Safety, success, and outcomes of percutaneous endoscopic gastrostomy performed under local anesthesia in ASA III–IV patients: a single-center retrospective analysis

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is widely used for long-term enteral nutrition; however, procedural sedation may increase cardiopulmonary risk in elderly, frail patients and those with comorbidities. This study evaluated the feasibility and safety of PEG placement under topical pharyngeal and local infiltrative anesthesia without procedural sedation in patients with American Society of Anesthesiologists (ASA) physical status III–IV.
METHODS: This retrospective, single-center observational study included patients with ASA physical status III–IV who underwent attempted PEG placement between January 2024 and December 2025. All procedures were initially attempted without procedural sedation. Patients requiring conversion to sedation because of intolerance were excluded from the local anesthesia-only outcome analysis. Demographic characteristics, comorbidities, procedure duration, complications, and 30-day mortality were analyzed.
RESULTS: Among 196 patients, PEG placement was technically successful in all cases. Thirty-eight patients required conversion to sedation, whereas 158 completed PEG placement without procedural sedation, yielding a local anesthesia-only completion rate of 80.6%. The mean age of the local anesthesia-only cohort was 81.6±9.7 years, and 92 patients (58.2%) were female. Early complications occurred in 11 patients (7.0%), late complications in 21 (13.3%), and overall patient-based complications in 31 (19.6%). One patient (0.6%) developed a perforation requiring surgery. Thirty-day all-cause mortality in the local anesthesia-only cohort was 8.2%, with no procedure-related mortality in either group.
DISCUSSION AND CONCLUSION: PEG placement without procedural sedation was feasible in most selected patients with ASA physical status III–IV, although approximately one-fifth required conversion to sedation. This approach may be considered for selected high-risk patients.

Keywords: ASA physical status, complications, enteral nutrition, local anesthesia, percutaneous endoscopic gastrostomy, unsedated