Intended for healthcare professionals

Rapid response to:

Clinical Review

Percutaneous endoscopic gastrostomy (PEG) feeding

BMJ 2010; 340 doi: (Published 07 May 2010) Cite this as: BMJ 2010;340:c2414

Rapid Response:

PEG tube feeding after stroke does not improve survival and may worsen functional outcomes

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.

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

15 May 2010
Martin Scott Dennis
Professor of Stroke medicine
Crewe Rd, Edinburgh, EH42XU
Western General Hospital