Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in the elderly with dysphagia: A propensity-matched cohort study

Background The long-term outcomes of artificial nutrition and hydration (ANH) in the elderly with dysphagia remain uncertain. Enteral nutrition via percutaneous endoscopic gastrostomy (PEG) and total parenteral nutrition (TPN) are major methods of ANH. Although both can be a life-prolonging treatments, Japan has recently come to view PEG as representative of unnecessary life-prolonging treatment. Consequently, TPN is often chosen for ANH instead. This study aimed to compare the long-term outcomes between PEG and TPN in the elderly. Methods This single-center retrospective cohort study identified 253 elderly patients with dysphagia who received enteral nutrition via PEG (n=180) or TPN (n=73) between January 2014 and January 2017. The primary outcome was survival time. Secondary outcomes were oral intake recovery, discharge to home, and the incidence of severe pneumonia and sepsis. We performed one-to-one propensity score matching using a 0.05 caliper. The Kaplan–Meier method, log-rank test, and Cox proportional hazards model were used to analyze the survival time between groups. Results Older patients with lower nutritional states, and severe dementia were more likely to receive TPN. Propensity score matching created 55 pairs. Survival time was significantly longer in the PEG group (median, 317 vs 195 days; P=0.017). The hazard ratio for PEG relative to TPN was 0.60 (95% confidence interval: 0.39–0.92; P=0.019). There were no significant differences between the groups in oral intake recovery and discharge to home. The incidence of severe pneumonia was significantly higher in the PEG group (50.9% vs 25.5%, P=0.010), whereas sepsis was significantly higher in the TPN group (10.9% vs 30.9%, P=0.018). Conclusions PEG was associated with a significantly longer survival time, a higher incidence of severe pneumonia, and a lower incidence of sepsis compared with TPN. These results can be used in the decision-making process before initiating ANH.


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Artificial nutrition and hydration (ANH) is a medical intervention for patients suffering 53 from dysphagia due to various clinical conditions. ANH is administered via the enteral or 54 intravenous route, and there are 2 representative types of ANH: Percutaneous endoscopic 55 gastrostomy (PEG) feeding and total parenteral nutrition (TPN). PEG was initially 4 56 developed as an enteral feeding technique for pediatric patients with dysphagia [1,2]. 57 Compared to feeding via a nasogastric tube, enteral feeding via PEG can relieve 58 laryngopharyngeal discomfort and prevent intervention failure; therefore, its use has 59 become widespread for long-term enteral feeding in multiple patient groups including 60 pediatric and geriatric populations [3]. However, studies have reported worse outcomes 61 following PEG feeding in patients with dementia [4,5]; therefore, the use of PEG in 62 elderly populations is controversial [6,7]. 63 TPN is another common method of nutritional management [8,9]. Similar to tube 64 feeding, TPN is also occasionally used for ANH in elderly patients with dysphagia [10]. 65 Comparing the outcomes of enteral nutrition and parenteral nutrition are major concerns 66 among clinicians. Previous studies have demonstrated conflicting results among patients 67 who received enteral nutrition versus those who received parenteral nutrition [11][12][13]. 68 Recently, the general population in Japan has come to view only PEG as representative 69 of unnecessary life-prolonging treatment although both PEG and TPN can be a life-70 prolonging treatment. PEG is generally avoided in elderly patients; hence, a greater 71 number of elderly patients with dysphagia choose TPN instead of PEG feeding for long-72 term ANH [14]. The long-term outcomes of PEG feeding versus TPN in elderly patients 73 with dysphagia have previously been poorly documented. Therefore, we aimed to and blood test results. We used blood test results performed within 7 days before the start 97 of PEG feeding or TPN. Body mass index (BMI) was calculated using the data of height 98 and weight measured on admission. We investigated daily calorie intake on the seventh 99 day after the procedure in both groups. We calculated the median (interquartile range; 100 IQR) values for BMI and daily calorie intake.  The primary outcome was defined as survival time after the start of the procedure. The 106 secondary outcomes included oral intake recovery, discharge to home, and the incidence 107 of severe pneumonia and sepsis. Oral intake recovery was defined as withdrawal from 108 PEG feeding or TPN over 1 month during the observational period. Discharge to home 109 included discharge to private residential home and housing with health and welfare  Statistical analysis 114 We used propensity score matching to adjust baseline differences between the groups 115 [15-17]. The propensity score was calculated by logistic regression for estimating the 116 probability that a patient would receive PEG feeding or TPN. We defined the following 117 variables as potential confounders: Age, gender, underlying diseases (cerebrovascular 118 diseases, severe dementia, neuromuscular diseases, previous history of aspiration 119 pneumonia, ischemic heart diseases, chronic heart failure, chronic lung diseases, chronic  between the groups are shown in Table 1.  The secondary outcomes of propensity-matched patients in the PEG and TPN groups 175 are shown in Table 3.  mortality, studies found that enteral nutrition was associated with lower mortality rates

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[11] or no effect on overall mortality [33]. It has also been demonstrated that enteral

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In this study, a comparison of baseline characteristics between the groups before 215 propensity score matching revealed that patients with older age, lower serum albumin 216 levels, higher C-reactive protein levels, and severe dementia were more likely to receive 217 TPN. Older age, lower serum albumin levels, higher C-reactive protein levels, and severe because TPN is more effective in reducing the risk of severe pneumonia than PEG feeding.

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In contrast, as expected, the incidence of sepsis in the TPN group was significantly higher 261 than that in the PEG group. This may be due to the fact that TPN has been associated with

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Several limitations of this study should be acknowledged. First, this was a retrospective 266 observational study without randomization; therefore, assignment to each group may 267 have been biased. Although propensity score matching was used to adjust the differences 268 in baseline characteristics, the results may still have been biased because of unmeasured 269 confounders. Second, the results of this study are applicable only to these patients who 270 were included in the paired analysis, and therefore the results may not be generalizable to 271 a broader population. Third, certain patients in the PEG group received not only PEG 18 272 feeding but also TPN depending on their clinical condition, and furthermore, the daily 273 calorie intake was not equal between the groups. Fourth, this was a single-center study 274 with a small sample size.

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In summary, we performed a propensity-matched analysis to compare the outcomes of 277 PEG and TPN in the elderly. We found that compared to TPN, PEG was associated with 278 better survival and a higher incidence of severe pneumonia as well as a lower incidence 279 of sepsis, with no significant inter-group differences noted in oral intake recovery and