Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) are minimally invasive techniques commonly used for prolonged enteral nutrition. Despite safe, both techniques may lead to complications, such as bleeding, infection, pain, peritonitis, and tube-related complications. The literature is unclear on which technique is the safest.

To establish which approach has the lowest complication rate.

A database search was performed from inception through November 2022, and comparative studies of PEG and PRG were selected following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All included studies compared the two techniques directly and provided absolute values of the number of complications. Studies with pediatric populations were excluded. The primary outcome of this study was infection and bleeding. Pneumonia, peritonitis, pain, and mechanical complications were secondary outcomes. The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB2) and we used The Risk of Bias in Nonrandomized Studies (ROBINS-I) to analyze the retrospective studies. We also performed GRADE analysis to assess the quality of evidence. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test.

Seventeen studies were included, including two randomized controlled trials and fifteen retrospective cohort studies. The total population was 465218 individuals, with 273493 having undergone PEG and 191725 PRG. The only outcome that showed a significant difference was tube related complications in retrospective studies favoring PEG (95%CI: 0.03 to 0.08; P < 0.00001), although this outcome did not show significant difference in randomized studies (95%CI: -0.07 to 0.04; P = 0.13). There was no difference in the analyses of the following outcomes: infection in retrospective (95%CI: -0.01 to 0.00; P < 0.00001) or randomized (95%CI: -0.06 to 0.04; P = 0.44) studies; bleeding in retrospective (95%CI: -0.00 to 0.00; P < 0.00001) or randomized (95%CI: -0.06 to 0.02; P = 0.43) studies; pneumonia in retrospective (95%CI: -0.04 to 0.00; P = 0.28) or randomized (95%CI: -0.09 to 0.11; P = 0.39) studies; pain in retrospective (95%CI: -0.05 to 0.02; P < 0.00001) studies; peritonitis in retrospective (95%CI: -0.02 to 0.01; P < 0.0001) studies.

PEG has lower levels of tube-related complications (such as dislocation, leak, obstruction, or breakdown) when compared to PRG.

Patients unable to tolerate oral intake for a prolonged period have an indication for an alternative route of enteral feeding, such as gastrostomy[1]. Gastrostomy involves connecting the stomach to an outflow in the skin with a tube, providing an alimentary route.

The first gastrostomy was performed in the 19^th century, and Stamm's technique, surgical gastrostomy described in 1894, was long considered standard for performing a prolonged enteric access. The surgical technique became less performed with the emergence of the endoscopic technique. The method of percutaneous endoscopic gastrostomy (PEG) was first used in 1980 by Gauderer and Ponsky[2]. The technique was developed as a minimally invasive feeding route for neurologically impaired patients.

In 1981, percutaneous radiologic gastrostomy (PRG) was described[3], expanding the options available. This was an important development for scenarios such as head and neck tumors, where endoscopy is sometimes not an option, due to upper obstruction.

Endoscopic and radiological gastrostomy are both considered effective, safe and minimally invasive[4,5]. The preferred method is often based on specialist opinion or institution preference. We aim to perform a systematic review of the literature and meta-analysis to establish which approach has the lowest complication rate.

The initial search showed 15585 results, after removing the duplicate articles, 6490 remained. A total of twenty studies passed the screening stage and were included in qualitative synthesis, seventeen studies met criteria to be included in the metanalysis, two were prospective randomized studies and fifteen were retrospective cohort studies. The search strategy can be visualized in the following diagram (Figure 1).

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Figure 1 Flow diagram showing study selection process.

Risk of bias within studies

The ROBINS-I and ROB-2 scoring system were used to evaluate risk of bias for observational[12-18,20-27] and randomized studies[11,19], respectively (Table 1). We identified a low risk of bias in the two RCT studies (Figure 2), and a strong methodological quality. As for the observational studies, we note that 5 of them present serious risk of bias[13,15,25,27] and 5 moderate risk[12,14,18,21,23], mostly due to issues in the dissemination of results (Figure 3).

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Figure 2 Risk of bias according to ROB-2.

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Figure 3 Risk of bias according to ROBINS-I.

Quality of evidence

The objective criteria of GRADE analysis to evaluate the quality of evidence identified moderate certainty for pain and infection, low certainty for peritonitis and very low certainty for bleeding and pneumonia (Figure 4).

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Figure 4 Quality of evidence assessed by Grading of Recommendations Assessment, Development, and Evaluation.

Infection

A total of 465198 patients from 17 studies[12-27] were analyzed. There was no difference in the incidence of infection in retrospective (95%CI: -0.01 to 0.00; P < 0.00001; I² = 74%) or randomized (95%CI: -0.06 to 0.04; P = 0.68; I² = 0%) studies. In the overall analysis there was no difference in the meta-analysis of observational and RCT studies combined (95%CI: -0.01 to 0.00; P = 0.56; I² = 70%) (Figure 5A).

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Figure 5 Forest plot studies reporting. A: Outcomes infection; B: Outcomes bleeding; C: Pneumonia; D: Outcomes peritonitis; E: Pain.

Tube related complications

A total of 464689 patients from 14 studies[11-19,21-23,25,26] were analyzed. This analysis showed a significant difference in tube related complications in observational studies favoring PEG (95%CI: -0.03 to -0.08; P < 0.00001), although there was no significant difference in randomized studies (95%CI: -0.07 to 0.04; P = 0.13). In the global analysis there was a difference, favoring PEG (95%CI: -0.07 to -0.03; P < 0.00001) (Figure 6).

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Figure 6 Forest plot with studies reporting tube related complications.

This meta-analysis shows that both PEG and PRG techniques are similar in terms of safety profile, except potentially in tube-related complications, which was higher for PRG in observational studies (Evidence 2A). We included 20 studies in this review (3 randomized and 17 comparative studies) and 17 in our meta-analysis, totaling 465218 individuals, with 273493 undergoing PEG and 191725 undergoing PRG. While other metanalyses compared these 2 approaches[28-34], this analysis is unique as it includes the largest number of adult patients and also separates RCT and observational studies providing further insight. This approach follows Cochrane recommendations and thus provides for a more reliable comparison. Additionally, we separated all adverse events, including pain and pneumonia, which have not been individually analyzed to date. The adverse effects chosen were based on previous publications showing the most frequent complications related to the method[4].

The three most common techniques for performing gastrostomy are endoscopic, radiologic, and surgical. Although surgical gastrostomy was the first described approach, it is now less used due to its invasiveness. A meta-analysis including RCT (evidence 1A) comparing endoscopic and surgical techniques demonstrated a lower number of minor complications for endoscopic procedures[35].

Until now, there is no consensus regarding the superiority of either endoscopic or radiologic gastrostomy. Our results clarify that both approaches are similar in terms of safety as shown in our meta-analysis including only RCTs. Furthermore, a recent RCT including 42 patients comparing the two techniques[36], showed similar results to this meta-analysis. Unfortunately, this RCT was not included due to a lack of data available in the published manuscript, despite our attempt to contact the author.

Local infection is a common adverse outcome of gastrostomy. For this reason, the American Society for Gastrointestinal Endoscopy[37] and the Society for Interventional Radiology[38,39] recommends administering periprocedural antibiotics. The studies utilized in this meta-analysis did not expressly state if antibiotics were administered or not, but as this is a common practice, it was likely used. Our meta-analysis did not demonstrate a significant difference regarding infection in both RCT and non-RCT analysis.

In previous publications[26,27], it has been stated that patients undergoing PEG have a higher rate of bleeding since PEG is preferentially performed in patients with diseases requiring antiplatelets or anticoagulants such as stroke and vascular dementia[27,40]. We expected to prove this hypothesis, however, this meta-analysis demonstrated a low risk of bleeding due to the gastrostomy procedure, without a statistically significant difference between PEG and PRG in both RCT and observational studies. Data on antiplatelet and/or anticoagulant medications among patients who bled were not available.

This study showed no significant difference in the incidence of pneumonia. In previous studies it was observed that gastrostomy compared to nasogastric feeding has a lower incidence of pneumonia, however, this complication is a major cause of mortality in patients undergoing gastrostomy[16]. It is important to state that we were not able to evaluate gastrostomy and gastrojejunostomy separately due to a lack of data. Gastrojejunostomy is associated with a theoretically lower rate of reflux and pneumonia[11,19].

Pain and peritonitis are complex outcomes to measure objectively. Since the definition of these outcomes differs in several studies[13,14,17,18,20-25]. There was no statistical difference between the two methods in our study.

In the analyzed studies, the types, brands, and sizes of tubes were not differentiated. This heterogeneity may influence the results of this analysis. The meta-analysis of observational studies demonstrated a statistically significant difference in the incidence of tube-related complications of a PEG and PRG, such as dislocation, leak, obstruction, or breakdown, showing a higher incidence in PRG. In the RCT meta-analysis, there was no difference. However, the observational studies included 464489 patients versus 200 patients from RCT studies and this should be considered if the RCTs were underpowered to detect a small difference between the techniques. A difference may be expected due to the size difference between endoscopic and radiological techniques. PEG is usually performed using 20FR or 24FR tubes whereas PRG uses 14-16 FR[41]. The size of the gastrostomy ostium influences the incidence of migration; a smaller caliber is associated with a higher incidence of migration and obstruction. The feeding tube can become blocked due to various reasons, such as the accumulation of food formula, medications, or debris. Smaller tubes increase the probability of the tube becoming blocked. Leaks can occur around the insertion site or through the tube itself, which can cause skin irritation and infection, so if the size of the skin insertion is larger than the tube caliber there is a greater chance of leakage.

Tube-related complications are usually associated with longer hospital stays, the need for further procedures, and potentially increased costs[16,33,42]. Evaluating costs is challenging since procedure cost varies significantly between countries. A study comparing the two techniques published in 2009 showed that the costs of the procedures are also different, with PEGs being 43% more expensive than PRGs[16] but the costs are related only to the procedure and not to the overall cost. In Brazil, PEG has a low cost, being more cost-effective than a CT scan. Although few studies provide information regarding costs, this information would be useful, given that these procedures are performed on a large scale worldwide[11,16].

The strengths of this study include a large number of patients from different continents, dedicated analysis of RCT data, use of a validated quality assessment tool, and application of the GRADE process to assess the quality of our data.

Although systematic review and meta-analysis represent the most thorough assessment of available evidence comparing the risks of PEG and PRG, our study has limitations as discussed above. Most data was gathered from observational studies. Additionally, lack of data on tube size, antibiotic, and anticoagulant use, indications for the gastrostomy procedure, and inclusion of both gastrostomy and gastrojejunostomy all limit understanding of potential nuances that differentiate PEG from PRG.

In summary, both approaches are safe. Thus, individual evaluation is required considering several factors including local and personal experience, device availability, cost, and patient preference.

PEG and PRG present a similar safety profile. However, PRG is associated with a slightly higher rate of tube-related complications, potentially related to the small caliber of the gastrostomy tube.