Survival of geriatric patients after percutaneous endoscopic gastrostomy in Japan

Sarcopenia Is a Prognostic Factor in Patients Undergoing Percutaneous Endoscopic Gastrostomy

(1) Background: Percutaneous endoscopic gastrostomy (PEG) is a widely used long-term enteral nutrition method, but little is known about the associated prognostic factors in patients with PEG. Sarcopenia, a condition characterized by a loss of skeletal muscle mass, increases the risk of developing various gastrointestinal disorders. Yet, the relationship between sarcopenia and the prognosis after PEG remains unclear. (2) Methods: We conducted a retrospective study of patients who underwent PEG consecutively from March 2008 to April 2020. We analyzed preoperative sarcopenia and the prognosis of patients after PEG. We defined sarcopenia as a skeletal muscle index at the level of the third lumbar vertebra of ≤29.6 cm²/m² for women and ≤36.2 cm²/m² for men. Cross-sectional computed tomography images of skeletal muscle at the level of the third lumbar vertebra were evaluated using DICOM image analysis software (OsiriX). The primary outcome was the difference in overall survival after PEG based on the status of sarcopenia. We also performed a covariate balancing propensity score matching analysis. (3) Results: Of 127 patients (99 men, 28 women), 71 (56%) were diagnosed with sarcopenia, and 64 patients died during the observation period. The median follow-up period did not differ between patients with and without sarcopenia (p = 0.5). The median survival time after PEG was 273 days in patients with sarcopenia and 1133 days in those without (p < 0.001). Cox proportional hazard model analyses identified three factors that were significantly associated with overall survival: sarcopenia (adjusted hazard ratio [HR]: 2.9, 95% confidence interval [CI]: 1.6-5.4, p < 0.001), serum albumin level (adjusted HR: 0.34, 95% CI: 0.21-0.55, p < 0.001) and male sex (adjusted HR: 2.0, 95% CI: 1.1-3.7, p = 0.03). Propensity score-matched analysis (n = 37 vs. 37) showed that the survival rate was lower in the sarcopenia group than in the non-sarcopenia group (at 90 days: 77% (95% CI, 59-88) vs. 92% (76-97), at 180 days: 56% (38-71) vs. 92% (76-97), and at one year: 35% (19-51) vs. 81% (63-91), p = 0.0014). (4) Conclusions: Sarcopenia was associated with poor prognosis in patients having undergone PEG.

Slow vital capacity as a useful indicator of the prognosis after percutaneous endoscopic gastrostomy in patients with amyotrophic lateral sclerosis

OBJECTIVES

Forced vital capacity (FVC) is recommended as a respiratory function test in patients with amyotrophic lateral sclerosis (ALS). However, in ALS associated with orofacial palsy, FVC may be an unreliable test. Slow vital capacity (SVC) is an easier and more reliable test even in cases with bulbar symptoms. However, it remains unclear whether respiratory function tests using SVC and FVC are associated with prognosis after percutaneous endoscopic gastrostomy (PEG) placement. This study aimed to confirm whether both SVC and FVC are related to prognosis after PEG placement in patients with ALS.

MATERIALS AND METHODS

We conducted this retrospective observational cohort study of 69 consecutive patients diagnosed with sporadic ALS who underwent PEG placement between July 2007 and February 2020. We analyzed the association with mortality 6 months after PEG placement and evaluated long-term prognosis.

RESULTS

Forty-four patients met the inclusion criteria. In cases with decreased SVC (p < .01) and FVC (p < .01), a significant difference was observed in mortality 6 months after PEG placement, with an optimal cut-off of SVC ≤57.4% (sensitivity, 0.828; specificity, 0.867) and FVC ≤57.3% (sensitivity, 0.828; specificity, 0.867). Multivariate analysis showed that onset age ≥ 65 years (p < .05), SVC ≤57.4% (p < .01), and FVC ≤57.3% (p < .01) were associated with survival after PEG placement.

CONCLUSIONS

SVC, like FVC, is an important prognostic factor after PEG placement in patients with ALS, and there is a possibility that evaluation using SVC can complement respiratory function testing even in cases where the evaluation of FVC is limited.

National trends in gastrostomy in older adults between 2014 and 2019 in Japan

AIM

Previous studies have shown temporal trends in the number of gastrostomies until 2016, but the recent trend is yet to be analyzed. This study aimed to evaluate temporal trends in gastrostomy (mostly percutaneous endoscopic gastrostomy) in older adults in Japan in more recent years.

METHODS

We extracted data on the numbers of gastrostomies and swallowing function assessment prior to gastrostomy, using the national aggregated open data (NDB Open Data) from 2014 to 2019.

RESULTS

Adults in their 80s accounted for the largest portion of gastrostomy during the study period. A decreasing trend in the total number of gastrostomy was observed in older adults from 2014 to 2016, but became almost stable thereafter (57 103 in 2014, 47 228 in 2016, and 47 944 in 2019). The age group-stratified numbers of gastrostomy per 100 000 individuals decreased by -33.9% (≥90 years group) to -6.1% (65-69 years group) from 2014 to 2019. The implementation rate of the swallowing function assessment remained relatively low, despite a slight increase (21.4% in 2015 to 23.7% in 2019).

CONCLUSION

We showed that the total number of gastrostomies remained almost stable after 2016 despite population aging. We considered that the avoidance of gastrostomy in frail or disabled older adults might explain the decrease, particularly for those aged over 80 years. Our findings would regain attention to appropriate decision-making for gastrostomy. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

Risk factors for postoperative bleeding and early death in percutaneous endoscopic gastrostomy: A multicenter retrospective study

BACKGROUND AND AIM

Comprehensive reports on the risk factors for bleeding and early death after percutaneous endoscopic gastrostomy (PEG) are limited. In this multicenter study, we retrospectively investigated the risk factors for bleeding and early death after PEG.

METHODS

Patients (n = 1234) who underwent PEG between 2015 and 2020 at Osaka Medical and Pharmaceutical University and its affiliated hospitals (11 institutions in total) were evaluated for postoperative bleeding and early death (within 60 days) after PEG according to patient characteristics, construction method, medical history, medications, preoperative hematological findings, and perioperative adverse events. Multivariate logistic regression was performed to identify independent predictors of bleeding and early death after PEG.

RESULTS

The risk factors for bleeding after PEG were PEG tube insertion using the modified introducer method (odds ratio [OR], 4.37; P = 0.0003), low platelet count (OR, 0.99; P = 0.014), antiplatelet therapy (OR, 2.11; P = 0.036), and heparinization (OR, 4.50; P = 0.007). Risk factors for early death were low body mass index (BMI) (OR, 0.89; P = 0.015), low serum albumin levels (OR, 0.50; P = 0.035), and comorbidity of active cancer (OR, 4.03; P < 0.0001). There was no significant association between bleeding and early death after PEG.

CONCLUSIONS

We identified several risk factors for bleeding and early death after PEG. Risk factors for bleeding were PEG tube insertion using the modified introducer method, low platelet count, antiplatelet therapy, and heparinization. Risk factors for early death were low BMI, low serum albumin levels, and comorbidity of active cancer.

Factors Associated with 30-Day Mortality in Patients after Percutaneous Endoscopic Gastrostomy

Introduction:

Percutaneous endoscopic gastrostomy (PEG) is the main accepted method for long-term tube feeding. The aim of this study is to investigate the risk factors associated with early mortality after PEG.

Methods:

It is a retrospective survival analysis in a tertiary-level hospital. We reviewed the medical records of 277 patients with PEG placement. The data were analyzed by the Kaplan-Meier method. Multivariable Cox proportional regression models were also built to test the effects of PEG on mortality.

Results:

A total of 277 patients who submitted to PEG were studied. One-hundred and sixty (58%) were female, mean age of 73.3 ± 15.7 years. Ninety-three patients (33.6%) had diabetes mellitus and 165 (59.6%) had blood hypertension. The indications for PEG placement were chronic neurologic dysphagia in 247 (89.5%) patients and tumors and other diseases in 29 (10.5%). The 30 days proportional mortality probability rate was 13%. In a multivariate Cox proportional regression model, preoperative ICU hospitalization (HR 1.79, 95% CI 1.36–2.36, P = 0.000) and hemoglobin (HR 0.91, 95% CI 0.85–0.98, P = 0.015) were predictors of early mortality.

Conclusion:

In patients who had underwent PEG tube insertion for long-term nutrition, anemia and previous ICU admission were predictors of mortality at four weeks. These factors may guide physicians to discourage the indication for PEG.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term prognosis of enteral feeding and parenteral nutrition in a population aged 75 years and older: a population-based cohort study

Background

Enteral feeding and parenteral nutrition (PN) using gastrostomy (GS) and a nasogastric tube feeding (NGT) and PN should be initiated for older patients based on their prognoses. This study aimed to investigate the long-term prognosis of patients aged ≥75 years who underwent enteral feeding via GS and NGT as well as PN.

Methods

A population-based cohort study was conducted using Japan’s universal health insurance claims in the Nara Prefecture. This study enrolled 3,548 patients aged ≥75 years who received GS (N=770), NGT (N=2,370), and PN (N=408) during hospital admissions between April 2014 and March 2016. The GS group was further categorized into secondary GS (N=400) with preceding NGT or PN within 365 days and primary GS (N=370) without preceding NGT or PN groups. In the secondary GS group, 356 (96%) patients received NGT (versus PN). The outcome was mortality within 730 days after receiving GS, NGT, and PN. Cox regression analyses in cases with or without malignant diseases, adjusted for sex, age, comorbidity, and hospital type, were performed to compare mortality in the groups.

Results

Of the 3,548 participants, 2,384 (67%) died within 730 days after the initiation of GS and NGT and PN. The 2-year mortality rates in the secondary GS, primary GS, NGT, and PN groups were 58%, 66%, 68%, and 83% in patients without malignancies and 67%, 71%, 74%, and 87% in those with malignancies, respectively. In the non-malignant group, Cox regression analysis revealed that secondary GS (hazard ratio (HR) = 0.43, 95% CI: 0.34–0.54), primary GS (HR = 0.51, 95% CI: 0.40–0.64), and NGT (HR = 0.71, 95% CI: 0.58-0.87) were statistically significantly associated with lower mortality compared with PN.

Conclusions

Approximately 58% to 87% patients aged ≥75 years died within 730 days after initiation of nutrition through GS, NGT, or PN. Patients with non-malignant diseases who received secondary GS exhibited better 2-year prognosis than those who received NGT or PN. Healthcare professionals should be aware of the effectiveness and limitations of enteral feeding and PN when considering their initiation.

Safely replacing a percutaneous endoscopic gastrostomy tube using a portable X-ray system at a patient's home

An 81-year-old woman who underwent percutaneous endoscopic gastrostomy (PEG) a year before, after cerebral infarction was receiving home medical care. The first accidental PEG tube removal occurred after clinic hours, and the home-care doctor visited her home to quickly reinsert the tube. After the narrowed fistula was dilated, the tube was reinserted with a guide wire. An X-ray taken with a CALNEO Xair, which is an easily portable X-ray system launched in 2018, confirmed that the tip of the PEG tube was successfully placed in the stomach. A similar accidental removal occurred 2 months later, and we managed it in the same way. Both events were resolved with a single radiograph without significant difficulty. With in-home medical care, PEG tube replacement can be performed easily and safely with a handy portable X-ray system.

Analysis of clinical outcomes in elderly patients with impaired swallowing function

Japan is the world’s leading aging society, and increasing medical expenses for elderly people is an urgent issue. Since aspiration pneumonia in elderly people with impaired swallowing function is a huge problem in Japan, their expected long-term clinical course should be clarified. Accordingly, we collected data from 991 elderly (≥75 years old) patients whose swallowing function was evaluated by Kitasato Institute Hospital’s speech therapists (January 1, 2010 to December 31, 2017). We analyzed the relationship between swallowing function and the subjects’ long-term prognosis. To clarify the prognostic factors of patients with dysphagia, we obtained their clinical information (age, gender, activities of daily living, nutritional status, availability of alternative feeding pathways such as percutaneous endoscopic gastrostomy, and cognitive function). We confirmed 372 death cases and stratified the cases into three groups using Fujishima’s swallowing ability grade, which is used to predict elderly people’s real-world life expectancy. Results showed the median survival days were 331 and 952 days in Groups I (Grades 1–3, n = 308) and II (Grades 4–6, n = 153), respectively, whereas the median survival days for Group III (Grades 7–10, n = 530) could not be calculated. We conducted a multivariate analysis using the Cox proportional hazards model with Group I, which revealed that initial grade and percutaneous endoscopic gastrostomy were significant prognostic factors for the subjects’ long-term survival. Nevertheless, further discussion is necessary, particularly to determine advanced care planning regarding indications for alternative feeding pathways in elderly patients with severe dysphagia, since percutaneous endoscopic gastrostomy could significantly prolong their survival.

Effect of dysphagia rehabilitation in patients receiving enteral nutrition at home nursing care: A retrospective cohort study

Objective

We considered the effect of dysphagia rehabilitation and investigated parameters associated with the resumption of oral intake in the elderly patients receiving home nursing care who were not eating by mouth.

Methods

The participants were 116 patients aged ≥65 years (66 men and 50 women, mean age 79.7 ± 8.9 years) who were receiving home nursing care and not eating by mouth because of dysphagia. All patients underwent dysphagia rehabilitation for 6 months with the objective of resuming oral intake. After 6 months of dysphagia rehabilitation, the patients’ eating status was assessed using the Functional Oral Intake Scale (FOIS) and the associations of the post‐intervention FOIS score with age, history of pneumonia, duration of enteral nutrition, body mass index (BMI), alertness, physical function (ability to walk) and swallowing function at the initial examination.

Results

Functional Oral Intake Scale scores increased significantly after 6 months rather than those at the initial evaluation (P < .001). Eighty patients (69.0%) resumed oral intake (FOIS score ≥2), thirty patients (25.9%) of whom became capable of daily oral intake (FOIS score ≥3). Swallowing function was associated with the resumption of oral intake. In addition, physical function before dysphagia rehabilitation was an important factor to resume daily oral intake.

Conclusions

The results of the present study suggest that the resumption of oral intake by patients receiving enteral nutrition requires improvement in swallowing function. In addition, anyone who cannot walk may not recover daily oral intake.

Association between delivery methods for enteral nutrition and physical status among older adults

Background

The physical status of patients who received enteral nutrition is still unclear. We aimed to compare the physical functional status among older adult patients who underwent percutaneous endoscopic gastrostomy (PEG) and those with nasogastric feeding.

Methods

We conducted a retrospective cohort study in an acute care hospital from August 1, 2009 to March 31, 2015. We included older adult patients (age ≥ 65 years) who were administered PEG or nasogastric feeding during hospitalization and received enteral nutrition for ≥14 days. We excluded patients who were completely bedridden at the administration of enteral nutrition. The primary outcome was death or becoming bedridden at discharge. The incidence of being bedridden among the patients who survived and received enteral nutrition at discharge was also compared according to the enteral nutrition method used.

Results

Among the 181 patients who were administered enteral nutrition during hospitalization, 40 patients (22%) died and 66 patients (36%) were bedridden at discharge. The proportions of patients who fully resumed oral intake were 30% in the nasogastric group and 2.3% in the PEG group. The adjusted odds ratios comparing PEG feeding to nasogastric feeding were 0.38 (95% CI, 0.16–0.93) for death or being bedridden and 0.09 (95% CI, 0.02–0.40) for being bedridden among the patients who were receiving enteral nutrition at discharge.

Conclusions

Among older adult patients who were administered enteral nutrition, more than half of these patients died or became bedridden. PEG feeding could be associated with a lower risk of becoming bedridden or death in comparison with nasogastric feeding, although PEG feeding may be offered to the most mobile/ambulatory patients within clinical decision-making. Clinicians should carefully consider the administration and choice of enteral nutrition methods, when considering the prognosis of the patients.

Clinical Features and Advantages of a Novel Percutaneous Endoscopic Gastrostomy Method

Background

To study the clinical characteristics of novel percutaneous endoscopic gastrostomy.

Material/Methods

We retrospectively analyzed the hospital records of 173 patients undergoing various methods of gastrostomy (a novel PEG, traditional PEG, and surgical gastrostomy). Clinical characteristics were analyzed. For the novel PEG, the operation was as same as the traditional method for initial steps until the annular guide wire was inserted. The following steps were different: water was injected through an injection port to expand the capsule, then the water sac was confirmed to be close to the gastric wall under endoscope, and, finally, the incision was sutured and covered.

Results

Patient ages ranged from 42 to 93 years (60.8±9.2 years, 91 males and 82 females). Among all patients, there were 27 cases of brain trauma, 42 cases of cerebral infarction, 74 cases of esophageal or cardiac carcinoma, 21 cases of laryngocarcinoma, and 9 cases of Alzheimer disease. Clinical features were significantly better for novel PEG compared to traditional PEG: duration of operation (19.75±3.14 min vs. 37.86±5.33 min and 54.12±9.48 min, P<0.001), intraoperative blood loss (27.14±3.63 ml vs. 43.53±6.24 ml and 75.78±12.41 ml, P<0.001), postoperative pain score (1.12±0.19 pts vs. 3.85±0.44 pts and 6.22±1.06 pts; P<0.001), infection rate (1.35% vs. 3.77% and 2.17%, P<0.001), length of hospital stay (3.16±0.42 d vs. 5.68±0.78 d and 8.29±1.31 d, P<0.001), and time to free activity (2.24±0.26h vs. 3.74±0.48 h and 14.85±2.38 d, P<0.001). The incidence of complications such as wound infection (1.35% vs. 3.77% and 4.76%), vomiting (1.35% vs. 5.66% and 6.52%), and nausea (2.70% vs. 1.88% and 6.52%) in the novel PEG group was lower than in the other groups (P<0.0001). Improved outcomes were obtained without increased medical costs in the novel PEG group.

Conclusions

For patients with difficult postoperative oral nutrition, the novel PEG treatment resulted in overall better clinical outcomes than traditional PEG.

Nutrition and hydration in palliative care

Anorexia, weight loss and muscle wasting commonly affect people approaching the end of life. It is critical that clinicians caring for people with advanced illness and progressive frailty can assess the nutritional and hydration needs of these people, engage them in shared decision making and support them to plan ahead regarding their nutritional care preferences as their health deteriorates.

New perspectives in aspiration community acquired Pneumonia

Introduction: Aspiration pneumonia is a subclass of community-acquired pneumonia that is expected to have an increasing contribution in mortality and morbidity, particularly in the elderly population over the next coming decades. While studies have revealed significant progress in identifying risk factors for aspiration pneumonia, the clinical presentation and diagnosis remain challenging to healthcare providers. Areas covered: We conducted a broad literature review using the MeSH heading in PubMed/MEDLINE of 'aspiration pneumonia' from January 1970 to July 2019. The understanding of the microbiology of aspiration pneumonia has evolved from a possible shift in the causative organisms away from anaerobes to traditional community-acquired pneumonia organisms. The importance of this shift is not yet known, but it has questioned the pathogenic role of anaerobes, appropriate anaerobic testing and the role of these pathogens in the pulmonary microbiome in patients with pneumonia. The identification of risk factors led to strategies to prevent or minimize the risk of aspiration pneumonia with moderate success. Expert opinion: Our expert opinion is that further research is needed to determine the role of the microbiome with aspiration pneumonia and patient risk factors. There is also a great need to develop clinical tools to help providers diagnose, treat, and prevent aspiration pneumonia.

Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in older persons with dysphagia: A propensity-matched cohort study

Background

The long-term outcomes of artificial nutrition in older people with dysphagia remain uncertain. Enteral nutrition via percutaneous endoscopic gastrostomy (PEG) is one of the major methods of artificial nutrition. Enteral feeding is indicated for patients with a functional gastrointestinal tract. However, total parenteral nutrition (TPN) is often inappropriately chosen for artificial nutrition in Japan, even in patients with a functional gastrointestinal tract, as PEG has recently been viewed as an unnecessary life-prolonging treatment in Japan. This study aimed to compare the long-term outcomes between PEG and TPN.

Methods

This single-center retrospective cohort study investigated long-term outcomes in older patients with dysphagia who received PEG or TPN between January 2014 and January 2017. The primary outcome was survival time. Secondary outcomes were oral intake recovery, discharge to home, and the incidence of severe pneumonia and sepsis. We performed 1-to-1 propensity score matching using a 0.05 caliper. The Kaplan–Meier method, log-rank test, and Cox regression analysis were used to compare the survival time between groups.

Results

We identified 253 patients who received PEG (n = 180) or TPN (n = 73). Older patients, those with lower nutritional states, and severe dementia were more likely to receive TPN. Propensity score matching created 55 pairs. Survival time was significantly longer in the PEG group (median, 317 vs 195 days; P = 0.017). The hazard ratio for PEG relative to TPN was 0.60 (95% confidence interval: 0.39–0.92; P = 0.019). There were no significant differences between the groups in oral intake recovery and discharge to home. The incidence of severe pneumonia was significantly higher in the PEG group (50.9% vs 25.5%, P = 0.010), whereas sepsis was significantly higher in the TPN group (10.9% vs 30.9%, P = 0.018).

Conclusions

PEG was associated with a significantly longer survival time, a higher incidence of severe pneumonia, and a lower incidence of sepsis compared with TPN.

Percutaneous Endoscopic Gastrostomy Tube Removal for Patients With Advanced Dementia: Case Series Study

Background

Although the notion of percutaneous endoscopic gastrostomy (PEG) tube placement for patients with dementia has been changing, the number of cases of PEG placement remains high as Japan has become a super-aged society. However, there is insufficient research about the clinical course of dementia patients with PEG, especially regarding PEG extubation after regaining full oral intake. This case series aimed to reveal the demographic data of patients who successfully underwent PEG extubation and to identify clinical factors that might help predict eventual resumption.

Methods

This retrospective case series was identified in a private, community-based long-term care hospital in Sapporo, Japan. Inclusion criteria for the series were: 1) age, ≥75 years, 2) diagnosis of any type of dementia, and 3) resumption of full oral intake after removal of PEG tubes.

Results

Eight female patients were identified. Decreased oral intake was triggered by acute medical conditions, such as infectious enteritis. A trial of oral intake was initiated mostly by speech therapists. A majority of the patients ate pureed food. The patients aged ≥85 years with advanced dementia could be weaned from PEG tubes.

Conclusion

The series indicates that even patients with limited life expectancy could recover swallowing function by receiving appropriate guidance and care. Constant evaluation for swallowing function even after PEG insertion may be important for PEG extubation.

Percutaneous endoscopic gastrostomy for enteral nutrition: a 5-year clinical experience with 324 patients

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is considered the route of choice for long-term enteral nutrition. In this study, we evaluated the short term outcomes of PEG and aimed to identify the risk factors for in-hospital mortality as well as adverse events such as aspiration pneumonia.

METHODS

Three hundred and twenty-four patients who received PEG for enteral nutrition between January 2007 and December 2011 were included in this study. Data regarding baseline characteristics, preoperative biomarkers and clinical outcomes were collected and analyzed.

RESULTS

The average patient age was 82.3±10.9 (SD) years old. 149 patients (46%) were men and 199 patients (61%) had stroke as a comorbidity. Postoperatively, feeding-related aspiration pneumonia was observed in 72 patients (22%), diarrhea in 40 patients (12%) and peristomal infection in 34 patients (11%). The average postoperative length of stay was 34.6 days. 51 patients (16%) died before discharge, 22 (6.8%) of them within 30 days after PEG. Two deaths (0.6%) were considered procedure-related (bleeding). Multivariate analysis revealed the male gender, lower serum albumin levels and higher blood urea nitrogen (BUN) levels as significant prognostic factors for in-hospital mortality. Higher C-reactive protein levels and BUN levels were found to be independently associated with the occurrence of postoperative aspiration pneumonia.

CONCLUSIONS

Our experience reconfirmed PEG as a minimally invasive and safe procedure for long-term enteral nutrition in patients with impaired oral intake. However, significant prognostic factors should be taken into account during the preoperative evaluation of patients. Deferral of procedure or specialized postoperative care may be indicated in high risk patients.

Survival times with and without tube feeding in patients with dementia or psychiatric diseases in Japan

BACKGROUND

It is widely supposed that there has been no evidence of increased survival in patients with advanced dementia receiving enteral tube feeding. However, more than a few studies have reported no harmful outcome from tube feeding in dementia patients compared to in patients without dementia.

METHODS

This was a retrospective study. Nine psychiatric hospitals in Okayama Prefecture participated in this survey. All inpatients fulfilling the entry criteria were evaluated. All subjects suffered from difficulty with oral intake. Attending physicians thought that the patients could not live without long-term artificial nutrition. The physicians decided whether to make use of long-term artificial nutrition between January 2012 and December 2014.

RESULTS

We evaluated 185 patients. Their mean age was 76.6 ± 11.4 years. Of all subjects, patients with probable Alzheimer's disease (n = 78) formed the biggest group, schizophrenia patients (n = 44) the second, and those with vascular dementia (n = 30) the third. The median survival times were 711 days for patients with tube feeding and 61 days for patients without tube feeding. In a comparison different types of tube feeding, median survival times were 611 days for patients with a nasogastric tube and more than 1000 days for those with a percutaneous endoscopic gastrostomy tube.

CONCLUSION

Patients with tube feeding survived longer than those without tube feeding, even among dementia patients. This study suggests that enteral nutrition for patients with dementia prolongs survival. Additionally, percutaneous endoscopic gastrostomy tube feeding may be safer than nasogastric tube feeding among patients in psychiatric hospitals.

Factors influencing decision regret regarding placement of a PEG among substitute decision-makers of older persons in Japan: a prospective study

Background

A tube feeding decision aid designed at the Ottawa Health Research Institute was specifically created for substitute decision-makers who must decide whether to allow placement of a percutaneous endoscopic gastrostomy (PEG) tube in a cognitively impaired older person. We developed a Japanese version and found that the decision aid promoted the decision-making process of substitute decision-makers to decrease decisional conflict and increase knowledge. However, the factors that influence decision regret among substitute decision-makers were not measured after the decision was made. The objective of this study was to explore the factors that influence decision regret among substitute decision-makers 6 months after using a decision aid for PEG placement.

Methods

In this prospective study, participants comprised substitute decision-makers for 45 inpatients aged 65 years and older who were being considered for placement of a PEG tube in hospitals, nursing homes and patients’ homes in Japan. The Decisional Conflict Scale (DCS) was used to evaluate decisional conflict among substitute decision-makers immediately after deciding whether to introduce tube feeding and the Decision Regret Scale (DRS) was used to evaluate decisional regret among substitute decision-makers 6 months after they made their decision. Normalized scores were evaluated and analysis of variance was used to compare groups.

Results

The results of the multiple regression analysis suggest that PEG placement (P < .01) and decision conflict (P < .001) are explanatory factors of decision regret regarding placement of a PEG among substitute decision-makers.

Conclusions

PEG placement and decision conflict immediately after deciding whether to allow PEG placement have an influence on decision regret among substitute decision-makers after 6 months.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0524-2) contains supplementary material, which is available to authorized users.

Percutaneous endoscopic gastrostomy for aspiration pneumonia: A 10-year single-center experience

BACKGROUND

The significance of percutaneous endoscopic gastrostomy (PEG) in patients with aspiration pneumonia is unknown. The purpose of this study was to evaluate the clinical characteristics and outcomes of aspiration pneumonia patients who underwent PEG.

METHODS

A retrospective cohort study of consecutive patients hospitalized with pneumonia who underwent PEG from 2005 to 2014.

RESULTS

Of 2281 cases of pneumonia, 92 patients with aspiration pneumonia underwent PEG during their hospital stay. The rate of PEG insertion significantly decreased after 2011, when Japanese therapeutic guidelines for pneumonia in the elderly were published (5.9% vs. 1.6% before and after guideline publication, respectively; p<0.01). The study population was male dominant (63%), with a mean age of 80.7 years. They had several risk factors for aspiration pneumonia, such as dementia (63.0%), cerebrovascular disorders (37.0%), and neurologic diseases (28.3%). Survival after PEG was 88.0% at day 30, 84.3% at 3 months, 73.8% at 6 months, and 61.1% at 1 year with a median survival of 751 days. Pneumonia was the most common cause of death during the follow-up period (22 of 51 patients, 43.1%). Cox proportional hazard model showed that independent predictors of mortality were older age, male gender, comorbidity of heart failure, and lower serum albumin values before PEG.

CONCLUSIONS

The rate of PEG placement is decreasing after the Japanese guidelines were published in 2011. While the overall median survival was approximately 2 years, the most common cause of death was pneumonia and mortality was associated with some significant factors.

Semi-solid feeds may reduce the risk of aspiration pneumonia and shorten postoperative length of stay after percutaneous endoscopic gastrostomy (PEG)

Background and study aims: Feeding-related adverse events after percutaneous endoscopic gastrostomy (PEG) such as aspiration pneumonia may result in prolonged hospitalization and postoperative mortality. This study evaluated the efficacy of using semi-solid feeds to reduce feeding-related adverse events and improve clinical outcomes. Patients and methods: Patients who received PEG for enteral nutrition at our hospital between January 2014 and December 2015 were allocated to a postoperative feeding protocol that used either liquid feed or semi-solid feed. Baseline characteristics, postoperative feeding-related adverse events and clinical outcomes in the 2 groups were prospectively analysed and compared. Results: One hundred and seventeen PEG patients (age range: 59 - 97 years, male: 53) were enrolled with 72 patients given liquid feed and 45 patients receiving semi-solid feed. Baseline characteristics were similar in both groups. The semi-solid feed group experienced fewer incidence of feeding-related aspiration pneumonia (2.2 % vs. 22.2 %, P < 0.005) and shorter postoperative hospital length of stay (12.7 days vs. 18.8 days, P < 0.01). Significant differences were not observed in the frequency of peristomal infection (11.1 % vs. 12.5 %, P = 0.82), feeding-related diarrhea (2.2 % vs. 12.5 %, P = 0.09) and 30-day mortality rates (2.2 % vs. 8.3 %, P = 0.25). Conclusions: Semi-solid feeding may reduce the risk of aspiration pneumonia and shorten postoperative hospital length of stay after PEG. Semi-solid feeds are safe to use and can be employed either as a first line feeding protocol or an alternative when liquid feeding is unsuccessful.

Heterogeneity of patients receiving artificial nutrition in Japanese psychiatric hospitals: a cross-sectional study

AIM

Artificial nutrition, including tube feeding, continues to be given to dementia patients in numerous geriatric facilities in Japan. However, the clinical characteristics of patients receiving artificial nutrition have not been fully investigated. Therefore, we tried to evaluate the clinical features of those patients in this study.

METHODS

Various clinical characteristics of all inpatients at 18 of 20 psychiatric hospitals in Okayama Prefecture, Japan, with a percutaneous endoscopic gastrostomy tube, nasogastric tube, or total parenteral nutrition were evaluated.

RESULTS

Two hundred twenty-one patients (5.4% of all inpatients) had been receiving artificial nutrition for more than 1 month, and 187 (130 women, 57 men; 84.6% of 221 patients) were fully investigated. The mean age was 78.3 years old, and the mean duration of artificial nutrition was 29.8 months. Eighty-four patients (44.7% of 187 patients) were receiving artificial nutrition for more than 2 years. Patients with Alzheimer's disease (n = 78) formed the biggest group, schizophrenia (n = 37) the second, and vascular dementia (n = 26) the third.

CONCLUSION

About one-fifth of the subjects receiving artificial nutrition were in a vegetative state. More than a few patients with mental disorders, including schizophrenia, also received long-term artificial nutrition. We should pay more attention to chronic dysphasia syndrome in mental disorders.

Long-Term Survival of Patients Receiving Artificial Nutrition in Japanese Psychiatric Hospitals

Background/Aims

Most patients with dementia suffer from dysphagia in the terminal stage of the disease. In Japan, most elderly patients with dysphagia receive either tube feeding or total parenteral nutrition.

Methods

In this study, we investigated the factors determining longer survival with artificial nutrition. Various clinical characteristics of 168 inpatients receiving artificial nutrition without oral intake in psychiatric hospitals in Okayama Prefecture, Japan, were evaluated.

Results

Multiple logistic regression analysis showed that the duration of artificial nutrition was associated with a percutaneous endoscopic gastrostomy (PEG) tube, diagnosis of mental disorder, low MMSE score, and absence of decubitus.

Conclusion

Patients with mental disorders survived longer than those with dementia diseases on artificial nutrition. A PEG tube and good nutrition seem to be important for long-term survival.

Percutaneous endoscopic gastrostomy (PEG) using a novel large-caliber introducer technique kit: a retrospective analysis

BACKGROUND AND STUDY AIMS

Percutaneous endoscopic gastrostomy (PEG) using the introducer technique is not only useful in patients with upper digestive tract stenosis but has been shown to reduce peristomal infection. In this study, we evaluated the safety and utility of a novel large-caliber introducer PEG kit (using 20 Fr size tube) compared with a push kit of similar size.

PATIENTS AND METHODS

One hundred and thirty-six patients who received PEG at our hospital between January 2014 and December 2015 were retrospectively analyzed. Baseline characteristics, laboratory biomarkers, hemodynamic changes, postoperative adverse events and clinical outcomes with both kits were compared.

RESULTS

The new introducer PEG kit was used in 61 patients while the remaining 75 patients received tube placement using a push technique PEG kit. Except for the prevalence of dementia, which was lower in the introducer PEG kit group, baseline characteristics were similar in both groups. Tube placements were 100 % successful with both PEG kits and there were no significant differences in the change of postoperative hemodynamic or laboratory biomarkers. The Introducer PEG kit group experienced fewer incidence of feeding-related aspiration pneumonia (8.2 % vs. 24 %, P = 0.02), lower peristomal infection scores (1.2 vs. 1.6, P < 0.01), shorter postoperative length of stay (16 days vs. 23.7 days, P = 0.01) and fewer deaths at day 60 (3.3 % vs. 16 %, P = 0.02).

CONCLUSIONS

Gastrostomy using the new large-caliber introducer PEG kit is safe and produced non-inferior (with some favourable) results when compared to the push technique using similar size tubes.

Outcome of Rehabilitation and Swallowing Therapy after Percutaneous Endoscopic Gastrostomy in Dysphagia Patients

The objective of this study was to investigate the outcomes of rehabilitation (with swallowing therapy) after percutaneous endoscopic gastrostomy (PEG) in patients with neurogenic dysphagia. Forty-seven patients (29 males and 18 females) who were transferred to the rehabilitation ward of our hospital after receiving PEG tube placements during a 5-year period were enrolled in this study. Patients' demographic data, comorbidities, nutritional statuses, and laboratory biomarkers before the PEG procedure were collected. Rehabilitation (with swallowing therapy) outcomes such as changes in Functional Independence Measure (FIM) and dysphagia grade (using Fujishima's classification) were evaluated. Significant improvements in FIM scores and dysphagia grades after rehabilitation therapy were observed. Twenty-seven patients (57.4 %) were discharged with some oral intake and 10 patients (21.3%) were discharged PEG-free (defined as the PEG tube not being used or removed). Factors associated with being discharged with some oral intake were increase in FIM score (adjusted OR 1.10, 95 % CI 1.02-1.19) and higher baseline dysphagia grade (adjusted OR 1.88, 95 % CI 1.04-3.39). Factors associated with being discharged PEG-free were longer rehabilitation period (OR 1.03, 95 % CI 1.01-1.04), absence of respiratory disorders (OR 0.12, 95 % CI 0.03-0.35), and increase in FIM score (OR 1.17, 95 % CI 1.08-1.28). Changes in dysphagia grade were significantly correlated with changes in FIM score (r ² = 0.46, p < 0.0001), indicating that improvement of FIM scores through general rehabilitation therapy may play an important role in the treatment of dysphagia.

Percutaneous endoscopic transgastric jejunostomy (PEG-J): a retrospective analysis on its utility in maintaining enteral nutrition after unsuccessful gastric feeding

Background/aims

Although percutaneous endoscopic gastrostomy (PEG) is the method of choice for long-term enteral nutrition, feeding-related adverse events such as aspiration pneumonia and peristomal leakage can impede the use of PEG. Percutaneous endoscopic transgastric jejunostomy (PEG-J) using large-bore jejunal tubes may help by circumventing gastric passage during enteral nutrition and improving drainage of gastric secretions.

Methods

20 patients (12 males and 8 females) who received PEG-J after unsuccessful PEG feeding during a 6-year period in our institution were analysed retrospectively to evaluate the efficacy of large-bore jejunal feeding tubes in maintaining enteral nutrition.

Results

The median age was 83.5 (71–96) years. The median period between PEG and PEG-J was 33 (14–280) days. Indications were aspiration due to gastro-oesophageal reflux in 18 patients and severe peristomal leakage in 2 patients. Tube placements were successful in all patients. There were 6 (30%) in-hospital mortalities, with 3 (15%) occurring within 30 days after procedure.

Conclusions

PEG-J can be performed safely in patients with PEG and may facilitate the maintenance of enteral nutrition in most of the patients. Patients with unsuccessful PEG feeding can be offered the option of jejunal feeding before considering termination of enteral nutrition.

Trends regarding percutaneous endoscopic gastrostomy: A nationwide population-based study from 1997 to 2010

Percutaneous endoscopic gastrostomy (PEG) is widely used in patients requiring long-term tube feeding. Traditional PEG studies usually focused on practical, technical, and ethical issues. There have been little epidemiological studies on PEG utilization and services in Asia. We evaluated the changes in PEG utilization, patient selection, patient characteristics, and medical service in Taiwan from 1997 to 2010.This retrospective study analyzed the data of patients admitted for PEG tube placement according to the International Classification of Diseases, Ninth Revision (procedure code 43.11) extracted from the National Health Insurance database between 1997 and 2010.From 1997 to 2010, the incidence of PEG increased from 0.1 to 3.8/10 population and incidence of PEG among aged patients increased from 0.9 to 19.0/10 population. Compared 1997-2004 to 2005-2010 periods, the percentage of cerebrovascular diseases decreased and esophageal cancer increased in the later period. PEG was mainly performed in male patients and at medical centers. Medical costs, Charlson Comorbidity Index (CCI) scores, and post-PEG mortality rates were higher in the 2005-2010 period than in the 1997-2004 period.PEG procedures are being increasingly performed in Taiwan, and changes in patient selection were noted. The seriousness of accompanying diseases, medical costs, and post-PEG mortality rates in patients undergoing PEG has increased. The present findings may help in the implementation of PEG, relocation of medical resources, and improvement of PEG-related care.

Predictive factors of early mortality after percutaneous endoscopic gastrostomy placement: The importance of C-reactive protein

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.

Comparison of short-term mortality and morbidity between parenteral and enteral nutrition for adults without cancer: a propensity-matched analysis using a national inpatient database

BACKGROUND

Proper artificial nutrition for patients who are unable to eat normally is an ongoing, unresolved concern in geriatric medicine and home medical care. Controversy surrounds prognostic differences between parenteral and enteral nutrition, 2 methods for artificial nutrition.

OBJECTIVES

Short-term outcomes of parenteral and enteral nutrition for patients who are unable to eat normally were compared and analyzed.

DESIGN

Data were acquired from patients selected from a national inpatient database covering 1057 hospitals in Japan. Participants had received artificial nutrition between April 2012 and March 2013, were aged ≥20 y, and did not have cancer. They were separated into 2 groups: those who received parenteral nutrition and those who received enteral nutrition. We performed one-to-one propensity score matching between the groups. The primary outcome measurements were mortality rates at 30 and 90 d after the start of the procedure. The secondary outcomes were postprocedural complications, pneumonia, and sepsis. We analyzed survival length of stay after the procedure with the use of a Cox proportional hazards model.

RESULTS

There were 3750 patients in the parenteral group and 22,166 patients in the enteral group. Propensity score matching created 2912 pairs in the 2 groups. Patients with a similar propensity score (probability of being assigned to the enteral group) calculated from the baseline condition were matched. Mortality rates at 30 and 90 d after start of treatment were 7.6% and 5.7% (P = 0.003) and 12.3% and 9.9% (P = 0.002) in the parenteral and enteral groups, respectively. In Cox regression analysis, the HR for the enteral group relative to the parenteral group was 0.62 (95% CI: 0.54, 0.71; P < 0.001). The incidences of postprocedural pneumonia and sepsis were 11.9% and 15.5% (P < 0.001) and 4.4% and 3.7% (P = 0.164) for the parenteral and enteral groups, respectively.

CONCLUSION

The present analysis showed the better survival rate with enteral compared with parenteral nutrition for adults who were not suffering from cancer. This trial was registered at clinicaltrials.gov as NCT02512224.

A systematic review and meta-analysis examining pneumonia-associated mortality in dementia

BACKGROUND

Although it is generally accepted that deaths associated with pneumonia are more common in patients with dementia, no comprehensive reviews on the subject have previously been published.

SUMMARY

Relevant studies were identified through a literature search of the PubMed, EMBASE, Scopus, and ISI Web of Science databases for publications up to August 2013. Studies were included if (1) a group of adult subjects with dementia and a (comparison) group composed of subjects without dementia were included, (2) the cause(s) of death was/were reported, and (3) pneumonia was identified as one of the possible causes of death. The occurrence of death due to pneumonia associated with dementia was expressed as an odds ratio (OR) with 95% confidence interval (CI). Thirteen studies were included. The odds of death resulting from pneumonia were significantly increased for persons with any form of dementia compared with those without dementia (OR = 2.22, 95% CI 1.44-3.42, p < 0.001). In a subgroup analysis, using the results from 8 studies that restricted inclusion to persons with Alzheimer's disease, the odds of death resulting from pneumonia were also significantly higher (OR = 1.70, 95% CI 1.12-2.58, p = 0.013). Key Messages: The odds of pneumonia-associated mortality were increased more than 2-fold for patients with dementia.

Prevalence and in-hospital mortality of gastrostomy and jejunostomy in Japan: a retrospective study with a national administrative database

BACKGROUND

PEG is widely used; however, large-scale data for PEG have been lacking.

OBJECTIVE

To estimate the prevalence of placement of gastrostomy and jejunostomy tubes and to elucidate the patient background characteristics and their associations with in-hospital mortality.

DESIGN

A retrospective analysis of the Japanese administrative claims database.

SETTING

Japanese acute-care hospitals.

PATIENTS

A total of 64,219 patients who underwent gastrostomy or jejunostomy tube insertion between July and December, 2007 to 2010, were identified among 11.6 million discharge records.

INTERVENTION

Placement of gastrostomy and jejunostomy tubes.

MAIN OUTCOME MEASUREMENTS

In-hospital mortality and the associated risk factors.

RESULTS

The mean age was 77.4 years; >90% of patients were aged >60 years. Cerebrovascular disease and pneumonia were the most frequently recorded diagnoses, followed by neuromuscular disease and dementia. The estimated annual number of gastrostomy and jejunostomy placements in Japan ranged from 96,000 to 119,000. The in-hospital mortality was 11.9%, and the significantly associated risk factors were male sex, older age, placement of a jejunostomy tube, urgent admission, hospital with lower bed capacity, the presence of malignancy, miscellaneous diseases, pneumonia, heart failure, renal failure, chronic liver diseases, pressure sores and sepsis, and occurrence of peritonitis and/or GI perforation, GI hemorrhage, and intra-abdominal hemorrhage.

LIMITATIONS

Retrospective investigation of administrative database.

CONCLUSION

Our large-scale data revealed the current status of gastrostomy tube placement in Japan. This can contribute to individual decision-making and the public consensus regarding artificial nutritional support in the elderly.

A decision aid regarding long-term tube feeding targeting substitute decision makers for cognitively impaired older persons in Japan: a small-scale before-and-after study

BACKGROUND

In Japan, there is no decision-making guide regarding long-term tube feeding that specifically targets individuals making decisions on behalf of cognitively impaired older persons (substitute decision makers). The objective of this study was to describe the development and evaluation of such a decision aid.

METHODS

In this before-and-after study, participants comprised substitute decision makers for 13 cognitively impaired inpatients aged 65 years and older who were being considered for placement of a percutaneous endoscopic gastrostomy tube in acute care hospitals and mixed-care hospitals in Japan. Questionnaires were used to compare substitute decision makers' knowledge, decisional conflict, and predisposition regarding feeding tube placement before and after exposure to a decision aid. The acceptability of the decision aid was also assessed. Paired t-tests were used to compare participants' knowledge and decisional conflict scores before and after using the decision aid.

RESULTS

Substitute decision makers showed significantly increased knowledge (P < .001) and decreased decisional conflict (P < .01) regarding long-term tube feeding after using the decision aid. All substitute decision makers found the decision aid helpful and acceptable.

CONCLUSIONS

The decision aid facilitated the decision-making process of substitute decision makers by decreasing decisional conflict and increasing knowledge.

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

BACKGROUND & AIMS

It is important to carefully select patients who undergo endoscopic procedures, to optimize health care. Percutaneous endoscopic gastrostomy (PEG) is a frequently performed invasive endoscopic procedure that has been associated with high short-term mortality. We used a national database to determine the incidence of, and factors associated with, in-hospital mortality among patients undergoing PEG.

METHODS

We conducted a nested, case-control, retrospective study using the US Nationwide Inpatient Sample (NIS) to analyze data from all hospitalizations in 2006 with an International Classification of Diseases, 9th revision, procedure code for PEG. Bivariate and multivariate logistic regression analyses were performed using demographic and clinical variables to identify predictors of in-hospital mortality after the procedure. A separate analysis using a propensity score matching technique was conducted to compare mortality with a control cohort. Results were validated in an independent analysis of 2007 NIS data.

RESULTS

In-hospital mortality was 10.8% among 181,196 patients who underwent PEG in 2006 (95% confidence interval, 10.3%-11.3%). Odds of death increased with age (1%/y), congestive heart failure, renal failure, chronic pulmonary disease, coagulopathy, pulmonary circulation disorders, metastatic cancer, and liver disease. The indication for PEG was associated strongly with mortality. Women and patients with diabetes mellitus or paralysis had a lower risk of death. PEG was associated with slightly higher odds of in-hospital mortality compared with patients who did not undergo PEG. Qualitatively and quantitatively similar results were obtained when 2007 NIS data were analyzed.

CONCLUSIONS

The mortality rate is almost 11% among hospital inpatients after PEG. We have identified factors that increase and decrease the risk of death after PEG; these factors could improve patient selection for those most likely to benefit from this procedure.

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.

[Age at the time of gastrostomy placement as a prognostic factor in long-term hospitalized patients]

OBJECTIVE

To evaluate the influence of age at the time of gastrostomy placement as a prognostic factor and examine the survival rate in long-term hospitalized patients with gastrostomy.

METHODS

The subjects were 408 inpatients with gastrostomy admitted to our hospital between December 2005 and March 2012. All inpatients, including the present subjects, received oral care in the form of attendant care by nurses or caregivers. First, the subjects were divided into two groups according to sex. Second, the subjects were divided into four groups according to the age at the time of gastrostomy placement: the sixties group (60-69 years), seventies group (70-79 years), eighties group (80-89 years), and nineties group (90-99 years). Each survival curve was drawn using the Kaplan-Meier method, and the log-rank tests were used for statistical analysis. The Cox proportional hazard models were used to calculate hazard ratios.

RESULTS

The overall survival rates at one year and five years after gastrostomy placement were 75.4% and 23.2%, respectively. The median survival period was 32.2 months. A significantly better prognosis was observed in women than in men; the age-adjusted hazard ratio was 1.748 (95% CI, 1.364-2.242) for men. The eighties and nineties groups exhibited significantly poorer prognoses than that of the sixties group (p<0.008); the sex-adjusted hazard ratios were 2.173 (95% CI, 1.341-3.521) and 3.071 (95% CI, 1.627-5.797), respectively.

CONCLUSIONS

These results suggest that oral care, even after gastrostomy placement, can improve the prognosis in patients with gastrostomy. Physicians should therefore be cautious when recommending gastrostomy placement for patients aged>80 years.

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.

Endoscopy in the elderly

With increasing age, the incidence of both benign and malignant gastrointestinal (GI) disease rises. Endoscopic procedures are commonly performed in elderly and very elderly patients to diagnose and treat GI disorders. There are a number of issues to contemplate when considering performing an endoscopic procedure in an elderly patient, including the anticipated benefits of endoscopy as well as the increased risks associated with procedural sedation and some endoscopic procedures. This review will focus on the yield and safety of endoscopic procedures in older adults.

The Effects of Percutaneous Endoscopic Gastrostomy on Quality of Life in Patients With Dementia

Background

To examine the effects of percutaneous endoscopic gastrostomy (PEG) on quality of life (QOL) in patients with dementia.

Methods

We retrospectively included 53 Japanese community and tertiary hospitals to investigate the relationship between the newly developed PEG and consecutive dementia patients with swallowing difficulty between Jan 1st 2006 and Dec 31st 2008. We set improvements in 1) the level of independent living, 2) pneumonia, 3) peroral intake as outcome measures of QOL and explored the factors associated with these improvements.

Results

Till October 31st 2010, 1,353 patients with Alzheimer’s dementia (33.1%), vascular dementia (61.7%), dementia with Lewy body disease (2.0%), Pick disease (0.6%) and others were followed-up for a median of 847 days (mean 805 ± 542 days). A total of 509 deaths were observed (mortality 59%) in full-followed patients. After multivariate adjustments, improvement in the level of independent living was observed in milder dementia, or those who can live independently with someone, compared with advanced dementia, characterized by those who need care by someone: Odds Ratio (OR), 3.90, 95% confidence interval (95%CI), 1.59 - 9.39, P = 0.003. Similarly, improvement of peroral intake was noticed in milder dementia: OR, 2.69, 95%CI, 1.17 - 6.17, P = 0.02. Such significant associations were not observed in improvement of pneumonia.

Conclusions

These results suggest that improvement of QOL after PEG insertion may be expected more in milder dementia than in advanced dementia.

Time for the world to move beyond the percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is a proven feeding tube, just as the nasogastric tube is proven to be able to deliver enteral nutrition. For long-term use, both patient and caregiver want neither. What is desired is the LOOPPEG^® 3G tube, more secure than the PEG, and less risky to change than the nasogastric tube. Future clinical research should focus on this high-comfort low-risk tube.