不同时期经皮内镜胃造瘘术在神经外科长期昏迷患者中的应用

目的 探讨不同时期经皮内镜胃造瘘术（PEG）在神经外科长期昏迷鼻饲患者中的应用价值.方法 将51例长期昏迷鼻饲患者随机分为25～39 d造瘘组和40～60 d造瘘组,在相应时间内行PEG术.对两组患者造瘘前后的上消化道出血率、出血患者的平均出血次数及平均止血时间、误吸率和吸入性肺炎发生率进行分析比较.结果 造瘘后上消化道出血率、误吸率和吸人性肺炎发生率均明显低于造瘘前（P〈0.05）.25～39 d造瘘组造瘘前上消化道出血率、出血患者平均出血次数、误吸率及吸入性肺炎发生率均明显低于40～60 d造瘘组（P〈0.05）,两组出血患者平均止血时间的差异无统计学意义（P〉0.05）.造瘘后两组患者的上消化道出血率、误吸率及吸入性肺炎发生率的差异无统计学意义（P〉0.05）.结论 在神经外科长期昏迷患者中,PEG能减少因长期置鼻胃管所致的上消化道出血、误吸和吸人性肺炎的发生,发病后25～39 d行PEG比发病≥40 d行PEG对患者更有利.如无PEG禁忌证,发病后25～39 d可能是行PEG的合适时机.     

Does the Presence of Esophagitis Prior to PEG Placement Increase the Risk for Aspiration Pneumonia?

The aim of this study is to determine if the endoscopic presence of esophagitis predicts aspiration pneumonia after the initiation of enteral feedings in a newly placed PEG tube. A retrospective analysis of 278 patients who received a PEG tube from November 1999 to June 2002 was performed. All PEG procedures performed by a single endoscopist were reviewed from the GI Trac database at the Medical University of South Carolina. Eleven of the procedures were aborted due to technical difficulties. Nine patients received the PEG for gastric decompression only. Seven patients died within 14 days of PEG placement from non-PEG-related complications and were excluded. The resulting 251 patients included for our analysis successfully had PEG tube placement and had at least 14 days of enteral feeding. Esophagitis was defined macroscopically by the endoscopic presence of mucosal edema, friability, or obscurity of the normal vascular pattern in the distal esophagus. Aspiration was defined as the witnessed regurgitation of or tracheal suctioning of PEG feedings. Pneumonia as a consequence of aspiration was defined by development of fever and new infiltrate on chest radiograph within 14 days of PEG placement. Two hundred fifty-one patients had PEG placement (M, 127; F, 124; average age, 62.4 year; age range, 18-95 years) performed by a single endoscopist over a 32-month period. Fourteen (5.6%) of these patients had clinically evident pulmonary aspiration, with seven of them developing pneumonia. Thirteen (93%) of these patients had normal esophageal mucosa. One of the 24 patients (4%) with esophagitis or esophageal ulceration present endoscopically had an aspiration event with subsequent pneumonia. None of the 20 patients found to have some other form of esophageal pathology had an aspiration event. The overall incidence of aspiration pneumonia after the initiation of PEG feedings was 2.7% (7/251). The odds ratio that the presence of esophagitis would predict the development of aspiration pneumonia was 1.60, with a 95% confidence interval of 0.18 to 13.89. This study argues that the presence of esophagitis alone does not increase the risk of aspiration pneumonia from PEG feedings. Other factors apart from esophagitis play an important role in the incidence of aspiration pneumonia with PEG feeding     

内镜下经皮胃造瘘对老年患者生活质量的影响

目的:评价内镜下经皮胃造瘘(PEG)在老年患者的应用、安全性及对生活质量的影响.方法:对32例PEG老年患者进行回顾性分析,采用同组对照的方法比较PEG与鼻胃管饲对患者的影响.结果:32例老年患者均在局麻下成功进行了PEG,仅1例发生造瘘口周围皮肤感染,抗生素治疗后短期内恢复.PEG较鼻胃管饲患者更易于接受,导管不易堵塞,能降低吸入性肺炎及反流性食管炎(15.6% vs 46.8%,P＜0.05)的发生率,提高生活质量.结论:PEG是一种安全有效的治疗方法,较鼻胃管饲能明显降低吸入性肺炎、反流性食管炎的发生率.     

The limitations of gastro-jejunal (G-J) feeding tubes in children: a 9-year pediatric hospital database analysis

BACKGROUND: A gastro-jejunal (G-J) feeding tube is a safe and useful temporizing method of providing enteral access in children. Although G-J tubes are often used to obviate the need for a surgical jejunostomy, their long-term use is often associated with mechanical failure. AIM: To review the clinically effective durability of G-J feeding tubes in providing enteral access in children. METHODS: We performed a retrospective review of 102 patients at the Johns Hopkins Children's Center from 1994-2003 whose underlying diagnosis necessitated the need for postpyloric enteral access. RESULTS: Long-term follow-up was obtained in 85 (48 M; 37 F) patients with a median (range) age of 2.0 (0.1-18.0) yr. The most common indication for G-J tube placement was gastroesophageal reflux with aspiration in 51 patients and feeding intolerance and vomiting in 19 patients. The mean (range) number of tube replacements was 2.2 (1-14) over a median (range) duration of follow-up of 39 (2-474) days. The indication for G-J tube replacement included: tube displacement (58), a clogged tube (41), and a cracked tube or ruptured balloon (35). In 52 cases, the cause for G-J tube replacement was undetermined. CONCLUSIONS: G-J feeding tubes are associated with the frequent need for tube maintenance and replacement and may not be the most feasible clinical option in providing long-term (>1 month) enteral access in children intolerant to gastrostomy tube feeds. Future studies are needed to develop innovative percutaneous jejunostomy tube placement techniques that facilitate long-term enteral access.     

Percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients with stroke

BACKGROUND: The use of percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients admitted for stroke is difficult, varying and needs specific consideration. There is therefore need for more data on this patient group. We examined the indications, survival, tube removal and time with PEG in stroke patients and in other patients with PEG with the aim of providing guidance for the management of enteral nutrition via PEG in stroke patients. METHODS: Retrospective assessment of data from all stroke patients and patients with other diseases (control group) who had received PEG for enteral nutrition during a period of 8.5 years. RESULTS: Eighty-three stroke patients with dysphagia received PEG after unsuccessful use of nasogastric tubes or long-term tube feeding. Early mortality rate was 19% in the stroke group, 26% in the older group (>74 years) and 12% in the younger group (60-74 years). The PEG tubes were later removed due to swallowing recovery in 20% of the older group and in 31% of the younger group. At 90 days, 50%-60% still needed PEG. The stroke patients were older compared to the control group (n = 115); 30-day mortality was similar but more patients recovered the ability to swallow. CONCLUSIONS: Stroke patients are older than other patients who receive PEG; 27% have swallowing recovery and more than 75% have long-term need for PEG. Nasogastric tubes often fail, and the need for early PEG placement (within 2 weeks) must be assessed in appropriate patients. The patient's prognosis, the objective of nutritional treatment, duration of dysphagia, age and comorbidity should all be taken into consideration.     

Percutaneous Endoscopic Gastrostomy (PEG) for Enteral Nutrition in Patients with Stroke

Background: The use of percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients admitted for stroke is difficult, varying and needs specific consideration. There is therefore need for more data on this patient group. We examined the indications, survival, tube removal and time with PEG in stroke patients and in other patients with PEG with the aim of providing guidance for the management of enteral nutrition via PEG in stroke patients. Methods: Retrospective assessment of data from all stroke patients and patients with other diseases (control group) who had received PEG for enteral nutrition during a period of 8.5 years. Results: Eighty-three stroke patients with dysphagia received PEG after unsuccessful use of nasogastric tubes or long-term tube feeding. Early mortality rate was 19% in the stroke group, 26% in the older group (>74 years) and 12% in the younger group (60-74 years). The PEG tubes were later removed due to swallowing recovery in 20% of the older group and in 31% of the younger group. At 90 days, 50%-60% still needed PEG. The stroke patients were older compared to the control group ( n &#114 = &#114 115); 30-day mortality was similar but more patients recovered the ability to swallow. Conclusions: Stroke patients are older than other patients who receive PEG; 27% have swallowing recovery and more than 75% have long-term need for PEG. Nasogastric tubes often fail, and the need for early PEG placement (within 2 weeks) must be assessed in appropriate patients. The patient's prognosis, the objective of nutritional treatment, duration of dysphagia, age and comorbidity should all be taken into consideration.     

Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluoroscopy

The 12-month clinical outcomes of nursing home patients who underwent videofluoroscopic swallowing evaluation was determined. A retrospective review of 40 patients in a teaching nursing home who had videofluoroscopic swallowing studies from 1987 through 1989 was performed. Clinical outcomes measured included feeding tube placement, rehospitalization within 1 year, prolonged nursing home stay (>6 months), pneumonia, and pneumonia death. It was determined if outcomes were associated with the presence of aspiration on videofluoroscopy and subsequent feeding tube placement. In the 12-month follow-up period, 17 of 40 patients (43%) who underwent videofluoroscopic swallowing evaluation developed pneumonia and 18 of 40 (45%) died. Twenty-two patients demonstrated aspiration on videofluoroscopy. Increased rehospitalization was the only outcome measure that was associated with the presence of aspiration on videofluoroscopy (p0.05). Of 22 patients with aspiration, 15 had feeding tubes placed. This group had a higher rate of pneumonia (p0.05) and pneumonia death (p0.05) compared with the 7 patients with aspiration who did not receive feeding tubes. Patients with nasogastric tubes had a higher death rate (7/9) than patients with gastrostomy tubes (2/8; p0.05), but similar rates of rehospitalization and pneumonia. Nursing home patients who underwent videofluoroscopic swallowing evaluation had poor clinical outcomes at 12 months, regardless of their test results. Though limited by its small size and retrospective nature, this pilot study questions whether videofluoroscopic swallowing studies accurately identify patients at risk for developing aspiration pneumonia and whether feeding tubes prevent aspiration or improve clinical outcomes. A larger, prospective study is needed to address these issues.Presented in part at the American Geriatrics Society Annual Meeting, Chicago, Illinois, May 1991.     

Percutaneous endoscopic gastrostomy and gastrojejunostomy: a critical reappraisal of patient selection, tube function and the feasibility of nutritional support during extended follow-up

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a generally accepted procedure, but the appropriateness of patient selection and the justification of jejunal feeding have not been systematically investigated. Also, a critical appraisal of the applicability and tolerance of nutritional support in the immediate postinsertion period and during prolonged outpatient care is lacking. METHODS: Prospectively collected data in adult and pediatric patients during a period of 7 years were analyzed. Follow-up data were available at days 1, 7 and 28 and thereafter every 6 to 12 weeks until gastrostomy removal, death or the conclusion of the study. RESULTS: A PEG was successfully positioned in 268 of the 286 referred patients (94%). A jejunal tube through the PEG (JETPEG) was placed beyond the duodenojejunal ligament in 38 patients. Procedure-related mortality was 1%, 30-day outpatient mortality 6.7%. Total follow-up was 295 patient-years with an overall mortality of 53% (PEG 53%; JETPEG 50%). Both major (8.4%) and minor (24.0%) procedure-related complications in the first 28 days consisted merely of (infectious) wound problems. In prolonged follow-up, the complications were more tube-related. The durability of the tube in surviving patients with a PEG or JETPEG in situ was a median of 495 days (range 162 to 1732 days). Tube dysfunction because of clogging, porosity and fracture occurred after a median of 347 days (range 9 to 1123 days). Nausea, vomiting, bloating and dumping interfered with feeding during the first week and during extended follow-up. Intrajejunal feeding was associated with dumping and diarrhea. In retrospect, the anticipated need of 4 weeks of enteral nutrition was not met in 9.0%. The extension of a PEG into a JETPEG was thought inappropriate in 23.7%. In the remainder, a 91% reduction in aspiration justified its use. The tube life span was equal to or greater than that of a PEG, despite tube dysfunction in 26.8%. CONCLUSIONS: Proper selection of patients for a PEG, i.e., those with an anticipated need of greater than 4 weeks of enteral nutrition, is a challenge. Notwithstanding an increased rate of tube dysfunction, well-selected patients may benefit from a JETPEG. Follow-up is mandatory because many patients might have become malnourished or underfed while on tube feeding, mainly because of GI intolerance.     

Prevalence of gastroesophageal reflux in patients who develop pneumonia following percutaneous endoscopic gastrostomy: A 24-hour pH monitoring study

Percutaneous endoscopic placement of feeding gastrostomies (PEG) was pioneered by Gauderer et. al. in 1980 [1]. Since then, it has become the preferred method of providing enteral nutritional support in children and adults because of advantages in morbidity and cost [2,3]. Pneumonia is a known sequel of this procedure, occurring at different rates, depending on the length of follow-up. Some series have shown an incidence of 10% at 30 days and others 56% at 11 months [4,5]. It does not appear that PEG feeding offers an advantage over the more traditional naso-enteric tube feeding methods in this respect. To study the prevalence of gastroesophageal reflux (GER) in PEG-fed patients, we quantitated GER by 24-hour intraesophageal pH monitoring in a group of patients who developed post-PEG pneumonia and compared it with a control group. Our study demonstrates an increased prevalence of GER in the pneumonia group compared with the control group. However, the exact contribution of this observed increased GER to the development of pneumonia needs to be determined.     

Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: a multicenter randomized trial

Steroids are recommended in severe alcohol-induced hepatitis, but some data suggest that artificial nutrition could also be effective. We conducted a randomized trial comparing the short- and long-term effects of total enteral nutrition or steroids in these patients. A total of 71 patients (80% cirrhotic) were randomized to receive 40 mg/d prednisolone (n = 36) or enteral tube feeding (2,000 kcal/d) for 28 days (n = 35), and were followed for 1 year or until death. Side effects of treatment occurred in 5 patients on steroids and 10 on enteral nutrition (not significant). Eight enterally fed patients were prematurely withdrawn from the trial. Mortality during treatment was similar in both groups (9 of 36 vs. 11 of 35, intention-to-treat) but occurred earlier with enteral feeding (median 7 vs. 23 days; P =.025). Mortality during follow-up was higher with steroids (10 of 27 vs. 2 of 24 intention-to-treat; P =. 04). Seven steroid patients died within the first 1.5 months of follow-up. In contrast to total enteral nutrition (TEN), infections accounted for 9 of 10 follow-up deaths in the steroid group. In conclusion, enteral feeding does not seem to be worse than steroids in the short-term treatment of severe alcohol-induced hepatitis, although death occurs earlier with enteral nutrition. However, steroid therapy is associated with a higher mortality rate in the immediate weeks after treatment, mainly because of infections. A possible synergistic effect of both treatments should be investigated.     

The provision of a percutaneously placed enteral tube feeding service

There is overwhelming evidence that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost. Short-term enteral access is usually achieved via naso-enteral tube placement. For longer term tube feeding there are recognised advantages for enteral feeding tubes placed percutaneously. The provision of a percutaneous enteral tube feeding service should be within the remit of the hospital nutrition support team (NST). This designated team should provide a framework for patient selection, pre-assessment and post-procedural care. Close working relations with community-based services should be established. An accredited therapeutic endoscopist should be a member of the NST and direct the technical aspects of the service. Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Specialist units should be identified where a more comprehensive service is provided, including direct jejunal placement (DPEJ), as well as radiological and laparoscopically placed tubes. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment. Careful adherence to the important technical details of tube insertion will reduce peri-procedural complications. Post-procedural complications remain relatively common, however, and an awareness of the correct approach to managing them is essential for all clinicians involved in providing a percutaneous enteral tube feeding service. Finally, ethical considerations should always be taken into account when considering long-term enteral feeding, especially for patients with a poor quality of life.     

Aspiration after percutaneous gastrostomy. Assessment by Tc-99m labeling of the enteral feed

Aspiration pneumonia, a recognized complication of enteral feeding via a nasogastric tube, is considered uncommon with percutaneously placed gastrostomy tube feeding. We report aspiration pneumonia during enteral alimentation in a neurologically compromised but conscious patient. Aspiration continued despite changing the route of enteral feeding from nasogastric to percutaneous gastrostomy. Quantitative scintigraphic studies with Tc-99m-labeled enteral infusion demonstrated frequent episodes of gastroesophageal reflux and aspiration of gastric contents, which increased when the infusion rate was speeded up for nutritional replacement. Gastric retention also occurred at the higher infusion rate. Thus, percutaneous gastrostomy may not decrease the frequency of aspiration in patients at risk.     

肠内营养支持在80岁以上反复肺部感染患者中的应用

目的 探讨肠内营养支持在≥80岁反复肺部感染患者中的临床应用效果. 方法 对34例≥80岁反复肺部感染患者肠内营养支持情况进行分析.采用经皮内镜下胃造瘘术(PEG/J)治疗组18例,采用鼻胃管治疗组16例,摄入同等热量和同等氮量,营养支持时间＞2月. 结果 经肠内营养支持后,全部患者的营养状况得到改善,2组各指标差异无显著性.PEG/J治疗组反流、误吸、吸入性肺炎的发生次数均明显少于鼻胃管组,对比差异均有统计学意义(P＜0.05). 结论 在≥80岁反复肺部感染患者中选择合适的肠内营养支持方式,不仅可以改善病人的营养状况,还可以减少肺部感染的发生,提高机体免疫功能,促进病人的康复.     

Decreasing use of percutaneous endoscopic gastrostomy tube feeding for veterans with dementia-racial differences remain

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) tube placement is a widely used method for long-term enteral feeding of demented patients unable to take sufficient food by mouth. National time trends in PEG tube use over the last decade have not been previously reported. The objective of this study was to determine whether use of PEG tubes for patients with dementia has changed over time and by race. DESIGN: Retrospective cohort study. SETTING: All Veterans Affairs hospitals. PARTICIPANTS: Using an administrative database of the Veterans Health Administration, all veterans with dementia and all veterans who received a PEG tube were identified between fiscal years 1990-2001. MEASUREMENTS: Proportion of PEG tube placement for dementia patients over time and by race. RESULTS: Four hundred thirteen thousand six hundred twenty-seven dementia patients aged 60 and older were identified, of whom 6,464 (1.6%) received a PEG tube. Use of PEG tubes for dementia patients increased during the first half of the decade but subsequently decreased almost to baseline after peaking in 1996 (1990: 1.2%, 1996: 1.8%, 2001: 1.3%). Time trends in the use of PEG tube feeding for dementia patients varied by race. Specifically, the relative risk for PEG tube placement in African-American dementia patients increased from 1.65 (95% confidence interval (CI)=1.25-2.17, FY 1990) to 1.97 (95% CI=1.62-2.4, FY 2001). CONCLUSION: Although the overall use of PEG tube feeding for dementia patients decreased over time, rates in use and changes in use over time varied significantly by race. Reasons for the differential use of this procedure should be explored.     

Tube dysfunction following percutaneous endoscopic gastrostomy and jejunostomy

Percutaneous endoscopic gastrostomy (PEG) and jejunostomy (PEJ) have supplanted their surgical counterparts in many institutions. Previous reports have claimed advantages in placing PEJ tubes because of reduced gastroesophageal reflux, prevention of aspiration, and improved tube anchoring distally. We reviewed the records of 191 patients who underwent placement of PEG/J tubes. Data collected included incidence of tube dysfunction, need for tube replacement or removal, and aspiration after PEG or PEJ tube placement. Tube dysfunction, defined as peritube leakage, plugging, fracture, or migration, occurred in 36% of patients over a mean follow-up period of 275 days and was significantly more common and likely to necessitate tube replacement in PEJ patients. Tube trade-out or removal and aspiration within a 30-day period after tube placement occurred in 28% and 10% of patients, respectively. These complications were significantly more common in PEJ patients than in PEG patients. Because of the increased incidence of tube dysfunction and the failure to prevent aspiration in predisposed patients, PEJ tube placement is not routinely indicated in patients requiring tube feedings.     

A 94-year-old woman with nontuberculous mycobacterium who developed small intestinal intussusception associated with a percutaneous endoscopic jejunostomy tube

We report a 94-year-old woman, who underwent percutaneous endoscopic Jejunostomy (PEJ) tube feeding for enteral nutrition, developed the intussusception of the small intestine. She suffered from nontuberculous mycobacterium (NTM), and her lung inflammation deteriorated due to aspiration pneumonia and malnutrition. Because of old age, dysphagia, esophageal hiatus hernia, gastro-esophageal reflux and her bedridden condition due to severe osteoporosis, oral nutritional supplementation is nearly impossible. To reduce the aspiration risk, we chose PEJ instead of percutaneous endoscopic gastrostomy (PEG) as the route of tube feeding. Six months after the placement of a PEJ tube, aspiration pneumonia was diagnosed and she was readmitted to our hospital. During hospitalization, she had sudden diarrhea, vomiting, and lower abdominal pain. Abdominal CT scan and radiographs using contrast medium showed small intestinal intussusception related to the PEJ tube. We observed the clinical course without performing surgery, pulling it back towards the stomach and placing an ileus tube, because the small intestine was not completely obstructed. Two months later, although she suffered from aspiration pneumonia once more, she remained in a stable condition without further intervention so that she could move to aother hospital. Recently PEJ has been expected to prevent aspiration pneumonia, but we believe that it can be a risk factor for intussusception. Although the PEJ can be a good parenteral nutrition route for frail elderly with dysphagia, we need to consider possible complications including intussusception.     

肠内营养在高龄多器官功能障碍综合征患者中的应用

目的 探讨不同途径营养支持治疗对高龄多器官功能障碍综合征(MODS)患者脏器功能恢复及预后的影响.方法 将确诊为MODS高龄患者85例随机分组为2组,肠内营养组43例,通过鼻饲管或内镜下经皮胃/肠造瘘术(PEG/PEJ)给予营养支持,全胃肠外营养组(对照组)42例,经中心静脉治疗,总疗程至少2个月;比较两组患者治疗前后体质指数(BMI)、血红蛋白(Hb)、肝肾功能、电解质、血糖、血脂、血清白蛋白(ALB)、转铁蛋白(TRF)及前白蛋白(PA)、免疫球蛋白(IgA、IgG、IgM)、T淋巴细胞亚群(CD3+,CD4+、CD4+/CD8+)等指标.结果 在摄入同等热量和氮量的条件下,两组患者血Hb、BMI、血清ALB、TRF及PA水平在营养支持治疗后第1个月(t1EN=2.672、2.440、2.209、3.331和5.025,t1TPN=2.720、2.337、2.179、3.418和2.221)、第2个月(t2EN =2.279、3.021、2.337、3.005和5.779,t2TPN=2.118、2.956、3.018、3.310和2.119)较治疗前均有明显改善(均为P＜0.05),肠内营养组PA水平较对照组变化更明显(t=2.336,P＜0.05).对照组治疗后第1、2个月都出现高脂血症(t1TPN=3.609,P＜0.05;t2TPN =3.114,P＜0.05).肠内营养组治疗第1、2个月后血IgG、IgA较治疗前均明显升高(t1 EN=2.664、2.437,P＜0.05;t2 EN=2.983、3.005,P＜0.05),血CD3+、CD4+、CD8+、CD4+/CD8+水平在治疗2个月后改变明显(t=2.399、3.478、2.579和3.995,P＜0.05),IgM于治疗后第2个月有明显升高(t=3.886,P＜0.05).肠内营养组中34例PEG/PEJ术前反复发生吸入性肺炎,术后2个月内仅发生5例(x2=51.12,P＜0.05);术后2个月反流性食管炎发生率减少、严重程度较术前明显减轻(x2=13.53,P＜0.05).结论 及时、充分的胃肠内营养支持治疗,可有效改善高龄MODS患者全身状况及营养;PEG/PEJ术可减少因鼻饲管引发的吸入性肺炎和反流性食管炎的发生.     

Relation between incidence of pneumonia and protective reflexes in post-stroke patients with oral or tube feeding

OBJECTIVES: Although attenuated protective reflexes have been implicated in the development of aspiration pneumonia, the relation between the incidence of pneumonia and the state of these reflexes has not been investigated. Furthermore, the role of feeding tube placement in preventing pneumonia in patients with attenuated protective reflexes is unknown. We studied the relationship between the incidence of pneumonia and the state of cough and swallowing reflexes in post-stroke patients with oral or tube feeding. DESIGN: The incidence of pneumonia was prospectively analysed for 1 year in three groups of post-stroke patients on the basis of the following clinical conditions: oral feeding without dysphagia (n = 43); oral feeding with dysphagia (n = 48); and nasogastric tube feeding with dysphagia (n = 52). We also studied the incidence of pneumonia in bedridden patients with nasogastric tube feeding (n = 14). Before the start of the study, the swallowing and cough reflexes of each patient were measured. The swallowing reflex was evaluated according to latency of response, which was timed from the injection of 1 mL of distilled water into the pharynx through a nasal catheter to the onset of swallowing. The cough threshold of citric acid aerosols was defined as the concentration at which the patient coughed five times. RESULTS.;: The incidence of pneumonia was observed in patients having both a latency of response longer than 5 s and a cough threshold for citric acid higher than a concentration of 1.35 (log mg mL-1). The incidence of pneumonia was significantly higher in patients with oral feeding than in those with tube feeding (54.3 vs. 13.2%, P < 0.001). In bedridden patients with tube feeding, the latency of response was longer than 20 s and no patient coughed at the highest concentration of citric acid. The incidence of pneumonia was 64.3% in such patients. CONCLUSIONS: The state of protective reflexes had a significant relation to the incidence of pneumonia. Feeding tube placement may have a beneficial role in preventing aspiration pneumonia in mildly or moderately disabled post-stroke patients with attenuated protective reflexes. Bedridden patients who were tube-fed had the highest incidence of pneumonia.     

Mini-laparoscopically guided percutaneous gastrostomy and jejunostomy

BACKGROUND: Percutaneous endoscopic tube placement can be problematic under certain circumstances: absence of transillumination of the abdominal wall, percutaneous jejunostomy in patients with a PEG tube and recurrent aspiration, enteral feeding access after gastrectomy, and obstruction of the upper GI tract. As an alternative in these problematic situations, a technique was developed for placing feeding tubes under visual control by using mini-laparoscopy. METHODS: Placement of a feeding tube with mini-laparoscopy with the patient under conscious sedation was considered for 17 patients in whom standard PEG placement was impossible. Techniques used were the following: combined mini-laparoscopy/endoscopy for placement of a percutaneous gastrostomy or jejunostomy, and mini-laparoscopic-guided direct tube placement in cases of obstruction of the upper GI tract. OBSERVATIONS: In 13 patients, mini-laparoscopic-assisted tube placement was successful. In 4 patients, adhesions or peritoneal carcinomatosis prevented laparoscopic visualization of the stomach or small bowel. The combined mini-laparoscopic/endoscopic approach allowed a successful insertion of gastric tubes in 6 patients and jejunal tubes in 4 patients. Direct insertion of a percutaneous endoscopic jejunostomy tube without enteroscopy was feasible in all 3 patients with obstruction of the upper GI tract. No complication occurred. CONCLUSIONS: Mini-laparoscopy-assisted tube placement is a simple and safe alternative when endoscopic percutaneous tube placement is problematic or not feasible.