A large prospective audit of morbidity and mortality associated with feeding gastrostomies in the community

Proportion of unplanned tube replacements and complications following gastrostomy: A systematic review and meta-analysis

AIMS

Gastrostomy feeding represents a vital component of supportive care provided to people with swallowing or feeding difficulties; however, the rate of specific long-term complications is currently unknown in the adult population. This study aimed to determine the prevalence of specific long-term gastrostomy-related complications and unplanned replacements in adults.

METHODS

A prospective systematic review of Medline, CINAHL and Embase databases was performed. Key complications of hypergranulation, infection and displacement among studies relevant to percutaneous endoscopic gastrostomy tubes, radiologically inserted gastrostomy tubes and balloon replacement tubes were critically appraised by two independent reviewers. Results were synthesised quantitatively in a meta-analysis using random effects where the population and condition were sufficiently homogeneous.

RESULTS

In total, 453 studies were identified, of which 17 met inclusion criteria. 8.5% of adults with a gastrostomy were found to have had an infection ≥42 days after initial tube insertion (p < 0.01), while 13% had hypergranulation (p < 0.01). Displacement occurred in 10.8% of adults (p < 0.01), with age (p < 0.001) and sex (p < 0.001) presenting as a risk factor (R2  = 75%) following meta-regression.

CONCLUSIONS

Approximately 1 in 10 people with a gastrostomy will experience a complication related to either hypergranulation, infection or dislodgement. Age, in combination with sex, may provide a guide for risk of displacement among adult female cohorts, though further studies reporting prevalence of gastrostomy-related complications along with participant demographics are required.

Evaluation of 644 Percutaneous Endoscopic Gastrostomy Patients in a Single Center

OBJECTIVE

Our study aimed to review and evaluate the indications, complications, complication-related risk factors, and mortality rates of percutaneous endoscopic gastrostomy (PEG) performed in a single university hospital.

METHODS

We retrospectively examined hospital records of all 819 patients who underwent PEG between January 2010 and January 2019. Patients whose information was not available for various reasons, who had a history of gastrectomy, who were under 18 years old, and/or who had undergone PEG before, were excluded from the study.

RESULTS

The mean age of the patients was 65.12 ± 15.42 years, and the majority of the patients (60.6%) were female. In the vast majority of patients, the PEG indication was due to neurological causes (71.5%), among which the majority was a stroke. The overall complication rate in our study was 11.2%. The most common was a peristomal infection in 37 (5.7%) patients. Patients who were not under any antibiotic treatment and/or had diabetes mellitus had a higher risk for peristomal infection. Dementia increased the risk of tube dislodgement. The use of clopidogrel, the simultaneous use of aspirin and clopidogrel, and hypertension were independent risk factors for bleeding complications. The one-year mortality risk was significantly higher in patients who underwent PEG due to neurological causes compared to those who underwent PEG due to malignancy or other reasons (p = 0.021, p = 0.038, respectively).

CONCLUSION

The PEG procedure is a safe and feasible technique due to its low complication and mortality rate in patients with swallowing disorders who need long-term nutritional support.

In Home Caregivers' Experiences With Percutaneous Endoscopic Gastrostomy Patients: A Qualitative Review

In home caregivers of patients with percutaneous endoscopic gastrostomy face physical, social, and psychological problems. The results of qualitative studies play a key role in determining in home caregivers' percutaneous endoscopic gastrostomy-related problems, attitudes, views, and experiences. The aim of this review was to survey the literature to assess the problems faced by in home caregivers of percutaneous endoscopic gastrostomy patients and identify solutions to these problems. PubMed, Cochrane, and Web of Science databases were screened using the key words qualitative research, percutaneous endoscopic gastrostomy, enteral nutrition, and mixed method for relevant articles published between 1945 and November 2019. The literature search yielded 446 scholarly articles. Their titles and abstracts were screened for possible inclusion in this review. Fifteen articles that met the inclusion criteria were included in the study. The quality of the included qualitative articles were assessed using the Critical Appraisal Skills Programme Qualitative Research Checklist, whereas mixed-methods articles were assessed using the Mixed Methods Appraisal Tool. Five major themes were developed: percutaneous endoscopic gastrostomy tube problems, training requirement, health support system, effect on life, and tube necessity. We believe that determining caregivers' physical and psychosocial problems around managing patients' percutaneous endoscopic gastrostomy tubes and developing support systems can help solve those problems and improve both patients' and caregivers' quality of life.

Gastrostomy tube migration causing gastric outlet obstruction and gastric perforation in children-two case reports

Gastrostomy creation is a common procedure in paediatric surgery. It provides enteral nutrition to patients who cannot achieve adequate nutrition by mouth. Common indications of gastrostomy placement in children include syndromic or neurodevelopmental diseases, severe malformations of the aerodigestive tract, craniofacial abnormalities, and intractable gastroesophageal reflux disease with recurrent aspiration. It is also indicated in patients who suffer from failure to thrive and require extra caloric intake. In contrast to adults, paediatric patients have a weaker ability to complain about problems with their gastrostomy tubes when they occur, in particular when some of these neurological patients are non-communicable. Complications may arise when migration of the catheter goes unnoticed, causing obstruction. Due to the smaller stomach size, thinner gastric wall and narrower gastric outlet in paediatric patients, obstruction from the gastrostomy balloon may result in serious sequelae. Here we present two unusual but serious complications of gastrostomy tubes causing suspected duodenal obstruction and subsequent gastric perforation in paediatric patients, requiring emergency operations. Furthermore, we would like to emphasize the importance of proper gastrostomy tube care and alert the caretakers of the potential sinister complications that can arise. We would also like to take this opportunity to suggest measures to prevent their occurrence.

Multicenter cohort study of patients with buried bumper syndrome treated endoscopically with a novel, dedicated device

BACKGROUND AND AIMS

Buried bumper syndrome (BBS) is a rare adverse event of percutaneous endoscopic gastrostomy (PEG) placement in which the internal bumper migrates through the stomal tract to become embedded within the gastric wall. Excessive tension between the internal and external bumpers, causing ischemic necrosis of the gastric wall, is believed to be the main etiologic factor. Several techniques for endoscopic management of BBS have been described using off-label devices. The Flamingo set is a novel, sphincterotome-like device specifically designed for BBS management. We aimed to evaluate the effectiveness of the Flamingo device in a large, homogeneous cohort of patients with BBS.

METHODS

A guidewire was inserted through the external access of the PEG tube into the gastric lumen. The Flamingo device was then introduced into the stomach over the guidewire. This dedicated tool can be flexed by 180 degrees, exposing a sphincterotome-like cutting wire, which is used to incise the overgrown tissue until the PEG bumper is exposed. A retrospective, international, multicenter cohort study was conducted on 54 patients between December 2016 and February 2019.

RESULTS

The buried bumper was successfully removed in 53 of 55 procedures (96.4%). The median time for the endoscopic removal of the buried bumper was 22 minutes (range, 5-60). Periprocedural endoscopic adverse events occurred in 7 procedures (12.7%) and were successfully managed endoscopically. A median follow-up of 150 days (range, 33-593) was performed in 29 patients (52.7%), during which no significant adverse events occurred.

CONCLUSIONS

Through our experience, we found this dedicated novel device to be safe, quick, and effective for minimally invasive, endoscopic management of BBS.

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

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

The Hidden Burden of Community Enteral Feeding on the Emergency Department

BACKGROUND

Enteral feeding tubes are associated with their most serious complications in the days and weeks after insertion, but there are limited published data in the literature on late complications and the implications for the healthcare service.

METHODS

This is a retrospective observational study of attendances to a UK hospital emergency department (ED), with enteral tube complications as the primary reason for attendance.

RESULTS

Over 24 months, 139 attendances were recorded. Dislodged tubes and blocked tubes accounted for the majority of complications and subsequent admissions, with a mixture of enteral tube types being associated with both. Thirty-five percent of patients were admitted, and the average healthcare cost per attendance was $1071.

CONCLUSION

Enteral tube complications can place a hidden burden on the patient, the ED, and healthcare costs. More work on education and supporting caregivers to resolve problems themselves could reduce the burden on busy EDs.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Gastropexy can be as safe as conventional percutaneous endoscopic gastrostomy (PEG), and biomarkers do not predict short-term or long-term outcomes: a 7-year follow-up audit

OBJECTIVE

Gastrostomy facilitates artificial enteral feeding but controversy exists around associated morbidity and mortality. This study aimed to report short and long-term outcomes, and identify parameters associated with overall survival.

METHODS

A 7-year follow-up audit was undertaken at Aberdeen Royal Infirmary, UK. All patients undergoing endoscopic gastrostomy insertion October 2011-September 2018 were included. Last follow-up was February 2019. Clinical data were prospectively collected. Blood results were retrospectively obtained from electronic records. Statistical analysis was with IBM SPSS V.25.

RESULTS

691 procedures were performed over the 7-year period (520 traditional pull-through percutaneous endoscopic gastrostomy (PEG) and 171 gastropexy procedures to facilitate gastrostomy). Frequency of complications (gastrointestinal bleeding, perforation and peritonitis) was low (each n=1). Overall 7-day and 30-day mortality was 2.2% and 8.4%, respectively. One-year mortality reached 47.6%. There was no difference in survival between PEG and gastropexy procedures (p=0.410). Multivariate analysis reported increased age (p<0.001), increased alkaline phosphatase (p<0.001) and clinical indication (p=0.002) as independently associated with an increased hazard of death. Only age was moderately predictive of mortality (area under the curve 0.74, 95% CI 0.70 to 0.78, p<0.001) in the PEG group. Clinical indication was the only parameter independently associated with mortality in the gastropexy cohort (p=0.003).

CONCLUSION

Endoscopic gastrostomy placement can be safe with a low mortality and low risk of serious complications. Blood markers were not associated with short-term or long-term outcomes. Gastropexy to facilitate gastrostomy is a safe alternative to traditional pull-through PEG procedures. Future work should consider quality of life outcomes to assess the benefit of gastrostomy from a patient perspective.

Outcomes following feeding gastrostomy (FG) insertion in patients with learning disability: a retrospective cohort study using the health improvement network (THIN) database

OBJECTIVES

To measure the rates of lower respiratory tract infection (LRTI) and mortality following feeding gastrostomy (FG) placement in patients with learning disability (LD). Following this to compare these rates between those having LRTI prior to FG placement and those with no recent LRTI.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The study population included patients with LD undergoing FG placement in the 'The Health Improvement Network' database. Patients with LRTI in the year prior (LYP) to their FG placement were compared with patients without a history of LRTI in the year prior (non-LYP) to FG placement. FG placement and LD were identified using Read codes previously developed by an expert panel.

MAIN OUTCOME MEASURES

Incidence rate ratio (IRR) of developing LRTI and mortality following FG, comparing patients with LRTI in the year prior to FG placement to patients without a history of LRTI.

RESULTS

214 patients with LD had a FG inserted including 743.4 person years follow-up. 53.7% were males and the median age was 27.6 (IQR 19.6 to 38.6) years. 27.1% were in the LYP patients. 18.7% had a LRTI in the year following FG, with an estimated incidence rate of 254 per 1000-person years. Over the study period the incidence rate of LRTI in LYP patients was 369 per 1000-person years, in non-LYP patients this was 91 per 1000-person years (adjusted IRR 4.21 (95% CI 2.68 to 6.63) p<0.001). 27.1% of patients died during study follow-up. Incidence rate of death was 80 and 45 per 1000-person year for LYP and non-LYP patients, respectively (adjusted IRR 1.80 (1.00 to 3.23) p=0.05).

CONCLUSION

In LD patients, no clinically meaningful reduction in LRTI incidence was observed following FG placement. Mortality and LRTI were higher in patients with at least one LRTI in the year preceding FG placement, compared with those without a preceding LRTI.

Home Percutaneous Endoscopic Gastrostomy Feeding: Difficulties and Needs of Caregivers, Qualitative Study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) may cause complications when adequate and appropriate care is not provided. To avoid these complications, caregivers' experiences and practices must be considered.

METHODS

This study used the phenomenological qualitative research method. Twenty-one caregivers underwent in-depth interviews and were observed for PEG practices. Interview and observational data were analyzed using content analysis.

RESULTS

This study revealed 8 themes and 24 subthemes under 3 categories of PEG management, social-emotional change of the caregivers, and expectations, and it was observed that caregivers made errors in stoma care, tube feeding, and medication administration through the PEG tube.

CONCLUSION

Results indicated that comprehensive and practical discharge training, and home care and counseling services should be provided to effectively address the challenges faced by caregivers of patients with PEG.

How long do percutaneous endoscopic gastrostomy feeding tubes last? A retrospective analysis

Background

Percutaneous endoscopic gastrostomy (PEG) tubes allow for long-term enteral feeding. Disk-retained PEG tubes may be suitable for long-term usage without planned replacement, but data on longevity are limited. We aimed to assess the rates and predictors of PEG longevity and post-PEG mortality.

Design

Single-centred retrospective cohort study of patients with disk-retained (Freka) PEG tubes.

Methods

All patients undergoing PEG between 2010 and 2013 were identified, and retrospective analysis of outcomes until 2017 (median 1062 days) was performed. Time-to-event data were plotted using Kaplan-Meier curves, with predictors of survival derived from multivariate Cox-regression analyses.

Results

277patients were studied, with a median age of 74 years (IQR 59–82). PEG tube failure occurred in 17.4%, due to: buried bumper syndrome (7.0%), split/broken tube (6.3%), peristomal infection (1.8%) and dislodged tube (1.1%). PEG tube longevity was 95.1% (1 year) and 68.5% (5 year), with age <70 (HR 2.65, 95% CI 1.25 to 5.62, p=0.011) being predictive of PEG failure. Post-PEG mortality was 10.5% (30 day), 35.4% (1 year) and 59.7% (5 year). Age ≥70 was associated with mortality (HR 2.79, 95% CI 1.92 to 4.05, p<0.001), whereas PEG failure (HR 0.46, 95% CI 0.27 to 0.77, p=0.003) and elective PEG removal (HR 0.23, 95% CI 0.08 to 0.64, p=0.005) were associated with reduced mortality.

Conclusions

68.5% of PEG tubes remain intact after 5 years. Younger age was associated with earlier PEG failure, whereas younger age, PEG replacement and elective PEG tube removal were associated with improved survival. These data may inform future guidance for elective PEG tube replacements.