Assessment of indications for percutaneous endoscopic gastrostomy--development of a predictive model

Evaluation of 644 Percutaneous Endoscopic Gastrostomy Patients in a Single Center

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mortality and complications after percutaneous endoscopic gastrostomy: a retrospective multicentre study

Background

Percutaneous endoscopic gastrostomy (PEG) is the method of choice for patients in need of long-term nutritional support or gastric decompression. Although it is considered safe, complications and relatively high mortality rates have been reported. We aimed to identify risk factors for complications and mortality after PEG in routine healthcare.

Methods

This retrospective study included all adult patients who received a PEG between 2013 and 2019 in Region Norrbotten, Sweden.

Results

389 patients were included. The median age was 72 years, 176 (45%) were women and 281 (72%) patients received their PEG due to neurological disease. All-cause mortality was 15% at 30 days and 28% at 90 days. Malignancy as the indication for PEG was associated with increased mortality at 90 days (OR 4.41, 95% CI 2.20–8.88). Other factors significantly associated with increased mortality were older age, female sex, diabetes mellitus, heart failure, lower body mass index and higher C-reactive protein levels. Minor and major complications within 30 days occurred in 11% and 15% of the patients, respectively. Diabetes increased the risk of minor complications (OR 2.61, 95% CI 1.04–6.55), while those aged 75 + years were at an increased risk of major complications, compared to those younger than 65 years (OR 2.23, 95% CI 1.02–4.85).

Conclusions

The increased risk of death among women and patients with malignancy indicate that these patients could benefit from earlier referral for PEG. Additionally, we found that age, diabetes, heart failure, C-reactive protein and body mass index all impact the risk of adverse outcomes.

Percutaneous endoscopic gastrostomy: dealing with the issue of dislodgement

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is accepted as an efficient method to provide long-term enteral nutrition. PEG accidental dislodgement (device exteriorization confirmed by expert evaluation) rate is high and can lead to major morbidity.Objective: To identify independent risk factors for PEG accidental dislodgement.Methods: Retrospective, single-center study, including consecutive patients submitted to PEG procedure, for 38 consecutive months. Every patient had 12 months minimum follow-up after PEG placement. Univariate analysis selected variables with at least marginal association (p < .15) with the outcome variable, PEG dislodgement, which were included in a logistic regression multivariate model. Discriminative power was assessed using area under curve (AUC) of the receiver operating curve (ROC).Results: We included 164 patients, 67.7% (111) were female, mean age was 81 years. We report 59 (36%) PEG dislodgements, of which 13 (7.9%) corresponded to early dislodgements. The variables with marginal association were hypoalbuminemia (p = .095); living at home (p = .049); living in a nursing home (p = .074); cerebrovascular disease (CVD) (p = .028); weight change of more than 5 kg, either increase or decrease (p = .001); psychomotor agitation (p < .001); distance inner bumper-abdominal wall (p = .034) and irregular appointment follow-up (p = .149). At logistic multivariate regression, the significant variables after model adjustment were CVD OR 4.8 (CI 95% 2.0-11.8), weight change OR 4.7 (CI 95%1.6-13.9) and psychomotor agitation OR 18.5 (CI 95% 5.2-65.6), with excellent discriminative power (AUC ROC 0.797 [CI95% 0.719-0.875]).Conclusion: PEG is a common procedure and accidental dislodgement is a frequent complication. CVD, psychomotor agitation and weight change >5 kg increase the risk of this complication and should be seriously considered when establishing patients' individual care requirements.

Prospective implementation of algorithmic patient selection for gastrostomy tube placement consultations: a pre- and post-intervention analysis

Background: Studies have shown high but variable mortality following gastrostomy tube (GT) placement. There are no standard practice guidelines for GT placement.

Aim: To evaluate if implementation of patient selection and prognosis algorithms for GT insertion has favorable effects on patient outcomes.

Methods: This was a pre-, post-cohort analysis in a Veterans Affairs hospital. We implemented a patient selection algorithm aided by the Sheffield Gastrostomy Scoring System (SGSS) in July 2015. We reviewed all referrals to the inpatient service for a GT between July 2014 and June 2016 (pre-, post- implementation), and collected albumin and SGSS at time of consultation, date of GT insertion, and outcomes including vital status and albumin 30 days post-consultation. Patients were followed until 30 October 2016. We compared outcomes pre- and post-implementation.

Results: A total of 126 referrals were reviewed, 68 pre- and 58 post-algorithm implementation. Seventy-seven GTs were placed; 58 (75.3%) fulfilled the algorithm-appropriate indications. The mean SGSS was significantly lower among patients in whom GT was placed for algorithm-appropriate indications 2.03 (SD =0.86) vs inappropriate indications (2.59, SD =0.63; p<0.001). Sixty-five (51.6%) patients died by conclusion of study. Thirty day mortality after GT placement was 26.2% (post- (22.4%) vs pre- (29.4%)). Changes in serum albumin at day 30 was non-significant.

Conclusion The use of algorithm guidance by the prospective use of the SGSS was associated with a higher likelihood of GT placement both overall and for algorithm-appropriate indications.

Indications and benefits of intraoperative esophagogastroduodenoscopy

Introduction

Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy.

Aim

To evaluate the indications, benefits and risks of IOG.

Material and methods

A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed.

Results

The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG.

Conclusions

The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.

Mortality risk factors after percutaneous gastrostomy: Who is a good candidate?

BACKGROUND

The percutaneous gastrostomy tube (PG) is an effective and safe way for the delivery of enteral nutrition. The aim of this study was to identify predictive factors for mortality after PG placement.

MATERIAL AND METHODS

An observational and analytical cohort study was conducted. All endoscopic or radiological percutaneous gastrostomy tubes placed between January 2009 and July 2016 were evaluated. Mortality was the dependent variable. Initial clinical and analytical patient features and the development of complications during follow-up were recorded. Cox regression models were used to evaluate the risk of mortality associated to the studied variables. Hazard ratios with the corresponding 95% confidence intervals were retrieved from these models.

RESULTS

A total of 289 patients underwent PG placement (57% male). The mean age was 70.1 (SD 13.6) years. The median follow-up period was 8.7 (IQR 18) months. One hundred and seventy-four patients died during the follow-up period. The overall mortality rate was 4.8 per 100 patients-month. The highest mortality rate was during the first month after PG placement (13.2 per 100 patients-month), subsequently decreasing. Multivariate regression analysis showed that age (HR_1year = 1.01; p = 0.015), Charlson comorbidity index ≥4 (HR = 1.69; p = 0.011), the presence of degenerative neurological disease (HR = 1.69; p = 0.012) or malignancy (HR = 2.02; p = 0.012) and the development of aspiration pneumonia during the follow-up period (HR = 3.29; p = 0.001) were statistically significant independent predictive risk factors associated with mortality. A model to predict survival probability prior to placing the PG was developed from the variables of the multivariate analysis.

CONCLUSION

Mortality after PG placement is high. Older age, higher comorbidity and the development of aspiration pneumonia are predictive factors for mortality. A more careful selection of candidates for PG placement should be done to improve the patient prognosis after the procedure.

Prospective experience of percutaneous endoscopic gastrostomy tubes placed by otorhinolaryngologist-head and neck surgeons: safe and efficacious

Percutaneous endoscopic gastrostomy (PEG) is often the treatment of choice in head and neck cancer (HNC) patients needing long-term nutritional support. Prospective studies on PEG tube placement in an otorhinolaryngologist service are lacking. At our hospital, otolaryngologist-head and neck (ORL-HN) surgeons-have performed PEG insertions for HNC patients since 2008. We prospectively analyzed 127 consecutive HNC patients who received their PEG tubes at the Department of Otorhinolaryngology-head and neck surgery, and evaluated the outcome of PEG tube insertions performed by ORL-HN surgeons. To compare time delays before and after, PEG placement service was transferred from gastrointestinal surgeons to ORL-HN surgeons, and we retrospectively analyzed a separate group of 110 HNC patients who had earlier received PEG tubes at the Department of Gastrointestinal Surgery. ORL-HN surgeons' success rate in PEG insertion was 97.6%, leading to a final prospective study group of 124 patients. Major complications occurred in four (3.2%): two buried bumper syndromes, one subcutaneous hemorrhage leading to an abscess in the abdominal wall, and one metastasis at the PEG site. The most common minor complication was peristomal granulomatous tissue affecting 23 (18.5%) patients. After the change in practice, median time delay before PEG insertion decreased from 13 to 10 days (P < 0.005). The proportion of early PEG placements within 0-3 days increased from 3.6 to 14.6% (P < 0.005). PEG tube insertion seems to be a safe procedure in the hands of an ORL-HN surgeon. Independence from gastrointestinal surgeons' services reduced the time delay and improved the availability of urgent PEG insertions.

Problems related to levodopa-carbidopa intestinal gel treatment in advanced Parkinson's disease

BACKGROUND

Continuous levodopa-carbidopa intestinal gel (LCIG) diminishes daily "off" time and dyskinesia in patients with advanced Parkinson's disease (PD). Complications are common with percutaneous endoscopic gastrostomy with a jejunal extension tube (PEG-J).

AIM OF THE STUDY

To report the clinical outcome of LCIG in patients with advanced PD in the years 2006-2014 at Helsinki University Hospital.

PATIENTS AND METHODS

Levodopa-carbidopa intestinal gel treatment started following PEG-J placement in patients with advanced PD after successful in-hospital LCIG trial with a nasojejunal tube. Demographics, PEG-J procedures, discontinuation of LCIG, complications and mortality were retrospectively analyzed.

RESULTS MEAN SD

Sixty patients with advanced PD [age 68(7) years; duration of PD: 11(4) years] had LCIG treatment for 26(23) months. The majority of patients with advanced PD were satisfied with the LCIG treatment. For 51 patients (85%), the pump was on for 16 hr a day, and for nine patients (15%) it was on for 24 hr a day. After 6 months, the levodopa-equivalent daily dose (LEDD) had increased by 30% compared to pre-LCIG LEDD. Sixty patients underwent a total of 156 PEG-J procedures, and 48 patients (80%) had a total of 143 complications. Forty-six patients (77%) had 119 PEG-J or peristomal complications, and 22 patients (37%) had a total of 25 other complications. The most common complications were accidental removal of the J-tube in 23 patients (38%) and ≥5% weight loss in 18 patients (30%). Fifteen patients discontinued the LCIG after 21 (21) months. At the end of the follow-up period of 33(27) months, 38 patients were still on LCIG and nine (15%) had died.

CONCLUSION

Most patients were satisfied with LCIG treatment. A few patients lost weight whereas the majority had complications with PEG-J. When LCIG treatment is carried out, neurological and endoscopic units must be prepared for multiple endoscopic procedures.

Early death among head and neck cancer patients

PURPOSE OF REVIEW

Management of advanced head and neck cancer (HNC) is characterized by high mortality. Furthermore, the treatment involves significant burden to patients and high costs to healthcare systems. Recognizing the risks of early death in patients with a high probability of noncurable disease is important for each individual treatment decision-making. It is thus critical to consider the benefits and side-effects of the planned treatment in relation to the expected survival and to discuss these factors with the patient. However, only few studies have documented early death in HNC patients, that is, during the first posttreatment 6 months. We performed a systematic literature review to find the incidence of this phenomenon and to outline the probable cause.

RECENT FINDINGS

Early mortality in patients with HNC can be explained either by direct effect of malignant disease, may be related to comorbidities, or secondary to the treatment. These factors act together resulting in expected or unexpected early death.

SUMMARY

The present review provides information on the mechanisms leading to early phase mortality (<6 months) after management of HNC. It also reports the incidence of this phenomenon among Finnish and Swedish patient populations.

Intraabdominal Infections in Older Adults

Intraabdominal infections represent a diagnostic and therapeutic challenge in the elderly population. Atypical presentations, diagnostic delays, additional comorbidities, and decreased physiologic reserve contribute to high morbidity and mortality, particularly among frail patients undergoing emergency abdominal surgery. While many infections are the result of age-related inflammatory, mechanical, or obstructive processes, infectious complications of feeding tubes are also common. The pillars of treatment are source control of the infection and judicious use of antibiotics. A patient-centered approach considering the invasiveness, risk, and efficacy of a procedure for achieving the desired outcomes is recommended. Structured communication and time-limited trials help ensure goal-concordant treatment.