Serum albumin is predictive of 30-day survival after percutaneous endoscopic gastrostomy

Malnutrition, Cancer Stage and Gastrostomy Timing as Markers of Poor Outcomes in Gastrostomy-Fed Head and Neck Cancer Patients

For percutaneous endoscopic gastrostomy (PEG)-fed head and neck cancer (HNC) patients, risk markers of poor outcomes may identify those needing more intensive support. This retrospective study aimed to evaluate markers of poor outcomes using TNM-defined stages, initial anthropometry [body mass index (BMI), mid-upper arm circumference (MUAC), tricipital skinfold (TSF), mid-arm muscle circumference (MAMC)] and laboratory data (albumin, transferrin, cholesterol), with 138 patients, 42-94 years old, enrolled. The patients had cancer, most frequently in the larynx (n = 52), predominantly stage IV (n = 109). Stage IVc presented a four times greater death risk than stage I (OR 3.998). Most patients presented low parameters: low BMI (n = 76), MUAC (n = 114), TSF (n = 58), MAMC (n = 81), albumin (n = 47), transferrin (n = 93), and cholesterol (n = 53). In stages I, III, IVa, and IVb, MAMC and PEG-timing were major survival determinants. Each MAMC unit increase resulted in 16% death risk decrease. Additional 10 PEG-feeding days resulted in 1% mortality decrease. Comparing IVa/IVb vs. IVc, albumin and transferrin presented significant differences (p = 0.042; p = 0.008). All parameters decreased as severity of stages increased. HNC patients were malnourished before PEG, with advanced cancer stages, and poor outcomes. Initial MAMC, reflecting lean tissue, significantly increases survival time, highlighting the importance of preserving muscle mass. PEG duration correlated positively with increased survival, lowering death risk by 1% for every additional 10 PEG-feeding days, signaling the need for early gastrostomy.

Underlying disease for percutaneous endoscopic gastrostomy tube placement predicts short- and long-term mortality

Background

PEG (percutaneous endoscopic gastrostomy) is a well established endoscopic procedure for enteral feeding. However, patients with a shorter life expectancy will not benefit from PEG tube placement. Furthermore, some specific evolving diseases will never benefit from PEG. The aim of the study focuses on short and long term mortality rates after PEG tube placement in a referral gastroenterology centre (Geneva University Hospital). 219 patients were enrolled in this study.

Patients and methods

All patients scheduled for a PEG procedure between January 2011 and December 2014 were included. Nine patient parameters were collected for further analysis as well as the main underlying disease requiring PEG tube placement. Patients were subsequently divided into 4 groups according to underlying disease: Group 1) swallowing disorders of neurologic origin; Group 2) swallowing disorders associated with upper digestive tract neoplasia ; Group 3) nutritional support for a non GI reason ; Group 4) Other.

Results

219 patients had undergone a PEG tube placement. 33 patients died within 60 days after the procedure. After one year, 71 patients died. Global survival was 870 days. The nutritional support group had the better survival rate with 1276 days compared to the swallowing groups and others. The multivariate analysis has highlighted the underlying disease as the only associated parameter with short and long term mortality.

Conclusions

PEG tube placement is associated with high short and long term mortality depending on the underlying disease. We outlined the potential role of PEG tube insertion as a supportive transient approach for nutritional support.

Prognostic outcomes after direct percutaneous endoscopic jejunostomy in elderly patients: comparison with percutaneous endoscopic gastrostomy

BACKGROUND AND AIMS

Direct percutaneous endoscopic jejunostomy (DPEJ) is an alternative method of enteral feeding to percutaneous endoscopic gastrostomy (PEG). Although long-term outcomes of PEG have been reported, little is known regarding the outcomes of DPEJ.

METHODS

A retrospective cohort study was conducted including 115 and 651 consecutive attempts of DPEJ and PEG, respectively, in a total of 766 elderly patients between April 2004 and March 2019. Patients' clinical background, procedural and long-term outcomes, survival analysis, and cause of death were analyzed.

RESULTS

Successful placement rates were 93.9% and 97.1% for DPEJ and PEG, respectively. There was no significant difference in procedure-related adverse events (AEs) between the DPEJ and PEG groups. Rates of pneumonia, vomiting, and upper GI bleeding were significantly lower, whereas those of fistula enlargement and ileus were significantly higher in the DPEJ group as long-term AEs. The median survival periods were 694 and 734 days for DPEJ and PEG, respectively, with no significant differences between the 2 groups. Multivariate analysis revealed that age 80 years old or older, C-reactive protein level of 1.0 mg/dL or higher, and the presence of diabetes were independent risk factors for mortality after DPEJ. Respiratory tract infection was the primary cause of death in both groups.

CONCLUSIONS

DPEJ is considered a safe and feasible method of access for enteral feeding as well as PEG. Although the survival period after DPEJ may be expected to be as long as that with PEG, DPEJ-specific AEs should be kept in mind on long-term feeding.

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

Background and Aim

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

Methods

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

Results

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

Conclusions

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

Simple Bedside Predictors of Survival after Percutaneous Gastrostomy Tube Insertion

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prognostic nutritional index and early mortality with percutaneous endoscopic gastrostomy

BACKGROUND

Although percutaneous endoscopic gastrostomy (PEG) is a well-accepted and less invasive method of feeding tube placement in patients with swallowing difficulties, complications and early death after PEG have been reported.

AIM

This study aimed to evaluate predictive factors associated with 30-day mortality after PEG, and to assess the utility of nutritional supporting period before PEG in reducing early mortality following PEG.

DESIGN

An observational study.

METHODS

We retrospectively analyzed 268 patients who underwent PEG at Sapporo Shirakaba-dai Hospital from 2006 to 2010, using clinical and laboratory data to analyze predictive factors associated with early death after PEG. Then, we prospectively assessed 152 consecutive patients assessed for eligibility for PEG from 2011 to 2014. We assessed the patients' nutritional condition using Onodera's prognostic nutritional index (PNI), and supported nutrition for more than 10 days before PEG in patients with a poor nutritional index (PNI < 37).

RESULTS

In both univariate and multivariate analyses in the retrospective study, Onodera's PNI of less than 37 was the only predictive factor for early mortality. In the second study, among the 115 patients who finally underwent PEG, early mortality rates improved to 1.7% from 5.2% in the first study. Conversely, 32% of patients with malnutrition who did not undergo PEG died within 30 days.

CONCLUSION

Nutritional status might be a predictive factor for early mortality after PEG. In patients with poor nutritional status, nutritional supporting period before PEG might improve the outcomes and reduce unnecessary PEG.

SERUM ELECTROLYTES AND OUTCOME IN PATIENTS UNDERGOING ENDOSCOPIC GASTROSTOMY

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a gold standard for long term enteral feeding. Neurologic dysphagia and head/neck cancer are the most common indications for PEG as they can lead to protein-energy malnutrition and serum electrolyte abnormalities, with potential negative impact on metabolic balance. Refeeding syndrome may also be related with severe electrolyte changes in PEG-fed patients and contribute to poor prognosis.

OBJECTIVE

This study aims to evaluate the changes in serum concentrations of the main electrolytes and its possible association with the outcome.

METHODS

Retrospective study of patients followed in our Artificial Nutrition Clinic, submitted to PEG from 2010 to 2016, having head/neck cancer or neurologic dysphagia, who died under PEG feeding. Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium and phosphorus) were evaluated immediately before the gastrostomy procedure. Survival after PEG until death was recorded in months.

RESULTS

We evaluated 101 patients, 59 with electrolyte alterations at the moment of the gastrostomy. Sodium was altered in 32 (31.7%), magnesium in 21 (20.8%), chlorine in 21 (20.8%), potassium in 14 (13.8%), calcium in 11 (10.9 %) and phosphorus in 11 (10.9%). The survival of patients with low sodium (<135 mmol/L) was significantly lower when compared to patients with normal/high values, 2.76 months vs 7.80 months, respectively (P=0.007).

CONCLUSION

Changes in serum electrolytes of patients undergoing PEG were very common. More than half showed at least one abnormality, at the time of the procedure. The most frequent was hyponatremia, which was associated with significantly shorter survival, probably reflecting severe systemic metabolic distress.

Mortality risk factors after percutaneous gastrostomy: Who is a good candidate?

BACKGROUND

The percutaneous gastrostomy tube (PG) is an effective and safe way for the delivery of enteral nutrition. The aim of this study was to identify predictive factors for mortality after PG placement.

MATERIAL AND METHODS

An observational and analytical cohort study was conducted. All endoscopic or radiological percutaneous gastrostomy tubes placed between January 2009 and July 2016 were evaluated. Mortality was the dependent variable. Initial clinical and analytical patient features and the development of complications during follow-up were recorded. Cox regression models were used to evaluate the risk of mortality associated to the studied variables. Hazard ratios with the corresponding 95% confidence intervals were retrieved from these models.

RESULTS

A total of 289 patients underwent PG placement (57% male). The mean age was 70.1 (SD 13.6) years. The median follow-up period was 8.7 (IQR 18) months. One hundred and seventy-four patients died during the follow-up period. The overall mortality rate was 4.8 per 100 patients-month. The highest mortality rate was during the first month after PG placement (13.2 per 100 patients-month), subsequently decreasing. Multivariate regression analysis showed that age (HR_1year = 1.01; p = 0.015), Charlson comorbidity index ≥4 (HR = 1.69; p = 0.011), the presence of degenerative neurological disease (HR = 1.69; p = 0.012) or malignancy (HR = 2.02; p = 0.012) and the development of aspiration pneumonia during the follow-up period (HR = 3.29; p = 0.001) were statistically significant independent predictive risk factors associated with mortality. A model to predict survival probability prior to placing the PG was developed from the variables of the multivariate analysis.

CONCLUSION

Mortality after PG placement is high. Older age, higher comorbidity and the development of aspiration pneumonia are predictive factors for mortality. A more careful selection of candidates for PG placement should be done to improve the patient prognosis after the procedure.

Severe hypernatremia as a predictor of mortality after percutaneous endoscopic gastrostomy (PEG) placement

BACKGROUND

Percutaneous endoscopic gastrostomy is the preferred option for providing enteral nutrition, allowing for an improvement in survival and quality of life.

AIM

To evaluate risk factors for early and delayed mortality after gastrostomy placement.

METHODS

A single-center retrospective analysis of a prospectively-collected database including all patients undergoing gastrostomy placement for enteral nutrition was performed. Two operators performed all the procedures according to the most recent guidelines.

RESULTS

Analysis included data on 438 patients [178 male; 80.5 (72-86) year-old]. Indications for PEG were stroke (34.0%), dementia (31.3%), neurodegenerative disorders (18.5%), coma (9.1%) and cancer (7.1%). No periprocedural adverse events was observed. Mean survival was 14.6±3.4months; 1-month and 3-month mortality rates were 4.0% and 8.1%, respectively. Severe hypernatremia (≥150mmol/L) was independently related to 1-month mortality (odds ratio 25.4; P<0.0001), while C-reactive protein level>4.3mg/dL was independently related to 3-month mortality (odds ratio 5.3; P=0.003). Kaplan-Meier and Cox-regression analysis identified male gender (hazard ratio 2.32; P=0.0002), severe hypernatremia (hazard ratio 4.3; P<0.0001), C-reactive protein>4.3mg/dL (hazard ratio 3.5; P=0.0014), leukocytosis (hazard ratio 1.97; P=0.0036) and presence of underlying malignancy (hazard ratio 2.4; P=0.0013) as independent risk factors for long-term mortality.

DISCUSSION

Presence of severe hypernatremia and increased C-reactive protein levels were strongly correlated with early and delayed mortality in our population. Studies are necessary to understand whether correcting underlying dehydration and inflammation further improves patients' outcomes.

Low Abdominal Wall Thickness May Predict Percutaneous Endoscopic Gastrostomy Complications

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

Malnutrition and Clinical Outcome of 234 Head and Neck Cancer Patients who Underwent Percutaneous Endoscopic Gastrostomy

Head and neck cancer (HNC) patients who underwent percutaneous endoscopic gastrostomy (PEG) present malnutrition risk and speech impairments. Their assessment relies on objective anthropometric/laboratory data. Focusing on HNC PEG patients, our aims were to evaluate: 1) outcome; 2) nutritional status when the patients underwent PEG; and 3) association of nutritional status/outcome, creating a survival predictive model. We evaluated the outcome based on NRS 2002, dietary assessment, body mass index (BMI), mid-upper arm circumference (MUAC), triceps skinfold thickness (TSF), mid-arm muscle circumference (MAMC), albumin, transferrin, and cholesterol on the day of gastrostomy. Using BMI, TSF, MAMC, and laboratory data, a survival predictive model was created. Of the 234 patients (cancer stages III-IV), 149 died, 33 were still PEG-fed, and 36 resumed oral intake (NRS-2002≥3, caloric needs <50% in all). BMI was 12.7-43. 189, 197, and 168 patients displayed, respectively, low MUAC, TSF, and MAMC. 91, 155, and 119 patients displayed low albumin, transferrin, and cholesterol. Albumin, cholesterol, and transferrin were strongly associated with the outcome. A predictive model was created, discriminating between short-term survivors (<4 months) and long-term survivors. HNC patients were malnourished. Using anthropometric/laboratory parameters, a predictive model provides discrimination between patients surviving PEG for <4 months and long-term survivors. Teams taking care of PEG patients may provide special support to potential short-term survivors.

Mortality trend and predictors of mortality in dysphagic stroke patients postpercutaneous endoscopic gastrostomy

Background:

Percutaneous endoscopic gastrostomy (PEG) feeding is widely used in stroke patients suffering from persistent dysphagia; however, predicting the risks and benefits of PEG insertion in the individual patient is difficult. The aim of our study was to investigate if candidate risk factors could predict short-term mortality risk in poststroke patients who had PEG tube insertion for persistent dysphagia.

Methods:

This was a retrospective study of 3504 consecutive stroke patients admitted to two metropolitan hospitals during the period January 2005 to December 2013 and who also underwent PEG insertion for feeding due to persistent dysphagia.

Results:

A total of 102 patients were included in the study. There were 22 deaths in 6 months after insertion of PEG tubes and 20 deaths of those occurred within 3 months post PEG. Those who survived beyond 6 months showed significantly lower mean age (75.9 ± 9.0 years vs. 83.0 ± 4.9 years, P < 0.001), a lower mean American Society of Anesthesia (ASA) score (3.04 ± 0.63 vs. 3.64 ± 0.58, P < 0.001) compared to nonsurvivors. In multiple Logistic, age (P = 0.004, odds ratio [OR] = 1.144; 95% confidence interval [CI]: 1.044–1.255); ASA (P = 0.002, OR = 5.065; 95% CI: 1.815–14.133) and albumin level pre-PEG insertion (P = 0.033, OR = 0.869; 95% CI: 0.764–0.988) were the independent determinants of mortality respectively.

Conclusions:

We propose that age, ASA score and albumin level pre-PEG insertion to be included as factors to assist in the selection of patients who are likely to survive more than 3 months post PEG insertion.

Mortality among patients who receive or defer gastrostomies

BACKGROUND & AIMS

There are few data on outcomes and mortality of patients who have received gastrostomies. We assessed 30-day and 1-year mortalities of patients in the United Kingdom who were referred to hospitals for gastrostomies and of patients who deferred this intervention.

METHODS

We collected data from 1327 patients referred to 2 hospitals in Sheffield, United Kingdom, for gastrostomies from February 2004 through May 2010. Data were analyzed to determine 30-day and 1-year mortalities. Predicted mortality by using the validated Sheffield Gastrostomy Scoring System (SGSS) was then compared with actual mortality by using area under the receiver operator curves to determine levels of agreement in patients referred for gastrostomy.

RESULTS

Three hundred four patients (23%) did not undergo gastrostomy after multidisciplinary team discussion, which was based on physicians' recommendations. This group had 35.5% mortality at 30 days and 74.3% at 1 year, whereas mortality among patients who underwent gastrostomy (n = 1027) was 11.2% at 30 days and 41.1% at 1 year (P < .0001, compared with patients who deferred the procedure). The area under the receiver operator curves for the SGSS demonstrated acceptable agreement between predicted and actual mortality in patients who underwent or were deferred gastrostomy.

CONCLUSIONS

On the basis of data from 1327 patients, those who undergo gastrostomy have significantly lower mortality than those who defer the procedure. Without applying the SGSS, clinicians are able to select patients most likely to benefit from gastrostomy. The SGSS could provide objective support to clinicians involved in making ethically contentious or potentially litigious decisions.

Does serum albumin and creatinine predict survival of inpatient palliative care patients?

INTRODUCTION

Low creatinine and albumin are found among the chronically ill patients. This study retrospectively reviewed albumin and creatinine levels for survival in patients upon admission.

METHODS

Records of patients admitted over 2 months were reviewed. Recursive partitioning analysis (RPA) identified cutpoints in albumin and creatinine that predicted survival. Kaplan-Meier survival, Cox proportional hazards, and stepwise Cox analyses identified prognostic factors.

RESULTS

Of 83 patients, 81 were assessable. Variables for worse survival were albumin <3.1 g/dL, creatinine >0.93 mg/dL, and male gender. Albumin by continuous, median, RPA, and tertiles was significant; creatinine by RPA. Hazard ratio for albumin >3.1 was 0.28 (P < .001) and for creatinine >0.91 mg/dL was 1.8 (P = .046).

DISCUSSION AND CONCLUSION

Albumin and creatinine are prognostically important.

Single endoscopist-performed percutaneous endoscopic gastrostomy tube placement

AIM: To investigate whether single endoscopist-performed percutaneous endoscopic gastrostomy (PEG) is safe and to compare the complications of PEG with those reported in the literature.

METHODS: Patients who underwent PEG placement between June 2001 and August 2011 at the Baskent University Alanya Teaching and Research Center were evaluated retrospectively. Patients whose PEG was placed for the first time by a single endoscopist were enrolled in the study. PEG was performed using the pull method. All of the patients were evaluated for their indications for PEG, major and minor complications resulting from PEG, nutritional status, C-reactive protein (CRP) levels and the use of antibiotic treatment or antibiotic prophylaxis prior to PEG. Comorbidities, rates, time and reasons for mortality were also evaluated. The reasons for PEG removal and PEG duration were also investigated.

RESULTS: Sixty-two patients underwent the PEG procedure for the first time during this study. Eight patients who underwent PEG placement by 2 endoscopists were not enrolled in the study. A total of 54 patients were investigated. The patients’ mean age was 69.9 years. The most common indication for PEG was cerebral infarct, which occurred in approximately two-thirds of the patients. The mean albumin level was 3.04 ± 0.7 g/dL, and 76.2% of the patients’ albumin levels were below the normal values. The mean CRP level was high in 90.6% of patients prior to the procedure. Approximately two-thirds of the patients received antibiotics for either prophylaxis or treatment for infections prior to the PEG procedure. Mortality was not related to the procedure in any of the patients. Buried bumper syndrome was the only major complication, and it occurred in the third year. In such case, the PEG was removed and a new PEG tube was placed via surgery. Eight patients (15.1%) experienced minor complications, 6 (11.1%) of which were wound infections. All wound infections except one recovered with antibiotic treatment. Two patients had bleeding from the PEG site, one was resolved with primary suturing and the other with fresh frozen plasma transfusion.

CONCLUSION: The incidence of major and minor complications is in keeping with literature. This finding may be noteworthy, especially in developing countries.

Predictive factors of mortality after PEG insertion: guidance for clinical practice

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is considered the preferred route for long-term enteral feeding. The aim of this study was to determine predictors of an increased mortality risk after PEG insertion.

METHODS

A retrospective study was conducted during a 13-year period in the gastroenterology department of Erlangen University Hospital. The authors completed a questionnaire with details of demographic data, diagnosis, indication for PEG, type of tube, and cause of death. Patients were contacted regularly at scheduled appointments.

RESULTS

In total, 787 patients (574 male [72.9%]) underwent PEG placement by the pull technique. The main underlying disease was malignant (75.6%). By the end of the study period, 614 patients had died. The average survival time was 720 days. The 30-, 60-, 90-day and 1-, 3-, and 5-year mortality rates amounted to 6.5%, 9.8%, 13%, 32.1%, 59.3%, and 69.8%, respectively. Predictive factors of increased 30-day mortality were higher age, lower body mass index (BMI), and the presence of diabetes mellitus. The presence of all 3 variables served as an indicator to detect high-risk patients, with a sensitivity of 0.80 and a specificity of 0.64.

CONCLUSION

Mortality predictors for patients after PEG insertion are higher age, lower BMI, and the presence of diabetes mellitus. To avoid unnecessary and dangerous examinations in high-risk patients, the above-mentioned predictive factors of mortality should be checked before PEG placement.

Low serum albumin level is risk factor for patients with percutaneous endoscopic gastrostomy

OBJECTIVE

In Japan, percutaneous endoscopic gastrostomy (PEG) has been used mainly in patients with stroke and dementia, who undertake oral ingestion voluntarily. We have used PEG for patients with various diseases in Saga Medical School Hospital, including postoperative recovery, malignant disease, and neurodegenerative diseases. This study evaluated prognostic factors in these patients regarding long-term survival.

METHODS

We analyzed retrospectively all patients who received PEG at our hospital. During the period of 1998-2007, 84 patients (32 females, 52 males; mean age, 60.3 years, range 20-89 years) were followed for more than 1 year. We analyzed sex, age, total lymphocyte count, serum albumin level, presence of malignant diseases, cerebrovascular diseases, neurodegenerative disorders, poor general condition after surgical procedures, dementia before PEG, pneumonia before PEG, and complications of PEG placement.

RESULTS

As for diseases, 23 patients had malignant diseases, 27 had cerebrovascular diseases, 19 had neurodegenerative disorders, 16 were in poor general condition after surgery for nonmalignant diseases, and 12 had dementia. Multivariate analysis indicated that risk factors for 1-year survival were low serum albumin level (≤2.9 g/dL), low lymphocyte count, and complications of malignant diseases. Low serum albumin level, low lymphocyte count, and malignant diseases were risk factors, and only the albumin level was a risk factor in those without malignant diseases.

CONCLUSION

Low serum albumin level was a risk factor for 1-year survival with PEG, which suggests that nutrient management before and during PEG placement should be monitored carefully.

Prediction of survival and complications after percutaneous endoscopic gastrostomy in an individual by using clinical factors with an artificial neural network system

BACKGROUND

The demand for percutaneous endoscopic gastrostomy (PEG) has increased because it is safe and a technically easy method, but it has risks of severe complications including death and a high mortality rate within 30 days. At present, we cannot predict survival or the incidence of complications before tube placement in an individual. Earlier studies have used traditional statistical analysis by assuming a linear relationship between clinical features, but most phenomena in the clinical situation are not linearly related.

AIMS

We predicted the survival and complications before PEG placement in an individual by using artificial neural network (ANN) system, which can assess the nonlinear relationship.

METHODS

We studied 100 patients who underwent PEG at the Kitasato Medical Institute Hospital from 1997 to 2005. Clinical data and laboratory data were used as input data. Complications related to PEG placement and survival dates were historically and prospectively measured. From the clinical data and laboratory data, we examined the prediction of outcome in individual patients using multiple logistic regression analysis and an ANN.

RESULTS

The correct answer rate of survival by multiple logistic regression analysis was 67.9%. In contrast, using the ANN, we correctly predicted the survival date and aspiration pneumonia in 75 and 89% of patients, respectively. There was a nonlinear relationship among input factors and survival and complications.

CONCLUSION

We correctly predicted the outcome and complications of individual patients with PEG with a high correct answer rate. Our data show the potential of an ANN as a powerful tool in daily clinical use to individualize treatment ('tailor-made medicine') for PEG and reduce costs.

Predicting the outcome of artificial nutrition by clinical and functional indices

OBJECTIVE

Artificial nutrition (AN) is now considered medical therapy and has progressively become one of the mainstays of the different therapeutic options available for home or hospitalized patients, including surgical, medical, and critically ill patients. The clinical relevance of any therapy is based on its efficacy and effectiveness and thus on the improvement of its cost efficiency, i.e., the ability to provide benefits to the patients with minimal wasting of human and financial resources. The aim of the present study was to identify those indices, clinical, functional, or nutritional, that may reliably predict, before the start of AN, those patients who are likely not to benefit from nutritional support.

METHODS

Three hundred twelve clinical charts of patients receiving AN between January 1999 and September 2006 were retrospectively examined. Data registered before starting AN were collected and analyzed: general data (age, sex), clinical conditions (comorbidity, quality of life, frailty), anthropometric and biochemical indices, type of AN treatment (total enteral nutrition, total parenteral nutrition, mixed AN), and outcome of treatment.

RESULTS

The percentage of negative outcomes (death or interruption of AN due to worsening clinical conditions within 10 d after starting AN) was meaningfully higher in subjects >80 y of age and with reduced social functions, higher comorbidity and/or frailty, reduced level of albumin, prealbumin, lymphocyte count, and cholinesterase and a higher level of C-reactive protein. The multivariate analysis showed that prealbumin and comorbidity were the best predictors of AN outcome. The logistic regression model with these variables showed a predictive value equal to 84.2%.

CONCLUSION

Proper prognostic instruments are necessary to perform optimal evaluations. The present study showed that a patient's general status (i.e., comorbidity, social quality of life, frailty) and nutritional and inflammatory statuses (i.e., lymphocyte count, albumin, prealbumin, C-reactive protein) have good predictive value on the effectiveness of AN.

Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death

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.

A better method for preventing infection of percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has been widely used to maintain enteral nutrition in dysphagic patients. Local and occasional life-threatening systemic infections are still the most common complications, and the major infection source may be nosocomial flora. The effect of antibiotic prophylaxis on reducing peristomal infection is popularly accepted. However, it is accompanied with a possible risk of increasing antibiotic resistance.

AIM

This study attempted to determine whether 14-day discharge before PEG could reduce the rate of peristomal infection.

MATERIALS AND METHODS

Fifty patients who had received PEG in our hospital were included in this study and followed for at least 6 months (except for those patients who died during this period). Patients were separated into two groups randomly. Twenty-five patients received PEG during in-hospitalization (group A). The other 25 patients received PEG until discharge at least for 14 days (group B). The most frequent indication for PEG insertion was the neurological condition. Risk factors for peristomal infection were analyzed statistically using logistic regression and expressed by odds ratios. Every possible factor was analyzed by chi-square test or Student's t test.

RESULT

Our data showed that group A had a higher peristomal infection rate than group B (32 vs 8%) (p < 0.05). Group A also showed more need of antibiotics. The risk factors related to peristomal infection were group A and lower albumin. The total rate of 30-day mortality was 4%.

DISCUSSION

When compared with previous data, our study showed a similar infection rate in group A, a lower infection rate in group B, and a lower 30-day mortality rate. This meant that one period of discharge could reduce the peristomal infections caused by colonized bacteria. It also decreased the need of using antibiotics and might avoid the possible adverse consequence of promoting bacterial resistance, which is an alarming and growing problem in hospital practice.

CONCLUSION

We suggest that a 14-day grace period after discharge, before PEG insertion, may decrease peristomal infection rate, length of hospital stay after PEG, and the need for antibiotics. This is suitable for moral and ethical considerations.

Clinical analysis of gastroesophageal reflux after PEG

BACKGROUND

It is difficult to predict whether or not gastroesophageal reflux (GER), such as aspiration or vomiting, will occur after PEG.

OBJECTIVE

To identify factors that would support the prediction of aspiration after PEG.

DESIGN

Case-control study.

SETTING

Patients who underwent PEG from February 1998 to June 2005 in our hospital.

PATIENTS

The study included 178 patients.

INTERVENTIONS

Endoscopic observation was carried out during PEG tube placement and at PEG tube replacement to determine the presence of hiatus hernia and/or reflux esophagitis.

MAIN OUTCOME MEASUREMENTS

Gastric emptying and GER index (GERI) were measured by using a radioisotope technique.

RESULTS

The patients were divided into 2 groups: the non-GER (NGER) group (n = 108), who had no symptoms of GER, and the GER group (n = 70), who showed these symptoms. No significant differences were observed between the groups in age, sex, morbidity, the presence of reflux esophagitis at PEG tube placement, gastric emptying, or serum albumin levels. The presence of a hiatus hernia (P = .028) and reflux esophagitis grading Los Angeles classification C or D (P = .008) were significantly more frequent in the GER group compared with the NGER group. The GERI was also significantly higher in the GER group than in the NGER group (P < .0001).

CONCLUSIONS

The presence of hiatus hernia, severe reflux esophagitis, and a high GERI might be predictive factors of aspiration or vomiting after PEG tube placement.

ESPEN Guidelines on Enteral Nutrition: Geriatrics

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.

Surrogate nutrition markers, malnutrition, and adequacy of nutrition support

Surrogate nutrition markers are used to assess adequacy of nourishment and to define malnutrition despite evidence that fails to link nourishment, surrogate markers, and outcomes. Markers such as serum levels of albumin, prealbumin, transferrin, and IGF-1 and delayed hypersensitivity and total lymphocyte count may be valid to help stratify risk. However, it is not appropriate to consider these as markers of adequacy of nourishment in the sick patient.

Gastrostomy and Jejunostomy Placement: The Urban Hospital Perspective Pertinent to Nursing Home Care

OBJECTIVES

In nursing home settings, providers often think that most percutaneous endoscopic gastrostomy (PEG) tubes are placed in older people, some perhaps inappropriately. We sought to describe the relationships between patient age and the indications for, the decision making behind, and the outcomes of gastrostomy and jejunostomy placement in an urban hospital to give perspective to those of us working in long-term care settings.

DESIGN

Retrospective, observational study.

SETTING

Urban hospital.

PARTICIPANTS

Two hundred thirty-nine inpatients who underwent gastrostomy or jejunostomy (G/J) placement.

MEASUREMENTS

Hospital records were reviewed for patient demographics, disease process, decision making, and short-term outcomes associated with G/J placement. Mortality at 30 days and 1 year was obtained by a search of the National Death Index. The prevalence of these variables in those aged 65 years and older was compared to the prevalence in those younger than 65 with associations calculated both unadjusted and adjusted for gender, place of residence, underlying condition, and Charlson comorbidity index.

RESULTS

Patients who were aged 65 years and older were more likely to be female with more comorbid illnesses and were more likely to have had a stroke that precipitated their difficulty eating. They were more likely to have been referred by a medical specialist, to have been seen by a speech pathologist, and to have had their procedure without general anesthesia. The older patients had a shorter mean hospital length of stay with fewer complications but had higher mortality rates at 30 days and 1 year.

CONCLUSION

Patient age was associated with gender and type of disease process and may have influenced the decisions made during the hospital stay. Despite a higher burden of chronic illness, older patient age was not associated with adverse short-term outcomes but was associated with higher mortality rates after discharge.

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.

Predicting which patients can resume oral nutrition after percutaneous endoscopic gastrostomy tube placement

BACKGROUND

Percutaneous endoscopic gastrostomy tubes are placed with high frequency and relative safety for a variety of indications. One of these indications is temporary nutritional support for patients expected to resume oral nutrition.

AIMS

To determine if baseline clinical characteristics can predict which patients attain the clinical goal of resuming oral nutrition with consequent tube removal.

METHODS

We conducted a single site observational cohort study from December 1999 to April 2001, enrolling all patients scheduled for percutaneous endoscopic gastrostomy placement. Standard descriptive and bivariate analyses were performed. Cox proportional hazard models were constructed to identify patient characteristics prior to percutaneous endoscopic gastrostomy placement that might predict resumption of oral nutrition with tube removal.

RESULTS

Bivariate analyses revealed four potential clinical predictors: age < 65 years, localized head and neck cancer, serum albumin > or = 3.75 g/dL, and serum creatinine < or = 1.1 mg/dL. In multivariable analysis, age < 65 years (HR = 3.7, 95% CI: 1.0-14.3) and a diagnosis of localized head and neck cancer (HR = 4.6, 95% CI: 1.4-15.0) predicted resumption of oral nutrition with percutaneous endoscopic gastrostomy removal.

CONCLUSIONS

When discussing percutaneous endoscopic gastrostomy placement, doctors should consider the likelihood of achieving clinically important outcomes such as the resumption of oral nutrition with tube removal. This clinical goal is unlikely for older patients with diagnoses other than localized head and neck cancer.

Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is the technique of choice for long-term enteral nutrition. Though safe and technically simple, PEG has been associated with significant morbidity and mortality.

AIM

We compared the outcome of strategies applied in two different periods; the original approach of PEG insertion during hospitalization (upon request), and PEG insertion 30 days after hospital discharge.

METHODS

A cohort of 127 patients scheduled for PEG insertion from 1.1.1997 to 31.12.2000, was evaluated. In 61 consecutive patients admitted from 1.1.1997 to 31.12.1998 the PEG insertion was planned during hospitalization, as close to the time of the physician's request (period 1). Sixty-six consecutive patients admitted from 1.1.1999 to 31.12.2000 were scheduled for the PEG insertion 30 days after discharge (period 2). The 30-day mortality rate was calculated from the time of the request. Univariate and multivariate analyses were used to find predictive factors for 30-day mortality.

RESULTS

There were 61 patients with a mean age of 78+/-13 in period 1, and 66 patients with a mean age of 77.8+/-15.5 in period 2. There was no significant difference between patients of the two periods in regard to age, sex, underlying disease, nutritional and mental status. Patients received PEG 30 days after hospital discharge had a 40% lower 30-day mortality rate than patients who received PEG during hospitalization from the time of request for PEG (P=0.01) and a 87.5% lower rate when calculated from the time of insertion (P<0.0001). In-hospital PEG insertion, bed-ridden and disorientation were found to be independent factors predictive of 30-day mortality after PEG insertion (P=0.016,P=0.001, and P=0.0005, respectively).

CONCLUSION

PEG insertion during hospitalization increases mortality and should be avoided. A grace period of 30 days with nasogastric tube feeding before PEG insertion may prevent mortality and achieve a long-term enteral nutrition.

Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials

OBJECTIVE

To determine whether hypoalbuminemia is an independent risk factor for poor outcome in the acutely ill, and to assess the potential of exogenous albumin administration for improving outcomes in hypoalbuminemic patients.

SUMMARY BACKGROUND DATA

Hypoalbuminemia is associated with poor outcomes in acutely ill patients, but whether this association is causal has remained unclear. Trials investigating albumin therapy to correct hypoalbuminemia have proven inconclusive.

METHODS

A meta-analysis was conducted of 90 cohort studies with 291,433 total patients evaluating hypoalbuminemia as an outcome predictor by multivariate analysis and, separately, of nine prospective controlled trials with 535 total patients on correcting hypoalbuminemia.

RESULTS

Hypoalbuminemia was a potent, dose-dependent independent predictor of poor outcome. Each 10-g/L decline in serum albumin concentration significantly raised the odds of mortality by 137%, morbidity by 89%, prolonged intensive care unit and hospital stay respectively by 28% and 71%, and increased resource utilization by 66%. The association between hypoalbuminemia and poor outcome appeared to be independent of both nutritional status and inflammation. Analysis of dose-dependency in controlled trials of albumin therapy suggested that complication rates may be reduced when the serum albumin level attained during albumin administration exceeds 30 g/L.

CONCLUSIONS

Hypoalbuminemia is strongly associated with poor clinical outcomes. Further well-designed trials are needed to characterize the effects of albumin therapy in hypoalbuminemic patients. In the interim, there is no compelling basis to withhold albumin therapy if it is judged clinically appropriate.

A prospective evaluation of outcome in patients referred for PEG placement

BACKGROUND

PEG feeding is not recommended for short-term use because the 30-day mortality after PEG placement is substantial. The primary aim of this study was to prospectively identify factors predictive of survival in patients referred for PEG placement.

METHODS

All patients for whom gastroenterology consultation was sought for feeding PEG placement were prospectively studied. Demographic data, Charlson comorbidity index, and functional status were recorded at entry. After PEG placement, patients were followed for up to 12 months.

RESULTS

Of the 67 patients for whom consultation was requested, 58 were eligible for the study and 50 underwent PEG placement. The 7-day and 30-day mortality rates in the PEG placement group were 4% and 20%, respectively. In multivariate analysis, only the Charlson index > or =4 was associated with decreased survival time (relative hazard = 2.9: 95% CI [1.20, 7.21], p = 0.019). Median survival in patients with Charlson comorbidity index > or =4 was significantly shorter than that in patients with Charlson index < 4 (p = 0.013).

CONCLUSIONS

A Charlson comorbidity index > or =4 was significantly associated with shorter patient survival after initial consultation. Careful consideration of predictive factors of survival may improve patient selection for feeding PEG placement.

Are we using percutaneous endoscopic gastrostomy appropriately in the elderly?

Many percutaneous endoscopic gastrostomy patients are very elderly and frail. Outcomes after percutaneous endoscopic gastrostomy have been disappointing in some instances: about a fifth of patients are dead within 30 days of the procedure and those that survive often have a severely impaired functional status. Many healthy elderly persons would not wish for tube feeding especially in the context of advanced dementia. Despite this the number of patients receiving percutaneous endoscopic gastrostomy continues to increase. The case mix, outcomes and ethical issues of percutaneous endoscopic gastrostomy feeding are reviewed. Guidance on selection of appropriate patients is given.

The adjunctive value of routine biochemistry in nutritional assessment of hospitalized patients

Nutritional screening and assessment of patients are not part of the routine procedures at hospital admission, although a large percentage of patients is malnourished. Similarly, nutritional status of patients and dietary intake is usually not monitored during hospitalization. In contrast a great number of laboratory investigations for screening purposes accompanies most, if not all, hospital admissions. Several of those routine markers carry important nutritional information and could convey several aspects of patients' nutritional requirements. This review proposes that laboratories in particular could provide a service for the nutritional interpretation of available routine data which would help clinicians to focus on nutrition related problems. The nutritional meaning of basic physical characteristics (age, sex, height, and weight), urinary excretion of ketone bodies, urea and creatinine, and serum concentrations of urea, phosphate, iron and albumin are discussed in detail and the assessment of protein malnutrition, metabolism, and requirements is emphasized. Finally, a proposed sample layout for the nutritional interpretation of routinely available biochemical and basic physical data is presented.

A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people

OBJECTIVE

To compare the indications for and the outcome of long-term enteral feeding by nasogastric tube (NGT) with that of percutaneous endoscopic gastrostomy (PEG) tube.

DESIGN

A prospective, multicenter cohort study.

SETTING

Acute geriatric units and long-term care (LTC) hospitals in Jerusalem, Israel.

PARTICIPANTS

122 chronic patients aged 65 years and older for whom long-term enteral feeding was indicated as determined by the treating physician. Patients with acute medical conditions at the time of tube placement were excluded.

MEASUREMENTS

We examined the indications for enteral feeding, nutritional status, outcome and complications in all subjects. Subjects were followed for a minimum period of six months.

RESULTS

Although the PEG patients were older and had a higher incidence of dementia, there was an improved survival in those patients with PEG as compared to NGT (hazard ratio (HR)=0.41; 95% confidence interval (CI) 0.22-0.76; P=0.01). Also, the patients with PEG had a lower rate of aspiration (HR=0.48; 95% CI 0.26-0.89) and self-extubation (HR=0.17; 95% CI 0.05-0.58) than those with NGT. Apart from a significant improvement in the serum albumin level at the 4-week follow-up assessment in the patients with PEG compared to those with NGT (adjusted mean 3.35 compared to 3.08; F=4.982), nutritional status was otherwise similar in both groups.

CONCLUSION

In long-term enteral feeding, in a selected group of non-acute patients, the use of PEG was associated with improved survival, was better tolerated by the patient and was associated with a lower incidence of aspiration. A randomized controlled study is needed to determine whether PEG is truly superior to NGT.

Low levels of gastric mucosal glutathione during upper gastric bleeding associated with the use of nonsteroidal anti-inflammatory drugs

OBJECTIVES

To investigate the glutathione concentrations in gastric mucosa from patients with acute gastric bleeding related to nonsteroidal anti-inflammatory drugs (NSAIDs), and to test the influence of nutritional status on mucosal glutathione. Glutathione protects the gastrointestinal mucosa against reactive oxygen species, and glutathione content in various tissues may be depleted during malnutrition.

METHODS

Endoscopic biopsies were obtained from 39 patients. Eighteen of these (9 well-nourished, 9 malnourished) presented with gastric bleeding ulcers related to NSAIDs. Twenty-one other patients (12 well-nourished, 9 malnourished) underwent normal routine diagnostic endoscopy and served as controls. Malnutrition was defined as a loss of over 10% of normal body weight and/or plasma albumin levels below 30 g/l. Gastric biopsies were taken from the fundus and antrum (controls) and from the region of the ulcer (patients with acute bleeding) and frozen quickly until glutathione analysis by high-performance liquid chromatography (HPLC) coulometric detection. Results were expressed as nmol/mg wet tissue.

RESULTS

Gastric mucosal glutathione levels were significantly (P < 0.05) lower in both the antrum (0.81 +/- 0.34 v. 1.41 +/- 0.88 nmol/mg tissue) and the fundus (1.04 +/- 0.54 v. 1.43 +/- 0.92 nmol/mg tissue, P < 0.05) in malnourished than in well-nourished control patients. Glutathione mucosal concentrations were decreased significantly in patients with NSAID-induced gastric bleeding compared with control patients (0.38 +/- 0.36 v. 1.12 +/- 0.56 nmol/mg tissue, P < 0.001), and the lowest glutathione levels were observed in malnourished patients (0.28 +/- 0.20 v. 0.48 +/- 0.15 nmol/mg tissue in well-nourished patients, not significant).

CONCLUSION

Malnutrition is associated with low levels of gastric glutathione. This may contribute to the severity and the onset of haemorrhage in NSAID-induced gastric ulcers.

Outcome of patients treated with home enteral nutrition

BACKGROUND

The aims of this study were to prospectively analyze the 1-month mortality and long-term outcome of home enteral nutrition (HEN) patients in order to determine the benefits of this treatment.

METHODS

Between 1990 and 1996, 417 patients, aged 64 +/- 25 years, were discharged on HEN and followed up until December 31, 1998, when outcome was assessed, which allowed us to determine survival probabilities and conditions associated with survival.

RESULTS

The mean duration of HEN was 242 +/- 494 days, with a 24- to 103-month follow-up. Probabilities of being alive at 1 month, 1 year, and 5 years were 80%, 41.7%, and 25%, respectively. Factors associated with death were dementia, neurologic disease, head and neck cancer, AIDS, and age over 70 years. A total of 5.5% of patients remained dependent on HEN, 32.6% resumed full oral nutrition, 20.2% of patients died during the first month on HEN, and 35% died after more than 1 month on HEN (219 +/- 257 days). A total of 6.7% of patients stopped HEN for other reasons.

CONCLUSIONS

HEN provides well-tolerated long-term nutritional support in many patients. However, because of their likelihood of being old and the nature of the underlying disease, these patients as a group tend to have a modest prognosis. This calls for the determination of more accurate selection criteria, and the measurement of the impact of HEN on quality of life.

Survival after percutaneous endoscopic gastrostomy placement in older persons

BACKGROUND

The prolongation of life is an important consideration in the decision to initiate long-term tube feeding. This report critically synthesizes the evidence regarding the impact of percutaneous endoscopic gastrostomy (PEG) tube placement on survival in older persons.

METHODS

A systematic search was conducted using MEDLINE from January 1980 until January 1999. Articles reporting survival data in older persons (mean or median age >65 years) after PEG tube placement were identified. The number and age of subjects, length of follow-up, setting, and survival data were extracted from all eligible studies. Mortality data at 1, 2, 6, and 12 months after PEG placement were quantitatively synthesized. Clinical characteristics associated with decreased survival among subjects with PEG tubes were identified.

RESULTS

Five cohort studies compared survival in patients with and without feeding tubes in nursing homes, but none demonstrated a survival benefit. Another cohort study reported increased survival for tube-fed patients with amyotrophic lateral sclerosis. The pooled proportion of all subjects surviving after PEG placement was as follows: 1 month = 0.81 (95% confidence interval [CI], 0.74-0.88), 2 months = 0.70 (95% CI, 0.65-0.74), 6 months = 0.56 (95% CI, 0.20-0.92), and 12 months = 0.38 (95% CI, 0.26-0.49). Advanced age and malignancy were the factors most often reported to be associated with poorer survival among subjects with PEG tubes.

CONCLUSIONS

The impact of PEG placement on survival is not known because the level of evidence is limited. PEG tubes may prolong life in selected populations. However, the majority of older patients selected for PEG placement will not survive 1 year after the procedure. Certain factors may identify those patients more likely to derive a survival benefit from long-term tube feeding. This information may offer some guidance to decision makers for whom prolongation of life is an important factor in the tube-feeding decision.

Complications and outcomes associated with use of gastrostomy tubes for nutritional management of dogs with renal failure: 56 cases (1994-1999)

OBJECTIVE

To evaluate complications and outcomes associated with use of gastrostomy tubes in dogs with renal failure.

DESIGN

Retrospective study.

ANIMALS

56 dogs.

PROCEDURE

Medical records were reviewed for dogs with renal failure that were treated by use of gastrostomy tubes.

RESULTS

Mean +/- SD BUN concentration was 134 +/- 79 mg/dl and mean serum creatinine concentration was 9.0 +/- 3.8 mg/dl. Low-profile gastrostomy tubes were used for initial placement in 10 dogs, and traditional gastrostomy tubes were used in 46 dogs. Mild stoma-site complications included discharge, swelling, erythema, and signs of pain in 26 (46%) of dogs. Twenty-six gastrostomy tubes were replaced in 15 dogs; 11 were replaced because of patient removal, 6 were replaced because of tube wear, and 3 were replaced for other reasons. Six tubes were replaced by low-profile gastrostomy tubes. Gastrostomy tubes were used for 65 +/- 91 days (range, 1 to 438 days). Eight dogs gained weight, 11 did not change weight, and 17 lost weight; information was not available for 20 dogs. Three dogs were euthanatized because they removed their gastrostomy tubes, 2 were euthanatized because of evidence of tube migration, and 1 died of peritonitis.

CONCLUSIONS AND CLINICAL RELEVANCE

Gastrostomy tubes appear to be safe and effective for improving nutritional status of dogs with renal failure.

Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) has become the preferred method to provide enteral tube feeding to older adults who have difficulty eating, but the impact of PEG on patient outcomes is poorly understood. The objective of this study was to describe changes in nutrition, functional status, and health-related quality of life among older adults receiving PEG.

DESIGN

A prospective cohort study.

SETTING

A small community of approximately 60,000 residents served by two hospital systems.

PARTICIPANTS

One hundred fifty patients aged 60 and older receiving PEG from one of the four gastroenterologists practicing in the targeted community.

MEASUREMENTS

Patients were assessed at baseline and every 2 months for 1 year to obtain clinical characteristics, process of care data, physical and cognitive function, subjective health status, nutritional status, complications, and mortality.

RESULTS

Over a 14-month period, 150 patients received PEG tubes in the targeted community; the mean age was 78.9. The most frequent indications for the PEG were stroke (40.7%), neurodegenerative disorders (34.7%), and cancer (13.3%). All measures of functional status, cognitive status, severity of illness, comorbidity, and quality of life demonstrated profound and life-threatening impairment; 30-day mortality was 22% and 1-year mortality was 50%. Among patients surviving 60 days or more, at least 70% had no significant improvement in functional, nutritional, or subjective health status. Serious complications were rare, but most patients experienced symptomatic problems that they attributed to the enteral tube feeding.

CONCLUSIONS

PEG tube feeding in severely and chronically ill older adults can be accomplished safely. However, there are important patient burdens associated with the PEG and there was limited evidence that the procedure improves functional, nutritional, or subjective health status in this cohort of older adults. The issues raised in this descriptive study provide impetus for a randomized trial of PEG tube feeding compared with alternative methods of patient care for older adults with difficulty eating.

Subcutaneous emphysema, pneumoperitoneum, and pneumoretroperitoneum after gastrostomy tube placement in a cat

A 17-year-old spayed female domestic shorthair cat developed subcutaneous emphysema, pneumoperitoneum, and pneumoretroperitoneum during endoscopic placement of a gastrostomy feeding tube after gastric insufflation and cannula insertion. The cat underwent exploratory laparotomy to investigate the possibility of gastric rupture but only a 2- to 3-mm defect was found in the gastric fundus at the site of cannula insertion. Pasteurella multocida and Enterobacter spp were cultured aerobically from the peritoneal cavity. The cat recovered without complications.

The cup is half full

BACKGROUND

The clinical outcomes following feeding tube procedures are infrequently studied because most patients have other incurable conditions.

METHODS

Multiple electronic databases were used to track clinical outcomes following all gastrostomies and jejunostomies performed at a single institution from October 1, 1992, through December 31, 1995. Preoperative risk factors and postoperative morbidity were available for all 104 cases; long-term status was available for all but 2 of 104.

RESULTS

The in-hospital mortality was 11.4%. Mortality was lower in those receiving feeding tubes as primary procedures (7.4%) than in those who had a feeding tube placed during other major procedures (24%, P <0.05). Postoperative pneumonia was frequent (24.7%), and was associated with preoperative gastroesophageal reflux (odds ratio 4.2, P = 0.01) and history of aspiration (odds ratio 3.9, P = 0.01). Although 14.5% of the patients were newly discharged to care facilities, the majority (74%) returned to their previous residence. Median survival was just over 6 months, with 18% surviving more than 2 years. Survival was inversely related to do-not-resuscitate status (odds ratio 4.6, P <0.001), metastatic tumor (odds ratio 2.7, P <0.001), dementia (odds ratio 2.3, P = 0.005), and unresectable tumor (odds ratio 2.1, P <0.001), but was unrelated to type of feeding tube.

CONCLUSIONS

Significant morbidity and mortality follow feeding enterostomies, but the majority of patients benefit and can return to their previous residence. Am J Surg. 1999;178:406-410. 1999 by Excerpta Medica, Inc.

Decision-making for percutaneous endoscopic gastrostomy among older adults in a community setting

OBJECTIVE

To describe clinical decision-making for percutaneous endoscopic gastrostomy from the perspective of patients, caregivers, and physicians.

DESIGN

A prospective cohort study.

SETTING AND PATIENTS

All patients aged 60 and older receiving percutaneous endoscopic gastrostomies in a defined community over a 16-month period.

MAIN OUTCOMES MEASURES

Either patients or their surrogate decision-makers completed a semistructured face-to-face interview to map out the information gathering process, expectations, and discussants involved in the decision to proceed with gastrostomy feeding. Physicians completed a written questionnaire to determine their likelihood of recommending percutaneous endoscopic gastrostomy, their involvement in the decision-making and recommendation process, and sources of perceived pressure in the decision-making.

RESULTS

We identified 100 patients who received percutaneous endoscopic gastrostomy during the study window and 82 primary care physicians who provided care in the defined community. The most common reasons for the procedure were stroke, neurologic disease, and cancer. Patients or their surrogate decision-makers reported multiple discussants, incomplete information, and considerable distress in arriving at the decision to proceed with artificial feeding. This distress was usually in the context of an acute and debilitating illness that often overshadowed the decision about artificial feeding. The decision for gastrostomy often appeared to be a "non-decision" in the sense that decision-makers perceived few alternatives. Physicians also reported considerable distress in arriving at recommendations to proceed with percutaneous endoscopic gastrostomy, including perceived pressures from families or other healthcare professionals. Physicians have clear patterns of triage for percutaneous endoscopic gastrostomy, but the assumptions underlying these patterns are not well supported by the medical literature.

CONCLUSIONS

Patients, caregivers, and physicians are often compelled to make decisions about long-term enteral feeding under tragic circumstances and with incomplete information. Decision-makers typically do not perceive any acceptable alternatives. Because data on these patients' long-term functional outcomes are lacking, decision-makers appear to focus primarily on the short-term safety of the procedure and the potential for improved nutrition.

Nutritional assessment in the critically ill

Essentially, there have not been any outstanding recent developments in nutritional assessment techniques. However, it would appear that the acceptance that there is no absolute gold standard for nutritional assessment has led to the development of disease specific and clinically relevant subjective global type-assessments, which are user-friendly and effective tools. The further development of dual frequency bioelectrical impedance models may allow for greater accuracy in the differentiation of alterations in body composition.