**3. Enteral nutrition routes**

There are different enteral nutrition routes, and the route chosen is determined according to the length of time and the type of enteral support needed for a specific patient. The different types of enteral nutrition include nasogastric tubes (NGTs) and nasojejenal tubes (NJTs); surgically placed gastrostomy tubes (GTs) and jejenostomy tubes (JTs); and non-surgical placement methods include percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejenostomy (PEJ).

Before the development of the PEG procedure by Gauderer and Ponsky in the early 1980s, a gastrostomy tube was placed under general anaesthetic. PEG has become the most popular method of tube placement because of the ease of insertion, minimal invasiveness and no requirement for a general anaesthetic [36-38]. A surgical gastrostomy may still be performed in cases where PEG is not possible due to obstruction which makes the passing of the scope down the gastrointestinal tract impossible [39].

### **4. Short term versus long-term enteral nutrition**

The placement of NGTs are recommended for the delivery of early enteral nutrition in the acute stages of disease [2, 10, 13, 40]. The benefits of early enteral nutritional have been documented within various groups of patients [41-44]. NGTs are for short term use only and should not be in situ for periods longer than 4 to 6 weeks [2, 15], as they can cause serious complications including nasal ulceration, chronic sinusitis and increased risk of aspiration pneumonia [15, 39, 45].

NGTs are easy to insert and require no surgical procedure or administration of anaesthetics for placement [10, 14, 46]. However they are poorly tolerated by patients, and are often pulled out after insertion thereby reducing the nutritional advantage which was the aim of placement [47-49]. NGTs may be placed incorrectly by the professional inserting them, with incidences reported to range from 0.3 to 27% (cited by [50] in [51]). A misplaced NGT may result in aspiration pneumonia which can be fatal [51]. Patient positioning, with most hospitalized patients being in a sedated state or lying flat, during NGT feeding can also result in aspiration pneumonia [52-53]. An increase in reflux with NGT placement has been noted [39, 46] particularly in cases with pre-existing gastro-oesophageal reflux [54]. Similar negative effects have been noted with the use of PEGs [46].

The most common indicator for long term enteral nutrition is a cerebral vascular accident (CVA) [3, 5, 10-12, 19-26]. Dysphagia with resulting malnutrition and/or dehydration is common in patients who have had a CVA, explaining the high need for enteral nutrition within this population [10, 13, 27-28]. Patients with other neurological deficits such as traumatic head injury or neuro-degenerative diseases, may also require short or long term enteral nutrition as

Certain medical conditions are more likely to predispose patients to require enteral nutrition because of concomitant dysphagia and increased nutritional needs. Patients with head and neck cancer may develop dysphagia after radiation treatment as a result of tissue damage to the swallow mechanism [18] with a resultant need for prophylactic enteral nutrition [17]. Those patients who continue on oral intake may require enteral nutrition as a supplement to ensure sufficient intake of the daily nutritional requirements while receiving radiotherapy [18]. In cases of trauma to the body or after surgery, enteral nutrition is also recommended to aid sufficient caloric intake to minimise loss of body fat and to support recovery [15, 29, 31-32,

There are different enteral nutrition routes, and the route chosen is determined according to the length of time and the type of enteral support needed for a specific patient. The different types of enteral nutrition include nasogastric tubes (NGTs) and nasojejenal tubes (NJTs); surgically placed gastrostomy tubes (GTs) and jejenostomy tubes (JTs); and non-surgical placement methods include percutaneous endoscopic gastrostomy (PEG) or percutaneous

Before the development of the PEG procedure by Gauderer and Ponsky in the early 1980s, a gastrostomy tube was placed under general anaesthetic. PEG has become the most popular method of tube placement because of the ease of insertion, minimal invasiveness and no requirement for a general anaesthetic [36-38]. A surgical gastrostomy may still be performed in cases where PEG is not possible due to obstruction which makes the passing of the scope

The placement of NGTs are recommended for the delivery of early enteral nutrition in the acute stages of disease [2, 10, 13, 40]. The benefits of early enteral nutritional have been documented within various groups of patients [41-44]. NGTs are for short term use only and should not be in situ for periods longer than 4 to 6 weeks [2, 15], as they can cause serious complications including nasal ulceration, chronic sinusitis and increased risk of aspiration

a safe method of hydration and nutrition [7, 29-33].

34-35].

138 Seminars in Dysphagia

**3. Enteral nutrition routes**

endoscopic jejenostomy (PEJ).

pneumonia [15, 39, 45].

down the gastrointestinal tract impossible [39].

**4. Short term versus long-term enteral nutrition**

If a patient requires enteral nutrition for a period longer than 4 to 6 weeks, and the prognosis justifies the intervention, placement of a gastrostomy or PEG tube for the provision of long term enteral nutrition could be considered [14, 19, 55, 56]. However, Maitines et al. (2009) suggest a longer period of at least 6 to 8 weeks with an NGT in situ, before considering a PEG to ensure a better outcome. Others [14] consider the prognosis and argue that a patient at the end stages of a disease should not be considered for PEG but should rather receive nutrition via NGT. No difference between NGT and PEG cohorts was found in the rate of complications [46], the rate of mortality post placement [45-46] or the occurrence of pneumonia post place‐ ment [46].

Higher complication rates for gastrostomies relative to PEG placements have been reported [57-58]. Complications include internal leakage, peritonitis, fistula, dislodgement, external leakage and skin infection. Higher mortality rates in surgical gastrostomy cases (29%, n=35) compared with PEG cases (17%, n=12) were not significantly different [58].

The reasons for high mortality rates include poor patient selection. Patients with risk factors for mortality have been recommended for a PEG resulting in poor outcomes that are being linked to the PEG procedure, when in fact these patients were at risk of death regardless of PEG placement [59-60]. There is strong evidence linking certain underlying medical conditions to higher mortality post PEG [5, 15, 36, 55-56, 59, 61-63]. The highest mortality rates occurred in patients who had CVA and malignancies [22, 62].

The timing of PEG placement [24, 64] is noted also to affect the outcome. It has been suggested that there be a 30 day delay in the placement of long term enteral nutrition to ensure a better chance of survival, leaving patients on short term enteral nutrition for a longer period [24, 64]. The notion of poor timing in the placement of PEG is linked to poor patient selection. If a patient has an underlying medical condition that places them at risk for mortality, it can be argued that they would have died regardless, and early PEG insertion, at a time when they are at risk of death due to an underlying medical condition, means that they die with a PEG in situ which makes their death a statistic of mortality post PEG placement. To counteract early PEG placement, it is suggested that if a patient has survived and still requires a PEG after their condition has stabilised, only then should it be considered. Abuksis et al. (2000) noted a lower mortality rate in patients who were deferred for the placement of a PEG until they were discharged from hospital and if it was still required at 30 days post discharge.

As an example, mortality in patients with CVAs usually occurs in the acute stage when a patient is still in the hospital [65]. Dysphagia is common following a CVA [65] and many CVA patients will regain their ability to swallow within two weeks post infarct [66]. A patient who receives a PEG at this stage is at high risk of dying due to the underlying medical condition of a CVA [65]. The high mortality will be reflected as a consequence of PEG placement in cases with a CVA. The timing for the placement of a PEG in a patient with a CVA is critical, and should only be considered if a patient has not regained their ability to swallow within four weeks [13, 67]. During the acute stages post CVA, an NGT is recommended for the provision of hydration and nutrition [13].

There are also a series of risk factors such as increased age, decreased body mass index, a higher number of co-morbidities, and decreased blood albumin levels have been identified as placing a patient at greater risk of mortality post PEG. Along with the primary medical condition and timing of placement, these factors also need to be considered when recommending a patient for a PEG to reduce the likelihood of poor outcomes. One such risk factor is increased age. Patients over the age of 60 were found to have the highest mortality rate at 30-days post insertion [20, 22-25, 55-56, 68-70]. Age together with diminished mental capacity, as with patients who have dementia, tripled mortality in the period after placement [22]. Such outcomes caution against PEG placement in older patients with dementia.

The positive outcomes of long term enteral nutrition should also guide decisions for such a recommendation. One such outcome post PEG placement is the ability to return to oral intake which can occur in patient populations with a range of medical conditions and depends on factors such as the presence of dysphagia, age, and the underlying medical condition that necessitated PEG placement [12, 17, 69]. Factors that determined a return to oral intake, were the ability to take some amount of nutrition orally at 3 and 6 months post PEG placement [12], regression of the tumour that had originally caused dysphagia post chemo/radiotherapy [12, 17] regaining of the swallow post CVA [12, 69], a younger age, the absence of dysphagia and intervention by a speech therapist to regain the swallow pre PEG placement [71].

The provision of nutrition into the stomach via NGT or gastrostomy/PEG is common [5, 21]. Gastrointestinal intolerance of tube feedings, identified by the presence of large gastric residual volumes, nausea and vomiting, ileus, abdominal distension, and diarrhoea [72], is a major factor limiting adequate enteral intake in patients. In cases such as these the stomach may be bypassed and nutrition delivered to a lower part of the gastro intestinal tract [4, 39, 73]. NJT/PEJ enteral nutrition has been noted to result in better energy intake due to improved absorption in the small bowel and a decreased risk of reflux related aspiration due to feeds being delivered into an area further away from the pharynx [74]. However, Davies et al*.* (2012) report no difference in energy intake and risk of aspiration between patients receiving enteral nutrition via NGT and NJT.
