Long-term outcome of percutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke

Age and Ageing, Nov, 1998 by Anthony James, Kapil Kapur, A. Barney Hawthorne

Abstract

Objective: investigation of length of survival, complications, level of dependence and recovery of swallow in patients who received percutaneous endoscopic gastrostomy (PEG) feeding for dysphagia due to stroke.

Design: a retrospective case note analysis of patients treated between 1991 and 1995 and telephone survey of modified Barthel index in October 1996.

Setting: Cardiff Royal Infirmary and the University Hospital of Wales in Cardiff.

Subjects: 126 patients who had PEG inserted after dysphagic stroke.

Main outcome measures: complications of PEG, length of survival, duration of PEG feeding, recovery of swallow and modified Barthel index score.

Results: median length of follow-up was 31 months (range 4-71). Median duration of PEG use was 127 days (range 1-1372). For patients with PEG inserted within 2 weeks the median duration was 52 days (range 2-1478). At follow up 36 (29%) had had PEG removed, 72 (57%) had died with PEG in use, 10 (8%) still had PEG and were nil by mouth and five (4%) had PEG in use with swallow recovered. The median survival was 305 days. Thirty-five (28%) patients died in hospital. Aspiration pneumonia was the commonest complication. Thirty-three patients were alive in October 1996. The modified Barthel index for nursing home patients was 4 (range O- 13) and for patients at home 11 (range 2-20).

Conclusion: PEG feeding is safe and well tolerated in patients with dysphagic stroke. Early PEG placement (within 2 weeks) is worthwhile with many going on to have long-term feeding. Although overall mortality is high, some patients have a long-term survival and a few attain a reasonable level of function in daily living activities. Late recovery of swallow occurs and patients should have follow-up swallowing assessment.

Keywords: aspiration pneumonia, dysphagia, percutaneous endoscopic gastrostomy, stroke

Introduction

Since being described in 1980 [1], percutaneous endoscopic gastrostomy (PEG) has become the preferred method of long-term enteral feeding. PEG tubes are better tolerated than nasogastric tubes and provide better short-term nutrition [2, 3]. They may improve the rehabilitation potential of patients [4]. Dysphagia associated with stroke is the commonest indication for PEG feeding [5-7] and the number of PEG tubes inserted has increased greatly in recent years.

Although the short-term benefits are clear, the long-term outcome of PEG feeding after dysphagic stroke is poorly documented [8, 9]. Many of these patients remain severely disabled and there are considerable resource implications of long-term survival. We investigated the length of survival, complications, level of dependence and recovery of swallow in patients who received PEG feeding after dysphagic stroke.

Methods

A retrospective analysis was undertaken of patients who had a PEG inserted for acute stroke with dysphagia, between 1991 and 1995 at the University Hospital of Wales, Cardiff and the Cardiff Royal Infirmary.

Study subjects were collected by referral to endoscopy unit records and computerized hospital diagnostic and activity data. All had a clinical diagnosis of acute stroke, with or without computed tomography (CT) scan evidence. Patients were selected for PEG insertion on the basis of a speech therapy assessment, identifying patients at risk of aspiration with oral intake without evidence of recovery of swallow. Consent for insertion of PEG was obtained from patients or on discussion with the patients' relatives. At the Cardiff Royal Infirmary, 103 PEGs were inserted for stroke patients and notes were recoverable in 72 cases. At the University Hospital, notes were available for 54 of 59 cases identified.

Data were collected from hospital notes, nursing home and long-stay hospital records and general practitioners. Some patients were followed up at a PEG clinic at the local day-hospital where records were kept.

Clinical findings at the time of the stroke, timing of PEG insertion, discharge destination, complications of PEG feeding and any subsequent assessment of swallowing were recorded. Surviving patients were contacted by telephone and a modified Barthel index calculated on the response of patients or carers.

Results

A total of 126 patients were assessed, 72 (57%) from Cardiff Royal Infirmary and 54 (43%) from the University Hospital. Three were lost to follow-up, so complete outcome data were not available for these patients. The median age was 80 (range 53-94), with 51% male. The median length of follow-up was 31 months (range 4-71). All had a clinical diagnosis of acute stroke and clinical details are shown in Table 1. Seventy-eight patients (62%) had a CT scan performed; 71 (91%) of these showed changes confirming stroke. Fifty-two (41%) had had a previous stroke, no data were available for a further nine (7%). All patients received bedside clinical swallow assessment from a speech and language therapist before PEG insertion. One patient had videofluoroscopy prior to PEG insertion and 19 after PEG insertion.

Table 1. Baseline details of 126 patients on whom percutaneous endoscopic gastrostomy was performed