Feeding via Nasogastric Tube or Percutaneous Endoscopic Gastrostorny A Comparison C. BAETEN & J. HOEFNAGELS Dept. of Surgery and Dept. of Dietetics, Academic Hospital Maastricht, Maastricht, The Netherlands
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Baeten C, Hoefnagels J. Feeding via nasogastric tube or percutaneous endoscopic gastrostomy. A comparison. Scand J Gastroenterol 1992;27 Suppl 194:95-98. When a patient needs enteral feeding, there are two methods to administer the nutrition. The method most used is the nasogastric tube (NGT), although in the literature little is published about the advantages and complications of the NGT. The second method is percutaneous endoscopic gastrostomy (PEG). A prospective randomized trial was started, and so far 90 patients have entered the study (46 NGT and 44 PEG), In four patients it was not possible to insert the NGT, and in three patients it was impossible to place the PEG. In both groups 6.5% aspiration was found. Nasal decubitus and swallowing problems were seen in 13% and 1796, respectively, in the NGT group. Intraperitoneal bleeding and abdominal pain were found in 2% and 11%, respectively, in the PEG group. Fixation of the patients was needed in 7% of the PEG and 22% in the NGT group. In eight patients in the NGT group the feeding had to be stopped owing to problems; in none of the PEG group was this necessary. The nursing staff awarded marks to each patient on a scale of 5 for the convenience of care (very good, 1; very bad, 5 ) . This resulted in a mean score of 2.6 in the NGT and 2.0 in the PEG group, The score given by the patients was 2.3 in the NGT and 1.8 in the PEG group. There seems to be a clear preference for the PEG as a method for enteral nutrition.
Key words: Endoscopy; gastrostomy, nasogastric tube; nutrition C. Baeten, M . D . , Dept. of Surgery, University Hospital Maastricht, P.O. Box 5800, NL-6202 A 2 Maastricht, The Netherlands
When a patient is not able to swallow, there is always the question as to how he can best be fed. The first step in the decision-making is of course whether the patient should be fed at all. When the answer is yes, the next step is to consider whether the digestive tract can be used for nutrition. In cases of inflammation, stenosis, short bowel, and so forth, the patient can be helped with parenteral nutrition. When the patient has a functional intact digestive tract, in most hospitals a nasogastric tube (NGT) will be inserted. It is unusual that in the literature nothing has been published about the advantages and problems an NGT can give. The procedure is so generally applied that nobody has ever thoroughly examined this method. Of course much is written about gastric or duodenal feeding, about the composition of the liquid food, and so forth, but the way of administration has been taken for granted (1, 2). During the past 10 years an alternative for the NGT has been developed in the form of percutaneous endoscopic gastrostomy (PEG) (3). PEG has been compared with operative gastrostomy (4, 5) and proved to be much safer. The method is now used in many hospitals and was applicable in many cases. The indications for PEG are almost the same as for NGT. Both NGT and PEG have their own and some common complications and advantages, and it seemed proper to
carry out a prospective randomized trial to compare these met hods. PATIENTS AND METHODS From June 1990 until February 1992, 200 patients were eligible for the study. All patients were asked whether they had a preference for one of the two methods. In all cases the responsible doctor was asked whether there was a contraindication for either method. Ninety patients in whom there were no objections from a medical point of view gave their informed consent. These 90 patients were subdivided into three groups, because we felt that there was a difference between patients with neurologic, ear, nose and throat
Table I. Division by group and method* ~~
Neurology Ear, nose and throat Surgery Total ~
* NGT
=
gastrostomy .
~~
~~
NGT
PEG
Total
23 18 5 46
19 21 4 44
42 39 9 90
~~
~~
~
nasogastric tube; PEG = percutaneous endoscopic
96
C. Baeten & J. Hoefnagels
Table 11. Mean age and sex division
Scand J Gastroenterol Downloaded from informahealthcare.com by Chulalongkorn University on 12/26/14 For personal use only.
Neurology Ear, nose and throat Surgery Total
Mean age, years
Men, n
Women,
Total,
n
n
79 t 8 63 + 10 80 8 7 2 + 10
19 34 3 56
23 5 6 34
42 39 9 90
*
(ENT), and surgical problems. For each group a fixed quantity of sealed envelopes was prepared, containing the method to be used for enteral nutrition. So far 42 neurologic, 39 ENT, and 9 surgical patients have entered the study. Of these 90 patients, 46 were randomized to the NGT and 44 to the PEG group. The division into three groups is given in Table I. The mean age of the patients was 72.2 years. The age of the ENT patients was significantly lower than that of the two other groups (Table 11). The division by sex was 56 men and 34 women and reflects the higher incidence of larynx carcinoma in men (34-5) in the ENT group. Within each group the mean age and sex divisions of the NGT and PEG groups were almost equal. After randomization the patients in the NGT group were provided with a silicone nasogastric tube with a ch 14 diameter by a nurse on that ward. The patients in the PEG group were brought to the endoscopy unit and received a gastrostomy under local anesthesia with lidocoine, 1 %. In all cases a Freka (Fresenius) gastrostomy set was used as previously described ( 6 ) . All patients were followed up daily during their hospital stay by one of the investigators. The time needed for introduction of the NGT and PEG and the problems with the insertion were noted. All tubes and gastrostomy sets used were listed but gave an underestimation in the NGT group because several times a tube was replaced during the night or during the weekend without proper notation. All method-specific and common problems during the time of enteral feeding were listed. In all cases the reason for stopping the enteral feeding was noted. In the NGT group the tube was simply withdrawn; in the PEG group the gastrostomy catheter was cut off at the level of the skin, and the internal part of the catheter left the body by the natural route.
Table IV. Number of failures and mean numbers of tubes used per patient
NGT* PEG*
No. of failures
No. of tubes and catheters
4 (8.8%) (n = 46) 3 (6.8%) ( n = 44)
2.7 1.9 ( n = 42) 1.0 ? 0 ( n = 41)
*
* NGT = nasogastric tube; PEG = percutaneous endoscopic gastrostomy.
In all cases the nurses on the wards were asked to give their opinion about the convenience of patient care on a 5graded scale (1 = very convenient; 2 = convenient; 3 = indifferent; 4 = difficult; 5 = very inconvenient) after stopping the enteral nutrition. When the method could not be used, it was given a rating of 5. In those cases when the patients were able to give their own opinion, they were asked to do so on a scale of 5 (1 = very good; 2 = good; 3 = indifferent; 4 = bad; 5 = very bad) after the tube or gastrostomy had been removed. Since this is a preliminary report and the study has not been finished yet, it is not possible to give any statistics. The study was approved by the ethical committee of the Academic Hospital, Maastricht. RESULTS The time needed for insertion of the NGT was registered in 26 cases and was 8.4 6.2 min. The time used for the introduction of the PEG at the endoscopy department was 11.4 k 5.6min (n = 41) (Table 111). The mean time used in the hospital for enteral nutrition was 16.4 days in the NGT group and 21.6 in the PEG group. In four cases it was not possible to place the NGT initially. In the PEG group it was not possible to introduce the gastrostomy catheter in three cases. One patient had an intrathoracic volvulus of the stomach, one patient had a stenosing tumor of the pharynx that could not be passed by the gastroscope, and one patient had had a Billroth I1 resection in the past (Table IV).
*
Table V. Complicationsand problems with nasogastric tubes (NGT) and percutaneous endoscopic gastrostomy (PEG) NGT ( n = 46)
Table 111. Introduction time and use in hospital Introduction time, min NGT' PEG* Total
8.4 2 6.2 11.4 -I- 5.6
No.
Days of enteral nutrition 14.4 + 16.4 21.6 + 22.4 17.9 k 19.9
* NGT = nasogastric tube; PEG = percutaneous endoscopic gastrostomy.
Clotting Fixation of the patient Aspiration Swallowing problems Nasal decubitus Inflammation Abdominal pain Abdominal bleeding
7 10 3 8 6
Percentage 15 22 7 17.4 13
PEG ( n = 44) No.
Percentage
7 3 3
16
12 5
27
1
2
7 7
11
Feeding via Nasogastric Tube or Gastrostomy Table VI. Reasons to stop enteral nutrition in the hospital in nasogastric tube group Ear, nose and throat Neurology Surgery Total
Scand J Gastroenterol Downloaded from informahealthcare.com by Chulalongkorn University on 12/26/14 For personal use only.
Indication Death Problems Aspiration Discharge Total
15 0 1 0 0 16
4 4 6 0 7 21
2 1 1 1 0 5
21 5 8 1 7 42
The mean number of tubes used in the NGT group was 2.7 per patient, and this is an underestimation because not all reinserted tubes were properly registered during the night and weekends. In the PEG group only one catheter per patient was used, The complications of both methods were comparable for some items but were method-related for some other items (Table V). The problems of aspiration were almost equal in the two groups, and the percentages of tube and catheter clotting also did not differ. A great difference was found in the need for fixation of the patients to prevent them from removing the NGT or PEG. Almost all these cases of fixation were in the neurologic group. Swallowing problems were only seen in the NGT group. In the NGT group nasal decubitus was a serious problem in a much larger percentage than expected. Esophagitis and pharyngitis were not checked routinely but were seen in a few cases in which gastroscopy was indicated. The PEG caused abdominal pain for a few days in five patients and caused intraperitoneal bleeding in one patient. This patient died of sepsis due to anastomatic leakage after low anterior resection for rectal cancer. At autopsy 1.5 1 of blood were found in the abdomen. The needle for the
Table VII. Reasons to stop enteral nutrition in the hospital in percutaneous endoscopic gastrostorny group
97
introduction of the PEG had perforated the left lobe of the liver. This bleeding may have contributed to her death. In 27% of the patients mild inflammation was seen around the gastrostomy. In none of the cases did an abscess have to be drained or the gastrostomy removed. The reasons to stop enteral feeding in the hospital are listed in Tables VI and VII. In most cases the NGT and PEG could be removed because there was no longer an indication, or the patients were discharged from the hospital with NGT or PEG, to be transferred to a nursing home (mainly in the neurology group) or to their own home (mainly in the ENT group). In the NGT group 5 and in the PEG group 13 patients died. There is no explanation for the difference. Autopsy was performed. in a few patients. In two patients in each group a bronchopneumonia was found, but there was no proof of aspiration. In one patient in the PEG group (surgery group) intra-abdominal bleeding was found, as mentioned before. In none of the other cases was there a clinical suspicion of a method-related cause of death. Because of too many problems enteral feeding had to be terminated in eight patients in the NGT group. Frequent unintentional removal by the patient and dislocation because of vomiting and coughing were the main reasons to stop the enteral feeding. In six of these eight patients a gastrostomy was introduced. With the PEG these patients of the NGT group could be fed without any further problems. In one of the eight patients it was decided to stop further treatment, and the last patient was transferred to a psychiatric clinic. In none of the patients of the PEG group was it necessary to stop the enteral feeding because of problems. The convenience of patient care was evaluated by the nurses on the wards and gave a mean score of 2.6 in the NGT group and 2.0 in the PEG group (Table VIII). The score of the patients who were able to give their own opinion about the method of enteral nutrition was 2.3 in the NGT group (n = 21) and 1.8 in the PEG group (n = 22) (Table IX).
Ear, nose and throat Neurology Surgery Total 14 1 0 0 5 20
Indication Death Problems Aspiration Discharge Total
1 1 0 0 2 4
2 11 0 0 4 17
17 12 0 0 11 41
Table IX. Score given by the patients NGT* (n = 21) PEG* (n = 22)
2.33 2 1.49 1.77 f 1.00
NGT = nasogastric tube; PEG = percutaneous endoscopic gastrostomy.
Table VIII. Score of convenience given by the nurses
NGT"
(n = 30) PEG* ( n = 38)
Ear. nose and throat
Neurology
Surgery
Total
2.17? 1.17
3.00 t 1.44
2.80 2 1.16
2.58 ? 1.35
* 1.43
2.25 ? 0.43
2.00 2 1.12
*
1.72 0.92
2.31
* NGT = nasogastric tube; PEG = percutaneous endoscopic gastrostomy.
98
C. Baeten & J . HoefnagerS
Scand J Gastroenterol Downloaded from informahealthcare.com by Chulalongkorn University on 12/26/14 For personal use only.
DISCUSSION When the two methods of administering enteral nutrition are compared, the time for the introduction of the PEG is not much longer than for the insertion of the NGT, but of course it takes some time to transport the patients to the endoscopy unit. When the transportation time is added to PEG introduction time and the insertion time is multiplied by the mean number of tubes for the NGT, the total of time investment is about equal in the two groups. In four patients it was initially impossible to introduce the tube, and in another eight patients it was impossible to keep them on enteral nutrition by this method. This means that this method had a failure rate of 26%. The failure rate in the PEG group was 3 of 44 patients (7%). It is obvious that in the NGT group the intention to treat the patients with a tube was less successful than in the PEG group. The costs of the two methods are almost equal when the cost for a tube is multiplied by the number of new tubes used. The clotting problems of the NGT and PEG were equal, but in the case of a nasal tube, the tube had to be renewed. The PEG catheters could in all cases be unplugged with a guidewire. For the patients the chance of being fixated in their bed was much higher in the NGT group. Obviously, the NGT caused more irritation than the PEG. The abdominal pain in the PEG group did not last more than 3 days and was never a reason not to use the catheter for enteral feeding. The complication of bleeding in one patient in the PEG group was strange. The catheter was placed more to the left than normal but nevertheless perforated the left lobe of the liver. There is no explanation for this complication because there was good diaphaniety at the puncture site.
In both groups 7% aspiration was found. In addition to this, in two patients in each group bronchopneumonia was seen at autopsy. It is hard to prove that this'was caused by aspiration. Not specially noted on the scoring list but an often-mentioned problem for the patients in the psychologic factor that in the NGT group the patients felt stigmatized by the nasogastric tube. This sight of a tube through the nose is repulsive to the patients themselves and to their relatives. CONCLUSION The study is not completed yet but it seems that there is a preference in the patient group and on the wards for the PEG. From the medical point of view the PEG seems to score better than NGT with regard to the minor complications, but with regard to severe complications the PEG is more dangerous than the NGT. REFERENCES 1. Owesen L,Hansen E, Allingstrup L, Adsersen M, Longbolk K, Frojhaer S. Bacterial contamination and growth in two defined formula diets of different pH. Clin Nutr 1991;10:114-9. 2. Mathus E . Sondevoeding en keuzebeleid. Ned Tijdschrift Geneesk 1990;134:11-7. 3. Gauderer M, Ponsky J, Irant R. Gastrostomy without laparotomy, a percutaneous endoscopic technic. J Pediatr Surg 1980;15:872. 4. Foutch P, Haynes W, Bollaprarolu S, Sanowski R. Percutaneous endoscopic gastrostomy (PEG), a new procedure comes of age. J Clin Gastroenterol 1986;8:10-5. 5. Steigman G, Goff J, Silas D, Perlanen N, Sun J, Norton L. Endoscopic versus operative gastrostomy: final results of a prospective randomised trial. Gastrointest Endosc 1990;36:1-5. 6. Baeten C, Vismans F, Von Meyenfeldt M. Percutaneous endoscopic gastrostomyusing a prefab set. Neth J Med 1988;32:172-7.
Scand J Gastroenterol Downloaded from informahealthcare.com by Chulalongkorn University on 12/26/14 For personal use only.
Baeten C, Hoefnagels J. Feeding via nasogastric tube or percutaneous endoscopic gastrostomy. A comparison. Scand J Gastroenterol 1992;27 Suppl 194:95-98. When a patient needs enteral feeding, there are two methods to administer the nutrition. The method most used is the nasogastric tube (NGT), although in the literature little is published about the advantages and complications of the NGT. The second method is percutaneous endoscopic gastrostomy (PEG). A prospective randomized trial was started, and so far 90 patients have entered the study (46 NGT and 44 PEG), In four patients it was not possible to insert the NGT, and in three patients it was impossible to place the PEG. In both groups 6.5% aspiration was found. Nasal decubitus and swallowing problems were seen in 13% and 1796, respectively, in the NGT group. Intraperitoneal bleeding and abdominal pain were found in 2% and 11%, respectively, in the PEG group. Fixation of the patients was needed in 7% of the PEG and 22% in the NGT group. In eight patients in the NGT group the feeding had to be stopped owing to problems; in none of the PEG group was this necessary. The nursing staff awarded marks to each patient on a scale of 5 for the convenience of care (very good, 1; very bad, 5 ) . This resulted in a mean score of 2.6 in the NGT and 2.0 in the PEG group, The score given by the patients was 2.3 in the NGT and 1.8 in the PEG group. There seems to be a clear preference for the PEG as a method for enteral nutrition.
Key words: Endoscopy; gastrostomy, nasogastric tube; nutrition C. Baeten, M . D . , Dept. of Surgery, University Hospital Maastricht, P.O. Box 5800, NL-6202 A 2 Maastricht, The Netherlands
When a patient is not able to swallow, there is always the question as to how he can best be fed. The first step in the decision-making is of course whether the patient should be fed at all. When the answer is yes, the next step is to consider whether the digestive tract can be used for nutrition. In cases of inflammation, stenosis, short bowel, and so forth, the patient can be helped with parenteral nutrition. When the patient has a functional intact digestive tract, in most hospitals a nasogastric tube (NGT) will be inserted. It is unusual that in the literature nothing has been published about the advantages and problems an NGT can give. The procedure is so generally applied that nobody has ever thoroughly examined this method. Of course much is written about gastric or duodenal feeding, about the composition of the liquid food, and so forth, but the way of administration has been taken for granted (1, 2). During the past 10 years an alternative for the NGT has been developed in the form of percutaneous endoscopic gastrostomy (PEG) (3). PEG has been compared with operative gastrostomy (4, 5) and proved to be much safer. The method is now used in many hospitals and was applicable in many cases. The indications for PEG are almost the same as for NGT. Both NGT and PEG have their own and some common complications and advantages, and it seemed proper to
carry out a prospective randomized trial to compare these met hods. PATIENTS AND METHODS From June 1990 until February 1992, 200 patients were eligible for the study. All patients were asked whether they had a preference for one of the two methods. In all cases the responsible doctor was asked whether there was a contraindication for either method. Ninety patients in whom there were no objections from a medical point of view gave their informed consent. These 90 patients were subdivided into three groups, because we felt that there was a difference between patients with neurologic, ear, nose and throat
Table I. Division by group and method* ~~
Neurology Ear, nose and throat Surgery Total ~
* NGT
=
gastrostomy .
~~
~~
NGT
PEG
Total
23 18 5 46
19 21 4 44
42 39 9 90
~~
~~
~
nasogastric tube; PEG = percutaneous endoscopic
96
C. Baeten & J. Hoefnagels
Table 11. Mean age and sex division
Scand J Gastroenterol Downloaded from informahealthcare.com by Chulalongkorn University on 12/26/14 For personal use only.
Neurology Ear, nose and throat Surgery Total
Mean age, years
Men, n
Women,
Total,
n
n
79 t 8 63 + 10 80 8 7 2 + 10
19 34 3 56
23 5 6 34
42 39 9 90
*
(ENT), and surgical problems. For each group a fixed quantity of sealed envelopes was prepared, containing the method to be used for enteral nutrition. So far 42 neurologic, 39 ENT, and 9 surgical patients have entered the study. Of these 90 patients, 46 were randomized to the NGT and 44 to the PEG group. The division into three groups is given in Table I. The mean age of the patients was 72.2 years. The age of the ENT patients was significantly lower than that of the two other groups (Table 11). The division by sex was 56 men and 34 women and reflects the higher incidence of larynx carcinoma in men (34-5) in the ENT group. Within each group the mean age and sex divisions of the NGT and PEG groups were almost equal. After randomization the patients in the NGT group were provided with a silicone nasogastric tube with a ch 14 diameter by a nurse on that ward. The patients in the PEG group were brought to the endoscopy unit and received a gastrostomy under local anesthesia with lidocoine, 1 %. In all cases a Freka (Fresenius) gastrostomy set was used as previously described ( 6 ) . All patients were followed up daily during their hospital stay by one of the investigators. The time needed for introduction of the NGT and PEG and the problems with the insertion were noted. All tubes and gastrostomy sets used were listed but gave an underestimation in the NGT group because several times a tube was replaced during the night or during the weekend without proper notation. All method-specific and common problems during the time of enteral feeding were listed. In all cases the reason for stopping the enteral feeding was noted. In the NGT group the tube was simply withdrawn; in the PEG group the gastrostomy catheter was cut off at the level of the skin, and the internal part of the catheter left the body by the natural route.
Table IV. Number of failures and mean numbers of tubes used per patient
NGT* PEG*
No. of failures
No. of tubes and catheters
4 (8.8%) (n = 46) 3 (6.8%) ( n = 44)
2.7 1.9 ( n = 42) 1.0 ? 0 ( n = 41)
*
* NGT = nasogastric tube; PEG = percutaneous endoscopic gastrostomy.
In all cases the nurses on the wards were asked to give their opinion about the convenience of patient care on a 5graded scale (1 = very convenient; 2 = convenient; 3 = indifferent; 4 = difficult; 5 = very inconvenient) after stopping the enteral nutrition. When the method could not be used, it was given a rating of 5. In those cases when the patients were able to give their own opinion, they were asked to do so on a scale of 5 (1 = very good; 2 = good; 3 = indifferent; 4 = bad; 5 = very bad) after the tube or gastrostomy had been removed. Since this is a preliminary report and the study has not been finished yet, it is not possible to give any statistics. The study was approved by the ethical committee of the Academic Hospital, Maastricht. RESULTS The time needed for insertion of the NGT was registered in 26 cases and was 8.4 6.2 min. The time used for the introduction of the PEG at the endoscopy department was 11.4 k 5.6min (n = 41) (Table 111). The mean time used in the hospital for enteral nutrition was 16.4 days in the NGT group and 21.6 in the PEG group. In four cases it was not possible to place the NGT initially. In the PEG group it was not possible to introduce the gastrostomy catheter in three cases. One patient had an intrathoracic volvulus of the stomach, one patient had a stenosing tumor of the pharynx that could not be passed by the gastroscope, and one patient had had a Billroth I1 resection in the past (Table IV).
*
Table V. Complicationsand problems with nasogastric tubes (NGT) and percutaneous endoscopic gastrostomy (PEG) NGT ( n = 46)
Table 111. Introduction time and use in hospital Introduction time, min NGT' PEG* Total
8.4 2 6.2 11.4 -I- 5.6
No.
Days of enteral nutrition 14.4 + 16.4 21.6 + 22.4 17.9 k 19.9
* NGT = nasogastric tube; PEG = percutaneous endoscopic gastrostomy.
Clotting Fixation of the patient Aspiration Swallowing problems Nasal decubitus Inflammation Abdominal pain Abdominal bleeding
7 10 3 8 6
Percentage 15 22 7 17.4 13
PEG ( n = 44) No.
Percentage
7 3 3
16
12 5
27
1
2
7 7
11
Feeding via Nasogastric Tube or Gastrostomy Table VI. Reasons to stop enteral nutrition in the hospital in nasogastric tube group Ear, nose and throat Neurology Surgery Total
Scand J Gastroenterol Downloaded from informahealthcare.com by Chulalongkorn University on 12/26/14 For personal use only.
Indication Death Problems Aspiration Discharge Total
15 0 1 0 0 16
4 4 6 0 7 21
2 1 1 1 0 5
21 5 8 1 7 42
The mean number of tubes used in the NGT group was 2.7 per patient, and this is an underestimation because not all reinserted tubes were properly registered during the night and weekends. In the PEG group only one catheter per patient was used, The complications of both methods were comparable for some items but were method-related for some other items (Table V). The problems of aspiration were almost equal in the two groups, and the percentages of tube and catheter clotting also did not differ. A great difference was found in the need for fixation of the patients to prevent them from removing the NGT or PEG. Almost all these cases of fixation were in the neurologic group. Swallowing problems were only seen in the NGT group. In the NGT group nasal decubitus was a serious problem in a much larger percentage than expected. Esophagitis and pharyngitis were not checked routinely but were seen in a few cases in which gastroscopy was indicated. The PEG caused abdominal pain for a few days in five patients and caused intraperitoneal bleeding in one patient. This patient died of sepsis due to anastomatic leakage after low anterior resection for rectal cancer. At autopsy 1.5 1 of blood were found in the abdomen. The needle for the
Table VII. Reasons to stop enteral nutrition in the hospital in percutaneous endoscopic gastrostorny group
97
introduction of the PEG had perforated the left lobe of the liver. This bleeding may have contributed to her death. In 27% of the patients mild inflammation was seen around the gastrostomy. In none of the cases did an abscess have to be drained or the gastrostomy removed. The reasons to stop enteral feeding in the hospital are listed in Tables VI and VII. In most cases the NGT and PEG could be removed because there was no longer an indication, or the patients were discharged from the hospital with NGT or PEG, to be transferred to a nursing home (mainly in the neurology group) or to their own home (mainly in the ENT group). In the NGT group 5 and in the PEG group 13 patients died. There is no explanation for the difference. Autopsy was performed. in a few patients. In two patients in each group a bronchopneumonia was found, but there was no proof of aspiration. In one patient in the PEG group (surgery group) intra-abdominal bleeding was found, as mentioned before. In none of the other cases was there a clinical suspicion of a method-related cause of death. Because of too many problems enteral feeding had to be terminated in eight patients in the NGT group. Frequent unintentional removal by the patient and dislocation because of vomiting and coughing were the main reasons to stop the enteral feeding. In six of these eight patients a gastrostomy was introduced. With the PEG these patients of the NGT group could be fed without any further problems. In one of the eight patients it was decided to stop further treatment, and the last patient was transferred to a psychiatric clinic. In none of the patients of the PEG group was it necessary to stop the enteral feeding because of problems. The convenience of patient care was evaluated by the nurses on the wards and gave a mean score of 2.6 in the NGT group and 2.0 in the PEG group (Table VIII). The score of the patients who were able to give their own opinion about the method of enteral nutrition was 2.3 in the NGT group (n = 21) and 1.8 in the PEG group (n = 22) (Table IX).
Ear, nose and throat Neurology Surgery Total 14 1 0 0 5 20
Indication Death Problems Aspiration Discharge Total
1 1 0 0 2 4
2 11 0 0 4 17
17 12 0 0 11 41
Table IX. Score given by the patients NGT* (n = 21) PEG* (n = 22)
2.33 2 1.49 1.77 f 1.00
NGT = nasogastric tube; PEG = percutaneous endoscopic gastrostomy.
Table VIII. Score of convenience given by the nurses
NGT"
(n = 30) PEG* ( n = 38)
Ear. nose and throat
Neurology
Surgery
Total
2.17? 1.17
3.00 t 1.44
2.80 2 1.16
2.58 ? 1.35
* 1.43
2.25 ? 0.43
2.00 2 1.12
*
1.72 0.92
2.31
* NGT = nasogastric tube; PEG = percutaneous endoscopic gastrostomy.
98
C. Baeten & J . HoefnagerS
Scand J Gastroenterol Downloaded from informahealthcare.com by Chulalongkorn University on 12/26/14 For personal use only.
DISCUSSION When the two methods of administering enteral nutrition are compared, the time for the introduction of the PEG is not much longer than for the insertion of the NGT, but of course it takes some time to transport the patients to the endoscopy unit. When the transportation time is added to PEG introduction time and the insertion time is multiplied by the mean number of tubes for the NGT, the total of time investment is about equal in the two groups. In four patients it was initially impossible to introduce the tube, and in another eight patients it was impossible to keep them on enteral nutrition by this method. This means that this method had a failure rate of 26%. The failure rate in the PEG group was 3 of 44 patients (7%). It is obvious that in the NGT group the intention to treat the patients with a tube was less successful than in the PEG group. The costs of the two methods are almost equal when the cost for a tube is multiplied by the number of new tubes used. The clotting problems of the NGT and PEG were equal, but in the case of a nasal tube, the tube had to be renewed. The PEG catheters could in all cases be unplugged with a guidewire. For the patients the chance of being fixated in their bed was much higher in the NGT group. Obviously, the NGT caused more irritation than the PEG. The abdominal pain in the PEG group did not last more than 3 days and was never a reason not to use the catheter for enteral feeding. The complication of bleeding in one patient in the PEG group was strange. The catheter was placed more to the left than normal but nevertheless perforated the left lobe of the liver. There is no explanation for this complication because there was good diaphaniety at the puncture site.
In both groups 7% aspiration was found. In addition to this, in two patients in each group bronchopneumonia was seen at autopsy. It is hard to prove that this'was caused by aspiration. Not specially noted on the scoring list but an often-mentioned problem for the patients in the psychologic factor that in the NGT group the patients felt stigmatized by the nasogastric tube. This sight of a tube through the nose is repulsive to the patients themselves and to their relatives. CONCLUSION The study is not completed yet but it seems that there is a preference in the patient group and on the wards for the PEG. From the medical point of view the PEG seems to score better than NGT with regard to the minor complications, but with regard to severe complications the PEG is more dangerous than the NGT. REFERENCES 1. Owesen L,Hansen E, Allingstrup L, Adsersen M, Longbolk K, Frojhaer S. Bacterial contamination and growth in two defined formula diets of different pH. Clin Nutr 1991;10:114-9. 2. Mathus E . Sondevoeding en keuzebeleid. Ned Tijdschrift Geneesk 1990;134:11-7. 3. Gauderer M, Ponsky J, Irant R. Gastrostomy without laparotomy, a percutaneous endoscopic technic. J Pediatr Surg 1980;15:872. 4. Foutch P, Haynes W, Bollaprarolu S, Sanowski R. Percutaneous endoscopic gastrostomy (PEG), a new procedure comes of age. J Clin Gastroenterol 1986;8:10-5. 5. Steigman G, Goff J, Silas D, Perlanen N, Sun J, Norton L. Endoscopic versus operative gastrostomy: final results of a prospective randomised trial. Gastrointest Endosc 1990;36:1-5. 6. Baeten C, Vismans F, Von Meyenfeldt M. Percutaneous endoscopic gastrostomyusing a prefab set. Neth J Med 1988;32:172-7.
