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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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Saneian H, Mehrannia A, Sabzghabaee AM, Feizi A, Famouri F, Abtahi‐Naeini B. Topical Sucralfate for Prevention of Peristomal Wound Reaction related to Percutaneous Endoscopic Gastrostomy in Children: A Randomized Controlled Trial. Dermatol Ther 2022; 35:e15729. [DOI: 10.1111/dth.15729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/22/2022] [Accepted: 07/21/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Hossein Saneian
- Department of Pediatric Gastroenterology, Child Growth and Development Research Center, Research Institute of Primordial Prevention of Non‐Communicable Disease Isfahan University of Medical Sciences Isfahan Iran
| | - Atoosa Mehrannia
- Department of Pediatrics Isfahan University of Medical Sciences Isfahan Iran
| | | | - Awat Feizi
- Department of Biostatistics and Epidemiology, School of Health Isfahan University of Medical Sciences Isfahan Iran
| | - Fatemeh Famouri
- Department of Pediatric Gastroenterology, Child Growth and Development Research Center, Research Institute of Primordial Prevention of Non‐Communicable Disease Isfahan University of Medical Sciences Isfahan Iran
| | - Bahareh Abtahi‐Naeini
- Pediatric Dermatology Division of Department of Pediatrics, Imam Hossein Children's Hospital Isfahan University of Medical Sciences Isfahan Iran
- Skin Diseases and Leishmaniasis Research Center Isfahan University of Medical Sciences Isfahan Iran
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Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11020279. [PMID: 35203881 PMCID: PMC8868062 DOI: 10.3390/antibiotics11020279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 01/26/2023] Open
Abstract
Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.
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Liu X, Yang Z, He S, Wang G. Percutaneous endoscopic gastrostomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii210015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Xudong Liu
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengqiang Yang
- Department of Radiology Intervention, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shun He
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guiqi Wang
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Antibiotic Prophylaxis for Percutaneous Endoscopic Gastrostomy in Children: A Randomised Controlled Trial. J Pediatr Gastroenterol Nutr 2021; 72:366-371. [PMID: 33148981 DOI: 10.1097/mpg.0000000000002981] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Paediatric studies on the role of antibiotic prophylaxis in the prevention of postoperative infections in children undergoing percutaneous endoscopic gastrostomy (PEG) are lacking. The aim of this study was to assess if a single dose of co-amoxiclav before PEG can decrease the rate of peristomal wound and systemic infection in children. METHODS In this prospective, randomised, double-blind, multicentre trial, children undergoing PEG were randomized to antibiotic prophylaxis with co-amoxiclav versus placebo and the rate of local and systemic infections were assessed. RESULTS Of the 106 patients considered for inclusion, 49 patients were randomized. In the per-protocol analysis, the occurrence of wound infection was 5% (1/20) in the antibiotic group and 21% (4/19) in the placebo group (P = 0.13, 16% difference in proportions, odds ratio [OR] 0.19, 95% confidence interval [CI] 0.02-1.9). The occurrence of systemic infection was 9% (2/22) in the antibiotic group and 27.2% (6/25) in the placebo group [P = 0.17, 18% difference in proportions, OR 0.32, 95% CI 0.06%-1.80%]. Similar results were obtained in intention-to-treat analysis. Interestingly, the overall infection rate was significantly higher in the placebo group as compared with the antibiotic group (40% vs 13.6%; P = 0.04) and the duration of hospital stay was significantly longer in the placebo group as compared with the antibiotic group (4.4 ± 1.6 vs 3.5 ± 1.05; P = 0.02). The number-needed-to-treat (NTT) to prevent 1 peristomal infection on average are 6.7 patients. CONCLUSIONS A preoperative dose of co-amoxiclav reduces the overall infection rate and the duration of hospital stay. Our data suggest that antibiotic prophylaxis should be recommended in every children undergoing PEG placement.
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Gkolfakis P, Arvanitakis M, Despott EJ, Ballarin A, Beyna T, Boeykens K, Elbe P, Gisbertz I, Hoyois A, Mosteanu O, Sanders DS, Schmidt PT, Schneider SM, van Hooft JE. Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:178-195. [PMID: 33348410 DOI: 10.1055/a-1331-8080] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Asuncion Ballarin
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Torsten Beyna
- Department of Gastroenterology and Therapeutic Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
| | - Kurt Boeykens
- Nutrition Support Team, AZ Nikolaas Hospital, Moerlandstraat 1, 9100, Sint-Niklaas, Belgium
| | - Peter Elbe
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Gisbertz
- Department of Gastroenterology, Bernhoven Hospital, Uden, the Netherlands
| | - Alice Hoyois
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ofelia Mosteanu
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital & University of Sheffield, United Kingdom
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Stéphane M Schneider
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Gastroentérologie et Nutrition, Nice, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Farag S, Georgy SS, Fathy M, elSadek A, Abdulghani KO. Attitude and experience of neurologists towards percutaneous endoscopic gastrostomy: an Egyptian study. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00233-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Dysphagia is a common symptom among various neurological diseases. Guidelines recommend gastrostomy insertion for prolonged dysphagia with lower rate of intervention failure encountered with percutaneous endoscopic gastrostomy (PEG) as compared to nasogastric tube insertion.
Methods
Neurology consultants only were included and completed a self-administered questionnaire concerning their practice backgrounds and previous experience with PEG feeding during their practice.
Results
Ninety-eight percent stated that they would recommend PEG for patients with prolonged need of nasogastric feeding. However, only 88% actually referred patients to perform PEG, with the cerebrovascular disorders being the most common cases to be referred. The main barriers the surveyed neurologists faced were family resistance and financial reasons (53.5%). Interestingly, younger neurologists practicing for less than 15 years referred patient to perform PEG significantly more frequent than older ones (p = 0.01). About 18% of our sample confirmed the lack of sufficient knowledge about the benefits of PEG feeding, and only 22% previously attended scientific sessions about the benefits and indications of PEG.
Conclusion
Based on our study, we recommend that PEG should be more encouraged in indicated neurological cases. Scientific sessions targeting neurologists and public awareness about the benefits of PEG and its relatively infrequent complications are highly demanded.
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Abstract
Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed.
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Do Antibiotics Reduce the Incidence of Infections After Percutaneous Endoscopic Gastrostomy Placement in Children? J Pediatr Gastroenterol Nutr 2020; 71:23-28. [PMID: 32205769 DOI: 10.1097/mpg.0000000000002709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Percutaneous endoscopic gastrostomy (PEG) provides a long-term solution for tube dependency. Pediatric guidelines recommend prophylactic antibiotic treatment (ABT) based on adult studies. AIM To compare wound infection and other complications in children receiving a PEG with and without prophylactic ABT. METHODS Retrospective study including children 0 to 18 years undergoing PEG placement. Patients with (2010-2013) and without (2000-2010) ABT were compared with respect to the occurrence of wound infection and other complications. RESULTS In total, 297 patients were included (median age 2.9 years, 53% boys). Patients receiving ABT per PEG protocol (n = 78) had a similar wound infection rate (17.9% vs 21%, P = 0.625), significantly less fever (3.8% vs 14.6%, P = 0.013), leakage (0% vs 9.1%, P = 0.003) and shorter hospital admission (2 vs 4 days, P = 0.000), but more overgranulation (28.2% vs 8.7%, P = 0.000) compared with those without (n = 219). Patients receiving any ABT, per PEG protocol or clinical indication (n = 115), had similar occurrence of wound infection (19.1% vs 20.9%, P = 0.768), fever (7.8% vs 14.3%, P = 0.100) and leakage (3.5% vs 8.8%, P = 0.096), a significantly shorter hospital admission (3 vs 4 days, P = 0.000), but more overgranulation (21.7% vs 8.8%, P =0.003) compared with those without (n = 182). CONCLUSIONS Prophylactic ABT does not seem to reduce the occurrence of wound infection but it might be beneficial with respect to fever, leakage and duration of hospital admission, but not overgranulation. A randomized controlled trial is needed to confirm our results.
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Espinet Coll E, Turró Arau R, Orive Calzada A, Dolz Abadía C, García Ruiz de Gordejuela A, Sánchez Yagüe A, Nebreda Durán J, Galvao Neto M, López-Nava Breviere G, Mata Bilbao A, Alcalde Vargas A, Abad Belando R, Del Pozo-García AJ, Esteban López-Jamar JM, Pujol Gebelli J, Torres García AJ, Ramírez Felipe JA, Muñoz Navas M. Main prophylactic measures in bariatric endoscopy. Spanish Expert Recommendations Guideline. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:491-500. [PMID: 32450708 DOI: 10.17235/reed.2020.6970/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Bariatric endoscopy (BE) encompasses a number of techniques -some consolidated, some under development- aiming to contribute to the management of obese patients and their associated metabolic diseases as a complement to dietary and lifestyle changes. To date different intragastric balloon models, suture systems, aspiration methods, substance injections and both gastric and duodenal malabsorptive devices have been developed, as well as endoscopic procedures for the revision of bariatric surgery. Their ongoing evolution conditions a gradual increase in the quantity and quality of scientific evidence about their effectiveness and safety. Despite this, scientific evidence remains inadequate to establish strong grades of recommendation allowing a unified perspective on prophylaxis in BE. This dearth of data conditions leads, in daily practice, to frequently extrapolate the measures that are used in bariatric surgery (BS) and/or in general therapeutic endoscopy. In this respect, this special article is intended to reach a consensus on the most common prophylactic measures we should apply in BE. The methodological design of this document was developed while attempting to comply with the following 5 phases: Phase 1: delimitation and scope of objectives, according to the GRADE Clinical Guidelines. Phase 2: setup of the Clinical Guide-developing Group: national experts, members of the Grupo Español de Endoscopia Bariátrica (GETTEMO, SEED), SEPD, and SECO, selecting 2 authors for each section. Phase 3: clinical question form (PICO): patients, intervention, comparison, outcomes. Phase 4: literature assessment and synthesis. Search for evidence and elaboration of recommendations. Based on the Oxford Centre for Evidence-Based Medicine classification, most evidence in this article will correspond to level 5 (expert opinions without explicit critical appraisal) and grade of recommendation C (favorable yet inconclusive recommendation) or D (inconclusive or inconsistent studies). Phase 5: External review by experts. We hope that these basic preventive measures will be of interest for daily practice, and may help prevent medical and/or legal conflicts for the benefit of patients, physicians, and BE in general.
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Affiliation(s)
| | - Román Turró Arau
- Aparato Digestivo. Endoscopia Digestiva-Bariátrica, Hospital Quirón Teknon
| | | | | | | | | | | | - Manoel Galvao Neto
- Endoscopia y Cirugía Bariátrica, Instituto Endovitta. Universidad Internacional de Florida, Brasil
| | | | | | | | | | | | | | - Jordi Pujol Gebelli
- Unidad de Cirugía Bariátrica y Metabólica, Hospital Universitari de Bellvitge, España
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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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MDCT evaluation of complications of percutaneous gastrostomy tube placement. Emerg Radiol 2019; 26:663-674. [PMID: 31444681 DOI: 10.1007/s10140-019-01716-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/06/2019] [Indexed: 01/12/2023]
Abstract
Percutaneous gastrostomy tube placement is a commonly performed procedure to provide enteral alimentation to patients unable to tolerate oral feeds. Percutaneous gastrostomy is a relatively safe procedure, and serious complications like gastrointestinal bleeding, perforated viscus, and adjacent organ injury are rare. The most common complications after gastrostomy tube placement occur early and are usually minor. The purpose of this review article is to describe the techniques of percutaneous gastrostomy tube insertion and imaging protocol for gastrostomy tube evaluation, and describe the early, late, and anytime complications. The article will also illustrate very rare late complications of gastrostomy tube placement like gastro-hepatic fistula, gastro-colic fistula, buried bumper syndrome, and gastrostomy site hernia.
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Vujasinovic M, Ingre C, Baldaque Silva F, Frederiksen F, Yu J, Elbe P. Complications and outcome of percutaneous endoscopic gastrostomy in a high-volume centre. Scand J Gastroenterol 2019; 54:513-518. [PMID: 30905223 DOI: 10.1080/00365521.2019.1594354] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction: Percutaneous endoscopic gastrostomy (PEG) is the method of choice for long-term enteral feeding for patients with swallowing disorders and normal gut function. There is limited data regarding the demographics and clinical characteristics of patients from whom PEG was removed. Patients and methods: We performed a retrospective analysis of all consecutive adult patients who underwent first placement of PEG between 1 August 2013 and 31 December 2015 at Karolinska University Hospital in Stockholm, Sweden. Results: In total, 495 PEG were inserted in 495 patients during the study period, 56% male, mean age at insertion 67 years (range 19-95). Most patients belonged to the neurologic group (52%), followed by the oncologic (32%), another diagnosis (9%) and trauma (7%). Major complications occurred in 10 (2.0%) patients. There were no differences in the age or BMI of patients with either minor or major complications but both parameters were risk factors in terms of survival. PEG was removed from 165 (33.3%) patients, most of them from the oncology group, due to the improvement of general status of patients after specific oncologic treatment. Conclusion: Increased age and low BMI were identified as risk factors for mortality but did not correspond with the rate of complications. Antibiotic prophylaxis with sulfamethoxazole and trimethoprim provides good protection for patients with PEG.
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Affiliation(s)
- Miroslav Vujasinovic
- a Department for Digestive Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Caroline Ingre
- b Department of Neurology , Karolinska University Hospital , Stockholm , Sweden
| | | | | | - Jingru Yu
- d Department of Medical Epidemiology and Biostatistics , Karolinska Institute , Stockholm , Sweden
| | - Peter Elbe
- a Department for Digestive Diseases , Karolinska University Hospital , Stockholm , Sweden
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Complications of percutaneous endoscopic and radiologic gastrostomy tube insertion: a KASID (Korean Association for the Study of Intestinal Diseases) study. Surg Endosc 2018; 33:750-756. [DOI: 10.1007/s00464-018-6339-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 07/06/2018] [Indexed: 12/13/2022]
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Vizhi K, Rao HB, Venu RP. Percutaneous endoscopic gastrostomy site infections-Incidence and risk factors. Indian J Gastroenterol 2018; 37:103-107. [PMID: 29473130 DOI: 10.1007/s12664-018-0822-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) placement is the modality of choice for long-term enteral nutrition in view of technical ease and cost-effectiveness. Peristomal infection (PI) remains the most common complication following PEG tube placement. The aim of this study was to assess the incidence and risk factors for PI and outline a microbiological profile that can aid in prophylactic and therapeutic strategies. METHODS A retrospective study of 781 patients who underwent PEG placement (Cook PEG-Pull-S-20Fr/24Fr) from 2010 to 2015 at our tertiary care center were included. Relevant data were collected from the hospital electronic medical records. The incidence of PI was computed and potential risk factors were assessed using univariate analysis. The microbiological profile was created along with sensitivity patterns after reviewing the culture reports. Statistical analysis was performed using SPSS version 20.0. RESULTS PEG tube placement was performed in 781 patients (mean age 55.9 ± 36.1; M:F = 2:75). The major indication was oropharyngeal malignancies. PI was seen in 171 patients (21.9%). Diabetes mellitus, duration of hospital stay more than 7 days, and hypoalbuminemia were found to be significant risk factors for the development of PI (p < 0.05). Patients who had chemotherapy or radiotherapy before PEG placement had a higher incidence of peristomal infections (p 0.00). Pseudomonas and Klebsiella were the most common organisms causing infection. CONCLUSIONS PI remains a significant complication of PEG placement. Pseudomonas and Klebsiella are the most common organisms and prophylactic antibiotic protocols should be tailored accordingly. Elective PEG before the institution of chemotherapy/radiotherapy in patients with oropharyngeal malignancies is recommended.
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Affiliation(s)
- Kayal Vizhi
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, 682 041, India
| | - Harshavardhan B Rao
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, 682 041, India.
| | - Rama P Venu
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, 682 041, India
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Mundi MS, Seegmiller S, Davidson J, Schneckloth J, Saied J, Hurt RT. Prospective Assessment of Peristomal Infections Using Objective Criteria. JPEN J Parenter Enteral Nutr 2017; 42:877-884. [DOI: 10.1002/jpen.1020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 08/24/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Manpreet S. Mundi
- 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
| | - Jacob Davidson
- Division of General Internal Medicine; Mayo Clinic; Rochester Minnesota USA
| | - Jill Schneckloth
- Division of Endocrinology, Diabetes; Metabolism and Nutrition; Mayo Clinic; Rochester Minnesota USA
| | - Jessica Saied
- 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
- Division of Gastroenterology; Hepatology and Nutrition; University of Louisville; Louisville Kentucky USA
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17
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Epstein M, Johnson DA, Hawes R, Schmulewitz N, Vanagunas AD, Gossen ER, Robieson WZ, Eaton S, Dubow J, Chatamra K, Benesh J. Long-Term PEG-J Tube Safety in Patients With Advanced Parkinson's Disease. Clin Transl Gastroenterol 2016; 7:e159. [PMID: 27030949 PMCID: PMC4822096 DOI: 10.1038/ctg.2016.19] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/23/2016] [Accepted: 02/25/2016] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES: The objectives of this study were to present procedure- and device-associated adverse events (AEs) identified with long-term drug delivery via percutaneous endoscopic gastrojejunostomy (PEG-J). Levodopa-carbidopa intestinal gel (LCIG, also known in US as carbidopa-levodopa enteral suspension, CLES) is continuously infused directly to the proximal small intestine via PEG-J in patients with advanced Parkinson's disease (PD) to overcome slow and erratic gastric emptying and treat motor fluctuations that are not adequately controlled by oral or other pharmacological therapy. METHODS: An independent adjudication committee of three experienced (>25 years each) gastroenterologists reviewed gastrointestinal procedure- and device-associated AEs reported for PD patients (total n=395) enrolled in phase 3 LCIG studies. The rate, clinical significance, and causality of the procedure/device events were determined. RESULTS: The patient median exposure to PEG-J at the data cutoff was 480 days. Procedure- and device-associated serious AEs (SAEs) occurred in 67 (17%) patients. A total of 42% of SAEs occurred during the first 4 weeks following PEG-J placement. SAEs of major clinical significance with the highest procedural incidence were peritonitis (1.5%), pneumonia (1.5%), and abdominal pain (1.3%). The most common non-serious procedure- and device-associated AEs were abdominal pain (31%), post-operative wound infection (20%), and procedural pain (23%). In all, 17 (4.3%) patients discontinued treatment owing to an AE. CONCLUSIONS: In conclusion, incidences of PEG-J AEs with the LCIG delivery system and PEG-J longevity were compared favorably with ranges described in the PEG/PEG-J literature. A low discontinuation rate in this study suggests acceptable procedural outcomes and AE rates in PD patients treated with this PEG-J drug delivery system.
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Affiliation(s)
| | - David A Johnson
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Robert Hawes
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Nathan Schmulewitz
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Arvydas D Vanagunas
- Department of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | - Susan Eaton
- Department of Pharmaceutical Development, AbbVie Inc., North Chicago, Illinois, USA
| | - Jordan Dubow
- Department of Pharmaceutical Development, AbbVie Inc., North Chicago, Illinois, USA
| | - Krai Chatamra
- Department of Pharmaceutical Development, AbbVie Inc., North Chicago, Illinois, USA
| | - Janet Benesh
- Department of Pharmaceutical Development, AbbVie Inc., North Chicago, Illinois, USA
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18
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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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19
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Krishna S, Singh S, Dinesh KR, Kp R, Siyad I, Karim S. Percutaneous endoscopic gastrostomy (PEG) site infections: a clinical and microbiological study from university teaching hospital, India. J Infect Prev 2014; 16:113-116. [PMID: 28989413 DOI: 10.1177/1757177414558956] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 10/16/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is used to provide enteral access in patients who are unable to swallow. Infection of the stoma is an important complication and there is little data from India on this problem, which can be used to inform infection prevention and prophylactic strategies. AIM The objective was to assess the prevalence and the role of contributory factors in PEG site infections. METHODS A total of 173 patients underwent PEG insertion from January 2011 to May 2012. Clinical and microbiological data were collected for culture-positive cases. Insertion was performed using a standard sterile pull-through technique. Infections were defined as two of: peristomal erythema, induration, and purulent discharge. RESULTS A total of 54 PEG infections occurred in 43 patients (28.85%). Seventy-seven organisms were isolated. Pseudomonas aeruginosa was the most common (n=29) followed by coliforms (n=21) and meticillin resistant Staphylococcus aureus (MRSA) (n=6). Thirty-one (72%) received amoxicillin-clavulanic acid as prophylaxis and 12 (28%) were receiving concomitant antibiotics for their underlying conditions. The occurrence of PEG site infections was statistically independent of the administered prophylactic antibiotics (p=0.3). CONCLUSIONS This study has demonstrated the importance of PEG sites as a cause of healthcare associated infections. Educating patients on wound care practices would play a significant role in prevention of PEG site infections.
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Affiliation(s)
- Sushma Krishna
- Department Of Microbiology, Amrita Institute of Medical Sciences, India. Current temporary address: MPH Scholar Institute of Tropical Medicine, Antwerp, Belgium
| | - Sanjeev Singh
- Departments of Infection Control and Medical Administration, Amrita Institute of Medical Sciences, Kochi, India
| | - Kavitha R Dinesh
- Department Of Microbiology, Amrita Institute of Medical Sciences, India. Current temporary address: MPH Scholar Institute of Tropical Medicine, Antwerp, Belgium
| | - Remya Kp
- Department Of Infection Control, Amrita Institute of Medical Sciences, Kochi, India
| | - Ismail Siyad
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Shamsul Karim
- Department Of Microbiology, Amrita Institute of Medical Sciences, India. Current temporary address: MPH Scholar Institute of Tropical Medicine, Antwerp, Belgium
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Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure performed to maintain nutrition in the short- or long-term. During the procedure, a feeding tube that delivers either a liquid diet, or medication, via a clean or sterile delivery system, is placed surgically through the anterior abdominal wall. Those undergoing PEG tube placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression, or underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and to the debate surrounding antibiotic prophylaxis for PEG tube placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient's serum and tissues, via a brief course of an appropriate agent, by the time of PEG tube placement in order to prevent any peristomal infections that might result from the procedure. OBJECTIVES To establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomy tubes. SEARCH METHODS In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid Medline; Ovid Medline (In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials during PEG tube placement, with no restrictions regarding language of publication, date of publication, or publication status. Both review authors independently selected studies. DATA COLLECTION AND ANALYSIS Both review authors independently extracted data and assessed study quality. Meta-analyses were performed where appropriate. MAIN RESULTS One new trial was identified and included in this update, bringing the total to 13 eligible RCTs, with a total of 1637 patients. All trials reported peristomal infection as an outcome. A pooled analysis of 12 trials resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (1271 patients pooled: OR 0.36, 95% CI 0.26 to 0.50). The newly identified trial compared IV antibiotics with antibiotics via PEG and could not be included in the meta-analysis. AUTHORS' CONCLUSIONS Administration of systemic prophylactic antibiotics for PEG tube placement reduces peristomal infection.
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Affiliation(s)
- Allyson Lipp
- Department of Care Sciences, University of South WalesFaculty of Health, Sport and ScienceGlyn Taff CampusPontypriddUKCF37 1DL
| | - Gail Lusardi
- Department of Care Sciences, University of South WalesFaculty of Health, Sport and ScienceGlyn Taff CampusPontypriddUKCF37 1DL
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21
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Dhooge M, Gaudric M. Non-surgical access for enteral nutritional: gastrostomy and jejunostomy, technique and results. J Visc Surg 2013; 150:S19-26. [PMID: 23790717 DOI: 10.1016/j.jviscsurg.2013.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Gastrostomy is the most efficient and best tolerated method of prolonged nutritional support. Jejunostomy is used more rarely. Indications for both techniques have increased because of progress in insertion techniques under endoscopic or radiologic guidance. The procedure is simple and rapid, performed under simple sedation with a success rate over 95% for gastrostomy, irrespective of the technique. Mortality directly related to the technique is less than 5%, but associated co-morbidity also explains a more variable but often higher 30-day mortality. Local care and maintenance of the catheter should help avoid most of the late complications such as peristomal leaks, local infection or sepsis of the tunneled catheter in the abdominal wall. The main indications are neurologic swallowing disorders, mechanical dysphagia from ENT or esophageal disease, when the expected duration of enteral nutrition is at least longer than 3 weeks. In patients with severe dementia, no benefit for either nutritional status or quality of life has been demonstrated. In all cases, adequate patient information and careful evaluation of the risk/benefit ratio are capital.
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Affiliation(s)
- M Dhooge
- Service de gastroentérologie, Hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
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22
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73-156. [PMID: 23461695 DOI: 10.1089/sur.2013.9999] [Citation(s) in RCA: 690] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Dale W Bratzler
- College of Public Health, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma 73126-0901, USA.
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23
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. [DOI: 10.2146/ajhp120568] [Citation(s) in RCA: 1364] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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24
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Stayner JL, Bhatnagar A, McGinn AN, Fang JC. Feeding tube placement: errors and complications. Nutr Clin Pract 2012; 27:738-48. [PMID: 23064019 DOI: 10.1177/0884533612462239] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Feeding tube placement for enteral nutrition (EN) support is widely used in both critically ill and stable chronically ill patients who are unable to meet their nutrition needs orally. Nasal or oral feeding tubes can be performed blindly at the bedside or with fluoroscopic or endoscopic guidance into the stomach or small bowel. Percutaneous feeding tubes are used when EN support is required for longer periods (>4-6 weeks) and are most commonly placed endoscopically or radiographically. Although generally safe and effective, there is a wide spectrum of known complications associated with feeding tube placement. Errors made at the time of feeding tube placement can result in a number of these procedural and postprocedural complications. In many cases, a single error at the time of placement can result in numerous complications. A thorough knowledge of these errors and avoiding them in practice will decrease iatrogenic complications in a vulnerable population. In addition, early recognition and management of complications will further minimize morbidity and even mortality in enteral feeding tube placement. This article reviews the common errors leading to complications of enteral feeding tube placement and their prevention and management.
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Affiliation(s)
- James L Stayner
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah 84132, USA
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25
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Ermis F, Ozel M, Oncu K, Yazgan Y, Demirturk L, Gurbuz AK, Akyol T, Nazik H. Indications, complications and long-term follow-up of patients undergoing percutaneous endoscopic gastrostomy: A retrospective study. Wien Klin Wochenschr 2012; 124:148-53. [PMID: 22382552 DOI: 10.1007/s00508-011-0082-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Accepted: 09/11/2011] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Gastroenterology units have faced a major increase in referrals for PEG insertion over the last decade. For this reason we decided to review our PEG insertion procedures with regard to indications, complications and follow-up. MATERIALS AND METHODS The indications, success of procedure, complications, long-term results of PEG in patients of Gulhane Military Medical Academy, Haydarpasa Training Hospital between October 2002 and April 2009 were retrospectively evaluated. RESULTS 81 patients had undergone PEG insertion and follow-up information has been available for 77 patients. 40 were men with the mean age of all patients 70.74 ± 20.82 (range 20 to 104 years). PEG was successfully placed in all patients except in one patient who had gastric bleeding during the procedure. There was only one mortality related with the placement procedure. The most common indication for PEG was neurologic disorders in 71 (92%) patients. Other indications were head and neck cancers in 6 (8%) patients. Median follow-up period was 12 months (range, 3 days to 78 months). PEG related complications were seen in only 14 patients (18.2%) in 16 events with a total complication rate as 21%. CONCLUSIONS PEG placement is a safe procedure and well-tolerated with a low mortality and complication rate even in older patients who have multiple co-morbidities under adequate precautions.
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Affiliation(s)
- Fatih Ermis
- Department of Gastroenterology, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey.
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26
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Kulvatunyou N, Joseph B, Tang A, O'Keeffe T, Wynne JL, Friese RS, Latifi R, Rhee P. Gut access in critically ill and injured patients: Where have we gone thus far? Eur Surg 2011. [DOI: 10.1007/s10353-011-0590-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Chadha KS, Thatikonda C, Schiff M, Nava H, Sitrin MD. Outcomes of Percutaneous Endoscopic Gastrostomy Tube Placement Using a T-Fastener Gastropexy Device in Head and Neck and Esophageal Cancer Patients. Nutr Clin Pract 2010; 25:658-62. [DOI: 10.1177/0884533610385350] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | - Chandana Thatikonda
- Department of Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Michael Schiff
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Hector Nava
- Department of Surgery, Roswell Park Cancer Institute, Buffalo, New York
| | - Michael D. Sitrin
- Department of Medicine, State University of New York at Buffalo, Buffalo, New York
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Zuercher BF, Grosjean P, Monnier P. Percutaneous endoscopic gastrostomy in head and neck cancer patients: indications, techniques, complications and results. Eur Arch Otorhinolaryngol 2010; 268:623-9. [PMID: 21046412 DOI: 10.1007/s00405-010-1412-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 10/13/2010] [Indexed: 12/13/2022]
Abstract
The aim of this study was to review our experience in percutaneous endoscopic gastrostomy (PEG) performed in patients with cancer of the upper aerodigestive tract. Descriptive retrospective study of 142 patients (115 males, 27 females), mean age 62.4 years (25-84 years), with head and neck or esophageal cancer, who underwent PEG tube insertion between January 2006 and December 2008. The studied parameters were indications, success rate, rate and type of complications, and their management. Percutaneous endoscopic gastrostomy was inserted before chemoradiation therapy in 80% and during or after cancer treatment in 20% of the patients. PEG placement was possible in 137 patients (96%). Major complications were observed in 9 (7%) and minor complications in 22 (17%) of the 137 patients. Seven of the 9 patients with a major complication needed revision surgery. The mortality directly related to the procedure was 0.7%. Percutaneous endoscopic gastrostomy tube insertion has a high success rate. In patients with upper aerodigestive tract cancer, PEG should be the first choice for enteral nutrition when sufficient oral intake is not possible. Although apparently easy, the procedure may occasionally lead to severe complications. Therefore, a strict technique and knowledge of clinical signs of possible complications are mandatory.
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Affiliation(s)
- Barbara F Zuercher
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital (CHUV), 1011, Lausanne, Switzerland.
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Abstract
Many patients with advanced head and neck cancer are already in a poor nutritional status and need supportive nutritional therapy at the time of initial diagnosis. Malnutrition is associated with delayed recovery, prolonged hospital stay and unfavorable prognosis. By using percutaneous endoscopic gastrostomy (PEG), the social stigmatization for the patient resulting from the conspicuous nasal feeding tube is avoided. The PEG can be easily implemented at the time of diagnosis by head and neck surgeons in patients suffering from massive tumor-associated weight loss, when definitive or adjuvant radiochemotherapy is anticipated, or prior to tumor surgery likely to be followed by prolonged significant dysphagia and protracted swallowing rehabilitation. Analgesics can be administered via the PEG tube, thus simplifying adequate pain management, which plays a central role in the care of head and neck cancer patients.
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30
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Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr 2010; 51:110-22. [PMID: 20453670 DOI: 10.1097/mpg.0b013e3181d336d2] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Enteral nutrition support (ENS) involves both the delivery of nutrients via feeding tubes and the provision of specialised oral nutritional supplements. ENS is indicated in a patient with at least a partially functioning digestive tract when oral intake is inadequate or intake of normal food is inappropriate to meet the patients' needs. The aim of this comment by the Committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition is to provide a clinical practice guide to ENS, based on the available evidence and the clinical expertise of the authors. Statements and recommendations are presented, and future research needs highlighted, with a particular emphasis placed on a practical approach to ENS.Among the wide array of enteral formulations, standard polymeric feeds based on cow's-milk protein with fibre and age adapted for energy and nutrient content are suitable for most paediatric patients. Whenever possible, intragastric is preferred to postpyloric delivery of nutrients, and intermittent feeding is preferred to continuous feeding because it is more physiological. An anticipated duration of enteral nutrition (EN) exceeding 4 to 6 weeks is an indication for gastrostomy or enterostomy. Among the various gastrostomy techniques available, percutaneous endoscopic gastrostomy is currently the first option. In general, both patients and caregivers express satisfaction with this procedure, although it is associated with a number of well-recognised complications. We strongly recommend the development and application of procedural protocols that include scrupulous attention to hygiene, as well as regular monitoring by a multidisciplinary nutrition support team to minimise the risk of EN-associated complications.
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Lloyd DAJ, Powell-Tuck J. Artificial nutrition: principles and practice of enteral feeding. Clin Colon Rectal Surg 2010; 17:107-18. [PMID: 20011255 DOI: 10.1055/s-2004-828657] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Enteral feeding is a commonly used form of nutritional supplementation for patients with intestinal failure, both in hospitals and in the community. This article concentrates on the basic principles of enteral feeding, including the physiological effects of feeding into the intestinal tract. It covers the indications for enteral feeding, the different methods of supplying enteral feeds to the gastrointestinal tract, and the potential complications. There is also a discussion of the indications for and practice of home enteral nutrition.
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Affiliation(s)
- David A J Lloyd
- Clinical Nutrition, Royal London Hospital, London, United Kingdom
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Local infection after placement of percutaneous endoscopic gastrostomy tubes: a prospective study evaluating risk factors. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 22:987-91. [PMID: 19096738 DOI: 10.1155/2008/530109] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Due to its high efficacy and technical simplicity, percutaneous endoscopic gastrostomy (PEG) has gained wide-spread use. Local infection, occurring in approximately 2% to 39% of procedures, is the most common complication in the short term. Risk factors for local infection are largely unknown and therefore--apart from calculated antibiotic prophylaxis--preventive strategies have yet to be determined. OBJECTIVE To assess the potential patient- and procedure-related risk factors for peristomal infection following PEG tube placement. METHODS Potential patient-related (eg, age, sex, diseases, body mass index, concomitant antibiotic therapy) and procedure-related (endoscopist experience, institutional factors, findings on endoscopy) risk factors and their coincidence with local infection, defined as a positive peristomal infection three days after PEG tube placement, were evaluated at two institutions. A standardized antibiotic prophylaxis was not performed. The peristomal infection score was also evaluated in 390 patients. RESULTS Using a multivariate binary regression analysis, four risk factors were established as relevant for local infection after PEG: clinical institution (OR 6.69; P = 0.0001), size of PEG tubes (15 Fr versus 9 Fr; OR 2.12; P = 0.05), experience of the endoscopist (more than 100 investigations versus less than 100 investigations; OR 0.54; P = 0.05) and the existence of a malignant underlying disease (OR 2.28; P = 0.019). CONCLUSIONS Similar to other endoscopic interventions, local infection as a complication of PEG tube placement depends on the experience of the endoscopist. Institutional factors also play a significant role. Additional risk factors include PEG tube size and underlying diseases. These findings indicate that the local infection after PEG tube placement may be influenced by both endoscopy-associated factors and by the underlying disease status of the patient.
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Abstract
AIM To establish whether prophylactic systemic antimicrobials reduce the risk of peristomal infection in placement of percutaneous endoscopic gastrostomies. BACKGROUND Percutaneous endoscopic gastrostomies, placed surgically through the anterior abdominal wall, maintain nutrition in the short or long term. Those undergoing percutaneous endoscopic gastrostomy placement are often vulnerable to infection. The increasing incidence of methicillin-resistant Staphylococcus aureus contributes an additional risk to the debate surrounding antibiotic prophylaxis. The aim of antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient, during placement. DESIGN Systematic review. METHODS We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals, relevant conference proceedings and bibliographies of publications identified, and contacted manufacturers and distributors of percutaneous endoscopic gastrostomy products. Randomised controlled trials were selected evaluating the use of prophylactic antimicrobials for percutaneous endoscopic gastrostomy placement, with no restrictions for language, date or publication status. Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate. RESULTS Ten eligible randomised controlled trials were identified evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22-0.44). The relative reduction in risk of infection for those given antibiotics was 19% with the need to treat 5.8 patients to prevent one infection - NNT. CONCLUSIONS Administration of systemic prophylactic antibiotics for percutaneous endoscopic gastrostomy placement reduces peristomal infection. RELEVANCE TO CLINICAL PRACTICE The nurse's role in endoscopy is expanding rapidly and demands that practice is based on the best available evidence. This systematic review seeks to make a contribution to best practice in percutaneous endoscopic gastrostomy placement.
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Affiliation(s)
- Allyson Lipp
- Faculty of Health, Sport and Science, University of Glamorgan, Pontypridd, UK.
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Shastri YM, Hoepffner N, Tessmer A, Ackermann H, Schroeder O, Stein J. New introducer PEG gastropexy does not require prophylactic antibiotics: multicenter prospective randomized double-blind placebo-controlled study. Gastrointest Endosc 2008; 67:620-8. [PMID: 18374024 DOI: 10.1016/j.gie.2007.10.044] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 10/14/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Peristomal infections are the most common complications of PEG, despite prophylactic antibiotics. The "introducer" PEG-placement technique avoids the sojourn of a PEG catheter through the oropharynx, and hence minimizes the chances of infectious complications. Despite the obvious potential advantage, this technique failed to gain popularity, mainly as a result of other associated risks and complications. Recently, a modified introducer endoscopic PEG-gastropexy technique was shown to be quite safe. The present study is the first study that evaluated the need of prophylactic antibiotics for "introducer" PEG. OBJECTIVE To determine the incidence of peristomal wound infections during the immediate 7-day postprocedure follow-up. DESIGN Prospective, randomized, double-blind, placebo-controlled trial. SETTINGS Multicenter; a university tertiary-care hospital and a private practice endoscopy clinic. PATIENTS A total of 633 patients undergoing PEG were assessed for inclusion. Ninety-seven patients who had malignant stenotic oropharyngeal stricture were randomized: group I (49 patients) received prophylactic ceftriaxone, and group II (48 patients) received a placebo. Both groups were similar in patient characteristics. INTERVENTIONS Introducer PEG was performed by using the Freka Pexact-15 CH/FR, with the gastric wall nonsurgically sutured to the anterior abdominal wall by use of an endoscope. MAIN OUTCOME MEASUREMENTS The peristomal area was assessed daily for 7 days by using 2 different types of infection scores. RESULTS Clinically significant wound reaction was observed in 1 patient in each group. Wound infection scores were marginally higher in the placebo group, but the differences in the values of infection scores between both the groups were not statistically significant during the 7-day post-PEG follow-up. LIMITATIONS The introducer gastropexy kit is 5 times more expensive than the "pull" PEG. CONCLUSIONS The new introducer PEG-gastropexy technique can be performed safely, without prophylactic antibiotics in patients potentially at high risk of peristomal infectious complications (those with advanced oropharyngeal malignancy) (ClinicalTrials.gov identifier NCT00375414).
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Affiliation(s)
- Yogesh M Shastri
- Division of Gastroenterology and Clinical Nutrition, Department of Medicine I-ZAFES, Johann Wolfgang Goethe-University Hospital, Bethanien, Frankfurt am Main, Germany
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Shaukat A, Nelson DB. Risks of Infection from Gastrointestinal Endoscopy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2007.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Intestinal failure refers to a condition in which inadequate digestion and/or absorption of nutrients leads to malnutrition and/or dehydration. Enteral access is occasionally used in patients with intestinal failure either for the purpose of providing nutrition or decompressing the gut. As a consequence, it is important that clinicians caring for these highly complex patients be knowledgeable in enteral access options and experienced in the subsequent care of these tubes. In this review, enteral access options and the potential complications associated with their use will be reviewed. Importantly, this information is relevant to both the pediatric and adult patient with intestinal failure.
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Affiliation(s)
- John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA.
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37
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Abstract
This article provides an overview of the various methods available for providing nutritional support. The various techniques available for both enteral and parenteral access are discussed. The selection of the most appropriate route of nutritional support is highly individual and recommendations are made regarding the factors that should be considered by the patient and the clinician in the decision-making process.
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Affiliation(s)
- Susannah R Green
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
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Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA, Galandiuk S. Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther 2007; 25:647-56. [PMID: 17311597 DOI: 10.1111/j.1365-2036.2007.03247.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite numerous guidelines recommending prophylactic antibiotics prior to percutaneous endoscopic gastrostomy, their use remains controversial. AIM To conduct a systematic literature review and performed meta-analyses to determine the benefit of antibiotic prophylaxis for percutaneous endoscopic gastrostomy placement. METHODS We performed a systematic literature review by searching healthcare databases and grey literature for randomized-controlled trials of antibiotic prophylaxis against wound infection after percutaneous endoscopic gastrostomy. Relative risks were calculated for individual trials and data pooled using fixed-effects model. Relative risk reduction, absolute risk reduction and number needed to treat were calculated and are reported with 95% confidence intervals. RESULTS Ten randomized-controlled trials met the inclusion criteria and 1059 cases were pooled. Overall findings indicated that antibiotic prophylaxis resulted in a relative risk reduction of 64% and an absolute risk reduction of 15%. Number needed to treat to prevent one wound infection was 8. Cephalosporin prophylaxis was associated with a relative risk reduction of 64%, absolute risk reduction of 10% and number needed to treat of 10, whereas penicillin-based prophylaxis was associated with a relative risk reduction of 62%, absolute risk reduction of 13% and number needed to treat of 8. CONCLUSIONS Antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy is effective in reducing the incidence of percutaneous endoscopic gastrostomy site wound infection. Based on sensitivity analyses, penicillin-based prophylaxis should be the prophylaxis of choice.
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Affiliation(s)
- N S Jafri
- Division of Internal Medicine, Department of Medicine, University of Louisville School of Medicine, Louisville, KY 40292, USA
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Thomas S, Cantrill S, Waghorn DJ, McIntyre A. The role of screening and antibiotic prophylaxis in the prevention of percutaneous gastrostomy site infection caused by methicillin-resistant Staphylococcus aureus. Aliment Pharmacol Ther 2007; 25:593-7. [PMID: 17305760 DOI: 10.1111/j.1365-2036.2006.03242.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Peristomal wound infections are common complications of percutaneous endoscopic gastrostomy (PEG), especially in hospitals where methicillin-resistant Staphylococcus aureus (MRSA) is endemic. Evidence suggests that antibiotic prophylaxis at PEG insertion may reduce infection rates. AIM To examine rates of peristomal MRSA infection before and after introduction of a screening, decontamination and antibiotic prophylaxis protocol. METHODS Retrospective case analysis detected new peristomal MRSA infections over a 33-month period. Prospectively from October 2004, patients requiring PEG were screened and, if MRSA positive, received decontamination (5 days) and prophylactic teicoplanin before insertion. Peristomal wound sites were monitored after insertion. RESULTS Peristomal MRSA infection was identified in 5/42 patients (12%) in 2002, 7/35 (20%) in 2003 and 7/24 (29%) in 2004 -- overall infection rate 19%. Of 47 patients undergoing new PEG insertions between October 2004 and August 2006 (four known MRSA and 10 identified by screening), one (2%) developed peristomal MRSA infection 14 days postprocedure. A significant reduction in MRSA peristomal infection has been demonstrated (P < 0.01). CONCLUSIONS Screening for MRSA before PEG insertion identifies MRSA colonization and subsequent decontamination and antibiotic prophylaxis reduces peristomal MRSA infection rates. Where MRSA is endemic, the risk of wound site infection may remain postprocedure unless high standards of wound care are maintained.
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Affiliation(s)
- S Thomas
- Department of Microbiology/Infection Control, Wycombe Hospital, High Wycombe, Buckinghamshire, UK
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40
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Radhakrishnan NV, Shenoy AH, Cartmill I, Sharma RK, George R, Foster DN, Quest L. Addition of local antiseptic spray to parenteral antibiotic regimen reduces the incidence of stomal infection following percutaneous endoscopic gastrostomy: A randomized controlled trial. Eur J Gastroenterol Hepatol 2006; 18:1279-84. [PMID: 17099376 DOI: 10.1097/01.meg.0000243871.48831.00] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To study the effectiveness of local antiseptic spray with or without a three-dose antibiotic regimen in the prevention of stomal infection following percutaneous endoscopic gastrostomy. METHODS Ninety-six patients were randomized into three groups: A, intravenous cefuroxime 750 mg just before the procedure followed by two further doses every 8 h; B, single application of povidone-iodine (Betadine) antiseptic spray; C, combination of A and B. The stomal site was examined at midweek and at the end of week 1 for evidence of infection using a validated scoring system. Fisher's exact test was used for analysis of primary end point, namely, stomal infection at midweek and at the end of week 1. Logistic regression models were used for secondary analysis to consider the effects of diabetes, acid suppressants, steroids, age and sex on outcome. RESULTS Group A had 34 patients, group B had 28 and group C had 34. Age, sex and indications in groups A, B and C are broadly comparable. Stomal infection was 32% in group B vs. groups A (6%) and C (9%) (P = 0.0114) at midweek, and 3% in group C vs. 32% each in groups A and B (P = 0.0013) at the end of week 1. Cumulative infections (n) at the end of week 1 were lower in group C (3) (9%) than in groups A (11) (32%) and B (12) (43%) (P = 0.003). No significant difference was observed between the three groups in terms of the number of patients who were given antibiotics for other indications (P = 0.363). By logistic regression only diabetes, but not other covariates, seems to have a significant effect on stomal infection (odds ratio, 33.34; 95% CI, 4.33-256.7). CONCLUSION A combination of cefuroxime and Betadine spray significantly reduces stomal infection following percutaneous endoscopic gastrostomy at the end of week 1. Both the antibiotic group (A) and the combined group (C) did well compared with the Betadine only group (B) at midweek.
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Affiliation(s)
- Nerukav V Radhakrishnan
- Department of Gastroenterology, Rochdale Infirmary, Pennine Acute Hospitals' NHS Trust, Rochdale, UK.
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Faias S, Cravo M, Claro I, Lage P, Nobre-Leitão C. High rate of percutaneous endoscopic gastrostomy site infections due to oropharyngeal colonization. Dig Dis Sci 2006; 51:2384-8. [PMID: 17078008 DOI: 10.1007/s10620-006-9216-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Accepted: 12/23/2005] [Indexed: 12/09/2022]
Abstract
We prospectively analyzed peristomal infection agents during the first week following percutaneous endoscopic gastrostomy (PEG) placement by the pull technique in patients with head and neck cancer. Nasal and pharyngeal swabs were obtained from a consecutive series of cancer patients prior to PEG placement. All patients underwent antibiotic prophylaxis with cefotaxime and oral disinfection. PEG site infection was prospectively evaluated at days 2, 3, and 7 after insertion. Twenty-eight patients (25 males; mean age, 58 years) were included. Oropharyngeal or nasal colonization were observed in 68% (19/28) and 19% (5/28) of patients, respectively. Early infections occurred in 36% (10/28) of the patients, all with oropharyngeal colonization and concordance between agents (P=0.01). Three patients required hospital admission and 1 required surgery. Head and neck cancer patients with oropharyngeal colonization have a high risk of early PEG site infection with substantial morbidity owing to oral-stomal spread.
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Affiliation(s)
- Sandra Faias
- Gastrenterology Department, Instituto Português de Oncologia de Francisco Gentil, CRL - Lisbon, Portugal
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42
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Suzuki Y, Urashima M, Ishibashi Y, Abo M, Mashiko H, Eda Y, Kusakabe T, Kawasaki N, Yanaga K. Covering the percutaneous endoscopic gastrostomy (PEG) tube prevents peristomal infection. World J Surg 2006; 30:1450-8. [PMID: 16855804 DOI: 10.1007/s00268-005-0628-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Because oropharyngeal bacteria can be brought through the abdominal wall during percutaneous endoscopic gastrostomy (PEG), peristomal infection is one of the most frequent complications in patients who undergo the procedure. This study aimed to determine whether covering the PEG tube with a sheath that could be detached in the stomach could help prevent peristomal infection. METHODS In three community hospitals in Japan, data from 449 patients with swallowing dysfunction were prospectively collected between March 2000 and February 2002 for non-covered PEG (n=206) and between March 2002 and February 2004 for covered PEG (n=243). RESULTS After adjusting for hospital, age, gender, and underlying diseases, covering the PEG significantly reduced peristomal purulent infection compared with non-covered PEG (odds ratio: 0.05; 95% confidence interval: 0.02-0.13). Body temperature, white blood cell count, and C-reactive protein at day 3 after PEG placement, as well as duration of antibiotics usage, were significantly lower or shorter in patients treated with covered PEG than non-covered PEG. In spite of the same frequencies in the two groups of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa in oropharyngeal cultures before PEG placement, these organisms were detected significantly less frequently in peristomal lesions of patients who underwent covered PEG. Moreover, 28 patients treated with covered PEG received no antibiotic therapy, and 27 of them had no signs of peristomal infection. CONCLUSIONS These results suggest that covering the PEG tube, with or without providing antibiotic therapy, may prevent peristomal infection in spite of the presence of oropharyngeal bacterial flora after percutaneous endoscopic gastrostomy.
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Affiliation(s)
- Yutaka Suzuki
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, and Department of Surgery, Mashiko Hospital, Saitama, Japan
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43
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Abstract
BACKGROUND Percutaneous endoscopic gastrostomies (PEG) maintain nutrition in the short or long term. A PEG is a feeding tube, placed surgically through the anterior abdominal wall, which delivers a liquid diet, or medication, via a clean or sterile delivery system. Those undergoing PEG placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression and underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and also to the debate surrounding antibiotic prophylaxis for PEG placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patients serum and tissues, via a brief course of an appropriate agent, by the time of PEG placement. OBJECTIVES The review seeks to establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomies. SEARCH STRATEGY We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals relevant conference proceedings, and bibliographies of relevant publications identified by these strategies for further studies; and contacted manufacturers and distributors of PEG products. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials for PEG placement, with no restrictions for language, date or publication status. DATA COLLECTION AND ANALYSIS Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate. MAIN RESULTS We identified 10 eligible RCTs evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome, and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22 to 0.44). AUTHORS' CONCLUSIONS Administration of systemic prophylactic antibiotics for PEG placement reduces peristomal infection.
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Affiliation(s)
- A Lipp
- University of Glamorgan, School of Care Sciences, Glyntaff, Pontypridd, UK.
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44
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Abstract
PURPOSE OF REVIEW Critical to realizing increasing benefits of enteral nutrition are techniques for feeding tube placement. Feeding tubes can be placed by bedside, endoscopic, fluoroscopic, and surgical methods. This review encompasses noteworthy studies on endoscopic approaches to enteral feeding published from January 2005 to the present. RECENT FINDINGS Studies involving placement of nasoenteric feeding tubes include description of new methods for endoscopic nasoenteric feeding tube placement using a push technique with a stiffened tube, a modification of the 'drag and pull' method using a distal suture tie, and placement using an ultrathin transnasal endoscopic technique compared with fluoroscopic placement. Recent studies involving percutaneous endoscopic gastrostomy tube placement have demonstrated equivalent outcomes of endoscopic and fluoroscopic approaches, description of unsedated placement using transnasal technique, and risk of percutaneous endoscopic gastrostomy site metastasis in head and neck cancer patients. Studies on percutaneous jejunal feeding tubes demonstrate: high complication rate and short functional duration of percutaneous endoscopic gastrojejunostomy and reported outcomes of direct percutaneous endoscopic jejunostomy placement. SUMMARY Enteral nutrition access can be obtained by a variety of methods depending on local expertise and resources. Endoscopic approaches have equivalent or better outcomes than other methods; however, these methods may still have limitations and distinct complications.
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Affiliation(s)
- Kathryn R Byrne
- Division of Gastroenterology, University of Utah Health Sciences Center, School of Medicine, Salt Lake City, Utah, USA
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Ockenga J, Grimble R, Jonkers-Schuitema C, Macallan D, Melchior JC, Sauerwein HP, Schwenk A, Süttmann U. ESPEN Guidelines on Enteral Nutrition: Wasting in HIV and other chronic infectious diseases. Clin Nutr 2006; 25:319-29. [PMID: 16698147 DOI: 10.1016/j.clnu.2006.01.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 01/20/2006] [Indexed: 01/10/2023]
Abstract
Undernutrition (wasting) is still frequent in patients infected with the human immunodeficiency virus (HIV), despite recent decreases in the prevalence of undernutrition in western countries (as opposed to developing countries) due to the use of highly active antiretroviral treatment. Undernutrition has been shown to have a negative prognostic effect independently of immunodeficiency and viral load. These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) in HIV-infected patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. Nutritional therapy is indicated when significant weight loss (>5% in 3 months) or a significant loss of body cell mass (>5% in 3 months) has occurred, and should be considered when the body mass index (BMI) is <18.5 kg/m(2). If normal food intake including nutritional counselling and optimal use of ONS cannot achieve an adequate nutrient intake, TF with standard formulae is indicated. Due to conflicting results from studies investigating the impact of immune-modulating formulae, these are not generally recommended. The results obtained in HIV patients may be extrapolated to other chronic infectious diseases, in the absence of available data.
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Affiliation(s)
- J Ockenga
- Department Gastroenterology, CCM, Universitätsmedizin Berlin, Berlin, Germany.
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Affiliation(s)
- Susan A Hussein
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH 45229, USA
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47
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Maetani I, Sakai Y. REDUCING THE RISK OF PERISTOMAL INFECTION AFTER PEG PLACEMENT. Dig Endosc 2005. [DOI: 10.1111/j.1443-1661.2005.00546.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Silas AM, Pearce LF, Lestina LS, Grove MR, Tosteson A, Manganiello WD, Bettmann MA, Gordon SR. Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: A comparison of indications, complications and outcomes in 370 patients. Eur J Radiol 2005; 56:84-90. [PMID: 16168268 DOI: 10.1016/j.ejrad.2005.02.007] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2004] [Revised: 02/11/2005] [Accepted: 02/16/2005] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Percutaneous access to the stomach can be achieved by endoscopic or fluoroscopic methods. Our objective was to compare indications, complications, efficacy and outcomes of these two techniques. METHODS Records of 370 patients with feeding tubes placed either endoscopically by gastroenterology, or fluoroscopically by radiology, at our university-based tertiary care center over a 54-month period were reviewed. RESULTS 177 gastrostomies were placed endoscopically and 193 fluoroscopically. Nutrition was the most common indication in each group (94 and 92%), but the most common underlying diagnosis was neurologic impairment in the endoscopic group (n=89, 50%) and malignancy in the fluoroscopic group (n=134, 69%) (p<0.001). Complications in the first 30 days were more common with fluoroscopic placement (23% versus 11%, p=0.002), with infection most frequent. Correlates of late complications were inpatient status (OR 0.26, 95%CI: 0.13-0.51) and a diagnosis of malignancy (OR 2.2, 95%CI: 1.03-4.84). Average follow-up time was 108 days in the fluoroscopic group and 174 days in the endoscopic group. CONCLUSIONS Both endoscopic and fluoroscopic gastrostomy tube placement are safe and effective. Outpatient status was associated with greater early and late complication rates; minor complications such as infection were greater in the fluoroscopic group, while malignancy was associated with late complications.
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Affiliation(s)
- Anne M Silas
- Department of Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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Saadeddin A, Freshwater DA, Fisher NC, Jones BJM. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy for non-malignant conditions: a double-blind prospective randomized controlled trial. Aliment Pharmacol Ther 2005; 22:565-70. [PMID: 16167973 DOI: 10.1111/j.1365-2036.2005.02578.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion has been encouraged following development of guidelines by a number of professional societies within the past few years. However, not all evidence supports routine prophylaxis, particularly in patients with 'benign' disease indications for percutaneous endoscopic gastrostomy insertion. AIM To identify whether prophylactic antibiotic usage is beneficial in patients undergoing percutaneous endoscopic gastrostomy insertion without malignant disease. METHODS Adult patients without malignant disease who were referred for percutaneous endoscopic gastrostomy insertion at our unit were assessed for participation in this prospective, double-blind, randomized controlled study. Patients were randomized to receive either placebo or 2.2 g co-amoxiclav (or 2 g cefotaxime if penicillin-allergic) at time of percutaneous endoscopic gastrostomy insertion. Clinical endpoints studies were percutaneous endoscopic gastrostomy site or systemic infection and death within 7 days of percutaneous endoscopic gastrostomy insertion. Results : Ninety-nine patients completed the study (51 antibiotics, 48 placebo). Outcomes in the antibiotic and placebo groups respectively were: percutaneous endoscopic gastrostomy site infection, 11% vs. 47% (P < 0.01); systemic infection, 16% vs. 38% (P < 0.05); and death, 8% vs. 15% (P = 0.5). CONCLUSIONS Antibiotic prophylaxis prior to percutaneous endoscopic gastrostomy insertion reduces both percutaneous endoscopic gastrostomy site and systemic infections in patients without malignant disease.
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Affiliation(s)
- A Saadeddin
- Department of Gastroenterology and Nutrition, Russells Hall Hospital, Dudley, West Midlands, UK
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Minicucci MF, Silva GF, Matsui M, Inque RMT, Zornoff LAM, Matsubara LS, Paiva SARD. O uso da gastrostomia percutânea endoscópica. REV NUTR 2005. [DOI: 10.1590/s1415-52732005000400010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A gastrostomia percutânea endoscópica foi introduzida na prática clínica como via alternativa de alimentação enteral. É procedimento que não necessita de anestesia ou laparotomia, como a gastrostomia cirúrgica. A gastrostomia percutânea endoscópica tem como objetivos a manutenção do aporte nutricional e a melhoria da qualidade de vida e sobrevida dos pacientes. É indicada quando o paciente necessita de dieta enteral por período superior a um mês. A freqüência de complicações varia de 1,0% a 10,0% e a mortalidade de 0,3% a 1,0%. É propósito deste trabalho abordar aspectos relevantes desse método de alimentação enteral, aprimorar seu manejo, bem como facilitar o manejo pelos pacientes que dele se utilizam. Para isso, vamos comentar as indicações e contra-indicações da gastrostomia percutânea endoscópica, técnica de colocação, material das sondas, antibiótico profilático, início de utilização, custo do procedimento, além de suas complicações, aspectos legais e éticos.
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