consent for PEGs is their proven benefit. There are certain situations in which there is no data showing a medical benefit for PEG placement and this should be openly discussed.

Controversial Benefit of PEGs in Elderly Demented Patients

As the United States population ages, we can expect that the incidence of dementia will increase. Currently, about 4 million Americans suffer from Alzheimer's disease and other forms of dementia. In the later stages of dementia, patients commonly experience difficulty eating or have a decreased interest in eating, and the decision is frequently made to place a feeding tube.(19)

Physicians, families, and patients can be easily persuaded by the apparent validity of tube feedings -- "if patients have trouble eating, it seems sensible to feed them by any means."(20) However, the lack of evidence demonstrating beneficial clinical outcomes in elderly demented patients receiving PEG feedings has lead several authorities to question the routine use of PEGs in this patient population. They argue that if there is no clinical benefit to be achieved from PEG feedings, then patients should not be subjected to the potential risks and burdens of the invasive procedure. They also urge physicians and families to realize that the natural history of dementia involves a progressive disinterest in eating.

Frequently cited medical goals for tube feeding demented patients include decreasing the risk of aspiration pneumonia, improving nutritional and functional status, relieving hunger and thirst, healing or preventing pressure ulcers and prolonging survival. However, a recent review of the medical literature analyzing reports from 1966 to 1999 found no published studies to support any of these goals.(20) To the contrary, the authors found evidence supporting equivalent or worse outcomes in patients fed by PEG when compared to hand-feeding. For example, two retrospective studies revealed that tube feedings were actually associated with higher rates of aspiration pneumonia when compared to oral feedings.(21) In terms of mortality, a nursing home study of demented patients with eating disorders showed no difference in survival between patients receiving gastrostomy feedings versus hand-feedings.(18)(19)

Because demented patients cannot communicate reliably, it may be difficult to determine their symptoms of hunger and thirst. However, inferences from studies of lucid patients with anorexia secondary to cancer and stroke have demonstrated that such patients experience only transient hunger and their thirst may be easily palliated with ice chips or sips of water.(19) Given the lack of substantiated clinical benefit from PEGs in this patient population, one authority concluded that "facilitation of hospital discharge into a less expensive home care or step-down facility is the most likely goal to be realized after PEG placement."(22)

Another finding elucidated by several observation studies is the relatively high 30-day post-PEG mortality rate.(23) A large, retrospective study of over 80,000 elderly, hospitalized patients receiving gastrostomy tubes reported a 30-day mortality of 25-30%.(1) Variables associated with higher 30-day post-PEG mortality included age over 75, concomitant infection and a previous history of aspiration pneumonia.(23) Based on these findings, some clinical investigators have interpreted PEG placement in elderly patients as a potential marker of a poor prognosis. Physicians need to be aware that their own inclination to request a PEG suggests that, at least some of the time, the recipient patient has a poor 30-day prognosis.

Based on the medical literature there is considerable uncertainty that PEG feedings will achieve their intended goals, and there is a need for guidelines to help physicians select which patients will benefit most from PEGs in terms of mortality and clinical outcomes. This medical uncertainty should be communicated to families and patients because, if the patient's value system places an emphasis on the quality of life, then it is legally, ethically and clinically justifiable to withhold tube feedings in severely demented elderly patients. This is especially true given that nasogastric feedings or hand-feedings are acceptable alternatives.

Available Guidelines

Adding to the complexity of issues surrounding PEG placement is the fact that the roles of the primary physician and the gastroenterologist are not clearly defined in the decision-making process. The gastroenterologist, who may have the most insight into these complex issues, often functions merely as a proceduralist who places the feeding tube, while the primary physician may fulfill the difficult task of discussing the issues with the patient and family. Clearly, there is a need for validated clinical practice guidelines to assist physicians in this difficult process but, unfortunately, none are available.

The American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy have published guidelines for PEGs that provide the accepted indications, contraindications and complications of the procedure.(3),, But these guidelines fail to provide a step-by-step approach for the physician to follow, do not delineate the roles of referring physicians and gastroenterologist or take into account ethical considerations.

Toward the aim of developing guidelines, a medical ethics group has published an algorithm for PEG placement that incorporates ethical considerations into the decision-making process.(24) With the algorithm, a physician can determine whether or not a PEG should be offered to a particular patient, whether to recommend a PEG or simply discuss placement in a non-directive fashion and which ethical principle is being invoked for each situation. For example, a patient with anorexia-cachexia syndrome as a result of cancer should not be offered a PEG because administration of nutrients cannot reverse the cachexia. In other words, the provision of nutrients to such a patient is futile and physicians have no ethical obligation to provide futile treatments. This particular algorithm, however, has not yet been validated in any clinical settings nor has it been endorsed by any professional association. Until widely accepted clinical practice guidelines are developed, physicians must continue to struggle with the complex task of deciding which patients they will refer for PEG.

Summary Recommendations

A physician's task of referring and counseling patients for PEG placement need not be a daunting one. Careful forethought and an appreciation of the complexities involved can enable a physician to make clinically and morally appropriate decisions. Physicians must realize that once the topic of PEG placement is introduced to the patient and family, the procedure will most likely take place because a sense of inevitability is created. Therefore, before approaching the patient and family, the physician should think about the indications and intended aims of PEG placement in any particular patient. Is there a proper indication? Are there any contraindications? What is the patient's prognosis? If the expected survival of the patient is less than 30 days, then a 30-day trial of nasoenteric feedings is appropriate prior to PEG placement.

Physicians need to be clear about the motivations and intended aims for recommending a PEG. Is there an expected clinical outcome such as improving nutritional or functional status, prolonging survival, or assisting wound healing? At least in the case of elderly demented patients, the clinical utility of tube feedings is very uncertain and conservative treatment with hand-feeding is a humane option.

If the referring physician has any reservations, then the advice of a gastroenterologist may be beneficial. Indeed, consultation with the gastroenterologist prior to approaching the patient and family is an excellent means of delineating respective physician roles in the PEG placement process. Once the referring physician is convinced that a PEG is indicated, that the intended outcomes are likely to be realized and that the physician understands their particular role, then the physician can approach the patient and family.

The patient's values and wishes need to be determined. If the patient is incompetent, the physician should seek out any available advance directives, such as a living will or proxy, to help elucidate patient wishes. The patient and family should be counseled that it is both legal and ethical to withhold artificial nutrition and hydration in cases where the patient has properly refused such life-sustaining treatment. Furthermore, patients and families must also realize that once a PEG has been placed, it is both legal and ethical to withdraw the tube in the future should the patient's suffering become too overwhelming. The conditions under which the PEG might be withdrawn in the future should be discussed and agreed upon prior to PEG placement.

The most appropriate setting for these difficult, often emotionally wrenching decisions is within the doctor-patient relationship, not courts of law. The physician should be able to draw upon a knowledge of the ethical debate in order to address anticipated questions. For example, if a family member asks "But without a PEG, won't he just starve to death?" the physician may offer the counter viewpoint that the patient is dying from an underlying disease and that if the goal is to relieve suffering then artifical feedings may be ethically withheld.

The physician should be open and direct in detailing current controversies surrounding the lack of proven medical benefit and the relatively high mortality rate in elderly demented patients undergoing PEG. Until such time as validated clinical guidelines are available, primary physicians and gastroenterologists will need to work together to properly refer and select patients for PEG.


Footnotes

1Grant MD, Rudberg MA, Brody JA. Gastrostomy Placement and Mortality Among Hospitalized Medicare Beneficiaries. JAMA 1998; 279: 1973-1976.
2Callahan CM., Haag KM, Nienaber-Buchanan N, Nisi R. Decision-Making for Percutaneous Endoscopic Gastrostomy Among Older Adults in a Community Setting. Journal of the American Geriatrics Society 1999;47:1105-1109.
3American Gastroenterological Association. American Gastroenterological Association medical position statement: guidelines for the use of enteral nutrition. Gastroenterology 1995:108;1280-1301.
4Safadi BY, Marks JM, Ponsky JL. Percutaneous endoscopic gastrostomy: an update. Endoscopy 1998;30:781-789.
5American Society for Gastrointestinal Endoscopy. Role of PEG/PEJ in enteral feeding. Gastrointestinal Endoscopy 1998;48:699-701.
6American Gastroenterological Association. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology 1995;108:1282-1301.
7Taylor CA, Larson DE, Ballard DJ, Bergstrom LR, Silverstein MD, Zinmeister AR, DiMango EP. Predictors of outcome after percutaneous endoscopic gastrostomy: a community-based study. Mayo Clinic Proceedings 1992;67:1042-1049.
8Fennerty, MB. Complications of Endoscopy. In Clinical Practice of Gastroenterology, 1st Ed. Edited by Brandt LJ. Philadelphia: Churchill Livingstone; 1539-1548.
9Mellinger JD and Ponsky JL. Percutaneous endoscopic gastrostomy: state of the art, 1998. Endoscopy 1998;30:126-132.
10Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. New England Journal of Medicine 2000;342:206-210.
11Ackerman RJ, Kemle KA, Vogel RL, Griffin RC. Emergency department use by nursing home residents. Annals of Emergency Medicine 1998;31:749-757.
12Schapiro GD and Edmundowicz SA. Complications of percutaneous endoscopic gastrostomy. Gastrointestinal Endoscopy Clinics of North America 1996;6:409-422.
13Kulling D, Sonnenberg A, Michael F, Bauerfeind P. Cost analysis of antibiotic prophylaxis for PEG. Gastrointestinal Endoscopy 2000;51:152-156.
14Meisel A. Legal myths about terminating life support. Archives of Internal Medicine 1991;151:1497-1502.
15Fairman RP. Withdrawing life-sustaining treatment. Archives of Iternal Medicine 1992;152:25-27.
16Herrmann VM and Norris PF. Ethical issues in instituting and discontinuing enteral feedings. Gastrointestinal Endoscopy Clinics of North America 1998;8:723-732.
17Fay DE, Poplausky M, Gruber M, Lance P. Long-term enteral feeding: a retrospective comparison of delivery via percutaneous endoscopic gastrostomy and nasoenteric tubes. American Journal of Gastroenterology 1991;86:1604-1609.
18Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Archives of Internal Medicine 1997;157:327-32.
19Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. The New England Journal of Medicine 2000;342:206-210.
20Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282:1365-1370.
21Finucane T, Bynum JPW. Use of tube feeding to prevent aspiration pneumonia. Lancet 1996;348:1421-1424.
22Wolfson HC, Kozarek RA, Ball TJ, Patterson DJ, Botoman VA, Ryan JA. Long-term survival in patients undergoing percutaneous endoscopic gastrostomy and jejunostomy. American Journal of Gastroenterology 1990; 85:1120-1122.
23Light VL, Slezak FA, Porter JA, Gerson LW, McCord G. Predictive factors for early mortality after percutaneous endoscopic gastrostomy. Gastrointestinal Endoscopy 1995;42:330-335.
24Rabeneck L, McCullough LB, Wray NP. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 1997;349:496-498.