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Mohamed Elfadil O, Velapati SR, Patel J, Hurt RT, Mundi MS. Enteral Nutrition Therapy: Historical Perspective, Utilization, and Complications. Curr Gastroenterol Rep 2024; 26:200-210. [PMID: 38787510 DOI: 10.1007/s11894-024-00934-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF REVIEW Enteral nutrition (EN) therapy can provide vital nutrition support for patients with various medical conditions as long as it is indicated and supported by ethical reasoning. This review seeks to offer a detailed account of the history of EN development, highlighting key milestones and recent advances in the field. Additionally, it covers common complications associated with EN and their management. RECENT FINDINGS After years of research and development, we have reached newer generations of enteral feeding formulations, more options for enteral tubes and connectors, and a better understanding of EN therapy challenges. Given the availability of many different formulas, selecting a feeding formula with the best evidence for specific indications for enteral feeding is recommended. Initiation of enteral feeding with standard polymeric formula remains the standard of care. Transition to small-bore connectors remains suboptimal. Evidence-based practices should be followed to recognize and reduce possible enteral feeding complications early.
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Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Saketh R Velapati
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Janki Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
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2
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Grund KE, Zipfel A, Jost WH. [Intrajejunal levodopa in Parkinson's disease: Optimization of PEG application]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024. [PMID: 38959947 DOI: 10.1055/a-2337-3433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
The various forms of Percutaneous Endoscopic Gastrostomy (PEG) are highly relevant in neurology, as pump-administered intrajejunal levodopa application is one of the indispensable forms of therapy in advanced Parkinson's disease. Optimal PEG placement and follow-up are therefore significant for the success of the therapy. However, the standard intrajejunal administration of levodopa gel via a JET-PEG, i. e. a PEG with an internal catheter inserted into the jejunum, is not without problems for various reasons. In particular, the considerable cumulative complication rates demand a reconsideration of the situation. The very limited absorption area of the drug in the region of the flexura duodenojejunalis must also be taken into account. Causes of complications are predominantly a non-optimal application technique of PEG and internal catheter as well as the frequent lack of an adequate follow-up. In this paper, the details of a modified and optimized application technique compared to the conventional techniques are presented. These new methods have proved their usefulness in clinical applications for years, and additionally a new application form, the Hybrid-PEG, is presented. However, many of the details derived from anatomical/physiological, surgical and endoscopic aspects must be strictly observed during the application in order to reduce or avoid minor and major complications. In particular, problems are caused by local infections in the area of the insertion point of the PEG including peritonitis, leaks and buried bumper syndrome (BBS). The relatively frequent dislocations of the internal catheter also prove to be particularly troublesome. These can ultimately be avoided by clip fixation of the catheter tip down in the jejunum. In particular, the use of the newly developed Hybrid-PEG, a combination of endoscopically controlled gastropexy with three sutures and subsequent central thread-pull-through of the PEG tube, can significantly reduce the complication rate and thus achieve a decisive improvement for patients. The aspects discussed here are highly relevant for all those involved in the therapy of advanced Parkinson's disease. Trustful interdisciplinary collaboration between neurology and endoscopy/surgery/gastroenterology is a prerequisite for good clinical outcomes.
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Affiliation(s)
- Karl-Ernst Grund
- Experimentelle chirurgische Endoskopie, Universitätsklinikum Tübingen, Universitätsklinik für Allgemeine Viszeral- und Transplantationschirurgie, Tübingen, Germany
| | - Annette Zipfel
- Experimentelle chirurgische Endoskopie, Universitätsklinikum Tübingen, Universitätsklinik für Allgemeine Viszeral- und Transplantationschirurgie, Tübingen, Germany
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3
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Novak I, Velazco NK. Gastrostomy Tubes: Indications, Types, and Care. Pediatr Rev 2024; 45:175-187. [PMID: 38556513 DOI: 10.1542/pir.2022-005647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Gastrostomy tube insertion has become a more common practice in pediatric patients. An increasing number of children both in health-care facilities and at home are relying on temporary or long-term enteral feeding. Gastrostomy tube placement can be accomplished by various methods and by a variety of specialists. Despite the overall safety of these procedures, both early and late complications can occur. It is important for pediatricians and pediatric subspecialists to be familiar with and aware of the indications, safety, and management of gastrostomies. This paper provides a comprehensive overview of the topic.
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Affiliation(s)
- Inna Novak
- Children's Hospital at Montefiore, Bronx, NY
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Tae CH, Lee JY, Joo MK, Park CH, Gong EJ, Shin CM, Lim H, Choi HS, Choi M, Kim SH, Lim CH, Byeon JS, Shim KN, Song GA, Lee MS, Park JJ, Lee OY. Clinical Practice Guideline for Percutaneous Endoscopic Gastrostomy. Gut Liver 2024; 18:10-26. [PMID: 37850251 PMCID: PMC10791499 DOI: 10.5009/gnl230146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/06/2023] [Accepted: 06/20/2023] [Indexed: 10/19/2023] Open
Abstract
With an aging population, the number of patients with difficulty swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. Long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach, aided endoscopically, which may be an alternative to a nasogastric tube when enteral nutritional is required for 4 weeks or more. This paper is the first Korean clinical guideline for PEG. It was developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tubes removal for PEG based on the currently available clinical evidence.
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Affiliation(s)
- Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Ju Yup Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyun Lim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyuk Soon Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Sang Hoon Kim
- Department of Gastroenterology, Dongguk University Ilsan Hospital, Goyang, Korea
- Korean College of Helicobacter and Upper Gastrointestinal Research–Metabolism, Obesity & Nutrition Research Group, Seoul, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Korean Society of Gastrointestinal Endoscopy–The Research Group for Endoscopes and Devices, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University College of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moon Sung Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jong-Jae Park
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea
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Kucha P, Zorniak M, Szmit M, Lipczynski R, Wieszczy-Szczepanik P, Kapala A, Wojciechowska U, Didkowska J, Rupinski M, Olesinski T, Maj T, Regula J, Kaminski MF, Januszewicz W. To push or to pull? A clinical audit on the efficacy and safety of the pull and push percutaneous endoscopic gastrostomy techniques in oncological patients. United European Gastroenterol J 2023; 11:951-959. [PMID: 37948117 PMCID: PMC10720683 DOI: 10.1002/ueg2.12467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/21/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The peroral "pull" technique and the direct "push" procedure are the two main methods for percutaneous endoscopic gastrostomy (PEG) placement. Although pull-PEG is generally recommended as the first-line modality, many oncological patients require a push-PEG approach to prevent tumor seeding or overcome tumor-related obstruction. OBJECTIVE We aimed to compare the efficacy and safety of both PEG procedures in cancer patients. METHODS We retrospectively analyzed all consecutive PEG procedures within a tertiary oncological center. Patients were followed up with the hospital databases and National Cancer Registry to assess the technical success rate for PEG placement, the rate of minor and major adverse events (AEs), and 30-day mortality rates. We compared those outcomes between the two PEG techniques. Finally, risk factors for PEG-related adverse events were analyzed using a multivariable Cox proportional-hazard regression model adjusted for patients' sex, age, performance status (ECOG), Body Mass Index (BMI), diabetes, chemoradiotherapy (CRT) status (pre-/current-/post-treatment), and type of PEG. RESULTS We included 1055 PEG procedures (58.7% push-PEG/41.4% pull-PEG) performed in 994 patients between 2014 and 2021 (mean age 62.0 [±10.7] yrs.; 70.2% males; indication: head-and-neck cancer 75.9%/other cancer 24.1%). The overall technical success for PEG placement was 96.5%. Although the "push" technique had a higher rate of all AEs (21.4% vs. 7.1%, Hazard Ratio [HR] = 2.9; 95% CI = 1.9-4.3, p < 0.001), most of these constituted minor AEs (71.9%), such as tube dislodgement. The methods had no significant difference regarding major AEs and 30-day mortality rates. Previous CRT was associated with an increased risk of major AEs (hazard ratio = 2.7, 95% CI = 1.0-7.2, p = 0.042). CONCLUSION The risk of major AEs was comparable between the push- and pull-PEG techniques in cancer patients. Due to frequent tube dislodgement in push-PEG, the pull technique may be more suitable for long-term feeding. Previous CRT increases the risk of major AEs, favoring early ("prophylactic") PEG placement when such treatment is expected.
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Affiliation(s)
- Piotr Kucha
- Department of Gastroenterology, Hepatology, and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Michal Zorniak
- Department of Gastroenterology, Hepatology, and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Mateusz Szmit
- Department of Gastroenterology, Hepatology, and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Rafal Lipczynski
- Department of Gastroenterology, Hepatology, and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Paulina Wieszczy-Szczepanik
- Department of Gastroenterology, Hepatology, and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Aleksandra Kapala
- Department of Clinical Nutrition, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Urszula Wojciechowska
- Polish National Cancer Registry, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Joanna Didkowska
- Polish National Cancer Registry, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Maciej Rupinski
- Department of Gastroenterology, Hepatology, and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Oncological Gastroenterology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Tomasz Olesinski
- Department of Oncological Gastroenterology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Tomasz Maj
- Department of Oncological Gastroenterology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jaroslaw Regula
- Department of Gastroenterology, Hepatology, and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Oncological Gastroenterology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology, and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Oncological Gastroenterology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Wladyslaw Januszewicz
- Department of Gastroenterology, Hepatology, and Clinical Oncology, Center of Postgraduate Medical Education, Warsaw, Poland
- Department of Oncological Gastroenterology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Colletier K, Toy G, Freeman R, Dixon R, Morris J, Sossenheimer M, Fang J. Safety and efficacy of direct percutaneous endoscopic jejunostomy placement in patients with previous upper gastrointestinal resection: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:796-801. [PMID: 37291075 DOI: 10.1002/jpen.2531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Percutaneous jejunal enteral access can be obtained with percutaneous endoscopic gastric jejunostomy (PEGJ) and direct percutaneous endoscopic jejunostomy (DPEJ) tubes. PEGJ may not be feasible in patients with previous gastric resection (PGR) and DPEJ may be the only option. Our aim is to determine if DPEJ tubes can be placed successfully in patients with history of gastrointestinal (GI) surgery and if success rates are comparable to DPEJ or PEGJ in those without prior GI surgery. METHODS We reviewed all tube placements performed from 2010 to present. Procedures were performed using a pediatric colonoscope. Previous upper GI surgery was defined as PGR or esophagectomy with gastric pull-up. Adverse events (AEs) were graded per American Society for Gastrointestinal Endoscopy criteria. Mild events included unplanned medical consultation or hospitalization <3 days, and moderate events included repeat endoscopy without surgical intervention. RESULTS Successful placement rates were high regardless of GI surgical history. Patients receiving a DPEJ with a history of GI surgery were significantly less likely to experience an AE compared with those receiving DPEJ with no history and compared with PEGJ patients with or without a history. CONCLUSIONS DPEJ placement in patients with previous upper GI surgery has very high success rate. It is associated with lower AE rates than patients receiving DPEJ without previous gastric surgery, or PEGJ regardless of previous gastric surgery. Patients with a history of upper GI surgery requiring enteral access may benefit from DPEJ over PEGJ placement considering its very high success rate and lower incidence of AEs.
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Affiliation(s)
- Keegan Colletier
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
- Division of Gastroenterology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Greg Toy
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
| | - Ryan Freeman
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Robert Dixon
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
- Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - John Morris
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
| | | | - John Fang
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
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Shah A, Busch RA, Koepsel EK, Eisa M, Woods M, Palchaudhuri S. Who Places Feeding Tubes and in What Scenario? Curr Gastroenterol Rep 2023:10.1007/s11894-023-00880-x. [PMID: 37452152 DOI: 10.1007/s11894-023-00880-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE OF REVIEW Enteral feeding is commonly used to provide patients with nutrition. Access via feeding tubes can be attained by multiple medical specialties through a variety of methods. RECENT FINDINGS There are limited data available on direct comparisons amongst gastroenterologist, interventional radiologists and surgeons, although there appears to be similar rates of complications. Fluroscopically and surgically placed feeding tubes may have a higher technical success rate than endoscopically placed tubes. The preferred specialty for feeding tube placement varies per institution, often due to logistical matters over technique or concern for complications. Ideally, a multidisciplinary team should exist to determine which approach is best in a patient-specific manner.
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Affiliation(s)
- Apeksha Shah
- Division of Gastroenterology and Hepatology, Cooper University Healthcare, Camden, NJ, USA.
- Division of Gastroenterology, Cooper Medial School of Rowan University (CMSRU), Cooper University Hospital, Camden, NJ, USA.
| | - Rebecca A Busch
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Erica Knavel Koepsel
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Mohamed Eisa
- Allegheny Center for Digestive Health, Allegheny Health Network, Pittsburgh, PA, USA
| | - Michael Woods
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sonali Palchaudhuri
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
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Mondorf A, Amini C, Graf C, Michael FA, Blumenstein I, Jung M, Friedrich-Rust M, Hack D, Besier SM, Hogardt M, Kempf VAJ, Zeuzem S, Welsch C, Bojunga J. Risk Factors and Role of Antibiotic Prophylaxis for Wound Infections after Percutaneous Endoscopic Gastrostomy. J Clin Med 2023; 12:jcm12093175. [PMID: 37176616 PMCID: PMC10179185 DOI: 10.3390/jcm12093175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/29/2023] [Accepted: 04/05/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND AND STUDY AIM The incidence of wound infections after percutaneous endoscopic gastrostomy (PEG) varies widely in recent studies. The present study systematically investigates the underlying risk factors for the development of wound infections in a large cohort of patients over a long-term follow-up period. PATIENTS AND METHODS A retrospective cohort study of patients undergoing PEG insertion using either the pull or push technique was conducted and patients followed up for 3 years. Tube-related wound infections were identified, and pathogens regularly cultured from wound swabs. Adjusted analysis was performed via univariate and multivariate logistic regression analysis. RESULTS 616 patients were included in this study. A total of 25% percent of patients developed wound infections upon PEG tube insertion and 6.5% showed recurrent infections. Nicotine abuse (p = 0.01), previous ischemic stroke (p = 0.01) and head and neck cancer (p < 0.001) showed an increased risk for wound infection after PEG placement. Moreover, radio-chemotherapy was associated with the occurrence of wound infections (p < 0.001). Infection rates were similar between pull and push cohorts. The most common bacterial pathogen detected was Enterobacterales (19.2%). Staphylococcus aureus, Pseudomonas aeruginosa and enterococci were frequently detected in recurrent infection (14.2%, 11.4% and 9.6%, respectively). Antibiotic prophylaxis showed no effect on infection rates. CONCLUSIONS Wound infections after PEG placement are common and occasionally occur as recurrent infections. There is potential for improvement in everyday clinical practice, particularly regarding antibiotic prophylaxis in accordance with guidelines.
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Affiliation(s)
- Antonia Mondorf
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
| | - Clara Amini
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
| | - Christiana Graf
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
| | - Florian Alexander Michael
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
| | - Irina Blumenstein
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
| | - Michael Jung
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
| | - Daniel Hack
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, 60596 Frankfurt am Main, Germany
| | - Silke M Besier
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, 60596 Frankfurt am Main, Germany
| | - Michael Hogardt
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, 60596 Frankfurt am Main, Germany
| | - Volkhard A J Kempf
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, 60596 Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
| | - Christoph Welsch
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
| | - Jörg Bojunga
- Department of Internal Medicine 1, Goethe University Hospital Frankfurt, Goethe-University, 60596 Frankfurt am Main, Germany
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Vadivelu N, Kodumudi G, Leffert LR, Pierson DC, Rein LK, Silverman MS, Cornett EM, Kaye AD. Evolving Therapeutic Roles of Nasogastric Tubes: Current Concepts in Clinical Practice. Adv Ther 2023; 40:828-843. [PMID: 36637690 PMCID: PMC9838367 DOI: 10.1007/s12325-022-02406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/08/2022] [Indexed: 01/14/2023]
Abstract
Nasogastric tubes (NGT) have been in use for over 100 years and are still considered as essential and resuscitative tools in multiple medical specialties for acute and chronic care. They are vital for decompression of the stomach in the presence of bowel obstruction in the critically ill and useful as a conduit for the administration of medications and sometimes for short term parenteral nutrition. The placement of nasogastric tubes is relatively routine. However, they must be inserted and maintained safely and effectively to avoid serious and possibly even fatal associated complications. This review focuses on recent updates in research regarding nasogastric tubes. Cognizance of the recent advances in indications, contraindications, techniques of insertion, confirmation of correct positioning, securement, complications, management of complications, and state of the art research about the nasogastric tube is crucial for practitioners of all medical and surgical specialties.
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Affiliation(s)
- Nalini Vadivelu
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Gopal Kodumudi
- grid.411417.60000 0004 0443 6864Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Hwy, Shreveport, LA 71103 USA
| | - Lisa R. Leffert
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Doris C. Pierson
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Laura K. Rein
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Matthew S. Silverman
- grid.47100.320000000419368710Department of Anesthesiology, Yale University School of Medicine, 333, Cedar Street, New Haven, CT 06520 USA
| | - Elyse M. Cornett
- grid.411417.60000 0004 0443 6864Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Hwy, Shreveport, LA 71103 USA
| | - Alan D. Kaye
- grid.411417.60000 0004 0443 6864Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Hwy, Shreveport, LA 71103 USA
- grid.279863.10000 0000 8954 1233Department of Anesthesiology, Louisiana State University Health Sciences Center at New Orleans, 1542 Tulane Avenue Room 659, New Orleans, LA 70112 USA
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Storm AC, AbiMansour JP, Bofill-Garcia A, Mahmoud T, Rapaka B, Lescalleet KE, Dayyeh BKA. Use of an intragastric trocar to perform a novel stapling procedure for reflux disease. Endosc Int Open 2022; 10:E1508-E1513. [PMID: 36397862 PMCID: PMC9666069 DOI: 10.1055/a-1933-6573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022] Open
Abstract
Background and study aims A percutaneous intragastric trocar (PIT) enables intraluminal use of laparoscopic tools and helps overcome traditional limitations of endoscopy. The aim of this study was to determine the efficacy of using a PIT to perform an anti-reflux stapling procedure. Materials and methods Trocars were placed in four animals and an articulating stapler was used to perform fundoplication under endoscopic guidance. Animals were monitored for 14 days post-procedure. Functional lumen imaging of the esophagogastric junction (EGJ) was performed at baseline, immediately post-intervention, and at 14 days. Results The procedure was successful in all animals who survived to day 14 without distress or significant adverse events. Baseline EGJ distensibility was 5.0 ± 1.2 mm 2 /mmHg, 2.7 ± 0.7 mm 2 /mmHg post-procedurally, and 3.0 ± 0.8mm 2 /mmHg on day 14. Average change in distensibility pre- and post-procedure was -2.3 ± 1.8 mm 2 /mmHg (95 % confidence interval [CI] -0.5 to 5.1, P = 0.08) while change in pre- and day 14 distensibility was -2.0 ± 1.4 mm 2 /mmHg (95 % CI -0.1 to 4.2, P = 0.06). Conclusions An intragastric trocar allows for use of large-diameter laparoscopic instruments to safely and effectively perform endoluminal fundoplication with anti-reflux properties that persist for at least 14 days.
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Affiliation(s)
- Andrew C. Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Developmental Endoscopy Unit, Mayo Clinic, Rochester, Minnesota, United States
| | - Jad P. AbiMansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Aliana Bofill-Garcia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Babusai Rapaka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kristin E. Lescalleet
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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11
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Reddy KM, Lee P, Gor PJ, Cheesman A, Al-Hammadi N, Westrich DJ, Taylor J. Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes. World J Gastrointest Pharmacol Ther 2022; 13:77-87. [PMID: 36157266 PMCID: PMC9453443 DOI: 10.4292/wjgpt.v13.i5.77] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/22/2022] [Accepted: 08/18/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Percutaneous Endoscopic Gastrostomy (PEG) tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake. The 2011 ASGE guidelines recommend delaying PEG tube placement for two weeks, as half of patients with dysphagia improve within 2 wk. There are few studies comparing outcomes based on timing of PEG tube placement, and there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehab and skilled nursing facilities.
AIM To assess the safety of early (≤ 7 d post stroke) vs late (> 7 d post stroke) PEG tube placement and evaluate whether pre-procedural risk factors could predict mortality or complications.
METHODS We performed a retrospective study of patients undergoing PEG tube placement for dysphagia following a stroke at two hospitals in Saint Louis, MO between January 2011 and December 2017. Patients were identified by keyword search of endoscopy reports. Mortality, peri-procedural complication rates, and post-procedural complication rates were compared in both groups. Predictors of morbidity and mortality such as protein-calorie malnutrition, presence of an independent cardiovascular risk equivalent, and presence of Systemic inflammatory response syndrome (SIRS) criteria or documented infection were evaluated by multivariate logistic regression.
RESULTS 154 patients had a PEG tube placed for dysphagia following a stroke, 92 in the late group and 62 in the early group. There were 32 observed deaths, with 8 occurring within 30 d of the procedure. There was an increase in peri-procedural and post-procedural complications with delayed PEG placement which was not statistically significant. Hospital length of stay was significantly less in patients with early PEG tube placement (12.9 vs 22.34 d, P < 0.001). Protein calorie malnutrition, presence of SIRS criteria and/or documented infection prior to procedure or having a cardiovascular disease risk equivalent did not significantly predict mortality or complications.
CONCLUSION Early PEG tube placement following a stroke did not result in a higher rate of mortality or complications and significantly decreased hospital length of stay. Given similar safety outcomes in both groups, early PEG tube placement should be considered in the appropriate patient to potentially reduce length of hospital stay and incurred costs.
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Affiliation(s)
- Kavya M Reddy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095, United States
| | - Preston Lee
- Department of Internal Medicine, Santa Clara Valley Medical Center, San Jose, CA 95128, United States
| | - Parul J Gor
- Division of Gastroenterology and Hepatology, Mercy Hospital, Saint Louis, MO 63141, United States
| | - Antonio Cheesman
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO 63104, United States
| | - Noor Al-Hammadi
- Saint Louis University Center for Health Outcomes Research, Saint Louis University, Saint Louis, MO 63104, United States
| | - David John Westrich
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO 63104, United States
| | - Jason Taylor
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO 63104, United States
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12
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The Outcomes of Nutritional Support Techniques in Patients with Gastrointestinal Cancers. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13030025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Gastrointestinal cancers represent a major cause of morbidity and mortality worldwide. A significant issue regarding the therapeutic management of these patients consists of metabolic disturbances and malnutrition. Nutritional deficiencies have a negative impact on both the death rates of these patients and the results of surgical or oncological treatments. Thus, current guidelines recommend the inclusion of a nutritional profile in the therapeutic management of patients with gastrointestinal cancers. The development of digestive endoscopy techniques has led to the possibility of ensuring the enteral nutrition of cancer patients without oral feeding through minimally invasive techniques and the avoidance of surgeries, which involve more risks. The enteral nutrition modalities consist of endoscopy-guided nasoenteric tube (ENET), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy with jejunal tube extension (PEG-J), direct percutaneous endoscopic jejunostomy (DPEJ) or endoscopic ultrasound (EUS)-guided gastroenterostomy.
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13
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Fugazza A, Capogreco A, Cappello A, Nicoletti R, Da Rio L, Galtieri PA, Maselli R, Carrara S, Pellegatta G, Spadaccini M, Vespa E, Colombo M, Khalaf K, Repici A, Anderloni A. Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques. World J Gastrointest Endosc 2022; 14:250-266. [PMID: 35719902 PMCID: PMC9157691 DOI: 10.4253/wjge.v14.i5.250] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/03/2021] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Antonio Capogreco
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Annalisa Cappello
- Unit of Gastroenterology and Digestive Endoscopy, AUSL Bologna Bellaria-Maggiore Hospital, Bologna 40121, Italy
| | - Rosangela Nicoletti
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Leonardo Da Rio
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Piera Alessia Galtieri
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Roberta Maselli
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Gaia Pellegatta
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Kareem Khalaf
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20072, Milan, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
| | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital - IRCCS, Rozzano 20089, Milan, Italy
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Philipose J, Gurala D, Polavarapu AD, Idiculla PS, Gumaste V. Can You Save the Site?: A Novel Approach to Percutaneous Endoscopic Gastrostomy Tube Replacement. Cureus 2021; 13:e20718. [PMID: 35141055 PMCID: PMC8802737 DOI: 10.7759/cureus.20718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 11/05/2022] Open
Abstract
Inadvertent removal or dislodgement is the most commonly encountered complication in patients with percutaneous endoscopic gastrostomy (PEG) tube. Once the gastrocutaneous fistula is formed, bedside tube replacement can be performed at the same site, within 24 hours of dislodgement. Usually, after this timeframe, the tract closes; hence, it is recommended to perform a replacement at a different site. We report a case of a 52-year-old female who presented after 24 hours of inadvertent PEG tube removal. A replacement was performed successfully via endoscopy at the same site of the erstwhile PEG tube, although it appeared to be closed.
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Mohamed Elfadil O, Ewy M, Patel J, Patel I, Mundi MS. Growing use of home enteral nutrition: a great tool in nutrition practice toolbox. Curr Opin Clin Nutr Metab Care 2021; 24:446-452. [PMID: 34148970 DOI: 10.1097/mco.0000000000000777] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Home enteral nutrition (HEN) is a well-established practical nutrition therapy tool that is typically managed by an interdisciplinary team. Prevalence of HEN is increasing across the globe given significant evidence for utility, feasibility, efficacy, safety, and reliability of HEN in helping patients meeting their nutrition needs. The current review highlights the growing use of HEN in the context of what is novel in the field including trends in HEN practice with regards to tubes and connectors, feeding formula and real food blends, and common complications. The review also highlights that the use of HEN is expected to expand further over coming years emphasizing the need for national consensus recommendations and guidelines for HEN management. RECENT FINDINGS The growing use of HEN has always been parallel to adoption of holistic definitions and concept of malnutrition in clinical nutrition practice and more understanding of the need for malnutrition risk stratification, meeting unmet needs in practice and addressing challenges that lead to suboptimal enteral nutrition. SUMMARY Research and advancements in technology as well as in tube feeding formula industry have led to the development of more solutions and have helped identify and implement best HEN practices.
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Affiliation(s)
| | - Matthew Ewy
- Division of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalpan Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition
| | - Ishani Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition
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16
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Bleeding Risk and Mortality Associated With Uninterrupted Antithrombotic Therapy During Percutaneous Endoscopic Gastrostomy Tube Placement. Am J Gastroenterol 2021; 116:1868-1875. [PMID: 34158462 DOI: 10.14309/ajg.0000000000001348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 05/17/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Antithrombotic therapy is often interrupted before the placement of a percutaneous endoscopic gastrostomy (PEG) tube because of potentially increased risk of hemorrhagic events. The aim of our study was to evaluate the risk of bleeding events and overall complication rates after PEG in patients on uninterrupted antiplatelet and anticoagulation therapy in a high-volume center. METHODS Data regarding demographics, diagnoses, comorbidities, and clinical outcomes pertinent to PEG were collected from 2010 to 2016. Furthermore, data regarding antithrombotic therapy along with the rate of minor or major complications including bleeding associated with this procedure were analyzed. Significant bleeding was defined as postprocedure bleeding from PEG site requiring a blood transfusion and/or surgical/endoscopic intervention. RESULTS We included 1,613 consecutive PEG procedures in this study, of which 1,540 patients (95.5%) received some form of uninterrupted antithrombotic therapy. Of those patients, 535 (34.7%) were on aspirin, 256 (16.6%) on clopidogrel, and 119 (7.7%) on both aspirin and clopidogrel. Subcutaneous heparin was uninterrupted in 980 (63.6%), intravenous heparin in 34 (2.1%), warfarin in 168 (10.9%), and direct-acting oral anticoagulation in 82 (5.3%) patients who overlapped on multiple drugs. We observed 6 significant bleeding events in the entire cohort (0.39%), and all were in subcutaneous heparin groups either alone or in combination with aspirin. No clinically significant bleeding was noted in patients on uninterrupted aspirin, warfarin, clopidogrel, or direct-acting oral anticoagulation groups. Only 5 patients (0.31%) had PEG-related mortality. DISCUSSION The risk of significant bleeding associated with the PEG placement was minimal in patients on uninterrupted periprocedural antithrombotic therapy.
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17
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Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment. Gastrointest Endosc 2021; 93:1077-1085.e1. [PMID: 32931781 DOI: 10.1016/j.gie.2020.09.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS A gastrostomy tube is often required for inpatients requiring long-term nutritional access. We compared the safety and outcomes of 3 techniques for performing a gastrostomy: percutaneous endoscopic gastrostomy (PEG), fluoroscopy-guided gastrostomy by an interventional radiologist (IR-gastrostomy), and open gastrostomy performed by a surgeon (surgical gastrostomy). METHODS Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a gastrostomy from 2016 to 2017. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System. The selected patients were divided into 3 cohorts: PEG (0DH64UZ), IR-gastrostomy (0DH63UZ), and open surgical gastrostomy (0DH60UZ). Adjusted odds ratios for adverse events associated with each technique were calculated using multivariable logistic regression analysis. RESULTS Of the 184,068 patients meeting the selection criteria, the route of gastrostomy tube placement was as follows: PEG, 16,384 (53.7 ± 29.0 years); IR-gastrostomy, 154,007 (67.2 ± 17.5 years); and surgical gastrostomy, 13,677 (57.9 ± 24.3 years). Compared with PEG, the odds for colon perforation using IR-gastrostomy and surgical gastrostomy, respectively, were 1.90 (95% confidence interval [CI], 1.26-2.86; P = .002) and 6.65 (95% CI, 4.38-10.12; P < .001), for infection of the gastrostomy 1.28 (95% CI, 1.07-1.53; P = .006) and 1.61 (95% CI, 1.29-2.01; P < .001), for hemorrhage requiring blood transfusion 1.84 (95% CI, 1.26-2.68; P = .002) and 1.09 (95% CI, .64-1.86; P = .746), for nonelective 30-day readmission 1.07 (95% CI, 1.03-1.12; P = .0023) and 1.13 (95% CI, 1.06-1.2; P = .0002), and for inpatient mortality 1.09 (95% CI, 1.02-1.17; P = .0114) and 1.55 (95% CI, 1.42-1.69; P < .0001). CONCLUSIONS Placement of a gastrostomy tube (PEG) endoscopically is associated with a significantly lower risk of inpatient adverse events, mortality, and readmission rates compared with IR-gastrostomy and open surgical gastrostomy.
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18
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Wescott B, Seegmiller S, Mohamed Elfadil O, Schneckloth J, Hurt RT, Mundi MS. Seeding of Gastrostomy Tube Site in Patient With Squamous Cell Carcinoma of the Tongue: A Case Report. Nutr Clin Pract 2020; 36:648-653. [PMID: 33615591 DOI: 10.1002/ncp.10606] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Enteral nutrition (EN) is a widely used therapeutic tool to provide nutrition support for patients with various clinical conditions, including different types of cancer. Head and neck cancers, often complicated by dysphagia, are among leading indications for enteral feeding. Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) tubes are typically used to deliver EN. This article presents a case report of a young male with squamous cell carcinoma of the tongue. Unfortunately, he developed metastasis of his cancer at the right lateral side of the PEG placement site, requiring surgical resection of seeded growth at the PEG site. This rare complication can be challenging, as it requires a high index of suspicion to diagnose and can potentially limit nutrition support options. A number of theories have been proposed to explain seeding during PEG/PEJ placement, including direct repositioning of malignant cells during instrumentation. A specific placement technique has not been shown to be superior, as seeding was reported with all placement techniques. However, given the lack of statistically powerful studies to describe this entity, there are still gaps we need to explore to better understand seeding of feeding tubes and best practices around diagnosis and early treatment. EN continues to be an important part of caring for patients with cancer during active or palliative treatments. Understanding potential risks in the setting of cancer metastasis is beneficial to the patients and multidisciplinary teams involved. Early recognition of possible seeding of feeding tube sites is necessary to ensure subsequent timely surgical intervention.
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Affiliation(s)
- Bethaney Wescott
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara Seegmiller
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jill Schneckloth
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Balekuduru AB, Bongu SS, Mandalapu NB, Ramachandraiah G, Khemka VK, Subbaraj SB. Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG)—Single-Center Experience and Outcome. JOURNAL OF DIGESTIVE ENDOSCOPY 2020. [DOI: 10.1055/s-0040-1716580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractBackground Gastrointestinal route is considered for feeding in subjects who are unable to swallow, either as a temporary or permanent option. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode for long-term enteral nutrition. The aim was to study the outcome of protocol-based PEG placement in a tertiary medical center.Materials and Methods All the patients who underwent PEG placement between January 2017 and December 2019 were included in the retrospective study. Study variables were entered into a uniform structured proforma. The procedure was done by two people using Ponsky-Gauderer pull-technique. Fluoroscopy guidance was considered for placement in special situations. Post-procedure, all the patients were regularly followed as per protocol to evaluate for adverse events.Results One hundred and eighteen patients with placement of PEG were included in the study. The mean age of the patients was 49.6 ± 7 years with 67.8% males. The most common indication of PEG was inability to swallow associated with head injury (43, 36.4%), followed by carcinoma esophagus (35, 29.8%) and stroke (24, 20.3%). Fluoroscopy was useful in 38 (32%) for PEG site identification. Tube dislodgement (16, 13.5%) and aspiration pneumonia (20, 16.9%) were the common adverse events. Age more than 60 years and dysphagia in neurologic disorders accounted for more than 60% of adverse events. Forty-nine (42%) of the PEG patients expired due to either primary illness or due to sepsis after a median time of 139 days (range: 32–288 days). There was no difference in the survival in patients with or without PEG-related complications (p = 0. 74).Conclusions Fluoroscopy assistance helps in accurate PEG placement in one third. Age > 60 years and dysphagia in neurologic disorders were independent risk factors associated with PEG tube complications.
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Affiliation(s)
| | - Shruti Sagar Bongu
- Department of Gastroenterology, M.S. Ramaiah Hospitals, Bangalore, Karnataka, India
| | | | | | - Vinit Kumar Khemka
- Department of Gastroenterology, M.S. Ramaiah Hospitals, Bangalore, Karnataka, India
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20
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Pérez Romero S, Alberca de Las Parras F, Sánchez Del Río A, López-Picazo J, Júdez Gutiérrez J, León Molina J. Quality indicators in gastroscopy. Gastroscopy procedure. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 111:699-709. [PMID: 31190549 DOI: 10.17235/reed.2019.6023/2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Within the project "Quality indicators in digestive endoscopy", pioneered by the Spanish Society for Digestive Diseases (SEPD), the objective of this research is to suggest the structure, process, and results procedures and indicators necessary to implement and assess quality in the gastroscopy setting. First, a chart was designed with the steps to be followed during a gastroscopy procedure. Secondly, a team of experts in care quality and/or endoscopy performed a qualitative review of the literature searching for quality indicators for endoscopic procedures, including gastroscopies. Finally, using a paired analysis approach, a selection of the literature obtained was undertaken. For gastroscopy, a total of nine process indicators were identified (one preprocedure, eight intraprocedure). Evidence quality was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification scale.
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Peveling-Oberhag J, Michael F, Tal A, Welsch C, Vermehren J, Farnik H, Grammatikos G, Lange C, Walter D, Blumenstein I, Filmann N, Herrmann E, Albert J, Zeuzem S, Bojunga J, Friedrich-Rust M. Capnography monitoring of non-anesthesiologist provided sedation during percutaneous endoscopic gastrostomy placement: A prospective, controlled, randomized trial. J Gastroenterol Hepatol 2020; 35:401-407. [PMID: 31222832 DOI: 10.1111/jgh.14760] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/28/2019] [Accepted: 06/02/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM A number of studies were able to show a reduction of hypoxemia episodes during procedural sedation through the use of capnography (CA). The present study investigates the number of episodes of hypoxemia during percutaneous endoscopic gastrostomy (PEG) placement with propofol sedation comparing standard monitoring (SM) versus SM with additional CA surveillance. METHODS In this single center randomized controlled trial, 150 patients were prospectively randomized 1:1 in either the SM group or the CA group after stratification for ASA class, PEG method (push or pull method), presence of head and neck tumor, and tracheostomy. CA analysis was performed for all patients but was blinded for the endoscopic team in the SM group. RESULTS In the SM group, 57% episodes of hypoxemia (SpO2 < 90% for > 15 s) and 41% episodes of severe hypoxemia (SpO2 < 85% for > 15 s) were observed in comparison with 28% and 20% in the CA group, respectively. Odds ratios for hypoxemia and severe hypoxemia were 0.29 (confidence interval 0.15-0.57; P = 0.0005) and 0.35 (confidence interval 0.17-0.73; P = 0.008) in favor of the CA group. On average, CA was able to detect imminent mild and severe hypoxemia 83 and 99 s before standard monitoring. Standard monitoring represented an independent risk factor for hypoxemia and severe hypoxemia. CONCLUSIONS Respiratory complications of sedation during PEG placement are frequent events. CA is able to detect imminent hypoxemia at an early time point. This allows an early intervention and consecutively the avoidance of mild and severe hypoxemia. Therefore, CA monitoring can be recommended particularly during PEG insertion procedures.
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Affiliation(s)
- Jan Peveling-Oberhag
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany.,Department of Internal Medicine I, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Florian Michael
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Andrea Tal
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christoph Welsch
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Johannes Vermehren
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Harald Farnik
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Georgios Grammatikos
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Lange
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Dirk Walter
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Irina Blumenstein
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Jörg Albert
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany.,Department of Internal Medicine I, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jörg Bojunga
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
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22
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Hausmann J, Kubesch A, Müller von der Grün J, Goettlich CM, Filmann N, Oliver Tal A, Vermehren J, Friedrich-Rust M, Wächtershäuser A, Bojunga J, Blumenstein I. Prophylactic percutaneous endoscopic gastrostomy in patients with head and neck cancer: Influence on nutritional status, utilisation rate and complications. Int J Clin Pract 2019; 73:e13405. [PMID: 31408231 DOI: 10.1111/ijcp.13405] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/30/2019] [Accepted: 08/08/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patients with head and neck cancer (HNC) are at high risk for malnutrition because of tumour localisation and therapy. Prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement is common practice to prevent malnutrition. OBJECTIVE To investigate the benefits of prophylactic PEG tube placement for HNC patients in terms of the influence on patients' nutritional status, utilisation rate, complications and to identify the predictors of PEG tube utilisation. METHODS All consecutive HNC patients who underwent prophylactic PEG tube insertion between 1 January 2011 and 31 December 2012 prior to therapy were enrolled. The PEG tube utilisation rate, complications, the patients' nutritional status and tumour therapy were evaluated with the help of electronic patient charts and telephone interviews. RESULTS A total of 181 patients (48 female, median 67.5 years) were included. The PEG utilisation rate in the entire cohort was 91.7%. One hundred and forty-nine patients (82.3%) used the PEG tube for total enteral nutrition, 17 patients (9.4%) for supplemental nutrition and 15 patients (8.3%) made no use of the PEG tube. Peristomal wound infections were the most common complications (40.3%) in this study. A high Nutritional Risk Screening (NRS) score prior to tube insertion was found to be independently associated with PEG utilisation. No significant weight changes were observed across the three patient subgroups. CONCLUSIONS The overall PEG tube utilisation rate was high in this study. However, given the high rate of infections, diligent patient selection is crucial in order to determine which patients benefit most from prophylactic PEG tube insertion.
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Affiliation(s)
- Johannes Hausmann
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Alica Kubesch
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jens Müller von der Grün
- Department of Radiotherapy and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Carmen M Goettlich
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Andrea Oliver Tal
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Johannes Vermehren
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Astrid Wächtershäuser
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jörg Bojunga
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Irina Blumenstein
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
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Novel Use for Maloney Dilators in the Management of Gastrostomy Stenosis. ACG Case Rep J 2019; 6:e00054. [PMID: 31616736 PMCID: PMC6658048 DOI: 10.14309/crj.0000000000000054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/01/2019] [Indexed: 11/17/2022] Open
Abstract
Gastrostomy tube dislodgement is a common complication after gastrostomy tube placement. If the tube is not immediately replaced, the gastrostomy stomal tract may close in as little as 8 hours. Small case series have reported the salvage of partially closed or stenosed gastrostomy stomal tracts using different types of dilators, but the use of Maloney dilators for this indication has not been reported. Dilation of a stenosed tract can allow for immediate re-establishment of enteral access without the need for a repeat invasive procedure. We present 3 instances of gastrostomy stenosis successfully dilated with Maloney dilators using minimal topical anesthesia.
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24
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Peveling-Oberhag J, Osman I, Walter D, Filmann N, Stratmann K, Hausmann J, Knop V, Waidmann O, Vermehren J, Herrmann E, Zeuzem S, Friedrich-Rust M, Blumenstein I, Albert JG. Risk factors for early and late procedure-related adverse events in percutaneous endoscopic gastrostomy: A single center, retrospective study. J Gastroenterol Hepatol 2019; 34:404-409. [PMID: 30070394 DOI: 10.1111/jgh.14407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/02/2018] [Accepted: 07/16/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Jan Peveling-Oberhag
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,Department of Internal Medicine 1, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Imad Osman
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Dirk Walter
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe-University, Frankfurt am Main, Germany
| | - Katharina Stratmann
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Johannes Hausmann
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Viola Knop
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Oliver Waidmann
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Johannes Vermehren
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modeling, Goethe-University, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Irina Blumenstein
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jörg G Albert
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,Department of Internal Medicine 1, Robert-Bosch-Hospital, Stuttgart, Germany
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25
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A novel percutaneous magnetically guided gastrostomy technique without endoscopy or imaging guidance: a feasibility study in a porcine model. Surg Endosc 2018; 32:4688-4697. [PMID: 30022288 DOI: 10.1007/s00464-018-6335-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/06/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND In order to simplify a percutaneous gastrostomy procedure and avoid the need of endoscopy or imaging methods, a novel percutaneous magnetically guided gastrostomy (PMG) technique was conceived. The aim of the present study is to evaluate the feasibility of a novel PMG technique with no endoscopy or any imaging guidance in a porcine model. METHODS Fourteen crossbred domestic pigs were used for prototype development (cadaveric experiments) and proof-of concept, survival study. The magnetic device was conceived using commercially available rare-earth neodymium-based magnets. The experimental design consisted of developing an internal magnetic gastric tube prototype to be orally inserted and coupled to an external magnet placed on the skin, which facilitated stomach and abdominal wall apposition for blind percutaneous gastrostomy tube placement. Then, a gastrostomy tube was percutaneously and blindly placed. RESULTS Twelve procedures were undertaken in animal cadavers and two in live models. The technique chosen consisted of using a magnetic gastric tube prototype using six 1 × 1-cm-ring magnets attached to its end. This device enabled successful magnetic coupling with a large (5 cm in diameter) magnet disc placed on the skin. For gastric tube placement, a direct trocar insertion allowed easier and safer placement of a gastric tube as compared to a needle-guide-wire dilation (Seldinger-based) technique. Gastropexy was added to avoid early gastric tube displacement. This novel PMG technique was feasible in a live model experiment. CONCLUSIONS A novel magnetically guided percutaneous gastrostomy tube insertion technique without the use of endoscopy or image-guidance was successful in a porcine model. A non-inferiority experimental controlled study comparing this technique to percutaneous endoscopic gastrostomy is needed to confirm its efficacy and safety.
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26
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García García de Paredes A, Mateos Muñoz B, Albillos A. [Gastrointestinal endoscopy in patients of advanced age]. Rev Esp Geriatr Gerontol 2018; 53:293-298. [PMID: 29598971 DOI: 10.1016/j.regg.2018.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 02/06/2018] [Accepted: 02/09/2018] [Indexed: 11/17/2022]
Abstract
The dramatic increase in life expectancy is leading to a significant increase in the use of gastrointestinal endoscopy in the elderly. Taking into account these demographic changes, the use of gastrointestinal endoscopy in this age group is of great importance. Although these procedures are generally safe and well tolerated even in very elderly patients, the onset of physiological changes associated with aging and the increased prevalence of cardiovascular and pulmonary comorbidities raise the risk of sedation related complications in these patients. Age alone is not a contraindication for performing any endoscopic procedure. However, elderly patients have their own peculiarities that require a detailed review of the characteristics, risks and benefits of endoscopic procedures in this specific context.
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Affiliation(s)
- Ana García García de Paredes
- Departamento de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, España.
| | - Beatriz Mateos Muñoz
- Departamento de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, España
| | - Agustín Albillos
- Departamento de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, España
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27
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Papakostas P, Tsaousi G, Stavrou G, Rachovitsas D, Tsiropoulos G, Rova C, Konstantinidis I, Michalopoulos A, Grosomanidis V, Kotzampassi K. Percutaneous endoscopic gastrostomy feeding of locally advanced oro-pharygo-laryngeal cancer patients: Blenderized or commercial food? Oral Oncol 2017; 74:135-141. [PMID: 29103742 DOI: 10.1016/j.oraloncology.2017.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/23/2017] [Accepted: 10/02/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Head and neck cancer patients commonly suffer from severe malnutrition at the time of tentative diagnosis. Percutaneous Endoscopic Gastrostomy [PEG] feeding is now considered as an efficient tool to reduce nutritional deterioration alongside concurrent treatment. We undertook the challenge to retrospectively evaluate the impact of a commercial, disease-specific, feeding formula [Supportan, Fresenius Kabi, Hellas] versus blenderized family food on nutritional outcome. MATERIALS AND METHODS This is a retrospective analysis of prospectively collected nutritional and anthropometric data at the time of PEG placement, at the 8th week [after treatment termination] and at 8 months [6mo of recovery from treatment]. All patients were prescribed a commercial feeding formula. RESULTS The final dataset included 212 patients: 112 received the commercial formula, 69 voluntarily decided to switch into blenderized-tube-feeding, and 31 were prescribed to receive a home-made formula of standard ingredients. The commercial formula seemed to help patients to fight the catabolism of concurrent treatment, since, at the 8mo assessment, both Body Mass index and Fat Free Mass had almost recovered to the values at the time of first diagnosis. Neither group on blenderized or home-made formulas exhibited nutritional improvement, but experienced a significant deterioration throughout the study period, with the home-made formula group being the worst. CONCLUSION These findings clearly indicate that home-made and blenderized foods do not adequately support the nutritional requirements of patients with HNC scheduled to receive concurrent CRT treatment.
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Affiliation(s)
- Pyrros Papakostas
- Endoscopy Unit, Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Georgia Tsaousi
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - George Stavrou
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Dimitrios Rachovitsas
- Department of Otorhinolaryngology - Head and Neck Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Gavriil Tsiropoulos
- Department of Otorhinolaryngology - Head and Neck Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Constantina Rova
- Department of Otorhinolaryngology - Head and Neck Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Ioannis Konstantinidis
- Department of Otorhinolaryngology - Head and Neck Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Antonios Michalopoulos
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Vasilios Grosomanidis
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Katerina Kotzampassi
- Endoscopy Unit, Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece; Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece.
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28
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Karasahin O, Tasar PT, Timur O, Binici DN, Yilmaz TK, Aslan A, Sahin S. High C-Reactive Protein and Low Albumin Levels Predict High 30-Day Mortality in Patients Undergoing Percutaneous Endoscopic Gastrotomy. Gastroenterology Res 2017; 10:172-176. [PMID: 28725304 PMCID: PMC5505282 DOI: 10.14740/gr862w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 05/31/2017] [Indexed: 01/16/2023] Open
Abstract
Background Percutaneous endoscopic gastrotomy (PEG) enables long-term enteral feeding. The aim of this study was to identify biomarkers that may guide the decision of whether to perform the elective procedure of PEG. Methods The medical records of all patients who underwent PEG in our hospital from 2010 to 2016 were screened retrospectively. Patients with mortality within a 30-day follow-up period and those without were compared using the Chi-square test, and continuous variables were compared with the Kruskal-Wallis and Mann-Whitney U tests. Receiver operating characteristic (ROC) curve analysis was used to demonstrate the ability of biomarkers to predict mortality; a cut-off point was determined and its sensitivity, specificity, and positive and negative predictive values were calculated. The Youden index was used to determine the cut-off point. Kaplan-Meier analysis was used to identify PEG-related mortality risk factors and a Cox regression model was applied for risk characterization. Results A total of 120 patients who underwent PEG were evaluated in the study. The mean age was 67.00 ± 18.00 years. The most common indication for PEG was cerebrovascular disease, in 69 (57.5%) of the patients. Infection of the PEG site was most common within 14 days after PEG tube placement, occurring in 13 patients (10.3%). The mortality rate among patients with post-PEG infection was 68.2%, significantly higher than in patients without infection (P = 0.012). Thirty-four patients (28.3%) died within 30 days of undergoing PEG. CRP values ≥ 78.31 mg/L increased mortality by 8.756-fold, and albumin levels < 2.71 g/dL increased mortality by 2.255-fold. Conclusion Our results indicate that the presence of both high CRP level and low albumin level were associated with significantly higher rate of mortality (73.1%) in patients who underwent PEG.
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Affiliation(s)
- Omer Karasahin
- Infectious Diseases Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Pinar Tosun Tasar
- Geriatrics Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Ozge Timur
- Internal Medicine Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Dogan Nasir Binici
- Internal Medicine Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Tugba Kiper Yilmaz
- Internal Medicine Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Adem Aslan
- General Surgery Clinic, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Sevnaz Sahin
- Department of Internal Medicine, Department of Geriatrics, Ege University School of Medicine, Izmir, Turkey
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29
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Abstract
There are a variety of techniques for gastrostomy tube placement. Endoscopic and radiologic approaches have almost entirely superseded surgical placement. However, an aging population and significant advancements in modern healthcare have resulted in patients with increasingly complex medical issues or postsurgical anatomy. The rising prevalence of obesity has also created technical challenges for proceduralists of many specialties. When patients with these comorbidities develop the need for long-term enteral nutrition and feeding tube placement, standard approaches such as percutaneous endoscopic gastrostomy (PEG) by endoscopists and percutaneous image-guided gastrostomy (PIG) by interventional radiologists may be technically difficult or impossible. For these challenging situations, laparoscopic-assisted PEG (LAPEG) is an alternative option. LAPEG combines the advantages of PEG with direct intraperitoneal visualization, helping ensure a safe tube placement tract free of intervening organs or structures. In this review, we highlight some of the important factors of first-line gastrostomy techniques, with an emphasis on the utility and procedural technique of LAPEG when they are not feasible.
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Affiliation(s)
- Adarsh M Thaker
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Ave, PVUB 2114, MC 694907, Los Angeles, CA, 90095-6949, USA.
| | - Alireza Sedarat
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Ave, PVUB 2114, MC 694907, Los Angeles, CA, 90095-6949, USA
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30
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Bechtold ML, Mir FA, Boumitri C, Palmer LB, Evans DC, Kiraly LN, Nguyen DL. Long-Term Nutrition. Nutr Clin Pract 2016; 31:737-747. [DOI: 10.1177/0884533616670103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
| | - Fazia A. Mir
- Department of Medicine, University of Missouri, Columbia, Missouri, USA
| | | | - Lena B. Palmer
- Department of Medicine, Loyola University, Chicago, Illinois, USA
| | - David C. Evans
- Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Laszlo N. Kiraly
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA
| | - Douglas L. Nguyen
- Department of Medicine, University of California, Irvine, California, USA
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31
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Lim JH, Choi SH, Lee C, Seo JY, Kang HY, Yang JI, Chung SJ, Kim JS. Thirty-day mortality after percutaneous gastrostomy by endoscopic versus radiologic placement: a systematic review and meta-analysis. Intest Res 2016; 14:333-342. [PMID: 27799884 PMCID: PMC5083262 DOI: 10.5217/ir.2016.14.4.333] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/10/2016] [Accepted: 02/22/2016] [Indexed: 02/07/2023] Open
Abstract
Background/Aims A percutaneous gastrostomy can be placed either endoscopically (percutaneous endoscopic gastrostomy, PEG) or radiologically (radiologically-inserted gastrostomy, RIG). However, there is no consistent evidence of the safety and efficacy of PEG compared to RIG. Recently, 30-day mortality has become considered as the most important surrogate index for evaluating the safety and efficacy of percutaneous gastrostomy. The aim of this meta-analysis was to compare the 30-day mortality rates between PEG and RIG. Methods Major electronic databases (MEDLINE, Embase, Scopus, and Cochrane library) were queried for comparative studies on the two insertion techniques of gastrostomy among adults with swallowing disturbance. The primary outcome was the 30-day mortality rate after gastrostomy insertion. Forest and funnel plots were generated for outcomes using STATA version 14.0. Results Fifteen studies (n=2,183) met the inclusion criteria. PEG was associated with a lower risk of 30-day mortality after tube placement compared with RIG (odds ratio, 0.60; 95% confidence interval [CI], 0.38–0.94; P=0.026). The pooled prevalence of 30-day mortality of PEG was 5.5% (95% CI, 4.0%–6.9%) and that of RIG was 10.5% (95% CI, 6.8%–14.3%). No publication bias was noted. Conclusions The present meta-analysis demonstrated that PEG is associated with a lower probability of 30-day mortality compared to RIG, suggesting that PEG should be considered as the first choice for long-term enteral tube feeding. Further prospective randomized studies are needed to evaluate and compare the safety of these two different methods of gastrostomy.
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Affiliation(s)
- Joo Hyun Lim
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Seung Ho Choi
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Changhyun Lee
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Ji Yeon Seo
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Hae Yeon Kang
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Jong In Yang
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Su Jin Chung
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
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Sohail U, Harleen C, Mahdi AO, Arif M, Nguyen DL, Bechtold ML. Bleeding risk with clopidogrel and percutaneous endoscopic gastrostomy. World J Gastrointest Endosc 2016; 8:553-557. [PMID: 27621767 PMCID: PMC4997785 DOI: 10.4253/wjge.v8.i16.553] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/27/2016] [Accepted: 06/29/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To compare bleeding within 48 h in patients undergoing percutaneous endoscopic gastrostomy (PEG) with or without clopidogrel.
METHODS After institutional review board approval, a retrospective study involving a single center was conducted on adult patients having PEG (1/08-1/14). Patients were divided into two groups: Clopidogrel group consisting of those patients taking clopidogrel within 5 d of PEG and the non-clopidogrel group including those patients not taking clopidogrel within 5 d of the PEG.
RESULTS Three hundred and nineteen PEG patients were found. One hundred and sixty-eight males and 151 females with mean body mass index 28.47 ± 9.75 kg/m2 and mean age 65.03 ± 16.11 years were identified. Thirty-three patients were on clopidogrel prior to PEG with 286 patients not on clopidogrel. No patients in either group developed hematochezia, melena, or hematemesis within 48 h of percutaneous endoscopic gastrostomy (PEG). No statistical differences were observed between the two groups with 48 h for hemoglobin decrease of > 2 g/dL (2 vs 5 patients; P = 0.16), blood transfusions (2 vs 7 patients; P = 0.24), and repeat endoscopy for possible gastrointestinal bleeding (no patients in either group).
CONCLUSION Based on the results, no significant post-procedure bleeding was observed in patients undergoing PEG with recent use of clopidogrel.
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Antibacterial gauzes are effective in preventing infections after percutaneous endoscopic gastrostomy placement: a retrospective analysis. Eur J Gastroenterol Hepatol 2016; 28:297-304. [PMID: 26735159 DOI: 10.1097/meg.0000000000000561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The most common complication after percutaneous endoscopic gastrostomy (PEG) placement is peristomal wound infection (up to 40% without antibiotic prophylaxis). Single-dose parenteral prophylactic antibiotics as advised by current guidelines decrease the infection rate to 9-15%. We assume a prolonged effect of local antibiotic treatment with antibacterial gauzes. This study is the first to describe the effect of antibacterial gauzes in preventing infections in PEG without the use of antibiotics. METHODS A retrospective data analysis was carried out of all patients with PEG insertion between January 2009 and October 2014 in the Catharina Hospital Eindhoven. Data include placement and the period of the first 2 weeks after PEG placement, and long-term follow-up. All patients received a locally applied antibacterial gauze polyhexamethylene biguanide immediately following PEG insertion for 3 days. No other antibiotics were administered. The main outcomes were wound infection, peritonitis, and necrotizing fasciitis; secondary outcomes included other complications. RESULTS A total of 331 patients with only antibacterial gauzes were analyzed. The total number of infections 2 weeks after PEG insertion was 9.4%, including 8.2% minor and 1.2% major infections (peritonitis). No wound infection-related mortality or bacterial resistance was found. Costs are five times lower than antibiotics, and gauzes are more practical and patient friendly for use. CONCLUSION Retrospectively, antibacterial gauzes are at least comparable with literature data on parenteral antibiotics in preventing peristomal wound infection after PEG placement, with an infection rate of 9.4%. Rates of other complications found in this study were comparable with current literature data.
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Practice variation in PEG tube placement: trends and predictors among providers in the United States. Gastrointest Endosc 2015; 82:37-45. [PMID: 25845635 PMCID: PMC4469567 DOI: 10.1016/j.gie.2014.12.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/21/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Enteral access placement is performed among a variety of providers and specialties, yet there is a dearth of literature on trends and factors related to enteral access placement in the United States. OBJECTIVE To examine trends in the incidence of enteral access procedures performed by gastroenterologists in the United States. DESIGN Retrospective review of upper endoscopic procedures that involved PEG tube placement between 2000 and 2010. SETTING Endoscopy sites participating in the Clinical Outcomes Research Initiative (CORI). PATIENTS Patients undergoing upper endoscopy. INTERVENTIONS PEG tube placement. MAIN OUTCOME MEASUREMENTS Number of PEG tubes placed. RESULTS Overall PEG tube placement by a provider from 2000 to 2010 was 1.7% (number of PEG tubes performed/number of upper endoscopies performed), with the majority of them being performed by gastroenterologists. Very young and very old, non-white racial background (Hispanic: odds ratio [OR] 1.21; 95% CI, 1.13-1.28; black: OR 2.24; 95% CI, 2.12-2.36), and men (OR 1.44; 95% CI, 1.39-1.50) were patient characteristics associated with greater PEG tube placement. In terms of practice setting, PEG tube placement occurred more frequently in community and/or health maintenance organization environments and on the East Coast. With respect to provider characteristics, male providers were less likely than female providers to perform a PEG tube insertion (OR 0.67; 95% CI, 0.64-0.71), and there was a trend that as providers were further out of medical school they were less likely to perform a PEG tube procedure. Interestingly, surgeons (OR 6.69; 95% CI, 6.18-7.24) and other providers (non-pediatric/non-general practice) (OR 3.22; 95% CI, 2.63-3.94) were more likely to perform PEG tube procedures than were gastroenterologists. LIMITATIONS Participation in CORI is voluntary and may not capture data on non-gastroenterologist providers. CONCLUSION Significant practice variation was noted in PEG tube placement in the United States with respect to patient and provider characteristics, geographic region, and endoscopy settings.
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Feasibility and Safety of Overtubes for PEG-Tube Placement in Patients with Head and Neck Cancer. Gastroenterol Res Pract 2015; 2015:612610. [PMID: 25977688 PMCID: PMC4419231 DOI: 10.1155/2015/612610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/24/2015] [Indexed: 01/16/2023] Open
Abstract
Background. Percutaneous endoscopic gastrostomy (PEG) placement using the “pull” technique is commonly utilized for providing nutritional support in head and neck cancer (HNC) patients, but it may be complicated by peristomal metastasis in up to 3% of patients. Overtube-assisted PEG placement might reduce this risk. However, this technique has not been systemically studied for this purpose to date. Methods. Retrospective analysis of consecutive patients with HNC who underwent overtube-assisted PEG placement at Westmead Hospital, Australia, between June 2011 and December 2013. Data were extracted from patients' endoscopy reports and case notes. We present our technique for PEG insertion and discuss the feasibility and safety of this method. Results. In all 53 patients studied, the PEG tubes were successfully placed using 25 cm long flexible overtubes, in 89% prophylactically (before commencing curative chemoradiotherapy), and in 11% reactively (for treatment of tumor related dysphagia or weight loss). During a median follow-up period of 16 months, 3 (5.7%) patients developed peristomal infection and 3 others developed self-limiting peristomal pain. There were no cases of overtube-related adverse events or overt cutaneous metastases observed. Conclusions. Overtube-assisted PEG placement in patients with HNC is a feasible, simple, and safe technique and might be effective for preventing cutaneous metastasis.
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Abstract
PURPOSE OF REVIEW This review addresses current controversies regarding appropriate indications for percutaneous endoscopic gastrostomy (PEG) insertion. We address specific indications, namely, dementia, stroke, aspiration, motor neurone disease/amyotrophic lateral sclerosis, and head and neck cancer. We recommend practical strategies for improving patient selection. RECENT FINDINGS There is now a general consensus in the United States that PEG feeding does not benefit patients with advanced dementia. 'Early' PEG insertion following stroke is similarly of no benefit. It is currently unclear whether patients with amyotrophic lateral sclerosis and head and neck tumors should have PEG or radiologically inserted gastrostomy. SUMMARY Decisions relating to PEG insertion remain difficult. The gastroenterologist, working as a member of a multidisciplinary nutrition team, needs to take a lead role in this regard, rather than functioning as a technician.
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Affiliation(s)
- Carthage Moran
- aDepartment of Medicine bDepartment of Gastroenterology, Cork University Hospital, Wilton, Cork, Ireland
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Mohanaruban A, Flanders L, Dor R. Consent in the endoscopy department. Frontline Gastroenterol 2014; 5:291-296. [PMID: 28839786 PMCID: PMC5369752 DOI: 10.1136/flgastro-2013-100394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 01/13/2014] [Accepted: 01/14/2014] [Indexed: 02/04/2023] Open
Abstract
The demand for endoscopic procedures continues to increase and is likely to continue to do so for the foreseeable future. Alongside elective diagnostic procedures, the number of complex and therapeutic procedures is increasing. It is therefore vital that the consent process is comprehensive, and high standards in consenting patients are maintained. Consent is defined as a patient's agreement to treatment or an intervention proposed by a health professional. Careful patient selection is required when proposing endoscopic procedures with an appreciation of the risks and complications that are involved. This paper addresses the various components of gaining informed consent and the legal issues surrounding this process. Additionally, this article reviews legislation and focuses upon specific instances where further considerations have to be made; in a patient who lacks capacity, in children, in percutaneous endoscopic gastrostomy and in the patient who is a Jehovah's Witness.
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Affiliation(s)
| | - Lucy Flanders
- Department of Gastroenterology, North Middlesex University Hospital, London, UK
| | - Riaz Dor
- Department of Gastroenterology, North Middlesex University Hospital, London, UK
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Tang SJ. Endoscopic Management of Gastrocutaneous Fistula Using Clipping, Suturing, and Plugging Methods. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.vjgien.2014.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: Techniques, problems and solutions. World J Gastroenterol 2014; 20:8505-8524. [PMID: 25024606 PMCID: PMC4093701 DOI: 10.3748/wjg.v20.i26.8505] [Citation(s) in RCA: 226] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 02/10/2014] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.
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Sako A, Yasunaga H, Horiguchi H, Fushimi K, Yanai H, Uemura N. Prevalence and in-hospital mortality of gastrostomy and jejunostomy in Japan: a retrospective study with a national administrative database. Gastrointest Endosc 2014; 80:88-96. [PMID: 24472760 DOI: 10.1016/j.gie.2013.12.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 12/04/2013] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Akahito Sako
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiromasa Horiguchi
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Care Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hidekatsu Yanai
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
| | - Naomi Uemura
- Department of Gastroenterology, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
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Tang SJ, Wu R. Percutaneous Endoscopic Gastrostomy (pull method) and Jejunal Extension Tube Placement. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.vjgien.2013.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Nevah MI, Lamberth JR, Dekovich AA. Transnasal PEG tube placement in patients with head and neck cancer. Gastrointest Endosc 2014; 79:599-604. [PMID: 24112593 DOI: 10.1016/j.gie.2013.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 08/15/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Head and neck cancer (H&NCa) patients have an increased risk of malnutrition and dysphagia because of their malignancy and the adverse events of therapy. Most of these patients require gastrostomies. Four percent to 7% of H&NCa patients are unable to undergo per oral percutaneous gastrostomies. Transnasal endoscopy is an option for gastrostomy placement in selected patients. OBJECTIVE Clinical, epidemiologic characteristics and outcomes of transnasal PEG (t-PEG) placement. DESIGN Retrospective analysis. SETTING Tertiary care hospital, The University of Texas MD Anderson Cancer Center. PATIENTS All patients who underwent t-PEG placement. MAIN OUTCOME MEASUREMENTS Epidemiology, adverse events, and outcomes of t-PEG placement. RESULTS Sixteen patients underwent t-PEG placement from January 2010 to May 2013. All patients had H&NCa and 56.3% had metastasis. Indications for the transnasal approach were airway compromise, malignant oropharyngeal obstruction, and trismus, among others. All procedures were successful using a 20F gastrostomy tube, push technique, anesthesiologist-guided propofol sedation, and/or nasotracheal intubation. Of all patients, 68.8% were white and 68.8% were men. Mean age was 54 years, and mean body mass index was 20.87. Two patients had a total of 2 adverse events: poor wound healing and wound site infection. Of all patients, 18.75% had leukopenia, 6.25% neutropenia, and 50% lymphopenia. Mean white blood cell count, absolute neutrophil count, and absolute lymphocyte count were 8.6 × 10(9)/L, 6.57 × 10(9)/L, and .93 × 10(9)/L, respectively. Eleven patients were alive, 2 were lost to follow-up, and 3 had died at the time of review. LIMITATIONS Retrospective analysis, small cohort, patient selection bias. CONCLUSION t-PEG placement is a viable and safe option for H&NCa patients when the standard endoscopic approach is not feasible.
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Affiliation(s)
- Moises I Nevah
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jennifer R Lamberth
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alexander A Dekovich
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Freedberg DE, Garcia-Carrasquillo RJ, Schwartz B, Rosenberg RM. A technique for skin-level gastrostomy tube placement after gastrostomy tube dislodgement. Gastrointest Endosc 2013; 78:963-964. [PMID: 24237952 DOI: 10.1016/j.gie.2013.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 07/29/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Daniel E Freedberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York, USA
| | | | - Benjamin Schwartz
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York, USA
| | - Richard M Rosenberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York, USA
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Chandrasekhara V, Early DS, Acosta RD, Chathadi KV, Decker GA, Evans JA, Fanelli RD, Fisher DA, Foley KQ, Fonkalsrud L, Hwang JH, Jue T, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Shergill AK, Cash BD. Modifications in endoscopic practice for the elderly. Gastrointest Endosc 2013; 78:1-7. [PMID: 23664042 DOI: 10.1016/j.gie.2013.04.161] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 12/12/2022]
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Lee C, Im JP, Kim JW, Kim SE, Ryu DY, Cha JM, Kim EY, Kim ER, Chang DK. Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study. Surg Endosc 2013; 27:3806-15. [PMID: 23644838 DOI: 10.1007/s00464-013-2979-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 04/14/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is performed to provide nutrition to patients with swallowing difficulties. A multicenter study was conducted to evaluate the predictors of complications and mortality after PEG placement. METHODS This study retrospectively analyzed patients who underwent initial PEG placement between January 2004 and December 2011 at seven tertiary hospitals in the Republic of Korea. RESULTS All 1,625 patients underwent PEG placement by the pull-string method. The median age of the patients was 66 years, and 1,108 of the patients were men. The median follow-up period was 254 days. The common indications were stroke (31.6%) and malignancy (18.9%). The complication rate was 13.2%. The prophylactic use of antibiotics (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.38-0.88; p = 0.010) reduced the PEG-related infection rate, but the actual usage rate was 81.1%. The use of anticoagulants (OR, 7.26; 95% CI, 2.23-23.68; p = 0.001) and the presence of diabetes mellitus (OR, 4.02; 95% CI, 1.49-10.87; p = 0.006) increased the risk of bleeding, but antiplatelet therapy did not. The procedural, 30-day, and overall mortality rates were 0.2, 2.4 and 14.0%, respectively. Serum albumin levels lower than 31.5 g/L (OR, 8.55; 95% CI, 3.11-23.45; p < 0.001) and C-reactive protein levels higher than 21.5 mg/L (OR, 3.01; 95% CI, 1.27-7.16; p = 0.012) increased the risk of 30-day mortality, and the patients who had both risk factors had a significantly shorter median survival time than those who did not (1,740 vs 3,181 days) (p < 0.001, log-rank). CONCLUSIONS The findings showed PEG to be a safe and feasible procedure, but the patient's nutritional and inflammatory status should be considered in predicting the outcomes of PEG placement.
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Affiliation(s)
- Changhyun Lee
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea,
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Evans JA, Early DS, Chandraskhara V, Chathadi KV, Fanelli RD, Fisher DA, Foley KQ, Hwang JH, Jue TL, Pasha SF, Sharaf R, Shergill AK, Dominitz JA, Cash BD. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc 2013; 77:328-34. [PMID: 23410694 DOI: 10.1016/j.gie.2012.10.001] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 10/01/2012] [Indexed: 02/08/2023]
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von Rosenvinge EC, O'May GA, Macfarlane S, Macfarlane GT, Shirtliff ME. Microbial biofilms and gastrointestinal diseases. Pathog Dis 2013; 67:25-38. [PMID: 23620117 DOI: 10.1111/2049-632x.12020] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Revised: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 12/16/2022] Open
Abstract
The majority of bacteria live not planktonically, but as residents of sessile biofilm communities. Such populations have been defined as 'matrix-enclosed microbial accretions, which adhere to both biological and nonbiological surfaces'. Bacterial formation of biofilm is implicated in many chronic disease states. Growth in this mode promotes survival by increasing community recalcitrance to clearance by host immune effectors and therapeutic antimicrobials. The human gastrointestinal (GI) tract encompasses a plethora of nutritional and physicochemical environments, many of which are ideal for biofilm formation and survival. However, little is known of the nature, function, and clinical relevance of these communities. This review summarizes current knowledge of the composition and association with health and disease of biofilm communities in the GI tract.
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Affiliation(s)
- Erik C von Rosenvinge
- Department of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Iqbal S, Babich JP, Grendell JH, Friedel DM. Endoscopist’s approach to nutrition in the patient with pancreatitis. World J Gastrointest Endosc 2012; 4:526-31. [PMID: 23293722 PMCID: PMC3536849 DOI: 10.4253/wjge.v4.i12.526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Revised: 11/10/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
Nutritional therapy has an important role in the management of patient with severe acute pancreatitis. This article reviews the endoscopist’s approach to manage nutrition in such cases. Enteral feeding has been clearly validated as the preferred route of feeding, and should be started early on admission. Parenteral nutrition should be reserved for patients with contraindications to enteral feeding such as small bowel obstruction. Moreover, nasogastric feeding is safe and as effective as nasojejunal feeding. If a prolonged course of enteral feeding (> 30 d) is required, endoscopic placement of feeding gastrostomy or jejunostomy tubes should be considered.
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Affiliation(s)
- Shahzad Iqbal
- Shahzad Iqbal, Jay P Babich, James H Grendell, David M Friedel, Department of Medicine, Division of Gastroenterology, Winthrop University Hospital, Mineola, NY 11501, United States
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Abstract
PURPOSE OF REVIEW Enteral nutrition support is often required in patients who are unable to meet their own nutritional requirements. Endoscopists play a key role in the placement of enteral feeding catheters. This review focuses on the recently published solutions to common problems encountered during endoscopic placement of enteral feeding devices. RECENT FINDINGS Case reports and case series describe solutions for overcoming common problems encountered during the placement of enteral feeding devices. Transnasal techniques can simplify nasojejunal tube placement, whereas deep enteroscopy techniques provide more reliable jejunostomy placement. Endoscopic ultrasound can help when transillumination is not possible or in the setting of postsurgical anatomy like Roux-en-Y. Laparoscopic-assisted procedures are useful when endoscopic techniques have failed in adults or in select high-risk pediatric patients. The American Society for Gastrointestinal Endoscopy and the American Gastroenterology Association both published comprehensive guidelines that outline the indications, contraindications, technical aspects of feeding catheter placement, and complications. SUMMARY Advances in endoscopic techniques, including deep enteroscopy, endoscopic ultrasound, ultra-slim transnasal endoscopes and laparoscopic-assisted procedures, have enabled endoscopists to successfully place enteral feeding tubes in patients who previously required open procedures.
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Abstract
This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.
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Affiliation(s)
- Gianluca Rotondano
- Division of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre del Greco, Italy.
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