Early percutaneous endoscopic gastrostomy nutrition in head and neck cancer patients
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Many head and neck cancer patients suffer from poor nutrition. Nutrition is a problem during and after therapy, especially when it consists of extensive surgery, intensive (chemo)radiotherapy or their combination. Additional enteral nutrition has been provided by means of either nasogastric tube feeding, surgical gastrostomy, radiologic percutaneous gastrostomy or percutaneous endoscopic gastrostomy (PEG). Because of the straightforward, easy technique involved and its low complication rate, PEG has become established as the primary route of nutrition in these patients. Previously, the aim of assisted enteral nutrition was to compensate for already existing malnutrition; nowadays, an additional purpose is to diminish or prevent the development of malnutrition. The main objective of this study was to evaluate the safety of pre-treatment PEG in a sample of patients with an upper aerodigestive tract area malignancy treated in a tertiary referral centre.A total of 79 patients with an upper aerodigestive tract area malignancy were treated with a total of 80 PEGs during the period 1997-2001.Most of the PEGs (62/80; 77.5%) were performed by an otolaryngologist. An open gastrostomy was needed in five cases because of unsuccessful gastroscopy due to oesophageal stricture (n=4) or severe trismus (n=1). Both acute and late complications were minor and the respective complication rates (1/80; 1.3% and 12/80; 15%) were low. In addition, all complications were easily managed and did not seriously affect the actual treatment.A major advantage of having the PEG performed by the otorhinolaryngologist was the possibility to combine it easily with other necessary procedures, such as panendoscopy, tracheostomy and additional biopsy. In addition, the timing of the procedure was easy to schedule.Keywords:
Percutaneous endoscopic gastrostomy
Trismus
Feeding tube
Gastrostomy feeding is commonly used to support patients with amyotrophic lateral sclerosis who develop severe dysphagia. Although recommended by both the American Academy of Neurology and the European Federation of Neurological Societies, currently little evidence indicates the optimum method and timing for gastrostomy insertion. We aimed to compare gastrostomy insertion approaches in terms of safety and clinical outcomes.In this large, longitudinal, prospective cohort study (ProGas), we enrolled patients with a diagnosis of definite, probable, laboratory supported, or possible amyotrophic lateral sclerosis who had agreed with their treating clinicians to undergo gastrostomy at 24 motor neuron disease care centres or clinics in the UK. The primary outcome was 30-day mortality after gastrostomy. This study was registered on the UK Clinical Research Network database, identification number 9923.Between Nov 2, 2010, and Jan 31, 2014, 345 patients were recruited of whom 330 had gastrostomy. 163 (49%) patients underwent percutaneous endoscopic gastrostomy, 121 (37%) underwent radiologically inserted gastrostomy, 43 (13%) underwent per-oral image-guided gastrostomy, and three (1%) underwent surgical gastrostomy. 12 patients (4%, 95% CI 2·1-6·2) died within the first 30 days after gastrostomy: five (3%) of 163 after percutaneous endoscopic gastrostomy, four (3%) of 121 after radiologically inserted gastrostomy, and three (7%) of 43 after per-oral image-guided gastrostomy (p=0·46). Including repeat attempts in 14 patients, 21 (6%) of 344 gastrostomy procedures could not be completed: 11 (6%) of 171 percutaneous endoscopic gastrostomies, seven (6%) of 121 radiologically inserted gastrostomies, and three (6%) of 45 per-oral image-guided gastrostomies (p=0·947).The three methods of gastrostomy seemed to be as safe as each other in relation to survival and procedural complications. In the absence of data from randomised trials, our findings could inform clinicians and patients in reaching decisions about gastrostomy and will stimulate further research into the nutritional management in patients with amyotrophic lateral sclerosis.Motor Neurone Disease Association of Great Britain and Northern Ireland (MNDA) and the Sheffield Institute for Translational Neuroscience (SITraN).
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Aims Insertion of percutaneous endoscopic gastrostomy (PEG) tube allows enteral feeding but isn't free form risks. The Sheffield Gastrostomy Score (SGS) was developed to predict 30-day all-cause mortality among patients undergoing PEG insertion based on age and serum albumin. The result varies between 0 and 3 and is associated to mortality risk. Our aim was validation of the SGS and determine other risk factors associated with mortality [1] [2].
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The laparoscopic-assisted gastrostomy tube placement (LAP) has increasingly become the preferred method for placing gastrostomy tubes in infants and children. The goal of this retrospective review was to examine our institutional experiences with our transition from the percutaneous endoscopic gastrostomy (PEG) procedure to LAP technique.All patients undergoing primary PEG or LAP gastrostomy at Boston Children's Hospital between January 2010 and June 2015 were identified. The primary aim was to compare complication rates within the first 6 months after tube placement; differences in total hospital procedural costs, hospital resource utilization, and postoperative gastroesophageal reflux disease were examined.Nine hundred and eighty-seven patients (442 PEG and 545 LAP gastrostomy tubes) were included. No differences in total complications within 6 months were seen. Patients undergoing PEG placement had more gastrostomy-related complications (PEG 30 [6.7%] vs LAP 13 [2.4%], P = 0.0007) and cellulitis (PEG 23 [5.1%] vs LAP 2 [0.4%], P = 0.03) within the first week of placement. Patients undergoing LAP procedures had more granulation tissue episodes (PEG 19 [4.4%] vs LAP 107 [19.8%], P = 0.005). No differences in emergency room visits, hospital readmissions, or postoperative gastroesophageal reflux disease were seen, although transition to a gastrojejunal tube was higher in patients undergoing LAP procedure (PEG 20 patients [4.6%] vs LAP 51 patients [9.5%], P = 0.0008).Total complications were similar between patients undergoing PEG versus LAP gastrostomy tube placement. Patients with the PEG procedure had more complications within the first week of placement versus patients with the LAP procedure had more granulation skin complications.
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To compare techniques of gastrostomy in elderly patients, the records of 100 patients age 70 and older who underwent gastrostomy tube placement as a primary procedure were reviewed. Two separate unmatched groups of 50 patients each were identified: those that underwent operative gastrostomy tube (OGT) placement and those that underwent percutaneous endoscopic gastrostomy tube (PEG) placement. The groups were studied for demographic similarities and for differences in morbidity, mortality, and ease of feeding. Comparison showed that PEGs had a lower mortality (0%) and morbidity (10%) than did OGTs where mortality was 4 per cent and morbidity was 22 per cent. PEGs began feeding sooner (1.0 day vs. 2.8 days) than OGTs. In addition, almost 60 per cent of the PEG patients underwent complete upper endoscopy at the time of the PEG, which revealed pathology that either altered the type of tube placed or the eventual medical management. PEG offers a less morbid, safer, and easier to use method of gastrostomy tube placement than OGT in the majority of elderly patients.
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Percutaneous endoscopic gastrostomy (PEG) feeding has been validated in specific clinical situations such as acute stroke with dysphagia and oropharyngeal malignancy. The perception that gastrostomy insertion is safe and technically simple has led to an increase in the demands for PEG insertion, encompassing clinical applications such as in patients with dementia, in whom its role has not been justified. The purpose of this study was to compare the mortality of patients with dementia who were fed by PEG to that of other subgroups of patients requiring gastrostomy feeding.The study focused on a cohort of 361 consecutive patients requiring PEG feeding between August 1992 and July 1997 from two District General Hospitals (Rotherham District General Hospital and Doncaster Royal Infirmary) in South Yorkshire. A retrospective cohort survival analysis was performed using the Kaplan-Meier survival method and Cox proportional hazards analysis.In all patients requiring gastrostomy feeding there is a high initial mortality of 28% at 30 days. However, patients with dementia have a worse prognosis compared to other subgroups, with 54% having died at 1 month and 90% at 1 yr (log rank test p < 0.0001). This difference remained significant (log rank p < 0.0001) after adjusting for age at the time of PEG insertion.This is the first demonstration in the United Kingdom that the mortality of patients with dementia who are fed by gastrostomy is considerable. Consequently, we may wish to advise against gastrostomy feeding in selected patients within this clinical setting.
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The buried gastrostomy bumper syndrome is one of the rare complications of PEG (percutaneous endoscopic gastrostomy) insertion. It develops when there is a combination of a rigid bumper and a tension build-up between internal and external bumpers. This condition is manifested by complete occlusion of the internal opening of the gastrostomy by mucosa, making it impossible to feed the patient. We report a case in which the PEG was inserted a year prior to the appearance of this rare complication. It was embedded beneath the gastric mucosa and we had difficulty in removing it to insert a new PEG. The bumpers are anchor-like attachments to each end of the gastrostomy, which keep it stationary. The rigid bumper is an integral part of the gastrostomy. However, a "soft" bumper has been developed, but its costliness has restricted its use. In our case the gastrostomy was removed with the aid of the cutting wire of a sphincterotome in light contact with the external tissue.
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Percutaneous gastrostomy (PEG) has become a key element in managing children with nutrition or feeding issues. Reversal of malnutrition shortly after gastrostomy has been shown in many pediatric studies, however literature on maintenance of nutritional status following initial catch-up growth is limited. To analyze the long-term follow-up of children with PEG in terms of nutritional outcomes as defined by improvement in weight-for-height z scores. To review the procedure-related complication rates specific to our center. This is a retrospective review of all PEG procedures performed at our tertiary Children’s Hospital from 1999 to 2015. All PEGs were placed by the same team of pediatric gastroenterologists using the standard pull technique. Prophylactic antibiotics were given for 24h. Nutritional outcomes were evaluated by comparing the weight-for-height z scores (CDC growth charts) at the time of tube placement and either at the time of last follow-up for children receiving gastrostomy feeding, or at the time of tube removal, fundoplication or death. PEG-related complications were recorded. In the 256 patients who underwent successful PEG placement, diagnoses were as follow: neuromuscular disease (n=136, 53%), cystic fibrosis (n=30, 12%), metabolic disease (n=18, 7%), chromosomal abnormalities/genetic syndromes (n=18, 7%), nonorganic failure to thrive (n=39, 15%) and other (n=15, 6%). Median age at the time of PEG placement was 3.9 years (0.4–19.9 years) and median follow-up duration was 3.2 years (0–16 years). Significant improvement in weight-for-heigth z score was reported for all subgroups except for the “metabolic disease” and “other” subgroups: neuromuscular disease (△=0.62, P=0.0008), cystic fibrosis (△=0.8, P=0.004), metabolic disease (△=0.37, P=0.4), chromosomal abnormalities/genetic syndromes (△=1.01, P=0.01), nonorganic failure to thrive (△=0.7, P=0.005). A total of 61 complications were reported: 35 cellulitis including 17 requiring intravenous antibiotics, 16 accidental dislodgements, 7 buried bumper syndromes, and 2 perforations. A total of 123 patients had known reflux prior to PEG placement, while 39 (32%) had resolution of symptoms, 84 (68%) had persistent reflux with 18 requiring fundoplicature. Our study illustrates that improvement in nutritional status following PEG is maintained during the long term, reinforcing the benefits of gastrostomy feeding when enteral nutrition is required. PEG is a safe method to provide enteral feeding in children. Future studies defining preoperative clinical factors to help clinicians to predict which patient populations are at higher risk of poor nutritional rehabilitation, complications or need for anti-reflux surgery are needed. None
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Percutaneous endoscopic gastrostomy (PEG) is a widely used method for insertion of gastrostomy tube for patients with dysphagia due neuromuscular disorders. Aim : this article highlights the role of PEG for such patients, how safe, effective than standard gastrostomy in providing long -term nutritional support for patients with dysphagic stroke.Over a four-year period (1995-1998), 27 patients had percutaneous endoscopic gastrostomy performed for neuromuscular dysphagia. A Wilson Cook (24G) gastrostomy tube was used and it was inserted with Ponsky-Gauderer pull technique.All the patients tolerated the procedure well. Stroke (81%) was the most common indication for PEG. Major gastroscopic finding was found in eight patients (29%). Minor complication was seen in only three patients (11%).PEG Feeding is safe, simple and effective procedure with no serious side effects. Patients and their relatives accept PEG better than nasogastric tube feeding. However, the ideal timing at which to institute gastrostomy feeding after dysphagic stroke is still not clear.
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