BACKGROUND: A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.
OBJECTIVES: To evaluate the effectiveness and safety of PEG compared with NGT for adults with swallowing disturbances.
SEARCH METHODS: We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to January 2014, and contacted the main authors in the subject area. There was no language restriction in the search.
SELECTION CRITERIA: We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment).
DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%.
MAIN RESULTS: We included 11 randomised controlled studies with 735 participants which produced 16 meta-analyses of outcome data. Meta-analysis indicated that the primary outcome of intervention failure, occurred in lower proportion of participants with PEG compared to NGT (RR 0.18, 95% CI 0.05 to 0.59, eight studies, 408 participants, low quality evidence) and this difference was statistically significant. For this outcome, we also subgrouped the studies by endoscopic gastrostomy technique into pull, and push and not reported. We observed a significant difference favouring PEG in the pull subgroup (RR 0.07, 95% CI 0.01 to 0.35, three studies, 90 participants). Thepush subgroup contained only one clinical trial and the result favoured PEG (RR 0.05, 95% CI 0.00 to 0.74, one study, 33 participants) techniques. We found no statistically significant difference in cases where the technique was not reported (RR 0.43, 95% CI 0.13 to 1.44, four studies, 285 participants).There was no statistically significant difference between the groups for meta-analyses of the secondary outcomes of mortality (RR 0.86, 95% CI 0.58 to 1.28, 644 participants, nine studies, very low quality evidence), overall reports of any adverse event at any follow-up time point (ITT analysis, RR 0.83, 95% CI 0.51 to 1.34), 597 participants, 6 studies, moderate quality evidence), specific adverse events including pneumonia (aspiration) (RR 0.70, 95% CI 0.46 to 1.06, 645 participants, seven studies, low quality evidence), or for the meta- analyses of the secondary outcome of nutritional status including weight change from baseline, and mid-arm circumference at endpoint, although there was evidence in favour of PEG for meta-analyses of mid-arm circumference change from baseline (MD 1.16, 95% CI 1.01 to 1.31, 115 participants, two studies), and levels of serum albumin were higher in the PEG group (MD 6.03, 95% CI 2.31 to 9.74, 107 participants).For meta-analyses of the secondary outcomes of time on enteral nutrition, there was no statistically significant difference (MD 14.48, 95% CI -2.74 to 31.71; 119 participants, two studies). For meta-analyses of quality of life measures (EuroQol) outcomes in two studies with 133 participants, for inconvenience (RR 0.03, 95% CI 0.00 to 0.29), discomfort (RR 0.03, 95% CI 0.00 to 0.29), altered body image (RR 0.01, 95% CI 0.00 to 0.18; P = 0.001) and social activities (RR 0.01, 95% CI 0.00 to 0.18) the intervention favoured PEG, that is, fewer participants found the intervention of PEG to be inconvenient, uncomfortable or interfered with social activities. However, there were no significant differences between the groups for pain, ease of learning to use, or the secondary outcome of length of hospital stay (two studies, 381 participants).
AUTHORS' CONCLUSIONS: PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT. There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration. Future studies should include details of participant demographics including underlying disease, age and gender, and the gastrostomy technique.
Not sure whether PEG vs NGT is the important comparison, as NGT is a short-term solution while PEG can be for the longer term. This isn't really the choice faced in practice.
Good systematic review but some of the information is not robust. PEG was associated with lower intervention failure compared with NG tube, but the quality of evidence was low.
This article confirms what most nutrition-support practitioners already suspect: intervention failure is more common in nasogastric tubes than with PEG tubes. I was surprised that the authors found 11 RCTs on this subject. I am not sure that intervention failure was the best primary outcome measure to use. The authors focused on adverse events associated with NG tubes, but not gastrostomy tubes. Additionally, contemporary gastrostomy tubes are often placed by interventional radiology rather than by endoscopy. The review should be updated to include this technique. Overall, the review reminds us of the low-quality evidence that drives our care in this area.
Intuitively, I think it is logical that PEG insertion would be easier; trade-off being cost and opportunity.
The importance of this review is the following statement from the authors themselves: "The findings of the present review of the literature should be interpreted with caution, given that there were methodological issues with most of the included studies which increase the risk of bias in the trial." This is important stuff, as this debate continues to rage on. The key element here is that the current research is not particularly helpful in answering the question as to which method is better.
I think this is a "messy" review in that the focus is on PEG vs NGT in a variety of neurological disorders. A better better review needs to focus on PEG vs NGT in specific disorders because the natural history, risk, and outcomes are very different.
It is useful to have an analysis of multiple studies which have examined this often vexing question of whether (and when) to consider inserting a PEG tube to replace an NGT. Though it does not address the "when" question directly, the results suggest that the common current practice is probably the best. Most practitioners, especially in neurologic disciplines, tend to opt for at least a short-term trial of NGT feeding before asking for PEG placement. This review would tend to support that practice, as it does tend to confirm the general impression that NGTs are more uncomfortable, less convenient, more prone to undesirable side effects, and more prone to becoming dislodged or experiencing other types of "failure."
Well done systematic review using studies with significant limitations. There may be subgroups that benefit from mg tube but overall, PEG had a higher success rate.