Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Percutaneous endoscopic gastrostomy feeding was more effective than nasogastric feeding for patients with neurological dysphagia

ACP J Club. 1993 Jan-Feb;118:9. doi:10.7326/ACPJC-1993-118-1-009


Source Citation

Park RH, Allison MC, Lang J, et al. Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ. 1992 May 30;304:1406-9.


Abstract

Objective

To compare the effectiveness of percutaneous endoscopic gastrostomy (PEG) and nasogastric tube feeding in patients with persisting neurologic dysphagia.

Design

Randomized trial of 28 days duration.

Setting

3 teaching hospitals in Glasgow, Scotland, United Kingdom.

Patients

40 patients (mean age 61 y, 55% men) with ≥ 4 weeks dysphagia caused by neurologic disease who had a normal gastrointestinal tract and were likely to survive for ≥ 1 month. Exclusion criteria were dementia; mechanical lesions causing obstruction of the esophagus or stomach; active intra-abdominal inflammation; partial gastrectomy, reflux esophagitis, or intestinal obstruction; presence of ascites, hepatomegaly, severe obesity, coagulopathy, or untreated aspiration pneumonia; or major systemic disease. 38 patients completed the study (1 patient in each treatment group died before feeding started).

Intervention

Patients were allocated to receive enteral nutrition with either a fine-bore nasogastric tube (n = 20) or a gastrostomy tube (n = 20) inserted percutaneously by endoscope with antibiotic prophylaxis. First feeding was after return of bowel sounds. The enteral liquid diets were infused over 24 hours with a volumetric pump. The volumes of feed were tailored to the patients' needs.

Main outcome measures

Treatment failure (failure to position the tube, displacement or blockage of the tube on ≥ 3 occasions, or refusal of the patient to continue), duration of feeding, amount of feed received, and complications.

Main results

Treatment failure occurred in 18 patients (95%) in the nasogastric group and in none in the gastrostomy group (P < 0.001) (Table). 14 (78%) of the treatment failures in the nasogastric group were because of tube displacement. One patient in the nasogastric group compared with all patients in the gastrostomy group completed 28 days of feeding (mean duration of feeding was 5.2 d in the nasogastric group) (P < 0.001). The nasogastric group received a mean of 55% of their prescribed feed compared with 93% in the gastrostomy group (P < 0.001). No complications occurred in the nasogastric group; in the gastrostomy group, 2 patients had aspiration pneumonia and 1 patient had a wound infection but this difference did not reach statistical significance (Table).

Conclusion

Percutaneous endoscopic gastrostomy tube feeding was more effective than nasogastric tube feeding in patients with persisting neurologic dysphagia.

Sources of funding: Scottish Motor Neurone Disease Association and Bard Limited.

For article reprint: Dr. P.R. Mills, Gartnavel General Hospital, Glasgow, Scotland G12 0YN, United Kingdom. FAX 44-141-2113466.


Table. Percutaneous endoscopic feeding vs nasogastric feeding for patients with neurological dysphagia*

Outcomes at 28 d Percutaneous feeding Nasogastric feeding RRR (95% CI) NNT (CI)
Failure 0% 95% 100% 2 (1 to 3)
Problems 0% 15.8% 100% Not significant

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

In the United States, over 50 000 percutaneous endoscopic gastrostomies (PEGs) are done yearly for patients who cannot eat because of chronic neurologic or oropharyngeal diseases. The superiority of PEG over nasogastric tube feeding, however, has not been established until now (1).

The decision to do PEG still needs to be carefully considered (2, 3). For example, patients who are likely to recover their ability to eat within a few weeks are not PEG candidates. Upper abdominal scars or previous gastric resection can make PEG tube placement technically impossible. Other relative contraindications include bleeding diatheses, portal hypertension, esophageal stricture (which should first be dilated), active peptic ulceration, or a short-bowel syndrome. Whether patients with a short life expectancy should be considered candidates for PEG is debatable (3).

PEG tube placement requires only local anesthesia and a short operating time. Wound infection is now uncommon because of the prophylactic use of antibiotics (e.g., cefazolin) (4). Minor complications do still occur within 3 months in up to two thirds of patients (2); tube replacement, although safe, is often required. Major complications, including gastric perforation, bleeding, prolonged ileus, and laryngospasm, occur in about 3% of patients (2). Over the long term, pneumonia is the most common cause of death in patients with a PEG tube, but this may be secondary to aspiration of oropharyngeal secretions because of the primary swallowing defect (2, 3). Jejunal tubes probably do not reduce the aspiration risk (3).

More recently, the superiority of PEG over nasogastric feeds was shown in a controlled trial in patients with acute dysphagia stroke treated approximately 2 weeks after hospital admission (5). In patients who require enteral nutrition and who have an intact, nonobstructed gut, PEG is the procedure of choice where technically feasible.

Nicholas J. Talley, MB, PhD
Nepean HospitalPenrith, New South Wales, Australia


References

1. Rabeneck L, Wray NP, Petersen NJ. Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. J Gen Intern Med. 1996;11:287-93.

2. Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology. 1987;93:48-52.

3. Taylor CA, Larson DE, Ballard DJ, et al. Predictors of outcome after percutaneous endoscopic gastrostomy: a community-based study. Mayo Clin Proc. 1992;67:1042-9.

4. Jain NK, Larson DE, Schroeder KW, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy. A prospective, randomized, double-blind clinical trial. Ann Intern Med. 1987;107:824-8.

5. Norton B, Homer-Ward M, Donnelly MT, et al. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ. 1996;312:13-6.