Early Insertion of Percutaneous Endoscopic Gastrostomy in Patients with Isolated Elevated White Blood Cell Counts

Abstract

Purpose: Percutaneous Endoscopic Gastrostomy (PEG) is a common procedure for patients with dysphagia. Several large prospective trials for PEG have evaluated the efficacy of the procedure. Traditionally gastroenterologists have been hesitant to perform PEG insertions in patients with elevated white blood cell (wbc) counts. Literature review shows that very few published studies have analyzed the complications of PEG placement in otherwise non infected patients with isolated elevated WBC counts. The aim of our study was to analyze complications of PEG placement in patients with isolated elevated WBC counts as compared to patients with normalized wbc counts at the time of PEG placement. Methods: This was a retrospective cohort analysis of a total of 465 patients, 60 men and 405 women who underwent PEG placement. All patients who underwent PEG placement in IMC and NYMH from January 2005 to June 2010 were included in the study. The patients were followed up for a period of one year following PEG placement. Patients with fever, hematological malignancies or on steroids were excluded. A cut off value of 11,000/ml WBCs or above was considered elevated in the study. Patients in group 1 had elevated WBC counts at PEG insertion and patients in group 2 had normal WBC counts. All patients in this study were free from active infections at the time of surgery. This was supported by clinical, laboratory, microbiological and radiologic data obtained from chart review. All patients received preoperative antibiotics as short-term prophylaxis. The data was analyzed using IBM SPSS 20.0. The comparisons between the groups were made using student's t test, Chi-square test and ANOVA. Results: There was significant reduction of 5.19 days in the length of hospital stay with early insertion of PEG (p 0.03). There was no statistically significant increased risk of complications with early insertion of PEG in the presence of isolated elevated WBC counts. There were no cases of severe complications including necrotizing fasciitis, esophageal perforation, colocutaneous fistula, peritonitis, ileus, gastric outlet obstruction or death secondary to PEG placement in either group. Conclusion: In our study, there was no evidence of increased complications or mortality related to early PEG placement in patients with isolated elevated WBC counts. Therefore it is reasonable to consider early PEG placement in patients with isolated elevated wbc counts rather than delaying the PEG procedure for WBC counts to normalize. In our study, early insertion of PEG led to reduction in the average length of hospital stay by 5.19 days (p 0.03). This can lead to substantial reduction in health care costs. Further prospective studies are needed to confirm our findings.Table: Results of PEG placement in isolated elevated wbc counts vs normalized wbc counts