American Journal of Gastroenterology ISSN 0002-9270 C  2008 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2008.02108.x Published by Blackwell Publishing Early Versus Delayed Feeding After Placement of a Percutaneous Endoscopic Gastrostomy: A Meta-Analysis Matthew L. Bechtold, M.D., Michelle L. Matteson, A.P.N., Abhishek Choudhary, M.D., Srinivas R. Puli, M.D., Peter P. Jiang, M.D., and Praveen K. Roy, M.D. Division of Gastroenterology, University of Missouri School of Medicine, Columbia, Missouri BACKGROUND: Traditionally, tube feedings have been delayed after percutaneous endoscopic gastrostomy (PEG) placement to the next day and up to 24 h postprocedure. However, results from various randomized controlled trials (RCTs) indicate earlier feeding may be an option. We conducted a meta-analysis to analyze the effect of early feedings (≤4 h) after PEG placement. METHODS: Multiple databases were searched (November 2007). Only RCTs on adult subjects that compared early (≤4 h) versus delayed or next-day feedings after PEG placement were included. Meta-analyses for the effect of early and delayed feedings were analyzed by calculating pooled estimates of complications, death ≤72 h, and significant increases in postprocedural gastric residual volume during day 1. RESULTS: Six studies (N = 467) met the inclusion criteria. No statistically significant differences were noted between early (≤4 h) and delayed or next-day feedings for patient complications (OR 0.86, 95% CI 0.47–1.58, P = 0.63) or death in ≤72 h (OR 0.56, 95% CI 0.18–1.74, P = 0.31). A statistically significant increase in gastric residual volumes during day 1 was noted (OR 1.80, 95% CI 1.02–3.19, P = 0.04). CONCLUSIONS: Early feeding ≤4 h after PEG placement may represent a safe alternative to delayed or next-day feedings. Although an increase in significant gastric residual volumes at day 1 was noted, overall complications were not affected. (Am J Gastroenterol 2008;103:2919–2924) INTRODUCTION Percutaneous endoscopic gastrostomies, first described in 1980, have assisted in the nutritional requirements for many patients who are unable to ingest adequate oral nutrition (1). These endoscopically placed gastrostomy tubes have been a valuable source of nutrition for patients with strokes, dys- phagia, and head and neck cancers undergoing treatment (2, 3). Because of the ease of placement and minimal com- plications, percutaneous endoscopic gastrostomy (PEG) has become widely available and utilized for many clinical situ- ations requiring long-term nutritional support. Although the benefits and techniques for insertion of PEGs have been de- scribed and accepted, the feeding after PEG placement is not as clear. Since 1980, feedings after PEG placement have been sig- nificantly delayed by many hours or to the next day. The delay was most likely a remnant of prior surgical guidelines regard- ing management of patients after surgically placed tubes, with very little evidence regarding feedings after PEG placement. The suspected rationale was to decrease the risk of significant gastric residual volumes during the first day that may lead to aspiration and to decrease the risk of peritoneal leakage that may lead to peritonitis. Over the past 15 yr, many studies have examined the use of early PEG feedings after insertion. Many randomized controlled trials on the subject indicate that early PEG feeding is safe and well tolerated by patients (4–9). Early feeding after PEG placement has also been shown to decrease length of hospitalization and, subsequently, may decrease cost (10). However, these studies differ in timing of post-PEG feedings, from less than 1 h to less than 6 h. Despite the recent literature indicating early PEG feedings as a safe alternative, the common practice continues to be to significantly delay post-PEG feedings. A survey of gastroen- terologists in northeastern United States in 1998 revealed that although 82% of specialists were aware of the recent literature showing early feedings to be safe, only 39% initiated feed- ings prior to 8 h and 11% initiated feedings prior to 3 h (11). The remaining 61% of gastroenterologists surveyed chose to delay feedings from 9 h to >24 h (11). Based upon the significant differences between the liter- ature and clinical practice and between the timing of early feedings within the literature, we conducted a meta-analysis to evaluate the use of early PEG feedings (≤4 h) versus de- layed or next-day feedings for complications, death within 2919