Indian J Gastroenterol (NovemberDecember 2013) 32(6):366368
DOI 10.1007/s12664-013-0348-8
ORIGINAL ARTICLE
A comparative observational study of early versus delayed
feeding after percutaneous endoscopic gastrostomy
Manoj A. Vyawahare & Mrunal Shirodkar &
Amit Gharat & Prachi Patil & Shaesta Mehta &
K. M. Mohandas
Received: 29 June 2012 / Accepted: 6 July 2013 / Published online: 17 August 2013
# Indian Society of Gastroenterology 2013
Abstract
Background Percutaneous endoscopic gastrostomy (PEG) is
the procedure of choice for long-term enteral feeding.
Objective This prospective observational study was carried
out to compare the safety of commencing feeding 3 h com-
pared to 1624 h after PEG tube placement.
Methods One hundred and ten patients with oropharyngeal
malignancies who had consented for PEG were enrolled.
Trial-specific consent and IRB approval were not obtained
because at the time when this study was done, this was not
mandatory for observational studies which involved stan-
dard procedures. Alternate patients were started on early
feeding within 3 h (group I) or after overnight observation
of 16 to 24 h (group II). Five hundred milliliters of Ringer's
lactate was infused over 4 h initially, followed 2 h later by
200 mL of formula feed. The patients were advised to take
bolus feeds of 200 mL every 2 h and oral feeds ad libitum
M. A. Vyawahare (*)
Department of Medical Gastroenterology and Hepatology,
Meditrina Institute of Medical Sciences, Ramdaspeth,
Nagpur 440 010, India
e-mail: drmanojvyawahare@gmail.com
M. Shirodkar
Abbott Nutrition India, Mumbai, India
A. Gharat
Department of Gastroenterology, Topiwala National Medical
College and B Y L Nair Hospital, Mumbai Central,
Mumbai 400 008, India
P. Patil : S. Mehta
Division of Digestive Diseases and Clinical Nutrition, Tata
Memorial Centre, Parel, Mumbai 400 012, India
K. M. Mohandas
Department of Digestive Diseases, Tata Medical Center,
Kolkata 700 156, India
from the next day. All patients were evaluated on days 1, 2, 7,
and 30.
Results There were 55 patients (47 males) in group I and 54
patients (38 males) in group II who were matched for age
(mean age 46.1 and 46.1 years, respectively). Complications
included PEG site infection (1), peristomal leak (3), and
displacement of the PEG tube (1) in group I. PEG site
infection was seen in five patients in group II. All the
complications were managed conservatively on an ambula-
tory basis.
Conclusion Initiation of tube feeding 3 h after an uncompli-
cated PEG was safe, well tolerated, and helped to reduce the
hospital stay.
Keywords Complications . Nutrition . Oropharyngeal
cancer
Introduction
Percutaneous endoscopic gastrostomy (PEG) is a time-tested
procedure for long-term enteral alimentation [1, 2]. It is
currently performed in patients suffering from neurological
disorders, neoplasms of the head, neck, and esophagus, and
those with head injury [3]. Two meta-analyses have con-
firmed the safety of early feeding after PEG placement [4,
5]. These studies have shown that feeding after PEG can be
started early within hours, thus making the procedure a day
care procedure without any significant increase in the
procedure-related morbidity or mortality and thereby reduc-
ing the healthcare costs [611]. In spite of the evidence, there
is a tendency to keep the patients fasting until the next
morning [3, 12, 13]. One of the views has been that Indian
patients are more malnourished and therefore more likely to
develop complications. We carried out this prospective ob-
servational study to compare the safety of starting early
feeding after PEG tube placement in Indian circumstances.
Indian J Gastroenterol (NovemberDecember 2013) 32(6):366368 367

Methods and Materials Table 1 Clinical features of the 109 patients

Characteristics Group I Group II

This prospective observational study was conducted at the
Division of Digestive Diseases and Clinical Nutrition, Tata Patients 55 55*
Memorial Centre, Mumbai. One hundred and ten consecu- Mean age (years) 46.1 46.1
tive patients with head and neck cancers who had consented Male/female 47:8 38:16
to undergo PEG from 1 May 2006 to 31 September 2006 Sites of cancer
were included. Trial-specific consent and Institutional Re- Tongue 21 18
view Board (IRB) approval were not obtained because at the Buccal mucosa 13 21
time when this study was done, it was not mandatory to get Alveolus 15 09
IRB approval for observational studies which involved stan- Others 6 6
dard procedures. All the PEGs were performed using the pull Subjective global assessment
technique [1], using 22 Fr or 24 Fr commercial PEG tubes A 15 10
(Cook Endoscopy, Winston Salem, NC27105, USA). Alter- B 32 39
nate patients undergoing PEG were started on early feeding C 8 5
after 3 h or delayed feeding after overnight observation. The Serum albumin, mean (g/dL) 4.2 4.0
PEG was abandoned in one patient who developed stridor Major complications 0 0
after the endoscopy. The PEG procedure was uncomplicated 30-day mortality 0 0
in all the other 109 patients. Thus, 55 patients received Minor complications 5 5
feeding 3 h after the PEG placement (group I) and 54 patients
received feeding 1624 h after the PEG (group II). All *One patient did not undergo percutaneous endoscopic gastrostomy
patients were evaluated by the physician who performed due to stridor
the PEG before starting the tube feedings. The PEG feedings
were initially started with 500 mL of Ringer's lactate infused Discussion
over 4 h, followed 2 h later by 200 mL of commercial
formula feeds for the first day. Thereafter, they were advised Many studies have examined the use of early PEG feedings
bolus feeds of 200 mL every 2 h and oral feeds ad libitum and indicate that early PEG feeding is safe and well tolerated
next day. The patients were evaluated on days 1, 2, 7, and 30 by adult and pediatric patients [611]. Bechtold et al.
for major and minor complications. The vital signs, abdom- performed a meta-analysis of six randomized control trials
inal distension, tenderness, position of the tube, peristomal (n=467) that compared the early (4 h) vs. delayed or next-
leakage, and wound sites were evaluated at each visit by un- day feeding after placement of a PEG [4]. No statistically
blinded investigators. significant differences were noted between early and delayed
or next-day feedings for patient complications or death in
72 h. A statistically significant increase in gastric residual
volumes during day 1 was noted which did not affect overall
Results complications. The authors concluded that early feeding 4 h
after PEG placement may represent a safe alternative to
The baseline characteristics of the patients in the two groups delayed or next-day feedings [4]. Szary et al. performed
are summarized in Table 1. While the two groups were another meta-analysis of five studies (n=355) and concluded
similar with regard to mean age, there were more male that early tube feeding 3 h after PEG placement had no
patients in group I. The sites of cancer in the study subjects significant differences to delayed or next-day feeding in
were similar in both groups. The extent of malnutrition respect to complications, death in 72 h, or number of
determined by using the subjective global assessment score significant gastric residual volumes at day 1 [5].
revealed that vast majority of our patients had moderate to Despite the level I evidence now available, it remains
severe nutritional risk in both arms. The mean serum albu- common practice to delay post-PEG feedings. A survey of
min was similar in both groups. gastroenterologists in north-eastern United States in 1998
There were no major complications requiring re- revealed that although 82 % of specialists were aware of
hospitalization or intervention and no mortality in this study. the recent literature showing early feedings to be safe, only
Infection at the PEG stoma was seen in one patient in group I 39 % initiated feedings prior to 8 h and 11 % initiated
and five patients in group II. Peristomal leak was seen in three feedings prior to 3 h. The remaining 61 % of gastroenterol-
patients and displacement of PEG tube was seen in one patient ogists surveyed chose to delay feedings from 9 h to more
in group I. There was no statistically significant difference in than 24 h [12]. A subsequent web-based review of practices
the overall complication rates in the two groups. revealed that only 9 % of gastroenterologists initiate PEG
368
tube feedings 3 h despite 41 % being aware of the recent
literature regarding PEG feeding initiation times [13]. De-
layed feeding was practiced by endoscopists in Canada, with
median time to initiation of feeding for inpatients being
approximately 48 h with a range of 24 to 48 h [3].
Based on the meta-analyses, current guidelines recom-
mend the initiation of PEG feedings within a few hours of
the procedure thereby enabling an early discharge [14]. At
the time while we were undertaking this study, multiple
surveys had indicated that many endoscopists still hold on
to delayed feeding until the next morning. This delay is
probably an extrapolation of the surgical gastrostomy prac-
tices. Delaying the feeding is also attributed to keeping the
gastric residual volumes low in order to minimize aspiration
and reduce the risk of peritoneal leakage and peritonitis.
Recent trials show that increased gastric residuals correlate
poorly with risk of aspiration [15]. Because the PEG stoma
tract will take a week or more to epithelize and mature,
delaying the feeds by a day would not have much role in
reducing leaks. Meta-analysis of several surgical studies show
that early postoperative nutrition is associated with significant
reductions in total complications compared with traditional
postoperative feeding practices and does not negatively affect
outcomes such as mortality, anastomotic dehiscence, resump-
tion of bowel function, or hospital length of stay [16]. Yarze
et al. studied the risk for hydroperitoneum/peristomal leak
with a water-soluble contrast agent within 3 h post endoscopic
gastrostomy button placement and none of the patients
showed evidence of leakage [17]. So, there is no rationale
for delaying the feeds by 24 h.
Our results concur with these recommendations and we
changed our practices and started early feeding in all those
who have had an uncomplicated PEG procedure. We were
able to initiate PEG feedings 3 h after the procedure without
any major detrimental effects. All of our patients had oro-
pharyngeal malignancies that are generally considered as
high risk patients. Over two-thirds of our patients had mod-
erate to severe malnutrition using the subjective global as-
sessment. There was no major morbidity like peritonitis,
intraabdominal hemorrhages requiring re-admission or re-
intervention, and no 30-day mortality. The frequencies of
minor complications were similar in both groups and were
managed on outpatient basis. This enabled us to discharge
patients early after starting early PEG feeds. Health care
costs are very relevant in India as in the West, as majority
of these are borne by the patients themselves. This also
helped to make beds to those on the admission waiting list.
Our study had some limitations with regards to external
validity. It was not a randomized controlled trial and hence
was prone to bias and confounding. The statistical power of
this study was low due to a convenience sample size of 110
subjects. Nonetheless, our study replicated and validated the
results of the meta-analysis in a routine practice scenario. We
Indian J Gastroenterol (NovemberDecember 2013) 32(6):366368
conclude that initiation of early feeding 3 h after an uncompli-
cated PEG is safe, well tolerated, and can shorten hospital stay.
References
1. Gauderer MWL, Ponsky JL, Izant RJ Jr. Gastrostomy without
laparotomy: a percutaneous technique. J Pediatr Surg. 1980;15:8725.
2. Gomes CA Jr, Lustosa SA, Matos D, Andriolo RB, Waisberg DR,
Waisberg J. Percutaneous endoscopic gastrostomy versus nasogas-
tric tube feeding for adults with swallowing disturbances. Cochrane
Database Syst Rev. 2010;11, CD008096.
3. Pruthi D, Duerksen DR, Singh H. The practice of gastrostomy tube
placement across a Canadian regional health authority. Am J
Gastroenterol. 2010;105:154150.
4. 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;103:291924.
5. Szary NM, Arif M, Matteson ML, Chaudhary A, Puli SR, Bechtold
ML. Enteral feeding within three hours after percutaneous endoscop-
ic gastrostomy placement: a meta-analysis. J Clin Gastroenterol.
2011;45:e348.
6. Chumley DL, Batch WJ, Hoberman LJ, et al. Same day PEG
feeding, is it safe? Results of randomized prospective study. Am J
Gastroenterol. 1993;88:1589.
7. Choudhry U, Barde CJ, Markert R, Gopalswamy N. Percuta-
neous endoscopic gastrostomy: a randomized prospective com-
parison of early and delayed feeding. Gastrointest Endosc.
1996;44:1647.
8. Werlin S, Glicklich M, Cohen R. Early feeding after percutaneous
endoscopic gastrostomy is safe in children. Gastrointest Endosc.
1994;40:6923.
9. McCarter TL, Condon SC, Aguilar RC, Gibson DJ, Chen YK. Ran-
domized prospective trial of early versus delayed feeding after percu-
taneous endoscopic gastrostomy placement. Am J Gastroenterol.
1998;93:41921.
10. Schulte-Bockholt A, Sabin M, Rosenstock U, et al. Immediate
versus next day PEG feeding: a randomized prospective study in
ICU/intermediate care patients. Gastroenterology. 1998;114:A907.
11. Stein J, Schulte-Bockholt A, Sabin M, Keymling M. A randomized
prospective trial of immediate vs. next-day feeding after percutane-
ous endoscopic gastrostomy in intensive care patients. Intensive
Care Med. 2002;28:165660.
12. Srinivasan R, Fisher RS. Early initiation of post-PEG feeding: do
published recommendations affect clinical practice? Dig Dis Sci.
2000;45:20658.
13. Tauseef A, Vu LE, Sharma T, Shrinivasan N, Tierney WM, Rizvi
SM. Post-PEG feeding time: a web-based national survey of gas-
troenterologists. Gastrointest Endosc. 2009;69:AB179.
14. Loser C, Aschl G, Hebuterne X, et al. ESPEN guidelines on
artificial enteral nutrition- percutaneous endoscopic gastrostomy
(PEG). Clin Nutr. 2005;24:84861.
15. McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual
volumes as a marker for risk of aspiration in critically ill patients.
Crit Care Med. 2005;33:32430.
16. Osland E, Yunus RM, Khan S, Memon MA. Early versus tradition-
al postoperative feeding in patients undergoing resectional gastro-
intestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr.
2011;35:47387.
17. Yarze JC, Herlihy KJ, Fritz HP, et al. Prospective trial evaluating
early initiation of feeding in patients with newly placed one-step
button gastrostomy devices. Dig Dis Sci. 2001;46:8548.