A systematic review of 9 studies comparing PEG and NG tube feeding in adults with swallowing disturbances found: 1) PEG was associated with a lower risk of treatment failure, especially in patients with neurological diseases. 2) There was no significant difference in complication rates between PEG and NG tubes. 3) PEG may be associated with a decreased risk of pneumonia compared to NG tubes and longer survival time.

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