Search strategy yield and study characteristics
The search identified 176 potentially relevant studies, 15 of which were examined in detail and 4 RCTs of which were included in the final analysis[5–8]. (Fig. 1) A total of 536 patients were included, of which 287 were in EM group and 249 in ENDO group. Mean age was 57.1 years with a range of 51.5 to 64.6 years. The sex distribution was 53.3% male patients, with a range of 51.3–63.6%. Two studies were conducted in Netherlands[5–8], one in Austria[5], and one in China[8]. Two of the studies[6, 7] were of multi-center design (3 or 5 recruiting sites). Two studies exclusively evaluated critical ill patients, one[6] evaluated patients from gastrointestinal surgical wards, and the remaining one[7] included outpatients, ward patients, and critically ill patients. In ENDO group, tube placement was performed by a gastroenterologist assisted by one or two nurses. For EM group, tube placement was performed by one nurse in two studies[6, 7], by a nutritional support team in one study[8], and the remaining one study[5] did not specify this issue. One study[6] included patients with prior altered upper gastrointestinal anatomy and the remaining three studies did not. For EM technique, pre-procedural fasting was required in one study[7], not required in one study[6], and the remaining two studies[5, 8] did not specify this issue. Conscious sedation in EM group was not required in two studies[6, 8], but was used if indicated in the remaining two studies. For ENDO group, conscious sedation was used in a large portion of patients. Details of the characteristics of included studies are given in Table 1.
Table 1
Characteristics of studies and patient demographics
Study (year) | Location | Setting | Number of centers | Type of patients | Indications for enteral nutrition | Arms | Sample size, n | Age (y), mean ± SD | Sex, male, % | Body mass index (kg/m2), mean ± SD | Prior altered upper gastrointestinal anatomy, n (%) | Sedation, n (%) | Preprocedural fasting | Use of prokinetic agents, n (%) | Operators required (n) |
Holzinger, U et al.( 2011) | Austria | Single | 1 | ICU patients | Intolerance of intragastric enteral nutrition | EM | 44 | 55 ± 18 | 63.6 | 28 ± 7 | 0 (0) | 39 (88.6) | NR | NR | NR |
ENDO | 22 | 56 ± 15 | 36.4 | 29 ± 8 | 0 (0) | 18 (81.8) | NR | 0 (0) | Gastroenterologist (1), nurse (NR) |
Gerritsen, A et al. (2016) | Netherlands | Multicenter | 5 | Patients from gastrointestinal surgical wards | Postoperative gastroparesis, malnutrition, pancreatitis, ileus, and other | EM | 80 | 63.2 ± 14.4 | 51.3 | 25.6 (22.4–27.7) median (interquartile range) | 14 (17.5) | 0 (0) | None | 49 (61.3) | Nurse (1) |
ENDO | 74 | 64.6 ± 13.1 | 56.8 | 24.7 (22.4–26.9) median (interquartile range) | 14 (18.9) | 61 (82.4) | Yes | 46 (62.2) | Gastroenterologist (1), nurse (1–2) |
Kappelle, WFW et al. (2018) | Netherlands | Multicenter | 3 | ICU patients and non-ICU patients | Postoperative gastroparesis, critical illness gastroparesis, pancreatitis, severe GERD , severe vomiting, low intake, and other | EM | 82 | 57.9 ± 16.8 | 53.7 | NR | 0 (0) | 11 (12.9) | Yes | 7 (9) | Nurse (1) |
ENDO | 73 | 56.6 ± 14.3 | 60.3 | NR | 0 (0) | 43 58.9) | Yes | 0 (0) | Gastroenterologist (1), nurse (1–2) |
Gao, XJ et al. (2018) | China | Single | 1 | ICU patients | Intolerance of intragastric enteral nutrition | EM | 81 | 51.5 ± 18.3 | 53.1 | 21.2 ± 3.3 | 0 (0) | 0 (0) | NR | 81 (100) | Member of nutritional support team (1) |
ENDO | 80 | 52.3 ± 18.2 | 51.3 | 21.6 ± 3.2 | 0 (0) | 80 (100) | Yes | 80 (100) | Gastroenterologist (1), nurse (1–2) |
RCT, randomized controlled trial; EM, electromagnetic-guided nasoenteral feeding tube placement; ENDO, endoscopic nasoenteral feeding tube placement; GERD, gastroesophageal reflux disease; ICU, intensive care unit; NR, not reported. |
Quality assessment
All of the included studies had a high risk of performance bias. This could not be avoided because the operators and patients could not be blinded to the method of examination. There was unclear risk of detection bias in all studies, as blinding of outcome assessment could only be done for subjective outcomes such as patient discomfort and patient recommendation. One study[5] had a unclear risk of selection bias owing to no reported concealment of allocations. Assessment of risk of bias is shown in Supplemental Digital Content 2.
Primary outcome: procedure success rate
Procedure success rate was reported in all included studies (Table 2). Pooled rate for EM and ENDO was 82.6% and 83.1%, respectively. No statistical difference was observed (RR 0.97; 95% confidence interval [95% CI]: 0.91–1.03; P = 0.81, I² = 0%) (Fig. 2a). We did not employ funnel plot to access for publication bias as fewer than 10 studies were included. There was no evidence of publication bias by Egger’ s test for the primary outcome (P = 0.18).
Table 2
Outcomes evaluated in studies
Study (year) | Arms | Procedure success rate, n (%) | Reinsertions, n (%) | Number of attempts, mean ± SD | Placement-related complications, n (%) | Tube-related complications, n (%) | Insertion time (min), median (IQR) | Total procedure time (min), median (IQR) | Patient discomfort, median (IQR) | Patient recommendation, median (IQR) | Length of hospital stay(days), median (IQR) | ICU mortality, n (%) | In-hospital mortality, n (%) | Total costs, mean ± SD |
Holzinger, U et al. ( 2011) | EM | 40 (90.9) | NR | 1.18 ± 0.54 | 8 (18.2) | NR | 11 (6–19) | NR | NR | NR | NR | 12 (27.3) | 17 (38.6) | NR |
ENDO | 21 (95.5) | NR | 1.82 ± 0.79 | 4 (18.2) | NR | 15 (10–21) | NR | NR | NR | NR | 7 (31.8) | 9 (40.9) | NR |
Gerritsen, A et al. (2016) | EM | 56 (70.9) | 20 (30.3) | NR | 2 (2.6) | 43 (53.8) | 15 (10–27) | 31 (25–45) | 3.9 (2.0-6.7) | 8.2 (4.8–9.9) | 12 (7–22) | 2 (2.5) | 2 (2.5) | € 584 (504–669) mean (95% BCaCI) |
ENDO | 52 (70.3) | 21 (35.0) | NR | 5 (6.8) | 36 (48.6) | 11 (8–18) | 60 (40–85) | 2.0 (0.2–5.6) | 5.5 (2.3–7.8) | 10 (7–18) | 5 (6.8) | 5 (6.8) | € 700 (585–835) mean (95% BCaCI) |
Kappelle, WFW et al. (2018) | EM | 67 (82) | 21 (26) | NR | 4 (4.9) | NR | 20 (10–30) | NR | NR | 4 (2–6) | NR | NR | NR | $ 522.3 ± 340.5 |
ENDO | 58 (73) | 23 (32) | NR | 4 (5.5) | NR | 10 (7–13) | NR | NR | 4 (0.8-7) | NR | NR | NR | $ 631.8 ± 332.5 |
Gao, XJ et al. (2018) | EM | 74 (91.4) | NR | 1.22 ± 0.42 | 4 (5.0) | 14 (17.3) | 13 ± 4 mean ± SD | 18 ± 3 mean ± SD | 4.3 ± 1.7 mean ± SD | 7.1 ± 1.8 mean ± SD | 17.6 ± 8.4 mean ± SD | 14 (17.3) | 20 (25) | $ 333 ± 24 |
ENDO | 76 (95.0) | NR | 1.08 ± 0.27 | 5 (6.3) | 14 (17.5) | 7 ± 2.5 mean ± SD | 26 ± 6 mean ± SD | 3.3 ± 1.5 mean ± SD | 4.9 ± 2.4 mean ± SD | 16.3 ± 7.3 mean ± SD | 16 (20) | 22 (27.5) | $ 461 ± 28 |
BCaCI, Bias corrected and accelerated confidence interval; EM, electromagnetic-guided placement; ENDO, endoscopic placement; GI, gastrointestinal tract; IQR, interquartile range; SD, standard deviation; NR, not reported. |
Secondary outcomes
Two studies[6, 7] with 281 patients were included to evaluate reinsertion rate. Of 148 patients undergoing EM-guided placement, reinsertion occurred in 41 patients (27.7%). As for ENDO, reinsertion occurred in 44 patients (33.1%). There was no significant difference between two groups (RR 0.84; 95% CI: 0.59–1.20; P = 0.86, I² = 0%) (Fig. 2b). Number of attempts was reported in 2 studies[6, 7]. No significant difference was found between two groups (1.2 vs. 1.5; WMD − 0.23; 95% CI: -0.99-0.53; P < 0.05, I² = 94%) (Fig. 2c).
All studies evaluated placement-related complications. In EM group, placement-related complications occurred in 18 patients (6.3%), which mainly contained 10 epistaxis (3.5%), 1 gastrointestinal tract blood (0.3%), 1 hypoxia (0.3%), 1 atrial fibrillation (0.3%), and 1 abdominal pain (0.3%). As for ENDO, placement-related complications occurred in 18 patients (7.2%), which mainly contained 12 epistaxis (4.8%), 1 gastrointestinal tract blood (0.4%), and 4 hypoxias (1.6%). No significant difference was found between the two groups (RR 0.78; 95% CI: 0.41–1.49; P = 0.78, I² = 0%) (Fig. 3a). Two studies[6, 8] with 315 patients reported tube-related complications. In EM group, tube-related complications occurred in 57 patients (35.4%), which mainly contained 45 dislodgements (28.0%), and 13 blockages (8.1%). As for ENDO, tube-related complications occurred in 50 patients (32.5%), which mainly contained 38 dislodgements (24.7%), 7 blockages (4.5%), and 3 aspirations (1.9%). No significant difference was found in total tube-related complications (RR 1.08; 95% CI: 0.82–1.44; P = 0.76, I² = 0%) (Fig. 3b). No procedure-related mortality was reported among studies.
All included studies evaluated insertion time. EM was associated with longer insertion time than ENDO (14.8 min vs. 10.8 min; WMD 4.3; 95% CI: 0.2–8.39; P < 0.05, I² = 89%) (Fig. 4a). Total procedure time was reported in 2 studies[6, 8] (n = 315). No significant difference was found between two groups (24.5 min vs. 43 min; WMD − 18.09; 95% CI: -38.66-2.47; P < 0.05, I² = 96%) (Fig. 4b).
Patient-assessed discomfort was reported in 2 studies[6, 8] (n = 315). EM showed higher discomfort level than ENDO (WMD 1.28; 95% CI: 0.46–2.1; P = 0.17, I² = 47%) (Fig. 4c). Patient recommendation was reported in 3 studies[6–8] (n = 470). EM group received higher recommendation scores than ENDO group (WMD 1.67; 95% CI: 0.24–3.10; P < 0.05, I² = 83%) (Fig. 4d).
Length of hospital stay was reported in 2 studies[6, 8] (n = 315). No significant difference was found between the 2 groups (14.8 days vs. 13.2 days; WMD 1.57; 95% CI: -0.33-3.47; P = 0.73, I² = 0%) (Fig. 5a). Mortality was reported in 3 studies[5, 6, 8] (n = 381). There was no difference between the two groups in ICU mortality (RR 0.80; 95% CI: 0.50–1.29; P = 0.61, I² = 0%) (Fig. 5b) and in-hospital mortality (RR 0.87; 95% CI: 0.59–1.28; P = 0.55, I² = 0%) (Fig. 5c).
Total costs were provided in 3 studies[6–8] (n = 470). Currency units were variably used euro and dollar. No significant difference was found between the two groups (SMD − 1.80; 95% CI: -3.96-0.36; P < 0.05, I² = 99%) (Fig. 5d).
Subgroup analyses
Subgroup analyses were performed for all outcomes. (Supplemental Digital Content 3) EM compared with ENDO was associated with lower total cost when only evaluating multicenter RCTs. (WMD − 0.29; 95% CI: -0.51–0.06; P = 0.01, I² = 0%). Other subgroup analysis results were accordant to the main analyses. Heterogeneity was reduced when subgroup analyses for total costs and insertion time was performed using level of BMI < 25 as a modifier. The other heterogeneity could not be explained by these variables with the available data.