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

Background: The long-term outcomes of artificial nutrition in older people with dysphagia remain uncertain. Enteral nutrition via percutaneous endoscopic gastrostomy (PEG) is one of the major methods of artificial nutrition. Enteral feeding is indicated for patients with a functional gastrointestinal tract. However, total parenteral nutrition (TPN) is often inappropriately chosen for artificial nutrition in Japan, even in patients with a functional gastrointestinal tract, as PEG has recently been viewed as an unnecessary life-prolonging treatment in Japan. This study aimed to compare the long-term outcomes between PEG and TPN.

Methods: This single-center retrospective cohort study investigated long-term outcomes in older patients with dysphagia who received PEG or TPN 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 1-to-1 propensity score matching using a 0.05 caliper. The Kaplan–Meier method, log-rank test, and Cox regression analysis were used to compare the survival time between groups.

Results: We identified 253 patients who received PEG (n=180) or TPN (n=73). Older patients, those 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.

背景：吞咽障碍老年患者接受人工营养的长期预后仍不明确。经皮内镜下胃造口术（percutaneous endoscopic gastrostomy, PEG）肠内营养是人工营养的主要方式之一，肠内营养适用于胃肠道功能完整的患者。然而在日本，即便胃肠道功能完整的患者，临床也常不恰当地选择全肠外营养（total parenteral nutrition, TPN）作为人工营养方案，因为近年来PEG在日本被视为不必要的延长生命治疗手段。本研究旨在对比PEG与TPN治疗吞咽障碍老年患者的长期预后。
方法：本项单中心回顾性队列研究纳入2014年1月至2017年1月期间接受PEG或TPN治疗的吞咽障碍老年患者，分析其长期预后。主要结局指标为生存时间；次要结局指标包括经口进食恢复情况、居家出院率以及重症肺炎与脓毒症的发生率。本研究采用0.05卡尺宽度进行1:1倾向性得分匹配。采用Kaplan-Meier法、log-rank检验及Cox回归分析对比两组患者的生存时间。
结果：本研究共纳入253例患者，其中180例接受PEG治疗，73例接受TPN治疗。年龄更大、营养状态更差以及合并重度痴呆的患者更倾向于接受TPN治疗。经倾向性得分匹配后，共得到55对匹配患者。PEG组患者的生存时间显著更长（中位生存时间：317天 vs 195天，P=0.017）。相较于TPN组，PEG组的风险比为0.60（95%置信区间：0.39~0.92，P=0.019）。两组患者的经口进食恢复率与居家出院率均无显著差异。PEG组重症肺炎发生率显著更高（50.9% vs 25.5%，P=0.010），而TPN组脓毒症发生率显著更高（10.9% vs 30.9%，P=0.018）。
结论：与TPN相比，PEG治疗可显著延长患者生存时间，提升重症肺炎发生率，但降低脓毒症发生率。