Review: early feeding and delayed feeding after PEG placement do not differ for complications or death within 72 hours
M L Bechtold
Dr M L Bechtold, University of Missouri School of Medicine, Columbia, MO, USA;
How does early (⩽4 h) feeding compare with delayed or next-day feeding after percutaneous endoscopic gastrostomy (PEG) placement in terms of complications and death within 72 hours?
Included studies compared early (⩽4 h) with delayed or next-day feeding after PEG placement. Outcomes were death within 72 hours, complications, and gastric residual volumes on day 1.
Medline, Cochrane Central Register of Controlled Trials, CINAHL, Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, OVID Healthstar and Journals, and conference proceedings were searched to November 2007 for randomised controlled trials (RCTs). 6 RCTs (n = 467, mean age 63–76 y) met the selection criteria; all had Jadad scores of 2 out of 5.
Meta-analysis showed that early and delayed feeding did not differ for death within 72 hours or complications (including local infections, diarrhoea, bleeding, fever, and vomiting) (table). More patients in the early-feeding group had higher gastric residual volumes at day 1 than in the delayed-feeding group (table).
Early feeding and delayed feeding after percutaneous endoscopic gastrostomy placement do not differ for complications or death within 72 hours.
Bechtold ML, Matteson ML, Choudhary A, et al. Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis. Am J Gastroenterol 2008;103:2919–24.
Clinical impact ratings: Gastrointestinal/colorectal surgery, 5/7; Perioperative 6/7
PEG feeding tubes are increasingly used for long-term enteral feeding in patients who cannot maintain adequate nutrition with oral intake. Disabling neurological conditions are the most common indication for PEG; patients having extensive head and neck surgery and those in intensive care units (ICUs) often require PEG placement as well. PEG is an easy and safe technique, and insertion can be done as an outpatient procedure lasting about 20 minutes. PEGs are better tolerated and easier to care for than nasogastric tubes.1 Patients have improved nutritional status, a lower incidence of complications, and reduced risk of aspiration pneumonia.2 As well, PEGs are cost-effective when long survival is expected.3 Evidence from underpowered but positive RCTs included in the review by Bechtold et al shows that early feeding after PEG placement may improve patient outcomes. Nurses sometimes fear infection or complications from raised gastric residual volume because it increases risk of aspiration pneumonia. Because of this, it is common to delay feedings until 8–12 hours after placement.
Bechtold et al pooled the results of 6 RCTs that compared early (⩽4 h) with delayed feeding and found no differences in complications or death within 72 hours, although overall, there were slightly fewer complications and deaths in patients receiving early feeding. However, more patients in the early feeding group had increased gastric residual volumes. The methodological quality of individual studies was relatively low (Jadad scores of 2 out of 5). Inadequate allocation concealment may have resulted in less severe patients receiving early feeding, which may explain the lower observed complication and death rates.
Better patient outcomes, such as shorter length of stay and resultant lower costs, are assumed to be the main benefits of early feeding.4 However, a recently published high-quality cluster RCT of 1100 ICU patients found that an early feeding guideline failed to improve clinical outcomes.5 Considering the overall quality of included studies and higher rates of increased gastric residual volumes in patients who received early feeding, clinicians should continue to balance the risks and benefits in individual patients when opting for early feeding after PEG.