Early Versus Delayed Feeding After Placement of a Percutaneous Endoscopic Gastrostomy: A Meta-Analysis Matthew L. Bechtold, M.D., Michelle L. Matteson, A.P.N., Abhishek Choudhary, M.D., Srinivas R. Puli, M.D. Division of Gastroenterology, University of Missouri School of Medicine, Columbia, Missouri American Journal of Gastroenterology (Am J Gastroenterol 2008;103:2919–2924)

INTRODUCTION PEG : Percutaneous endoscopic gastrostomiy ▫ First described in 1980 ▫ Nutritional requirements for many patients who are unable to ingest adequate oral nutrition ▫ With strokes, dysphagia, and head and neck cancers ▫ Ease of placement and minimal complications ▫ Widely available and utilized for many clinical situations requiring long-term nutritional support Although the benefits and techniques for insertion of PEGs have been described and accepted, the feeding after PEG placement is not as clear.

Feedings after PEG placement ▫ Significantly delayed by many hours or to the next day ▫ Most likely a remnant of prior surgical guidelines regarding management of patients after surgically placed tubes The suspected rationale ▫ Risk of significant gastric residual volumes during the first day that may lead to aspiration ▫ Risk of peritoneal leakage that may lead to peritonitis Many studies have examined the use of early PEG feedings after insertion.

Many randomized controlled trials ▫ Early PEG feeding  Safe and well tolerated by patients  Decrease length of hospitalization & cost A survey of gastroenterologists in northeastern USA ▫ 82% of specialists were aware of the recent literature showing early feedings to be safe ▫ 39% initiated feedings prior to 8 h ▫ 11% initiated feedings prior to 3 h ▫ 61% to delay feedings from 9 h to >24 h

Significant differences ▫ Between the literature and clinical practice ▫ Between the timing of early feedings ▫ Meta-analysis  Early PEG feedings (≤4 h) versus Delayed or next-day feedings  Complications  Death within 72 h  Significant gastric residual volumes during 1 day

METHODS Study Selection Criteria ▫ Randomized controlled trials (RCTs) ▫ Comparing the outcomes of early (≤4 h) versus delayed or next-day feeding after PEG placement

Data Collection and Extraction ▫ In Medline, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, DARE, OVID Healthstar and Journals, Cumulative Index for Nursing and Allied Health Literature, PubMed (from 1950 to 2006), and recent abstracts from major conference proceedings (Digestive Disease Week and American College of Gastroenterology National Meeting from 1993 to 2007) were searched (November 2007). ▫ The search terms  Early feeding / Delayed feeding / Next-day feeding / Gastrostomy

▫ Only RCTs on adult subjects (≥18 yr old) ▫ By two independent reviewers in extracting the data, with differences being resolved by mutual agreement ▫ Each study was assigned a Jadad score to assess the quality of the study (5 = excellent quality, 0 = poor quality) ▫ Complications, death, and gastric residual volumes during day 1 were identified and extracted from the randomized trials.

RESULTS

Complications ▫ Local infections, diarrhea, bleeding, GERD, fever, vomiting, stomatitis, leakage, and death. ▫ Early feedings resulted in 25 complications / 232 patients ▫ Delayed feedings resulted in 29 complications / 235 patients. ▫ Not statistically significant between the early (≤4 h) and delayed or next-day feedings after PEG placement (OR 0.86, 95% CI 0.47–1.58, P = 0.63). Heterogeneity was not statistically significant (I2 = 0%, P = 0.58).

Death ≤72 h ▫ Outcome in 12 patients (early = 4, delayed = 8) ▫ Death in ≤72 h was not statistically significant between the early (≤4 h) and delayed or next-day feedings after PEG placement (OR 0.56, 95% CI 0.18–1.74, P = 0.31). Heterogeneity was not statistically significant (I2 = 0%, P = 0.95).

Gastric Residual Volumes During Day 1 ▫ The number of significant gastric residual volumes during day 1 ranged from 0 to 14 episodes. ▫ Early feedings after PEG placement resulted in 40 episodes of significant gastric residuals during day 1 in 205 patients while delayed or next-day feedings resulted in 25 episodes in 205 patients. Increased gastric residual volumes during day 1 were statistically significant between the early (≤4 h) and delayed or next-day feedings after PEG placement (OR 1.80, 95% CI 1.02–3.19, P = 0.04). Heterogeneity was not statistically significant (I2 = 0%, P = 0.76).

CONCLUSIONS Early feeding ≤4 h after PEG placement may represent a safe alternative to delayed or next- day feedings. Although an increase in significant gastric residual volumes at day 1 was noted, overall complications were not affected.