Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Enteral feeding by endoscopic gastrostomy reduced 6-week mortality after dysphagic stroke

ACP J Club. 1996 July-Aug;125:5. doi:10.7326/ACPJC-1996-125-1-005


Source Citation

Norton B, Homer-Ward M, Donnelly MT, Long RG, Holmes GK. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ. 1996 Jan 6;312:13-6. [PubMed ID: 8555849]


Abstract

Objective

To determine the effectiveness of percutaneous endoscopic gastrostomy compared with nasogastric tube feeding after acute dysphagic stroke.

Design

6-week randomized controlled trial.

Setting

2 hospitals in England.

Patients

30 patients (63% women) who had clinical evidence of a severe stroke and dysphagia and who were unconscious at hospital admission. Patients with a history of gastrointestinal disease were excluded. Follow-up was complete for mortality at 6 weeks.

Intervention

Approximately 14 days after hospital admission, patients were allocated to enteral feeding by nasogastric tube (Flocare 500) (n = 14) or percutaneous endoscopic gastrostomy tube (12-French gauge Fresenius or 24-French gauge Wilson Cook) (n = 16). Feeds were administered at 50 mL/h for 24 hours and gradually increased to 100 mL/h.

Main outcome measures

Mortality and changes in nutritional state (weight, upper-arm skin-fold thickness, mid-arm circumference, and levels of hemoglobin, serum total protein, and serum albumin).

Main results

At 6 weeks, 2 patients (12.5%) fed by gastrostomy tube had died compared with 8 patients (57%) fed by nasogastric tube (P = 0.01) (Table). 77% of patients fed by gastrostomy tube gained weight (mean increase of 2.2 kg) compared with 12% of nasogastrically fed patients (P = 0.004). Patients fed by gastrostomy tube had a mean increase of 2.7 g/L in serum albumin level compared with a mean reduction of 9.5 g/L in the patients fed nasogastrically (P < 0.003). The groups did not differ for change in hemoglobin level. At 6 weeks, 6 patients (38%) in the gastrostomy-fed group were discharged from the hospital compared with none of the patients in the nasogastrically fed group (P < 0.05).

Conclusion

Enteral feeding by percutaneous endoscopic gastrostomy reduced mortality at 6 weeks and improved nutritional status in patients with acute dysphagic stroke.

Source of funding: None.

For article reprint: Dr. G.K. Holmes, Derbyshire Royal Infirmary, Derby DE1 2QY, England, UK. FAX 44-13-32-254-764.


Table. Enteral feeding by percutaneous endoscopic gastrostomy tube (PEG) vs nasogastric tube (NG) in patients with acute dysphagic stroke*

Outcome at 6 wk PEG NG RRR NNT (CI)
Mortality 12.5% 57% 78% (27 to 94) 2 (1 to 9)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

Residual swallowing disorders are common in patients after they have had a stroke. A short segment of dysmotile oropharynx might prevent these patients from having sufficient nutritional intake, impair their health-related quality-of-life, and predispose them to aspiration pneumonia.

Norton and colleagues assessed 2 different methods for addressing this problem. The short-term nutritional outcome was better in patients randomized to gastrostomy than it was in those randomized to nasogastric feeding. Results were similar in a trial of 40 patients who had more chronic neurologic swallowing disorders that were caused by various conditions (1).

Although the effect on pneumonia was not reported in the study by Norton and colleagues, the most compelling finding was the dramatic reduction in 6-week mortality associated with gastrostomy feeding. In another trial of 90 patients with neurologic and non-neurologic causes of dysphagia, the mortality rate was higher in the gastrostomy group (30% vs 11%, P = 0.05) (2). These conflicting studies suggest that further, large, randomized trials are needed to obtain better estimates of the benefit, risk, and discomfort associated with gastrostomy feeding compared with nasogastric feeding. Given the incidence of dysphagia after stroke and the need to use the most widely accepted and cost-effective means of nutritional delivery, these trials should rank high in priority on stroke research agendas.

At this time, it is difficult to establish an evidence-based clinical policy for feeding patients with dysphagia after stroke. Although a clearer picture would be obtained with a large, rigorously done trial that examined both clinical and economic sequelae, we wonder whether more extensive data already exist. Do we need some way to identify, critically appraise, and pool unpublished information?

Ronald Koretz, MD
University of California, Los AngelesLos Angeles, California, USA

Deborah J. Cook, MD
McMaster UniversityHamilton, Ontario, Canada


References

1. Park RH, Allison MC, Lang J, et al.Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ. 1992;304:1406-9.

2. Baeten C, Hoefnagels J. Feeding via nasogastric tube or percutaneous endoscopic gastrostomy. A comparison. Scand J Gastroenterol Suppl. 1992;194:95-8.