Percutaneous Endoscopic Gastrostomy for Elderly Patients; A Comparative Study with Nasogastric Feeding

Abstract: Elderly patients who are unable to swallow due to disorders of the central nervous system and other disorders require parenteral alimentation for nutritional maintenance. Nasogastric feeding (NGF) which is widely employed for this purpose often causes problems such as the removal of the tube by the patient, difficulty of insertion or changing of the tube, and the induction of wheezing or even aspiration pneumonia. To avoid these difficulties, we performed a percutaneous endoscopic gastrostomy (PEG) on 10 patients, aged 80.7±19.3 years, who had previously been managed by nasogastric feeding for an average period of 10.8±19.3 months. No severe complications occurred during or after the operation. A comparison between 10 patients receiving gastrostogavage (PEG) and another 20 on NGF also revealed that PEG resolved the problems associated with NGF and achieved alimentary effects similar to NFG in the serum levels of albumin and hemoglobin. The autopsies of two elderly PEG patients who died of cardiac disease demonstrated that the serosa of their stomach and anterior abdominal wall firmly adhered. Our observations suggest that PEG is a safe and beneficial means of feeding for certain aged patients.     

Early Initiation of Post-PEG Feeding

Since its introduction in 1980, percutaneous endoscopic gastrostomy (PEG) has become the procedure of choice for long-term enteral feeding in patients who are unable to take adequate oral nutrition. Traditionally, gastroenterologists have waited for 24 hr after PEG tube placement before initiating feedings. However, recently published data have described the safety and efficacy of initiating PEG tube feedings as early as 3 hr after PEG tube placement. The objectives of this study were to determine how many hours after PEG tube placement practicing gastroenterologists initiate feedings and to determine whether they were aware of the pertinent literature. A four-page questionnaire was mailed to 35 practicing gastroenterologists, and the data gathered were analyzed using the SAS statistical package. A majority (81.5%) were aware of articles published in the last six years regarding the safety and efficacy of early initiation of feeding after PEG; of interest, however, only 10.7% were initiating feedings less than 3 hr after PEG tube placement. In conclusion, there exists a discrepancy between published recommendations and clinical practice regarding early initiation of feedings after PEG tube placement in this group of gastroenterologists who were surveyed.     

Nutritional Status and Quality of Life in Patients with Percutaneous Endoscopic Gastrostomy (PEG) in Practice: Prospective One-Year Follow-Up

Sixty patients (age 73 ± 14 years; 22 women, 38 men) with dysphagia (67% neurological diseases, 33% tumors) were followed up for 1 year after placement of a percutaneous endoscopic gastrostomy (PEG). Before PEG placement and at six appointments thereafter, the patients' nutritional status was measured using bioelectric impedance analysis (BIA) and hematological nutritional parameters. A validated questionnaire was used to assess quality of life (the Gastrointestinal Quality of Life Index, GIQLI). The overall mortality rate was 65%, and mortality during the hospitalization period was 22%. Depending on the duration of the dysphagia, marked nutritional deficits were observed at the start of the study (deficiencies in albumin in 49% of the patients, calcium in 15%, magnesium in 18%, retinol in 78%, -tocopherol in 16%, folic acid in 16%, vitamin B₁₂ in 8%, vitamin D in 40%, and zinc in 46%). With the exception of vitamin E, all parameters returned to normal during the follow-up period. At the start of the study, BIA indicated nutritional deficiency in 90% of the patients, with no overall improvement being observed during the follow-up period. The GIQLI scores, on average, reached a figure of 61% of an unrestricted quality of life. In conclusion, long-term nutrition via the PEG tube maintained the patients' quality of life. For BIA most patients were malnourished during the follow-up period, but nevertheless PEG feeding was enough to compensate for gross nutritional deficiencies. Not infrequently, the indication for PEG placement is established too late.     

Randomized Prospective Trial of Early Versus Delayed Feeding After Percutaneous Endoscopic Gastrostomy Placement

Objective : By convention, most clinicians delay feeding through the gastrostomy tube until 24 h after placement. However, evidence is lacking to support the rationale for such a delay in PEG use. This randomized, prospective study was designed to assess the safety of early feeding after PEG placement. Methods : One hundred-twelve patients referred for PEG were randomized to begin tube feedings at 4 h (group A) or at 24 h (group B) after placement. All patients received prophylactic antibiotics. Full-strength Isocal was administered with the following schedule: day 1,100 ml every 4 h for six feedings; day 2, 200 ml every 4 h for six feedings. Immediately before each scheduled feeding, gastric residual volume was recorded and the next feeding was withheld if the residual volume was > 50 percent (gastric retention). Patients were evaluated on day 1, day 2, day 7, and day 30 for major and minor complications. Results : The two groups were similar with regard to age, gender, baseline nutritional status, and indications for PEG placement. On the first day of feeding, 14 of 57 patients (25%) in group A, but only five of 55 patients (9%) in group B, had evidence of gastric retention,   p × 0.029  . The proportion of patients with high gastric residual volumes was not significantly different on day two. In group B, one death occurred because of aspiration of gastric contents on day 2. All other complications were minor and did not differ significantly between the two groups. Conclusions : Early initiation of PEG feedings is safe, well tolerated, and reduces cost by decreasing hospital stay.     

Percutaneous Endoscopic Gastrostomy Prevents Gastroesophageal Reflux in Patients with Nasogastric Tube Feeding: A Prospective Study with 24-Hour pH Monitoring

Background/Aims

Percutaneous endoscopic gastrostomy (PEG) has been widely used for patients with swallowing dysfunction. However, its beneficial effects in the treatment of gastroesophageal reflux (GER) are controversial. The aim of this study was to evaluate the effect of PEG on the prevention of GER in patients with nasogastric tube (NGT) feeding.

Methods

Continuous 24-hour pH monitoring was performed prospectively in 21 patients receiving NGT feeding before and 7.3±2.2 days after PEG placement to compare the severity of GER.

Results

We studied 21 patients with a mean age of 59.8±14.1 years. The mean duration of NGT placement was 5.8±5.4 months. The causes of swallowing dysfunction included cerebral infarction, cerebral hemorrhage and other central nervous system (CNS) lesions. When all of the patients were considered, there were no significant differences in reflux parameters after PEG placement compared to before PEG placement. However, all seven patients who had preexisting GER showed significant improvement (p<0.05) of the reflux parameters, including the frequency of acid reflux, duration of acid reflux, total time with a pH below 4.0 and the fraction of time with a pH below 4.0, after PEG placement.

Conclusions

PEG might prevent GER in patients receiving NGT feeding, especially in those patients with GER.     

Placement of Gastrostomy Tubes in Patients with Ventriculoperitoneal Shunts Does Not Result in Increased Incidence of Shunt Infection or Decreased Survival

The objective of this study was to examine if G-tube (G-tube) placement in patients with ventriculoperitoneal (VP) shunts results in shunt infection or impacts patient survival. We performed a retrospective cohort study. Patients underwent VP shunt and G-tube placement. Incidence of shunt infection and patient survival were calculated. Fifty-five patients qualified for the study. Shunt infection occurred in seven patients (12.5%). The incidence of shunt infection did not differ between surgically placed G-tubes (2/7=29%) and PEG tubes (5/7=71%; P=0.69). There was no difference in the risk of VP infection based on the order of placement (OR=0.61 [0.12–3.02]; P=0.69). No predictors for shunt infection were identified. Kaplan-Meier mortality estimates demonstrated a 21% 1-year mortality rate. There were no predictors of patient survival. We conclude that placement of G-tubes in patients with shunts is safe. The order of placement of G-tube and VP shunt does not affect the incidence of shunt infection or survival.     

Gastric Emptying and Gastroesophageal Reflux in Patients Fed via Percutaneous Endoscopic Gastrostomy: Effects of Erythromycin

Abstract: Percutaneous endoscopic gastrostomy (PEG) has been suggested to affect gastric emptying. The aims of this prospective study were to examine the effects of erythromycin, known to act as a motilin agonist, on gastroesophageal motility in nine patients fed via PEG tubes and nine fed via nasogastric tubes. The gastric emptying time and gastroesophageal reflux index were simultaneously measured in each patient after the intravenous administration of erythromycin (200 mg) or a placebo on different days, using a radioisotopic method. The alteration of gastric emptying time produced by intravenous erythromycin in the PEG group was smaller than that in the nasogastric group (p<0.05). However, gastroesophageal reflux indices in the two groups were similar. We conclude that PEG may impair gastric emptying subclinically without affecting gastroesophageal reflux.     

The Effect of Early Time-Restricted Feeding on Glycemic Profile in Adults: A Systematic Review of Interventional Studies

BACKGROUNDEarly time-restricted feeding (eTRF) is a new dietary strategy, involving extended fasting (>14h) from midafternoon onwards with or without calorie restriction. Most of the published studies indicate controversial effects on several glycemic markers.AIMTo evaluate the effect of non-calorie restricted eTRF on the glycemic profile of adults.METHODthis systematic review was designed according to PRISMA guidelines. Pubmed/ Medline, the Cochrane library and EBSCO electronic databases were systematically searched for eligible clinical trials. Studies with eTRF or with daily fasting regimens that presented all the characteristics of eTRF were selected and compared with regular diet schedules or delayed time-restricted feeding. Blood glucose and insulin markers were extracted from each study as the main outcome measures.RESULTSFive articles including 67 adult subjects in total were selected. The period of intervention varied between 3 days to 5 weeks. Three of the included studies were diet- controlled for weight maintenance, whereas the other two studies allowed for free living. Quality assessment identified two studies of low and three studies of high risk of bias. two studies showed clear positive effects of eTRF on both glucose and insulin markers, including fasting glucose levels, muscle glucose intake, glucose iAUC responses insulin levels, and insulin resistance (p<0.05). Two other studies showed beneficial effects on glucose markers only (fasting glucose, 24h mean glucose levels, and iAUC responses, p<0.05) and the fifth study showed positive effects on insulin markers only (insulin resistance, p<0.05).CONCLUSIONSeTRF seems to have positive effects on the glycemic profile mainly in healthy individuals with normal BMI. However, other factors should also be taken into account to address overweight, obese, and prediabetic individuals. Further research is required to clarify better the effectiveness of eTRF among individuals with different characteristics.     

A Retrospective Survey of Tube-Related Complications in Patients Receiving Long-Term Home Enteral Nutrition

Percutaneous gastrostomy tubes are associated with low insertional morbidity. The purpose of this study was to determine the long-term complications of enteral feeding tubes and the effect of these complications on patients, their caregivers and health care utilization. In the province of Manitoba, a regional program supervises all individuals on home enteral nutrition. A retrospective survey was administered to individuals agreeing to participate in the study. This retrospective survey included 30 questions relating to the frequency and severity of tube-related problems, utilization of health care resources due to tube-related problems, and effects of tube feeding on the quality of life of patients and their caregivers. The survey was completed by 55/211 patients in the home enteral nutrition program. Adult and pediatric patients were included and the mean duration of time on home enteral nutrition was 25.9 months. Common complications (percentage of patients experiencing complication) included granulation tissue formation (67%), broken or leaking tube (56%) leakage around the tube site (60%) and stomal infection requiring antibiotics (45%). Health care utilization (% of individuals) related to gastrostomy tubes included phone contact (69%), clinic visit (45%) ER visit (35%), and hospital admission (11%). This survey reveals that tube-related complications are common in patients receiving long-term home enteral nutrition. While these complications are not life threatening, they are associated with increased health care utilization. Prospective studies are needed to confirm these findings and assess the effect of these complications on health care utilization and quality of life of the patient and the primary caregiver.     

Ten-Year Follow-Up of Early Intensive Self-Management Guidance in Newly Diagnosed Patients with Asthma

Objective. We assessed the 10-year effectiveness of self-management guidance in a prospective follow-up study of patients with asthma when inhaled corticosteroids were used from the beginning in the treatment. Methods. Consecutive newly diagnosed asthmatics (n = 162) were randomized: 80 to an intervention group (IG) and 82 to a control group (CG). Lung function (LF), airway hyperresponsiveness (AHR), and health-related quality of life (HRQoL) were examined at 10 years. Results. The advantages of intensive education with regards to LF measured by forced expiratory volume in 1 second and forced vital capacity were seen only after the first year. Later, there were no statistically significant differences in any parameters between the groups. However, during 10-year follow-up, peak expiratory flow, AHR, and HRQoL improved significantly in both groups (no differences as regards gender, smoking, or atopy). At 10 years, 68% of the IG and 75% of the CG patients still showed AHR after histamine challenge. Generic HRQoL scores in both groups equaled that of the age-standardized group a general population but only 50% in the IG and 55% in the CG had normal disease-specific HRQoL scores. According to Global Initiative for Asthma (GINA) criteria 23% of patients in the IG and 25% in the CG had asthma under control. Conclusions. The effectiveness of intensive self-management education could be shown only in the short term. The groups did not differ significantly in any of the parameters investigated, and showed nearly normal LF and HRQoL. AHR improved only partly and only a minority of the patients had asthma under good control according to GINA criteria. This study showed that evaluation of asthma using LF alone does not show the whole truth about asthma treatment results. HRQoL should be used in conjunction with GINA criteria, to assess asthma treatment outcomes. The value and importance of AHR for the evaluation of treatment remains obscure.     

A Pilot Study Exploring the Factors that Influence the Decision to have PEG Feeding in Patients with Progressive Conditions

This original pilot study was conducted to explore and understand the factors that influence a patient’s decision-making when considering percutaneous endoscopic gastrostomy placement for nonoral nutrition and hydration supplementation. Seven patients living with progressive dysphagic symptoms who had made a decision about percutaneous endoscopic gastrostomy placement were interviewed and their responses analyzed using the constant comparison method. All participants felt they had no option other than to accept the percutaneous endoscopic gastrostomy. The impact of visible physical deterioration and medical opinion were the most powerful influences on patients’ decisions. Patients’ perception of their involvement in the decision varied. This was linked to the amount and timing of information supplied and support they felt they received. Few patients have prior knowledge of tube feeding and rely heavily on medical advice. Effective communication by healthcare professionals can promote an environment that is supportive of patients’ involvement in decisions. Adequate preparation time is vital if patients are to stop feeling uninvolved or peripheral to the decision-making process. Multidisciplinary teams need to address their working practices so that they do not intimidate patients, but rather empower patients in their decision-making.

Prospective Randomized Trial of External Versus Internal Transcatheter Cardioversion in Patients with Chronic Atrial Fibrillation

To evaluate the safety and long-term efficacy of internal transcatheter cardioversion, forty patients with chronic, lone atrial fibrillation were studied. The patients were randomised to internal transcatheter cardioversion or to conventional external cardioversion. In cases where the procedure was unsuccessful, cross-over to the alternate method was performed. Oral anticoagulation therapy was started three weeks prior to the procedure and was maintained for another three weeks following successful cardioversion.Sinus rhythm was restored in 16/18 patients (88%) in the internal cardioversion group, versus 9/22 patients (40%) in the external cardioversion group (p < 0.01). In addition, 8/13 (61%) patients who were crossed-over to internal cardioversion were successfully cardioverted to sinus rhythm. In contrast, both patients who were crossed-over to external cardioversion remained in atrial fibrillation.During a mean follow-up period of 23 months, 13 (39.3%) patients maintained sinus rhythm. Using the intention to treat principle, the recurrence rate was not statistically different between the two methods.It is concluded that internal cardioversion is more effective in acutely restoring sinus rhythm compared to external cardioversion. However, both methods have similar long-term recurrence rates.     

High Dose and Short-Term Streptokinase Infusion in Patients with Pulmonary Embolism: Prospective with Seven-Year Follow-Up Trial

Background: High dose and short-term streptokinase infusion has proved to improve survival among few patients with pulmonary embolism and cardiogenic shock, without increasing hemorrhagic complications. However its efficacy and safety in terms of long follow-up and in major number of patients requires to be established. Methods: Patients with pulmonary embolism proved through high probability V/Q lung scan, suggestive echocardiogram, or deep venous thrombosis were enrolled. All were assigned to receive 1,500,000 IU in one-hour streptokinase infusion. The primary end point was efficacy and safety of streptokinase regimen in terms of pulmonary arterial hypertension, right ventricular dysfunction, perfusion abnormalities, recurrence, mortality and hemorrhagic complications. In long-term follow-up, we assessed functional class, recurrence, chronic pulmonary arterial hypertension, postthrombotic-syndrome and mortality. Results: A total of 40 consecutive patients (47.3±15.3 years of age) with large or massive pulmonary embolism were enrolled. In 35 patients high dose and short-term streptokinase regimen reversed acute pulmonary arterial hypertension, clinical and echocardiographic evidence of right ventricular dysfunction and improved pulmonary perfusion without increasing hemorrhagic complications. In acute phase 5 patients died, necropsy study performed in 4 patients showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. Risk factors for mortality and recurrence were: right ventricular global hypokinesis (p<0.0001), 6 hours or over between onset symptoms and streptokinase regimen (p=0.02), severe systolic pulmonary arterial hypertension (p=0.001) right ventricular hypokinesis (p=0.001), hypoxemia (p=0.02) and right ventricular acute myocardial infarction (p<0.0001). Right ventricular hypokinesis (p=0.02) was the only independent risk factor for recurrence. In a seven-year follow-up of the original 35 patients who survived in acute phase, 2 patients were lost and 33 are alive, in functional class I, without recurrence or chronic pulmonary arterial hypertension. Conclusions: Our report indicates that among properly selected high-risk PE patients, short-term streptokinase infusion is effective and safe.     

Gastric Acid Response to Sham Feeding and Pentagastrin before and after Parietal Cell Vagotomy in Patients with Duodenal Ulcer

The influence of sham feeding (PAO_Sh) preceding pentagastrin-stimulated gastric acid secretion (PAO_Pg) was investigated in 28 patients with duodenal ulcer (DU) before vagotomy and in 36 after parietal cell vagotomy (PCV). Sham feeding had little influence on PAO_Pg and it is concluded that the two secretion tests may be combined. The ratio PAO_Sh/PAO_Pg was significantly reduced by PCV. Fourty-four patients with DU were studied for 1 year after PCV. and their PAO_Pg was measured preoperatively and their PAO_Pg and PAO_Sh postoperatively. Seven of the 44 patients had recurrent ulcer within 1 year. PAO_Pg had no predictive value pre- and postoperatively, but postoperative PAO_Sh and PAO_Sh/PAO_Pg were both significantly higher in patients with recurrent ulcer. It is concluded that PAO_Sh and PAO_Sh/PAO_Pg after PCV may assess completeness of vagotomy, but the relationship between PAO_Sh and risk of recurrent ulcer may be stronger than that between PAO_Sh/PAO_Pg and recurrence.     

Health-Related Quality of Life in Patients with Crohn's Disease (Influence of Surgical Operation-A Prospective Trial)

Improvement of health-related quality of life(HRQOL) is a major determinant in decisionmaking forsurgery in patients with Crohn's disease (CD). Thisstudy was designed to investigate the short- andlong-term effect of surgical resection for CD on HRQOL.Sixteen patients were investigated within one weekbefore surgery and 3, 6, and 24 months postoperatively.Besides the Crohn's disease activity index (CDAI), four instruments: the time trade-off technique(TTO), the direct questioning of objectives (DQO), therating form of inflammatory bowel disease patientsconcerns (RFIPC), and the Beck depression inventory-were used for assessment of HRQOL. CDAI decreasedsignificantly after operation and 10 patients remainedin remission for 24 months. Two patients hadpostoperative relapses and went into remission afterprednisolone treatment. Four patients developed chronicactive disease. HRQOL was significantly improved in allpatients three and six months postoperatively. Exceptfor the four patients with chronic active disease, all other patients (N = 12) had alsosignificantly improved HRQOL after 24 months. Inconclusion, surgical resections in CD lead to along-term improvement of HRQOL with the exception ofpatients with chronic active disease. This finding might be taken inconsideration for the indication of surgery inCD.     

Predictors of Insulin Initiation in Patients with Type 2 Diabetes: An Analysis of the Look AHEAD Randomized Trial

Background

The decision to initiate insulin in patients with type 2 diabetes is a challenging escalation of care that requires an individualized approach. However, the sociodemographic and clinical factors affecting insulin initiation are not well understood.

Objective

We sought to identify patient factors that were independent predictors of insulin initiation among participants in the Look AHEAD (Action for Health in Diabetes) clinical trial.

Design

Retrospective analysis of a randomized clinical trial.

Participants

Beginning in 2001, Look AHEAD enrolled ambulatory U.S. adults with type 2 diabetes who were overweight or obese and had a primary healthcare provider. Participants were randomized (1:1) to an intensive lifestyle intervention, or diabetes support and education. This study examined 3913 participants across the two trial arms who were not using insulin at baseline.

Main Measures

We used Cox proportional hazards models to estimate the association between participant characteristics and time to insulin initiation. We performed time-varying adjustment for HbA1c measured eight times over the 10-year study period, as well as for multiple clinical and socioeconomic factors.

Key Results

A total of 1087 participants (27.8%) initiated insulin during a median follow-up of 8.0 years. Age was inversely associated with insulin initiation (adjusted hazard ratio [aHR] 0.88 per 10 years, P?=?0.025). The risk of insulin initiation was greater with a higher number of diabetes complications (P?<?0.001 for trend); chronic kidney disease and cardiovascular disease were independently associated with insulin initiation. There was a lower risk of insulin initiation in black (aHR 0.77, P?=?0.008) and Hispanic participants (aHR 0.66, P?<?0.001) relative to white participants. Socioeconomic factors were not associated with insulin initiation.

Conclusions

Patient age, race/ethnicity, and diabetes complications may influence insulin initiation in type 2 diabetes, independent of glycemic control. Future work is needed to understand the drivers of racial differences in antihyperglycemic treatment, and to identify patients who benefit most from insulin.