Percutaneous endoscopic gastrostomy feeding in patients with cystic fibrosis

Background—Malnutritionis a common management problem in patients with cystic fibrosis (CF).Various approaches to supplemental nutrition by both parenteral andenteral routes have been used.
Aim—To analyse theefficacy and acceptability of supplemental overnight feeding using apercutaneous endoscopic gastrostomy (PEG) in patients with CF.
Patients—53 patientswith CF (43 adults; age >17 years) with severe pulmonary disease.
Methods—The technicalsuccess and complications of PEG insertion were documented togetherwith changes in nutritional and pulmonary status of the cohort.
Results—PEGtubes were successfully inserted in all patients, with immediatecomplications (respiratory depression) in two (4%) and latecomplications in 13 (25%). Feeding was well tolerated by 50/51 (98%)of the cohort during a mean (SEM) follow up of 14.5 (2.1) months. Theadult cohort had a significant increase in weight and body mass indexat six months which was maintained at 12 months. Serum albuminconcentration remained stable at six months but had fallen by 12 months, although the differences were not statisticallysignificant. These results were reflected in the paediatric cohort.Pulmonary function in those followed up for one year had apparentlystabilised, but the number of admissions to hospital over the yearbefore and the year after PEG did not change. Half of the cohort wereaccepted for heart-lung/lung transplantation, the improvement innutritional status being a prerequisite for this.
Conclusion—SupplementalPEG tube feeding is well tolerated and results in a significantimprovement in nutritional status and an apparent stabilisation ofpulmonary function in severely malnourished CF patients with advancedpulmonary disease.

Keywords:cystic fibrosis; malnutrition; enteral nutrition; percutaneous endoscopic gastrostomy

     

Biological observation during the daytime of elderly patients with advanced dementia cared for with and without artificial nutrition by percutaneous endoscopic gastrostomy

Aim: To clarify the activity of demented patients cared for with and without artificial nutrition in a care facility, sequential biological observation was applied using electroencephalograms (EEG), electromyograms (EMG) and electro‐oculograms (EOG). Methods: Awake and sleep patterns and spontaneous swallowing were measured during the daytime in 13 patients with advanced dementia who could orally intake meals (OR patients), and 13 patients with advanced dementia, who received artificial nutrition by percutaneous endoscopic gastrostomy (PEG patients). Results: The awake/sleep pattern fluctuated during daytime in OR and PEG patients, but a fully awake state was relatively preserved around meal times in OR patients. The number of spontaneous swallowing was small in PEG patients (0.1 ± 0.3/h), and the value correlated with the Barthel Index in OR patients. Conclusion: Continuous recording of biological activity in demented patients could be informative in providing an overview of their activities. The present results disclosed that meal times were the limited periods keeping OR patients awake consistently, while there was no opportunity for such periods for PEG patients. The number of spontaneous swallowing was especially small in PEG patients, although low Mini‐Mental State Examination and Barthel Index scores and poor awake state during daytime were considerable in those patients. Geriatr Gerontol Int 2011; 11: 221–228.     

Percutaneous endoscopic gastrostomy feeding in AIDS*

Reduced energy intake is the most important reason for weight loss in advanced human immunodeficiency virus (HIV) infection. From January 1989 to August 1995 enteral feeding via a percutaneous endoscopic gastrostomy tube (PEG) was offered to all human immunodeficiency virus(HIV)/AIDS patients attending Fairfield Hospital, Melbourne who were unable to maintain 85% ideal body weight. A total of 71 patients received enteral feeding (1000–2000 kcal/day) for a median period of 161 days (range 4–644 days). Fifty-one (72%) patients gained 5.8 ± 4.4kg (range 0.4 - 19.2kg). Nine gained 10 kg or more. The median time to maximum weight was 74 days after PEG insertion. Those who gained weight had a longer median survival, but this difference was not statistically significant (210 vs 109 days, P=0.07). The only predictor of weight gain was a CD4 count greater than 100/μL. Patients who gained weight reported improved quality of life and increased independence. However, early complications, especially wound infection, were common. Although these data have been gathered retrospectively, our experience suggests that enteral feeding can maintain or improve nutritional status and may improve quality of life in advanced HIV infection.     

Percutaneous endoscopic gastrostomy: a review of indications, complications and outcome

Percutaneous endoscopic gastrostomy (PEG) was first described in 1980 as an effective method of feeding via the stomach in situations where oral intake is not possible. Its simplicity has led to its potential use in areas of dubious clinical benefit. Our unit has faced a major increase in referrals for PEG insertion over the last 2 years. For this reason we decided to audit our PEG insertion procedures with regard to indications, complications, outcome and follow up. We studied 168 patients who had an initial PEG insertion during the period 1 February 1996-31 January 1998. The medical records of these patients were reviewed with regard to the procedure, antibiotic use and complications. All patients (or carers or next of kin) were contacted by telephone to provide details regarding late complications and follow up. There were 87 females and 81 males (aged 16-98 years, median age 70 years). At 2 years, 67% were alive. The most frequent indication for PEG insertion was a neurological condition, the commonest being stroke. Most patients received either ticarcillin/clavulanic acid or cephazolin antibiotic prophylaxis before and after the procedure. In six patients (3.6%) infection at the PEG site required intravenous antibiotics. Four of these six patients did not have antibiotic prophylaxis. Only two deaths could be directly related to the procedure. Three died within 7 days of the procedure due to unrelated medical complications. Sixteen patients died within 1 month, the majority of these patients did not leave hospital. One-fifth of the patients (35/168) had their PEG removed due to the re-establishment of oral feeding, with median time of use, 4.3 months. It is a safe, effective feeding method in the elderly, but experience with case selection, the procedure and careful follow up remain essential. The use of prophylactic antibiotics resulted in few significant infections of the PEG site. Up to one-fifth of patients will require their PEG only for a short term.     

Long-term outcome following placement of percutaneous endoscopic gastrostomy in younger and older patients

Objective. Percutaneous endoscopic gastrostomy (PEG) is the method of choice in maintaining enteral nutrition in patients with swallowing and nutritional disorders of different etiology. The aim of this study was to assess the long-term outcome of patients following placement of a PEG. Material and methods. All patients who received a PEG between October 1999 and September 2000 were included in this prospective study. Long-term function, replacement or removal of the PEG, complications and survival of the patients were analyzed in group A (younger than 75 years) and group B (75 years or older). Results. The indications for PEG placement in group A (54 patients, mean age 54.5 years) were neurological (66.7%) and malignant (31.5%) disorders, whereas in group B (40 patients, mean age 81 years) the indications were predominantly neurological diseases (87.5%). The majority of patients (91 of 94 patients; 96.8%) could be followed long term or until death. In group A, 46 patients (85.2%) had uncomplicated long-term function of their PEG and interventions were necessary in only 8 patients. Removal of the PEG was possible during the course in 17 patients (31.5%). In group B, uncomplicated long-term function was observed in 34 patients (85%) and interventions were required in only 6 patients. Removal of the PEG was not possible in group B. Survival rates for 1-, 2- and 5 years in group A were 73.9%, 61.8% and 43.9%, respectively, and in group B 41.4%, 31.9% and 15.9%, respectively; the difference was statistically significant (p=0.002). Conclusions. Excellent long-term function of PEG was seen in this study of 94 consecutive patients, and interventions were necessary only in a minority of patients. The prognosis for older patients was worse; however, the 2-year survival rate of 32% justified the PEG insertion.     

Increased risk of peristomal wound infection after percutaneous endoscopic gastrostomy in patients with diabetes mellitus

Background. Results of prospective studies on the effect of prophylactic antibiotics before percutaneous endoscopic gastrostomy are conflicting. Factors for increased risk of peristomal wound infection have not been clearly identified.

Aim. To evaluate the incidence of complications of percutaneous endoscopic gastrostomy and to determine the predictors of wound infection.

Patients and Methods. Percutaneous endoscopic gastrostomy was performed on 134 patients in different disease groups between January 1996 and June 2000. Medical records were carefully reviewed for demographic data, indications for percutaneous endoscopic gastrostomy, use of prophylactic antibiotics, complications and comorbid conditions predisposing to wound infection.

Results. Of 134 patients, 22 (16.4%) developed complications after percutaneous endoscopic gastrostomy. Wound infection, the most common complication, occurred in 19 patients (14.2%) and Pseudomonas aeruginosa was the most frequently isolated microorganism. In univariate analysis, non-malignant disease and diabetes mellitus were significantly associated with peristomal wound infection after percutaneous endoscopic gastrostomy. In multivariate analysis, only diabetes mellitus was an independent risk factor for the development of peristomal wound infection after percutaneous endoscopic gastrostomy (p=0.035).

Conclusions. Patients with diabetes mellitus have a higher risk of peristomal wound infection after percutaneous endoscopic gastrostomy.     

Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) tube placement is the preferred method for long-term enteral feeding of patients who are unable to take food by mouth. Despite the widespread acceptance of the procedure, no large-scale study of the long-term outcomes of patients receiving PEG tubes has been reported. The objective of this study was to determine the survival of patients in whom PEG tubes are placed. DESIGN: Retrospective cohort study using data obtained from two computerized databases. SETTING: Department of Veterans Affairs hospitals. PATIENTS: Seven thousand three hundred sixty-nine patients who received a PEG tube in fiscal years 1990 through 1992. RESULTS: For the 7,369 patients, the mean age was 68.1 years and 98.6% were men. PEG tubes were most commonly placed in patients with cerebrovascular disease (18.9%), other organic neurologic disease (28.6%), or head and neck cancer (15.7%). Although the complication rate of the procedure itself was low (4%), because of the severity of their underlying disease, 1,732 patients (23.5%) died during the hospitalization in which the PEG tube was placed. The median survival of the full cohort was 7.5 months. CONCLUSIONS: This study documents the widespread placement of PEG tubes in severely ill patients, half of whom are in the terminal phase of their illness. Further study is needed to determine whether these patients benefit from PEG tube placement in terms of their quality of life and survival. From the Department of Veterans Affairs Health Services Research and Development (HSR&D) Field Program, and the Department of Medicine, Baylor College of Medicine, Houston, Tex. Supported by the Department of Veterans Affairs Health Services Research and Development Houston Field Program. Presented at the 95th annual meeting of the American Gastroenterological Association, New Orleans, La., May 15–18, 1994.     

Enteral nutrition via percutaneous endoscopic gastrostomy and nutritional status of patients: five-year prospective study

BACKGROUND: Since it was described in 1980, percutaneous endoscopic gastrostomy (PEG) has been a widely used method for insertion of a gastrostomy tube in patients who are unable to swallow or maintain adequate nutrition. The aim of the present paper was to determine the complications of PEG insertion and to study pre- and post-procedural nutritional status. METHODS: During the period of March 1999-September 2004, placement of PEG tube was performed in 85 patients (22 women and 63 men). Patient nutritional status was assessed before and after PEG insertion via anthropometric measurements. RESULTS: The most frequent indication for PEG insertion was neurological disorders (65.9%). Thirty patients died due to primary disease and two patients due to PEG-related complications within 5 years. There were 14 early complications in 10 patients (15.2%; <30 days), and 18 late complications in 12 patients (19.6%). Total mortality was 37.6%. All complications other than four were minor. Before PEG insertion, patients were assessed with subjective global assessment and it was determined that 43.2% of them had severe, and 41.9% of them had mild malnutrition. After PEG insertion, significant improvements on patient nutrition levels was observed. CONCLUSION: Percutaneous endoscopic gastrostomy is a minimally invasive gastrostomy method with low morbidity and mortality rates, is easy to follow up and easy to replace when clogged.     

Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy

AIM:To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy(PEG)could be a valuable option for patients with complicated anatomy.METHODS:A retrospective analysis of twelve patients(seven females,five males;six children,six young adults;mean age 19.2 years)with cerebral palsy,spastic quadriparesis,severe kyphoscoliosis and interposed organs and who required enteral nutrition(EN)due to starvation was performed.For all patients,standard PEG placement was impossible due to distorted anatomy.All the patients qualified for the laparoscopyassisted PEG procedure.RESULTS:In all twelve patients,the laparoscopy-assisted PEG was successful,and EN was introduced four to six hours after the PEG placement.There were no complications in the perioperative period,either technical or metabolic.All the patients were discharged from the hospital and were then effectively fed using bolus methods.CONCLUSION:Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.     

Percutaneous endoscopic gastrostomy: dealing with the issue of dislodgement

Abstract

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.     

经皮内镜下胃造瘘术应用进展

经皮内镜下胃造瘘术(PEG)是20世纪80年代开始应用于临床的一种新的内镜介入技术,主要用于胃肠减压和肠内营养,在国外已广泛应用。此文就其方法、适应症、并发症及禁忌症等作一综述。     

Percutaneous endoscopic gastrostomy (PEG): A critical appraisal

Percutaneous endoscopic gastrostomy (PEG) can quickly, reliably, and safely establish enteral feedings for a wide variety of indications. Morbidity associated with PEG is less than conventional surgical gastrostomy, and no mortality has been reported to date. PEG can be performed safely at the bedside, if needed. Moreover, there is no period of gastric atony, and feedings can be initiated after 1 day. PEG is contraindicated in patients with altered hemostasis or mechanical barriers to apposing the stomach to the anterior abdominal wall. Routine broad spectrum antibiotic prophylaxis may limit procedure-related cellulitis and pneumonia.     

Survival of geriatric patients after percutaneous endoscopic gastrostomy in Japan

AIM: To examine the long term survival of geriatric patients treated with percutaneous endoscopic gastrostomy (PEG) in Japan. METHODS: We retrospectively included 46 Japanese community and tertiary hospitals to investigate 931 consecutive geriatric patients (≥ 65 years old) with swallowing difficulty and newly performed PEG between Jan 1st 2005 and Dec 31st 2008. We set death as an outcome and explored the associations among patient’s characteristics at PEG using log-rank tests and Cox proportional hazard m...     

Percutaneous endoscopic gastrostomy——Too often? Too late? Who are the right patients for gastrostomy?

Percutaneous endoscopic gastrostomy is an established method to provide nutrition to patients with restricted oral uptake of fluids and calories. Here, we review the methods, indications and complications of this procedure. While gastrostomy can be safely and easily performed during gastroscopy, the right patients and timing for this intervention are not always chosen. Especially in patients with dementia, the indication for and timing of gastrostomies are often improper. In this patient group, clear data for enteral nutrition are lacking;however, some evidence suggests that patients with advanced dementia do not benefit, whereas patients with mild to moderate dementia might benefit from early enteral nutrition. Additionally, other patient groups with temporary or permanent restriction of oral uptake might be a useful target population for early enteral nutrition to maintain mobilization and muscle strength. We plead for a coordinated study program for these patient groups to identify suitable patients and the best timing for tube implantation.     

Marked pneumoperitoneum 3 weeks after percutaneous endoscopic gastrostomy

In November 2001, a 29-year-old woman was admitted to the hospital because of dysphagia due to an apallic state caused by cerebral anoxia. Nutritional support was maintained by nasogastric tube feeding for approximately 3 months. For improvement of the body state maintenance and quality of life, a percutaneous endoscopic gastrostomy (PEG) was performed. Three weeks after the PEG, the patient had a wound infection and abdominal distension appeared. Marked pneumoperitoneum was confirmed by radiological examination. No signs or symptoms of peritoneal inflammation developed. A gastrografin study showing that the PEG tube was in the stomach appropriately was checked, and it was noted to be firmly in place without extravasation of contrast. After suspension of the tube feeding and tube opening to decrease intragastric pressure, intravenous hyperalimentation was performed. The pneumoperitoneum resolved within 7 days. Forty days after the PEG, tube feeding was resumed successfully. No recurrence of pneumoperitoneum developed and the patient has remained stable until the present time. The etiology of this finding probably occurs by insufficient fixation of the PEG, causing leakage of air through the gastric wall which enters the free peritoneal space. We recommend that the external binder should be kept 1 cm away from the abdominal skin after the gastrostomy fistula has formed and matured, and periodic rotation of the tube to verify that the internal bumper is free and sufficiently fixed to the gastric wall. In the case of abdominal distension after PEG placement, a X-ray examination and computed tomography (CT) scan with contrast medium would be helpful to ascertain pneumoperitoneum.     

Percutaneous endoscopic gastrostomy and gastro-oesophageal reflux in neurologically impaired children

AIM:To investigate the effects of percutaneous endoscopic gastrostomy(PEG) feeding on gastro-oesophageal reflux(GOR) in a group of these children using combined intraluminal pH and multiple intraluminal impedance(pH/MII) . METHODS:Ten neurologically impaired children underwent 12 h combined pH/MII procedures at least 1 d before and at least 12 d after PEG placement. METHODS:Prior to PEG placement(pre-PEG) a total of 183 GOR episodes were detected,156(85.2%) were non-acidic.After PEG placement(post-PEG) a to...