Feeding after Gastrostomy: It’s Time to Stop the Delay

Commentary

Percutaneous endoscopic gastrostomy (PEG) is a common procedure for those patients who are malnourished and unable to ingest adequate calories by mouth. In the past, initiation of feedings has been delayed after placement of a PEG based upon historical dogma of old surgical literature suggesting significantly delaying feedings after abdominal surgery. However, more recently, early initiation of feeding has been suggested as an alternative to delaying feeding until the next day or 24 hours after PEG.

As of 1993, multiple non-randomized prospective studies [1-4] and randomized controlled trials have been performed on feeding after PEG [5-10]. Chumley, et al. was the first randomized controlled trial evaluating early (3 hours) versus delayed (24 hours) feeding after PEG and found no differences between the groups for complications or gastric residual volumes [5]. In a 1995 randomized controlled trial at our institution, Brown, et al. found no significant differences in complications when comparing feeding within 3 hours versus nextday after PEG placement in 57 patients [6]. Subsequently, multiple other randomized controlled trials were performed showing similar results [7-10]. Despite the evidence suggesting early feeding after PEG may be just as safe, changes in clinical practice have been slow. In 2000, Srinivasan, et al. performed a survey study showing clinical practice may not reflect the literature for feeding after PEG. Although 81.5% of physicians were aware of literature regarding early feeding after PEG, 89.3% continued to delay feedings for four or more hours while only 10.7% fed patients within three hours [11]. Due to this difference in clinical practice and the literature, the first meta-analysis was published on this issue in 2008.

Our meta-analysis demonstrated no statistically significant differences between early (=4 hours) and delayed (>4 hours) feeding for complications and mortality with 72 hours [12]. However, gastric residual volumes during day 1 were slightly increased in those receiving early feedings (OR 1.80; 95% CI: 1.02-3.19; p=0.04). Given that the clinical usefulness of monitoring gastric residual volumes has been heavily questioned in the literature over the past decade, this outcome likely has no clinical relevance in today’s practice [13- 15]. Furthermore, a second meta-analysis in 2011 demonstrated that no statistically significant differences were noted between early (=3 hours) versus delayed (>3 hours) feeding after PEG for complications, mortality within 72 hours, and gastric residual volumes during day 1 (OR 1.46; 95% CI: 0.75-2.84; p=0.27) [16]. Despite the multiple randomized controlled trials and meta-analyses, physicians continued to delay feedings in clinical practice.

In 2011, a repeat survey study of gastroenterologists conducted by Ali, et al. showed that 38% of private and 52% of academic gastroenterologists still delay feedings for more than 12 hours after PEG [17]. Given all the positive data related to early feeding after PEG, the dogma of delaying feedings seems to have more impact in practice than the evidence in the literature.

In 2013, our institution published a retrospective study on our experience on the use of early feeding (=4 hours) versus delayed (>4 hours) after PEG [18]. This study evaluated 444 patients from 2006- 2011 and revealed no differences between the two groups for mortality (within 24 hours, 24-72 hours, or 3-30 days) or complications (wound infection, melena, vomiting, leakage, stomatitis, or other). Interestingly, in this study, gastroenterologists were much more likely to initiate feedings with 4 hours than surgeons (60% vs. 9%, p<0.01).

With the overwhelming evidence in the literature for early feeding after PEG, including randomized controlled trials, meta-analyses, and a large retrospective study of long-term experience, it is time to stop delaying post-PEG feeding based upon the dogma of practice or experience of a prior mentor. Early feeding after PEG should be routinely performed in an effort to supply nutrition more rapidly to our malnourished patients requiring enteral nutrition via PEG.

References

1. Navarro L, Reymunde A. Outcome of early feeding after percutaneous endoscopic gastrostomy. Gastroenterology. 1995; 108: A656.
2. Dubagunta S, Still CD, Kumar A, Makhdoom Z, Inverso NA, Bross RJ, et al. Early initiation of enteral feeding after percutaneous endoscopic gastrostomy tube placement. Nutr Clin Pract. 2002; 17: 123-125.
3. Yarze JC, Herlihy KJ, Fritz HP, Bolton CH, Schupp SL, Brooks RL, et al. Prospective trial evaluating early initiation of feeding in patients with newly placed one-step button gastrostomy devices. Dig Dis Sci. 2001; 46: 854-858.
4. Bajaj A, Moran J, Rashed A. Safety of immediate feedings in contrast to delayed feeding following percutaneous endoscopic gastrostomy (PEG). Am J Gastroenterol. 1993; 88: 1503.
5. Chumley DL, Batch WJ, Hoberman LJ. Same day PEG feeding, is it safe? Results of randomized prospective study. Am J Gastroenterol. 1993; 88: 1589-1595.
6. Brown DN, Miedema BW, King PD, Marshall JB. Safety of early feeding after percutaneous endoscopic gastrostomy. J Clin Gastroenterol. 1995; 21: 330- 331.
7. Choudhary U, Barde CJ, Markert R, Gopalswamy N. Percutaneous endoscopic gastrostomy: A randomized prospective comparison of early and delayed feeding. Gastrointest Endosc. 1996; 44: 164-167.
8. McCarter TL, Condon SC, Aguilar RC, Gibson DJ, Chen YK. Randomized prospective trial of early versus delayed feeding after percutaneous endoscopic gastrostomy placement. Am J Gastroenterol. 1998; 93: 419-421.
9. Schulte-Bockholt A, Sabin M, Rosenstock U, Clemens SA, Hofmann U. Brandt M, et al. Immediate versus next day PEG feeding: A randomized prospective study in ICU/intermediate care patients. Gastroenterology. 1998; 114: A907.
10. Stein J, Schulte-Bockholt A, Sabin M, Keymling M. A randomized prospective trial of immediate vs. next-day feeding after percutaneous endoscopic gastrostomy in intensive care patients. Intensive Care Med. 2002; 28: 1656- 1660.
11. Srinivasan R, Fisher RS. Early initiation of post-PEG feeding: do published recommendations affect clinical practice? Dig Dis Sci. 2000; 45: 2065-2068.
12. Bechtold ML, Matteson ML, Choudhary A, Puli SR, Jiang PP, Roy PK. Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis. Am J Gastroenterol. 2008; 103: 2919-2924.
13. Elpern EH, Stutz L, Peterson S, Gurka DP, Skipper A. Outcomes associated with enteral tube feedings in a medical intensive care unit. Am J Crit Care. 2004; 13: 221-227.
14. McClave SA, Lukan JK, Stefater JA, Lowen CC, Looney SW, Matheson PJ, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med. 2005; 33: 324-330.
15. Lukan J, McClave S, Lowen C. Poor validity of residual volume as a marker for risk of aspiration. Am J Clin Nutr 2002; 75: 417-8S.
16. Szary NM, Arif M, Matteson ML, Choudhary A, Puli SR, Bechtold ML, et al. Enteral feeding within three hours after percutaneous endoscopic gastrostomy placement: a meta-analysis. J Clin Gastroenterol. 2011; 45: e34-e38.
17. Ali T, Le V, Sharma T, Vega KJ, Srinivasan N, Tierney WM, et al. Post-PEG feeding time: a web based national survey amongst gastroenterologists. Dig Liver Dis. 2011; 43: 768-771.
18. Cobell WJ, Hinds AM, Nayani R, Akbar S, Lim RG, Theivanayagam S, et al. Feeding after percutaneous endoscopic gastrostomy: experience of early versus delayed feeding. South Med J. 2014; 107: 308-311.