Endoscopic versus operative gastrostomy: final results of a prospective randomized trial

Safety of Prophylactic Anticoagulation During Bedside Procedures: A Prospective Multicenter Observational Study

BACKGROUND

Bedside percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) are common procedures performed in the intensive care unit (ICU). Venous thromboembolism (VTE) prophylaxis is frequently prescribed to ICU patients and it remains unclear whether pre-procedure discontinuation is necessary.

METHODS

This multi-center prospective observational study aimed to describe bleeding rates in patients undergoing bedside PEG or PDT who did or did not have VTE prophylaxis held. Decision to hold prophylaxis was made by the operating physician. The primary endpoint was the rate of peri-procedural bleeding complications. Secondary endpoints included quantification of held doses in the peri-procedural period, rate of venous thromboembolism, and characteristics associated with having prophylaxis held.

RESULTS

91 patients were included over a 2-year period. Patients were on average aged 54 years, 40% female, mostly admitted to the trauma service (59%), and most commonly underwent bedside PDT (59%). Overall, 21% of patients had doses of pre-procedure prophylaxis held. Bleeding events occurred in 1 patient (1.4%) who had prophylaxis continued and in 1 patient (5.0%) who had prophylaxis held, a rate difference of 3.6% (95% CI-9.5%, 16.7%). One bleeding event was managed with bedside surgical repair and one with blood transfusion. There were 10 VTE events, all of whom had prophylaxis continued during the pre-procedure period but 3 had prophylaxis held after the procedure.

CONCLUSIONS

Bleeding complications were rare and did not significantly differ depending on whether prophylaxis was held or not. Future research is required to confirm the lack of risk with continuing prophylaxis through bedside procedures.

A Rare Case of Gastric Outlet Obstruction With Severe Reflux Esophagitis Due to a Percutaneous Endoscopic Gastrostomy Tube Balloon Displacement

In patients with a functional gastrointestinal (GI) tract, enteral feeding is preferred over parenteral feeding as it has fewer complications and a relatively lower cost. Nasogastric and nasoenteric feeding tubes are available options but when long-term enteral feeding is desired, a percutaneous endoscopic gastrostomy (PEG) tube is more convenient. PEG tube can be associated with multiple complications; however, its displacement which causes gastric outlet obstruction (GOO) is a rare one. Here we present a case of an 81-year-old woman with dementia who presented with upper GI bleeding and was found to have GOO causing reflux esophagitis due to PEG tube displacement.

Gastrostomy Tube Outcomes Among Surgical and Non-Surgical Services: A Retrospective Review

BACKGROUND

Our objective was to evaluate differences in baseline characteristics, complications, and mortality among patients receiving a gastrostomy tube (GT) by surgical or non-surgical services.

METHODS

We performed a retrospective analysis of adult patients who underwent GT placement from 2014 to 2017 at a single institution. Using bivariate and multivariable analyses, we compared baseline characteristics, complications, and overall 30-day mortality of patients undergoing GT placement with surgical or non-surgical services.

RESULTS

Of the 1339 adults who underwent GT placement, surgical and non-surgical services performed 45% (n = 609) and 55% (n = 730) procedures, respectively. Gastrostomy tube-related complications were similar (29.6% surgical vs 28.8% non-surgical, P = .76). Thirty-day mortality was higher among non-surgical services (23.7% vs 16.5%, P = .004). On multivariable analysis, this was not significant (OR 1.21, 95% CI 0.83; 1.77).

CONCLUSION

Surgical and non-surgical service placement of GTs had equivalent GT-related mortality and complication rates.

Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

Role of Enteral Nutrition in Advanced Cancer Patients: Indications and Contraindications of the Different Techniques Employed

Over the last 20 years there has been great progress regarding total parenteral nutrition and enteral nutrition for patients who cannot take food by mouth or cannot swallow, or so that controlled feeding can be established in anorexic and malnourished patients. The use and the role of artificial nutrition is still controversial in advanced cancer patients. Such controversies often are due to the fact that these patients have a survival expectancy that varies from one to several months. The present review describes the most frequent techniques used for enteral nutrition (nasoenteral tubes, gastrostomy and jejunostomy), their indications, contraindications and complications, and gives an indication regarding which patients may really benefit from enteral nutrition taking into consideration not only the potential advantages but also the discomfort and distress related to enteral nutrition and the different techniques that are employed.

Enteral Access and Associated Complications

Enteral access is the foundation for feeding in patients unable to meet their nutrition needs orally and have a functional gastrointestinal tract. Enteral feeding requires placement of a feeding tube. Tubes can be placed through an orifice or percutaneously into the stomach or proximal small intestine at the bedside or in specialized areas of the hospital. Bedside tubes can be placed by the nurse or the physician, such as in the intensive care unit. Percutaneous feeding tubes are placed by the gastroenterologist, surgeon, or radiologist. This article reviews the types of enteral access and the associated complications.

Percutaneous endoscopic gastrostomy: confirming the clinical benefits far beyond anthropometry

OBJECTIVES

The real benefit of gastrostomy is still a matter of debate. We aimed to prospectively evaluate the global impact of percutaneous endoscopic gastrostomy (PEG) in patients followed at a specialized multidisciplinary clinic, namely, the impact on the need for healthcare resources, anthropometric measures, pressure ulcers prevention and healing, and nutritional and hydration status.

PATIENTS AND METHODS

From the 201 patients who underwent PEG between May 2011 and September 2014, 60 were included in a prospective study. Anthropometric, clinical, and laboratorial variables were collected and compared before and after PEG. Follow-up duration, mortality, and number of emergency department visits or hospital admissions were also assessed.

RESULTS

Thirty-three (55.0%) patients were women and the median age was 79 years. The main indications for PEG were dementia (43.3%) and poststroke dysphagia (30.0%). Four months following PEG, significant decreases in the tricipital skinfold (P=0.002) and brachial perimeter (P=0.003) were found. A decrease in the mean number of hospitalizations (1.4 vs. 0.3; P<0.001) and visits to emergency department (2.2 vs. 1.1; P=0.003) was noted in the next 6 months after PEG compared with the previous semester. In 53.8% of patients with pressure ulcers, complete healing was observed after PEG. PEG was associated with increases in hemoglobin (P=0.024), lymphocytes (P=0.041), cholesterol (P=0.008), transferrin (P<0.001), albumin (P<0.001), and total proteins (P<0.001), and a decrease in serum sodium (P=0.001).

CONCLUSION

Anthropometric values may not translate the early benefits of a gastrostomy. PEG decreases the need for hospital health care, facilitates healing of pressure ulcers, and induces biochemical changes that may reflect better nutrition and hydration.

Enteral Access in Mechanically Ventilated Patients

The early institution of enteral nutrition is now accepted as the preferred route of feeding in critically ill patients with a functioning gastrointestinal tract. It is particularly important to establish early enteral nutrition in mechanically ventilated patients because of the metabolic demands associated with mechanical ventilation. The options for enteral access in mechanically ventilated patients are reviewed, with an emphasis on those techniques that may be performed at the bedside. The advantages, disadvantages, and complications of the different techniques will be considered.

The role of surgical gastrostomy in the age of endoscopic gastrostomy: a 13 years and 543 patients retrospective study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) became the gold standard for enteral feeding. Currently, surgical gastrostomy is seldom used.

OBJECTIVE

Evaluating the role of surgical gastrostomy in a center with a large experience in PEG.

METHODS

A retrospective study ranged 13 years, collecting from clinical records: age, gender, underlying disease, date of procedure, technique, primary surgery, complications, 30-day mortality. Patients were divided according to indication for gastrostomy: a) neurological; b) head and neck cancer; c) other diseases; and d) drainage. PEG, open surgical and laparoscopic gastrostomies were compared concerning evolution of the number of procedures, characteristics of patients, complications and mortality.

RESULTS

We identified 509 PEG, 26 open and 8 laparoscopic surgical gastrostomies. An increasing number of the percutaneous approach over the years was observed, while the number of surgical gastrostomies remains steady (mean: 2.6/year). All percutaneous endoscopic gastrostomies but three were feeding procedures, mostly in neurological patients. All laparoscopic gastrostomies were feeding procedures in head and neck cancer. Most open surgical gastrostomies were secondary procedures, part of more complex surgeries, and frequently for drainage purposes. The open surgical approach displayed more morbidity and mortality, reflecting the severity of underlying diseases.

CONCLUSIONS

In our institution, open surgical gastrostomy is seldom used, and mostly as part of complex procedures, frequently for drainage purposes. PEG is the choice to most dysphagic patients needing an enteral feeding access. When not feasible, laparoscopic gastrostomy is a suitable alternative.

Complications of percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) has become the method of choice for mid-to long-term enteral feeding. The majority of complications that occur are minor, but the rare major complications may be life threatening. Some complications occur soon after tube placement, others develop later, when the gastrostomy tract has matured. Older patients with comorbidities and infections appear to be at a greater risk of developing complications. Apart from being aware of indications and contraindications, proper technique of PEG placement, including correct positioning of the external fixation device, and daily tube care are important preventive measures. Adequate management of anticoagulation and antithrombotic agents is important to prevent bleeding, and administration of broad spectrum antibiotics prior to the procedure helps prevent infectious complications. Early recognition of complications enables prompt diagnosis and effective therapy.

Percutaneous endoscopic versus surgical gastrostomy in patients with benign and malignant diseases: a systematic review and meta-analysis

To compare the complications and mortality related to gastrostomy procedures performed using surgical and percutaneous endoscopic gastrostomy techniques, this review covered seven studies. Five of these were retrospective and two were randomized prospective studies. In total, 406 patients were involved, 232 of whom had undergone percutaneous endoscopic gastrostomy and 174 of whom had undergone surgical gastrostomy. The analysis was performed using Review Manager. Risk differences were computed using a fixed-effects model and forest and funnel plots. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test. There was no difference in major complications in retrospective (95% CI (-0.11 to 0.10)) or randomized (95% CI (-0.07 to 0.05)) studies. Regarding minor complications, no difference was found in retrospective studies (95% CI (-00.17 to 0.09)), whereas a difference was observed in randomized studies (95% CI (-0.25 to -0.02)). Separate analyses of retrospective and randomized studies revealed no differences between the methods in relation to mortality and major complications. Moreover, low levels of minor complications were observed among endoscopic procedures in randomized studies, with no difference observed compared with retrospective studies.

Feeding tube replacement: not always that simple!

Although surgical gastrostomy is not a technically troublesome surgery, the procedure may be accompanied by unfavorable outcomes. Most complications occur early in the post-operative period and include feeding tube dislodgment, stomal infection, peritonitis, and pneumonia. The authors report the case of an 83-year-old man who underwent a surgical gastrostomy because of a swallowing disorder after an ischemic stroke. Nine months after the procedure, the feeding tube dislodged and a new tube was inserted with a certain delay and with some difficulty, causing a false path and consequently an intrabdominal abscess after diet infusion. The outcome was fatal. The authors call attention for meticulous care with the insertion of feeding tubes and advise the performance of imaging control to assure its precise positioning.

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances

BACKGROUND

A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

OBJECTIVES

To evaluate the effectiveness and safety of PEG compared with NGT for adults with swallowing disturbances.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to January 2014, and contacted the main authors in the subject area. There was no language restriction in the search.

SELECTION CRITERIA

We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%.

MAIN RESULTS

We included 11 randomised controlled studies with 735 participants which produced 16 meta-analyses of outcome data. Meta-analysis indicated that the primary outcome of intervention failure, occurred in lower proportion of participants with PEG compared to NGT (RR 0.18, 95% CI 0.05 to 0.59, eight studies, 408 participants, low quality evidence) and this difference was statistically significant. For this outcome, we also subgrouped the studies by endoscopic gastrostomy technique into pull, and push and not reported. We observed a significant difference favouring PEG in the pull subgroup (RR 0.07, 95% CI 0.01 to 0.35, three studies, 90 participants). Thepush subgroup contained only one clinical trial and the result favoured PEG (RR 0.05, 95% CI 0.00 to 0.74, one study, 33 participants) techniques. We found no statistically significant difference in cases where the technique was not reported (RR 0.43, 95% CI 0.13 to 1.44, four studies, 285 participants).There was no statistically significant difference between the groups for meta-analyses of the secondary outcomes of mortality (RR 0.86, 95% CI 0.58 to 1.28, 644 participants, nine studies, very low quality evidence), overall reports of any adverse event at any follow-up time point (ITT analysis, RR 0.83, 95% CI 0.51 to 1.34), 597 participants, 6 studies, moderate quality evidence), specific adverse events including pneumonia (aspiration) (RR 0.70, 95% CI 0.46 to 1.06, 645 participants, seven studies, low quality evidence), or for the meta- analyses of the secondary outcome of nutritional status including weight change from baseline, and mid-arm circumference at endpoint, although there was evidence in favour of PEG for meta-analyses of mid-arm circumference change from baseline (MD 1.16, 95% CI 1.01 to 1.31, 115 participants, two studies), and levels of serum albumin were higher in the PEG group (MD 6.03, 95% CI 2.31 to 9.74, 107 participants).For meta-analyses of the secondary outcomes of time on enteral nutrition, there was no statistically significant difference (MD 14.48, 95% CI -2.74 to 31.71; 119 participants, two studies). For meta-analyses of quality of life measures (EuroQol) outcomes in two studies with 133 participants, for inconvenience (RR 0.03, 95% CI 0.00 to 0.29), discomfort (RR 0.03, 95% CI 0.00 to 0.29), altered body image (RR 0.01, 95% CI 0.00 to 0.18; P = 0.001) and social activities (RR 0.01, 95% CI 0.00 to 0.18) the intervention favoured PEG, that is, fewer participants found the intervention of PEG to be inconvenient, uncomfortable or interfered with social activities. However, there were no significant differences between the groups for pain, ease of learning to use, or the secondary outcome of length of hospital stay (two studies, 381 participants).

AUTHORS' CONCLUSIONS

PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT. There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration. Future studies should include details of participant demographics including underlying disease, age and gender, and the gastrostomy technique.

Long-term outcome after percutaneous endoscopic gastrostomy in children

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is widely accepted as the preferred procedure to establish long-term enteral feeding.

OBJECTIVE

To learn the long-term outcomes of the patients who have undergone PEG placement, we reviewed our experience with children who underwent this procedure in our institute.

METHODS

A total of 83 pediatric patients (42 males and 41 females), who were aged from 3 months to 20 years, underwent PEG insertion in National Taiwan University Hospital from January 2000 to April 2011. The underlying diseases of the patients receiving PEG were neurological dysfunction (n = 67), metabolic disorders (n = 9), gastrointestinal disease (n = 2), and congenital heart disease (n = 1). This procedure was performed under intravenous sedation or under general anesthesia. Prophylactic antibiotics were administered for 1 day. Tube feeding began 24 hours after the PEG placement. The body weight of the patients was recorded 1 day before PEG placement and at least 6 months after PEG placement.

RESULTS

The weight-for-age Z-score before and at 6 months after PEG placement were -1.5 ± 2.0 and -0.9 ± 2.1, respectively, which was statistically significant (paired t test, p = 0.006). The catch-up growth was recorded after PEG placement. Complications of PEG in our patients included cellulitis at the gastrostomy wound (n = 14), dislodgement of the tube (n = 17), and persistent gastrocutaneous fistula (n = 3). The PEG tube was removed permanently in seventeen patients because they resumed an adequate oral intake. During the follow-up period, 14 patients died of an underlying disease or infection.

CONCLUSION

Our experience confirmed that PEG placement is a good long-term route for nutritional supply with no serious complications in children.

Interventions for dysphagia and nutritional support in acute and subacute stroke

BACKGROUND

Dysphagia (swallowing problems) are common after stroke and can cause chest infection and malnutrition. Dysphagic, and malnourished, stroke patients have a poorer outcome.

OBJECTIVES

To assess the effectiveness of interventions for the treatment of dysphagia (swallowing therapy), and nutritional and fluid supplementation, in patients with acute and subacute (within six months from onset) stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (February 2012), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), CINAHL (1982 to July 2011) and Conference Proceedings Citation Index- Science (CPCI-S) (1990 to July 2011). We also searched the reference lists of relevant trials and review articles, searched Current Controlled Trials and contacted researchers (July 2011). For the previous version of this review we contacted the Royal College of Speech and Language Therapists and equipment manufacturers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in dysphagic stroke patients, and nutritional supplementation in all stroke patients, where the stroke occurred within six months of enrolment.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, assessed trial quality, and extracted data, and resolved any disagreements through discussion with a third review author. We used random-effects models to calculate odds ratios (OR), 95% confidence intervals (95% CI), and mean differences (MD). The primary outcome was functional outcome (death or dependency, or death or disability) at the end of the trial.

MAIN RESULTS

We included 33 studies involving 6779 participants.Swallowing therapy: acupuncture, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, physical stimulation (thermal, tactile), transcranial direct current stimulation, and transcranial magnetic stimulation each had no significant effect on case fatality or combined death or dependency. Dysphagia at end-of-trial was reduced by acupuncture (number of studies (t) = 4, numbers of participants (n) = 256; OR 0.24; 95% CI 0.13 to 0.46; P < 0.0001; I(2) = 0%) and behavioural interventions (t = 5; n = 423; OR 0.52; 95% CI 0.30 to 0.88; P = 0.01; I(2) = 22%). Route of feeding: percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding did not differ for case fatality or the composite outcome of death or dependency, but PEG was associated with fewer treatment failures (t = 3; n = 72; OR 0.09; 95% CI 0.01 to 0.51; P = 0.007; I(2) = 0%) and gastrointestinal bleeding (t = 1; n = 321; OR 0.25; 95% CI 0.09 to 0.69; P = 0.007), and higher feed delivery (t = 1; n = 30; MD 22.00; 95% CI 16.15 to 27.85; P < 0.00001) and albumin concentration (t = 3; n = 63; MD 4.92 g/L; 95% CI 0.19 to 9.65; P = 0.04; I(2) = 58%). Although looped NGT versus conventional NGT feeding did not differ for end-of-trial case fatality or death or dependency, feed delivery was higher with looped NGT (t = 1; n = 104; MD 18.00%; 95% CI 6.66 to 29.34; P = 0.002). Timing of feeding: there was no difference for case fatality, or death or dependency, with early feeding as compared to late feeding. Fluid supplementation: there was no difference for case fatality, or death or dependency, with fluid supplementation. Nutritional supplementation: there was no difference for case fatality, or death or dependency, with nutritional supplementation. However, nutritional supplementation was associated with reduced pressure sores (t = 2; n = 4125; OR 0.56; 95% CI 0.32 to 0.96; P = 0.03; I(2) = 0%), and, by definition, increased energy intake (t = 3; n = 174; MD 430.18 kcal/day; 95% CI 141.61 to 718.75; P = 0.003; I(2) = 91%) and protein intake (t = 3; n = 174; MD 17.28 g/day; 95% CI 1.99 to 32.56; P = 0.03; I(2) = 92%).

AUTHORS' CONCLUSIONS

There remains insufficient data on the effect of swallowing therapy, feeding, and nutritional and fluid supplementation on functional outcome and death in dysphagic patients with acute or subacute stroke. Behavioural interventions and acupuncture reduced dysphagia, and pharyngeal electrical stimulation reduced pharyngeal transit time. Compared with NGT feeding, PEG reduced treatment failures and gastrointestinal bleeding, and had higher feed delivery and albumin concentration. Nutritional supplementation was associated with reduced pressure sores, and increased energy and protein intake.

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances

BACKGROUND

A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

OBJECTIVES

To evaluate the effectiveness and safety of PEG as compared to NGT for adults with swallowing disturbances, by updating our previous Cochrane review.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to September 2011, as well as contacting main authors in the subject area. There was no language restriction in the search.

SELECTION CRITERIA

We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment).

DATA COLLECTION AND ANALYSIS

Review authors performed selection, data extraction and evaluation of methodological quality of studies. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%.

MAIN RESULTS

We included nine randomised controlled studies. We did not identify new eligible studies published after our previous review literature search date (August 2009). Intervention failure occurred in 19/156 patients in the PEG group and 63/158 patients in the NGT group (RR 0.24, 95%CI 0.08 to 0.76, P = 0.01) in favour of PEG. There was no statistically significant difference between comparison groups in complications (RR 1.00, 95%CI 0.91 to 1.11, P = 0.93).

AUTHORS' CONCLUSIONS

PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure is more effective and safe as compared to NGT. There is no significant difference of mortality rates between comparison groups, and pneumonia irrespective of underlying disease (medical diagnosis). Future studies should include previously planned and executed follow-up periods, the gastrostomy technique, and the experience of the professionals to allow more detailed subgroup analysis.

Post-PEG feeding time: a web based national survey amongst gastroenterologists

BACKGROUND

Literature suggests early post-percutaneous endoscopic gastrostomy (PEG) feeding is as safe as delayed feeding. No consensus exists regarding feeding initiation after PEG placement. We performed a national survey to assess current practice regarding feeding initiation after PEG placement as well as clinical and practitioner based factors associated with early or delayed feeding.

METHODS

A survey assessing feeding initiation in general ward and intensive care unit patients, current literature knowledge, motility agent use, number of PEG placed per year, along with physician demographics was emailed to 5256 gastroenterologists. Statistical analysis was done using SAS software (V.9).

RESULTS

28% of gastroenterologists responded. Amongst respondents, 59% were private consultants, 25% academic physicians and 16% trainees. Private gastroenterologists initiated feeding earlier (≤12 h) compared to academic gastroenterologists in general ward and intensive care unit patients (p<0.0001). Amongst respondents, 41% of physicians were aware of current literature on post-PEG feeding times. Physicians aware of current literature started feeding earlier (<12h) compared to those not aware in general ward and intensive care unit patients (p=0.0002). Male physicians instituted feeding earlier than females (p<0.0001).

CONCLUSIONS

Feeding initiation after PEG placement varies amongst gastroenterologists. Further studies are required to explore obstacles in standardizing post-PEG feeding practices.

Safety of percutaneous endoscopic gastrostomy in medically complicated infants

BACKGROUND AND OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) tubes have been placed in children for more than 2 decades to provide nutrition to those unable to adequately and safely feed orally. Despite the well-documented success of PEG placement in older children, there is only 1 published article documenting the safety of PEG placement in small infants. In all children, PEG studies demonstrate the major complication rate to vary from 0.5% to 17%. The objective of this study was to evaluate the incidence of acute complications of PEG placement in medically complicated infants with a weight of less than 6 kg.

PATIENTS AND METHODS

: We reviewed the charts of all infants cared for in the neonatal intensive care unit of Wheaton Franciscan Health Care-St Joseph's Regional Hospital, Milwaukee, WI, who received a PEG tube between January 2001 and June 30, 2008.

RESULTS

Forty infants with a mean gestational age of 29 weeks (range 23-41 weeks) with a mean weight of 3250 g (range 2100-5600 g) at time of PEG placement were included. The primary indication for most infants was dysphagia or inability to orally feed safely. A PEG was successfully placed in 38 of 40 (95%) infants. There was 1 major complication: a 38-week infant with Prader-Willi syndrome developed a pneumomediastinum caused by a tear at the upper esophageal sphincter. In a second infant the PEG bumper could not be passed beyond the upper esophageal sphincter. Sixteen infants had other surgical procedures performed at the time of PEG placement. For those infants only having a PEG placed, the mean procedure time was 10 minutes.

CONCLUSIONS

PEG placement is both feasible and safe in small, medically complicated infants.

Outcomes of percutaneous endoscopic gastrostomy in children

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe and minimally invasive surgical method for providing enteral access in children. In pediatrics, the indications for PEG placement frequently include malnutrition or failure to thrive, as well as oropharyngeal dysphagia, especially in children with neurological impairment (NI). The risk for postoperative complications is low. However, among children with NI, gastroesophageal reflux disease (GERD) may necessitate fundoplication prior to gastrostomy tube placement. Preoperative pH probe testing has not been shown to be an effective screening tool prior to PEG placement among patients with GERD. Laparoscopic gastrostomy tube insertion was introduced in pediatric patients in an attempt to decrease complications associated with PEG. Although outcomes were reported to be similar to or better than PEG alone, future comparative studies are needed to better define the optimal patient demographic for this technique.

[Endoscopic percutaneous gastrostomy: an update on the indications, technique and nursing care]

There are numerous conditions and pathologies in which the patient's swallowing ability is diminished or prevented despite having working digestive system. These are the fundamental requirements for the placement of a percutaneous gastrostomy tube (PEG) as a method of choice to provide safe, effective, and prolonged enteral nutrition for the patient at home or when admitted to hospital. Due to its simplicity, safety and low cost, PEG offers several advantages over other feeding techniques, particularly nasogastric tube and parenteral feeding, although it does require simple and accurate knowledge and application of care that ensures low incidence of complications. The placement of a PEG tube should be contemplated in several clinical situations: a) for temporal use in those patients with potentially reversible diseases; b) in non-reversible diseases in which a long survival (of more than 6 months) is foreseeable, and c) in patients affected of terminal and debilitating illnesses in whom a relatively long survival is probable. In these last cases the indication and implementation for PEG should be individualized and agreed jointly. The appropriate training of care professionals and familiar supporters in charge of the patients carrying a PEG tube ensures its continuous functioning and reduces the risk of complications. This paper aims to review the indications and appropriate care for patients carrying a PEG tube and presents the most accurate care that should be provided by both the professional health carers and caregivers.

Open gastrostomy by mini-laparotomy: a comparative study

BACKGROUND

Gastrostomy tube feeding is the best option for long lasting nutritional support in patients with dysphagia caused by obstructive tumours of the mouth, pharynx, larynx and ooesophagus or neuromuscular diseases. However, these severely compromised patients often present severe respiratory risks, precluding the use of general anesthesia, sedation or even endoscopy. A simplified open gastrostomy (SOG) under local anesthesia has been in practice in our institution, especially for patients with severe neuromuscular diseases and continuous non-invasive ventilatory support. In this study, we try to compare the surgical outcomes of this technique, with the classical Stamm gastrostomy (SG).

MATERIAL AND METHODS

This simplified technique uses a minimal vertical midline incision (3 cm), just below the xyphoid process, under local anesthesia. The gastrostomy tube is passed by a left lateral stab wound, inserted in a double purse-string in the gastric wall and pulled to the anterior abdominal wall. No sutures between the stomach and the peritoneum are placed. We retrospectively analyzed the clinical records of 63 consecutive gastrostomies performed upon a 3-year period, 23 of which were by SOG.

RESULTS

The SG was performed mainly in oncological patients, and SOG in patients with neuromuscular diseases (p < 0.001). In the SOG group, 95,4% (n = 22) of the patients were ASA IV, compared with 74,4% (n = 29) in SG (p = 0,03). The mean operative time was shorter in the simplified technique (37 vs 60 min; p = 0,01). All the surgeries in the SOG group were performed exclusively with local anesthesia and in the Stamm procedure, 47,5% required invasive ventilatory support (p < 0.001). There were no significant differences regarding in-hospital morbi-mortality (p = 0,18). The patients were able to receive adequate nutritional support, and the overall satisfaction of the patients and family/caregivers is very good.

CONCLUSION

The simplified mini-laparotomy gastrostomy is a safe and effective alternative to other approaches. The association of local anesthesia with a minimal surgical offense and a short operative time render its effectiveness, even in high-risk patients.

Incidence and predictors of gastrocutaneous fistula in the pediatric patient

Background/Purpose. To determine the incidence, predictors, and outcomes of repair of gastrocutaneous fistulae (GCF) in pediatric patients. Methods. Patients were identified through a medical records search of all gastrostomy insertions performed from 1997–2007. Results. Of 1083 gastrostomies, 49 had GCF closure. Gastrostomy indications were reflux/aspiration (30/43 [70%]) and feeding intolerance/failure to thrive (7/43 [16%]). Gastrostomies were performed as open surgical procedures (84%) with fundoplication (66% of all cases) at an age of 0.5 ± 0.57 (median ± inter-quartile range) years. Gastrostomies were removed in outpatient settings when no longer used and were present for 2.3 ± 2.2 years, and GCF persisted for 2.0 ± 3.0 months. GCF were closed by laparotomy and stapling. GCF closure length of stay was 2.0 ± 3.3 days. Complications occurred in 6/49 patients and included infection/fever (4/6) and localized skin redness/breakdown (2/6). Conclusions. From our collected data, GCFs occur at a frequency of 4.5% and persist for 2.0 ± 3.0 months until closed. Given the complicated medical histories of patients and relatively high rate of postoperative infection/reaction (12.2%), GCF closure is not a benign, “uncomplicated” procedure. Further information describing factors determining which patients develop GCF requiring closure is needed.

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances

BACKGROUND

A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

OBJECTIVES

To evaluate the effectiveness and safety of PEG as compared to NGT for adults with swallowing disturbances.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to August 2009, as well as contacting main authors in the subject area. There was no language restriction in the search.

SELECTION CRITERIA

We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failures (feeding interruption, blocking or leakage of the tube, no adherence to treatment).

DATA COLLECTION AND ANALYSIS

Review authors performed selection, data extraction and evaluation of methodological quality of studies. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I(2) > 50%.

MAIN RESULTS

We included nine randomised controlled studies. Intervention failure occurred in 19/156 patients in the PEG group and 63/158 patients in the NGT group (RR 0.24 (95%CI 0.08 to 0.76, P = 0.01)) in favour of PEG. There was no statistically significant difference between comparison groups in complications (RR 1.00, 95%CI 0.91 to 1.11, P = 0.93).

AUTHORS' CONCLUSIONS

PEG was associated to a lower probability of intervention failure, suggesting the endoscopic procedure is more effective and safe as compared to NGT. There is no significant difference of mortality rates between comparison groups, and pneumonia irrespective of underlying disease (medical diagnosis). Future studies should include previously planned and executed follow-up periods, the gastrostomy technique, and the experience of the professionals to allow more detailed subgroup analysis.

Enteral nutrition access devices

The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, performing a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such situations, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the ASGE Governing Board. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to endoscopy in patients requiring enteral feeding access by using the keywords "endoscopy," "percutaneous," "gastrostomy," "jejunostomy," "nasogastric," "nasoenteric," "nasojejunal," "transnasal," "feeding tube," "enteric," and "button." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Artificial nutrition: principles and practice of enteral feeding

Enteral feeding is a commonly used form of nutritional supplementation for patients with intestinal failure, both in hospitals and in the community. This article concentrates on the basic principles of enteral feeding, including the physiological effects of feeding into the intestinal tract. It covers the indications for enteral feeding, the different methods of supplying enteral feeds to the gastrointestinal tract, and the potential complications. There is also a discussion of the indications for and practice of home enteral nutrition.

Tube feeding in children with chronic kidney disease: technical and practical issues

This review discusses the indications for enteral feeding in children with chronic kidney disease, the types of feeding tubes that can be used, methods of insertion and their benefits and complications.

DPEJ tube placement prevents aspiration pneumonia in high-risk patients

Percutaneous endoscopic gastrostomy (PEG) or PEG tube with transgastric jejunostomy tube (PEG-J) feeding has not been shown to decrease aspiration pneumonia. The aim of this study was to determine if direct percutaneous endoscopic jejunostomy (DPEJ) tube placement results in a decreased incidence of aspiration pneumonia in high-risk patients. The design was a retrospective review of all patients receiving DPEJ tube for aspiration pneumonia from 1999 to 2005. Demographics, incidence of aspiration pneumonia, and outcomes were collected and compared before and after the DPEJ placement. Eleven patients (4 women, 7 men) were identified; their mean age was 44.9 years (range, 18-94 years). The etiologies for recurrent aspiration pneumonia were neurologic disease (9), esophageal surgery (1), and severe debilitation (1). The mean follow-up was 20.9 months (range, 6-48 months). The patients' mean weight increased from 43.8 kg (range, 19-55 kg) to 48.3 kg (range, 30-65 kg) after placement (P < .001). The total number of documented aspiration pneumonia episodes for all patients decreased from 29 (mean, 3.64; range, 1-6) before DPEJ placement to 3 (mean, 0.27; range, 0-2) after DPEJ placement (P < .001). The mean number of aspiration pneumonia events per month prior to the DPEJ placement was 3.39 and postplacement was 0.42 (P < .001). DPEJ placement appears to decrease recurrent aspiration pneumonia in patients with history of aspiration pneumonia.

Laparoscopic gastrostomy: the preferred method of gastrostomy in children

We present a paediatric institutional experience with laparoscopic gastrostomies (LG) and evaluate its appropriateness as the recommended method for gastrostomy placement. We also sought to evaluate the efficacy of a simple technique for LG and collected information on long-term follow-up after LG. LG was performed in 112 children over a 6-year-period. The procedure involves visualization of the stomach through an umbilical port and a second epigastric gastrostomy site to select and anchor the stomach with sutures prior to the placement of a low profile gastrostomy feeding device (LPGD). The follow-up details of the patients were analysed. A review of literature was done to compare LG with percutaneous endoscopic gastrostomy (PEG). The median operating time for the procedure in 112 patients was 48 min. There was one open conversion. Median postoperative length of stay was 6 days. Other complications were vomiting (11%), peri- gastrostomy leak (26%), granulation tissue (42%), accidental dislodgement of the LPGD (4%), faulty device requiring replacement (10%), gastric mucosal prolapse (2%) and localized infection (2%). Follow-up ranged from 6 to 75 months with a cumulative gastrostomy usage of 2,352 months. The advantages of the described technique are virtual feasibility in all patients, primary placement of a LPGD, simplicity with requirement of minimal laparoscopic expertise and safety. Comparison with reports of PEG in the literature indicates that LG should be the preferred method of gastrostomy placement in children.

Clinical experience of percutaneous endoscopic gastrostomy in Taiwanese patients--310 cases in 8 years

Although percutaneous endoscopic gastrostomy (PEG) has become a popular method for long-term tube feeding worldwide, there are only a few reports about its application in Taiwan. From May 1997 to May 2005, we performed 302 PEG insertions successfully in 310 attempts (97.4% success rate) using modified Ponsky's pull method with 24-Fr feeding tubes. All the patients received PEG for tube feeding except for two patients with cancerous peritonitis for decompression. The underlying diseases in these 308 patients who received PEG for tube feeding were 161 cerebrovascular accidents (52.3%), 62 head and neck cancers (20.1%), 21 cases of Parkinsonism (6.8%), and others. There were 11 major complications (3.6%) and 57 minor complications (18.9%). Ten patients (3.3%) died within 30 days after PEG insertion. However, no procedure-related mortality occurred. In conclusion, PEG is an effective method for tube feeding and drainage with a high success rate. PEG insertion was often indicated for patients with dysphagia caused by cerebrovascular accident, head and neck cancer, and Parkinsonism in Taiwan. It is a relatively safe procedure, with a 3.6% rate of major complications and 18.9% rate of minor complications.

Percutaneous endoscopic gastrostomy site metastasis

Metastases to gastrostomy sites are a rare but significant complication of percutaneous endoscopic gastrotomy (PEG) placement in cancer patients. Both direct seeding and hematogenous spread have been suggested as possible mechanisms. This article outlines the incidence, presentation, pathogenesis, and management of PEG-site metastases.

Utility of esophageal gastroduodenoscopy at the time of percutaneous endoscopic gastrostomy in trauma patients

Background

The utility of esophagogastroduodenoscopy (EGD) performed at the time of percutaneous endoscopic gastrostomy (PEG) is unclear. We examined whether EGD at time of PEG yielded clinically useful information important in patient care. We also reviewed the outcome and complication rates of EGD-PEG performed by trauma surgeons.

Methods

Retrospective review of all trauma patients undergoing EGD with PEG at a level I trauma center from 1/01–6/03.

Results

210 patients underwent combined EGD with PEG by the trauma team. A total of 37% of patients had unsuspected upper gastrointestinal lesions seen on EGD. Of these, 35% had traumatic brain injury, 10% suffered multisystem injury, and 47% had spinal cord injury. These included 15 esophageal, 61 gastric, and six duodenal lesions, mucosal or hemorrhagic findings on EGD. This finding led to a change in therapy in 90% of patients; either resumption/continuation of H₂ -blockers or conversion to proton-pump inhibitors. One patient suffered an upper gastrointestinal bleed while on H2-blocker. It was treated endoscopically. Complication rates were low. There were no iatrogenic visceral perforations seen. Three PEGs were inadvertently removed by the patient (1.5%); one was replaced with a Foley, one replaced endoscopically, and one patient underwent gastric repair and open jejunostomy tube. One PEG leak was repaired during exploration for unrelated hemorrhage. Six patients had significant site infections (3%); four treated with local drainage and antibiotics, one requiring operative debridement and later closure, and one with antibiotics alone.

Conclusion

EGD at the time of PEG may add clinically useful data in the management of trauma patients. Only one patient treated with acid suppression therapy for EGD diagnosed lesions suffered delayed gastrointestinal bleeding. Trauma surgeons can perform EGD and PEG with acceptable outcomes and complication rates.

U-Stitch Laparoscopic Gastrostomy Technique Has a Low Rate of Complications and Allows Primary Button Placement: Experience with 461 Pediatric Procedures

BACKGROUND

Gastrostomy tube placement is among the most common gastrointestinal procedures performed in children. The U-stitch laparoscopic technique allows primary button placement and the advantages of laparoscopy. The purpose of this study was to quantify the completion rate and the occurrence of complications in a large single-institution experience.

MATERIALS AND METHODS

All laparoscopic gastrostomy procedures between April 2000 and May 2005 were reviewed. Complications that required operative treatment or hospital readmission were classified as early (<90 days) or late (> or =90 days).

RESULTS

Laparoscopic gastrostomies were created in 461 patients during the study period with primary buttons being placed in 444 (96%). No procedure-related deaths occurred. Early complications included: reoperation secondary to tube dislodgement in 7 patients (1.5%), herniation of omentum postoperatively in 3 patients (0.6%), and development of granulation tissue or everted gastric mucosa requiring excision in 13 patients (3.2%). Late complications occurred in 8 patients (1.7%), with three (0.7%) requiring revision of the gastrostomy due to local site problems. Five patients (1.1%) had intraperitoneal placement of tubes during attempted replacement after 90 days. Age, infancy, and neurological impairment were not associated with a higher rate of complications.

CONCLUSION

The U-stitch gastrostomy technique is safe and allows primary button placement in infants and children. Its complication rate compares favorably to other reported gastrostomy techniques.

[Surgical access routes in enteral nutrition]

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last < or = 6 weeks, nasoenteral tubes are the best option. In NE > or = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 +/- 21.9 days, and 72 double lumen nasojejunal tubes.

Endoscopic placement of enteral feeding catheters

PURPOSE OF REVIEW

Critical to realizing increasing benefits of enteral nutrition are techniques for feeding tube placement. Feeding tubes can be placed by bedside, endoscopic, fluoroscopic, and surgical methods. This review encompasses noteworthy studies on endoscopic approaches to enteral feeding published from January 2005 to the present.

RECENT FINDINGS

Studies involving placement of nasoenteric feeding tubes include description of new methods for endoscopic nasoenteric feeding tube placement using a push technique with a stiffened tube, a modification of the 'drag and pull' method using a distal suture tie, and placement using an ultrathin transnasal endoscopic technique compared with fluoroscopic placement. Recent studies involving percutaneous endoscopic gastrostomy tube placement have demonstrated equivalent outcomes of endoscopic and fluoroscopic approaches, description of unsedated placement using transnasal technique, and risk of percutaneous endoscopic gastrostomy site metastasis in head and neck cancer patients. Studies on percutaneous jejunal feeding tubes demonstrate: high complication rate and short functional duration of percutaneous endoscopic gastrojejunostomy and reported outcomes of direct percutaneous endoscopic jejunostomy placement.

SUMMARY

Enteral nutrition access can be obtained by a variety of methods depending on local expertise and resources. Endoscopic approaches have equivalent or better outcomes than other methods; however, these methods may still have limitations and distinct complications.

Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: a prospective, randomized trial

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has increasingly replaced surgical gastrostomy (SG) as the primary procedure for the long-term nutrition of patients with swallowing disorders. This prospective randomized study compares PEG with SG in terms of effectiveness and safety.

METHODS

This study enrolled 70 patients with swallowing disorders, mainly attributable to neurologic impairment. All the patients, eligible for both techniques, were randomized to PEG (pull method) or SG. The groups were comparable in terms of age, body mass index, and underlying diseases. Complications were reported 7 and 30 days after the operative procedure.

RESULTS

The procedures were successfully completed for all the patients. The median operative time was 15 min for PEG and 35 min for SG (p < 0.001). The rate of complications was lower for PEG (42.9%) than for SG (74.3%; p < 0.01). The 30-day mortality rates were 5.7% for PEG and 14.3% for SG (nonsignificant difference).

CONCLUSION

The findings show PEG to be an efficient method for gastrostomy tube placement with a lower complication rate than SG. In addition, PEG is faster to perform and requires fewer medical resources. The authors consider PEG to be the primary procedure for gastrostomy tube placement.

Enteral access in home care

Enteral nutrition is the delivery of nutrients through the gastrointestinal tract. For those patients who cannot or will not swallow, an enteral access device (EAD) is required. Some of these devices can be passed through the oral or nasal cavity into the stomach or small bowel. Alternatively, the devices can be percutaneously placed by an endoscopist or a radiologist into the stomach or small bowel. Knowledge of the appropriate use of these devices, the appropriate maintenance management of these devices, and the appropriate treatment of EAD-related complications is essential for the clinician to understand in order to provide effective nutrition therapy.

La gastrostomía endoscópica percutánea. Realidad en la práctica nutricional clínica intra y extrahospitalaria

BACKGROUND

This study aimed to review our experience during 8 years in the use of percutaneous endoscopic gastrostomy (PEG) and its application in home enteral nutrition (HEN).

MATERIAL

We studied 207 patients (56 women and 151 men) who had undergone a PEG from the beginning of 1994 to the end of 2002 as they needed prolonged enteral nutrition (> 4 weeks). In those cases in which home enteral nutrition was programmed, the patients/relatives were trained in the techniques and care of the PEG and EN, and the control was done through the nutrition out-patient clinic.

RESULTS

Mean duration time of the PEG was 640 days and 175 patients (84.6%) needed PEG for more than 60 days and 135 for more than 6 months. Mean calorie supply was 1,730 +/- 288 Kcal/day. Administration mode was by intermittent infusion due to seriousness in 162 cases and continuous infusion through volemetric pump in 45 patients. In 2 patients with hyperemesis gravidarum, percutaneous endoscopic gastrojejunostomy (PEGJ) was done in the 3rd and 4th month of pregnancy, the pregnancy finishing successfully by vaginal delivery. Performance of PEG facilitated hospital discharge and programming of home enteral nutrition in 195 patients (94%). The most frequent complications were gastrostomy infection that occurred in 41 patients and the appearance of granuloma in the ostomy in 34 cases. Only one patient died in direct relationship due to peritonitis after PEG.

CONCLUSION

Our study includes the advantages of PEG as an enteral nutrition technique, permitting the establishment of a home enteral nutrition program with limited incidence of complications and very low mortality.

Predictors of survival after severe dysphagic stroke

BACKGROUND AND PURPOSE

Dysphagia is estimated to occur in up to 50% of the stroke neurorehabilitation population. Those patients with severe neurogenic oropharyngeal dysphagia (NOD) may receive feeding gastrostomy tubes (FGT) if noninvasive therapies prove ineffective in eliminating aspiration or sustaining adequate nutritional intake. Our aim was to quantify the recovery of swallowing function, and to identify variables predictive of survival after dysphagic stroke requiring FGT placement.

METHODS

We identified consecutive stroke patients with severe dysphagic stroke requiring FGT placement admitted to a rehabilitation hospital between May 1998 and October 2001. The medical records were reviewed, and demographic, clinical, videofluoroscopic (VSS) and neuroimaging information were abstracted. A follow-up telephone interview was performed to determine whether the FGT was still in use, had been removed,or if the patient had died. State death certificate records were reviewed to ascertain date of death for subjects who had expired by the time of follow-up. Univariate and multivariate analyses were performed.

RESULTS

11.6 % (77/664) of stroke patients admitted during the study period had severe dysphagic stroke with FGT insertion. Follow-up was available for 66 (85.7 %) of these individuals at a mean of two years after acute stroke. On follow-up 64% (42/66) of the patients were alive and 45 % had had the FGT removed and resumed oral diets. On univariate analysis patients who were alive at the time of follow-up had received FGT feeding for a shorter period of time (p < 0.0003), showed no signs of aspiration on the Clinical Assessment of Feeding & Swallowing (CAFS,p < 0.020) and on the Videofluoroscopic Swallowing Study (VSS, 0.001), had a better discharge FIM-Score (Functional Independence Measure) for eating (p < 0.0002) and cognitive function (p < 0.002) as well as better discharge FCM-Score (Functional Communication Measure) for swallowing (p < 0.0001). On multivariate analysis we developed a model consisting of FGT removal at discharge from the rehabilitation hospital (p < 0.011) and non-aspiration during VSS (p < 0.040) that was significantly associated with longer survival time during follow-up.

CONCLUSIONS

Severe dysphagia requiring FGT is common in patients with stroke referred for neurorehabilitation. Patients who had a FGT in place at the time of discharge from the stroke rehabilitation unit or aspirated during VSS were substantially more likely to have died by the time of follow-up compared to those who had had the FGT removed and had no signs of aspiration on VSS. However functional outcome measurements (FIM, FCM) including the cognitive function (attention, concentration etc.) could play an important role for prediction of swallowing regeneration and survival in neurorehabilitation. These findings may have practical utility in guiding physicians and speech language pathologists when advising patients and families about prognosis in stroke survivors with severe dysphagia.

PEGs and Ethics Revisited

Percutaneous endoscopic gastrostomy is an accepted technique for long-term enteral feeding. The demand of percutaneous endoscopic gastrostomy placement continues to increase because of the increasing numbers of vulnerable patients with chronic diseases coupled with the relative ease of insertion, and societal ambivalence about such treatment. Despite the demand and improvements in placement technique, the issue of tube feeding in vulnerable patients remains an ethical minefield, leading to considerable discussion and debate. This contentious area of clinical ethics is further complicated by the recent papal allocution regarding artificial nutrition and hydration. The case of Terri Schiavo should serve as a timely reminder of those problematic clinical and ethical issues inherent in percutaneous endoscopic gastrostomy placement and feeding in vulnerable patients.

Percutaneous Endoscopic Gastrostomy in ICU Patients with Previous Laparotomy

To our knowledge, there is an absence of data evaluating the safety and efficacy of percutaneous endoscopic gastrostomy (PEG) placement in ICU patients with previous abdominal surgery. Our goals were to determine the complication rate of PEG in ICU patients who either had a recent or prior laparotomy compared to patients without any prior abdominal surgery. Prospective data was collected on 42 consecutive patients with prior abdominal surgery who underwent PEG placement in a university ICU setting during a 3-year period. These patients were further stratified by time of previous abdominal surgery: recent = abdominal surgery during the current hospitalization; old = abdominal surgery done prior to the current hospitalization and >30 days. Complications were defined as technical problems, local infection, tube dislodgment, and bleeding. This data was compared to results of 75 consecutive PEG placements in ICU patients with no previous abdominal surgery (NPAS) at the same institution. A total of 117 patients were included in the study. Sixty-two (58%) of the patients were trauma patients and 45 (42%) had other pathology. The mean age of the study population was 53 ± 15 years and they were primarily male (75%). The overall complication rates were as follows: local wound = 18.7 per cent, technical problems = 4 per cent, PEG dislodgment = 7.4 per cent, and bleeding = 3 per cent. Of the 42 patients with prior abdominal surgery, 22 were recent, and 20 were old. Local wound complications were the most common complication when stratified by PEG category (virgin = 17.3%, recent = 18%, and old = 15%) followed by dislodgment (virgin = 6.7%, recent = 9%, and old = 5%). There were no significant differences in complication rates when comparing specific complications by PEG category as analyzed by χ2 analysis. PEG should be considered in all patients with previous laparotomy in need for long-term enteral access.