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Study flow diagram.
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Figure 1

Study flow diagram.

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Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Comparison 1 PEG versus NGT, Outcome 1 intervention failure (subgrouped by baseline disease).
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Analysis 1.1

Comparison 1 PEG versus NGT, Outcome 1 intervention failure (subgrouped by baseline disease).

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Comparison 1 PEG versus NGT, Outcome 2 intervention failure (subgrouped by gastrostomy technique).
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Analysis 1.2

Comparison 1 PEG versus NGT, Outcome 2 intervention failure (subgrouped by gastrostomy technique).

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Comparison 1 PEG versus NGT, Outcome 3 mortality irrespective of follow‐up time.
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Analysis 1.3

Comparison 1 PEG versus NGT, Outcome 3 mortality irrespective of follow‐up time.

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Comparison 1 PEG versus NGT, Outcome 4 pneumonia irrespective of follow‐up time.
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Analysis 1.4

Comparison 1 PEG versus NGT, Outcome 4 pneumonia irrespective of follow‐up time.

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Comparison 1 PEG versus NGT, Outcome 5 complications irrespective of follow‐up time.
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Analysis 1.5

Comparison 1 PEG versus NGT, Outcome 5 complications irrespective of follow‐up time.

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Comparison 1 PEG versus NGT, Outcome 6 mean survival (months).
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Analysis 1.6

Comparison 1 PEG versus NGT, Outcome 6 mean survival (months).

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Comparison 1 PEG versus NGT, Outcome 7 weight (endpoint).
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Analysis 1.7

Comparison 1 PEG versus NGT, Outcome 7 weight (endpoint).

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Comparison 1 PEG versus NGT, Outcome 8 weight (change from baseline).
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Analysis 1.8

Comparison 1 PEG versus NGT, Outcome 8 weight (change from baseline).

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Comparison 1 PEG versus NGT, Outcome 9 albumin (endpoint).
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Analysis 1.9

Comparison 1 PEG versus NGT, Outcome 9 albumin (endpoint).

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Comparison 1 PEG versus NGT, Outcome 10 reflux esophagitis.
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Analysis 1.10

Comparison 1 PEG versus NGT, Outcome 10 reflux esophagitis.

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Comparison 1 PEG versus NGT, Outcome 11 length of stay (days).
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Analysis 1.11

Comparison 1 PEG versus NGT, Outcome 11 length of stay (days).

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Comparison 1 PEG versus NGT, Outcome 12 time of enteral nutrition (days).
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Analysis 1.12

Comparison 1 PEG versus NGT, Outcome 12 time of enteral nutrition (days).

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Comparison 1 PEG versus NGT, Outcome 13 score of patients satisfaction.
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Analysis 1.13

Comparison 1 PEG versus NGT, Outcome 13 score of patients satisfaction.

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Comparison 1 PEG versus NGT, Outcome 14 score of inconvenience by de nurses.
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Analysis 1.14

Comparison 1 PEG versus NGT, Outcome 14 score of inconvenience by de nurses.

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Comparison 1 PEG versus NGT, Outcome 15 mid‐arm circumference in cm (endpoint).
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Analysis 1.15

Comparison 1 PEG versus NGT, Outcome 15 mid‐arm circumference in cm (endpoint).

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Comparison 1 PEG versus NGT, Outcome 16 Functional ability (MRS).
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Analysis 1.16

Comparison 1 PEG versus NGT, Outcome 16 Functional ability (MRS).

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Summary of findings for the main comparison. Percutaneous endoscopic gastrostomy compared to nasogastric tube feeding for adults with swallowing disturbances

Percutaneous endoscopic gastrostomy compared with nasogastric tube feeding for adults with swallowing disturbances

Patient or population: adult patients with swallowing disturbances
Settings: in‐patient
Intervention: percutaneous endoscopic gastrostomy
Comparison: nasogastric tube feeding

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Nasogastric tube feeding

Percutaneous endoscopic gastrostomy

Treatment failure
Feeding interruption, blocking or leakage of the tube, non‐adherence
Follow‐up: 0 to 6 months

Study population

RR 0.24
(0.08 to 0.76)

314
(7 studies)

⊕⊕⊝⊝
low1,2

The subgroup of stroke/neurological diseases was associated with a lower risk of intervention failure compared with the subgroup composed of mixed diseases.

40 per 100

10 per 100
(3 to 30)

Low

20 per 100

5 per 100
(2 to 15)

High

95 per 100

23 per 100
(8 to 72)

Mortality irrespective of follow‐up time
Follow‐up: 0 to 6 months

36 per 100

34 per 100
(23 to 51)

RR 0.96
(0.64 to 1.44)

584
(8 studies)

⊕⊝⊝⊝
very low1,2,3

Pneumonia irrespective of follow‐up time
Follow‐up: 0 to 6 months

39 per 100

33 per 100
(24 to 45)

RR 0.84
(0.61 to 1.14)

585
(6 studies)

⊕⊕⊝⊝
low1,3

Complications irrespective of follow‐up time
Follow‐up: 0‐17 months

43 per 100

43 per 100
(39 to 47)

RR 1
(0.91 to 1.11)

503
(5 studies)

⊕⊕⊕⊝
moderate

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Unclear sequence generation and concealment and loss to follow‐up.
2 Heterogeneity high at 68%, subgroup analysis showed differences between neurological and other diseases.
3 Large 95% confidence intervals including the absence of difference between comparison groups

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Summary of findings for the main comparison. Percutaneous endoscopic gastrostomy compared to nasogastric tube feeding for adults with swallowing disturbances
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Table 1. Continuous data unsuitable for imputation in forest plot

1 median albumin (endpoint)

PEG (n = 8)

NGT (n = 10)

P value

39.5 (R 36 to 44)

36.0 (R 31 to 45)

0.045

2 mean albumin (endpoint)

PEG (n = 42)

NGT (n = 40)

P value

36

32

0.01

3 median length of stay (days)

PEG (n = 162)

NGT (n = 159)

P value

34.0 (IQR 17 to 66)

37.0 (IQR 17 to 76)

not reported

4 utility mean difference between comparison groups (endpoint)

mean difference

95%CI

P value

0.035

‐ 0.024 to 0.093

0.12

5 median patient overall quality of life at first week

PEG (n = 15)

NGT (n = 18)

P value

4.0 (R 2.0 to 7.0)

4.0 (R 2.0 to 7.0)

0.89

6 anthropometric parameters

PEG (n = 8)

NGT (n = 10)

P value

median TSFT (mm)

20.1 (R 9.6 to 34)

12.7 (R 9.8 to 32)

0.076

median BSFT (mm)

10.3 (R 4.8 to 13)

7.4 (R 4.4 to 15)

0.533

median MAC (cm)

31.4 (R 22 to 36)

27.8 (R 21 to 37)

0.182

median serum albumin (g/l)

39.5 (R 36 to 44)

36.0 (R 31 to 45)

0.045

7 median change in GER (%) on day 7

PEG

NGT

P value

2.7 (R 0 to 10.4)

10.8 (R 6.3 to 36.6)

P<0.01

Outcome 1 ‐ Median albumin (endpoint) as reported in Hamidon 2006.

Outcome 2 ‐ Mean albumin (endpoint) as reported in Yata 2001 (abstract).

Outcome 3 ‐ Median length (days) of stay as reported in Dennis 2005.

Outcome 4 ‐ Utility mean difference derived from Euroqol between comparison groups  (endpoint) favouring NGT group, but without statistical significance (Dennis 2005)

Outcome 5 ‐ Median patient overall quality of life at first week (endpoint) reported by Corry 2008.

Outcome 6 ‐ Anthropometric medians (endpoint) as reported in Hamidon 2006.

Outcome 7 ‐ Median Gastroesophageal reflux (%, endpoint) as reported in Douzinas 2006.

IQR: interquartile range

R: range

CI: confidence interval

TSFT: triceps skin‐fold thickness

BSTF: biceps skin‐fold thickness

MAC: mid‐arm circumference
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Table 1. Continuous data unsuitable for imputation in forest plot
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Comparison 1. PEG versus NGT

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 intervention failure (subgrouped by baseline disease) Show forest plot

7

314

Risk Ratio (M‐H, Random, 95% CI)

0.24 [0.08, 0.76]

1.1 AVC/neurological baseline diseases

4

109

Risk Ratio (M‐H, Random, 95% CI)

0.08 [0.02, 0.33]

1.2 mixed baseline diseases

3

205

Risk Ratio (M‐H, Random, 95% CI)

0.62 [0.23, 1.72]

2 intervention failure (subgrouped by gastrostomy technique) Show forest plot

7

314

Risk Ratio (M‐H, Random, 95% CI)

0.24 [0.08, 0.76]

2.1 pull technique

3

90

Risk Ratio (M‐H, Random, 95% CI)

0.07 [0.01, 0.35]

2.2 push technique

1

33

Risk Ratio (M‐H, Random, 95% CI)

0.05 [0.00, 0.74]

2.3 non‐reported technique

3

191

Risk Ratio (M‐H, Random, 95% CI)

0.81 [0.48, 1.37]

3 mortality irrespective of follow‐up time Show forest plot

8

584

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.64, 1.44]

4 pneumonia irrespective of follow‐up time Show forest plot

6

585

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.61, 1.14]

5 complications irrespective of follow‐up time Show forest plot

5

503

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.91, 1.11]

6 mean survival (months) Show forest plot

1

82

Mean Difference (IV, Random, 95% CI)

4.30 [3.28, 5.32]

7 weight (endpoint) Show forest plot

1

21

Mean Difference (IV, Random, 95% CI)

3.20 [‐5.95, 12.35]

8 weight (change from baseline) Show forest plot

2

54

Mean Difference (IV, Random, 95% CI)

2.03 [‐2.66, 6.72]

9 albumin (endpoint) Show forest plot

1

25

Mean Difference (IV, Random, 95% CI)

7.80 [5.52, 10.08]

10 reflux esophagitis Show forest plot

1

82

Risk Ratio (M‐H, Random, 95% CI)

0.45 [0.22, 0.92]

11 length of stay (days) Show forest plot

1

321

Mean Difference (IV, Random, 95% CI)

2.0 [‐11.23, 15.23]

12 time of enteral nutrition (days) Show forest plot

2

119

Mean Difference (IV, Random, 95% CI)

14.48 [‐2.74, 31.71]

13 score of patients satisfaction Show forest plot

1

43

Mean Difference (IV, Random, 95% CI)

‐0.56 [‐1.32, 0.20]

14 score of inconvenience by de nurses Show forest plot

1

68

Mean Difference (IV, Random, 95% CI)

‐0.58 [‐1.18, 0.02]

15 mid‐arm circumference in cm (endpoint) Show forest plot

1

21

Mean Difference (IV, Random, 95% CI)

2.5 [‐0.64, 5.64]

16 Functional ability (MRS) Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

16.1 MRS scale from 0‐3

1

321

Risk Ratio (M‐H, Random, 95% CI)

0.59 [0.34, 1.01]

16.2 MRS scale from 4‐5

1

321

Risk Ratio (M‐H, Random, 95% CI)

1.20 [0.90, 1.61]

16.3 MRS scale from 4‐5 or death

1

321

Risk Ratio (M‐H, Random, 95% CI)

1.10 [1.00, 1.20]
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Comparison 1. PEG versus NGT
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