胃瘻と経鼻経管の比較：コクランレビュー

成人の嚥下障害患者に対する、胃瘻と経鼻経管の比較をしたコクランレビューがありました。

Gomes CA Jr, Lustosa SA, Matos D, Andriolo RB, Waisberg DR, Waisberg J. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database Syst Rev. 2010 Nov 10;11:CD008096.

経口摂取困難な場合の経管栄養ルートとして、どちらが優れているかを検討した結果、介入の失敗（経管栄養の中断、チューブの詰まりや漏れ、治療の順守負荷no adherence）は、胃瘻で19/156、経鼻経管で63/158と、胃瘻のほうが有意に少ない結果でした(RR 0.24 (95%CI 0.08 to 0.76, P = 0.01)) 。

合併症や死亡率には有意差はありませんでしたが、介入の失敗を考えると、経鼻経管より胃瘻のほうが効果的で安全だという結論です。

ただ、嚥下障害の程度から4－6週間以内の経管栄養で経口摂取に移行できると判断される場合には、やはりガイドライン通りに胃瘻造設ではなく経鼻経管にするべきでしょう。

Abstract
BACKGROUND: A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

OBJECTIVES: To evaluate the effectiveness and safety of PEG as compared to NGT for adults with swallowing disturbances.

SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to August 2009, as well as contacting main authors in the subject area. There was no language restriction in the search.

SELECTION CRITERIA: We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failures (feeding interruption, blocking or leakage of the tube, no adherence to treatment).

DATA COLLECTION AND ANALYSIS: Review authors performed selection, data extraction and evaluation of methodological quality of studies. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I(2) > 50%.

MAIN RESULTS: We included nine randomised controlled studies. Intervention failure occurred in 19/156 patients in the PEG group and 63/158 patients in the NGT group (RR 0.24 (95%CI 0.08 to 0.76, P = 0.01)) in favour of PEG. There was no statistically significant difference between comparison groups in complications (RR 1.00, 95%CI 0.91 to 1.11, P = 0.93).

AUTHORS' CONCLUSIONS: PEG was associated to a lower probability of intervention failure, suggesting the endoscopic procedure is more effective and safe as compared to NGT. There is no significant difference of mortality rates between comparison groups, and pneumonia irrespective of underlying disease (medical diagnosis). Future studies should include previously planned and executed follow-up periods, the gastrostomy technique, and the experience of the professionals to allow more detailed subgroup analysis.