Percutaneous endoscopic gastrostomy in the neurosurgical intensive care unit: complications and outcome

BACKGROUND: Even with a functioning gastrointestinal tract, it is not always easy to initiate oral feeding in some neurosurgical patients because of their persistently depressed neurologic status or severe lower cranial nerve palsies. Percutaneous endoscopic gastrostomy (PEG) may be required for long-term feeding in these patients. The purpose of the present study is to report our experience with PEG chosen for establishing an enteral route in patients of neurosurgical intensive care unit (ICU). METHODS: The outcome and complications of PEG in neurosurgical ICU patients of Marmara University Institute of Neurological Science between January 2001 and November 2006 were retrospectively evaluated. RESULTS: Thirty-one patients, with the median age of 51 years (range, 14-78 years) underwent PEG placement. PEG was placed before the craniotomy in 2 patients and after in 29. Indications for PEG were absent gag reflex in 10 patients and low Glasgow Coma Scale score in 21. Before the PEG tube insertion, 18 patients had enteral nutrition by a nasogastric tube and 10 had parenteral nutrition (PN), with a median duration of 14.5 (range, 4-60) and 12 (range, 7-25) days, respectively. Two patients accidentally pulled out the gastrostomy tubes 10 and 11 days after insertion. Buried bumper syndrome developed in 1 patient. Two patients died 8 and 34 days after the procedure in the neurosurgical ICU. Twenty-nine patients were discharged from the hospital while being fed via the PEG tubes. In 11 patients who were able to resume oral feeding, the tube was removed, with a median interval of 62 (range, 25-150) days. Procedure-related mortality, 30-day mortality, and overall mortality of the patients were 0%, 6.4%, and 45%, respectively. CONCLUSION: PEG is a safe and well-tolerated gastrostomy method for neurosurgical ICU patients with depressed neurologic state or severe lower cranial nerve palsies.     

内镜下胃肠造口在术后危重病人中的应用

目的:探讨内镜下胃肠造口在术后危重病人中的临床应用. 方法:对22例外科手术后出现并发症的危重病人进行经皮内镜下胃肠造口,并总结其手术指征、相关并发症、操作过程和临床疗效等. 结果:22例病人经皮内镜下胃肠造口术(PEG/PEJ)均获得成功,未发生与PEG/PEJ操作相关的死亡和严重并发症.21例(95%)病人放置PEG/PEJ管后进行肠道营养的时间超过30天.3例(14%)出现胃造口部位感染和渗漏,经局部换药、引流和全身应用抗生素后治愈.6例(27%)在后期出现空肠造口管的阻塞. 结论:外科术后危重病人,经皮内镜下胃肠造口术是建立长期胃肠道营养通路的安全、微创、简便、高效的方法.     

Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is the technique of choice for long-term enteral nutrition. Though safe and technically simple, PEG has been associated with significant morbidity and mortality. AIM: We compared the outcome of strategies applied in two different periods; the original approach of PEG insertion during hospitalization (upon request), and PEG insertion 30 days after hospital discharge. METHODS: A cohort of 127 patients scheduled for PEG insertion from 1.1.1997 to 31.12.2000, was evaluated. In 61 consecutive patients admitted from 1.1.1997 to 31.12.1998 the PEG insertion was planned during hospitalization, as close to the time of the physician's request (period 1). Sixty-six consecutive patients admitted from 1.1.1999 to 31.12.2000 were scheduled for the PEG insertion 30 days after discharge (period 2). The 30-day mortality rate was calculated from the time of the request. Univariate and multivariate analyses were used to find predictive factors for 30-day mortality. RESULTS: There were 61 patients with a mean age of 78+/-13 in period 1, and 66 patients with a mean age of 77.8+/-15.5 in period 2. There was no significant difference between patients of the two periods in regard to age, sex, underlying disease, nutritional and mental status. Patients received PEG 30 days after hospital discharge had a 40% lower 30-day mortality rate than patients who received PEG during hospitalization from the time of request for PEG (P=0.01) and a 87.5% lower rate when calculated from the time of insertion (P<0.0001). In-hospital PEG insertion, bed-ridden and disorientation were found to be independent factors predictive of 30-day mortality after PEG insertion (P=0.016,P=0.001, and P=0.0005, respectively). CONCLUSION: PEG insertion during hospitalization increases mortality and should be avoided. A grace period of 30 days with nasogastric tube feeding before PEG insertion may prevent mortality and achieve a long-term enteral nutrition.     

Does percutaneous endoscopic gastrostomy prevent gastro-oesophageal reflux during the enteral feeding of elderly patients?

Percutaneous endoscopic gastrostomy (PEG) is reported to be a safe method for enteral feeding, although its ability to prevent gastro-oesophageal reflux (GOR) during enteral feeding remains controversial. In 12 elderly patients fed enterally to avoid the risk of tracheal aspiration, we have compared two 24-h oesophageal pH profiles, one recorded when enteral feeding was delivered at first via a nasogastric tube (NGT), and the other via a PEG. The second recording was always performed at least 8 days after gastrostomy placement. Enteral nutrition consisted of 500 ml of a polymeric diet delivered 3 times a day at 08:00, 13:00 and 18:00. After gastrostomy placement, enteral feeding was associated with a pathological acid reflux in 8 out of 12 patients. In all of these 8 patients, GOR was mostly related to a high number of reflux episodes. In 4 out of 8 patients, GOR occurred only during the 3 h following the administration of the nutritive diet. In 4 of the patients, GOR did not occur any more after removal of the NGT, whilst gastrostomy placement was followed by GOR in 5 patients. GOR during enteral feeding via PEG is common in elderly subjects. We have shown that a chronological relationship existed in some patients between the endoscopic procedure and the onset of a pathological GOR.     

Early initiation of enteral feeding after percutaneous endoscopic gastrostomy tube placement.

Enteral feeding through the percutaneous endoscopic gastrostomy (PEG) tube is usually initiated about 12 to 24 hours after insertion of the tube. There have been earlier studies evaluating the efficacy of early initiation of enteral feedings that had encouraging results. However, delayed initiation of feeding following PEG placement continues to be practiced widely. We believe that feeding can be done earlier without any increase in associated morbidity or mortality and with obvious reduction in the need for parenteral nutrition and healthcare costs. We evaluated a protocol to initiate enteral nutrition 4 hours after the PEG tube insertion with subsequent discharge of the outpatients on the same day. We conducted a prospective study to assess the efficacy of early initiation of PEG feeding. We enrolled 77 patients in our study who were having PEG tubes placed for enteral feeding. Only patients who had a PEG placed for gastric venting procedures were excluded from our study. During the course of our study, no patient had to be excluded for the latter reason. Patients were evaluated by the physician performing the procedure, 4 hours after the tube was inserted. Their vital signs were checked, and a thorough abdominal examination was performed. Minimal tenderness around the PEG site was the most frequent finding. Otherwise, all the patients had a benign abdominal examination. The tube was flushed with 60 mL of sterile water. Following the examination, orders were given to restart the feedings. These patients were followed for a 30-day period to evaluate complications associated with PEG tube placement and early initiation of PEG feeding. There was one case of aspiration pneumonia (1.3%) and one death that was attributed to the underlying disease out of our 77 patients. Early initiation of enteral feeding after PEG tube placement can be successfully completed with a systematic protocol and close observation. Not only was this protocol found to be safe, it can also have significant cost savings by eliminating the need for inpatient hospitalization for the procedure.     

Home enteral nutrition in patients with Acquired Immunodeficiency Syndrome

14 patients in advanced stages of HIV infection (1 ARC, 13 AIDS; sex: 1 female, 13 male; age 37.8 +/- 6.3 years; body mass index (BMI): 17.4 +/- 2.4 kg/m(2)) were followed prospectively while receiving home enteral nutrition (observation period: 62 +/- 75 days). Artificial nutrition was indicated because of severe weight loss (9-38 kg within 6-48 months, n = 7) or cerebral toxoplasmosis with eating and swallowing disorders (n = 7). In all patients a defined formula diet (175 +/- 17.7 kJ/kg body weight) was administered through an endoscopically placed gastrostomy tube (PEG). Home enteral nutrition was well tolerated by all patients and no significant PEG-related complications occurred. Enteral nutrition resulted in significant increases in body weight (p < 0.005), body cell mass (BCM, p < 0.05), total body fat (TBF, p < 0.005), serum albumin concentration (p < 0.05), and serum total iron-binding capacity (transferrin, p < 0.01). Conclusion: Home enteral nutrition via PEG is safe and well tolerated in patients with advanced HIV-related immunodeficiency and is capable of improving nutritional state including BCM.     

经皮内镜下胃和空肠造口术在临床中的应用

目的: 探讨经皮内镜下胃和空肠造口术的方法. 方法: 114例病人胃造口术(PEG)采用Pull法,26例空肠造口术(PEJ),在PEG基础上用异物钳钳夹胃腔内空肠造口管,推送胃镜将其送至Treitz韧带以下. 结果: PEG成功率为100%,通过改良胃镜下直接置管方法,26例PEJ全部一次放置成功.15例局部有活动性出血, 8例局部有分泌物和红肿,经相应处理后缓解.21例引起呼吸道感染,用抗生素治愈,1例胃黏膜下出血,形成血肿, 1例在第8天发现胃造口内固定片嵌顿,未出现严重并发症. 结论: PEG简单、安全、可行;PEJ方法可一次使造口管到达空肠,有临床应用价值.     

Percutaneous endoscopic gastrostomy (PEG) placement in the overweight and obese patient

BACKGROUND: Traditionally, percutaneous endoscopic gastrostomy (PEG) placement in the obese patient has been considered a relative contraindication due to the impedance of gastric transillumination and inability to approximate the abdominal and gastric wall. The aim of this study was to determine the overall success rate, morbidity, and PEG-related mortality in overweight and obese patients. METHODS: Three hundred fifty-five consecutive patients were retrospectively evaluated over a 1-year period at the Virginia Commonwealth University Medical Center for postprocedure-related PEG and PEG/jejunostomy (J) complications. One hundred thirty-four patients were considered overweight (body mass index [BMI] > or = 27 kg/m(2)). Of those, 80 patients were found to be obese (BMI > or = 30 kg/m(2)) with a BMI ranging 30-63 kg/m(2). RESULTS: Gastrostomy placement was successful in 130 of 134 (97%) overweight patients (p < .05). The overall procedure-related mortality was 0%. The rate of significant complications in overweight and obese patients remained 0% when compared with those patients with a normal BMI. Out of 355 patients, 14 failed to receive a PEG; 3 of these were obese and 1 was overweight. These 4 procedures were aborted due to a paucity of anatomical landmarks and failure to transilluminate the abdominal wall. CONCLUSIONS: We believe that PEG placement in the overweight and obese patient can be a technically safe procedure according to our success rate of 100%, with a procedure-related mortality rate of 0%. In those overweight and obese patients who require specialized long-term enteral nutrition support, PEG placement should be considered earlier and more frequently.     

经皮内镜下胃造口在放射性肠炎病人围手术期的应用

目的:报道经皮内镜下胃造口(PEG)在2例放射性肠炎手术病人围手术期的应用经验.方法:2例放射性肠炎病人,术前因肠梗阻需肠外营养支持及长期胃肠减压,手术时切除大段小肠导致术后发生短肠综合征,需长期肠内营养支持.2例病人均行PEG治疗,术前通过PEG进行胃肠减压,术后通过PEG进行长期肠内营养支持.结果:术前通过PEG引流胃肠液500～1 000 ml/d,术后通过PEG输入肠内营养,能量为2 092～5 020.8 kJ/d.结论:PEG在一些特殊病人的围手术期应用,可以同时发挥胃肠减压和长期肠内营养的作用.     

经皮内镜下胃造瘘术在上段食管癌患者中的临床应用

目的探讨经皮内镜下胃造瘘术（percutaneous endoscopic gastrostomy,PEG）在上段食管癌患者中的临床应用。方法回顾分析2005年1月～2010年3月在本院行PEG术的25例上段食管癌患者的临床资料。结果所有患者PEG均获成功,术后患者营养状况明显好转。无手术相关死亡病例发生,25例患者中1例术后出现黑便,3例出现造瘘口局部少许渗血,2例出现造瘘管周围皮肤感染,经对症处理后均改善。结论PEG技术操作简单易行、安全,创伤小,并发症少,可避免食管上段癌患者营养状态的恶化,是上段食管癌并恶性梗阻患者行肠内营养支持治疗的可供选择的一种方法。     

PEG--管饲肠内营养的新方法

目的 旨在探讨经皮胃镜下胃造口术（ＰＥＧ）在神经科应用的临床价值。方法 对３０例神经内，外科病人，需肠道内营养而又无法经口进食者，行经皮胃镜下胃造口术，方法 经造口管喂养后营养不良状况明显改善，使肺部感染得到了控制，其中能经口进食而拔管者７例，术后带管出院者１０例，因原发疾病加重而死亡者３例，除２例出现局部皮肤炎症反应外，并无其他严重并发症。结论 对需要长期营养支持的神经内，外科病人，ＰＥＧ是一种     

经皮透视下胃造口术在恶性肿瘤病人中的应用

目的:报道10例经皮透视下胃造口的临床应用经验.方法:10例恶性肿瘤病人因食管狭窄不能进食,长期依赖肠外营养支持,并且不能通过胃镜进行经皮胃造口.在影像科于局部麻醉下行经皮透视下胃造口术.结果:10例均操作成功,无并发症发生,术后行肠内营养支持,并且成功摆脱肠外营养支持,行家庭肠内营养支持,明显改善了生活质量.结论:经皮透视下胃造口术操作简便、易行、并发症少,特别适用于不能进行经皮内镜胃造口的病人.     

One‐Step Insertion of Low‐Profile Gastrostomy in Pediatric Patients vs Pull Percutaneous Endoscopic Gastrostomy

Background: Standard care for initiation of enteral feeding in children has been pull percutaneous endoscopic gastrostomy (pull‐PEG). As an alternative to pull‐PEG, a 1‐step endoscopic procedure for inserting a low‐profile gastrostomy tube “button” has been developed that allows initial placement of a balloon‐retained device. This report presents outcomes of metrics used to compare button placement with pull‐PEG in a pediatric population. Methods: Data were generated from procedural experiences of surgeons on pediatric patients (n = 374) with a variety of clinical indications for gastrostomy. Study population ages ranged from 6 days to 16 years, while weights were from 2–84 kg. Results: The button was successfully placed by the 1‐step procedure in 98% of the respective study population, and median procedural times were 20 and 15 minutes for button and pull‐PEG placements, respectively. Median times to first feeds were equivalent for the 1‐step procedure and pull‐PEG (6 hours), while times to first nutrition feeds were 12.5 and 10 hours, respectively. Stoma site complications within each study group were similar. Healthy stoma proportions were 65.2% and 73.2% in the 1‐step procedure and pull‐PEG groups, respectively, at first follow‐up. Conclusions: Similar study outcomes between the 1‐step procedure and pull‐PEG groups suggest that the former is a feasible alternative to pull‐PEG for initial tube placement in children. The 1‐step method involves a single procedure and reduces patient exposure to anesthesia, operating room time, and the potential for complications compared with a pull‐PEG requirement for multiple procedures.     

Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease

Background:  Motor neurone disease (MND) is a progressive neurodegenerative disease leading to limb weakness, wasting and respiratory failure. Prolonged poor nutritional intake causes fatigue, weight loss and malnutrition. Consequently, disease progression requires decisions to be made regarding enteral tube feeding. The present study aimed to investigate the survival, nutritional status and complications in patients with MND treated with enteral tube feeding. Methods:  A retrospective case note review was performed to identify patients diagnosed with MND who were treated with enteral tube feeding. A total of 159 consecutive cases were identified suitable for analysis. Patients were treated with percutaneous endoscopic gastrostomy (PEG), radiologically inserted gastrostomy (RIG) or nasogastric feeding tube (NGT). Nutritional status was assessed by body mass index (BMI) and % weight loss (% WL). Serious complications arising from tube insertion and prescribed daily energy intake were both recorded. Results:  Median survival from disease onset was 842 days [interquartile range (IQR) 573–1263]. Median time from disease onset to feeding tube was PEG 521 days (IQR 443–1032), RIG 633 days (IQR 496–1039) and NGT 427 days (IQR 77–781) (P = 0.28). Median survival from tube placement was PEG 200 (IQR 106–546) days, RIG 216 (IQR 83–383) days and NGT 28 (IQR 14–107) days. Survival between gastrostomy and NGT treated patients was significant (P ≤ 0.001). Analysis of serious complications by nutritional status was BMI (P = 0.347) and % WL (P = 0.489). Conclusions:  Nutritional factors associated with reduced survival were weight loss, malnutrition and severe dysphagia. Serious complications were not related to nutritional status but to method of tube insertion. There was no difference in survival between PEG and RIG treated patients.     

肌萎缩侧索硬化症患者经皮内镜下胃造瘘术研究

目的 探讨经皮内镜下胃造瘘术在肌萎缩侧索硬化症导致吞咽困难患者中的应用价值.方法 回顾性分析2005年4月至2010年7月65例住院经皮内镜下胃造瘘术的肌萎缩侧索硬化症患者的临床资料.结果 65例患者中共有63例操作成功,成功率96.9%(63/65).操作时间8～17 min.操作失败2例,均为操作过程中窒息.术后感染2例.术后3个月随访,63例患者体重均有所增加,体质指数由术前的(18.3±1.0)kg/m2增加到(19.7±1.2)kg/m2,两者比较差异有统计学意义(t=15.8,P＜0.01),无其他术后并发症.结论 经皮内镜下胃造瘘术可以明显改善肌萎缩侧索硬化症患者的营养状况,安全而且有效.窒息是导致操作失败的主要原因.

Abstract：

Objective To evaluate the value of percutaneous endoscopic gastrostomy (PEG) in the treatment of amyotrophic lateral sclerosis (ALS) patients with dysphagia. Method Sixty-five ALS patients underwent PEG from April 2005 to July 2010 were analysed retrospectively. Results All the 65 patients underwent PEG,and 2 patients failed because of dyspnea. Totally 63 patients were intubated successfully,the successful rate was 96.9%(63/65). The operation time was 8-17 min. Two patients had local infection.After 3 months, the body mass index was increased from (18.3 ± 1.0) kg/m2 to (19.7 ± 1.2) kg/m2(t = 15.8,P ＜ 0.01), without peritonitis, migration of the gastrostomy tube and other complications. Conclusions PEG is a safe method with a low complication for ALS patients to get enteral nutrition. Dyspnea is the main reason of failure.     

Cologastric fistula as a complication of percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is frequently used for long-term enteral nutrition or gastrointestinal decompression in both adults and children. The rare complication of a cologastric fistula following PEG has been seen recently in two pediatric patients. One fistula did not close after removal of the gastrostomy tube. A mechanism for the occurrence of this complication in these two children is proposed and technical points are emphasized to prevent this complication.     

Prevention of percutaneous endoscopic gastrostomy site infections caused by methicillin-resistant Staphylococcus aureus

Percutaneous endoscopic gastrostomy (PEG) is widely used to maintain enteral nutrition in patients who are unable to swallow. Peristomal wound infection is the most common complication of this procedure. In a hospital endemic for methicillin-resistant Staphylococcus aureus (MRSA), MRSA can be the most common organism associated with these infections. We have evaluated a strategy consisting of screening, skin decontamination and glycopeptide prophylaxis for preventing PEG-site infections. None of the 34 patients who received the decontamination protocol and glycopeptide prophylaxis (Group A) developed PEG-site infections within one month of surveillance. Two patients were infected with MRSA after that period. One of seven patients who received the decontamination protocol alone (Group B) was infected within the period of surveillance, while another patient was infected after that period. Both were infected with MRSA. None of nine patients who received glycopeptide prophylaxis alone (Group C) were infected. The results suggest that the strategy of screening, decontamination and glycopeptide prophylaxis is effective in the prevention of PEG-site infections with MRSA. Further trials are necessary to confirm these findings.     

Assessment by a multidisciplinary clinical nutrition team before percutaneous endoscopic gastrostomy placement reduces early postprocedure mortality

BACKGROUND: The purpose of this study was to determine whether preassessment by a multidisciplinary nutrition team before percutaneous endoscopic gastrostomy (PEG) placement can reduce postprocedure mortality. This was a prospective single-center audit. METHODS: Patients who had been referred to the Gastroenterology Department for consideration of PEG placement between 1995 and 2004 were included. In the index year, 2003-2004, where a formal nutrition team assessment was commenced, 79 patients were enrolled into our study group on a consecutive basis. These patients were subdivided into 3 groups; group A, PEG placed (51 patients); group B, PEG not placed due to severe comorbidity (19 patients); and group C, PEG not placed as deemed unnecessary (9 patients). Comparison was made with previous years where no formal preassessment had occurred. At Staffordshire General Hospital, a comparison of mortality post-PEG placement was made between the index group and previous years. Secondary measures included complication rates and frequency of biochemical monitoring. RESULTS: One week post-PEG mortality fell from 10%-20% in previous years to 0% in the index year (p < .02). This improved survival extended to 3 months postprocedure (p < .016). Three patients (6%) had biochemical evidence of refeeding syndrome postplacement. Biochemical monitoring was inadequate, with only 27/51 (53%) patients being completely monitored. No complications pertaining to the endoscopy were reported. CONCLUSIONS: This study demonstrates that early post-PEG mortality can be reduced by preassessment of patients by a multidisciplinary nutrition team and is evidence supporting the recommendations of the National Confidential Enquiry into Patient Outcome and Death report.     

Prospective Cohort Study Comparing the Effects of Different Artificial Nutrition Methods on Long‐Term Survival in the Elderly

Background: The effects of various artificial nutrition methods on the long‐term outcomes of elderly patients are still not well known. We aimed to compare the long‐term survival of the elderly newly administered with parenteral nutrition (PN) or enteral nutrition. Materials and Methods: This multicenter, prospective, observational cohort study was conducted on 546 elderly patients who were administered artificial nutrition. The main outcome was the survival ratio at 180 and 360 days after initiation of 3 different nutrition methods and estimated mean survival time: PN, nasal tube feeding (EN_N), and percutaneous endoscopic gastrostomy (PEG) feeding (EN_G). The incidence of systemic infection was also compared among different cohorts. Results: At 180 and 360 days after initiation of artificial nutrition, the mortality rates in the PN, EN_N, and EN_G cohorts were 52% and 63%, 32% and 41%, and 22% and 33%, respectively. Multivariate logistic regression analysis showed that, whereas PN nutrition had significant associations with a higher death rate at 180 and 360 days in all samples, there is no significant difference on the main outcome among the 3 cohorts with neurological diseases. A subgroup analysis with neurological diseases showed that the proportional hazard ratios of the PN and EN_N cohorts in comparison with the EN_G cohort were 1.13 (95% confidence interval [CI], 0.66–1.92) and 1.22 (95% CI, 0.82–1.81). Conclusion: There is no significant superiority of PEG feeding compared with nasal tube feeding or PN. Clinicians should consider the choice of nutrition support method, taking into consideration the limitation of the patient's interest.     

The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high-risk dysphagic stroke patients

INTRODUCTION: In the management of dysphagic stroke patients, percutaneous endoscopic gastrostomies (PEGs) are frequently sited early due to the failure of nasogastric tube (NGT) feeding, with NGTs becoming displaced in over 58% of cases. PEG insertion is a procedure with significant mortality and morbidity. We adapted a novel technique of securing NGTs (a nasal loop) which is non-invasive, allows successful NG feeding and may avoid the need for PEG placement. AIMS: To show that nasal loops result in improved delivery of enteral nutrition. To compare the outcome and complication rate of nasal loop fed patients with those undergoing PEG feeding. METHODS: A 6 month prospective audit of dysphagic stroke patients who were referred for PEG. All patients who were referred with failed NG feeding within 28 days of presentation were offered a nasal loop. Patients who were 28 days post-stroke had a PEG placed if appropriate. The daily feed intake was monitored before and after nasal loop placement. Complication rates and patient outcomes were documented at 2 week and 3 month follow-up. RESULTS: Nasal loop group: 14 patients had a nasal loop for a median of 15 days. The median daily feed provided was 0% before nasal loop and 100% after. Four patients went on to recover normal swallowing, 4 patients died and 6 later proceeded to PEG. PEG group: Seven patients proceeded direct to PEG, 1 died and 6 were alive and PEG fed at 3 months. There were 6 complications from PEG insertion. No patients recovered normal swallowing. CONCLUSIONS: Nasal loops are safe, well tolerated, and effective at delivering full enteral nutrition. Nasal loops allow time for patients who may recover normal swallowing to do so, and thus avoid a PEG. Nasal loops avoid unnecessary PEG insertion in those with a poor prognosis who will not ultimately survive their initial stroke.