American Journal of Gastroenterology ISSN 0002-9270


C 2008 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2008.02108.x
Published by Blackwell Publishing

Early Versus Delayed Feeding After Placement of a

Percutaneous Endoscopic Gastrostomy: A Meta-Analysis
Matthew L. Bechtold, M.D., Michelle L. Matteson, A.P.N., Abhishek Choudhary, M.D., Srinivas R. Puli, M.D.,
Peter P. Jiang, M.D., and Praveen K. Roy, M.D.
Division of Gastroenterology, University of Missouri School of Medicine, Columbia, Missouri

BACKGROUND: Traditionally, tube feedings have been delayed after percutaneous endoscopic gastrostomy (PEG)
placement to the next day and up to 24 h postprocedure. However, results from various randomized
controlled trials (RCTs) indicate earlier feeding may be an option. We conducted a meta-analysis to
analyze the effect of early feedings (≤4 h) after PEG placement.
METHODS: Multiple databases were searched (November 2007). Only RCTs on adult subjects that compared
early (≤4 h) versus delayed or next-day feedings after PEG placement were included. Meta-analyses
for the effect of early and delayed feedings were analyzed by calculating pooled estimates of
complications, death ≤72 h, and significant increases in postprocedural gastric residual volume
during day 1.
RESULTS: Six studies (N = 467) met the inclusion criteria. No statistically significant differences were noted
between early (≤4 h) and delayed or next-day feedings for patient complications (OR 0.86, 95% CI
0.47–1.58, P = 0.63) or death in ≤72 h (OR 0.56, 95% CI 0.18–1.74, P = 0.31). A statistically
significant increase in gastric residual volumes during day 1 was noted (OR 1.80, 95% CI 1.02–3.19,
P = 0.04).
CONCLUSIONS: Early feeding ≤4 h after PEG placement may represent a safe alternative to delayed or next-day
feedings. Although an increase in significant gastric residual volumes at day 1 was noted, overall
complications were not affected.
(Am J Gastroenterol 2008;103:2919–2924)

INTRODUCTION
Percutaneous endoscopic gastrostomies, first described in
1980, have assisted in the nutritional requirements for many
patients who are unable to ingest adequate oral nutrition (1).
These endoscopically placed gastrostomy tubes have been a
valuable source of nutrition for patients with strokes, dys-
phagia, and head and neck cancers undergoing treatment
(2, 3). Because of the ease of placement and minimal com-
plications, percutaneous endoscopic gastrostomy (PEG) has
become widely available and utilized for many clinical situ-
ations requiring long-term nutritional support. Although the
benefits and techniques for insertion of PEGs have been de-
scribed and accepted, the feeding after PEG placement is not
as clear.
Since 1980, feedings after PEG placement have been sig-
nificantly delayed by many hours or to the next day. The delay
was most likely a remnant of prior surgical guidelines regard-
ing management of patients after surgically placed tubes, with
very little evidence regarding feedings after PEG placement.
The suspected rationale was to decrease the risk of significant
gastric residual volumes during the first day that may lead to
aspiration and to decrease the risk of peritoneal leakage that
may lead to peritonitis. Over the past 15 yr, many studies
have examined the use of early PEG feedings after insertion.
Many randomized controlled trials on the subject indicate
that early PEG feeding is safe and well tolerated by patients
(4–9). Early feeding after PEG placement has also been
shown to decrease length of hospitalization and, subsequently,
may decrease cost (10). However, these studies differ in
timing of post-PEG feedings, from less than 1 h to less than
6 h.
Despite the recent literature indicating early PEG feedings
as a safe alternative, the common practice continues to be to
significantly delay post-PEG feedings. A survey of gastroen-
terologists in northeastern United States in 1998 revealed that
although 82% of specialists were aware of the recent literature
showing early feedings to be safe, only 39% initiated feed-
ings prior to 8 h and 11% initiated feedings prior to 3 h (11).
The remaining 61% of gastroenterologists surveyed chose to
delay feedings from 9 h to >24 h (11).
Based upon the significant differences between the liter-
ature and clinical practice and between the timing of early
feedings within the literature, we conducted a meta-analysis
to evaluate the use of early PEG feedings (≤4 h) versus de-
layed or next-day feedings for complications, death within

2919
2920 Bechtold et al.
72 h, and significant gastric residual volumes during the first
day.
METHODS
Study Selection Criteria
Randomized controlled trials (RCTs) comparing the out-
comes of early (≤4 h) versus delayed or next-day feeding
after PEG placement were identified and selected.
Data Collection and Extraction
Articles were searched in Medline, Cochrane Central Regis-
ter of Controlled Trials and Database of Systematic Reviews,
DARE, OVID Healthstar and Journals, Cumulative Index for
Nursing and Allied Health Literature, PubMed (from 1950
to 2006), and recent abstracts from major conference pro-
ceedings (Digestive Disease Week and American College of
Gastroenterology National Meeting from 1993 to 2007) were
searched (November 2007). The search terms used were early
feeding, delayed feeding, next-day feeding, and gastrostomy.
Only RCTs on adult subjects (≥18 yr old) that compared
early (≤4 h) versus delayed or next-day feedings after PEG
placement were included. Standard forms were utilized by
two independent reviewers in extracting the data, with differ-
ences being resolved by mutual agreement. Each study was
assigned a Jadad score to assess the quality of the study (5 =
excellent quality, 0 = poor quality) (12). The Jadad score
evaluates the quality of the trial by giving a point for each
of five components: randomization, method of randomiza-
tion being appropriate and described, double-blinding, dou-
ble blinding being appropriate and described, and description
of withdrawal and dropouts (12). If the methods of double
blinding or randomization were inappropriate, a point may
be deducted for each inappropriate criteria (12). Complica-
tions, death, and gastric residual volumes during day 1 were
identified and extracted from the randomized trials.
Potentially relevant articles identified (N = 231)
Potentially appropriate articles (N = 18)
Trials included in meta-analysis (N = 6)
Figure 1. Article identification and selection algorithm.
Statistical Methods
Meta-analyses for the effect of early and delayed feedings af-
ter PEG tube placement were analyzed by calculating pooled
estimates of complications, death ≤72 h, and number of sig-
nificant increases in postprocedural gastric residual volume
during day 1. Odds ratios (OR) were calculated separately
for each main outcome using both the fixed and random ef-
fects models. Significance was indicated by P value <0.05.
Heterogeneity was assessed by calculating the I 2 measure of
inconsistency with significant heterogeneity indicated by an
I 2 value > 50% or P value <0.05. Publication bias was as-
sessed by funnel plot. RevMan 4.2 software was utilized for
statistical analysis of the data.
RESULTS
The initial search identified 231 articles (Fig. 1). Of these
articles, 18 relevant articles were selected and reviewed by
two independent authors (MLB and MLM). Six randomized
controlled trials (N = 467) met the inclusion criteria and
were selected for this study. Data were extracted from these
six studies. Table 1 shows the details and Jadad scores for
the selected studies. All of the studies received Jadad scores
of 2. All randomized trials were published from 1993 to 2002.
Studies were performed in two countries, the United States
(4) and Germany (2). The mean age of patients participating
in the selected studies ranged from 63 to 76 yr. Results were
consistent between the fixed and random effects models.
Complications
Observed patient complications after PEG placement in-
cluded local infections, diarrhea, bleeding, GERD, fever,
vomiting, stomatitis, leakage, and death (Table 2). Early feed-
ings resulted in 25 complications in 232 patients while de-
layed or next-day feedings resulted in 29 complications in
235 patients. Complications were not statistically significant
Excluded N = 213
Case Reports/Series
Retrospective
Reviews
Pediatric
Excluded N = 12
Not RCTs N = 9
Pediatric N = 3
 Early Versus Delayed Feeding After Placement of PEG 2921

Table 1. Details of Included Studies in the Meta-Analysis

Study Number of Pts/ Jadad
Author Type Blinded Location Antibiotics Patients Feedings Time Group Score
Brown et al. 1995 RCT None United States Yes 57 Early <3 h 27 2
Delayed Next day 30
McCarter et al. 1997 RCT None United States Yes 112 Early 4h 57 2
Delayed 24 h 55
Choudhry et al. 1996 RCT None United States Yes 41 Early 3h 21 2
Delayed 24 h 20
Stein et al. 2002 RCT None Germany No 80 Early <1 h 40 2
Delayed 24 h 40
Chumley et al. 1993 RCT - Abst None United States Yes 100 Early 3h 50 2
Delayed 24 h 50
Schulte-Bockholt et al. 1998 RCT - Abst None Germany No 77 Early <1 h 37 2
Delayed Next day 40
RCT = randomized controlled trial; Abst = abstract.
Jadad Score (5 = excellent quality and 0 = poor quality).

Table 2. Summary of Complications, Death ≤72 h, and Number Death ≤72 h

of Significant Gastric Residual Volumes During Day 1 Among the Death ≤72 h was the outcome in 12 patients (early = 4, de-
Included Studies
layed = 8). Death in ≤72 h was not statistically significant
Outcome Early Delayed between the early (≤4 h) and delayed or next-day feedings af-
All Complications (n) 25 29 ter PEG placement (OR 0.56, 95% CI 0.18–1.74, P = 0.31).
Vomiting 7 8 Figure 3 shows the Forrest plot of death within 72 h with
Diarrhea 5 5 early versus delayed or next-day feeding after PEG place-
Death ≤72 h 4 8 ment. Heterogeneity was not statistically significant (I 2 =
Stomatitis 4 0
Leakage 0 4 0%, P = 0.95).
Local infection 2 3 Gastric Residual Volumes During Day 1
Bleeding 1 1
Fever 1 0
The number of significant gastric residual volumes during
Transient GERD 1 0 day 1 ranged from 0 to 14 episodes. Early feedings after PEG
Death ≤72 h (n) 4 8 placement resulted in 40 episodes of significant gastric resid-
Increased gastric residuals during day 1 (n) 40 25 uals during day 1 in 205 patients while delayed or next-day
feedings resulted in 25 episodes in 205 patients. Increased
gastric residual volumes during day 1 were statistically sig-
between the early (≤4 h) and delayed or next-day feedings af- nificant between the early (≤4 h) and delayed or next-day
ter PEG placement (OR 0.86, 95% CI 0.47–1.58, P = 0.63). feedings after PEG placement (OR 1.80, 95% CI 1.02–3.19,
Figure 2 shows the Forrest plot of all complications with P = 0.04). Figure 4 shows the Forrest plot of significant gas-
early versus delayed or next-day feeding after PEG place- tric residual volumes during day 1 with early versus delayed
ment. Heterogeneity was not statistically significant (I 2 = or next-day feeding after PEG placement. Heterogeneity was
0%, P = 0.58). not statistically significant (I 2 = 0%, P = 0.76).

Figure 2. Forrest plot demonstrating all complications between early (≤4 h) versus delayed or next-day feedings after PEG placement.
2922 Bechtold et al.
Figure 3. Forrest plot demonstrating death ≤72 h between early (≤4 h) versus delayed or next-day feedings after PEG placement.
Publication bias was evaluated by funnel plot with no sig-
nificant publication bias identified (Fig. 5).
DISCUSSION
Percutaneous endoscopic gastrostomies are extremely ben-
eficial for long-term nutrition in those patients unable to
maintain adequate oral intake for various reasons. However,
the timing of feedings after PEG placement has not been
fully established, with delayed feeding predominating. The
American Gastroenterological Association (AGA) and the
American Society for Gastrointestinal Endoscopy (ASGE)
have yet to established solid guidelines referring to timing
of feeds after PEG placement (13, 14). Because of this lack
of consensus, many studies have been performed to evaluate
this subject further.
Initially, prospective nonrandomized trials were performed
to evaluate the use of early feedings after PEG placement.
These prospective nonrandomized trials demonstrated very
few complications with early feeding (3–6 h) after PEG place-
ment (15–17). Of the 136 patients evaluated in these three
trials, only five adverse events occurred, including aspiration
Figure 4. Forrest plot demonstrating significant gastric residual volumes between early (≤4 h) versus delayed or next-day feedings after
PEG placement.
pneumonia in one patient, death in one patient attributed to
underlying disease, and PEG site infections in three patients
(15–17). To evaluate further, RCTs were performed directly
comparing early versus delayed or next-day feeding after PEG
placement.
Most of the RCTs comparing early feedings to delayed or
next-day feedings after PEG placement examined complica-
tions and gastric residual volumes. Six RCTs consisting of
a total of 467 patients found no statistically significant dif-
ferences in complications between early feeding (≤4 h) and
delayed or next-day feedings (4–9). Similarly, four RCTs con-
sisting of 298 patients demonstrated no statistically signifi-
cant episodes of increased gastric residual volumes between
the early feeding (<1–3 h) and delayed or next-day feeding
after PEG placement (6–9). However, one study, McCarter
et al., demonstrated statistically significant gastric residual
volumes (>50% of prior volume) on day 1 for the 4-h group
(14 episodes) as compared with the 24-h group (5 episodes)
(5). Based upon this information, a meta-analysis was per-
formed to fully evaluate the early versus delayed feeding after
PEG placement.
This meta-analysis of randomized controlled trials demon-
strates that no statistically significant difference exists

Figure 5. Funnel plot showing no significant publication bias.
between early (≤4 h) and delayed or next-day feeding in
respect to complications or death ≤72 h. However, a sta-
tistically significant difference was noted between the two
groups for number of increased gastric residual volumes dur-
ing day 1. Although gastric residual volumes were increased
during day 1, overall complications were not affected. Sim-
ply holding tube feeds for a minimal period of time alleviated
the significant residual volumes; however, feeding interrup-
tions because of elevated gastric residuals do decrease overall
nutrition (18). Although gastric feeding is a risk factor for as-
piration and subsequent pneumonia (19, 20), recent data from
various trials question the clinical significance of increased
gastric residuals (18, 21, 22). McClave et al. demonstrated
that when the discontinuation threshold of gastric residual
volumes was raised from 200 mL to 400 mL, no statistically
significant difference in the incidence of aspiration or regur-
gitation was observed (21). Furthermore, over an extensive
range of gastric residuals (0 to >400 mL), the frequency of
aspiration and regurgitation did not significantly change (21).
Elpern et al. found that, although significant gastric residuals
(>150 mL) occurred multiple times in 11 of 39 patients, only
four patients experienced feeding aspiration (18). Although
significant gastric residual volumes were significant in early
feeding after PEG placement, no patients were reported to
suffer from massive aspiration in the included studies. Only
one patient in a delayed group with feeding initiated at 24 h
post-PEG placement was reported to have death related to
massive aspiration (5).
This study’s strengths include the use of only RCTs, vary-
ing populations within Germany and the United States, and
similar outcomes between studies in regards to complica-
tions and residual volumes. Also, no heterogeneity between
the studies for any of the three variables and no publication
Early Versus Delayed Feeding After Placement of PEG 2923
bias were observed. However, some limitations were appar-
ent. First, the timing of early feedings differed slightly among
the studies (<1 h, 2 studies; ≤3 h, 3 studies; and ≤4 h, 1
study) (4–9). In an effort to decrease potential bias, the anal-
ysis used ≤4 h as the point for pooling of data. However, even
earlier feeding may be as beneficial as pooled effect of ≤4 h.
Second, significant gastric residual volumes did slightly vary
depending on the study. Stein et al. and Schulte-Bockholt
et al. used >100 mL, McCarter et al. used >50% of the last
volume administered, and Choudhry et al. used >60 mL as
significant residual volumes (5–7, 9). To pool the data and
to minimize the different criteria utilized, the number of sig-
nificant gastric residual volumes were used rather than the
volumes themselves. Third, PEG sizes differed among the
studies from 15-Fr to 20-Fr gastrostomies (4, 5, 7, 9) while
two studies did not specify the size of gastrostomy used (6,
8). Although the PEG sizes were different, both populations
(early vs delayed feeding groups) in each study had approx-
imately equal sizes, minimizing any effects of PEG size on
the overall outcomes. Last, the quality of studies was not ex-
cellent. All studies received a Jadad score of 2 based upon
randomized trials with lack of double blinding or descriptions
of withdrawals. Although the study quality was not excellent,
these are the only randomized studies published to date on
the subject. Also, all studies followed a similar protocol and
evaluated similar outcomes.
In conclusion, this meta-analysis reveals that early feeding
≤4 h after PEG placement appears to be a safe and well-
tolerated alternative to delayed feedings. Despite the popular
opinion of delaying feedings after PEG placement (11), early
feeding appears to be safe and, if implemented in clinical
practice, may result in decreased hospital stays and health-
care costs for those patients undergoing PEG placement.
2924 Bechtold et al.
Reprint requests and correspondence: Matthew L. Bechtold,
M.D., Division of Gastroenterology, M580, DC 043.00, University
of Missouri Health Sciences Center, One Hospital Drive, Columbia,
MO 65212.
Received March 26, 2008; accepted June 16, 2008.
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CONFLICT OF INTEREST
Guarantor of the article: Matthew L. Bechtold, M.D.
Specific author contributions: Conception and design:
Bechtold, Matteson, Jiang, Roy; Acquisition of data: Bech-
told, Matteson, Puli, Choudhary, Jiang, Roy; Analysis and
interpretation of data: Bechtold, Matteson, Puli, Choudhary,
Jiang, Roy; Drafting of manuscript: Bechtold, Matteson, Puli,
Choudhary; Critical revision of manuscript: Bechtold, Matte-
son, Puli, Choudhary, Jiang, Roy; Statistical Expertise: Puli,
Bechtold, Choudhary, Roy; Overall supervision of project:
Jiang, Roy; and Administrative/technical/material support:
None.
Financial Support: None.
Potential competing interests: None.