High In-hospital mortality after percutaneous endoscopic gastrostomy: results of a nationwide population-based study

One-Year Mortality After Percutaneous Endoscopic Gastrostomy: The Prognostic Role of Nutritional Biomarkers and Care Settings

Background/Objectives: This study aimed to evaluate the clinical outcomes, complications, and one-year mortality of patients undergoing percutaneous endoscopic gastrostomy (PEG) in different care settings (hospital, nursing home, and home). Additionally, we investigated the comparative prognostic role of the prognostic nutritional index (PNI) and the CRP-to-albumin ratio (CAR) in predicting mortality among these patients. Methods: A retrospective analysis of 236 adult patients who underwent PEG placement between January 2022 and December 2023 was performed. Demographic, clinical, and laboratory data were collected. The PNI was calculated according to the following formula: PNI = 10 × (albumin) + 0.005 × (lymphocyte count). The CAR was obtained by the ratio of the CRP level to the albumin level. Patients were categorized based on their post-PEG care settings. Results: Neurologic disorders were the most common indication for PEG (69.9%). The one-year mortality was 32.2%, with a median survival of 38 weeks (95% CI: 35-41). In the multivariable model, a lower PNI (HR = 0.93, 95% CI: 0.89-0.97, p < 0.001), as well as being followed in a hospital setting, emerged as independent predictors of mortality. Patients with timely PEG tube replacement showed a reduced mortality risk. The ROC analysis showed that the PNI had a higher AUROC (0.78 ± 0.04) compared to the CAR (0.69 ± 0.04), indicating superior prognostic accuracy for predicting one-year mortality. Conclusions: Care settings significantly influence survival outcomes, with better mortality rates observed in nursing homes and home environments. The PNI was superior to the CAR in predicting one-year mortality, emphasizing its clinical utility in risk stratification for PEG patients. Proactive tube management and individualized care strategies are critical for improving the prognosis in this population.

Outcomes of percutaneous endoscopic gastrostomy (PEG) in HIV patients

BACKGROUND

Percutaneous Endoscopic Gastrostomy (PEG) tube insertion, a routine procedure for long-term enteral nutrition, serves as a crucial intervention for patients who are incapable of tolerating oral intake or meeting adequate nutritional requirements. PEG tube placement carries complications like bleeding and infection. Impact of PEG tubes on the 30-day and long-term mortality in HIV patients is unknown. Despite the ongoing utilization of PEG tubes in HIV patients, a comprehensive exploration of its outcomes is yet to be explored. We intended to study the impact of HIV positive status on post-PEG mortality and review other PEG tube related complications.

METHODS

Our study comprised a total of 639 PEG tubes placed on 461 unique patients, from which 85 patients (n = 18%) were HIV positive. We reviewed all these PEG tube patients at our institution and compared their complications and mortality outcome between the two groups of HIV positive as against HIV negative.

RESULTS

Our findings reveal a statistically significant increase (p-value 0.001) in post-PEG insertion site bleeding in the HIV group (15.3%) compared to the non-HIV group (4.5%). This difference occurred despite no notable variations in laboratory parameters such as platelet count and (international normalized ratio), as well as similar usage of anticoagulant or antiplatelet medications between the two groups. Notably, the 1-year mortality rate in the HIV group stands at 37.6% (p < 0.001), contrasting sharply with the non-HIV group's rate of 17.8%.

CONCLUSION

This study underscores the need for heightened vigilance and tailored management strategies when considering PEG tube procedures in the context of HIV, given the observed elevated bleeding risks and increased 1-year mortality rates in this patient population. Further research is warranted to elucidate the underlying factors contributing to these outcomes, facilitating the development of targeted interventions to optimize the care of HIV patients undergoing PEG placement.

Comparative Analysis of Early Versus Late Feeding Post-percutaneous Endoscopic Gastrostomy Tube Placement: A Systematic Review and Meta-Analysis

INTRODUCTION

In clinical practice, tube feedings have been delayed after the percutaneous endoscopic gastrostomy (PEG) tube placement. Previous studies, including a meta-analysis in 2008, have shown that it is safe to start tube feeding ≤ 4 h of PEG tube placement. However, it is still a common practice to delay the initiation of tube feeding up to 24 h after PEG tube placement. We have performed an updated analysis of studies comparing early versus delayed tube feedings following PEG placement.

METHODS

Major databases like PubMed, EMBASE, and Web of Science were searched in June 2022 for randomized controlled trial (RCT) studies reporting on comparative outcomes with early (< or = 4 h) versus delayed (> 4 h) feeding after PEG tube placement in adult patients. The primary outcomes in our study include complication rates and mortality rates within 72 h of the procedure. The outcomes were reported as pooled odds ratio (95% confidence interval (CI) (Moole et al. in Indian J Gastroenterol. 35:323-330, 2016), p value, I2 values).

RESULTS

A total of 212 individuals in the early feeding group and 215 individuals in the late feeding group were analyzed from six studies. The pooled odds ratio of total complication events between early and late feed groups was 0.86 (CI 0.51-1.45, p = 0.58). The pooled odds ratio of fever, vomiting, and local infection was 0.94 (CI 0.186-4.74, p = 0.94), 1.0 (CI 0.38-2.65, p = 0.9), and 1.25 (0.36-4.3, p = 0.72), respectively, between early and late feeding post-PEG tube placement. In conclusion, this meta-analysis confirms that early feeding ≤ 4 h after PEG placement does not increase the odds of poor outcomes or mortality, and it is a well-tolerated, safe, and effective alternative to delayed feeding. Furthermore, early feeding may decrease hospital stays and healthcare costs.

Timing and Outcomes of Percutaneous Endoscopic Gastrostomy After Ischemic Stroke

Background

Guidelines recommend using percutaneous endoscopic gastrostomy (PEG) for dysphagia after 2 weeks of stroke onset. We aimed to study the impact of PEG timing on outcomes in patients with ischemic stroke.

Methods

In this retrospective study of patients with ischemic stroke and PEG between 2014 and 2019, early PEG was defined as PEG tube placed within 14 days of stroke and late PEG after 14 days. Outcomes of 30-day mortality, PEG-related complications, and functional swallow recovery were compared between early and late PEG. Logistic regression model assessed factors associated with PEG timing.

Results

The median time of PEG tube placement after stroke was 10.9 days. Of the 161 included patients, 60.9% had early PEG, and its associated patient factors were nursing facility discharge (adjusted odds ratio (OR): 3.4, confidence interval (CI): 1.48 - 7.82) and infection (OR: 0.32, CI: 0.139 - 0.178). Late PEG had 3.27 times greater odds of swallowing recovery, but mortality and complications were not significantly different between early and late PEG.

Conclusions

Skilled nursing facility disposition and lack of infection were predictors of early PEG, constituting the majority of PEG placed for ischemic stroke-related dysphagia. Although better odds of swallowing recovery were seen with late PEG, likely implicating better patient selection, overall, the timing of PEG tube placement did not impact short-term mortality and complications.

Effectiveness and safety of an atropine/midazolam and target controlled infusion propofol-based moderate sedation protocol during percutaneous endoscopic transgastric jejunostomy procedures in Parkinson's disease: a real-life retrospective observational study

Patients with Parkinson's disease (PD), often elderly with various comorbidities, may require a continuous intestinal infusion of carbidopa/levodopa gel by the placement of a percutaneous endoscopic gastrostomy (PEG) with a jejunal tube (PEG-J) to improve their motor outcome and quality of life. However, it is unclear what is the best procedural sedation protocol for PEG-J procedures. Fifty patients with PD and indication for PEG-J procedure (implantation, replacement, removal) underwent, from 2017 to 2022, a sedation protocol characterized by premedication with atropine (0.01 mg/Kg i.v.), midazolam (0.015-0.03 mg/Kg i.v.) and induction with bolus propofol (0.5-1 mg/Kg i.v.) as well as, finally, sedation with continuous infusion propofol (2-5 mg/Kg/h i.v.) by Target Controlled Infusion (TCI) technique. Ninety-eight per cent of patients experienced no intraprocedural or peri-procedural adverse events. All the procedures were technically successful. A good discharge time was recorded. The vital parameters recorded during the procedure did not vary significantly. A PEG-J procedure conducted within 30 min showed a significant advantage over end-tidal carbon dioxide (EtCO2). Indeed, the latter showed some predictive behavior (OR: 1.318, 95% CI 1.075-1.615, p = 0.008). In the real world, this sedation protocol showed a good safety and effectiveness profile, even with reduced doses of midazolam and a TCI propofol technique in moderate sedation.

In-hospital, 30- and 90-day mortality in elderly trauma patients with operative feeding tubes

BACKGROUND

Nutrition is essential in the treatment of elderly trauma patients (ETP). ETP experience dysphagia at rates six times higher than the non-trauma elderly population (NTEP) and are at increased risk for malnutrition. Operative feeding tube (OFT) placement is often used to aid with the nutritional management of ETP. Elderly patients experience higher rates of morbidity and mortality when compared to the general population, especially in the traumatic setting, with some data suggesting in-hospital mortality as high as 10%. However, the mortality rates and associated comorbidities associated with OFT in ETP are unknown. The purposes of this study were to establish the mortality rate in hospital as well as 30- and 90-days following discharge among elderly trauma patients (ETP) receiving OFT, and to assess factors associated with mortality within this population.

METHODS

A retrospective review of all trauma patients from a single Level I Trauma Center from 01/2010-09/2020 was conducted. Exclusion criteria were patients under 65 years of age or those with previously placed OFT. Demographics, comorbidities, injury mechanisms, injury severity scores (ISS), and OFT data were collected from the institutional trauma registry. Mortality data were obtained using the Social Security Death Index. Mortality at discharge, 30 days, and 90 days following discharge were the primary outcomes. Bivariate analysis was conducted to compare characteristics and comorbidities of patients alive and dead at the time points of interest.

RESULTS

There were 151 ETP who received OFT. Patients were largely male (67.5%), severely injured via a blunt mechanism (95%), and had a median age of 76 years. 11 (7.3%) experienced in-hospital mortality following feeding tube placement, 21 (13.9%) died within 30 days, and 31 (20.5%) within 90 days. Bivariate analysis demonstrated that ETP who died were more likely to have a history of dementia (p = 0.004), congestive heart failure (p = 0.014), and end-stage liver disease (p = 0.034). No other patient or injury factors were associated with mortality after OFT placement.

CONCLUSION

Mortality rates for ETP with OFT were higher than anticipated, yet favorable compared to recently reported data. Patients who died were more likely to have dementia, CHF, or ESLD than those who survived. The few comorbidities associated with mortality suggest that nearly all ETP who undergo OFT placement are at risk for mortality. Additionally, the data highlights the importance of early goals of care discussions for ETP and their loved ones when operative feeding tubes are being considered.

LEVEL OF EVIDENCE

Level III.

STUDY TYPE

Prognostic/Therapeutic/Diagnostic Test/Economic/Decision.

Improving 30-day mortality after PEG tube placement in England from 2007 to 2019: a retrospective national cohort analysis of 87,862 patients

BACKGROUND AND AIMS

PEG has been associated with poor case selection and high mortality. We examined indications, 30-day mortality, and 7-day adverse events in a national cohort undergoing PEG tube insertion.

METHODS

Adult patients undergoing their first PEG tube insertion from 2007 to 2019 were identified in the Hospital Episode Statistics database. Indications and adverse events were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes. Multivariable logistic regression modeling examined factors associated with mortality.

RESULTS

Of 87,682 patients identified, 58% were men and median age was 69 years (interquartile range, 57-79). The number of patients with dementia or stroke as the indication for PEG fell from 2007 to 2019 (dementia, from 147 to 28 [P < .001]; stroke, from 2851 to 1781 [P < .001]). The median interval from stroke admission to PEG tube insertion increased from 21 (interquartile range, 12-36) to 28 (interquartile range, 13-45) days (P < .001). Aspiration pneumonia within 7 days of PEG fell from 10.2% to 8.6% (P = .04). Thirty-day mortality fell from 13.2% to 5.3% (P < .001), with associated factors of increasing age (≥82 years quintile odds ratio [OR], 4.44; 95% confidence interval [CI], 4.01-4.92), PEG tube insertion during emergency admission (OR, 2.10; 95% CI, 1.97-2.25), Charlson comorbidity score ≥5 (OR, 1.67; 95% CI, 1.53-1.82), and dementia (OR, 1.46; 95% CI, 1.26-1.71). Female sex (OR, .81; 95% CI, .77-.85), least-deprived quintile (OR, .88; 95% CI, .81-.95), and more recent years of PEG tube insertion (2019; OR, .44; 95% CI, .39-.51) were negatively associated with mortality.

CONCLUSIONS

Thirty-day mortality after PEG tube insertion has fallen 60% over 13 years. Dementia or stroke as an indication for PEG fell, and the time interval from stroke to PEG tube insertion increased. These findings may be attributable to improved patient selection and timing for PEG tube insertion.

The Outcomes of Nutritional Support Techniques in Patients with Gastrointestinal Cancers

Gastrointestinal cancers represent a major cause of morbidity and mortality worldwide. A significant issue regarding the therapeutic management of these patients consists of metabolic disturbances and malnutrition. Nutritional deficiencies have a negative impact on both the death rates of these patients and the results of surgical or oncological treatments. Thus, current guidelines recommend the inclusion of a nutritional profile in the therapeutic management of patients with gastrointestinal cancers. The development of digestive endoscopy techniques has led to the possibility of ensuring the enteral nutrition of cancer patients without oral feeding through minimally invasive techniques and the avoidance of surgeries, which involve more risks. The enteral nutrition modalities consist of endoscopy-guided nasoenteric tube (ENET), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy with jejunal tube extension (PEG-J), direct percutaneous endoscopic jejunostomy (DPEJ) or endoscopic ultrasound (EUS)-guided gastroenterostomy.

Defining the Mortality Rate of Elderly Trauma Patients With Operative Feeding Tubes

INTRODUCTION

Placement of feeding tubes in elderly patients has not been studied in elderly trauma patients. The objectives of this study were to determine in-hospital mortality in elderly trauma patients receiving operative feeding tubes and to identify factors associated with in-hospital mortality.

METHODS

A retrospective study utilizing 2017 National Trauma Data Bank data was conducted. Trauma patients aged 65 and older with operative feeding tubes were included. Demographic, injury, comorbidity, and general hospital course data were analyzed. Two cohorts were constructed: survival and non-survival to hospital discharge. Bivariate analysis and logistic regression were performed to determine factors independently associated with in-hospital mortality.

RESULTS

A total of 3,398 patients were analyzed with 331 (9.7%) dying during hospitalization. Patients had a median age of 75 years and sustained severe injuries (median ISS 17). Patients who died were older (76 vs. 75 years, p = .03), more severely injured (ISS 22 vs. 17, p < .001), had a higher geriatric trauma outcome score (134 vs. 121, p < .001), and had lower rates of dementia (8 vs. 13%, p = .01). Multivariate regression showed male sex, lower admission GCS, higher Charlson Comorbidity Index, and an Advance Directive Limiting Care (ADLC) were independently associated with in-hospital mortality. Dementia diagnosis was negatively associated with in-hospital mortality.

CONCLUSIONS

The in-hospital mortality rate for elderly trauma patients with operative feeding tubes placed was notably high. Identifying factors associated with in-hospital mortality will serve to assist providers in counseling patients and caregivers about the outcomes of operative feeding tube placement in this patient population.

Comparative Safety of Endoscopic vs Radiological Gastrostomy Tube Placement: Outcomes From a Large, Nationwide Veterans Affairs Database

INTRODUCTION

A gastrostomy is generally performed in patients who are unable to maintain volitional intake of food. We compared outcomes of percutaneous endoscopic gastrostomy (PEG) and interventional radiologist-guided gastrostomy (IRG) using an integrated nationwide database.

METHODS

Using the VA Informatics and Computing Infrastructure database, patients who underwent PEG or IRG from 2011 through 2021 were selected using Current Procedural Terminology and International Classification of Diseases codes. The primary outcome was the comparative incidence of adverse events between PEG and IRG. Secondary outcomes included all-cause mortality. Comorbidities were identified using International Classification of Diseases codes, and adjusted odds ratio (OR) for adverse events were calculated using multivariate logistic regression analysis.

RESULTS

A total of 23,566 (70.7 ± 10.2 years) patients underwent PEG and 9,715 (69.6 ± 9.7 years) underwent IRG. Selected frequent indications for PEG vs IRG were as follows: stroke, 6.8% vs 5.3%, P < 0.01; aspiration pneumonia, 10.9% vs 6.8%, P < 0.001; feeding difficulties, 9.8% vs 6.3%, P < 0.01; and upper aerodigestive tract malignancies 58.8% vs 79.8%, P < 0.01. Across all subtypes of malignancies of the head and neck and foregut, the proportion of patients undergoing IRG was greater than those undergoing PEG (P < 0.001). The all-cause 30-day mortality and overall incidence of adverse events were significantly lower for PEG compared with those for IRG (PEG vs IRG): all-cause 30-day mortality, 9.35% vs 10.3% (OR 0.80; 95% confidence interval [CI] 0.74-0.87; P < 0.01); perforation of the colon, 0.12% vs 0.24% (OR 0.50; 95% CI 0.29-0.86; P = 0.04); peritonitis, 1.9% vs 2.7% (OR 0.68; 95% CI 0.58-0.79; P < 0.01); and hemorrhage 1.6% vs 1% (OR 1.47; 95% CI 1.18-1.83; P < 0.01).

DISCUSSION

In a large nationwide database of more than 33,000 gastrostomy procedures, PEG was associated with a lower incidence of adverse outcomes and the 30-day mortality than IRG.

Evaluation of the Integrated Pulmonary Index® during non-anesthesiologist sedation for percutaneous endoscopic gastrostomy

Standard monitoring of heart rate, blood pressure and arterial oxygen saturation during endoscopy is recommended by current guidelines on procedural sedation. A number of studies indicated a reduction of hypoxic (art. oxygenation < 90% for > 15 s) and severe hypoxic events (art. oxygenation < 85%) by additional use of capnography. Therefore, U.S. and the European guidelines comment that additional capnography monitoring can be considered in long or deep sedation. Integrated Pulmonary Index® (IPI) is an algorithm-based monitoring parameter that combines oxygenation measured by pulse oximetry (art. oxygenation, heart rate) and ventilation measured by capnography (respiratory rate, apnea > 10 s, partial pressure of end-tidal carbon dioxide [PetCO2]). The aim of this paper was to analyze the value of IPI as parameter to monitor the respiratory status in patients receiving propofol sedation during PEG-procedure. Patients reporting for PEG-placement under sedation were randomized 1:1 in either standard monitoring group (SM) or capnography monitoring group including IPI (IM). Heart rate, blood pressure and arterial oxygen saturation were monitored in SM. In IM additional monitoring was performed measuring PetCO2, respiratory rate and IPI. Capnography and IPI values were recorded for all patients but were only visible to the endoscopic team for the IM-group. IPI values range between 1 and 10 (10 = normal; 8-9 = within normal range; 7 = close to normal range, requires attention; 5-6 = requires attention and may require intervention; 3-4 = requires intervention; 1-2 requires immediate intervention). Results on capnography versus standard monitoring of the same study population was published previously. A total of 147 patients (74 in SM and 73 in IM) were included in the present study. Hypoxic events occurred in 62 patients (42%) and severe hypoxic events in 44 patients (29%), respectively. Baseline characteristics were equally distributed in both groups. IPI = 1, IPI < 7 as well as the parameters PetCO2 = 0 mmHg and apnea > 10 s had a high sensitivity for hypoxic and severe hypoxic events, respectively (IPI = 1: 81%/81% [hypoxic/severe hypoxic event], IPI < 7: 82%/88%, PetCO2: 69%/68%, apnea > 10 s: 84%/84%). All four parameters had a low specificity for both hypoxic and severe hypoxic events (IPI = 1: 13%/12%, IPI < 7: 7%/7%, PetCO2: 29%/27%, apnea > 10 s: 7%/7%). In multivariate analysis, only SM and PetCO2 = 0 mmHg were independent risk factors for hypoxia. IPI (IPI = 1 and IPI < 7) as well as the individual parameters PetCO2 = 0 mmHg and apnea > 10 s allow a fast and convenient conclusion on patients' respiratory status in a morbid patient population. Sensitivity is good for most parameters, but specificity is poor. In conclusion, IPI can be a useful metric to assess respiratory status during propofol-sedation in PEG-placement. However, IPI was not superior to PetCO2 and apnea > 10 s.

Managing complications of percutaneous tracheostomy and gastrostomy

Percutaneous tracheostomy and gastrostomy are some of the most commonly performed procedures at bedside in the intensive care unit. While they are generally considered safe, they can be associated with numerous short and long-term complications, many of which can occur long after their placement and cause significant morbidity. Performers of these procedures should possess a comprehensive understanding of procedural indications and contraindications, and know how to recognize and manage complications that may arise. In this review, we highlight complications of percutaneous tracheostomy and describe strategies for their prevention and management, with a special focus on post-tracheostomy tracheal stenosis. Other complications reviewed include bleeding, pneumothorax and subcutaneous emphysema, posterior wall injury, tube displacement, tracheomalacia, tracheoinominate artery fistula, tracheo-esophageal fistula, and stomal cellulitis. Gastrostomy complications and their management are also discussed including bleeding, internal organ injury, necrotizing fasciitis, aspiration pneumonia, buried bumper syndrome, tumor seeding, wound infection, tube displacement, peristomal leakage, and gastric outlet obstruction. In light of the potentially serious outcomes associated with complications of percutaneous tracheostomy and gastrostomy, the emphasis should be placed on risk-reduction strategies to minimize morbidity and mortality. We therefore present detailed pragmatic and comprehensive checklists to serve as a reference for clinicians involved in performing these procedures.

Percutaneous endoscopic gastrostomy in children: A single center experience in Saudi Arabia

OBJECTIVES

To evaluate the demographic data and complications in children who had undergone percutaneous endoscopic gastrostomy (PEG) over 9 years period.

METHODS

The demographic data, complications, length of hospital admission related to PEG insertion and follow-up findings of 39 patients who had undergone percutaneous endoscopic gastrostomy using the standard pull-through technique between 2011 and 2020 were examined. The study took place at the Gastroenterology Division, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia RESULTS: The most common indications of feeding with a gastrostomy tube include neurological diseases (n=30, 76.9%), followed by metabolic disorders (n=3, 7.69%), chronic diarrhea (n=2, 5.1%), chronic kidney diseases (n=2, 5.1%), cystic fibrosis (n=1, 2.56%), feeding aversion fibrosis (n=1, 2.56%). Out of the 39 patients, 20 (51%) did not have any complications. However, minor complication are expected. Most common complications included local infection (n=14, 35.89%) followed by granulation tissue (n=6, 15.38%), "buried bumper syndrome" developed in one.

CONCLUSION

Percutaneous endoscopic gastrostomy tube is the desirable method for patients who are unable to feed orally, feeding is not adequate for demands, has special feeding requirements, or swallowing dysfunction. The technique has become more widespread because of its simplicity, safety, and low cost. Major complications are rare. The procedure is safe and effective and could be carried out by pediatric gastroenterologists after training.

Improving All-Cause Inpatient Mortality After Percutaneous Endoscopic Gastrostomy

BACKGROUND AND AIMS

Percutaneous gastrostomy (PEG) is a common inpatient procedure. Prior data from National Inpatient Sample (NIS) in 2006 reported a mortality rate of 10.8% and recommended more careful selection of PEG candidates. This study assessed for improvement in the last 10 years in mortality rate and complications for hospitalized patients.

METHODS

A retrospective cohort analysis of all adult inpatients in the NIS from 2006 to 2016 undergoing PEG placement compared demographics and indication for PEG placement per ICD coding. Survey-based means and proportions were compared to 2006, and rates of change in mortality and complication rates were trended from 2006 through 2016 and compared with linear regression. Multivariable survey-adjusted logistic regression was used to determine predictors of mortality and complications in the 2016 sample.

RESULTS

A total of 155,550 patients underwent PEG placement in 2016, compared with 174,228 in 2006. Mortality decreased from 10.8 to 6.6% without decreased comorbidities (p < 0.001). This trend was gradual and persistent over 10 years in contrast to a stable overall inpatient mortality rate (p = 0.113). Stroke remained the most common indication (29.7%). The majority of patients (64.6%) had Medicare. Indications for placement were stable. Complication rates were stable from 2006 (4.4%) to 2016 (5.1%) (p = 0.201).

CONCLUSIONS

Inpatient PEG placement remains common. Despite similar patient characteristics, mortality has decreased by approximately 40% over the last 10 years without a decrease in complications likely reflecting improved patient selection.

Factors predicting major complications, mortality, and recovery in percutaneous endoscopic gastrostomy

BACKGROUND AND AIM

Percutaneous endoscopic gastrostomy (PEG) has been used in patients with dysphagia and inadequate food intake via an oral route. Despite being a procedure with a high success rate, complications and death have been reported. The aim was to identify the factors related to major complications and mortality, as well as PEG removal prognostic factors due to improvement of their general condition.

METHODS

Patient characteristics, comorbidities, laboratory data, concomitant medication, sedation, and indication for PEG placement were collected. Major complications, mortality, and PEG removal factors were assessed.

RESULTS

A total of 388 patients were enrolled. There were 15 (3.9%) cases of major complications, with major bleeding being the most frequent in 6 (1.5%) patients. Corticosteroids were the independent variable associated with major complications (odds ratio [OR] 5.85; 95% confidence interval [CI] 1.71-20; P = <0.01). Advanced cancer (hazard ratio [HR] 0.5; 95% CI 0.3-1; P = 0.05), albumin (HR 0.6; 95% CI 0.4-0.9; P = <0.01), and C-reactive protein (CRP) (HR 1.1; CI 1-1.2; P = 0.01) were considered risk factors for mortality. Previous pneumonia (HR 0.4; CI 0.2-0.9; P = 0.02) was a factor for permanent use of a PEG; however, oncological indication (HR 8.2; CI 3.2-21; P = <0.01) was factors for PEG withdrawal.

CONCLUSIONS

Chronic corticosteroid users potentially present with major complications. Low albumin levels and elevated CRP were associated with death. Previous aspiration pneumonia was a factor associated with permanent use of PEG; however, patients with oncological indication were the most benefited.

Early versus late tube feeding initiation after PEG tube placement: Does time to feeding matter?

BACKGROUND

Variation exists in the timing of tube feed initiation after percutaneous endoscopic gastrostomy (PEG) tube placement. The aim of our study was to review outcomes of early tube feed (ETF) versus late tube feed (LTF) initiation after PEG tube placement.

METHODS

We performed a retrospective review of all trauma patients who underwent PEG tube placement from 1/2014 to 12/2018. ETF was defined as initiation < 24 h and LTF > 24 h after placement. The primary outcome measure was feeding intolerance and secondary outcomes included post-operative complications. All statistical analyses were performed using standard statistical methods (e.g. Pearson's Chi-squared, Fisher's exact and Mann Whitney-U tests).

RESULTS

There were 295 patients (164 ETF and 131 LTF) that received a PEG tube at our level 1 trauma center. There was no difference with feeding intolerance at 12 h (5% vs. 4%; p = 0.88), 24 h (1% vs. 2%; p = 1.00), and 48 h (4% vs. 4%; p = 1.00). There was no difference when comparing intolerance symptoms such as nausea and vomiting (1% vs. 2%; p = 0.79), abdominal tenderness (2% vs. 3%; p = 0.76), high gastric residuals (2% vs. 2%; p = 1.00) and aspiration (0% vs. 2%; p = 0.39). There was no difference when comparing post-operative complications (4% vs. 8%; p = 0.21).

CONCLUSIONS

Early tube feeding after PEG placement is safe and equivalent to late tube feeding in the adult trauma population. Future prospective studies are warranted to establish the optimal timing for initiation of tube feeds after PEG tube placement.

Procedure-Related Complications and Survival after Gastrostomy: Results from a Japanese Cohort

INTRODUCTION

In 2010, a large-scale multi-institutional study in Japan showed a good prognosis for percutaneous endoscopic gastrostomy (PEG). However, the function and efficacy of PEG are not fully understood by patients, families, and health-care professionals; thus, the number of PEG treatments in Japan has declined. Therefore, we aimed to investigate the safety of the PEG procedure and subsequent survival after PEG.

METHODS

In total, 249 PEGs were performed at Juzenkai Hospital from 2005 to 2017. PEG was originally performed using the pull method and then by a modified introducer method from mid-2011. We examined procedure-related complications and survival rates after PEG.

RESULTS

Fifty-one (20.5%) procedure-related complications occurred; emergency surgery was required in 4 cases. Infections accounted for 76.5% (39/51) of complications. More infections occurred with the pull method than with the modified introducer method. The 1-year survival rate was 66.8%; the median survival time was 678 days. Nine patients (3.6%) died within 30 days; no deaths were directly related to PEG. Sex, age, and albumin level before surgery significantly influenced the prognosis.

CONCLUSION

Due to changes in the PEG insertion method and other factors, PEG has become a safer treatment method. Additionally, PEG-based nutritional supplementation is associated with adequate survival.

Attitude and experience of neurologists towards percutaneous endoscopic gastrostomy: an Egyptian study

Background

Dysphagia is a common symptom among various neurological diseases. Guidelines recommend gastrostomy insertion for prolonged dysphagia with lower rate of intervention failure encountered with percutaneous endoscopic gastrostomy (PEG) as compared to nasogastric tube insertion.

Methods

Neurology consultants only were included and completed a self-administered questionnaire concerning their practice backgrounds and previous experience with PEG feeding during their practice.

Results

Ninety-eight percent stated that they would recommend PEG for patients with prolonged need of nasogastric feeding. However, only 88% actually referred patients to perform PEG, with the cerebrovascular disorders being the most common cases to be referred. The main barriers the surveyed neurologists faced were family resistance and financial reasons (53.5%). Interestingly, younger neurologists practicing for less than 15 years referred patient to perform PEG significantly more frequent than older ones (p = 0.01). About 18% of our sample confirmed the lack of sufficient knowledge about the benefits of PEG feeding, and only 22% previously attended scientific sessions about the benefits and indications of PEG.

Conclusion

Based on our study, we recommend that PEG should be more encouraged in indicated neurological cases. Scientific sessions targeting neurologists and public awareness about the benefits of PEG and its relatively infrequent complications are highly demanded.

Trends and outcomes of percutaneous endoscopic gastrostomy in hospitalized patients with malignant and nonmalignant ascites: a nationwide population study

Background

Patients with ascites resulting from chronic debilitating diseases often require non-oral enteral nutrition and undergo placement of a percutaneous endoscopic gastrostomy (PEG) tube. The aim of our study was to assess the nationwide trends and outcomes of PEG tube placement among patients with ascites.

Methods

Using the Nationwide Inpatient Sample (NIS), we conducted a retrospective analysis of adult patients (≥18 years) who underwent PEG tube placement (n=789,167) from 2010-2014. We divided these patients into 2 groups: with or without ascites. We compared demographics, complications, and in-hospital outcomes between the groups. STATA-13 was used for statistical analysis. Statistical significance was assigned at P<0.05.

Results

Patients with ascites who underwent PEG tube placement were found to have a significantly higher rate of complications, including peritonitis (7.52 vs. 0.72%; P<0.001), aspiration pneumonia (20.41 vs. 2.69%; P<0.001), hemoperitoneum (0.72 vs. 0.19%; P<0.001), procedure-related hemorrhage (1.69 vs. 0.9%; P<0.001) and esophageal perforation (0.51 vs. 0.47%; P<0.001). In addition, these patients also had higher in-hospital mortality (16.33% vs. 7.02%; P<0.001) despite having a relatively lower prevalence of comorbidities. Length of stay was longer in the ascites group (28.08 vs. 19.45 days; 0.001). Over the study period, however, we observed an increasing trend for PEG tube placement in hospitalized patients with ascites.

Conclusion

PEG tube placement in hospitalized patients with ascites is associated with significantly higher mortality, a longer stay, and more procedure-related complications.

Comparison of Clinical Outcomes Between Surgical Gastrostomy and Percutaneous Endoscopic Gastrostomy with Introducer Technique in Patients with Upper Aerodigestive Malignancies: A Single-Center Analysis

BACKGROUND

Conventional percutaneous endoscopic gastrostomy (PEG) in patients with upper aerodigestive malignancies inevitably carries a risk of stomal metastasis that could be avoided by the direct insertion of the gastrostomy tube through the abdomen. This study compared the efficacy and safety between surgical gastrostomy (SG) and Introducer PEG in patients with upper aerodigestive malignancies.

METHODS

We retrospectively reviewed patients with upper aerodigestive malignancies undergoing SG or Introducer PEG. Procedure data, postprocedural clinical outcomes and 30-day mortality were assessed.

RESULTS

In total, 99 patients were feasible to analysis: 53 were in the SG group, and 46 were in the Introducer PEG group. The SG group had a higher incidence of (in-hospital) major complications [28.3% VS 4.3%, p = 0.002], a longer procedure duration [52.02 ± 21.30 VS 21.46 ± 8.22 min, p < 0.001], higher pain scores at 24 h [median (interquartile range, IQR); 5(3-8) VS 1(0-5), p < 0.001] and longer length of hospitalization (LOH) [median (IQR); 5(4-6) days VS 3(2-4) days, p < 0.001)]. In-hospital (3.8% VS 0%, p = 0.493) and 30-day mortality (17.0% VS 13.0%, p = 0.586) were not different between the two groups. In univariate analysis, high BMI, anemia (hemoglobin <11 g/dL), normal nutritional status (serum albumin >3 g/dL) and procedural type were found to be predicting factors for complications. Procedural type (Introducer PEG) was an independent factor for major complications in multivariate analysis [OR = 0.12, 95% CI 0.02-0.61, p= 0.011].

CONCLUSIONS

In patients with upper aerodigestive malignancies, Introducer PEG was associated with lower rate of (in-hospital) major complications, faster operative time, lower pain scores and shorter LOH.

CLINICAL TRIALS REGISTRY NUMBER

TCTR20181220004.

Percutaneous endoscopic gastrostomy – Too often? Too late? Who are the right patients for gastrostomy?

Percutaneous endoscopic gastrostomy is an established method to provide nutrition to patients with restricted oral uptake of fluids and calories. Here, we review the methods, indications and complications of this procedure. While gastrostomy can be safely and easily performed during gastroscopy, the right patients and timing for this intervention are not always chosen. Especially in patients with dementia, the indication for and timing of gastrostomies are often improper. In this patient group, clear data for enteral nutrition are lacking; however, some evidence suggests that patients with advanced dementia do not benefit, whereas patients with mild to moderate dementia might benefit from early enteral nutrition. Additionally, other patient groups with temporary or permanent restriction of oral uptake might be a useful target population for early enteral nutrition to maintain mobilization and muscle strength. We plead for a coordinated study program for these patient groups to identify suitable patients and the best timing for tube implantation.

Percutaneous endoscopic gastrostomy: dealing with the issue of dislodgement

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is accepted as an efficient method to provide long-term enteral nutrition. PEG accidental dislodgement (device exteriorization confirmed by expert evaluation) rate is high and can lead to major morbidity.Objective: To identify independent risk factors for PEG accidental dislodgement.Methods: Retrospective, single-center study, including consecutive patients submitted to PEG procedure, for 38 consecutive months. Every patient had 12 months minimum follow-up after PEG placement. Univariate analysis selected variables with at least marginal association (p < .15) with the outcome variable, PEG dislodgement, which were included in a logistic regression multivariate model. Discriminative power was assessed using area under curve (AUC) of the receiver operating curve (ROC).Results: We included 164 patients, 67.7% (111) were female, mean age was 81 years. We report 59 (36%) PEG dislodgements, of which 13 (7.9%) corresponded to early dislodgements. The variables with marginal association were hypoalbuminemia (p = .095); living at home (p = .049); living in a nursing home (p = .074); cerebrovascular disease (CVD) (p = .028); weight change of more than 5 kg, either increase or decrease (p = .001); psychomotor agitation (p < .001); distance inner bumper-abdominal wall (p = .034) and irregular appointment follow-up (p = .149). At logistic multivariate regression, the significant variables after model adjustment were CVD OR 4.8 (CI 95% 2.0-11.8), weight change OR 4.7 (CI 95%1.6-13.9) and psychomotor agitation OR 18.5 (CI 95% 5.2-65.6), with excellent discriminative power (AUC ROC 0.797 [CI95% 0.719-0.875]).Conclusion: PEG is a common procedure and accidental dislodgement is a frequent complication. CVD, psychomotor agitation and weight change >5 kg increase the risk of this complication and should be seriously considered when establishing patients' individual care requirements.

A Literature Review of Percutaneous Endoscopic Gastrostomy: Dealing With Complications

Sufficient energy and essential nutrients are vital for normal growth and development in childhood. Ideally, nutrition should be provided orally. However, if the gastrointestinal system is functional, enteral tube feeding can be used when nutritional requirements cannot be provided orally, thus providing nutritional benefits and enabling positive disease management in pediatric patients. Postoperative care in children allows monitoring of the position and functionality of the tube; performing nutrition intolerance, growth, hydration, and nutritional assessments; and performing metabolic and complication follow-ups. Tube feeding in pediatric patients is beneficial and has positive effects in controlling and managing diseases and providing appropriate nutrition in children. However, in postoperative patients, it is important to prevent potential complications, which can be classified into 5 groups: mechanical, gastrointestinal, metabolic, infectious, and pulmonary complications. Important points for managing complications include having enteral nutrition practices based on evidence-based guidelines, sharing outcomes with nurses working in clinical settings, creating enteral feeding guides in clinical settings, providing patients/patients' family with training in line with these guides, and maintaining follow-ups at home. This literature review discusses complications and practices regarding the management of complications after percutaneous endoscopic gastrostomy.

Capnography monitoring of non-anesthesiologist provided sedation during percutaneous endoscopic gastrostomy placement: A prospective, controlled, randomized trial

BACKGROUND AND AIM

A number of studies were able to show a reduction of hypoxemia episodes during procedural sedation through the use of capnography (CA). The present study investigates the number of episodes of hypoxemia during percutaneous endoscopic gastrostomy (PEG) placement with propofol sedation comparing standard monitoring (SM) versus SM with additional CA surveillance.

METHODS

In this single center randomized controlled trial, 150 patients were prospectively randomized 1:1 in either the SM group or the CA group after stratification for ASA class, PEG method (push or pull method), presence of head and neck tumor, and tracheostomy. CA analysis was performed for all patients but was blinded for the endoscopic team in the SM group.

RESULTS

In the SM group, 57% episodes of hypoxemia (SpO₂  < 90% for > 15 s) and 41% episodes of severe hypoxemia (SpO₂  < 85% for > 15 s) were observed in comparison with 28% and 20% in the CA group, respectively. Odds ratios for hypoxemia and severe hypoxemia were 0.29 (confidence interval 0.15-0.57; P = 0.0005) and 0.35 (confidence interval 0.17-0.73; P = 0.008) in favor of the CA group. On average, CA was able to detect imminent mild and severe hypoxemia 83 and 99 s before standard monitoring. Standard monitoring represented an independent risk factor for hypoxemia and severe hypoxemia.

CONCLUSIONS

Respiratory complications of sedation during PEG placement are frequent events. CA is able to detect imminent hypoxemia at an early time point. This allows an early intervention and consecutively the avoidance of mild and severe hypoxemia. Therefore, CA monitoring can be recommended particularly during PEG insertion procedures.

Survival following the placement of gastrostomy tube in patients with multiple sclerosis

Background

Around a third of people with multiple sclerosis (MS) experience dysphagia. There is a need for disease-specific information on survival following placement of gastrostomy tube in people with MS.

Objective

We aimed to study survival following gastrostomy in patients with MS.

Methods

We reviewed medical records, home enteral feeding database and death certificates of people with MS who had gastrostomy from 2005 to 2017. Cox regression analysis was performed to identify independent predictors associated with mortality after gastrostomy.

Results

Median survival of 53 patients with MS after gastrostomy was 21.73 months. Median duration of hospital stay after gastrostomy was 14 days (IQR 5.25, 51.5). Survival at 30 days, 3 months, 1, 2, 5 and 10 years were 100% (53/53), 98.1% (52/53), 81.1% (43/53), 54.7% (29/53), 22.4% (11/49) and 6.8% (3/44), respectively. Of 53 patients, 24 died due to respiratory tract infection. Patients who had gastrostomy tube before 50 years of age survived longer (median 28.48 months) compared with those who had the gastrostomy after age 50 years (median 17.51 months) (p = 0.040).

Conclusion

Around 54% of patients with MS survived two or more years following gastrostomy. Younger patients had better survival. The most frequent cause of death was respiratory infection.

Predictors for 30-day mortality and complications following radiologically inserted gastrostomies: a single centre, large cohort review

AIM

To measure the 30-day mortality and delayed complication rates following radiologically inserted gastrostomy (RIG) placement and determine the predictive risk factors for 30-day mortality and delayed complications to aide pre-procedure informed consent.

MATERIALS AND METHODS

Retrospective analysis was undertaken of RIG insertions between July 2012 and August 2017 at a single tertiary centre, which included 373 patients (56% male; median age: 65 years, range: 19-92 years). Data were collected from electronic databases on patient demographics, RIG indication, all-cause mortality, complication rates, patient co-morbidities, and biochemical/haematological parameters. Multivariate analysis was performed to identify predictive risk factors for complications and mortality.

RESULTS

The RIG procedural success rate was 97.9%. The overall 30-day mortality rate was 7.8%; associated with pre-procedural haemoglobin <130 g/l in men (p=0.030, odds ratio [OR] 23.38), white cell count >11×10⁹/l (p=0.001, OR 4.18), C-reactive protein >10 mg/l (p=0.003, OR 10.10) and international normalised ratio (INR) >1.2 (p=0.03, OR 4.63). Inpatient RIG referrals were associated with 10% 30-day mortality; compared to 1.1% for outpatients (p=0.028, OR 9.51). The incidence of immediate and delayed complications was 2.4% and 42.1%, respectively. Neuromuscular disease was associated with gastrostomy dislodgement (p=0.0001, OR 4.99) and fracture (p=0.0009, OR 13.45), cerebrovascular disease with gastrostomy dislodgement (p=0.009, OR 2.51), cardiovascular disease with sepsis 30-days post-RIG (p=0.02, OR 2.94), and diabetes mellitus with gastrostomy dislodgement (p=0.0001, OR 29.45), fracture (p=0.027, OR 5.63) and stoma site infections (p=0.0003, OR 7.16).

CONCLUSION

RIG 30-day mortality was significantly associated with inpatient procedures compared to outpatient, and a range of biochemical/haematological parameters that suggest infection pre-intervention. It is advised that the markers of infection and catabolism are investigated pre-intervention, which may reduce mortality and complication rates.

RISK FACTORS ASSOCIATED WITH EARLY MORTALITY AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN PATIENTS AT A TERTIARY CARE CENTER IN BRAZIL: A RETROSPECTIVE SINGLE-CENTER SURVIVAL STUDY

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is the main accepted method for long-term tube feeding.

OBJECTIVE

To investigate the risk factors associated with early mortality after PEG.

METHODS

Retrospective survival analysis in a tertiary-level center in Recife, Brazil. We reviewed the medical records of 150 patients with PEG placement. The data were analysed by the Kaplan-Meier method. Multivariable Cox proportional regression models were also built to test the effects of PEG on mortality.

RESULTS

A total of 150 patients who submitted to PEG were studied (70 male). Of the participants, 87 (58%) had blood hypertension; 51 (34%) patients had diabetes; 6 (4%) patients had chronic renal disease; and 6 (4%) had malignancy. Chronic neurodegenerative diseases were the more common clinical indication for PEG. The 30-day and 60-day proportional mortality probability rates were 11.05% and 15.34% respectively. A multivariate Cox proportional regression model, haemoglobin (HR 4.39, 95%CI 1.30-14.81, P=0.017) and pre-procedure UCI staying (HR 0.66, 95% CI 0.50-0.87, P=0.004) were significant predictors of early mortality.A haemoglobin cut-off value of 10.05 g/dL was shown to have a sensibility of 82.6% (61.2% to 95% CI) and an acceptable sensitivity of 59.0 (50.6% to68.6% CI), and a likelihood ratio of 2.06 for eight weeks mortality.

CONCLUSION

In patients who had been subjected to the PEG procedure for long-term nutrition, low haemoglobin, pre-procedure intensive care unit internment or both are associated with the risk of early mortality.

Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits

Background

Dementia remains a growing concern for societies globally, particularly as people now live longer. About 90% of individuals with advanced dementia suffer from eating problems that lead to general health decline and ultimately impacts upon the physical, psychological, and economic wellbeing of the individuals, caregivers, and the wider society.

Objective

To evaluate the burdens and perceived benefits of tube feeding in individuals with advanced dementia.

Design

Narrative review.

Methods

Computerized databases, including PubMed, Embase, Medline, CINAHL, PsycInfo, and Google Scholar were searched from 2000 to 2019 to identify research papers, originally written in or translated into English language, which investigated oral versus tube feeding outcome in individuals with advanced dementia.

Results

Over 400 articles were retrieved. After quality assessment and careful review of the identified articles, only those that met the inclusion criteria were included for review.

Conclusion

Tube feeding neither stops dementia disease progression nor prevents imminent death. Each decision for feeding tube placement in individuals with advanced dementia should be made on a case-by-case basis and involve a multidisciplinary team comprising experienced physicians, nurses, family surrogates, and the relevant allied health professionals. Careful considerations of the benefit-harm ratio should be discussed and checked with surrogate families if they would be consistent with the wishes of the demented person. Further research is required to establish whether tube feeding of individuals with advanced dementia provides more burdens than benefits or vice-versa and evaluate the impacts on quality of life and survival.

Simple Bedside Predictors of Survival after Percutaneous Gastrostomy Tube Insertion

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tube insertion is an increasingly used minimally invasive method for long-term enteral feeding. Identification of simple predictors for short-term mortality (up to one month) after PEG insertion is of paramount importance.

AIM

We aimed to explore a simple noninvasive parameter that would predict survival following PEG insertion.

METHODS

We performed a retrospective study of all patients who underwent PEG insertion at the Galilee Medical Center from January 1, 2014 to December 30, 2018. We collected simple clinical and laboratory parameters and survival data and looked for predictors of short-term mortality.

RESULTS

A total of 272 patients who underwent PEG insertion were included. Sixty-four patients (23.5%) died within one month after PEG insertion compared to 208 patients (76.5%) who survived for more than one month. Univariate analysis revealed several short-term mortality-related predictors, including older age (OR 1.1, P=0.005), ischemic heart disease (OR 2, P=0.0197), higher creatinine level (OR 2.3, P=0.0043), and elevated CRP level and CRP-to-albumin ratio (OR 1.1, P < 0.0001; OR 1.0031, P < 0.0001, respectively). In multivariate logistic analysis, older age (OR 1.1, P=0.019), higher creatinine level (OR 1.6, P=0.074), and elevated CRP-to-albumin ratio (OR 1.1, P=0.002) remained significant predictors of short-term mortality after PEG insertion with an ROC of 0.7274.

CONCLUSION

We could identify several simple parameters associated with high risk of mortality, and we recommend considering using these parameters in decision-making regarding PEG insertion. Further prospective studies are needed to validate our findings.

Percutaneous Endoscopic Gastrostomy After Cardiac Surgery: A Temporary Measure in a High-Risk Cohort

BACKGROUND

A subset of patients who undergo cardiac surgery require percutaneous endoscopic gastrostomy (PEG) tube for enteral access to receive nutritional support. There are limited data evaluating the outcomes of these patients and the duration of nutritional support required.

METHODS

All cardiac surgery patients (1994 to 2017) were stratified by postoperative PEG requirement. Patients were excluded if they required preoperative nutritional support, began nutritional support more than 30 days postoperatively, or if the PEG was placed more than 90 days after the index cardiac operation. Kaplan-Meier survival analysis was used to estimate overall survival and time to PEG removal. A Fine-Gray competing risk model was constructed to determine factors impacting PEG removal.

RESULTS

A total of 16,727 cardiac surgery patients were included, with 310 (1.9%) requiring PEG. The median time to PEG placement was 14.5 (interquartile range, 10 to 22) days with 1 (0.3%) PEG procedural mortality. One-year survival was 50.4% vs 91.8% in the general cardiac surgery population. A total of 113 patients had their PEG removed at a median of 255 days. Of living PEG patients at 1 year, 52.1% had their PEG removed. Factors that were associated with PEG removal were age (hazard ratio [HR], 0.98; P = .03), ejection fraction (HR, 1.03; P < .01), and renal failure (HR, 0.50; P < .01).

CONCLUSIONS

Patients who require PEG after cardiac surgery are a high-risk cohort. However, those who survive their acute illness often recover to a point where nutrition can be maintained without a feeding tube. These data provide meaningful information for counseling patients and their families that are considering PEG after cardiac surgery.

A Successful Percutaneous Endoscopic Gastrostomy Tube Feeding over Two Decades with No Complication: A Rare Case Report

Percutaneous endoscopic gastrostomy (PEG) feeding is a common and widely performed procedure appropriate for long-term enteral nutrition in patients with multiple indications. We present the case of a 59-year-old woman with a PEG tube placed owing to complication following thyroid surgery approximately 20 years ago, representing the most extended duration of PEG tube feeding without any significant complication for chronic mechanical dysphagia. This case highlights the importance of PEG feeding, where this route can be used indefinitely in an appropriate clinical setting without complications. Interestingly, self-replacement of PEG tube was performed by the patient herself whenever she noticed clogging up of tube while self-feeding.

Tracheostomies and PEGs: When Are They Really Indicated?

Surgeons are often asked to perform tracheostomies and percutaneous endoscopic gastrostomies for a wide variety of patients. As consultants, surgeons are tasked with honoring the relationship between the referring provider and the patient while also assessing whether the consult is appropriate given the patient's prognosis and goals of care. This article discusses the most common conditions for which these procedures are requested and reviews the evidence supporting either the placement or avoidance of these tubes in each condition. It provides a framework for surgeons to use when discussing these procedures in the context of goals of care.

Prospective implementation of algorithmic patient selection for gastrostomy tube placement consultations: a pre- and post-intervention analysis

Background: Studies have shown high but variable mortality following gastrostomy tube (GT) placement. There are no standard practice guidelines for GT placement.

Aim: To evaluate if implementation of patient selection and prognosis algorithms for GT insertion has favorable effects on patient outcomes.

Methods: This was a pre-, post-cohort analysis in a Veterans Affairs hospital. We implemented a patient selection algorithm aided by the Sheffield Gastrostomy Scoring System (SGSS) in July 2015. We reviewed all referrals to the inpatient service for a GT between July 2014 and June 2016 (pre-, post- implementation), and collected albumin and SGSS at time of consultation, date of GT insertion, and outcomes including vital status and albumin 30 days post-consultation. Patients were followed until 30 October 2016. We compared outcomes pre- and post-implementation.

Results: A total of 126 referrals were reviewed, 68 pre- and 58 post-algorithm implementation. Seventy-seven GTs were placed; 58 (75.3%) fulfilled the algorithm-appropriate indications. The mean SGSS was significantly lower among patients in whom GT was placed for algorithm-appropriate indications 2.03 (SD =0.86) vs inappropriate indications (2.59, SD =0.63; p<0.001). Sixty-five (51.6%) patients died by conclusion of study. Thirty day mortality after GT placement was 26.2% (post- (22.4%) vs pre- (29.4%)). Changes in serum albumin at day 30 was non-significant.

Conclusion The use of algorithm guidance by the prospective use of the SGSS was associated with a higher likelihood of GT placement both overall and for algorithm-appropriate indications.

Risk factors for prolonged need for percutaneous endoscopic gastrostomy (PEG) tubes in adult trauma patients: Experience of a level 1 trauma

BACKGROUND

Percutaneous endoscopic gastrostomy tubes are a means of providing an alternative enteric route of nutrition. This study sought to identify risk factors for the prolonged need of a percutaneous endoscopic gastronomy tube (≥90 days) in adult trauma patients.

METHODS

The trauma database of a level 1 trauma center was queried retrospectively to identify patients who had percutaneous endoscopic gastronomy tubes placed.

RESULTS

A total of 9,772 charts were reviewed with 282 patients (2.9%) undergoing successful percutaneous endoscopic gastronomy tube placement. On review of discharged living patients, 195 had adequate clinical documentation to allow for analysis. The mean age was 57.5 years, admission serum albumin was 3.7 g/dL, and Charlson Comorbidity Index score was 1.1. The first recorded mean Glasgow Coma Scale was 10.7, and their Injury Severity Score was 23.2. The mean duration of total hospital stay was 23.8 days, intensive care unit stay was 16.5 days, and in-hospital ventilator days was 11.5. Of the 272 patients, 77 (41.4%) required percutaneous endoscopic gastronomy tubes for >90 days. Statistically significant characteristics on univariate analysis included increasing age, a greater Charlson Comorbidity Index score, and a greater number of in-hospital ventilator days. On logistic regression, a Charlson Comorbidity Index score >1 (odds ratio 1.27, 95% confidence interval 1.03-1.56, P = .02) and greater in-hospital ventilator days (odds ratio 1.05, 95% confidence interval 1.02-1.09, P < .01) were predictive of the need for prolonged percutaneous endoscopic gastronomy tube placement.

CONCLUSION

A Charlson Comorbidity Index score >1 and prolonged in-hospital ventilator days were risk factors for the necessity of a percutaneous endoscopic gastronomy tube for ≥90 days after placement. This observation may assist patients/surrogates in decision-making when needing alternative routes for nutrition.

Using tube feeding and levodopa-carbidopa intestinal gel application in advanced Parkinson's disease

The inability to achieve adequate nutrition and weight loss are serious problems for patients with advanced Parkinson's disease (PD). To ensure the optimal intake of nutrition and fluids and to administer levodopa-carbidopa intestinal gel (LCIG) (which patients need to increase or maintain their mobility as long as possible), different artificial feeding tubes can be used. Although percutaneous endoscopic gastrostomy (PEG) tubes are frequently used in medical practice, there is little research that addresses key questions, including if and when to administer artificial fluids, nutrition and/or LCIG via tubes. Weight gain through tube feeding is only possible for some patients; nurses should keep in mind that tube insertion and feeding may lead to frequent adverse events. Administering LCIG via tubes is usually advisable as it seems to enhance patients' mobility and therefore has positive outcomes in terms of the quality of life of patients and their families ( Lim et al, 2015 ). The authors aimed to examine the use and consequences of providing nutrition and LCIG via gastrostomy tubes in PD patients with advanced disease.

In-Hospital Mortality with Use of Percutaneous Endoscopic Gastrostomy in Traumatic Brain Injury Patients: Results of a Nationwide Population-Based Study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a frequently performed invasive procedure that has been associated with high short-term mortality. Its use of special interest in traumatic brain injury (TBI) patients as nutrition support constitutes important issues in intensive care of this group. We used a national database to determine the incidence of, and factors associated with, in-hospital mortality among TBI patients undergoing PEG.

METHODS

We conducted a retrospective study using the US nationwide inpatient sample to analyze data from all hospitalizations in 2008 with International Classification of Diseases, Ninth Revision, diagnostic and procedure codes identifying patients with TBI and hemorrhagic stroke who received PEG. Bivariate and multivariate logistic regression analyses were performed using demographic and clinical variables to identify predictors of in-hospital mortality in this patient population. Patients who did not undergo PEG were used as control.

RESULTS

In-hospital mortality after PEG was 6% (95% CI, 0.05-0.76%) among the TBI population with 0.2% occurring in the first 7 days and 2% occurring in the first 14 days. These patients had a higher incidence of other trauma-related comorbidities and were classified as high-risk stratification based on SRRi score compared to the non-PEG group. Factors strongly predictive of in-hospital mortality were age >51 years, not receiving a PEG, and having a high comorbidity burden of >2.

CONCLUSION

Understanding the rate of mortality associated with PEG in this patient population and identifying factors that increase and decrease the risk of death will improve patient selection for those most likely to benefit from this procedure.

Safety of Percutaneous Endoscopic Gastrostomy Tubes in Centenarian Patients

BACKGROUND/AIMS

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure; however, no study has evaluated the safety of PEG tube placement in patients over the age of 100 years.

METHODS

We conducted a retrospective review of patient records for patients who underwent PEG tube placement. Thirty patients aged 100 years and older were identified and a random sample of 275 patients was selected for comparison.

RESULTS

The mean age of the patients was 80.6±16.2 years. No procedure-related deaths or major complications were identified; the overall inpatient mortality rate was 7.6%. Minor complications were noted in 4% (n=12) of the patients. Centenarian patients were predominantly female (80% [n=24] vs. 54% [n=147], p=0.006), with a mean age of 100.5±0.9 years. There was no significant difference in procedural success rates (93.3% vs. 97.4%, p=0.222) or inpatient mortality (6.7% [n=2] vs. 7.7% [n=21], p=1.000) between the two groups. However, a higher minor complication rate was noted in the older patients (13.3% [n=4] vs. 2.9% [n=8], p=0.022).

CONCLUSIONS

Success rates, major complications and inpatient mortality associated with PEG tubes in patients aged over 100 years are comparable to those observed in relatively younger patients at our center; however minor complication rates are relatively higher. These findings lead us to believe that PEG tubes may be safely attempted in carefully selected patients in this subset of the population.

Gastrostomies Preserve But Do Not Increase Quality of Life for Patients and Caregivers

BACKGROUND & AIMS

Gastrostomies are widely used to provide long-term enteral nutrition to patients with neurologic conditions that affect swallowing (eg, following a cerebrovascular accident or for patients with motor neuron disease) or with oropharyngeal malignancies. The benefits derived from this intervention are uncertain for patients and caregivers. We conducted a prospective, multicenter cohort study to determine how gastrostomies affect health-related quality of life (HRQoL) in recipients and caregivers.

METHODS

We performed a study of 100 patients who received gastrostomies (55% percutaneous endoscopic gastrostomy, 45% radiologically inserted) at 5 centers in the United Kingdom, 100 caregivers, and 200 population control subjects. We used the EuroQol-5D (comprising a questionnaire, index, visual analogue scale) to assess HRQoL for patients and caregivers before the gastrostomy insertion and then 3 months afterward; findings were compared with those from control subjects. Ten patients and 10 caregivers were also interviewed after the procedure to explore quantitative findings. Findings from the EuroQol-5D and semi-structured interviews were integrated using a mixed-methods matrix.

RESULTS

Six patients died before the 3-month HRQoL reassessments. We observed no significant longitudinal changes in mean EuroQol-5D index scores for patients (0.70 before vs 0.710 after; P = .83) or caregivers (0.95 before vs 0.95 after; P = .32) following gastrostomy insertion. The semi-structured interviews revealed problems in managing gastrostomy tubes, social isolation, and psychological and emotional consequences that reduced HRQoL.

CONCLUSIONS

We performed a mixed-methods prospective study of the effects of gastrostomy feeding on HRQoL. HRQoL did not significantly improve after gastrostomy insertion for patients or caregivers. The lack of significant decrease in HRQoL after the procedure indicates that gastrostomies may help maintain HRQoL. Findings have relevance to those involved in gastrostomy insertion decisions and indicate the importance of carefully selecting patients for this intervention, despite the relative ease of insertion.

Low Abdominal Wall Thickness May Predict Percutaneous Endoscopic Gastrostomy Complications

Although percutaneous endoscopic gastrostomy (PEG) tube placement is a common and safe procedure to provide enteral feeding, some patients develop complications. The aim of this study was to identify risk factors for the development of post-PEG complications. We hypothesized that patients with low albumin, diabetes, higher body mass index (BMI), thicker abdominal walls, or psychomotor agitation would have more complications. A 2-year retrospective review was performed on patients who received a PEG tube at a single institution. Variables collected included age, preoperative albumin, BMI, abdominal wall thickness (AWT), psychomotor agitation, pre-operative diabetes mellitus, and mortality. A total of 91 patients (70.3% male) were identified (mean age 58.7 years, SD 18.6). Seventeen patients (18.7%) had post-PEG complications and the 30-day mortality rate was 14.3 per cent. Mortality was not attributable to tube placement. Patients with complications weighed less (P = 0.005) and had a lower BMI (P = 0.010) than patients without complications. Additionally, patients with complications had significantly lower AWT (P = 0.02), mean AWT was 21.6 mm (SD 7.6) versus 27.6 mm (SD 8.1) in the noncomplication patients. AWT was the only factor independently associated with post-PEG complications (P = 0.047). There was no significant association between complications and mortality. Continued investigation on how to limit post-PEG complications remains imperative. In our population, lower AWT was independently associated with complications. Preoperative measurement of AWT by pre-procedural imaging can potentially be used to predict the risk of post-PEG complications.