The impact of percutaneous endoscopic gastrostomy feeding upon daily life in adults

Trends and challenges in home enteral feeding methods for children with gastrointestinal disorders: an expert review on bolus feeding delivery methods

INTRODUCTION

New evidence supports the benefits of bolus feeding for children receiving home enteral feeding (HEN). Current home methods of bolus feeding have certain limitations, particularly in mobile or restless patients. Therefore, innovative delivery methods have been introduced to provide more flexible methods of reducing feeding time and formula handling.

AREAS COVERED

This manuscript presents an expert review of the updates in HEN for children and the results of an online user experience questionnaire about an innovative new cap-based bolus feeding system. A literature bibliographic search was conducted on Medline via PubMed up to September 2023 to collect relevant studies. We presented recent evidence demonstrating a dramatic increase in HEN use among children requiring EN and its benefits on patients' nutritional status and quality of life. In addition, the article examined the clinical and social benefits of bolus feeding and current challenges in delivery methods. We described the benefits of the new system and its user experience.

EXPERT OPINION

The uses and indications for bolus feeding in HEN are increasing among children. However, there are still some unmet needs regarding traditional delivery methods. Innovative techniques can improve flexibility, reduce feeding time, and improve user experience and quality of life.

A qualitative systematic review of family caregivers' experiences of artificial nutrition and hydration at home: A meta-ethnography

BACKGROUND

Artificial nutrition and hydration (AN&H) may be provided to individuals in the home environment, and family caregivers are often involved in the management of this intervention. This experience can have multiple consequences for families.

AIMS

The aim of this meta-ethnography is to explore and synthesize the personal experiences of family caregivers providing care to a person receiving home AN&H.

METHODS & PROCEDURES

A comprehensive search of the literature was conducted without any time limitations applied. Seven stages of meta-ethnography were followed. Public and patient involvement was incorporated into the development of the line of argument synthesis in this review. This review is reported following the eMERGe guidelines and it was registered in PROSPERO.

MAIN CONTRIBUTION

A total of 22 studies were included representing the experiences of 336 family caregivers. Two main themes emerged: (1) sink or swim, being thrown in at the deep end; and (2) professional support as a bedrock. The first theme represents the experiences from the very start of home AN&H when the family caregivers may be overwhelmed with the level of skills they have to acquire. With time, family caregivers perceived the benefits, but also the challenges, associated with managing home AN&H. If a person receiving home AN&H was able to continue with some oral intake, it had a positive impact on family caregivers' experiences. The second theme represents the influence of professional support on the lived experience of family caregivers managing home AN&H. This support should be individualized, comprehensive, and co-created with the family caregiver and the person receiving home AN&H.

CONCLUSIONS & IMPLICATIONS

This review concluded that caring for a person receiving home AN&H can be very challenging for family caregivers. Family caregivers require personalized support from a multidisciplinary team of healthcare professionals to acquire skills, competence and confidence in this new role. Speech and language therapists are important members of this multidisciplinary team because they can facilitate a continuation of oral intake as appropriate.

WHAT THIS PAPER ADDS

What is already known on the subject AN&H has an impact not only on the person receiving it but also on the wider family and family caregivers. Healthcare professionals have a role in supporting people living with AN&H. What this paper adds to existing knowledge This review presents a rigorous qualitative evidence synthesis that adheres fully to the eMERGe guidance for reporting of meta-ethnography. Within this meta-ethnography a current caregiver was consulted during the creation of the line of argument synthesis to provide a unique perspective to the review process. This review synthesized the current body of evidence that explores the lived experience of home AN&H (any type) for family caregivers, identifies where professional support is required and highlights current gaps. What are the potential or actual clinical implications of this work? Family caregivers require personalized support from a multidisciplinary team of healthcare professionals to adjust to living with home AN&H. This support assists people living with home AN&H in perceiving benefits and developing more positive experiences. Speech and language therapists are important members of the multidisciplinary team supporting individuals with home AN&H and their family caregivers as they can facilitate a continuation of oral intake as appropriate.

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

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

A meta-synthesis exploring caregiver experiences of home enteral tube feeding

BACKGROUND

It is estimated that 18,232 people received home enteral tube feeding (HETF) in the UK in 2013 and HETF often requires reliance on a caregiver. Caregivers are an essential resource, and so research is needed to explore their perspectives to inform how best to support them. Therefore, this meta-synthesis aimed to explore caregiver experiences of HETF.

METHODS

A systematic search and a meta-synthesis of the literature relating to caregiver experiences of HETF were undertaken. Ethical approval was obtained from Coventry University Ethics. A comprehensive search of CINAHL, MEDLINE, Academic Search Complete and SCOPUS databases was conducted, followed by a reference list search of included studies. Studies were screened for eligibility using a priori inclusion criteria. Included studies used qualitative methodology, were in English, and explored caregivers' experiences of supporting an adult or child receiving HETF for at least 1 month. The meta-synthesis was conducted using a thematic-synthesis method. Included studies were assessed for quality, and rigour was ensured via transparent reporting of methodology, peer review and reflexivity.

RESULTS

In total, 328 records were screened, with 10 studies included and a total of 97 caregivers' experiences were reported. Four analytical themes were developed: loss of a normal life, psychological impact, practical challenges and becoming the 'expert'. Overall quality of the included studies was assessed as good.

CONCLUSIONS

This meta-synthesis highlighted the challenges experienced by caregivers, and revealed the need for improved HETF training for caregivers and psychological support from healthcare professionals, with the aim of providing personalised advice and regimes as part of holistic care.

Children's Perspectives on Mealtimes When Living with a Gastrostomy Tube: A Qualitative Study

PURPOSE

To explore children's experiences of mealtimes when living with a gastrostomy tube.

DESIGN AND METHODS

The study used a qualitative descriptive design framed within ecocultural theory. Seven children, three girls and four boys, aged 6-12 years with long-term health conditions and a gastrostomy tube participated in individual interviews. The interviews were qualitatively analysed by means of systematic text condensation.

RESULTS

Four main categories comprised the findings of the children's mealtimes experiences: "Stable in form, open to variation," "An individual, and a shared activity," "An object that needs to be dealt with" and "A part of me." A complex picture emerged, where the children experienced nutrition, whether through the gastrostomy tube or orally, as necessary for a healthy body, although this did not suffice to make the mealtime experience positive.

CONCLUSIONS

Regardless of the children's amount of oral intake, everyday mealtimes were valued as opportunities for social interaction and experienced as a predictable, routine activity no different from the mealtimes of other families. The accounts illustrated that in many situations the children knew precisely what they needed and did not need, what they liked and disliked and why.

PRACTICE IMPLICATIONS

Healthcare professionals should take children's knowledge into consideration to a greater extent when planning follow-up and intervention. The study illuminates that children can take an active part in their healthcare when offered flexible and carefully designed communication material, even in the presence of communicative and/or intellectual disability.

Home enteral nutrition and oral nutritional supplements in postoperative patients with upper gastrointestinal malignancy: A systematic review and meta-analysis

BACKGROUND

The safety and potential benefits of home enteral route nutrition (HERN), referring specifically to home enteral nutrition (HEN) and oral nutritional supplements (ONS) in this article, after upper gastrointestinal (GI) resection are inconsistent.

OBJECTIVE

To evaluate the impact of HERN on nutritional status, complications, and quality of life (QOL) after upper GI resection.

METHODS

This systematic review was conducted in accordance with the PRISMA statement. Nine databases were searched from inception to October 2019. Randomized controlled trials (RCTs) comparing the impact of HERN after upper gastrointestinal resection were included. Relative risk/weighted mean difference/standardized mean difference (RR/WMD/SMD) and corresponding 95% confidence intervals (95% CI) were calculated using fixed- or random-effects models.

RESULTS

Overall, 15 RCTs involving 1059 patients were included. Compared with normal oral diet, HERN significantly prevented weight loss (-3.95 vs -5.82 kg; SMD: 1.98 kg; 95% CI: 1.24-2.73); improved added-level of albumin (3.48 vs 2.41 g/L; SMD: 1.36 g/L; 95% CI: 0.81-1.91), hemoglobin (6.54 vs -1.29 g/L; WMD: 7.45 g/L; 95% CI: 5.05-9.86), pre-albumin (37.59 vs 7.35 mg/L; WMD: 21.6 mg/L; 95% CI: 5.96-37.24), and transferrin (63.08 vs 50.45 mg/L; WMD: 16.44 mg/L; 95% CI: 13.51-19.38); and reduced the incidence of malnutrition or latent malnutrition (RR = 0.54; P < 0.01). Subgroup analysis based on the approach of HERN showed that weight loss in the HEN subgroup was significantly lower than that of the control group (WMD = 2.69, P < 0.01), while there was no significant difference between the ONS subgroup and the control group (P = 0.1). The same results were found in albumin. Physical function (WMD: 5.29; 95% CI: 1.86-8.73) and fatigue (WMD: -8.59; 95% CI: -12.61, -4.58) dimensions in QOL were significantly better in the HERN group. No significant differences in gastrointestinal and tube-related complications.

CONCLUSION

HERN improved nutritional status and some dimensions of QOL in upper GI malignancy patients after surgery, without increasing complications. Subgroup analysis showed that HEN experienced more benefits than ONS.

Biodegradable oesophageal stents: A potentially useful adjunct in the treatment of dysphagia in patients undergoing radiotherapy for oesophageal carcinoma

Aim:

Dysphagia is common in patients presenting with oesophageal malignancy. This study aimed to determine the clinical effectiveness of biodegradable stents to help with malignant dysphagia due to radiotherapy for oesophageal cancer and furthermore to establish the complication and re-intervention rates associated with their use.

Methods:

This was a retrospective, observational study of 22 patients between 2008 and 2013. Complications within 2 weeks and episodes of re-intervention required within 4 months of stent insertion prior to radiotherapy were recorded.

Results:

Pre-stent insertion, the mean O’Rourke dysphagia score was 3·5 (median 3, range 2–5). This improved to a mean score of 2·8 (median 3, range 1–4) 1–3 weeks following stent insertion. Complications occurred in seven patients (32%) in an immediate 2-week period, including: pain (2), dysphagia requiring dilatation (1), food obstruction not requiring intervention (1), food obstruction requiring intervention (2) and upper gastrointestinal bleed not requiring intervention (1). Re-intervention was required in 18% within a 4-month period.

Findings:

We propose that biodegradable oesophageal stents are safe and may have benefit over self-expanding metal stents. We recommend they are placed alongside a radiologically inserted gastrostomy in a combined procedure prior to radiotherapy planning.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Home enteral nutrition: Use of photo-elicitation to capture patient and caregiver experiences

BACKGROUND

Despite the importance of home enteral nutrition (HEN), there is a lack of understanding within the medical and general community of how HEN impacts the lives of patients and caregivers. Using a theoretical orientation that attends to the materiality of both everyday and medical objects, we explored patients' and family caregivers' everyday experiences of administering feeds during HEN.

METHODS

Using the photo-elicitation interviewing method, patients on HEN and their family caregivers were asked to take up to 10 photographs to portray material items and activities that they considered foundational to HEN. They subsequently narrated their experiences and the participant-generated photographs in an interview. Participant-generated photographs (126) and accompanying narratives were analyzed using layered analysis, and results were theorized with attention to both social and material significance of HEN.

RESULTS

Patients and caregivers detailed overcoming misconceptions of HEN, and through their use of photographs, they conveyed their expertise in developing their own HEN feeding systems and practices, that used both the material artifacts provided by the hospital (the tube, syringe, and formula) as well as everyday material items found in the patient's home. More than this, photographs and patient narratives depicted intimate involvement of patients' families in tube feeding. This yielded a more comprehensive understanding of the material and experiential realities of HEN.

CONCLUSION

Home enteral nutrition was found to be a shared familial experience, that in addition to requiring medical equipment also incorporated ordinary material artifacts within the social setting of the home and family life. To more accurately convey the material, experiential, and social realities of HEN to future patients, our findings underscore the importance of drawing on both visual and textual forms of patient-produced information in the development of HEN patient educational materials.

Tube feeding during treatment for head and neck cancer - Adherence and patient reported barriers

OBJECTIVES

The main aim was to investigate the incidence of patient adherence to nutritional tube feeding recommendations in patients with head and neck cancer and to determine patient barriers to meeting tube feeding prescription.

MATERIALS AND METHODS

This was an observational study from a randomised controlled trial in patients with head and neck cancer deemed at high nutritional risk with prophylactic gastrostomy (n=125). Patients were randomised to receive early tube feeding prior to treatment (intervention group) or standard care. All patients in the intervention and standard care groups then commenced clinical tube feeding as required during treatment. Patients maintained a daily record of gastrostomy intake, main nutrition impact symptom necessitating gastrostomy use, and reasons for not meeting nutrition prescription. Adherence was defined as meeting ≥75% of total prescribed intake.

RESULTS

Patients were predominantly male (89%), median age 60, with oropharyngeal tumours (78%), stage IV disease (87%) treated with chemoradiotherapy (87%). Primary reasons for gastrostomy use were poor appetite/dysgeusia (week 2-3) and odynophagia/mucositis (week 4-7). Early tube feeding adherence was 51%. Clinical tube feeding adherence was significantly higher in the intervention group (58% vs 38%, p=0.037). Key barriers to both phases of tube feeding were; nausea, early satiety and treatment factors (related to hospital healthcare processes).

CONCLUSIONS

Early tube feeding can improve patient adherence to clinically indicated tube feeding during treatment. Low adherence overall is a likely explanation for clinically significant weight loss despite intensive nutrition interventions. Optimising symptom management and strategies to overcome other barriers are key to improving adherence.

CLINICAL TRIAL REGISTRATION

This trial has been registered in the Australian New Zealand Clinical Trials registry as ACTRN12612000579897.

A Necessary Evil? Patients' Experiences Receiving Tube Feeding in Acute Care

BACKGROUND

Tube feeding (TF) is frequently prescribed for adults admitted to acute care facilities to prevent or ameliorate malnutrition, yet little is known about patients' needs and experiences with receiving this therapy. Patients' perspectives regarding the factors influencing their experiences, as well as their information and support needs, are required to inform healthcare providers' (HCPs') patient-centered practices.

METHODS

Based on an interpretive description qualitative approach, 12 unstructured face-to-face interviews were conducted with participants admitted to acute care hospitals in Northwestern Ontario, Canada.

RESULTS

Analysis of data revealed variations in participants' perceptions of the necessity for TF and the discomfort resulting from this therapy. Perceived necessity was influenced by interrelated themes: the meaning of TF (beyond necessity), the trust held in HCPs, and the resilience of participants in response to all that they were experiencing. Collectively, these findings are encompassed within the central theme, phrased as a question, about the experience of TF: "A necessary evil?" Participants' answers to this question revealed the nature of their overall response throughout TF therapy (ie, indifferent, resistant, relieved, or tolerant).

CONCLUSIONS

The range of perceptions and the complexity of patients' experiences during TF revealed in the data can inform HCPs' patient-centered approaches to TF care. Assessing and incorporating patients' values, beliefs, needs, and goals into, and exploring their choices in, nutrition care planning can promote resilience in response to TF therapy. HCPs may then well enhance patients' comfort and overall experience with TF therapy.

American Society of Parenteral and Enteral Nutrition Presidential Address: Food for Thought: It's More Than Nutrition

Three issues were highlighted in the 30(th) Presidential Address to the society: (1) A.S.P.E.N.'s unique interdisciplinary structure; (2) support of the A.S.P.E.N. Rhoads Research Foundation; and (3) the meaning of food from the perspective of the patient who is receiving life-sustaining home enteral or parenteral nutrition. A.S.P.E.N., founded as a multidisciplinary society in the 1970s has evolved into an interdisciplinary society with an expanded and diverse membership of health care professionals and scientists with overlapping interests in clinical nutrition and metabolism. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high quality patient care. The society is committed to advancing the science and practice of nutrition support therapy. In support of this direction, the A.S.P.E.N. Rhoads Research Foundation exists to fund research grants, promote evidence-based practice, and foster training and mentorship in nutrition and metabolic research. The scientific advances and technologic innovations that have enabled our profession to provide enteral and parenteral nutrition to patients has caused practitioners to forget that the meaning of food extends beyond nutrient value. Some individuals receiving long term enteral nutrition or home parenteral nutrition have expressed feelings of anger, anxiety, and depression resulting from the inability to eat normally, from losses of independence, and control of body functions. The ritual of eating may be altered when the enteral or intravenous feedings provide nourishment and, for some, the loss of the eating function is a distressing experience, especially given the cultural focus on social gatherings and meals. The emotional meaning attributed to food, and changes in food preferences and eating behaviors, may become a source of conflict for individuals who have substantial dietary restrictions, or for those individuals dependent on enteral or parenteral nutrition therapy. The value of food intake on social patterns, self-esteem, pleasure, and enjoyment, may impact quality of life. While nutrition support can provide the basic need for nutrients, its impact on human needs associated with food requires further investigation.

A randomised controlled trial of six weeks of home enteral nutrition versus standard care after oesophagectomy or total gastrectomy for cancer: report on a pilot and feasibility study

Background

Poor nutrition in the first months after oesophago-gastric resection is a contributing factor to the reduced quality of life seen in these patients. The aim of this pilot and feasibility study was to ascertain the feasibility of conducting a multi-centre randomised controlled trial to evaluate routine home enteral nutrition in these patients.

Methods

Patients undergoing oesophagectomy or total gastrectomy were randomised to either six weeks of home feeding through a jejunostomy (intervention), or treatment as usual (control). Intervention comprised overnight feeding, providing 50 % of energy and protein requirements, in addition to usual oral intake. Primary outcome measures were recruitment and retention rates at six weeks and six months. Nutritional intake, nutritional parameters, quality of life and healthcare costs were also collected. Interviews were conducted with a sample of participants, to ascertain patient and carer experiences.

Results

Fifty-four of 112 (48 %) eligible patients participated in the study over the 20 months. Study retention at six weeks was 41/54 patients (76 %) and at six months was 36/54 (67 %). At six weeks, participants in the control group had lost on average 3.9 kg more than participants in the intervention group (95 % confidence interval [CI] 1.6 to 6.2). These differences remained evident at three months (mean difference 2.5 kg, 95 % CI −0.5 to 5.6) and at six months (mean difference 2.5 kg, 95 % CI −1.2 to 6.1). The mean values observed in the intervention group for mid arm circumference, mid arm muscle circumference, triceps skin fold thickness and right hand grip strength were greater than for the control group at all post hospital discharge time points. The economic evaluation suggested that it was feasible to collect resource use and EQ-5D data for a full cost-effectiveness analysis. Thematic analysis of 15 interviews identified three main themes related to the intervention and the trial: 1) a positive experience, 2) the reasons for taking part, and 3) uncertainty of the study process.

Conclusions

This study demonstrated that home enteral feeding by jejunostomy was feasible, safe and acceptable to patients and their carers. Whether home enteral feeding as ’usual practice’ is a cost-effective therapy would require confirmation in an appropriately powered, multi-centre study.

Trial registration

UK Clinical Research Network ID 12447 (main trial, first registered 30 May 2012); UK Clinical Research Network ID 13361 (qualitative substudy, first registered 30 May 2012); ClinicalTrials.gov NCT01870817 (first registered 28 May 2013)

Patient and Family Caregivers' Experiences of Living With a Jejunostomy Feeding Tube After Surgery for Esophagogastric Cancer

BACKGROUND

Jejunostomy feeding tubes (JFTs) can be used to provide nutrition support to patients who have had surgery for esophagogastric cancer. Although previous research reports how patients cope with a gastrostomy tube, little is known about the impact of having a JFT. The aim of this qualitative study was to explore how patients and their informal caregivers experience living with a JFT in the first months following surgery.

METHODS

Participants were purposively sampled from a cohort of patients recruited to a trial investigating home enteral nutrition vs standard care after esophagogastric surgery for cancer. The sampling framework considered age, sex, and marital status. Informal caregivers were also invited to participate. Interviews were audio recorded, transcribed verbatim, and anonymized. Inductive thematic analysis was used to identify key themes related to living with a JFT.

RESULTS

Fifteen patient interviews were conducted; 8 also included a family caregiver. Analysis of the data resulted in 2 main themes: "challenges" and "facilitators" when living with a JFT. While "physical effects," "worries" and "impact on routine" were the main challenges, "support," "adaptation" and "perceived benefit" were what motivated continuation of the intervention.

CONCLUSION

Findings suggest that participants coped well with a JFT, describing high levels of compliance with stoma care and the feeding regimen. Nonetheless, disturbed sleep patterns and stoma-related problems proved troublesome. A better understanding of these practical challenges, from the patient and family caregiver perspective, should guide healthcare teams in providing proactive support to avoid preventable problems.

Quality of life among adults with epidermolysis bullosa living with a gastrostomy tube since childhood

Epidermolysis bullosa (EB) is a rare genetic condition characterized by blistering to the skin and internal mucous membranes arising from mild mechanical trauma. The impact on those affected can be significant. They might have increased nutritional requirements because of blistering, chronic wounds, infection, and loss of exudates, and nutritional intake might be compromised because of oropharyngeal blistering and strictures, resulting in malnutrition in many patients. Placement of gastrostomy tubes can help some patients meet nutritional requirements. We report a recent study on how EB patients and their families approached the issue of whether to have a gastrostomy tube placed and how such tubes affect quality of life. Our findings include important insights for clinicians and families about how patients experience life with a gastrostomy. We show how the process of consent can be improved and how patients with a gastrostomy tube can feel more in control of their lives.

Patients’ experiences of home enteral tube feeding (HETF) – a qualitative study

Use of home enteral tube feeding (HETF) has increased in Western countries but research is scarce, especially about patients’ experiences of daily life when being treated with HETF. This study aimed to explore what it means to live with HETF and how the situation can be managed. A qualitative method was carried out according to Grounded Theory. In total, 22 interviews were performed with 11 patients treated with HETF for between 8 weeks and 2 years, using open-ended questions. Sampling, data collection and data analysis were carried out simultaneously. To be treated with HETF was experienced as positive as it meant survival, but the most prominent finding told about experiences of restrictions, practical problems and distress in the patients’ daily lives. How daily life turned out seemed to depend on the patient’s ability to manage problems, but was also strongly related to the amount and quality of information and support they received from health professionals. Lacking preparation before discharge as well as lacking support at home meant insecurity and uncertainty. The findings stress the need for comprehensive preparation and support from health professionals, and improvements are needed to facilitate HETF patients’ daily life.

Six weeks of home enteral nutrition versus standard care after esophagectomy or total gastrectomy for cancer: study protocol for a randomized controlled trial

BACKGROUND

Each year approximately 3000 patients in the United Kingdom undergo surgery for esophagogastric cancer. Jejunostomy feeding tubes, placed at the time of surgery for early postoperative nutrition, have been shown to have a positive impact on clinical outcomes in the short term. Whether feeding out of hospital is of benefit is unknown. Local experience has identified that between 15 and 20% of patients required 'rescue' jejunostomy feeding for nutritional problems and weight loss while at home. This weight loss and poor nutrition may contribute to the detrimental effect on the overall quality of life (QoL) reported in these patients.

METHODS/DESIGN

This randomized pilot and feasibility study will provide preliminary information on the routine use of jejunostomy feeding after hospital discharge in terms of clinical benefits and QoL. Sixty participants undergoing esophagectomy or total gastrectomy will be randomized to receive either a planned program of six weeks of home jejunostomy feeding after discharge from hospital (intervention) or treatment-as-usual (control). The intention of this study is to inform a multi-centre randomized controlled trial. The primary outcome measures will be recruitment and retention rates at six weeks and six months. Secondary outcome measures will include disease specific and general QoL measures, nutritional parameters, total and oral nutritional intake, hospital readmission rates, and estimates of healthcare costs. Up to 20 participants will also be enrolled in a qualitative sub-study that will explore participants' and carers' experiences of home tube feeding.The results will be disseminated by presentation at surgical, gastroenterological and dietetic meetings and publication in appropriate peer review journals. A patient-friendly lay summary will be made available on the University of Leicester and the University Hospitals of Leicester NHS Trust websites. The study has full ethical and institutional approval and started recruitment in July 2012.

TRIAL REGISTRATION

UKClinical Research Network ID #12447 (Main study); UKCRN ID#13361 (Qualitative sub study); ClinicalTrials.gov #NCT01870817 (First registered 28 May 2013).

Dysphagia and quality of life

Swallowing difficulties can be a symptom of many different disease processes, and are associated with adverse health outcomes; malnutrition, dehydration, pneumonia and death. The use of feeding tubes directly into the stomach as in percutaneous endoscopic gastrosomy (PEG) is an increasingly common treatment option for these patients with more and more being cared for in the community. Living with a gastrostomy tube brings physical and emotional impacts and direct consequences for quality of life. Guidance from the Royal College of Physicians recommends 'nil by mouth' should be a last resort even when swallow function is deemed unsafe. Impaired swallowing can cause increased anxiety and fear. Many patients avoid oral intake leading to malnutrition, isolation and depression. Understanding and balancing the risks and potential benefits of continuing oral intake or choosing gastrostomy makes this a complex and challenging area of health care.

Family members' experiences caring for patients with advanced head and neck cancer receiving tube feeding: a descriptive phenomenological study

CONTEXT

Head and neck cancer patients with dysphagia frequently require tube feeding. Family members are often involved in caring for such patients but feel ill prepared to do so. Health professionals are in a key position to support family members who undertake caregiving responsibilities. The ability to provide support requires that the experiences of family caregivers (FCs) are well understood; however, few studies examining these experiences have been conducted. To address this gap, research is needed that examines and describes the caregiving experience from the perspective of family members themselves. Such work will provide an empirical base to guide health professionals' practice with FCs.

OBJECTIVES

To explicate the lived experience of caring for a dysphagic relative with advanced head and neck cancer receiving tube feeding.

METHODS

A descriptive phenomenological approach was used. Six FCs participated in two in-depth interviews each. Spiegelberg's three-step approach guided data analysis.

RESULTS

The essence of FCs' experience was "negotiating a new normal" and includes the themes of 1) negotiating changing roles, 2) negotiating an altered lifestyle, 3) negotiating ways of coping, and 4) negotiating the meaning of the feeding tube. Themes 1 and 2 are reported on here.

CONCLUSION

FCs experience significant challenges. Study findings provide direction for health professionals who work with FCs and underscore the need for future research geared toward developing and testing psychoeducational interventions aimed at supporting FCs in the important and difficult caregiving work they do.

Eating-derived pleasure in amyotrophic lateral sclerosis as a predictor of non-oral feeding

Our objective was to examine the pleasure derived from eating in patients with advanced ALS and how this affects advice to have a gastrostomy. Patients with advanced ALS completed a visual analogue scale indicating the pleasure they derived from eating. Data were also collected on the severity of swallow using the Hillel scale, the independent feeding status, and on whether gastrostomy was accepted or not. The findings from 38 consecutive patients indicate that pleasure derived from eating is a powerful indicator of a person's acceptance of gastrostomy. In conclusion, the study showed that a simple analogue scale is quick and practical in a clinical setting even in severely compromised people with ALS and that the eating pleasure score was a strong predictor of the final decision to accept gastrostomy placement (p = 12.2 = 10(-4)).

Overcoming alterations in body image imposed by the left ventricular assist device: a case report

Little is known about clothing issues among patients with implantable left ventricular assist devices (LVADs). This article describes the experience of a woman who had challenges in adapting to an altered body image imposed by the external components of the LVAD system. The woman discusses her problems about clothes that fit her personal style and shares her strategies and recommendations in overcoming the problem. Her description of how she approached and resolved the problem is situated within the Apparel Body Construct Model. In this context, appropriate selection of apparrel is crucial not only to preserving the integrity and function of the LVAD system but also to the recipient's satisfaction with her body image. The information presented is a catalyst for knowledge development and heightening health care providers' awareness of patients' perception of body image, which is vital to adapting to an LVAD as a component of the recipient's body and life.

Patients' perspectives of living with a percutaneous endoscopic gastrostomy (PEG)

BACKGROUND

Since enteral nutrition therapy is the preferred nutritional support for dysphagic patients with a range of diagnoses, PEG has become part of traditional care. However, enteral nutrition with PEG transfers treatment responsibility and activity to the patients and their carers, so the advantages should be discussed. The aim of this study was therefore to investigate patients' experience of living with a percutaneous endoscopic gastrostomy (PEG) in order to increase the understanding of patients' need for support.

METHOD

In a prospective study at Karolinska University Hospital in Sweden, data were collected consecutively at the time of PEG and two months later using a study-specific questionnaire about each patient's experience of living with a PEG. Fishers exact test was used to test for statistically significant difference at five per cent level.

RESULTS

There were 104 responders (response rate of 70%). Women felt more limited in daily activity compared to men (p = 0.004). Older patients experienced a more limited ability to influence the number of feeding times compared to younger (p = 0.026). Highly educated patients found feeding more time-consuming (p = 0.004). Patients with a cancer diagnosis reported that the PEG feeding interfered with their oral feeding more than patients with a neurological disease (p = 0.009). Patients mostly contacted the PEG outpatient clinic with problems regarding their PEG, and were mainly assisted by their spouse rather than district nurses.

CONCLUSIONS

PEG feeding is time-consuming and interferes with daily life. Although 73% was satisfied, patients' experiences of living with a PEG may be dependent on age, sex, education and diagnosis. Spouses are the main carers for PEG patients at home, and patients prefer to go to the PEG outpatient clinic for help if problems occur.

Different experiences and perspectives between head and neck cancer patients and their care-givers on their daily impact of a gastrostomy tube

BACKGROUND

Gastrostomy feeding in head and neck cancer patients is recognised standard practice in some cancer centres with beneficial effects on outcomes for appropriately selected patients. However, the impact on patients and care-givers needs consideration. The present study aimed to understand the daily impact of gastrostomy feeding on head and neck cancer patients and their care-givers to identify improvements to services.

METHODS

Twenty-one adult patients were randomly selected from the Head and Neck centre at University College London Hospital. Six head and neck cancer patients and three care-givers participated in focus groups. The sessions were recorded, fully transcribed and qualitatively thematically analysed, and the resulting data were tabulated.

RESULTS

Patients and care-givers expressed opposite experiences within knowledge and understanding of why the tube was necessary; their personal perceptions and objectives of nutritional support. Themes expressing similar experiences included: developing positive coping strategies; preventing nutritional decline; tube dependency; dentures; finance; active care; and psychological support. Furthermore, both groups expressed the benefits of retaining a support network for rehabilitation with the hospital-based specialist team. Also patients and carers recognised that the gastrostomy tube helped patient survival and, with timely dietetic management, helped them wean off the tube reliance with more confidence.

CONCLUSIONS

It is essential that patients and care-givers attend pretreatment clinics to discuss nutritional support via the artificial route; their quality of life can be enhanced if guided through a specialist support pathway based at the clinical site where they initiated their care, with links to key agencies.

Current microbiology of percutaneous endoscopic gastrostomy tube (PEG tube) insertion site infections in patients with cancer

PURPOSE

Percutaneous endoscopic gastrostomy (PEG) is frequently used to provide enteral access in cancer patients who are unable to swallow. Infection is an important complication in this setting. Current microbiological data are needed to guide infection prevention and treatment strategies.

METHODS

The microbiological records of our institution (a 550-bed comprehensive cancer center) were retrospectively reviewed over an 8-month study period in order to identify patients who developed PEG tube insertion site infections, and review their microbiological details and susceptibility/resistance data.

RESULTS

Fifty-eight episodes of PEG tube insertion site infections were identified. Of these, 31 (53%) were monomicrobial, and the rest were polymicrobial. The most common organisms isolated were Candida species, Staphylococcus aureus, and Pseudomonas aeruginosa. All infections were local (cellulitis, complicated skin, and skin structure infections including abdominal wall abscess) with no cases of concomitant bacteremia being documented. Most of the organisms isolated were susceptible to commonly used antimicrobial agents, although some quinolone-resistant and some multidrug-resistant organisms were isolated.

CONCLUSIONS

This retrospective study provides descriptive data regarding PEG tube insertion site infections. These data have helped us update institutional guidelines for infection prevention and treatment as part of our focus on antimicrobial stewardship.

Struggling in an inescapable life situation: being a close relative of a person dependent on home enteral tube feeding

AIM

To explore what it means to be a close relative of a person dependent on home enteral tube feeding (HETF) and how they can manage this situation.

BACKGROUND

Previous studies have shown that the situation of close relatives in home care in general can be burdensome and difficult. Research is scarce about experiences of close relatives when patients are treated with HETF.

DESIGN

A qualitative design was used, in accordance with grounded theory (GT).

METHODS

Twelve close relatives were interviewed twice, using open-ended questions. Five were relatives of patients supported by home care services or advanced home care teams. Using the GT method, sampling, data collection and data analysis were carried out simultaneously.

RESULTS

One core category, 'Struggling in an inescapable life situation' and eight categories were found. The situation led to involuntary changes in the lives of the close relatives, something they could do little about. Their lives had become completely upturned and restricted by the HETF. Togetherness and pleasure was lost and they felt lonely. The relatives faced a new role of being informal caregivers and they had to adjust their daily life accordingly. They felt forced to take on a heavy responsibility for which they lacked support. The close relatives struggled to manage and to make the best of their new situation.

CONCLUSIONS

This study highlighted the demands and vulnerability which is embedded in the role of being a close relative of a patient with HETF. It also pointed out their need for comprehensive support from the health care system.

RELEVANCE TO CLINICAL PRACTICE

Support to facilitate the situation of close relatives should be given from the health care. One way to organise the care could be through a nurse-led clinic, which provides continuous support, information and counseling.

Balloon gastrostomy tubes for long-term feeding in the community

AIM

Dysphagic patients with functional guts often receive nutritional and hydration support through enteral feeding tubes. These include percutaneous endoscopic gastrostomy (PEG) and radiologically inserted gastrostomy (RIG) tubes. The balloon gastrostomy tube (BGT) as a primary tube of choice in tube-fed patients, including head and neck cancer patients, offers a new approach to enteral tube feeding in the community. There are complications associated with the use of enteral feeding tubes. This study compared the complication rates and the costs of PEG tubes and BGTs in patients on long-term enteral feeding in the community and looked at the possible use of BGTs as an alternative to PEG tubes.

METHODS

The records of all 15 BGT-fed patients on the caseload and 15 randomly selected PEG tube-fed patients were reviewed. The study was based on two consecutive visits to these patients. Tube and stoma complications were clinically scored in order of increasing severity (0-10) and statistically tested. The prevalence of stoma and tube complications was expressed in percentages.

RESULTS

There was no significant difference (P>0.05) in the overall clinical scores between BGT-fed and PEG tube-fed patients at both initial and final visits. However, with regard to specific complications-infected sites, tube dislodgement, overgranulation, and infection with overgranulation-significant differences were observed between the two groups of patients at the initial and final visits. In addition, the total costs of inserting and managing BGTs were significantly higher than those for PEG tubes.

CONCLUSIONS

Although BGTs may be used as analternative to PEG tubes in patients on long-term enteral feeding in the community, the higher cost of using BGTs over PEG tubes should be considered when selecting feeding tubes for these patients.

Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease

BACKGROUND

Motor neurone disease (MND) is a progressive neurodegenerative disease leading to limb weakness, wasting and respiratory failure. Prolonged poor nutritional intake causes fatigue, weight loss and malnutrition. Consequently, disease progression requires decisions to be made regarding enteral tube feeding. The present study aimed to investigate the survival, nutritional status and complications in patients with MND treated with enteral tube feeding.

METHODS

A retrospective case note review was performed to identify patients diagnosed with MND who were treated with enteral tube feeding. A total of 159 consecutive cases were identified suitable for analysis. Patients were treated with percutaneous endoscopic gastrostomy (PEG), radiologically inserted gastrostomy (RIG) or nasogastric feeding tube (NGT). Nutritional status was assessed by body mass index (BMI) and % weight loss (% WL). Serious complications arising from tube insertion and prescribed daily energy intake were both recorded.

RESULTS

Median survival from disease onset was 842 days [interquartile range (IQR) 573-1263]. Median time from disease onset to feeding tube was PEG 521 days (IQR 443-1032), RIG 633 days (IQR 496-1039) and NGT 427 days (IQR 77-781) (P = 0.28). Median survival from tube placement was PEG 200 (IQR 106-546) days, RIG 216 (IQR 83-383) days and NGT 28 (IQR 14-107) days. Survival between gastrostomy and NGT treated patients was significant (P < or = 0.001). Analysis of serious complications by nutritional status was BMI (P = 0.347) and % WL (P = 0.489).

CONCLUSIONS

Nutritional factors associated with reduced survival were weight loss, malnutrition and severe dysphagia. Serious complications were not related to nutritional status but to method of tube insertion. There was no difference in survival between PEG and RIG treated patients.

Dermatology and the community nurse: actinic (solar) keratosis

Community nurses are in daily contact with patients and, in the course of their day's work, have every opportunity of recognizing those patients who are more vulnerable to the sun's rays, and noticing actual sun damage and actinic keratoses. They are then able to check other sun-exposed areas such as the face, ears, scalp, back and limbs to discover any other lesions or more serious problems of basal cell carcinoma, squamous cell carcinoma or malignant melanoma the would require referral, sometimes urgently, to a dermatologist for full assessment and treatment. In any case, sound advice about further protection from the sun, both for themselves and their families may help to reduce the likelihood of further problems.

Quality of life and enteral nutrition

PURPOSE OF REVIEW

The quality of life is in essence, the patients' subjective view of their own health status and can add another dimension to the evaluation of a treatment as the enteral nutrition.The recent clinical investigations on this topic are critically summarized in this review.

RECENT FINDINGS

Three areas of potential impact of enteral nutrition on quality of life of patients have been identified: elderly and neurological patients, cancer patients and patients with anorexia nervosa.A major problem is the difficulty to define quality of life, due to the holistic and subjective nature of this dimension. Moreover, many patients require help to complete the forms of the questionnaire. Finally, many factors besides the enteral nutrition can affect the quality of life of these patients, namely the basic condition and the primary disease of the patients.

SUMMARY

Although the enteral nutrition often represents a life-saving procedure, this does not necessarily translate in an appreciation of a better quality of life by the patients.Additional factors as the gustatory deprivation and the loss of social contacts usually associated with eating and the frequent problems related to tube function and tube-feeding represent severe limitations to a good quality of life of these patients.

Percutaneous endoscopic gastrostomy feeding in nursing homes: relatives' perceptions

The aim of this study is to explore the experiences of relatives of nursing home residents receiving percutaneous endoscopic gastrostomy feeding. Qualitative methodology using semistructured interviews explores the experiences and perceptions of eight relatives. Data are analyzed using thematic analysis. Four themes are constructed from the data: dependence and resulting disempowerment, having minimal or no involvement in the decision-making process for PEG placement, betrayal, and the losses associated with the social aspects of eating. There is a need for professional education about the psychosocial implications of feeding and an increased level of support for relatives to assist them to develop coping strategies. This will require an expansion of current professional roles to include assessment of individual need, setting of appropriate goals, and the coordination of the provision of multiagency services, likely to include counseling and social support. Further research is required in this field to inform service developments.