Gastrostomies et nutrition entérale lors des maladies neuromusculaires

Neuromuscular diseases (NMD) are disorders of often severe prognosis, and can easily lead to malnutrition. Swallowing disorders are frequent, and the patients can profit from enteral nutrition (EN), for which the way of election is gastrostomy. The aim of this review is to give a progress report on the evolution of NMD care since the 2000s for amyotrophic lateral sclerosis (ALS), the best explored disease, and for the other NMD. For ALS, percutaneous endoscopic gastrostomy (PEG) is the main method used, competed with because of its relative simplicity by radiological inserted gastrostomy (RIG). The indications are swallowing disorders, loss of weight, insufficient feeding, and difficulties of catching the meals. Current studies, not enough methodologically valuable, does not allow to affirm that EN improves survival of the patients nor their quality of life, but it could improve nutritional status. The complications after gastrostomy are aspecific, similar between PEG and RIG but the methods of evaluation are imprecise. The PEG is desirable if the patients forced vital capacity (FVC) is >50%. RIG is needed when FVC is <50%, after PEG failure or if the patients are in bad general condition. Documentation is limited for other NMD, including particularly child diseases and Duchenne muscular dystrophy (DMD). The indications and complications of gastrostomy are close to those of the ALS. EN improves patients nutritional status and, in DMD, quality of life. The families, the patients and the medical teams, often because of an insufficient communication, can be reserved considering nutrition support.     

Gastrostomy tube placement outcomes: comparison of surgical, endoscopic, and laparoscopic methods.

BACKGROUND: Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques now allow for less invasive placement of gastrostomy tubes. This study compared morbidities and feeding outcomes of these procedures with standard surgical (OPEN) insertion. METHODS: Gastrostomy tubes placed in the operating room by the PEG, LAP, and OPEN methods were compared for insertion times, tube insertion and maintenance complications, enteral feeding complications, and feeding start days. Patients with concomitant intra-abdominal procedures were excluded. Patients were followed for 6 days after tube placement. RESULTS: A total of 91 catheters (PEG = 23, LAP = 39, OPEN = 29) were inserted in the operating room for indications of ventilator-dependent respiratory failure (45), dysphagia (30), head and neck cancer (9), and decreased mental status (7). No patients were fed on the day of the procedure. Insertion times were significantly longer (p < .05) in the OPEN technique (68 minutes) vs LAP (48 minutes) and PEG (30 minutes). Insertion complications occurred in the LAP and PEG cohorts (3 failed LAP, 1 failed PEG), and maintenance complications were higher in the LAP group, including 1 episode each of cellulitis, bleeding, and serous drainage. Twenty enteral feeding complications in 17 patients occurred in all groups (9 in LAP vs 6 in PEG and 5 in OPEN), and included emesis (6), high residual (5), diarrhea (3), ileus (3), nausea (2), and pain after feeding (1). Overall complications were significantly lower in the PEG (7) and OPEN (5) groups compared with the LAP group (15). Feeding start day was significantly delayed in the OPEN technique (2.1 days vs 1.7 in PEG and 1.5 in LAP); however, no difference was found in days to goal among groups (4.4-4.8 days). CONCLUSIONS: PEG should be the procedure of choice for placement of gastrostomy tubes. If PEG is contraindicated, then OPEN technique may be best due to fewer complications, although insertion time is longer than the LAP technique.     

One‐Step Insertion of Low‐Profile Gastrostomy in Pediatric Patients vs Pull Percutaneous Endoscopic Gastrostomy

Background: Standard care for initiation of enteral feeding in children has been pull percutaneous endoscopic gastrostomy (pull‐PEG). As an alternative to pull‐PEG, a 1‐step endoscopic procedure for inserting a low‐profile gastrostomy tube “button” has been developed that allows initial placement of a balloon‐retained device. This report presents outcomes of metrics used to compare button placement with pull‐PEG in a pediatric population. Methods: Data were generated from procedural experiences of surgeons on pediatric patients (n = 374) with a variety of clinical indications for gastrostomy. Study population ages ranged from 6 days to 16 years, while weights were from 2–84 kg. Results: The button was successfully placed by the 1‐step procedure in 98% of the respective study population, and median procedural times were 20 and 15 minutes for button and pull‐PEG placements, respectively. Median times to first feeds were equivalent for the 1‐step procedure and pull‐PEG (6 hours), while times to first nutrition feeds were 12.5 and 10 hours, respectively. Stoma site complications within each study group were similar. Healthy stoma proportions were 65.2% and 73.2% in the 1‐step procedure and pull‐PEG groups, respectively, at first follow‐up. Conclusions: Similar study outcomes between the 1‐step procedure and pull‐PEG groups suggest that the former is a feasible alternative to pull‐PEG for initial tube placement in children. The 1‐step method involves a single procedure and reduces patient exposure to anesthesia, operating room time, and the potential for complications compared with a pull‐PEG requirement for multiple procedures.     

Percutaneous endoscopic gastrostomy: experience of three years]

Patients who are not able to eat do need tube feeding. The most preferred way of artificial enteral nutritional support is feeding via percutaneous endoscopic gastrostomy (PEG) tubes. Head and neck cancer patients do represent a special group of patients needing a PEG. On the one hand at the time of admission to the hospital they are mainly undernourished. On the other hand the failure rate of placing a PEG is the highest among them. Furthermore in the perioperative period nasogastric tubes do cause a lot of complications in these settings. 188 PEG placements were carried out from July 1995 till November 1998. Indications: head and neck cancer (n = 171), neurologic disorders (n = 17). PEG tubes were placed 76 times during intratracheal narcosis and 112 times following local anaesthesia. 39 times there was a prior abdominal surgery in our patients medical history. The pull-through, the push-wire and the introducer techniques were used. Beside the usual oro-gastric way of endoscopying (n = 163), 25 times the following alternative ways of entering the upper gastrointestinal tract were used: transnasal route (n = 4), through a Kleinsasser type direct laryngoscope (n = 7) and via the opened pharynx (n = 14). No immediate or late onset procedure related complications occurred. During a follow-up of 22,480 tubedays 26 minor (dermatitis n = 24, ulcer n = 2) and 8 major (abscess n = 4, perforation/peritonitis n = 3, stomach and bowel wall necrosis n = 1) complications occurred. The success rate of placing a PEG was 98.9%. In head and neck cancer patients placing a PEG is suggested when there is a need for at least a 7 days time tube-feeding. Using the described alternative ways, a PEG tube can be placed almost always. Because of the uncertain outcome, nutritional support via PEG tubes is suggested also in cachectic patients and in vegetative state as well.     

Early percutaneous endoscopic gastrostomy insertion maintains nutritional state in patients with aerodigestive tract cancer

Patients with upper aerodigestive tract (UAT) cancers often suffer from malnutrition and compromised functional ability. We compared clinical outcome with percutaneous endoscopic gastrostomy (PEG) tube feeding begun at two different time points. The records of 151 patients with UAT carcinomas were reviewed retrospectively. We included patients undergoing radical radiochemotherapy and PEG tube feeding. Subjects were evaluated before PEG insertion and at the end of the treatment. Patients (n=15, 100%) were divided into two groups according to the presence (group A) or absence (group B) of mucositis. Group A (51.7% of patients) received early PEG: before or within 2 wk of radiotherapy. Group B (48.3%) received delayed PEG: between 2 wk and 3 mo after the start of radiotherapy. Mean weight loss was 1.03 kg in group A vs. 4.0 kg in group B, P=0.004. Treatment interruptions were significantly (P=0.01) more common in group B. Early PEG placement at the beginning of radiochemotherapy in patients with UAT tumors maintains the patient's nutritional state and reduces treatment interruptions.     

Does percutaneous endoscopic gastrostomy prevent gastro-oesophageal reflux during the enteral feeding of elderly patients?

Percutaneous endoscopic gastrostomy (PEG) is reported to be a safe method for enteral feeding, although its ability to prevent gastro-oesophageal reflux (GOR) during enteral feeding remains controversial. In 12 elderly patients fed enterally to avoid the risk of tracheal aspiration, we have compared two 24-h oesophageal pH profiles, one recorded when enteral feeding was delivered at first via a nasogastric tube (NGT), and the other via a PEG. The second recording was always performed at least 8 days after gastrostomy placement. Enteral nutrition consisted of 500 ml of a polymeric diet delivered 3 times a day at 08:00, 13:00 and 18:00. After gastrostomy placement, enteral feeding was associated with a pathological acid reflux in 8 out of 12 patients. In all of these 8 patients, GOR was mostly related to a high number of reflux episodes. In 4 out of 8 patients, GOR occurred only during the 3 h following the administration of the nutritive diet. In 4 of the patients, GOR did not occur any more after removal of the NGT, whilst gastrostomy placement was followed by GOR in 5 patients. GOR during enteral feeding via PEG is common in elderly subjects. We have shown that a chronological relationship existed in some patients between the endoscopic procedure and the onset of a pathological GOR.     

Home enteral tube feeding in children following percutaneous endoscopic gastrostomy: perceptions of parents, paediatric dietitians and paediatric nurses

BACKGROUND: The perceptions of parents and professionals are important in deciding to feed children by gastrostomy, yet there are few published studies in this field. This study explored and compared the perceptions of parents to those of paediatric outreach nurses and paediatric dietitians. METHODS: A cross-sectional mixed-method study with purposive sampling was undertaken using structured interviews and questionnaires to explore perceptions of percutaneous endoscopic gastrostomy (PEG) placement and feeding. Binomial regression was used to investigate differences in perceptions across the groups of participants. RESULTS: Parents, paediatric outreach nurses and dietitians shared similar perceptions regarding success of feeding, support for gastrostomy reinsertion and the acceptability of the child's quality of life. Much greater differences in perceptions were evident regarding the parents' involvement in the decision-making process for PEG placement and the adequacy of the support received from healthcare professionals. CONCLUSIONS: A high level of support for feeding was demonstrated together with strong perceptions across all groups that feeding was successful. It is important for healthcare professionals to consider the perceptions of the parents throughout decision making and provision of care following PEG placement because it is highly likely there will be differences in the perceptions between parents and healthcare professionals.     

A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people

OBJECTIVE: To compare the indications for and the outcome of long-term enteral feeding by nasogastric tube (NGT) with that of percutaneous endoscopic gastrostomy (PEG) tube. DESIGN: A prospective, multicenter cohort study. SETTING: Acute geriatric units and long-term care (LTC) hospitals in Jerusalem, Israel. PARTICIPANTS: 122 chronic patients aged 65 years and older for whom long-term enteral feeding was indicated as determined by the treating physician. Patients with acute medical conditions at the time of tube placement were excluded. MEASUREMENTS: We examined the indications for enteral feeding, nutritional status, outcome and complications in all subjects. Subjects were followed for a minimum period of six months. RESULTS: Although the PEG patients were older and had a higher incidence of dementia, there was an improved survival in those patients with PEG as compared to NGT (hazard ratio (HR)=0.41; 95% confidence interval (CI) 0.22-0.76; P=0.01). Also, the patients with PEG had a lower rate of aspiration (HR=0.48; 95% CI 0.26-0.89) and self-extubation (HR=0.17; 95% CI 0.05-0.58) than those with NGT. Apart from a significant improvement in the serum albumin level at the 4-week follow-up assessment in the patients with PEG compared to those with NGT (adjusted mean 3.35 compared to 3.08; F=4.982), nutritional status was otherwise similar in both groups. CONCLUSION: In long-term enteral feeding, in a selected group of non-acute patients, the use of PEG was associated with improved survival, was better tolerated by the patient and was associated with a lower incidence of aspiration. A randomized controlled study is needed to determine whether PEG is truly superior to NGT.     

Percutaneous endoscopic gastrostomy complication rates and compliance with the American Society for Gastrointestinal Endoscopy guidelines for the management of antithrombotic therapy

Background: The American Society for Gastrointestinal Endoscopy (ASGE) has published recommendations in regards to anticoagulant (AC) and antiplatelet (AP) therapy management during endoscopic procedures. So far, no study has assessed either ASGE recommendation compliance during percutaneous endoscopic gastrostomy (PEG) placement or procedure‐associated complication rates as related to the observance of these recommendations. The aims of this study were to compare the incidence and type of complications during PEG placement in patients receiving or not receiving AC and/or AP therapy and to determine the compliance with ASGE's AC and AP management guidelines. Methods: Medical files of patients who underwent PEG placement from January 2004 to December 2008 were reviewed. Clinical and procedure‐related data were recorded. Patients were separated into 1 of 2 groups: patients under AP and/or AC therapy prior to PEG placement (n = 51) and a control group of patients (n = 40) not receiving any AP and/or AC treatment at least 6 months prior to the procedure. Results: A total of 91 patients (51 cases) were included. Groups were comparable in demographics and clinical characteristics. No differences in the frequency and type of complications were found between groups. ASGE's recommendations were not followed in any of these patients. Conclusions: Overall PEG placement complication rate was 13.7%. AP therapy may be safely discontinued closer to the time of endoscopic procedure than the time currently recommended by the ASGE guidelines.     

Safety techniques for percutaneous endoscopic gastrostomy tube placement in Pierre Robin Sequence

Pierre Robin Sequence (PRS) is a craniofacial anomaly characterized by a triad of micrognathia, glossoptosis, and cleft palate. Infants with PRS frequently have feeding problems that may require supplemental nutrition through a nasogastric or gastrostomy tube. Very few published studies have illustrated the most appropriate method for securing an enteral feeding route in this patient population. One case report described a major complication leading to death from airway compromise following percutaneous endoscopic gastrostomy (PEG) tube placement. The authors describe a case of an infant with PRS who underwent successful PEG tube placement without complications, and they highlight certain techniques to improve procedure success and patient safety.     

Percutaneous endoscopic gastrostomy (PEG) placement in the overweight and obese patient

BACKGROUND: Traditionally, percutaneous endoscopic gastrostomy (PEG) placement in the obese patient has been considered a relative contraindication due to the impedance of gastric transillumination and inability to approximate the abdominal and gastric wall. The aim of this study was to determine the overall success rate, morbidity, and PEG-related mortality in overweight and obese patients. METHODS: Three hundred fifty-five consecutive patients were retrospectively evaluated over a 1-year period at the Virginia Commonwealth University Medical Center for postprocedure-related PEG and PEG/jejunostomy (J) complications. One hundred thirty-four patients were considered overweight (body mass index [BMI] > or = 27 kg/m(2)). Of those, 80 patients were found to be obese (BMI > or = 30 kg/m(2)) with a BMI ranging 30-63 kg/m(2). RESULTS: Gastrostomy placement was successful in 130 of 134 (97%) overweight patients (p < .05). The overall procedure-related mortality was 0%. The rate of significant complications in overweight and obese patients remained 0% when compared with those patients with a normal BMI. Out of 355 patients, 14 failed to receive a PEG; 3 of these were obese and 1 was overweight. These 4 procedures were aborted due to a paucity of anatomical landmarks and failure to transilluminate the abdominal wall. CONCLUSIONS: We believe that PEG placement in the overweight and obese patient can be a technically safe procedure according to our success rate of 100%, with a procedure-related mortality rate of 0%. In those overweight and obese patients who require specialized long-term enteral nutrition support, PEG placement should be considered earlier and more frequently.     

Percutaneous endoscopic gastrostomy in the neurosurgical intensive care unit: complications and outcome

BACKGROUND: Even with a functioning gastrointestinal tract, it is not always easy to initiate oral feeding in some neurosurgical patients because of their persistently depressed neurologic status or severe lower cranial nerve palsies. Percutaneous endoscopic gastrostomy (PEG) may be required for long-term feeding in these patients. The purpose of the present study is to report our experience with PEG chosen for establishing an enteral route in patients of neurosurgical intensive care unit (ICU). METHODS: The outcome and complications of PEG in neurosurgical ICU patients of Marmara University Institute of Neurological Science between January 2001 and November 2006 were retrospectively evaluated. RESULTS: Thirty-one patients, with the median age of 51 years (range, 14-78 years) underwent PEG placement. PEG was placed before the craniotomy in 2 patients and after in 29. Indications for PEG were absent gag reflex in 10 patients and low Glasgow Coma Scale score in 21. Before the PEG tube insertion, 18 patients had enteral nutrition by a nasogastric tube and 10 had parenteral nutrition (PN), with a median duration of 14.5 (range, 4-60) and 12 (range, 7-25) days, respectively. Two patients accidentally pulled out the gastrostomy tubes 10 and 11 days after insertion. Buried bumper syndrome developed in 1 patient. Two patients died 8 and 34 days after the procedure in the neurosurgical ICU. Twenty-nine patients were discharged from the hospital while being fed via the PEG tubes. In 11 patients who were able to resume oral feeding, the tube was removed, with a median interval of 62 (range, 25-150) days. Procedure-related mortality, 30-day mortality, and overall mortality of the patients were 0%, 6.4%, and 45%, respectively. CONCLUSION: PEG is a safe and well-tolerated gastrostomy method for neurosurgical ICU patients with depressed neurologic state or severe lower cranial nerve palsies.     

Laparoscopic‐Assisted Percutaneous Endoscopic Gastrostomy

Background/Purpose: Percutaneous endoscopic gastrostomy (PEG) is a simplified catheter placement procedure for alimentation. Although the endoscopic approach to gastrostomy tube placement is a safe and well‐tolerated procedure in most patients, the PEG procedure is difficult in elderly patients disabled since childhood who have severe scoliosis and malpositioning of the stomach. We describe a simple and effective laparoscopic‐assisted PEG (LAPEG) technique that can be used for catheter placement in severely disabled patients. Methods: Thirteen severely disabled patients aged 14–57 years underwent gastrostomy tube placement with the LAPEG technique. After general anesthesia was achieved, an endoscope was placed into the stomach. Then, a 5‐mm camera port was inserted at the umbilicus, and a 3‐mm working port was inserted to identify and lift the optimal site for gastrostomy tube placement. After the 4‐point fixation of the stomach, the 20‐Fr gastrostomy tube was placed under endoscopic and laparoscopic observation. Results: All patients tolerated the procedure well, and there were no major complications. The procedure was successful, and all patients could feed via the tube. Conclusions: Elderly disabled patients who have been bedridden since childhood often have severe scoliosis and malpositioning of the stomach. Our LAPEG procedure is effective, well tolerated, and safe for gastrostomy tube placement in such elderly patients.     

DPEJ tube placement prevents aspiration pneumonia in high-risk patients.

Percutaneous endoscopic gastrostomy (PEG) or PEG tube with transgastric jejunostomy tube (PEG-J) feeding has not been shown to decrease aspiration pneumonia. The aim of this study was to determine if direct percutaneous endoscopic jejunostomy (DPEJ) tube placement results in a decreased incidence of aspiration pneumonia in high-risk patients. The design was a retrospective review of all patients receiving DPEJ tube for aspiration pneumonia from 1999 to 2005. Demographics, incidence of aspiration pneumonia, and outcomes were collected and compared before and after the DPEJ placement. Eleven patients (4 women, 7 men) were identified; their mean age was 44.9 years (range, 18-94 years). The etiologies for recurrent aspiration pneumonia were neurologic disease (9), esophageal surgery (1), and severe debilitation (1). The mean follow-up was 20.9 months (range, 6-48 months). The patients' mean weight increased from 43.8 kg (range, 19-55 kg) to 48.3 kg (range, 30-65 kg) after placement (P < .001). The total number of documented aspiration pneumonia episodes for all patients decreased from 29 (mean, 3.64; range, 1-6) before DPEJ placement to 3 (mean, 0.27; range, 0-2) after DPEJ placement (P < .001). The mean number of aspiration pneumonia events per month prior to the DPEJ placement was 3.39 and postplacement was 0.42 (P < .001). DPEJ placement appears to decrease recurrent aspiration pneumonia in patients with history of aspiration pneumonia.     

Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease

Background:  Motor neurone disease (MND) is a progressive neurodegenerative disease leading to limb weakness, wasting and respiratory failure. Prolonged poor nutritional intake causes fatigue, weight loss and malnutrition. Consequently, disease progression requires decisions to be made regarding enteral tube feeding. The present study aimed to investigate the survival, nutritional status and complications in patients with MND treated with enteral tube feeding. Methods:  A retrospective case note review was performed to identify patients diagnosed with MND who were treated with enteral tube feeding. A total of 159 consecutive cases were identified suitable for analysis. Patients were treated with percutaneous endoscopic gastrostomy (PEG), radiologically inserted gastrostomy (RIG) or nasogastric feeding tube (NGT). Nutritional status was assessed by body mass index (BMI) and % weight loss (% WL). Serious complications arising from tube insertion and prescribed daily energy intake were both recorded. Results:  Median survival from disease onset was 842 days [interquartile range (IQR) 573–1263]. Median time from disease onset to feeding tube was PEG 521 days (IQR 443–1032), RIG 633 days (IQR 496–1039) and NGT 427 days (IQR 77–781) (P = 0.28). Median survival from tube placement was PEG 200 (IQR 106–546) days, RIG 216 (IQR 83–383) days and NGT 28 (IQR 14–107) days. Survival between gastrostomy and NGT treated patients was significant (P ≤ 0.001). Analysis of serious complications by nutritional status was BMI (P = 0.347) and % WL (P = 0.489). Conclusions:  Nutritional factors associated with reduced survival were weight loss, malnutrition and severe dysphagia. Serious complications were not related to nutritional status but to method of tube insertion. There was no difference in survival between PEG and RIG treated patients.     

Transnasal endoscopic placement of nasoenteric feeding tubes: outcomes and limitations in non-critically ill patients.

Transnasal endoscopic placement of nasoenteric tubes (NETs) has been demonstrated to be useful in the critical care setting, with limited data on its role in non-critically ill patients. The authors collected data on consecutive patients from a non-critical care setting undergoing transnasal endoscopic NET placement. All NETs were endoscopically placed using a standard over-the-guidewire technique, and positions were confirmed with fluoroscopy. Patients were monitored until the removal of NETs or death. Twenty-two patients (median age = 62.5 years, 36.4% female) were referred for postpyloric feeding, with main indications of persistent gastrocutaneous fistula (n = 6), gastroparesis or gastric outlet obstruction (n = 5), duodenal stenosis (n = 6), acute pancreatitis (n = 4), and gastroesophageal reflux after surgery (n = 1). Postpyloric placement of NET was achieved in 19 of 22 (86.3%) patients, with 36.8% tube positions in the jejunum, 47.4% in the distal duodenum, and 15.8% in the second part of the duodenum. NET placement was least successful in cases with duodenal stenosis. NETs remained in situ for a median of 24 days (range, 2-94), with tube dislodgement (n = 3) and clogging (n = 5) as the main complications. NET feeding resulted in complete healing of gastrocutaneous fistulae in 5 of 6 patients and provision of total enteral nutrition in 3 of 4 cases of acute pancreatitis and 9 of 11 cases of gastroparesis or proximal duodenal obstruction. Transnasal endoscopy has a role in the placement of NET in non-critically ill patients requiring postpyloric feeding. However, there are some limitations, particularly in cases with altered duodenal anatomy.     

Percutaneous Gastrostomy Tube Placement Using a Balloon Catheter in Patients With Head and Neck Cancer

Background: Patients with head and neck cancer frequently require gastrostomy feeding. The aim of this study was to evaluate the safety and feasibility of percutaneous radiologic gastrostomy with push‐type gastrostomy tubes using a rupture‐free balloon (RFB) catheter under computed tomography (CT) and fluoroscopic guidance in patients with head and neck cancer with swallowing disturbance or trismus. Methods: Percutaneous CT and fluoroscopic gastrostomy placement of push‐type gastrostomy tubes using a RFB catheter was performed in consecutive patients with head and neck cancer between April 2007 and July 2010. The technical success, procedure duration, and major or minor complications were evaluated. Results: Twenty‐one patients (14 men, 7 women; age range, 55–78 years; mean age, 69.3 years) underwent gastrostomy tube placement. The tumor location was the pharynx (n = 8), oral cavity (n = 7), and gingiva (n = 6). Gastrostomy was performed in 15 patients during treatment and 6 patients after treatment. Percutaneous radiologic gastrostomy was technically successful in all patients. The median procedure time was 35 ± 19 (interquartile range) minutes (range, 25–75). The average follow‐up time interval was 221 days (range, 10–920 days). No major complications related to the procedure were encountered. No tubes failed because of blockage, and neither tube dislodgement nor intraperitoneal leakage occurred during the follow‐up periods. Conclusion: Percutaneous CT and fluoroscopic‐guided gastrostomy with push‐type tubes using a RFB catheter is a relatively safe and effective means of gastric feeding, with high success and low complication rates in patients with head and neck cancer in whom endoscopy was not feasible.     

Comparison of Nutritional and Clinical Outcomes in Patients with Head and Neck Cancer Undergoing Chemoradiotherapy Utilizing Prophylactic versus Reactive Nutrition Support Approaches

Background

The optimal method of tube feeding for patients with head and neck cancer remains unclear. A validated protocol is available that identifies high-nutritional-risk patients who would benefit from prophylactic gastrostomy tube placement. Adherence to this protocol is ultimately determined by clinical team discretion or patient decision.

Early initiation of enteral feeding after percutaneous endoscopic gastrostomy tube placement.

Enteral feeding through the percutaneous endoscopic gastrostomy (PEG) tube is usually initiated about 12 to 24 hours after insertion of the tube. There have been earlier studies evaluating the efficacy of early initiation of enteral feedings that had encouraging results. However, delayed initiation of feeding following PEG placement continues to be practiced widely. We believe that feeding can be done earlier without any increase in associated morbidity or mortality and with obvious reduction in the need for parenteral nutrition and healthcare costs. We evaluated a protocol to initiate enteral nutrition 4 hours after the PEG tube insertion with subsequent discharge of the outpatients on the same day. We conducted a prospective study to assess the efficacy of early initiation of PEG feeding. We enrolled 77 patients in our study who were having PEG tubes placed for enteral feeding. Only patients who had a PEG placed for gastric venting procedures were excluded from our study. During the course of our study, no patient had to be excluded for the latter reason. Patients were evaluated by the physician performing the procedure, 4 hours after the tube was inserted. Their vital signs were checked, and a thorough abdominal examination was performed. Minimal tenderness around the PEG site was the most frequent finding. Otherwise, all the patients had a benign abdominal examination. The tube was flushed with 60 mL of sterile water. Following the examination, orders were given to restart the feedings. These patients were followed for a 30-day period to evaluate complications associated with PEG tube placement and early initiation of PEG feeding. There was one case of aspiration pneumonia (1.3%) and one death that was attributed to the underlying disease out of our 77 patients. Early initiation of enteral feeding after PEG tube placement can be successfully completed with a systematic protocol and close observation. Not only was this protocol found to be safe, it can also have significant cost savings by eliminating the need for inpatient hospitalization for the procedure.     

Complications arising from percutaneous endoscopic and radiologically inserted gastrostomies in a cohort of head and neck cancer patients

Background:  Gastrostomy placement is often required to help maintain and/or improve nutritional status in head and neck cancer patients. In this hospital trust, radiologically inserted gastrostomies (RIGs) have been the preferred route for head and neck cancer patients as a result of the physical problems associated with the percutaneous endoscopic gastrostomy (PEG) procedure in this patient group. Previous studies have revealed higher complication rates with RIGs compared to PEGs (Rustom et al., 2006, Bailey et al., 2007). This audit aimed to evaluate complications arising from PEG or RIG placement in this patient group.
Method:  Twenty-six head and neck cancer patients (19 male, seven female), who had either a PEG ( n  = 5) or RIG ( n  = 21) inserted between January 2006 to December 2007, were retrospectively audited. The methodology was based on a similar audit carried out by Bailey et al. (2007). Medical, nursing and dietetic documentation were reviewed for any complications as shown in Table 1.