Percutaneous endoscopic gastrostomy (PEG) feeding
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2414 (Published 07 May 2010) Cite this as: BMJ 2010;340:c2414
All rapid responses
Kurien et al. correctly identify buried bumper syndrome as an
important complication of percutaneous endoscopic gastrostomy (PEG)
insertion. Unfortunately they do not outline the instructions that should
be given to patients and/or their carers which are thought to prevent this
occurring (1).
We believe that these instructions are important to all practitioners
involved in the care of these patients. The correct instructions are as
follows:
Once the stoma tract is mature (approximately 3 weeks post insertion), the
external skin fixator should be loosened once-weekly, the PEG tube should
be rotated one full-turn and advanced a few centimetres into the stoma
tract. The PEG tube should then be withdrawn until the internal bumper is
felt to rest against the gastric wall and the skin fixator replaced.
If the PEG tube cannot be rotated or advanced within the stoma tract,
buried bumper syndrome should be suspected and review by the local
nutrition team arranged.
Reference List
(1) Foutch PG, Talbert GA, Waring JP et al. Percutaneous endoscopic
gastrostomy in patients with prior abdominal surgery: virtues of the safe
tract. Am J Gastroenterol 1988;83(2):147-50.
Competing interests:
None declared
Competing interests: No competing interests
Kurien et al state in their review of percutaneous endoscopic
gastrostomy(PEG) that "Clinical studies have shown clear benefits of PEG
feeding after stroke (in terms of improving nutritional status and
reducing mortality") and that "Randomised studies in patients after stroke
who received gastrostomy feeding have shown improved nutritional outcomes,
higher likelihood of survival, and earlier discharge." They reference two
randomised trials which compared outcomes in stroke patients fed via
either nasogastric or PEG tubes to back-up this claim [1,2].
The first was a small single centre trial which included only 30
patients[1]. No baseline characteristics were reported to enable one to
establish the comparability of the groups. This trial showed an
implausibly large absolute reduction in death of 45% (95% CI 14 to 75%).
There were apparent improvements in weight, serum albumen and early
discharge from hospital amongst survivors but valid comparisons are
difficult when so few patients survived in the nasogastric group.
The second was the FOOD trial, which enrolled 321 stroke patients
from 47 hospitals in 11 countries [2]. PEG feeding was associated with an
absolute increase in risk of death of 1.0% (-10.0 to 11.9, p=0.9) and an
increased risk of death or poor outcome (modified Rankin scale 4-5) of
7.8% (0.0 to 15.5, p=0.05). Length of stay was not different and no
nutritional parameters were reported.
A systematic review of all RCTs comparing NG and PEG feeding showed a
small and non significant reduction in deaths (Odds ratio = 0.88 (95% CI
0.59 to 1.33))[3].
Thus, the evidence from relevant RCTs does not support the statements
concerning mortality, nutritional status or hospital discharge. Indeed,
the FOOD trial provides evidence that patients' functional recovery may
even be worse with PEG feeding. I am puzzled how the authors of this
review came to their stated conclusions.
References
1. Norton B, Homer-Ward M, Donnelly MT, Long RG, Homes
GKT. A randomised prospective comparison of percutaneous
endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic
stroke. Br Med J 1996;312:13–16.
2. The FOOD Trial Collaboration. Effect of timing and method of enteral
tube feeding for dysphagic stroke patients (FOOD): a multicentre
randomised controlled trial. Lancet 2005;365:764–72.
3. Dennis M. Lewis S. Cranswick G. Forbes J. FOOD Trial Collaboration.
FOOD: a multicentre randomised trial evaluating feeding policies in
patients admitted to hospital with a recent stroke. Health Technology
Assessment 2006;10(2):1-120.
Competing interests:
I was the chief investigator of the FOOD trials
Competing interests: No competing interests
Re: PEG tube feeding after stroke does not improve survival and may worsen functional outcomes
Author’s response
We agree with Professor Dennis summary of the FOOD data. Nevertheless
prior to this there were 2 smaller randomized trials 1,2 which had shown
some clinical benefit with regards to improved nutritional outcomes,
higher likelihood of survival, and earlier discharge. We specifically
cited the FOOD study as we felt this was the most comprehensive work in
this area and we accept that the findings were different to the initial
reports. Our view is very much in concordance with the overview of the
FOOD study – ‘nasogastric feeding early and consider the role of PEG for
patients who cannot tolerate a naso-gastric tube or if patients are
dysphagic for a longer period of time’. 3
The aim of our article was to try and provide an evidence summary for
generalists and our message was that we believe there is a role for PEG in
dysphagic stroke but more importantly perhaps not in other areas where PEG
is being employed.
1. RH Park, MC Allison and J Lang et al., Randomised comparison of
percutaneous endoscopic gastrostomy and nasogastric tube feeding in
patients with persisting neurological dysphagia, BMJ 304 (1992), pp.
1406–1409.
2. B Norton, M Homer-Ward, MT Donnelly, RG Long and GK Holmes, A
randomised prospective comparison of percutaneous endoscopic gastrostomy
and nasogastric tube feeding after acute dysphagic stroke, BMJ 312 (1996),
pp. 13–16
3. Donnan GA, Dewey HM. Stroke and nutrition: FOOD for thought. Lancet.
2005 Feb 26-Mar 4;365(9461):729-30.
Competing interests:
None declared
Competing interests: No competing interests