ACG American College of Gastroenterology Show European Society for Paediatric Gastroenterology, Hepatology and Nutrition Ggastrostomy GJgastrojejunostomy GRADEGrading of Recommendations, Assessment, Development, and Evaluation Jjejunostomy NDnasoduodenal NGnasogastric NICENational Institute for Clinical Excellence NJnasojejunal PEGpercutaneous endoscopy gastrostomy RCTrandomized controlled trial SRSystematic review Maintaining adequate nutrition in patients with acute and chronic illnesses that interfere with the patient’s oral intake is vitally important. Providing nutrients through the gastrointestinal tract, or enteral nutrition, is generally preferred over parenteral nutrition.1 Gastric feeding is well tolerated by most patients, however, there are many reasons for which post-pyloric feeding might be indicated (e.g., severe gastroesophageal reflux).1 There are two options for providing gastric or post-pyloric nutrition: temporary and permanent tubes.2,3 Temporary tubes include the nasogastric (NG) tube and the nasojejunal (NJ) tube; these tubes are inserted through the nose and advanced through the esophagus and into the stomach (NG tube), through the pylorus, and into the jejunum (NJ tube).2 Permanent feeding tubes are placed directly into the stomach (gastrostomy [G] tubes) or intestine (jejunostomy [J] tubes or gastrojejunostomy [GJ] tubes), either percutaneously, laparoscopically, or surgically.3 Temporary tubes are generally the first means of supplying enteral nutrition support, however, if enteral nutrition is needed for longer than four to five weeks, a permanent feeding tube should be considered.1 In Canada, some hospitals may not be equipped to insert or replace both types of feeding tubes, and patients with GJ and J tubes may need to be referred to a different hospital for replacement of the tubes. It is unknown whether feeding tubes into the jejunum are still worthy, or whether G tubes into the stomach are acceptable replacements for preventing aspiration in patients who require feeding tubes. The purpose of this report is to synthesize and critically appraise the available evidence on the clinical effectiveness, cost-effectiveness, and guidelines for the use of G tubes versus J tubes in patients requiring feeding tubes. Research Questions
Four systematic reviews were identified that addressed the research question in patients requiring temporary feeding tubes; three in critically ill patients, and one in preterm infants. In critically ill patients, the three systematic reviews had numerous overlapping studies and found moderate to high quality evidence that nasogastric tubes were no different in terms of the risk of mortality, aspiration, gastrointestinal complications, or length of stay in hospital, when compared to nasojejunal or nasoduodenal feeding tubes. These systematic reviews also identified moderate to high quality evidence that nasojejunal or nasoduodenal feeding tubes are associated with a lower risk of pneumonia compared to gastric tubes. In preterm infants, evidence from one moderate quality systematic review indicated that post-pyloric tubes were associated with an increased risk of mortality and gastrointestinal complications when compared to gastric feeding tubes, but there was no difference in aspiration pneumonia. In patients requiring permanent feeding tubes, limited evidence from low quality nonrandomized studies suggests that gastrostomy tubes offer a modest benefit or no benefit when compared to jejunostomy tubes. No evidence regarding the comparative cost-effectiveness of gastrostomy tubes, gastrojejunostomy and/or jejunostomy tubes for preventing aspiration in patients requiring a feeding tube was identified. Three evidence-based guidelines were identified, and all three recommended gastric feeding tubes as the preferred method of enteral feeding, unless there is upper gastrointestinal dysfunction, in which case post-pyloric feeding is recommended. A limited literature search was conducted on key resources including PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination databases, Canadian and major international health technology agencies, as well as a focused Internet search. No filters were applied to limit the retrieval by study type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2013 and June 26, 2018. One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1. For the context of this report, G tubes were considered any feeding tubes inserted into the stomach, including NG and percutaneous endoscopy gastrostomy (PEG) tubes; and GJ and J tubes also encompassed NJ and nasoduodenal (ND) tubes. Articles were excluded if they did not meet the selection criteria outlined in Table 1, they were duplicate publications, or were published prior to 2008. Guidelines with unclear methodology were excluded. The included systematic reviews were critically appraised by one reviewer using AMSTAR II,4 non-randomized studies were critically appraised using the Downs and Black checklist,5 and guidelines were assessed with the AGREE II instrument.6 Summary scores were not calculated for the included studies; rather, a review of the strengths and limitations of each included study were described narratively. A total of 489 citations were identified in the literature search. Following screening of titles and abstracts, 459 citations were excluded and 30 potentially relevant reports from the electronic search were retrieved for full-text review. 30 potentially relevant publications were retrieved from the grey literature search for full text review. Of these potentially relevant articles, 46 publications were excluded for various reasons, and 14 publications met the inclusion criteria and were included in this report. These comprised 4 systematic reviews, 7 non-randomized studies, and 3 evidence-based guidelines. Appendix 1 presents the PRISMA7 flowchart of the study selection. Additional references of potential interest are provided in Appendix 6. Additional details regarding the characteristics of included publications are provided in Appendix 2. Four systematic reviews (SRs) with the objective of comparing the clinical effectiveness of post-pyloric versus gastric feeding tubes were identified.8–11 The reviews included literature searches up to 2011,9 2012,11 and 20138; one SR did not provide the dates of their search strategy but was published in 2014.10 Three SRs included only randomized controlled trials (RCTs), and there was overlap with 16 RCTs in these SRs (See Appendix 5: Overlap between Included Systematic Reviews for the overlap of RCTs between the SRs.).8–10 The other SR included RCTs and quasi-randomized controlled trials.11 All SRs pooled results across studies using meta-analyses where appropriate. Six retrospective cohort studies12–17 and one prospective cohort study18 comparing gastric and post-pyloric feeding tubes were identified. No relevant economic studies were identified. Three relevant evidence based guidelines were identified by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN),19 the National Institute for Clinical Excellence (NICE),20 and the American College of Gastroenterology (ACG).21 All three guidelines used a literature search to identify the evidence. The ESPGHAN guideline included SRs, prospective or retrospective controlled studies, and prospective or retrospective cohort studies, used GRADE to rate the quality of the evidence, and a consensus meeting with voting to develop the recommendations.19 The NICE guideline included only SRs, meta-analyses of RCTs and RCTs, graded the type of evidence and the strength of the evidence, and a multidisciplinary guideline group to develop the recommendations. 20 The ACG guideline used GRADE to evaluate the evidence, and an expert committee to develop the recommendations, but they did not specify the types of literature they included.21 The SRs were led by authors based in Canada,8 China,9 and the UK.10,11 The nonrandomized studies were led by authors based in Canada,12,17 China,15 France,13 Turkey,18 and the US.14,16 The guidelines are meant to apply to Europe,19 the UK,20 and the US.21 Three SRs included critically ill patients,8–10 and one included preterm infants requiring enteral tube feeding.11 Two of the non-randomized studies examined adult patients (18 years of age or greater) requiring feeding tubes; one examined tube insertion (n = 559)17 and the other examined emergency department visits (n = 94).18 Two retrospective cohort studies examined pediatric patients; one with pediatric cancer patients undergoing tube placement (n = 122; less than 21 years of age),14 and the other with children presenting to the emergency department with feeding tube complications (n = 31; less than 18 years of age).16 The other non-randomized study populations included patients who underwent pancreatoduodenectomy with pancreaticogastrostomy for pancreatic tumor (n = 86; aged 25 to 80 years,13 patients who underwent esophagectomy with gastric tract reconstruction (n = 274; aged 44 to 78 years),15 and patients discharged from a home enteral nutrition program (n = 129; mean age greater than 55 years).12 The intended users of the NICE guideline are healthcare professionals, patients and their carers, and the guideline targets adult patients who are malnourished or at risk of malnutrition.20 The ESPGHAN and ACG guidelines do not report an intended user for their guidelines, but the guidelines target children with neurological impairments19 and the hospitalized patient,21 respectively. The SRs included studies examining temporary enteral feeding tubes that used catheters passed via the nose or the mouth, and compared NG feeding tubes to post-pyloric (ND or NJ) feeding tubes.8–11 The non-randomized studies examined permanent feeding tubes; three studies compared G tubes to GJ tubes,13,16,17 three studies compared G or PEG tubes with J tubes,12,14,15 and one study compared PEG tubes to ND/NJ tubes.18 The three guidelines examine which type of feeding tube to use.19–21 In the SRs, the outcomes related to the clinical effectiveness of gastric and post-pyloric feeding tubes were: time to achieve nutritional target,8 caloric delivery,8,10 gastric residual volume,10 and growth (rate of change in weight),11 The outcomes related to harms were: pneumonia,8–11 mortality,8,10,11 length of stay in the intensive care unit,8,10 gastrointestinal complications,8,10,11 duration of mechanical ventailation,8 complications from tube insertion and maintenance,8 vomiting,9 aspiration,9 necrotising enterocolitis,11 and intestinal perforation.11 The length of follow-up ranged from the time in the hospital,9,11 from the time of tube insertion until removal or tube or death,8 and up to 24 weeks.10 In the non-randomized studies, the outcomes related to the clinical effectiveness were: caregiver satisfaction,18 and time to removal feeding tube.15 The outcomes related to harms were: complication rate,13,14,16,17 mortality,13,17,18 readmission to the hospital,13 length of stay in hospital,13,15 obstructions,12,15 dislodgement,12 leakage,12 aspiration complications,18 surgery complications,15 complications with the catheter,15 abdominal distension,15 and non-routine tube replacement.15 The length of follow-up ranged from the time in-hospital,18 30 days,13,14,17 6 months,18 3 years,12 and 5 years.16 Additional details regarding the strengths and limitations of included publications are provided in Appendix 3. The AMSTAR II assessment of the four SRs found that none of the reviews contained an explicit reference to a protocol.8–11 Although one SR did mention deviations from a protocol, it was unclear whether the protocol was registered and how the protocol was used to guide the work.8 In general, the SRs reported adequate methods for study selection and data extraction, including the use of a comprehensive literature search strategy, duplicate data extraction and detailed descriptions of the included studies. However, none of the SRs justified only including RCTs, and only two provided a list of the excluded studies.8,11 In one SR it was unclear whether study selection was performed in duplicate, and this SR also lacked details about the study populations.10 All of the SRs reported assessing the risk of bias of the included RCTs, but none reported the sources of funding of the included studies. Three SRs did not assess the potential impact of the risk of bias in the individual studies on the meta-analysis,8,10,11 while two SRs did not account for study quality when interpreting their results.8,10 The methods reported for the synthesis of the results was appropriate in three SRs,8,9,11 and in the remaining SR it was unclear whether the results were weighted appropriately and whether they adjusted for heterogeneity.10 The review authors declared no conflicts of interest in the four SRs, but one review did not investigate the risk of publication bias.10 All seven non-randomized studies included in this report were either single12,14–18 or two13 center cohort studies, of which all but one18 had a retrospective design; as such, no randomization of the interventions took place. In addition, due to the nature of the interventions and study designs, it was not possible to blind the patients or data abstractors in any of the studies. Taken together, these studies are limited by high risk of bias for selection and detection bias. In addition, two studies had additional concerns with regards to patient selection and treatment allocation.12,18 One study did not provide the details of their systematic sampling of a larger cohort to obtain a convenience sample for one of their groups,12 and therefore it is unknown whether the selection of this group is biased. In another study, patients were allowed to choose their treatment, but they were presented with the treatment options in a sequential manner. They were only presented the next option after refusing the previous one, and therefore treatment allocation may be biased.18 The quality of the reporting in the non-randomized studies was generally well done, with all studies clearly outlining their objective, providing detailed descriptions of their patient population and the treatments, and reporting actual probability values. However, one study failed to clearly define the main outcomes of the study and did not clearly describe their findings,16 while two studies did not report results for some of their listed outcomes.15,18 In four studies, the statistical tests were unclear or not appropriate: in two studies, statistical tests designed for comparing two groups (e.g., chi square, Fisher’s exact test, or student’s t-test) were used in analyses where three groups were being compared and a different statistical test would have been more appropriate (e.g., ANOVA or Kruskal-Wallis test),13,14 in one study, it is unclear if the odds ratios were calculated correctly,16 and in other study, a log rank test was used inappropriately to conclude which group was different from the other two.18 Furthermore, it was not possible to determine whether all analyses were planned a prior in some studies,12–14,16 and adjusting for confounders was only done in three studies;12,13,15 meanwhile two studies explicitly stated that there was significant difference in age between the groups but then failed to adjust for age in their analysis.16,18 There was one high quality guideline,20 one moderate quality guideline,19 and one poor quality guideline.21 All three guidelines clearly describe their scope and purpose, and provide clear, easily identifiable recommendations. The NICE guideline reports rigorous methods for the development of their recommendations, including the details of stakeholder involvement, such as a diverse guideline development group and the views of the target population.20 The development of the ESPGHAN guideline is well reported, but the authors do not describe the strengths and limitations of the evidence, and the guideline lacks a procedure for being updated.19 On the contrary, the ACG guideline does not report all the details of their search strategy, the criteria for selecting the evidence, the methods for formulating the recommendations, the strengths and limitations of the evidence, whether the guideline was externally reviewed, and the procedure for updating the guideline.21 The overall findings of this review are summarized below. Additional details are available in Appendix 4, in which the main study findings and author’s conclusions are provided. There is considerable overlap between the primary studies included in three of the SRs (See Appendix 5: Overlap between Included Systematic Reviews).8–10 Two SRs8,10, with considerable overlap between primary studies, found that based on evidence they evaluated to be of moderate quality that there was no difference in mortality between critically ill patients with gastric versus post-pyloric feeding tubes. A SR of preterm infants found a statistically significant increase in risk of death prior to discharge with transpyloric versus gastric feeding tubes.11 Two non-randomized studies reported on mortality.13,18 In patients who underwent pancreatoduodenectomy with pancreaticogastrostomy for pancreatic tumor, there was no difference in post-operative mortality between patients with a G (n = 3) or NG (n = 0) feeding tube when compared to those with a GJ tube (n = 2),13 however, a statistical test designed to compare two groups was used to compare three groups. In women admitted to the emergency department due to aspiration pneumonia, there was a statistically significant difference in estimated mean survival between the PEG (4.8 months), ND/NJ (2.0 months), and oral feeding (4.7 months) groups, however, the statistical test used can only determine that a difference exists between the groups, and not the magnitude of the difference between groups.18 All four SRs reported pneumonia as a study outcome. In critically ill patients, three SRs with considerable overlap between primary studies, found that based on evidence they evaluated to be of moderate to high quality evidence that post-pyloric feeding tubes were associated with a statistically significant lower risk of pneumonia compared to gastric feeding tubes.8–10 In preterm infants, a SR with five primary studies did not show any difference in aspiration pneumonia prior to hospital discharge.11 One non-randomized study reported the incidence of pneumonia as statistically significantly higher in patients with a J tube (26.1%) versus a G tube (11.6%) after esophagectomy with gastric tract reconstruction surgery.15 One SR in critically ill patients reported aspiration as an outcome, but did not observe any difference in risk of aspiration between post-pyloric and gastric feeding tubes, even when only the authors only included studies that they determined to be of high quality in the analysis.9 In one non-randomized study, in patients who were admitted to the emergency department due to aspiration pneumonia, a statistically significant difference in re-aspiration rates was detected between the three groups: PEG tubes (58%), ND/NJ tubes (78%), and oral feeding (91%).18 In critically ill patients, two SRs reported vomiting as an outcome,8,9 one SR reported diarrhoea,8 and one reported on gastrointestinal complications which included nausea, vomiting, diarrhoea, abdominal distension, reflux and gastrointestinal minor or major bleeding.10 The risk of vomiting was not different between gastric and post-pyloric feeding tubes, except when the authors only included two studies that they determined to be of high quality in a sensitivity analysis, and then post-pyloric feeding was associated with a statistically significant lower risk of vomiting.9 The feeding tubes did not differ in their risk of diarrhoea (evidence quality not evaluated by the authors),8 or the odds of gastrointestinal complications between nasogastric and post-pyloric feeding tubes (based on high quality evidence, as evaluated by the author).10 In preterm infants, transpyloric feeding tubes were associated with a statistically significant increased risk of gastrointestinal disturbances (including diarrhoea) prior to hospital discharge.11 Two SRs8,10, with considerable overlap between primary studies, reported no differences in length of stay in the intensive care unit between the gastric and post-pyloric feeding tubes, but the quality of the evidence was only evaluated by the authors of one SR, and they found the evidence to be of moderate quality.10 Two non-randomized studies reported length of stay as an outcome.13,15 In patients who underwent pancreatoduodenectomy with pancreaticogastrostomy for pancreatic tumors, the mean length of stay was not statistically different between G or NG versus GJ tubes,13 however, an inappropriate statistical test may have been used. In patients who underwent esophagectomy with gastric tract reconstruction, patients with J tubes had a significantly longer median length of stay (15 days) versus patients with a G tube (11 days).15 One SR found based on moderate quality evidence a statistically significant higher odds of high gastric residual volume for nasogastric feeding tubes compared to post-pyloric feeding tubes.10 Three non-randomized studies reported overall complication rates,13,14,17 while three nonrandomized studies reported specific complications.12,15,16 In adults undergoing a primary G or GJ tube insertion, the overall 30-day complication rate was significantly higher in the GJ tube group (13.5% versus 5.8%), but there was no significant difference between the rate of major or minor complications.17 In patients who underwent pancreatoduodenectomy with pancreaticogastrostomy for pancreatic tumor, there was no significant difference in overall morbidity or severe morbidity when GJ tubes were compared to NG or G tubes,13 however, an inappropriate statistical test may have been used. Similarly, in pediatric (less than 21 years of age) cancer patients undergoing the placement of enteral feeding tubes, there was no difference in the rate of any complications or major complications when J, G, and both J and G tubes were compared,14 however, an inappropriate statistical test may have been used. In children (less than 18 years of age) who presented to the emergency department with a G or GJ tube related complication, the odds of a dislodgement, clogging, or leaking were similar between the G and GJ tubes,16 although the accuracy of the statistical analysis is unclear. In patients discharged from a home enteral nutrition program, J tubes were associated with a significantly higher rate of non-routine tube replacement (45.3%) compared to PEG tubes (13.8%), however, there was no difference in the indications for tube replacement, such as obstruction, dislodged, leakage, or infection.12 In patients who underwent esophagectomy with gastric tract reconstruction, J tubes were associated with a significantly higher rate of bowel obstructions and abdominal distention when compared with G tubes.15 One non-randomized study reported statistically significantly higher care giver satisfaction scores with PEG tubes compared to ND/NJ tubes and oral feeding at 6 months in adult patients requiring long term-enteral feeding.18 No relevant evidence regarding the cost effectiveness of G versus GJ and/or J tubes was identified. All three guidelines make recommendations in support of gastric feeding tubes as the first choice in treatment, with post-pyloric feeding tubes recommended if gastric feeding is poorly tolerated.19–21 The NICE guideline makes one recommendation based on high quality, evidence: adults who are malnourished or at risk of malnutrition should be fed via a tube into the stomach unless there is upper gastrointestinal dysfunction.20 This guideline also provides a good clinical practice point, based on expert opinion: patients who are malnourished or at risk of malnutrition with upper gastrointestinal dysfunction should be considered for post-pyloric feeding. The ESPGHAN guideline makes two recommendations for feeding tubes in children with neurological impairments, based on a moderate level of evidence.19 They recommend that G tubes be used as the preferred intragastric access for long-term tube feeding in children with neurological impairments, and that jejunal feeding can be used in cases of aspiration due to gastroesophageal reflux disease, refractory vomiting, retching, and bloating.19 The ACG guideline for the hospitalized patient makes one recommendation based on moderate-to-high level of evidence: “conversion to post-pyloric feeding tube should be carried out only when gastric feeding has been shown to be poorly tolerated or the patient is at high risk for aspiration”(p. 324).21 The guideline makes other conditional recommendations, but they are based on a very low level of evidence. There are various limitations associated with the evidence in our report comparing the use of G tubes versus GJ and/or J tubes. A key limitation was the availability of evidence. Despite the inclusion of four SRs, seven non-randomized studies, and three guidelines, there is still a paucity of recent, high quality evidence. In each of the three SRs on critically ill patients requiring temporary enteral feeding there was considerable overlap between the RCTs; in two SRs8,9 there was only one RCT that was uniquely captured in that review and in the other SR10 there were three RCTs that were uniquely captured in that review, with the remaining RCTs overlapping across the SRs. In addition, the literature in these reviews was only searched until 2013, and therefore, there was no evidence from RCTs in the past 5 years. Another limitation was the lack of evidence comparing the different types of feeding tubes; specifically there was no high quality evidence directly comparing permanent G versus GJ/J tubes. The four SRs8–11 only included RCTs of temporary enteral feeding tubes that passed first through the nose or mouth before entering the stomach or intestine (i.e. NG versus ND or NJ tubes). No SRs or RCTs were identified that compared permanent feedings tubes that go directly into the stomach (i.e. G tubes) with feeding tubes that go into the jejunum (i.e. J or GJ tubes). Although seven non-randomized studies were identified comparing G with GJ/J tubes, the retrospective and prospective cohort study designs only provide low quality evidence. The inclusion criteria for the population of this report was very broad (patients of any age requiring a feeding tube), which ensured that all relevant populations were captured, however, some of the patient populations were very specific, particularly in the nonrandomized studies (e.g., patients who underwent pancreatoduodenectomy with pancreaticogastrostomy for pancreatic tumor,13 or patients who underwent esophagectomy with gastric tract reconstruction by a retrosternally positioned gastric tube15) which may limit the generalizability of the findings. One SR was conducted by Canadian authors,8 but only included the findings from one RCT conducted in Canada. Two non-randomized studies were conducted in Canada; one study of adults undergoing G or GJ tube insertion17, and the other study of patients discharged from a home enteral nutrition program.12 It is unknown if the results from the other studies are generalizable to Canadian clinical practice as there may be geographic differences in the manner in which care for patients with feeding tubes is provided between countries. Several outcomes were captured in the body of evidence for this report, however, most outcomes were only reported in two to four studies across a variety of populations and feeding tube types, therefore making it challenging to form definitive conclusions. Unfortunately, no cost-effectiveness studies were identified in the literature search, nor were any studies found that included patient satisfaction as an outcome. This report identified four SRs8–11 and seven non-randomized studies12–18 that compared the clinical effectiveness of gastric versus post-pyloric feeding tubes. No cost-effectiveness studies were identified. Three guidelines were summarized that inform the use of G and J tubes for preventing aspiration in patients requiring a feeding tube.19–21 For temporary gastric and post-pyloric feeding tubes that are first passed through the nose or mouth tubes, the findings differed between critically ill patients and pre-term infants. In critically ill patients, three SRs of moderate quality, with a considerable number or overlapping RCTs, found evidence evaluated by the authors to be of moderate to high quality that there was no difference between gastric and post-pyloric feeding tubes for mortality,8,10 aspiration,9 gastrointestinal complications,8–10 or length of stay in hospital.8,10 Meanwhile, the three SRs found evidence evaluated by the authors to be of moderate to high quality that post-pyloric feeding tubes were associated with a lower risk of pneumonia compared to gastric tubes.8–10 In contrast, in preterm infants, one moderate quality SR found that transpyloric tubes were associated with an increased risk of death and gastrointestinal complications prior to discharge compared to gastric feeding tubes, with no difference in risk of aspiration pneumonia.11 For permanent feeding tubes, only limited evidence from low quality cohort studies was available comparing G versus J tubes, but in general, G tubes had a beneficial or no effect when compared to J tubes or NJ/ND tubes. Evidence from high risk of bias cohort studies found no difference in post-operative mortality between patients with G, NG and GJ tubes,13 and longer survival in patients with PEG tubes compared to NJ/ND tubes.18 One low quality study reported higher rates of pneumonia in patients with J tubes versus G tubes,15 and one study of low quality reported higher aspiration rates with NJ/ND tubes compared to PEG tubes.18 Following feeding tube insertion, three low quality studies reported no differences in overall complication rates.13,14,17 Two low quality studies reported higher rates of non-routine replacements12, bowel obstructions,15 and abdominal distensions,15 for J tubes, and one high risk of bias study reported similar odds of dislodgement, clogging, or leaking in children with G and GJ tubes.12 Similarly, one low quality study reported longer lengths of stay in patients with J tubes,15 while a study with a high risk of bias reported no differences in the length of stay.13 Further research from well conducted RCTs is required to reduce the uncertainty with regards to the clinical effectiveness of G versus J tubes. No evidence was identified regarding the cost-effectiveness of G tubes versus GJ and/or J tubes for preventing aspiration in patients requiring a feeding tube. Three evidence-based guidelines were identified, all of which recommend the use of gastric feeding tubes as the first choice of treatment, and the use of post-pyloric feeding tubes if gastric feeding is poorly tolerated.19–21 1. Heuschkel R, Duggan C. Enteral feeding: gastric versus post-pyloric. UpToDate. Waltham (MA): Wolters Kluwer; 2018 May. 2.3.4.5.6.7.Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1–e34. [PubMed: 19631507] 8.Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F. Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015(8):Cd008875. [PMC free article: PMC6516803] [PubMed: 26241698] 9.Jiyong J, Tiancha H, Huiqin W, Jingfen J. Effect of gastric versus post-pyloric feeding on the incidence of pneumonia in critically ill patients: observations from traditional and Bayesian random-effects metaanalysis. Clin Nutr. 2013;32(1):8–15. [PubMed: 22853861] 10.Sajid MS, Harper A, Hussain Q, Forni L, Singh KK. An integrated systematic review and meta-analysis of published randomized controlled trials evaluating nasogastric against postpyloris (nasoduodenal and nasojejunal) feeding in critically ill patients admitted in intensive care unit. Eur J Clin Nutr. 2014;68(4):424–432. [PubMed: 24518748] 11.12.Ao P, Sebastianski M, Selvarajah V, Gramlich L. Comparison of complication rates, types, and average tube patency between jejunostomy tubes and percutaneous gastrostomy tubes in a regional home enteral nutrition support program. Nutr Clin Pract. 2015;30(3):393–397. [PubMed: 25378355] 13.14.Hamilton EC, Curtin T, Slack RS, et al. Surgical feeding tubes in pediatric and adolescent cancer patients: a single-institution retrospective review. J Pediatr Hematol Oncol. 2017;39(7):e342–e348. [PMC free article: PMC5610072] [PubMed: 28678086] 15.Huang K, Wu B, Ding X, Xu Z, Tang H. Post-esophagectomy tube feeding: a retrospective comparison of jejunostomy and a novel gastrostomy feeding approach. PLoS One. 2014;9(3):e89190. [PMC free article: PMC3962330] [PubMed: 24658763] 16.Ronning MM, Gaillard P, Wey A, Roback MG. Comparison of emergency department visits for complications of gastrostomy versus gastrojejunostomy tubes in children. Pediatr Emerg Care. 2017;33(10):e71–e74. [PubMed: 28968311] 17.Zener R, Istl AC, Wanis KN, et al. Thirty-day complication rate of percutaneous gastrojejunostomy and gastrostomy tube insertion using a single-puncture, dual-anchor technique. Clin Imaging. 2018;50:104–108. [PubMed: 29348052] 18.Onur OE, Onur E, Guneysel O, Akoglu H, Denizbasi A, Demir H. Endoscopic gastrostomy, nasojejunal and oral feeding comparison in aspiration pneumonia patients. J Res Med Sci. 2013;18(12):1097–1102. [PMC free article: PMC3908533] [PubMed: 24523803] 19.Romano C, van Wynckel M, Hulst J, et al. European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines for the evaluation and treatment of gastrointestinal and nutritional complications in children with neurological impairment. J Pediatr Gastroenterol Nutr. 2017;65(2):242–264. [PubMed: 28737572] McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG clinical guideline: nutrition therapy in the adult hospitalized patient. Am J Gastroenterol. 2016;111(3):315–334; quiz 335. [PubMed: 26952578] 22.23.Balshem H, Helfand M, Schunemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401–406. [PubMed: 21208779] View in own window ICU = intensive care unit; ITU = intensive therapy unit; LOS = length of stay; ND = nasoduodenal; NG = nasogastric; NJ = nasojenunal; RCT = randomized controlled trial; View in own window EN = enteral nutrition; G = gastrostomy; GJ = gastrojejunostomy; J = jejenostomy; NG = nasogastric; ND/NJ = nasoduodenal/nasojejunal; PEG = percutaneous endoscopy gastrostomy; RCT = randomized controlled trial; TPN = total parenteral nutrition View in own window GI = gastrointestinal; GRADE = Grades of Recommendation, Assessment, Development and Evaluation; NR = not reported; RCT = randomized controlled trial; SRs = systematic reviews View in own window RCTs = randomized controlled trials View in own window
View in own window ICU = intensive care unit; ITU = intensive therapy unit; NG = nasogastric; OR = odds ratio; RR = risk ratio; SD = standard deviation View in own window EN = enteral nutrition; G = gastrostomy; GJ = gastrojejunostomy; J = jejenostomy; NG = nasogastric; ND/NJ = nasoduodenal/nasojejunal; PEG = percutaneous endoscopy gastrostomy; SE = standard error; TPN = total parenteral nutrition View in own window ACG = American College of Gastroenterology; ESPGHAN = European Society for Paediatric Gastroenterology, Hepatology and Nutrition; G = gastrostomy; NG = nasogastric; NICE = National Institute for Clinical Excellence; PEG = percutaneous endoscopy gastrostomy Systematic reviews
All of the studies in those two reviews were fully captured in two of the more comprehensive reviews already included in the report, and were thus excluded to avoid overlap. Guidelines with Unclear MethodologyNo direct comparison to J tubes (Rapid Review of Gastronomy)Not a direct comparison: PEG was changed to PEG-J following aspiration pneumonia
CADTH Rapid Response Report: Summary with Critical Appraisal Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec. Gastrostomy versus gastrojejunostomy and/or jejunostomy feeding tubes: a review of clinical effectiveness, cost-effectiveness and guidelines. Ottawa: CADTH; 2018 Jul. (CADTH rapid response report: summary with critical appraisal). Disclaimer: The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. The information in this document should not be used as a substitute for professional medical advice or as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not endorse any information, drugs, therapies, treatments, products, processes, or services. While care has been taken to ensure that the information prepared by CADTH in this document is accurate, complete, and up-to-date as at the applicable date the material was first published by CADTH, CADTH does not make any guarantees to that effect. CADTH does not guarantee and is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in any third-party materials used in preparing this document. The views and opinions of third parties published in this document do not necessarily state or reflect those of CADTH. CADTH is not responsible for any errors, omissions, injury, loss, or damage arising from or relating to the use (or misuse) of any information, statements, or conclusions contained in or implied by the contents of this document or any of the source materials. This document may contain links to third-party websites. CADTH does not have control over the content of such sites. Use of third-party sites is governed by the third-party website owners’ own terms and conditions set out for such sites. CADTH does not make any guarantee with respect to any information contained on such third-party sites and CADTH is not responsible for any injury, loss, or damage suffered as a result of using such third-party sites. CADTH has no responsibility for the collection, use, and disclosure of personal information by third-party sites. Subject to the aforementioned limitations, the views expressed herein are those of CADTH and do not necessarily represent the views of Canada’s federal, provincial, or territorial governments or any third party supplier of information. This document is prepared and intended for use in the context of the Canadian health care system. The use of this document outside of Canada is done so at the user’s own risk. This disclaimer and any questions or matters of any nature arising from or relating to the content or use (or misuse) of this document will be governed by and interpreted in accordance with the laws of the Province of Ontario and the laws of Canada applicable therein, and all proceedings shall be subject to the exclusive jurisdiction of the courts of the Province of Ontario, Canada. |
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