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Survival outcomes of percutaneous endoscopic gastrostomy, comparison of cerebrovascular event and non-cerebrovascular event in malnourished patients. JOURNAL OF SURGERY AND MEDICINE 2019. [DOI: 10.28982/josam.581155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Predictive factors of early mortality after percutaneous endoscopic gastrostomy placement: The importance of C-reactive protein. Clin Nutr ESPEN 2016; 14:19-23. [PMID: 28531394 DOI: 10.1016/j.clnesp.2016.04.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/09/2016] [Accepted: 04/23/2016] [Indexed: 01/28/2023]
Abstract
INTRODUCTION AND AIMS Percutaneous endoscopic gastrostomy (PEG) is considered one of the preferred routes for long-term enteral feeding. However, early mortality after PEG placement is high. We aimed at analyzing overall and early mortality in patients who underwent PEG insertion and at identifying risk factors of increased mortality after the procedure. METHODS Retrospective study which included patients who had a PEG insertion at our department between May 2007 and January 2013. Variables analyzed: demographic, Charlson's co-morbidity index, past aspiration pneumonia, indication for PEG, hemogram, ionogram, urea, creatinine, albumin and C-reactive protein (CRP). OUTCOME death. Kaplan-Meier survival analysis was used to calculate mortality after PEG placement. Predictive factors of overall mortality were identified by univariate and multivariate analysis and of 30-day, 90-day and 180-day mortality by logistic regression. The AUROC analysis for CRP levels was performed. RESULTS Inclusion of 135 patients: 51.9% female, mean age of 73 ± 17 years, 90.4% with neurological dysphagia and 9.6% with tumors compromising oral intake. The median survival time was 272 days. The 30-day, 90-day and 180-day mortality was 0.14 ± 0.06 (95% CI 0.08-0.20), 0.29 ± 0.08 (95% CI 0.21-0.37) and 0.43 ± 0.08 (95% CI 0.35-0.51), respectively. Patients with higher levels CPR (hazard ratio (HR) 1.009 95% CI 1.002-1.160, p = 0.012) and higher levels of urea (HR 1.009 95% CI 1.002-1.160, p = 0.012) had worse outcome and those with higher sodium levels (HR 0.945 95% CI 0.908-0.983, p = 0.005) had better prognosis. Higher CRP levels was the only independent predictive factor for 30-day mortality (odds ratio (OR) 1.008 95% CI 1.001-1.014, p = 0.029), and was also a risk factor for 90-day and 180-day mortality (OR 1.013 95% CI 1.005-1.021, p = 0.002 and OR 1.009 95% CI 1.001-1.018, p = 0.026, respectively). CRP levels ≥35.9 mg/dL could predict death at 30 days with a sensitivity of 0.810 and a specificity of 0.614. CONCLUSIONS The early mortality after PEG placement is high. CRP, an indicator of acute illness, is a useful parameter at identifying patients with increased probability of dying after PEG insertion. High CRP levels should be considered in the decision making process.
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Holt DQ, McDonald JF, Murray ML, Hair C, Devonshire DA, Strauss BJ, Moore GT. Clinical selection criteria can predict futile intervention in patients referred for percutaneous endoscopic gastrostomy insertion. Intern Med J 2015; 45:648-52. [DOI: 10.1111/imj.12705] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/28/2015] [Indexed: 01/12/2023]
Affiliation(s)
- D. Q. Holt
- Gastroenterology and Hepatology Unit; Monash Health; Melbourne Australia
- Clinical Nutrition and Metabolism Unit; Monash Health; Melbourne Australia
- Department of Medicine, School of Clinical Sciences; Monash University; Melbourne Australia
| | - J. F. McDonald
- Clinical Nutrition and Metabolism Unit; Monash Health; Melbourne Australia
- PEG Outreach Service; Monash Health; Melbourne Australia
| | - M. L. Murray
- Clinical Nutrition and Metabolism Unit; Monash Health; Melbourne Australia
- PEG Outreach Service; Monash Health; Melbourne Australia
| | - C. Hair
- School of Medicine; Deakin University; Geelong Victoria Australia
| | - D. A. Devonshire
- Gastroenterology and Hepatology Unit; Monash Health; Melbourne Australia
| | - B. J. Strauss
- Clinical Nutrition and Metabolism Unit; Monash Health; Melbourne Australia
- Department of Medicine, School of Clinical Sciences; Monash University; Melbourne Australia
| | - G. T. Moore
- Gastroenterology and Hepatology Unit; Monash Health; Melbourne Australia
- Department of Medicine, School of Clinical Sciences; Monash University; Melbourne Australia
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Udd M, Lindström O, Mustonen H, Bäck L, Halttunen J, Kylänpää L. Assessment of indications for percutaneous endoscopic gastrostomy--development of a predictive model. Scand J Gastroenterol 2015; 50:245-52. [PMID: 25540954 DOI: 10.3109/00365521.2014.927914] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Percutaneous endoscopic gastrostomy (PEG) is used for long-term enteral nutrition in neurological patients with dysphagia (NEUR), in head and neck cancer patients prior to chemoradiation therapy (head and neck malignancy group [HNM]), or in cases of oropharyngeal or esophageal tumor obstruction or stricture (OBSTR). Considerable morbidity and overall mortality is reported. Aim was to analyze the complication rates and mortality with PEG and to identify subgroups with poor outcomes. MATERIAL AND METHODS Patients underwent PEG (n = 401) in a single tertiary care center. Indications, characteristics, and causes of death were recorded. RESULTS Number of patients in groups: HNM 135 (34%), OBSTR 74 (18%), and NEUR 192 (48%); follow-up time median (interquartile range): 17 (39) months; the time PEG used for feeding: 4 (7) months. A total of 91 patients (23%) had 110 complications, 31 patients (8%) had early (≤30 days) complications, and 49 patients (12%) major complications. Two deaths (0.5%, 2 peritonitis) were related to PEG. The 30-day mortality was 11% (n = 47). According to multivariate analysis, an increased 30-day mortality was associated with ≥75 years of age, American Society of Anesthesiologists (ASA) class IV, a Charlson comorbidity index (CCI) ≥4, body mass index (BMI) <18.5, and ongoing antibiotic therapy. With this model, 95% specificity was obtained in the 30-day survival figures. CONCLUSION The presented predictive model derived from our analysis may recognize patients with poor outcome when referred for PEG. The parameters in the present model (age, ASA class, CCI score, BMI, and data of ongoing antibiotic treatment) are easily measurable, and it is possible to integrate them into everyday work.
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Affiliation(s)
- Marianne Udd
- Department of Gastroenterological and General Surgery, Unit of Therapeutic Endoscopy, Helsinki University Central Hospital and Helsinki University , Helsinki , Finland
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Chang WK, Hsieh TY. Safety of percutaneous endoscopic gastrostomy in high-risk patients. J Gastroenterol Hepatol 2013; 28 Suppl 4:118-22. [PMID: 24251717 DOI: 10.1111/jgh.12300] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2013] [Indexed: 12/21/2022]
Abstract
Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure. However, failure to transilluminate the anterior wall of the stomach or visualize the indentation of the physician's finger represents the most frequent obstacles encountered by the endoscopist in safely completing PEG tube placement. We described several methods to safely assess PEG placement in high-risk patients. An abdominal plain film after gastric insufflated with 500 mL of air is obtained before PEG in patients. The body of the stomach near the angularis, equidistant from the greater and lesser curves, was defined as the optimal gastric puncture point. The location of the puncture points varied greatly, being situated over the right upper quadrant in 31% of patients, left upper in 59%, left lower in 5%, and right lower quadrant in 5% of patients. If there is any question of safe puncture site selection, safe track technique can be used to provide the information of depth and angle of the puncture tract. Computed tomography can provide detailed anatomy and orientation along the PEG tube and show detailed anatomical images along the PEG tract. Computed tomography-guided PEG tube placement is used when there is difficulty either insufflating the stomach, or the patients had previous surgery, or anatomical problems. Full assessment of the position of the stomach and adjacent organs prior to gastric puncture may help minimize the risk for potential complications and provide safety for the high-risk patients.
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Affiliation(s)
- Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure performed to maintain nutrition in the short- or long-term. During the procedure, a feeding tube that delivers either a liquid diet, or medication, via a clean or sterile delivery system, is placed surgically through the anterior abdominal wall. Those undergoing PEG tube placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression, or underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and to the debate surrounding antibiotic prophylaxis for PEG tube placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient's serum and tissues, via a brief course of an appropriate agent, by the time of PEG tube placement in order to prevent any peristomal infections that might result from the procedure. OBJECTIVES To establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomy tubes. SEARCH METHODS In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid Medline; Ovid Medline (In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials during PEG tube placement, with no restrictions regarding language of publication, date of publication, or publication status. Both review authors independently selected studies. DATA COLLECTION AND ANALYSIS Both review authors independently extracted data and assessed study quality. Meta-analyses were performed where appropriate. MAIN RESULTS One new trial was identified and included in this update, bringing the total to 13 eligible RCTs, with a total of 1637 patients. All trials reported peristomal infection as an outcome. A pooled analysis of 12 trials resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (1271 patients pooled: OR 0.36, 95% CI 0.26 to 0.50). The newly identified trial compared IV antibiotics with antibiotics via PEG and could not be included in the meta-analysis. AUTHORS' CONCLUSIONS Administration of systemic prophylactic antibiotics for PEG tube placement reduces peristomal infection.
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Affiliation(s)
- Allyson Lipp
- Department of Care Sciences, University of South WalesFaculty of Health, Sport and ScienceGlyn Taff CampusPontypriddUKCF37 1DL
| | - Gail Lusardi
- Department of Care Sciences, University of South WalesFaculty of Health, Sport and ScienceGlyn Taff CampusPontypriddUKCF37 1DL
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Keung EZ, Liu X, Nuzhad A, Rabinowits G, Patel V. In-hospital and long-term outcomes after percutaneous endoscopic gastrostomy in patients with malignancy. J Am Coll Surg 2012; 215:777-86. [PMID: 22999329 DOI: 10.1016/j.jamcollsurg.2012.08.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/15/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although percutaneous endoscopic gastrostomy (PEG) is widely performed for nutrition or palliation, PEG-associated outcomes in cancer patients remain poorly described. We examined the safety and benefits of PEG placement in this population at our institution. STUDY DESIGN A 5-year retrospective review of patients with malignancy (excluding head/neck and thoracic malignancy) who underwent PEG at our institution was performed. RESULTS One hundred and eighty-nine patients with malignancy underwent PEG; 33.9% had hematologic malignancy, 66.1% had nonhematologic malignancy, and 44.4% had metastatic disease. Indications for PEG were enteral access (73%) and gastric decompression/management of obstructive symptoms (27%). Few patients achieved independence from total parenteral nutrition (22%) or diet advancement (24.6%). Overall rates of major complications (eg, aspiration, tube dislodgement/leakage, bleeding, visceral injury, respiratory failure after procedure, and cardiac arrest) and minor complications (eg, superficial infection and ileus) were 10.2% and 11.3%, respectively. All-cause in-hospital mortality was high (19.6%) and was associated with ICU admission (p = 0.018), earlier bone marrow transplantation (p = 0.022), steroid treatment (p = 0.024), and lower preoperative albumin (p = 0.003). Code status was changed after PEG in 44 patients from full code to DNR/do no intubate or comfort measures only. CONCLUSIONS Percutaneous endoscopic gastrostomy placement in this study population was associated with major procedure-related complications. The majority of patients failed to achieve total parenteral nutrition independence or advancement of diet. Nearly 25% of patients declined aggressive resuscitation strategies after undergoing surgery for PEG. This study cautions to carefully weigh the risks and benefits of PEG placement in this patient population. Prospective studies are needed to uncover factors affecting the decision process and patient selection.
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Affiliation(s)
- Emily Z Keung
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Chang WK, Huang WC, Yu CY, Hsieh TY. Long-term percutaneous endoscopic gastrostomy: characteristic computed tomographic findings. ACTA ACUST UNITED AC 2012; 36:684-8. [PMID: 21203756 DOI: 10.1007/s00261-010-9678-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patients with a long-term PEG may suffer from complications and received physical and endoscopic examinations. However, these examinations do not provide information between skin and stomach. We present the findings of computed tomography (CT) for patients with long-term percutaneous endoscopic gastrostomy (PEG). After 1 year PEG (183 patients), 57 patients had received CT examinations. Skin indentation, soft-tissue thickening, peritoneal gap, internal bumper migration, and clinical abnormalities detected by CT examination were recorded. Thickness of subcutaneous fat, muscle, and abdominal wall along the tract were measured. The same parameters at 3 cm away from the tract were obtained for comparison. CT demonstrated that 28 (49.1%) patients present soft-tissue thickening, 19 (33.3%) patients present skin indentation, and 24 (42.1%) patients present a peritoneal gap. One patient with internal bumper migration, 3 patients had buried bumper syndrome, 2 patients had gastric herniation, and 1 patient had esophageal cancer metastasizes to the PEG site. Thickness of subcutaneous fat, muscle, and abdominal wall decreased significant. CT can provide detailed anatomy and orientation along the PEG tube. Familiarity of the CT appearance can minimize potential complications before PEG tube replacement.
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Affiliation(s)
- Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Chengong Rd., Sec. 2, Neihu, Taipei 114, Taiwan, ROC.
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Malmgren A, Hede GW, Karlström B, Cederholm T, Lundquist P, Wirén M, Faxén-Irving G. Indications for percutaneous endoscopic gastrostomy and survival in old adults. Food Nutr Res 2011; 55:6037. [PMID: 21799666 PMCID: PMC3144742 DOI: 10.3402/fnr.v55i0.6037] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 06/13/2011] [Accepted: 06/23/2011] [Indexed: 11/30/2022] Open
Abstract
Background Many diseases striking old adults result in eating difficulties. Indications for selecting individuals for percutaneous endoscopic gastrostomy (PEG) are unclear and everybody may not benefit from the procedure. Objective The aim of this study was to evaluate indications for and survival after PEG insertion in patients older than 65 years. Design and Methods A retrospective analysis including age, gender, diagnosis, indication, and date of death was made in 201 consecutive individuals, 94 male, mean age 79±7 years, who received a nutritional gastrostomy. Results Dysphagia was present in 86% of the patients and stroke was the most common diagnosis (49%). Overall median survival was 123 days and 30-day mortality was 22%. Patients with dementia and Mb Parkinson had the longest survival (i.e. 244 and 233 days), while those with other neurological diseases, and head and neck malignancy had the shortest (i.e. 75 and 106 days). There was no difference in mortality in patients older or younger than 80 years, except in patients with dementia. Conclusions Old age should not be a contraindication for PEG. A high 30-day mortality indicates that there is a need of better criteria for selection and timing of PEG insertion in the elderly.
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Affiliation(s)
- Anna Malmgren
- Department of Surgical and Medical Gastroenterology and Hepatology, Karolinska University Hospital, Stockholm, Sweden
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Rio A, Ellis C, Shaw C, Willey E, Ampong MA, Wijesekera L, Rittman T, Nigel Leigh P, Sidhu PS, Al-Chalabi A. Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease. J Hum Nutr Diet 2010; 23:408-15. [PMID: 20487174 DOI: 10.1111/j.1365-277x.2010.01057.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Motor neurone disease (MND) is a progressive neurodegenerative disease leading to limb weakness, wasting and respiratory failure. Prolonged poor nutritional intake causes fatigue, weight loss and malnutrition. Consequently, disease progression requires decisions to be made regarding enteral tube feeding. The present study aimed to investigate the survival, nutritional status and complications in patients with MND treated with enteral tube feeding. METHODS A retrospective case note review was performed to identify patients diagnosed with MND who were treated with enteral tube feeding. A total of 159 consecutive cases were identified suitable for analysis. Patients were treated with percutaneous endoscopic gastrostomy (PEG), radiologically inserted gastrostomy (RIG) or nasogastric feeding tube (NGT). Nutritional status was assessed by body mass index (BMI) and % weight loss (% WL). Serious complications arising from tube insertion and prescribed daily energy intake were both recorded. RESULTS Median survival from disease onset was 842 days [interquartile range (IQR) 573-1263]. Median time from disease onset to feeding tube was PEG 521 days (IQR 443-1032), RIG 633 days (IQR 496-1039) and NGT 427 days (IQR 77-781) (P = 0.28). Median survival from tube placement was PEG 200 (IQR 106-546) days, RIG 216 (IQR 83-383) days and NGT 28 (IQR 14-107) days. Survival between gastrostomy and NGT treated patients was significant (P < or = 0.001). Analysis of serious complications by nutritional status was BMI (P = 0.347) and % WL (P = 0.489). CONCLUSIONS Nutritional factors associated with reduced survival were weight loss, malnutrition and severe dysphagia. Serious complications were not related to nutritional status but to method of tube insertion. There was no difference in survival between PEG and RIG treated patients.
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Affiliation(s)
- A Rio
- Department of Nutrition & Dietetics, King's College Hospital, London SE5 9RS, UK.
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Ney DM, Weiss JM, Kind AJH, Robbins J. Senescent swallowing: impact, strategies, and interventions. Nutr Clin Pract 2009; 24:395-413. [PMID: 19483069 DOI: 10.1177/0884533609332005] [Citation(s) in RCA: 218] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.
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Affiliation(s)
- Denise M Ney
- University of Wisconsin, Department of Nutritional Sciences, and the William S. Middleton Memorial VA Hospital GRECC, 2500 Overlook Terrace, GRECC 11G, Madison, WI 53705, USA
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Abstract
AIM To establish whether prophylactic systemic antimicrobials reduce the risk of peristomal infection in placement of percutaneous endoscopic gastrostomies. BACKGROUND Percutaneous endoscopic gastrostomies, placed surgically through the anterior abdominal wall, maintain nutrition in the short or long term. Those undergoing percutaneous endoscopic gastrostomy placement are often vulnerable to infection. The increasing incidence of methicillin-resistant Staphylococcus aureus contributes an additional risk to the debate surrounding antibiotic prophylaxis. The aim of antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient, during placement. DESIGN Systematic review. METHODS We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals, relevant conference proceedings and bibliographies of publications identified, and contacted manufacturers and distributors of percutaneous endoscopic gastrostomy products. Randomised controlled trials were selected evaluating the use of prophylactic antimicrobials for percutaneous endoscopic gastrostomy placement, with no restrictions for language, date or publication status. Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate. RESULTS Ten eligible randomised controlled trials were identified evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22-0.44). The relative reduction in risk of infection for those given antibiotics was 19% with the need to treat 5.8 patients to prevent one infection - NNT. CONCLUSIONS Administration of systemic prophylactic antibiotics for percutaneous endoscopic gastrostomy placement reduces peristomal infection. RELEVANCE TO CLINICAL PRACTICE The nurse's role in endoscopy is expanding rapidly and demands that practice is based on the best available evidence. This systematic review seeks to make a contribution to best practice in percutaneous endoscopic gastrostomy placement.
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Affiliation(s)
- Allyson Lipp
- Faculty of Health, Sport and Science, University of Glamorgan, Pontypridd, UK.
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McClave SA, Delegge MH. Predicting life expectancy before percutaneous endoscopic gastrostomy placement: a lesson in futility or an exercise of injustice? Gastrointest Endosc 2008; 68:228-30; quiz 333, 335. [PMID: 18656594 DOI: 10.1016/j.gie.2008.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Accepted: 01/03/2008] [Indexed: 02/08/2023]
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Johnston SD, Tham TCK, Mason M. Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death. Gastrointest Endosc 2008; 68:223-7. [PMID: 18329030 DOI: 10.1016/j.gie.2007.10.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Accepted: 10/02/2007] [Indexed: 01/27/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is an accepted method of placing a feeding tube to enable enteral feeding in patients with swallowing difficulties. However, the factors associated with complications and death after PEG have not been studied in detail. We describe the largest audit of deaths after PEG tube insertion. OBJECTIVE Our purpose was to determine the factors associated with death after PEG tube insertion. DESIGN Deaths occurring within 30 days after PEG tube insertion in the United Kingdom between April 2002 and March 2003 were identified and a questionnaire was sent to the consultant endoscopist for completion. PATIENTS A total of 719 patients (391 male, median age 80 years, range 26-98 years) who died within 30 days after PEG insertion were identified for this study. SETTING United Kingdom hospitals. MAIN OUTCOME MEASUREMENT Cause of death. RESULTS A total of 97% of the identified patients had coexistent neurologic disease. PEG tubes were inserted by specialized GI physicians in 522 cases (73%). Seventy-two patients (10%) required reversal agents after sedation. After PEG tube insertion, 309 patients (43%) died within 1 week. Death was due to cardiovascular disease (n = 175), respiratory disease (n = 508), central nervous system disease (n = 358), renal disease (n = 38), and hepatic failure (n = 11). In 136 cases (19%) the National Confidential Enquiry into Patient Outcome and Death expert panel regarded the procedure as futile. LIMITATIONS Retrospective review of case records. CONCLUSIONS Mortality and morbidity rates after PEG tube insertion are not insignificant. Selection of patients is paramount to good patient outcomes. Multidisciplinary team assessment should be performed on all patients being referred for PEG tube insertion.
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Affiliation(s)
- Simon D Johnston
- Department of Gastroenterology, Belfast City Hospital, Northern Ireland
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McGrath P, Henderson D. Resolving End-of-Life Ethical Concerns: Important Palliative Care Practice Development Issues for Acute Medicine in Australia. Am J Hosp Palliat Care 2008; 25:215-22. [DOI: 10.1177/1049909108315514] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Historically palliative care research has focused on issues associated within the hospice and palliative care system. The findings presented in this manuscript reverse this assumption to argue that significant palliative care issues can only be understood if the focus is on the acute care system. Although a major proportion of deaths happen in the acute hospital setting, the acute care clinicians are the gate keepers to the palliative system. In short, understanding the ethical decision making of acute care professionals in relation to end-of-life care can illuminate many important palliative care practice development issues. The findings indicate that all professional groups in this study of an acute medical ward find end-of-life issues the most challenging of all the ethical challenges.
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Affiliation(s)
- Pam McGrath
- International Program of Psycho-Social Health Research, Central Queensland University, Brisbane, Kenmore,
| | - David Henderson
- Division of Medicine, Redland Hospital, Brisbane Queensland, Australia
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Brotherton AM, Carter B. Percutaneous endoscopic gastrostomy feeding in nursing homes: relatives' perceptions. Clin Nurs Res 2008; 16:350-69. [PMID: 17991913 DOI: 10.1177/1054773807306551] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study is to explore the experiences of relatives of nursing home residents receiving percutaneous endoscopic gastrostomy feeding. Qualitative methodology using semistructured interviews explores the experiences and perceptions of eight relatives. Data are analyzed using thematic analysis. Four themes are constructed from the data: dependence and resulting disempowerment, having minimal or no involvement in the decision-making process for PEG placement, betrayal, and the losses associated with the social aspects of eating. There is a need for professional education about the psychosocial implications of feeding and an increased level of support for relatives to assist them to develop coping strategies. This will require an expansion of current professional roles to include assessment of individual need, setting of appropriate goals, and the coordination of the provision of multiagency services, likely to include counseling and social support. Further research is required in this field to inform service developments.
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Chang WK, McClave SA, Yu CY, Huang HH, Chao YC. Positioning a safe gastric puncture point before percutaneous endoscopic gastrostomy. Int J Clin Pract 2007; 61:1121-5. [PMID: 17343669 DOI: 10.1111/j.1742-1241.2006.01106.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
To position a safe gastric puncture point prior to the percutaneous endoscopic gastrostomy (PEG) a technique using an abdominal plain film with a gastric insufflation was assessed. After insufflated with 500 ml of air, an abdominal plain film was obtained before PEG in 84 patients. The body of the stomach near the angularis, equidistant from the greater and lesser curves, was defined as the optimal gastric puncture point. The location of the puncture points varied greatly, being situated over the right upper quadrant in 31% of patients, left upper in 59%, right lower in 5% and left lower quadrant in 5% of patients. The marked puncture points on abdominal film in some patients were shown to be partially covered by colon or small bowel loop, lie high under the costal margin, or low beneath the umbilicus. An abdominal plain film utilising a gastric insufflation technique prior to PEG may help to determine optimal gastric puncture site selection. Use this technique in clinical practice might hasten procedural time, provide better assurance to the clinical doctor, and provide an added margin of safety for the patient.
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Affiliation(s)
- W-K Chang
- Division of Gastroenterology, Department of Internal MedicineTri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Abstract
BACKGROUND Percutaneous endoscopic gastrostomies (PEG) maintain nutrition in the short or long term. A PEG is a feeding tube, placed surgically through the anterior abdominal wall, which delivers a liquid diet, or medication, via a clean or sterile delivery system. Those undergoing PEG placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression and underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and also to the debate surrounding antibiotic prophylaxis for PEG placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patients serum and tissues, via a brief course of an appropriate agent, by the time of PEG placement. OBJECTIVES The review seeks to establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomies. SEARCH STRATEGY We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals relevant conference proceedings, and bibliographies of relevant publications identified by these strategies for further studies; and contacted manufacturers and distributors of PEG products. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials for PEG placement, with no restrictions for language, date or publication status. DATA COLLECTION AND ANALYSIS Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate. MAIN RESULTS We identified 10 eligible RCTs evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome, and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22 to 0.44). AUTHORS' CONCLUSIONS Administration of systemic prophylactic antibiotics for PEG placement reduces peristomal infection.
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Affiliation(s)
- A Lipp
- University of Glamorgan, School of Care Sciences, Glyntaff, Pontypridd, UK.
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Brotherton A, Abbott J, Aggett P. The impact of percutaneous endoscopic gastrostomy feeding upon daily life in adults. J Hum Nutr Diet 2006; 19:355-67. [PMID: 16961682 DOI: 10.1111/j.1365-277x.2006.00712.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The provision of home enteral tube feeding in adults has increased in the UK. This study explored how percutaneous endoscopic gastrostomy (PEG) feeding impacts on daily lives of adult patients, from the patients' and carers' perspectives. METHODS A semi-structured interview approach was developed to obtain participants' views of the impact of living with a PEG. A cross-sectional qualitative purposive sampling design was employed. Thirty-four semi-structured interviews were conducted (15 adult patients and 19 carers) and data were analysed descriptively and thematically. RESULTS Difficulties arising from PEG feeding included vomiting, diarrhoea, infection of the PEG site and leakage. The key issues that emerged included relief of pressure to consume an oral diet, disturbed sleep, restricted ability to go out, restricted choice of clothing, difficulties finding a place to feed, missing being able to eat and drink, social occasions, negative attitudes of others towards feeding and the burden placed on family members. CONCLUSIONS The key themes that emerged from participants were diverse and highlight a need for increased social support for both patients and their carers, planned on an individual basis.
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Affiliation(s)
- A Brotherton
- Faculty of Health, University of Central Lancashire, Preston, Lancashire, UK.
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Coletti D, Genuit T, Ord R, Engroff S. Metastasis to the percutaneous endoscopic gastrostomy site in the patient with head and neck cancer: a case report and review of the literature. J Oral Maxillofac Surg 2006; 64:1149-57. [PMID: 16781352 DOI: 10.1016/j.joms.2006.03.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Domenick Coletti
- Department of Oral and Maxillofacial Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Ljungdahl M, Sundbom M. Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: a prospective, randomized trial. Surg Endosc 2006; 20:1248-51. [PMID: 16865614 DOI: 10.1007/s00464-005-0757-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Accepted: 04/02/2006] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- M Ljungdahl
- Department of Surgery, University Hospital, Uppsala, Sweden.
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Volkert D, Berner YN, Berry E, Cederholm T, Coti Bertrand P, Milne A, Palmblad J, Schneider S, Sobotka L, Stanga Z, Lenzen-Grossimlinghaus R, Krys U, Pirlich M, Herbst B, Schütz T, Schröer W, Weinrebe W, Ockenga J, Lochs H. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr 2006; 25:330-60. [PMID: 16735082 DOI: 10.1016/j.clnu.2006.01.012] [Citation(s) in RCA: 384] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Accepted: 01/19/2006] [Indexed: 12/16/2022]
Abstract
Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.
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Affiliation(s)
- D Volkert
- Head Medical Science Division, Pfrimmer-Nutricia, Erlangen, Germany.
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Gencosmanoglu R. Percutaneous endoscopic gastrostomy: a safe and effective bridge for enteral nutrition in neurological or non-neurological conditions. Neurocrit Care 2006; 1:309-17. [PMID: 16174928 DOI: 10.1385/ncc:1:3:309] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly used methods for nutritional support in patients who are unable to take food orally. Traditional surgical gastrostomy, percutaneous radiologic gastrostomy, and laparoscopic gastrostomy are the alternatives. The most common indication is neurogenic dysphagia followed by obstructive causes such as head and neck tumors. Ethically justified and clinically comprehensive guidelines should be followed during the decision-making process for PEG tube placement. A limited life expectancy; technical difficulties, such as the inability to bring the anterior gastric wall in apposition to the abdominal wall; or pharyngeal/esophageal obstruction, which compromise tube insertion, peritonitis, and uncorrectable coagulopathy are absolute contraindications. The "pull method" is the first described and still the most performed technique of PEG tube placement. The procedure is simple, safe, and effective and fulfills all requirements to provide an ideal route for nutritional support. This article summarizes the reported experience on PEG in the current literature and discusses its utility in patients with neurological conditions.
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Affiliation(s)
- Rasim Gencosmanoglu
- Department of Gastrointestinal Surgery, Marmara University Institute of Gastroenterology, Istanbul, Turkey.
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Lipp A, Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2006. [DOI: 10.1002/14651858.cd005571] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Saadeddin A, Freshwater DA, Fisher NC, Jones BJM. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy for non-malignant conditions: a double-blind prospective randomized controlled trial. Aliment Pharmacol Ther 2005; 22:565-70. [PMID: 16167973 DOI: 10.1111/j.1365-2036.2005.02578.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion has been encouraged following development of guidelines by a number of professional societies within the past few years. However, not all evidence supports routine prophylaxis, particularly in patients with 'benign' disease indications for percutaneous endoscopic gastrostomy insertion. AIM To identify whether prophylactic antibiotic usage is beneficial in patients undergoing percutaneous endoscopic gastrostomy insertion without malignant disease. METHODS Adult patients without malignant disease who were referred for percutaneous endoscopic gastrostomy insertion at our unit were assessed for participation in this prospective, double-blind, randomized controlled study. Patients were randomized to receive either placebo or 2.2 g co-amoxiclav (or 2 g cefotaxime if penicillin-allergic) at time of percutaneous endoscopic gastrostomy insertion. Clinical endpoints studies were percutaneous endoscopic gastrostomy site or systemic infection and death within 7 days of percutaneous endoscopic gastrostomy insertion. Results : Ninety-nine patients completed the study (51 antibiotics, 48 placebo). Outcomes in the antibiotic and placebo groups respectively were: percutaneous endoscopic gastrostomy site infection, 11% vs. 47% (P < 0.01); systemic infection, 16% vs. 38% (P < 0.05); and death, 8% vs. 15% (P = 0.5). CONCLUSIONS Antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion reduces both percutaneous endoscopic gastrostomy site and systemic infections in patients without malignant disease.
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Affiliation(s)
- A Saadeddin
- Department of Gastroenterology and Nutrition, Russells Hall Hospital, Dudley, West Midlands, UK
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