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Gastroenterology Research

Original Article

Volume 16, Number 2, April 2023, pages 79-91

Outcomes and Complications of Radiological Gastrostomy vs. Percutaneous Endoscopic Gastrostomy for Enteral Feeding: An Updated Systematic Review and Meta-Analysis

Enteral feeding is a common strategy to maintain nutritional status when oral feeding is unfeasible, high risk, or requires supplementation. Gastrostomy feeding is favored over nasogastric tube feeding when medium and long-term enteral nutrition is indicated [1]. Enteral nutrition is superior to parenteral nutrition in terms of nutritional outcome, morbidity reduction, and gut function preservation [2]. Head and neck cancers, motor neuron disorders, cerebral vascular accidents, and malnutrition are the most common indications for gastrostomy tube placement [3]. The two most common placement techniques are percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) [4]. While PEG is the preferred approach at many centers, PRG and surgical gastrostomy are still frequently performed, especially in patients unable to undergo PEG [5, 6].

Current literature regarding adverse event rates of different gastrostomy tube placement approaches presents conflicting findings. Some studies have found that PRG leads to fewer adverse events than PEG [7], while some suggest that PEG is safer than PRG in select patients. Other studies have found no significant difference between the various approaches [8, 9]. Several systematic reviews and meta-analyses comparing PEG and PRG have previously been published [10-12]. However, these meta-analyses have certain drawbacks because they mainly focus on a single outcome or include only a small number of studies. Therefore, we aimed to conduct an updated systematic review of the literature and a comprehensive meta-analysis comparing PEG and PRG outcomes.

A comprehensive search strategy to identify reports of studies comparing radiologically and endoscopically guided placement of gastrostomy tubes was constructed using truncated keywords, phrases, and database subject headings developed in Embase by an experienced health sciences librarian (WL-S). This strategy was translated to MEDLINE (PubMed platform, NCBI), Cochrane Central Register of Controlled Trials, the Web of Science Core Collection, Korean Citation Index, SciELO (Web of Science platform, Clarivate) and the regional indexes of the Global Index Medicus (World Health Organization) with all searches performed on December 21, 2021 and subsequently updated on February 24, 2023 (Supplementary Material 1, www.gastrores.org). No publication date or language limits were used. All results were exported to EndNote 20 citation management software (Clarivate, Philadelphia, PA, USA) and duplicates were removed by successive iterations of EndNote’s duplicate detection algorithms and manual inspection.

The studies were screened by two independent reviewers (ZA and UI). The initial screening was based on titles and abstracts, with the full-text screening of relevant publications following. Next, two independent reviewers extracted the data (ZA and JB). Any discrepancies in study selection and data extraction were resolved through mutual discussion and consensus between the authors. Finally, data on demographics (age, gender), indications for the procedure, and outcomes (30-day mortality, tube leakage, tube dislodgement, perforation, peritonitis, bleeding, infections, and aspiration pneumonia) were collected and summarized using Microsoft Excel (Microsoft, Redmond, Washington, USA).

Statistical analysis was conducted utilizing Comprehensive Meta-analysis Software. We used both fixed and random-effects model for this meta-analysis, with point estimates, variance, and weights for each study based on study size and the number of events. When there was significant statistical heterogeneity, we used the random effects model. In outcomes with low or no statistical heterogeneity, we used the fixed effects model. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for all the outcomes. An I² test was used to evaluate the heterogeneity of the studies. An I² value of 0-25% represented insignificant heterogeneity, and > 75% represented significant heterogeneity. To assess the robustness of our study results, we performed a sensitivity analysis after removing one study at a time. This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [13]. The PRISMA checklist is provided in Supplementary Material 2 (www.gastrores.org).

Methodological Index for Non-Randomized Studies (MINORS) was used to assess study quality [14]. Non-comparative studies are graded on eight MINORS criteria, with each item ranging from 0 to 2 (0 if not reported; 1 if reported but inadequate; 2 if reported and adequate). A global score of 16 for non-comparative studies and 24 for comparative studies is considered ideal. Two authors (ZA and UF) independently carried out the quality assessment, and disagreements were handled by a third reviewer (JB).

The risk of bias within each individual study was determined using the MINORS scale for cohort studies and the Cochrane risk of bias tool for randomized controlled trials (RCTs) [14, 15]. Publication bias was assessed qualitatively by funnel plot visualization and quantitatively by Egger’s regression analysis.

The initial search revealed 872 studies. Of these, 43 studies including 471,208 patients met our inclusion criteria and were included in the final meta-analysis [6, 16-57]. There was one RCT, five non-randomized prospective studies, and 37 retrospective studies. Figure 1 elaborates our systematic literature search process. A total of 194,350 patients underwent PRG placement, and 276,741 patients underwent PEG placement. Baseline characteristics, including patient demographics and indications for gastrostomy tube placement, are reported in Table 1. The quality and bias assessment of studies is summarized in Table 2 and 3. There was no publication bias as assessed by the funnel plot diagram and Egger’s regression test (two-tailed P-value = 0.72259) (Fig. 2).

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Figure 1. PRISMA flow diagram of the literature review process.

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Table 1. Study Characteristics

The quality assessment of studies is summarized in Table 2, and the bias assessment is summarized in Table 3. There was no publication bias as assessed by the funnel plot diagram and Egger’s regression test (two-tailed P-value = 0.72259) (Fig. 2).

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Table 2. Quality Assessment of Non-Randomized Studies via Methodological Index for Non-Randomized Studies (MINORS)

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Table 3. Risk of Bias Assessment of the Included RCTs

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Figure 2. Publication bias assessed by funnel plot diagram.

PRG was associated with higher odds of 30-day mortality when compared to PEG (OR: 1.205, 95% CI: 1.015 - 1.430, I² = 55%) on primary analysis (Fig. 3a). Sensitivity analysis revealed consistent results, with PRG being associated with a higher risk of 30-day mortality when compared to PEG placement. We performed a subgroup analysis after removing the three studies with the largest sample sizes, which confirmed consistent results without their influence (OR = 1.352, 95% CI = 1.001 - 1.826).

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Figure 3. Forest plot of (a) 30-day mortality, (b) tube leakage, and (c) tube dislodgement between PRG and PEG. PEG: percutaneous endoscopic gastrostomy; PRG: percutaneous radiological gastrostomy.

PRG was associated with higher odds of tube leakage when compared to PEG (OR: 2.231, 95% CI: 1.184 - 4.2, I² = 76%) on primary analysis (Fig. 3b). Sensitivity analysis revealed consistent results, with PRG associated with higher odds of leakage compared to PEG.

PRG was associated with higher odds of tube dislodgement when compared to PEG (OR: 2.602, 95% CI: 1.911 - 3.541, I² = 94%) on primary analysis (Fig. 3c). Sensitivity analysis confirmed these results. On subgroup analysis without the three largest studies, results were again consistent (OR = 2.927, 95% CI = 1.755 - 4.882).

PRG was associated with higher odds of perforation when compared to PEG (OR: 1.758, 95% CI: 1.45 - 2.31, I²: 33.13%) on primary analysis. However, this did not achieve statistical significance in the sensitivity analysis (OR: 1.306, 95% CI: 0.971 - 1.755).

PRG was associated with higher odds of peritonitis when compared to PEG (OR: 1.369, 95% CI: 1.81 - 1.586, I² = 0%) on primary analysis. However, this did not achieve statistical significance in sensitivity analysis (OR: 1.066, 95% CI: 0.653 - 1.742).

PRG was associated with a greater risk of bleeding than PEG (OR: 1.376, 95% CI: 1.257 - 1.507, I² = 72%). However, this did not achieve statistical significance on sensitivity analysis (OR: 0.883, 95% CI: 0.74 - 1.051).

PRG was associated with higher odds of infectious complications than PEG (OR: 1.193, 95% CI: 1.136 - 1.253, I² = 23.3%). However, this did not achieve statistical significance on sensitivity analysis (OR: 1.124, 95% CI: 0.996 - 1.268).

There was no significant difference in risk of aspiration pneumonia when comparing PRG with PEG (OR: 0.931, 95% CI: 0.654 -1.324, I² = 15%). Sensitivity analysis confirmed these results.

This systematic review and meta-analysis comparing PRG and PEG outcomes found higher odds of 30-day mortality, tube leakage, and tube dislodgement with PRG compared to PEG. Rates of bleeding, perforation, infectious complications, and peritonitis were significantly higher with PRG than PEG, but these results did not achieve statistical significance in a sensitivity analysis.

The odds of 30-day mortality after PRG was significantly higher than PEG, which is consistent with the results of previously published meta-analyses. Strijbos et al [12] reported a 30-day mortality rate of 7% for PEG vs. 11% for PRG in their 2017 meta-analysis of 2,027 patients. Lim et al also reported a lower 30-day mortality rate of 5.5% for PEG vs. 10.5% for PRG (OR: 0.6, CI 0.38 - 0.94, P = 0.026) in their 2016 meta-analysis of 2,183 patients [11]. The lower 30-day mortality rate in the PEG group could be attributed to several factors. First, prophylactic antibiotics are widely used and recommended among patients undergoing PEG placement [58], while present data on the use of antibiotics before PRG are conflicting. Clements et al reported no significant difference with antibiotic prophylaxis in early peristomal infection rate in their retrospective analysis [59]. In contrast, in an RCT, Ingraham et al reported early infection rate was 11.8% in the placebo arm and 0.0% in the antibiotic arm [60]. Currently, prophylactic antibiotics are not widely recommended for patients undergoing PRG, as the procedure avoids the oropharyngeal bacterial contamination of the endoscope as it traverses through the mouth and pharynx that occurs during PEG [61]. Second, PEG and PRG often use gastrostomy tubes of different sizes. PRG tubes are thinner in diameter (10 - 14 French) than PEG tubes (20 French), which could affect rates of tube blockage and result in aspiration pneumonia, increasing risk of respiratory decompensation and mortality [62]. In addition, because PRG tubes are secured using a balloon retention system, they are typically less secure than PEG tubes, resulting in greater risk of peristomal leakage and tube displacement, potentially leading to peritonitis and bowel perforation [63]. Furthermore, the two groups differed in terms of indication for gastrostomy tube placement. PEG patients had a higher prevalence of neurological disorders, whereas PRG patients had a higher prevalence of head and neck malignancy. These distinctions could have influenced our study’s findings.

Tube-related complications, tube leakage, and tube dislodgement were more common among patients undergoing PRG than PEG. Strijbos et al reported the rate of tube-related complications to be 16% for PRG vs. 6% for PEG [12]. Failure of equipment, particularly balloon failure, has been identified as a primary cause of tube dislodgment in PRG [22]. Additionally, the smaller diameter of PRG tubes compared to PEG tubes may increase the chance of blockage, as well as risk of tube dislodgement. Contrary to our results, a meta-analysis by Wollman et al reported a higher rate of tube-related complications in PEG patients (16%) than PRG patients (12%) (P ≤ 0.001) [10].

To assess whether any single study had a dominant effect on the meta-analysis, we excluded one study at a time and analyzed its impact on the primary summary estimate. We found that after removing certain studies from the analysis one at a time, some results were no longer significant. For example, overall results indicated that PRG is associated with a higher rate of infections than PEG. However, this was not significantly different based on our sensitivity analysis, which is consistent with previous studies.

Despite being associated with higher 30-day mortality rates and tube-related complications, PRG is still an important option for patients requiring gastrostomy tubes. In contrast to PEG, PRG can be placed without requiring sedation. PRG can also be used in patients with severe esophageal stenosis or malignant esophageal and oropharyngeal cancers that are poor candidates for PEG [64].

We compared our study to the meta-analysis by Strijbos et al [12] published in 2018. The limitations of their meta-analysis included a low number of studies, failure to include all available studies that met inclusion criteria, and lack of reporting on all outcomes. Our meta-analysis has the following strengths: systematic literature search with well-defined inclusion criteria, inclusion of all available studies in the current literature, careful exclusion of redundant studies, high-quality studies with detailed data extraction, and rigorous study quality evaluation. Our pooled rates are calculated from 471,091 patients, a very robust figure. However, our study has some limitations, many of which are inherent to any meta-analysis. Most of the studies included are retrospective, which likely contributed to selection bias. Although 30-day mortality is high with PRG, it should be highlighted that the underlying comorbid illnesses that required the patient to have a gastrostomy tube were likely the cause of mortality, rather than procedural complications. Because we were unable to account for comorbidities, it is plausible that individuals who received PRG were sicker than those who received PEG, which could explain the higher mortality rate. Furthermore, because our meta-analysis identified studies from various databases, there is a chance of patient overlap. However, our sensitivity analysis for each outcome bolsters our meta-analysis findings. Nonetheless, our study represents the best estimate of PRG and PEG clinical outcomes currently available in the literature.

In summary, PRG is associated with higher 30-day mortality and gastrostomy tube-related complications than PEG. Additional studies, particularly large RCTs, are warranted.

Suppl 1. Search strategy.

Suppl 2. PRISMA checklist.

Acknowledgments

This research was originally presented at the American College of Gastroenterology 2022 Annual Scientific Meeting in Charlotte, NC on October 25, 2022.

Financial Disclosure

No funding was received for the preparation of this manuscript.

Conflict of Interest

The authors declare no conflict of interest.

Informed Consent

Not applicable.

Author Contributions

Zohaib Ahmed contributed to study planning and conduction, data collection and interpretation, manuscript drafting and revision. Umair Iqbal contributed to study planning, statistical analysis, manuscript drafting and revision. Muhammad Aziz contributed to statistical analysis, manuscript drafting. Syeda Faiza Arif, Joyce Badal, and Umer Farooq contributed to data collection, manuscript drafting. Faisal Kamal contributed to data interpretation, manuscript drafting and revision. Wade Lee-Smith contributed to study search strategy, data collection, manuscript drafting. Asif Mahmood contributed to manuscript revision. Abdallah Kobeissy, Harshit S. Khara, Ali Nawras, Bradley Confer, and Douglas G. Adler contributed to study design and conception, and critical manuscript revision.

Data Availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

ALS: amyotrophic lateral sclerosis; CI: confidence interval; CVA: cerebrovascular accident; HNC: head and neck cancers; MINORS: Methodological Index for Non-Randomized Studies; OR: odds ratio; PEG: percutaneous endoscopic gastrostomy; PRG: percutaneous radiological gastrostomy

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