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

     

Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy

Feeding gastrostomy is a useful means of providing nutrition in patients unable to swallow. Percutaneous endoscopic gastrostomy provides a means for creating a feeding gastrostomy without the necessity for laparotomy. It adds a new tool to the armamentarium of the therapeutic endoscopist.     

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 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.     

Classification of nutritional status in cystic fibrosis

PURPOSE OF REVIEW: Nutritional status impacts on the progression of cystic fibrosis. Current guidelines recommend the use of anthropometric indicators to classify nutritional status and identify malnutrition. However, the current nutrition-classification systems are problematic. I summarize these problems and review recent progress in the development of evidence-based anthropometric criteria for classifying nutritional status in cystic fibrosis patients. RECENT FINDINGS: Percentage of ideal body weight as a malnutrition index is flawed. In children with cystic fibrosis, this index underestimates the severity of underweight in short patients and overestimates it in tall patients. In adults with cystic fibrosis, percentage of ideal body weight based on the Metropolitan Life Insurance reference weights for medium/large frames overestimates the severity of underweight. Body-mass-index percentile for children and body mass index for adults as underweight indices have been proven to be valid. Strong associations between body mass index and lung function are also observed, but cutoff values to maintain a desirable level of lung function can vary. SUMMARY: Body mass index should replace the use of percentage of ideal body weight for classifying underweight in cystic fibrosis patients. More research is needed to identify appropriate indicators to classify short stature in children with cystic fibrosis.     

Percutaneous endoscopic gastrostomy and outcome in dementia

The use of percutaneous endoscopic gastrostomy for the administration of food and medications in patients with dementia has been on an increase. Many studies have failed to demonstrate the positive outcome expected of this feeding modality for the indications that required tube placement. Hence, the concept of feeding through gastrostomy tubes has become the subject of much discussion and controversy in recent times. We have reviewed the literature with regard to outcome in older patients with dementia and percutaneous endoscopic gastrostomy with respect to nutritional parameters, quality of life, and survival. A brief discussion on ethical and legal aspects is included. Much of the data do not suggest that outcome in dementia is favorably improved after percutaneous gastrostomy.     

Effects of nutritional status on exercise performance in advanced cystic fibrosis

Initial evaluation of 22 patients with cystic fibrosis (CF) on entry into a trial of home oxygen therapy was used to elucidate the possible effects of poor nutritional status on exercise performance in CF. The patients had advanced lung disease (mean FEV1, 36 percent predicted) and all had a stable resting PaO2 less than or equal to 65 mm Hg. Nutritional status was determined by calculating weight as a percentage of ideal for height (Wt/Ht) for each subject. Exercise testing consisted of a progressive exercise test on a cycle ergometer to measure maximum work capacity (Wmax), and a steady state test at 50 percent of baseline Wmax. During the steady state test, cardiac output (Q) and stroke volume (SV) were computed by the indirect Fick (CO2) method. Wmax, SV, Q and lung function results are expressed as percent predicted. Mean (+/- SD) Wmax was 58 +/- 15 percent predicted. Wmax correlated with both FEV1 and Wt/Ht, but FEV1 and Wt/Ht were not related. During steady state exercise, 12 of 22 patients had a SV less than 80 percent predicted. SV correlated with Wt/Ht, but not with lung function. Thirteen of the 22 patients had a Wt/Ht less than or equal to 90 percent and were considered malnourished. When compared with the well-nourished patients (Wt/Ht greater than 90%), these malnourished subjects had significantly lower mean values for Wmax%, SV% and Q% predicted, but not for lung function parameters. We conclude that: in patients with CF and advanced lung disease, nutritional status plays a significant role in determining exercise capacity; lower exercise tolerance of malnourished patients is an independent effect, as nutritional status and lung function were not related; and malnourished patients with CF have an altered cardiac performance on exercise testing which is due to a reduced SV rather than an impaired heart rate response.     

Percutaneous endoscopic gastrostomy; evidence of different prognosis in various patient subgroups

BACKGROUND: As there are no prospective randomised trials about percutaneous endoscopic gastrostomy (PEG) insertion, the medical staff and caregivers encounter great difficulty in deciding when and if to perform this procedure. OBJECTIVE: To explore which variables are associated with increased mortality after PEG insertion. DESIGN: Prospective observational study. SETTING: Gastroenterological unit of a 500-bed community hospital. SUBJECTS: All patients over the age of 50 years referred for PEG insertion between January 1992 and December 2002. METHODS: Patients were studied for their indication for PEG insertion as well as their main medical problems, and demographic details and medical records were reviewed yearly until mortality. RESULTS: 674 patients were enrolled (mean age 80.1 years, 42% men). The median survival was worst in diabetic patients (128 days, P <0.05), patients referred from hospital (161 days, P <0.01) and patients over the age of 80 years with dementia (171 days, P <0.001). The best median survival was found among demented patients under the age of 80 (467 days, P <0.05) and women under the age of 80 referred from nursing homes (780 days, P <0.01). CONCLUSIONS: The outcome after PEG insertion is variable, with survival of over a year in many of the patients. These data are important for the medical staff, the patients and their caregivers when deciding about PEG placement.     

Half-solid enteral nutrient prevents chronic complications of percutaneous endoscopic gastrostomy tube feeding

An 85-year-old woman was receiving enteral feeding via percutaneous endoscopic gastrostomy (PEG). The patient exhibited symptoms of gastro-esophageal reflux, leakage of nutrient from the PEG insertion point, vomiting, pyrexia, dyspnea when given nutrients and recurrent pneumonia. We therefore gave a half-solid nutrient, which was made by a mixture of agar powder and conventional liquid nutrient Immediately after starting the half-solid nutrient feeding via PEG, the patients no longer exhibited the above symptoms apart from mild pyrexia, which also vanished two weeks later. This case suggested that simply changing the fluidity of nutrients can contribute to a reduction of complications expected to occur in patients on PEG tube feeding.     

Percutaneous endoscopic gastrostomy: results of 115 cases

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy is one of the gastrostomy methods used for patients who are unable to take food orally. We aimed to present our results for percutaneous endoscopic gastrostomy. METHODOLOGY: One hundred and fifteen patients undergoing percutaneous endoscopic gastrostomy by pull technique were retrospectively evaluated in terms of indications, complications, durability of tube, and mortality. RESULTS: Of the 115 cases, 60 were males and 55 females with the median age of 67 (2-93) years. Indications for percutaneous endoscopic gastrostomy placement were cerebrovascular accident in 39, brain tumors in 24, subarachnoidal hemorrhage in 21, several neurologic disorders in 17, miscellaneous extracerebral tumors in 6, head injury in 5, hypoxic encephalopathy in 2, and iatrogenic in 1. The durability of the tube was a median of 242 (9-1988) days. The tube was removed in 16 patients and was changed in 11 patients with a median interval of 142.5 (35-427) and 133 (24-1251) days, respectively. Four wound infections, two buried bumper syndromes, and two aspiration pneumonias developed. Total follow-up was 114.1 patient-years with procedure-related mortality, 30-day mortality, and overall mortality of 0%, 3.5% (4/115), and 17.4% (20/115), respectively. The mortality rate was 45% for patients who had brain tumor and 11.6% for the remainder. CONCLUSIONS: Percutaneous endoscopic gastrostomy is a minimally invasive gastrostomy method with low morbidity and mortality rates, easy to follow-up, and easy to replace when clogged.     

内镜下经皮胃造瘘术对患者营养及生活质量的改善

目的:评价内镜下经皮胃造瘘术(percutaneous endoscopic gastrostomy,PEG)对患者营养及生活质量的改善作用.方法:对73例行PEG患者进行回顾性分析,观察患者PEG置管前、置管后1、3及6mo的营养指标结果,包括白细胞、淋巴细胞计数、血浆血红蛋白、总蛋白、白蛋白及转铁蛋白变化及体质量、体质量指数的改变.记录置管前后患者并发肺炎、反流性食管炎情况.同时采用SF-36生活质量量表调查患者PEG术前后生活质量的变化.结果:73例患者共完成PEG操作107例次,患者术后体质量增加,营养状况明显改善,肠内营养1mo、3mo及6mo后血红蛋白、总蛋白、白蛋白及转铁蛋白及体质量、体质指数均有不同程度的改善,置管前、后组内比较差异有统计学意义(P<0.05).肺部感染的发生率由PEG术前的63.0%(46/73),术后降低至16.7%(11/66);反流性食管炎由PEG术前的27.4%(20/73)降至术后的7.6%(5/66).PEG置管术后1mo、3mo及6mo患者的生理健康和心理健康均较术前有明显改善,生理功能、社会功能明显高于PEG术前.结论:PEG术后患者营养状况明显改善,体质量指数增加,血红蛋白、总蛋白、白蛋白及转铁蛋白明显改善.同时PEG可减少因留置鼻胃管引起的反流性食管炎及肺部感染,患者耐受性好,生活质量提高.