Percutaneous endoscopic gastrostomy (PEG) is essential for enteral feeding in patients with neurologic or head/neck/esophageal disorders. Direct puncture (DP) after gastropexy is suggested to reduce complication rates compared to pull-through (PT) technique. However, indications determine the choice between both techniques. In this large, retrospective propensity score matched study from a German tertiary endoscopic center, we aim to comprehensively evaluate the complication profiles of DP technique and compare it to the more frequently performed PT method stratified by indications.

Retrospective data of all PEG procedures from 2015 to 2024 were collected from electronic patient charts including general demographic information, comorbidities, medication, laboratory results and outcomes.

Propensity score matching between DP and PT was performed (1:2) for underlying disease and current treatment of malignant diseases to reduce selection bias.

Primary outcomes were occurrence of major (bleeding, pneumoperitoneum, perforation, systemic infection and tube dislodgment) and minor adverse events (pain and local infection). Secondary outcome was 60-day-mortality.

A total of 1002 consecutive PEG procedures (n = 178 DP, n = 816 PT, n = 8 for other techniques) were included. Overall, baseline characteristics were significantly different for underlying disease and current treatment for malignant disease in the DP group (PT: 44.1% vs. DP: 87.6%, p < 0.001). Overall major and minor adverse events were 34,8% but significantly lower in PT (PT: 32% vs. DP: 48,3%, p < 0.001).

Following 1:2 propensity score matching, 513 procedures (171 DP, 342 PT) were analyzed. The median age was 64 years with 68.6% male patients. Baseline demographics, medication and comorbidities were not significantly different between the matched cohorts.

Major (PT: 41.8% vs. DP: 47.3%, p = 0.24) and minor (PT: 11.7% vs. DP: 9.4%, p = 0.423) adverse events were similar between both groups matched for tumour disease and treatment.

However, tube dislodgment occurred significantly more frequently in the DP compared to the PT group (7.6% vs. 1.5%, p < 0.001).

60-day-mortality was similar between PT and DP (8.5 vs. 10.5%, p = 0.449).

Our results show that, except for tube dislodgment, adverse event rates are comparable between PT and DP and thus, do not confirm previous reports of reduced complication rates in DP, when matched for underlying disease. In our study different complication rates are observed with types of underlying disease. This study underlines the current ESGE recommendation to perform pull through technique if technically feasible.