**5. Decision making between the different routes of enteral nutrition**

PEGs, GTs and NGTs have advantages and possible complications. The outcomes relate to mortality and improved nutrition. Adequate nutrition is linked to better medical outcomes and survival [35, 73]. PEG is noted to be superior to NGT with regard to improvement in general medical outcomes [46] with NGT candidates being statistically more prone to inter‐ vention failure, such as tube blockage or leakage, feed interruption and recurrent displace‐ ment, than patients who were fitted with PEG, regardless of the patient's underlying medical condition [46]. With better provision of feeds when a PEG is used, better medical outcomes may be expected as a patient is more likely to receive adequate hydration and nutrition.

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

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

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

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

outcomes caution against PEG placement in older patients with dementia.

intervention by a speech therapist to regain the swallow pre PEG placement [71].

**5. Decision making between the different routes of enteral nutrition**

PEGs, GTs and NGTs have advantages and possible complications. The outcomes relate to mortality and improved nutrition. Adequate nutrition is linked to better medical outcomes

of hydration and nutrition [13].

140 Seminars in Dysphagia

nutrition via NGT and NJT.

When patients who had a CVA were considered as a separate group from other medical conditions, neither NGT nor PEG were superior in the delivery of nutrition. The presence of dysphagia was the key indicator for mortality rather than the type of enteral nutrition used [36].

There exists debate around which method of enteral intake is best suited for patients with head and neck cancer specifically. A large majority of patients with cancer are malnourished throughout the disease process and require enteral nutrition [75]. Determining the optimal mode of enteral nutrition in this patient population bears consideration of the benefits and drawbacks. Sobani et al. (2011) reported PEG as being superior to NGT in that it resulted in greater weight gain and lower mortality, but others [76] note a lower clinical risk of compli‐ cations, and a greater chance of returning to full oral intake after a six month period, with patients left on NGT rather than fitted with a PEG. It was argued that a patient with an NGT would be more eager to feed orally in order to progress towards removal of the tube because of the visibility of an NGT, which can be unsightly to some. Beginning partial oral intake made muscle atrophy less likely and sped up the return to full oral intake, compared to those receiving nutrition exclusively via a PEG [76]. In patients with dysphagia and a range of medical conditions including neurological fallout and head and neck cancer, Gomes et al. (2012) noted no difference in mortality rates post PEG or NGT placement.

Mortality rates after PEG placement has been reported to be low as a direct result of the PEG procedure [11, 77]. However, Malmgren et al. (2011) suggest that the mortality rate in the first few weeks post PEG placement is 'high' and ranges between 10% and 36% depending on sample size and medical conditions [5, 22, 55-56, 69, 78-79). The greatest majority of patients died within a 30 day period post PEG placement and in patients with dementia, the mortality rate was as high as 54% [79]. The 30 day mortality rates were from both developed and developing countries where a variety of medical conditions were included in the sample.

Strong evidence links poor nutrition upon hospitalization with poor medical outcomes, such as greater incidence of morbidity and mortality [45, 73, 80]. Malnourishment is measured using the body mass index (BMI), with a BMI of <18.5 indicating malnutrition (WHO, 1995). Malnourishment can be as a result of the disease process or due to socioeconomic factors [81] and can be further exacerbated by hospitalization [13, 15, 35, 44, 48, 56, 73], because of interruptions in the provision of enteral nutrition, inadequate nutrition prescribed and the inability of a patient, who may be on oral intake, to physically eat independently [81]. Mal‐ nourishment at the time of PEG placement is a crucial factor noted to place a patient at risk for mortality [19, 45, 55-56, 70, 77].

Upon admission to hospital an NGT may be placed to improve nutrition before placement of a PEG [77]. But NGT feeds can result in minimal improvement in nutritional status because of interrupted feeds when the patient has a procedure, late placement and commencement of


**Table 1.** International mortality rates 30 days post PEG placement

feeds or accidental removal of tubes [47-48, 72]. A nutritionally compromised patient would benefit from placement of a PEG with the aim of improving nutrition, based on evidence that PEG placement facilitates better improvement in nutrition [5, 75]. However PEG placement comes with a high risk of mortality due to the patient's initial poor nutritional status.

Based on the high mortality rate of malnourished patients, it is important to consider the nutritional status of individuals prior to PEG placement [19, 45, 55-56, 70, 77]. A review of the literature suggests that albumin levels may be used as a marker of a patient's nutritional status [82]. Albumin is a protein made by the liver, and is a measure of protein in the body. Albumin balances the amount of blood flowing through the body's arteries and veins and helps to transport calcium, progesterone, bilirubin and medications through the blood. A serum albumin test will measure the amount of protein in the blood and can be used as an indicator of the presence of liver or kidney disease [83] which can affect patient survival. Normal levels of albumin are considered to be in the range of 3.4-5.4 g/dL or 35-50 g/L, depending on how specific laboratories measure it. Blomberg et al., (2011) noted the link between low albumin levels pre-insertion of PEG and a high mortality rate post insertion. This link confirms that hypo- albuminaemia is a risk factor that should be considered in all patients being medically worked up for PEG placement [45, 56, 59, 77, 84]. Co morbidities like diabetes and cardiac disease were also noted to be significant risk factors for high mortality in patients post PEG placement [19, 56, 59, 70, 82].
