1. Jonathan Benjamin Wilfong
Fletcher Allen Heath Care
March 18, 2014

2. Jonathan Benjamin Wilfong
Fletcher Allen Heath Care
March 18, 2014

3. 1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions

4. 1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions

5.  39 y/o W w a history of schizophrenia
 s/p 19-day ICU course for influenza pneumonia
and secondary MRSA pneumonia
 resolving AKI and hypoxic respiratory failure
 Laryngeal and esophageal paralysis post-
extubation impairs speech and swallow
 16 kg weight loss in the last month
 NG tube in place for last 14 days

6. 1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions

7.  “Malnourished or at risk of malnutrition and have
1) inadequate or unsafe oral intake, and a
functional, 2) accessible gastrointestinal tract.”
 Long or unpredictable duration

8.  Preferred route for feeding of indeterminate
duration in patients with dysphagia?
 Risks and rates of complication associated with
each intervention?
Should we use PEG or NG tube, why or
why not?

9. 1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions

10. Percutaneous endoscopic gastrostomy
versus nasogastric tube feeding for
adults with swallowing disturbances
(Review)
Gomes Jr CAR, Lustosa SAS, Matos D, Andriolo RB,
Waisberg DR, Waisberg J
March 14, 2012 Cochrane Database Systematic Review

11.  Systematic review of the literature
 RCTs comparing NG tube to PEG
 Dysphagia as indication
 Adults, all primary diagnoses included
 Study bias assessment
 Measures of Treatment Effect
◦ Risk Ratio for dichotomous variables
◦ Mean Difference w CI for continuous variables
◦ Heterogeneity of studies, I2
◦ Sensitivity analysis based on intention to treat

12.  474 records identified
◦ 456 not comparing interventions
 18 assessed
◦ 3 inappropriate study design (Retrospective)
 9 included in meta-analysis

13.  PEG
◦ n = 345
◦ Mean age = 56
 NG
◦ n = 341
◦ Mean age = 65
 Follow-up time: 4 weeks – 6 months
 Included diagnoses:
◦ Cancer, Neurological, ENT, Stroke, VAP

14.  Primary: Intervention failure
 Secondary
◦ Nutritional status
◦ Mortality
◦ Adverse events
◦ Time on Enteral Nutrition
◦ Quality of life
◦ Length of stay
◦ Cost

16. Treatment Failure (n = 314)
◦ PEG 12.7%
◦ NG 39.87%
◦ RR 0.24 (0.8-0.76), p = 0.01
◦ I2
= 0.68 (corrected by sub-group of PEG)
◦ ITT: RR 0.51 (0.31- 0.83)
◦ Statistically significant only in neurological subgroup
Defined as any event leading to failure to introduce the tube,
recurrent displacement, and treatment interruption

17. Mortality (n = 584)
◦ PEG: 37.24%
◦ NG: 35.71%
◦ RR 0.96 (0.64-1.44), p = 0.84
◦ I2
= 0.38

18. Complications (n = 503)
◦ PEG 42.0%
◦ NG 42.68%
◦ RR 1.00 (0.93-1.11), p = 0.93
◦ I2
= 0.0
◦ ITT: RR 0.51 (0.31- 0.83)
◦ Statistically significant only in neurological subgroup
Defined as complication not due to other studied factors. i.e
aspiration, hemorrhage, fistula, wound infection, etc.

19. Pneumonia (n = 585)
◦ PEG 32.53%
◦ NG 39.25%
◦ RR 0.84 (0.61-1.14), p = 0.26
◦ I2
= .61
◦ ITT: RR 0.51 (0.31- 0.83)
◦ Statistically significant only in neurological subgroup

20. Survival
◦ Means Difference 4.30 (3.28-5.32), p < 0.00001
◦ Favoring PEG
Clarification of Terms
I2
: likelihood the difference is due to study heterogeneity
Relative Risk: ratio of the probability of an event occurring in an
exposed group to the probability of the event occurring in a
comparison, non-exposed group
Means Difference: the "average" or "mean", formally the expected
value, of the absolute difference of two random variables

23. 1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions

24.  Lower rate of treatment failure in PEG
 Benefit in neurological disease
 Trend toward increased risk for PNA in NG
 Higher mortality in NG group
◦ MD 4.3 years
 No significant difference in complication rate
 No significant difference in proximal clinical
endpoints noted (i.e. nutrition)

25.  Adequately powered for primary outcome
 Overall limited bias, high-quality data
 Clinically relevant outcomes
 Generalizable given patient population

26.  Concealment bias
 Significant heterogeneity for most outcomes
 Small patient numbers
 Under-powered for subgroup analysis
 High loss-to-follow-up
 No association of event rates over time

27. 1 The encounter
2 The clinical problem
3 The evidence
4 Discussion
5 Conclusions

28.  Lower risk of treatment failure in PEG
◦ Significant for neurological diseases
 No difference in complications
 Increased risk of pneumonia in NGT?
 PEG associated with longer survival