“Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes”: Commentary

Abstract

In this commentary, we summarize some of the key points of the original paper “Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes” and offer support for the proposed results. Specifically, we address how early percutaneous endoscopic gastrostomy (PEG) tube placement may reduce hospital length of stay and costs. We also discuss topics related to the article including PEG weaning and post-stroke nutritional formulation. However, we note that concerns purported by previous studies that early PEG placement may worsen outcomes are not fully addressed, and further research is needed.

Key Words: Percutaneous endoscopic gastrostomy tube, Post-stroke, Nutritional management, Rehabilitation, Dysphagia

Core Tip: Here we summarize some of the key points of the original paper and offer support for the proposed results. Specifically, we address how early percutaneous endoscopic gastrostomy (PEG) tube placement may reduce hospital length of stay and costs. We also discuss topics related to the article including PEG weaning and post-stroke nutritional formulation. However, we note that concerns purported by previous studies that early PEG placement may worsen outcomes are not fully addressed, and further research is needed.

INTRODUCTION

Early percutaneous endoscopic gastrostomy (PEG) tube placement may reduce hospital length of stay and costs. Extensive PEG tube use in post-stroke patients highlights new topics of interest such as proper PEG weaning protocols and post-stroke nutritional formulation. In addition, further research is needed to fully address concerns raised by previous studies that early PEG placement may worsen certain patient outcomes.

ARTICLE FINDINGS AND RECENT SUPPORT

The findings of the study, “Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes”, indicate that early PEG tube placement may be associated with a shorter length of hospital stay and likely a reduction in costs[1]. This has been further supported by recent research[2]. In addition, this concept that early PEG placement may reduce hospital stay has been supported by research in a number of diverse fields, including post-head and neck surgery recovery[3]. Furthermore, the authors’ suggestion that delayed PEG placement may be associated with higher rates of complications is endorsed by recent studies that have found higher pneumonia rates in post-stroke patients treated with a nasogastric tube instead of PEG[4,5].

ARTICLE LIMITATIONS

This study by Reddy et al[1] highlights a number of factors that support early PEG placement in post-stroke patients, including that there may be no significant difference in mortality outcomes between early and late PEG placement, and that early PEG placement may reduce hospital length of stay and feasibly cost of stay. However, the authors do not fully address the concerns purported by the FOOD trial that while early PEG placement may be associated with reduced mortality rates, it was also associated with higher rates of patients living with worse outcomes[6]. While it is possible that the higher rates of patients with poorer outcomes is due only to higher rates of survival in those with greater complications who would have otherwise died, further research is needed to elucidate this finding.

THE DIRECTION OF FUTURE RESEARCH AND THERAPEUTIC GUIDANCE

It has been well demonstrated that post-stroke patients are at a higher risk for malnutrition[7]. Recent research has shown that a nutritional regimen that is high in protein may rescue post-stroke muscle loss and promote recovery from dysphasia[8].

It is also worth noting that PEG tube weaning benefits from a multidisciplinary approach with swallowing assessment, swallowing therapy, and a steady increase in oral consumption until the PEG tube can be safely removed[9,10].

CONCLUSION

The findings of this study by Reddy et al[1] add substantially to the question of whether early PEG placement is beneficial both economically and therapeutically, but further research is needed for therapeutic guidance.