RESUMEN
BACKGROUND: When commencing enteral feeding, patients and families will want to know the likelihood of returning to an oral diet. There is a paucity of data on the prognosis of patients with gastrostomies. We describe a large dataset of patients, which identifies factors influencing gastrostomy removal and assesses the likelihood of the patient having at home enteral nutrition. METHODS: Retrospective data was collected on patients from Sheffield Teaching Hospitals who had received a gastrostomy and had outpatient enteral feeding between January 2016 and December 2019. Demographic data, indication and outcomes were analysed. RESULTS: A total of 451 patients were assessed, median age: 67.7. 183/451(40.6%) gastrostomies were for head and neck cancer, 88/451 (19.5%) for stroke, 28/451 (6.2%) for Motor Neuron Disease, 32/451 (7.1%) for other neurodegenerative causes, 120/451 (26.6%) other. Of the 31.2% who had their gastrostomy removed within 3 years, head and neck cancer was the most common indication (58.3%) followed by stroke (10.2%), Motor Neuron Disease (7.1%) and other neurodegenerative diseases (3.1%). Gastrostomy removal was significantly influenced by age, place of residence, and having head and neck cancer (p < 0.05). There was the greatest likelihood of removal within the first year (24%). 70.5% had enteral feeding at home. CONCLUSION: This large cohort study demonstrates 31.2% of patients had their gastrostomy removed within 3 years. Head and neck cancer patients, younger age and residing at home can help positively predict removal. Most patients manage their feeding at home rather than a nursing home. This study provides new information on gastrostomy outcomes when counselling patients to provide realistic expectations.
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Remoción de Dispositivos , Nutrición Enteral , Gastrostomía , Humanos , Gastrostomía/estadística & datos numéricos , Masculino , Femenino , Estudios Retrospectivos , Anciano , Nutrición Enteral/estadística & datos numéricos , Persona de Mediana Edad , Remoción de Dispositivos/estadística & datos numéricos , Anciano de 80 o más Años , Neoplasias de Cabeza y Cuello/cirugía , Neoplasias de Cabeza y Cuello/terapia , Accidente Cerebrovascular , Enfermedad de la Neurona Motora/terapia , Adulto , Enfermedades Neurodegenerativas/terapiaRESUMEN
BACKGROUND: Gastrostomy insertion is one of the most frequently performed procedures by specialist paediatric surgeons. We aimed to determine practice across the United Kingdom (UK) and in particular to identify areas where there was consistency or variation in practice between practitioners and centres. METHODS: A structured survey was distributed to all consultant practitioners who insert gastrostomies in the UK. Practice surrounding a range of aspects of gastrostomy care including insertion technique, device use, post-operative management and subsequent care were determined. RESULTS: Of total 135 practitioners who insert gastrostomies, responses were received from 103 (76%) with responses received from all UK centres. There was variation between centres in the provision of pre-operative information, and between practitioners in preferred device, insertion techniques, post-operative feeding practice and change/removal procedures. The most frequently preferred device for primary gastrostomy insertion was a Freka® PEG (36%) button device (30%), CorFlo™ PEG (21%), or G-tube (10%). Laparoscopy was always used when inserting either PEG or button device by over 50% of respondents and selectively used by the majority of the remainder. Feeds were started between 1 and 24 h post-insertion, most practitioners (64%) plan a minimum one night hospital stay but a third plan for more than one night. CONCLUSION: There is considerable variation in practice for most stages of the pathway for children having a gastrostomy. Further work is warranted to understand the relationship between different practices and patient outcomes, resource use and cost and subsequently to develop best practice guidelines.
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Gastrostomía , Encuestas de Atención de la Salud , Pautas de la Práctica en Medicina , Gastrostomía/estadística & datos numéricos , Gastrostomía/métodos , Humanos , Reino Unido , Pautas de la Práctica en Medicina/estadística & datos numéricos , Niño , Nutrición Enteral/estadística & datos numéricos , Laparoscopía/estadística & datos numéricos , Laparoscopía/métodos , Pediatría/estadística & datos numéricos , Cuidados Posoperatorios/estadística & datos numéricos , Cuidados Posoperatorios/métodosRESUMEN
INTRODUCTION: Patients admitted with principal cardiac diagnosis (PCD) can encounter difficult inpatient stays that are often marked by malnutrition. In this setting, enteral feeding may improve nutritional status. This study examined the association of PCD with perioperative outcomes after elective enteral access procedures. METHODS: Adult patients who underwent enteral access procedures between 2018 and 2020 at a tertiary care institution were reviewed retrospectively. Differences in baseline characteristics between patients with and without PCD were adjusted using entropy balancing. Multivariable logistic and linear regressions were subsequently developed to evaluate the association between PCD and nutritional outcomes, perioperative morbidity and mortality, length of stay, and nonelective readmission after enteral access. RESULTS: 912 patients with enteral access met inclusion criteria, of whom 84 (9.2%) had a diagnosis code indicating PCD. Compared to non-PCD, patients with PCD more commonly received percutaneous endoscopic gastrostomy by general surgery and had a higher burden of comorbidities as measured by the Charlson comorbidity index. Multivariable risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups (standardized differences ranged from -2.45 × 10-8 to 3.18 × 108). After adjustment, despite no significant association with in-hospital mortality, percentage change prealbumin, length of stay, or readmission, PCD was associated with an approximately 2.25-day reduction in time to meet goal feeds (95% CI -3.76 to -0.74, P = 0.004) as well as decreased odds of reoperation (adjusted odds ratio 0.28, 95% CI 0.09-0.86, P = 0.026) and acute kidney injury (adjusted odds ratio 0.24, 95% CI 0.06-0.91, P = 0.035). CONCLUSIONS: Despite having more comorbidities than non-PCD, adult enteral access patients with PCD experienced favorable nutritional and perioperative outcomes.
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Nutrición Enteral , Cardiopatías , Humanos , Estudios Retrospectivos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Nutrición Enteral/estadística & datos numéricos , Cardiopatías/mortalidad , Cardiopatías/terapia , Tiempo de Internación/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Mortalidad Hospitalaria , Estado Nutricional , Anciano de 80 o más Años , Gastrostomía/estadística & datos numéricos , Desnutrición/diagnóstico , Desnutrición/terapia , Desnutrición/epidemiología , Desnutrición/etiología , Hospitalización/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
Resumo Objetivo identificar o perfil de crianças e adolescentes dependentes de tecnologia de um hospital de referência pediátrica do sul do país. Método estudo descritivo, com abordagem quantitativa. A coleta de dados ocorreu por meio da análise de prontuários, entre janeiro de 2016 e dezembro de 2019, armazenados em planilha Microsoft Excel para a análise estatística descritiva. Um projeto aprovado pelo Comitê de Ética sob o parecer 5.115.194. Resultados prevaleceu o sexo masculino (50,8%), em idade pré-escolar (30,8%), proveniente da Grande Florianópolis (60,1%). Os diagnósticos mais frequentes foram relacionados à prematuridade/período neonatal, anomalias congênitas/defeitos genéticos, doenças neurológicas e/ou neuromusculares, correspondendo a 37%, 33,2% e 18,5%. Os dispositivos tecnológicos mais utilizados foram gastrostomia (56,3%) e traqueostomia (36,6%). A utilização de medicamentos contínuos se deu em 93,4% e 49,2% utilizavam quatro ou mais medicamentos. As mães foram as principais cuidadoras (80,9%). Ocorreram 31 óbitos no período. Conclusão e implicação para a prática este grupo apresenta grande demanda de cuidados decorrentes do diagnóstico principal, dos dispositivos tecnológicos, das medicações e das possíveis complicações. A identificação do perfil das crianças e adolescentes dependentes de tecnologia contribuiu para ampliar a visibilidade de uma população que está em constante crescimento e, assim, prestar uma assistência integral, de acordo com suas especificidades e reais necessidades.
Resumen Objetivo identificar el perfil de niños y adolescentes dependientes de tecnología atendidos en un hospital de referência pediátrica del sur del país. Método estudio descriptivo con enfoque cuantitativo. La recolección de datos ocurrió através del análisis de las historias clínicas, desde enero de 2016 hasta diciembre de 2019, almacenadas en una hoja de cálculo de Microsoft Excel para el análisis estadístico descriptivo. El proyecto fue aprobado por el Comité de Ética bajo el parecer 5.115.194. Resultados predominaron varones (50,8%), en período de desarrollo preescolar (30,8%), la región más frecuentada de la Gran Florianópolis (60,1%). Los diagnósticos más frecuentes estuvieron relacionados con prematuridad/el período neonatal, anomalías congénitas/defectos genéticos, enfermedades neurológicas y/o neuromusculares, correspondiendo al 37%, 33,2% y 18,5%, respectivamente. Los dispositivos tecnológicos más utilizados fueron la gastrostomía (56,3%) y la traqueotomía (36,6%). El uso de medicación continua ocurrió en el 93,4% y el 49,2% utilizó cuatro o más medicamentos. Las madres fueron las principales cuidadoras en 80,9% de los casos, ocurriendo 31 óbitos en el período. Conclusión e implicación para la práctica este grupo tiene una alta demanda de atención debido al diagnóstico principal, dispositivos tecnológicos, medicamentos y posibles complicaciones. Identificar el perfil de niños y adolescentes dependientes de tecnología contribuye a aumentar la visibilidad de una población en constante crecimiento y, por lo tanto, calificar la asistencia, de acuerdo com sus especificidades y reales necesidades.
Abstract Objective to identify the profile of technology-dependent children and adolescents at a pediatric referral hospital in southern Brazil. Method a descriptive study with a quantitative approach. Data was collected by analyzing medical records between January 2016 and December 2019 and stored in a Microsoft Excel spreadsheet for descriptive statistical analysis. The project was approved by the Ethics Committee under protocol number 5.115.194. Results: The prevalence was male (50.8%), pre-school age (30.8%), from Greater Florianópolis (60.1%). The most frequent diagnoses were related to prematurity/neonatal period, congenital anomalies/genetic defects, and neurological and/or neuromuscular diseases, corresponding to 37%, 33.2%, and 18.5%. The most commonly used technological devices were gastrostomy (56.3%) and tracheostomy (36.6%). 93.4% used continuous medication and 49.2% used four or more medications. Mothers were the main caregivers (80.9%). There were 31 deaths during the period. Conclusion and implications for practice this group has a high demand for care due to the main diagnosis, technological devices, medications, and possible complications. Identifying the profile of technology-dependent children and adolescents has helped to increase the visibility of a population that is constantly growing and thus provides comprehensive care according to their specific needs.
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Humanos , Masculino , Femenino , Lactante , Preescolar , Niño , Adolescente , Adulto Joven , Salud Infantil/estadística & datos numéricos , Traqueostomía/estadística & datos numéricos , Gastrostomía/estadística & datos numéricos , Registros Electrónicos de SaludRESUMEN
INTRODUCTION: Many patients with advanced dementia and Parkinson's disease and related disorders (PDRD) are receiving gastrostomy tube (GT) placement annually, despite its lack of proven benefit for preventing aspiration, enhancing nutrition, or prolonging survival. Given clinical practice variability in the care of people with neurodegenerative disorders, we sought to examine racial and geographic disparities in GT placement for these populations in the United States. METHOD: Data were extracted from a publicly-available national database using diagnostic and procedural codes from 2006 to 2010. GT placement rates and odds ratios were calculated for two groups: PDRD and non-parkinsonian dementia (NPD). RESULTS: In the PDRD group, odds of GT placement were higher among patients coded as Black (OR 1.69, CI 0.80-3.56, p = 0.17) and Asian (OR 2.17, CI 0.70-6.78, p = 0.18) than Whites; although these tendencies did not reach statistical significance. In the NPD group, GT placement among Black patients was significantly more likely (OR 2.88, CI 1.90-4.36, p < 0.001) than their white counterparts, while Asian patients were significantly less likely (OR 0.12, CI 0.02-0.91, p = 0.04). Compared to the Northeast region, there were significantly lower odds of GT placement in the Midwest region (OR 0.37, CI 0.24-0.58, p < 0.001) in the NPD group only. No difference in odds was observed between the sexes in both groups. CONCLUSION: This study showed geographic and racial disparities in GT placement among PDRD and NPD patients. Further studies should aim to clarify best practices for GT placement in PDRD and causes of practice differences within and between PDRD and NPD groups.
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Demencia/terapia , Nutrición Enteral/estadística & datos numéricos , Gastrostomía/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Trastornos Parkinsonianos/terapia , Grupos Raciales/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Demencia/etnología , Femenino , Geografía , Humanos , Masculino , Oportunidad Relativa , Trastornos Parkinsonianos/etnología , Estados UnidosRESUMEN
BACKGROUND: Nutritional complications in patients with locally advanced head and neck cancer (LA-HNC) treated by concurrent chemoradiotherapy (CCRT) often lead to placement of a prophylactic gastrostomy (PG) tube, while indication lacks harmonization. Our aim was to explore the current PG tube utilization among Belgian radiation oncology centers. METHODS: A survey was distributed to all 24 Belgian Radiation oncology departments, with questions about the number of patient treated per year, whether the PG indication is discussed at the multidisciplinary board, placement technique, time of starting nutrition and removal, its impact on swallowing function and importance of clinical factors. For the latter Relative Importance and Discordance Indexes were calculated to describe the ranking and agreement. RESULTS: All 24 centers submitted the questionnaire. Twenty three treat more than 20 head and neck (HNC) patients per year, while four (1 in 21-50; 3 in 51-100) are not discussing the gastrostomy tube indication at the multidisciplinary board. For the latter, endoscopic placement (68%) is the dominant technique, followed by the radiologic (16%) and laparoscopic (16%) methods. Seventy-five percent start the enteral nutrition when clinically indicated, 17% immediately and 8% from the start of radiotherapy. Majority of specialists (19/24) keep the gastrostomy tube until the patient assume an adequate oral feeding. Fifteen centres are considering PG decrease swallowing function. Regarding factors and their importance in the decision for the PG, foreseen irradiated volume reached highest importance, followed by 'anatomical site', 'patients' choice' and 'postoperative versus definitive' and 'local expertise', with decreasing importance respectively. Disagreement indexes showed moderate variation. CONCLUSIONS: The use of a PG tube for LAHNC patients treated by CCRT shows disparity at national level. Prospective studies are needed to ensure proper indication of this supportive measure.
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Quimioradioterapia/efectos adversos , Gastrostomía/estadística & datos numéricos , Neoplasias de Cabeza y Cuello/terapia , Trastornos Nutricionales/terapia , Procedimientos Quirúrgicos Profilácticos/estadística & datos numéricos , Traumatismos por Radiación/terapia , Nutrición Enteral/instrumentación , Nutrición Enteral/métodos , Nutrición Enteral/estadística & datos numéricos , Neoplasias de Cabeza y Cuello/diagnóstico , Neoplasias de Cabeza y Cuello/patología , Humanos , Estadificación de Neoplasias , Trastornos Nutricionales/epidemiología , Trastornos Nutricionales/etiología , Estado Nutricional , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estudios Prospectivos , Traumatismos por Radiación/epidemiología , Traumatismos por Radiación/etiología , Oncólogos de Radiación/estadística & datos numéricosRESUMEN
OBJECTIVE: Dysphagia is a common symptom with associated complications ranging from mild discomfort to life-threatening pulmonary compromise. Videofluoroscopic swallow is the 'gold standard' evaluation for oropharyngeal dysphagia, but little is known about how patients' performance changes over time. METHOD: This was a retrospective cohort study evaluating dysphagia patients' clinical course by serial videofluoroscopic swallow study. Univariate analysis followed by multivariate analysis were used to identify correlations between pneumonia outcomes, diet allocation, aetiology and comorbidities. RESULTS: This study identified 104 patients (53 per cent male) stratified into risk groups by penetration-aspiration scale scores. Mean penetration-aspiration scale worsened over time (p < 0.05), but development of pneumonia was not associated with worsened penetration-aspiration scale score over time (p = 0.57) or severity of dysphagia (p = 0.88). CONCLUSION: Our dataset identified a large cohort of patients with oropharyngeal dysphagia and demonstrated mean penetration-aspiration scale tendency to worsen. Identifying prognostic factors associated with worsening radiological findings and applying this to patients at risk of clinical swallowing difficulty is needed.
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Trastornos de Deglución/fisiopatología , Gastrostomía/estadística & datos numéricos , Neumonía por Aspiración/epidemiología , Aspiración Respiratoria/fisiopatología , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Trastornos de Deglución/diagnóstico por imagen , Dietoterapia , Progresión de la Enfermedad , Femenino , Fluoroscopía , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Aspiración Respiratoria/diagnóstico por imagen , Estudios RetrospectivosRESUMEN
OBJECTIVES/HYPOTHESIS: Evaluate swallowing and airway outcomes following laryngotracheoplasty with posterior grafting (LTP PCCG). METHODS: Retrospective review of pediatric patients undergoing LTP PCCG from 2016 to 2019 at a tertiary care pediatric hospital. We included demographics, indications, approach, and revision status. We evaluated preoperative and postoperative instrumental and functional swallow evaluations, and we also gathered information on airway outcomes. RESULTS: Thirty-one patients were included in the study. Median (interquartile range [IQR]) age was 4.0 (2.0, 7.0) years old. Primary indication for surgery was bilateral vocal cord immobility (BVCI) in 11 (35.5%) and posterior glottic stenosis (PGS) in 20 (64.5%). Mean (standard deviation) length of follow-up was 11.0 (8.3) months. Twelve patients had gastrostomy tubes (GT) before surgery, and no patients required placement of GT after surgery. Of the remaining 19 patients, 6 required nasogastric feeding for >4 weeks (average length 1.8 months, longest 3.5 months). At last follow-up, 25 (80.6%) patients were primarily orally fed. Eighteen patients had tracheotomies prior to surgery. No patients without a tracheostomy required placement of tracheostomy before or after surgery and only 1 patient had a tracheostomy at last follow-up. Average time to decannulation was 3.7 months, with surgery-specific success of 87.1% and overall success of 96.8%. Four (12.9%) patients required a major intervention to achieve decannulation. CONCLUSION: LTP PCCG is an effective surgical technique to address PGS and BVCI with high decannulation rates. It may cause temporary swallowing dysfunction, but in this series a majority of children were orally fed at last follow-up. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2798-2804, 2021.
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Trastornos de Deglución/cirugía , Laringoplastia/efectos adversos , Laringoestenosis/cirugía , Tráquea/cirugía , Parálisis de los Pliegues Vocales/cirugía , Niño , Preescolar , Trastornos de Deglución/etiología , Femenino , Estudios de Seguimiento , Gastrostomía/estadística & datos numéricos , Humanos , Lactante , Laringoplastia/métodos , Laringoestenosis/complicaciones , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Parálisis de los Pliegues Vocales/complicacionesRESUMEN
BACKGROUND: Gastrostomy tube (G-tube) placement for children with neurologic impairment with dysphagia has been suggested for pneumonia prevention. However, prior studies demonstrated an association between G-tube placement and increased risk of pneumonia. We evaluate the association between timing of G-tube placement and death or severe pneumonia in children with neurologic impairment. METHODS: We included all children enrolled in California Children's Services between July 1, 2009, and June 30, 2014, with neurologic impairment and 1 pneumonia hospitalization. Prior to analysis, children with new G-tubes and those without were 1:2 propensity score matched on sociodemographics, medical complexity, and severity of index hospitalization. We used a time-varying Cox proportional hazard model for subsequent death or composite outcome of death or severe pneumonia to compare those with new G-tubes vs those without, adjusting for covariates described above. RESULTS: A total of 2490 children met eligibility criteria, of whom 219 (9%) died and 789 (32%) had severe pneumonia. Compared to children without G-tubes, children with new G-tubes had decreased risk of death (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.39-0.55) but increased risk of the composite outcome (HR 1.21, CI 1.14-1.27). Sensitivity analyses using varied time criteria for definitions of G-tube and outcome found that more recent G-tube placement had greater associated risk reduction for death but increased risk of severe pneumonia. CONCLUSION: Recent G-tube placement is associated with reduced risk of death but increased risk of severe pneumonia. Decisions to place G-tubes for pulmonary indications in children with neurologic impairment should weigh the impact of severe pneumonia on quality of life.
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Gastrostomía/instrumentación , Intubación Gastrointestinal/efectos adversos , Enfermedades del Sistema Nervioso/complicaciones , Enfermedades del Sistema Nervioso/mortalidad , Adolescente , California , Niño , Preescolar , Estudios de Cohortes , Femenino , Gastrostomía/métodos , Gastrostomía/estadística & datos numéricos , Humanos , Lactante , Intubación Gastrointestinal/métodos , Intubación Gastrointestinal/estadística & datos numéricos , Masculino , Morbilidad/tendencias , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Adulto JovenRESUMEN
PURPOSE: In infants and toddlers, gastrostomy tube placement (GT) is typically accompanied by consideration of concomitant Nissen fundoplication (NF). Historically, rates of NF have varied across providers and institutions. This study examines practice variation and longitudinal trends in NF at pediatric tertiary centers. METHODS: Patients ≤ 2 years who underwent GT between 2008 and 2018 were identified in the Pediatric Health Information System database. Patient demographics and rates of NF were examined. Descriptive statistics were used to evaluate the variation in the proportion of GT with NF at each hospital, by volume and over time. RESULTS: 40,348 patients were identified across 40 hospitals. Most patients were male (53.8%), non-Hispanic white (49.5%) and publicly-insured (60.4%). Rates of NF by hospital varied significantly from 4.2 to 75.2% (p < 0.001), though were not associated with geographic region (p = 0.088). Rates of NF decreased from 42.8% in 2008 to 14.2% in 2018, with a mean annual rate of change of - 3.07% (95% CI - 3.53, - 2.61). This trend remained when stratifying hospitals into volume quartiles. CONCLUSION: There is significant practice variation in performing NF. Regardless of volume, the rate of NF is also decreasing. Objective NF outcome measurements are needed to standardize the management of long-term enteral access in this population.
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Fundoplicación , Gastrostomía , Femenino , Fundoplicación/estadística & datos numéricos , Fundoplicación/tendencias , Gastrostomía/estadística & datos numéricos , Gastrostomía/tendencias , Humanos , Lactante , Recién Nacido , Masculino , Estudios RetrospectivosRESUMEN
Background There are limited contemporary data prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI). Methods and Results Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000-2017) were evaluated for in-hospital AIS. Outcomes of interest included in-hospital mortality, hospitalization costs, length of stay, discharge disposition, and use of tracheostomy and percutaneous endoscopic gastrostomy. The discharge destination was used to classify survivors into good and poor outcomes. Of a total 11 622 528 AMI admissions, 183 896 (1.6%) had concomitant AIS. As compared with 2000, in 2017, AIS rates increased slightly among ST-segment-elevation AMI (adjusted odds ratio, 1.10 [95% CI, 1.04-1.15]) and decreased in non-ST-segment-elevation AMI (adjusted odds ratio, 0.47 [95% CI, 0.46-0.49]) admissions (P<0.001). Compared with those without, the AIS cohort was on average older, female, of non-White race, with greater comorbidities, and higher rates of arrhythmias. The AMI-AIS admissions received less frequent coronary angiography (46.9% versus 63.8%) and percutaneous coronary intervention (22.7% versus 41.8%) (P<0.001). The AIS cohort had higher in-hospital mortality (16.4% versus 6.0%; adjusted odds ratio, 1.75 [95% CI, 1.72-1.78]; P<0.001), longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and percutaneous endoscopic gastrostomy, and less frequent discharges to home (all P<0.001). Among AMI-AIS survivors (N=153 318), 57.3% had a poor functional outcome at discharge with relatively stable temporal trends. Conclusions AIS is associated with significantly higher in-hospital mortality and poor functional outcomes in AMI admissions.
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Mortalidad Hospitalaria/tendencias , Hospitalización/estadística & datos numéricos , Accidente Cerebrovascular Isquémico , Infarto del Miocardio , Causalidad , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Estado Funcional , Gastrostomía/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Humanos , Accidente Cerebrovascular Isquémico/etiología , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/terapia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/clasificación , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Evaluación de Procesos y Resultados en Atención de Salud , Prevalencia , Traqueostomía/estadística & datos numéricos , Estados Unidos/epidemiologíaRESUMEN
PURPOSE: The aim of the present study was to compare the difference between double tract reconstruction and esophagogastrostomy. MATERIALS AND METHODS: Patients who underwent radical proximal gastrectomy with esophagogastrostomy or double tract reconstruction were included in this study. RESULTS: Sixty-four patients were included in this study and divided into two groups according to reconstruction method. The two groups were well balanced in perioperative safety and 3-year overall survival (OS). The rates of postoperative reflux esophagitis in the double tract reconstruction group and esophagogastrostomy group were 8.0% and 30.8%, respectively (p=0.032). Patients in the double tract reconstruction group had a better global health status (p < 0.001) and emotional functioning (p < 0.001), and complained less about nausea and vomiting (p < 0.001), pain (p=0.039), insomnia (p=0.003), and appetite loss (p < 0.001) based on the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire. Regarding the EORTC QLQ-STO22 questionnaire, patients in the double tract reconstruction group complained less about dysphagia (p=0.030), pain (p=0.008), reflux (p < 0.001), eating (p < 0.001), anxiety (p < 0.001), dry mouth (p=0.007), and taste (p=0.001). The multiple linear regression analysis showed that reconstruction method, postoperative complications, reflux esophagitis, and operation duration had a linear relationship with the global health status score. CONCLUSION: Double tract reconstruction could better prevent reflux esophagitis and improve quality of life without scarifying perioperative safety or 3-year OS.
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Adenocarcinoma/cirugía , Esofagitis Péptica/epidemiología , Gastrectomía/efectos adversos , Procedimientos de Cirugía Plástica/métodos , Complicaciones Posoperatorias/epidemiología , Neoplasias Gástricas/cirugía , Adenocarcinoma/patología , Anciano , Esofagitis Péptica/etiología , Esofagitis Péptica/prevención & control , Unión Esofagogástrica/patología , Unión Esofagogástrica/cirugía , Esofagostomía/métodos , Esofagostomía/estadística & datos numéricos , Femenino , Gastrostomía/métodos , Gastrostomía/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Calidad de Vida , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Estudios Retrospectivos , Neoplasias Gástricas/patología , Resultado del TratamientoRESUMEN
OBJECTIVE: The aim of this study is to evaluate the feasibility, safety, and efficacy of discharge with supplemental nasogastric tube (NGT) feeds in medically complex infants. STUDY DESIGN: Cohort study of 400 infants enrolled in the Transitional Medical Home (TMH) program at Duke University Level IV neonatal intensive care unit from January 2013 to 2017. RESULTS: Among 400 infants enrolled in the TMH, 57 infants were discharged with an NGT. A total of 45 infants with a variety of diagnoses and comorbidities were included in final analysis. Among 45 infants, 5 obtained a gastrostomy tube (GT) postdischarge. Median (25-75th percentile) length of use of NGT in 40 infants was 12 days (4-37). Excluding four outliers who used NGT for ≥140 days, the median length of use was 8 days (3-24). This extrapolates to a median of 288 hospital days saved for the remaining 36 infants. There were only three emergency room visits related to parental concern for incorrect NGT placement. There was no statistically significant difference in percent oral feeding predischarge or growth in first month postdischarge between infants who orally fed versus those who obtained GTs. CONCLUSION: Discharge with supplemental NGT feeds is safe and feasible utilizing a standardized protocol and close postdischarge follow-up. This practice can decrease length of stay and prevent need for GT. KEY POINTS: · Discharge with nasogastric tube (NGT) supplementation is safe.. · Discharge with NGT supplementation decreases cost.. · Discharge with NGT can decrease neonatal intensive care unit length of stay.. · Medical home model facilitates safe discharge..
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Cuidados Posteriores/normas , Intubación Gastrointestinal/métodos , Padres/psicología , Alta del Paciente/estadística & datos numéricos , Femenino , Gastrostomía/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Unidades de Cuidado Intensivo Neonatal/organización & administración , Intubación Gastrointestinal/efectos adversos , Tiempo de Internación/estadística & datos numéricos , Masculino , Estudios RetrospectivosRESUMEN
BACKGROUND: Long-term functional outcomes are poorly characterized for salvage laryngectomy. We identified predictors of esophageal stricture and swallowing function after salvage laryngectomy in a large cohort. METHODS: A retrospective study of 233 patients who underwent salvage total laryngectomy for recurrent/persistent squamous cell carcinoma of the larynx or hypopharynx after radiation (XRT) or chemoradiation (CRT) was performed. Primary outcomes were esophageal dilation within 1 year, time to dilation, and gastrostomy tube dependence. Multivariate logistic and Cox regressions were used for statistical analysis. RESULTS: Dilation was performed in 29.9% of patients. Dilation was twice as likely in patients with post-operative fistula compared to those without (Hazard Ratio (HR) 2.10, 95% Confidence Interval (CI) 1.06-4.13, P = .03). Every year between XRT/CRT and salvage was associated with 10% increase in dilation (HR 1.09, 95% CI 1.03-1.17, P = .01). No factors were associated with dilation by 1 year. About 10% of patients were at least partially gastrostomy tube-dependent 1 year post-operatively. At last follow-up (median 29 months), this rate was 13%. Patients with supraglottic recurrence had an increased risk of gastrostomy tube dependence at 1 year compared to glottic (OR 16.7, 95% CI 1.73-160, P = .02). For every 10 pack years pre-salvage, the OR of requiring tube feeds at last follow-up was 1.24 (95% CI 1.04-1.48, P = .02). CONCLUSIONS: Fistula and pre-salvage smoking were associated with stricture post-salvage laryngectomy. No factors were associated with dilation by 1 year. Supraglottic recurrence and smoking were associated with gastrostomy tube dependence. These findings are important for pre-operative counseling prior to salvage laryngectomy. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 131:1229-1234, 2021.
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Carcinoma de Células Escamosas/fisiopatología , Estenosis Esofágica/etiología , Neoplasias Hipofaríngeas/fisiopatología , Neoplasias Laríngeas/fisiopatología , Laringectomía/efectos adversos , Complicaciones Posoperatorias/etiología , Terapia Recuperativa/efectos adversos , Anciano , Carcinoma de Células Escamosas/cirugía , Constricción Patológica/etiología , Deglución , Fístula Esofágica/etiología , Femenino , Gastrostomía/estadística & datos numéricos , Humanos , Neoplasias Hipofaríngeas/cirugía , Hipofaringe/cirugía , Neoplasias Laríngeas/cirugía , Laringe/cirugía , Modelos Logísticos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/fisiopatología , Recurrencia Local de Neoplasia/cirugía , Oportunidad Relativa , Periodo Posoperatorio , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Fumar/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES/HYPOTHESIS: To better assess rates of postoperative complications and mortality following esophageal dilation, and to identify factors associated with adverse outcomes. STUDY DESIGN: Observational, retrospective cohort study. METHODS: We queried a national database of insurance claims for Current Procedural Terminology (CPT) codes representing esophageal dilation performed between 2011 and 2017. Patients aged 18 to 100 who were continuously enrolled with their insurance provider were included. Demographic information, additional CPT codes, concomitant diagnoses, and anticoagulant medication data were collected for all patients included. Postoperative mortality was assessed and International Classification of Diseases (ICD)9/10 codes for complications, including esophageal perforation, hemorrhage, mediastinitis, and sepsis were flagged. RESULTS: We identified 202,965 encounters for esophageal dilation. Of these procedures, 193 were performed on a patient who underwent percutaneous endoscopic gastrostomy (PEG) during the study period and was analyzed separately. Another 244 dilations were excluded due to repeat entries. Of the remaining 202,528 procedures remaining, 42,310 were repeat dilations in the same patient. Data analysis was confined to each patient's initial dilation. 160,218 initial dilations remained. Of these, 62,107 were performed on male patients and 98,111 were performed on female patients. The average age was 57.7 years. There were 12 mortalities within 30 days postoperatively, representing 0.0075% of all dilations. Esophageal perforation and esophageal hemorrhage were the most common reported complications, with 139 and 110 occurrences, respectively. The overall per-dilation complication rate was 0.215%. CONCLUSIONS: Evidence from a national insurance claim database suggests that esophageal dilation is a safe procedure with a low rate of serious complications and a 30-day all-cause mortality rate of less than 1 per 10,000 dilations. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2436-2440, 2021.
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Trastornos de Deglución/cirugía , Dilatación/efectos adversos , Esófago/cirugía , Complicaciones Posoperatorias/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Estudios de Casos y Controles , Current Procedural Terminology , Bases de Datos Factuales , Dilatación/estadística & datos numéricos , Enfermedades del Esófago/patología , Perforación del Esófago/epidemiología , Esófago/patología , Femenino , Gastrostomía/estadística & datos numéricos , Gastrostomía/tendencias , Hemorragia/epidemiología , Humanos , Clasificación Internacional de Enfermedades/normas , Masculino , Mediastinitis/epidemiología , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Sepsis/epidemiologíaRESUMEN
BACKGROUND: Practices of performing gastrostomy tubes vary across institutions for patients undergoing cardiac surgery. We aim to elucidate the outcomes of gastrostomy and the duration of feeding assistance in these patients. MATERIALS AND METHODS: Patients undergoing cardiac surgery (CS) at our institution from 2013 to 2017 were retrospectively reviewed using the Society of Thoracic Surgery database. A cohort of non-CS patients undergoing gastrostomy tube (g-tube) placement from 2013 to 2015 was used as control. Technical complications and postoperative feeding intolerance were analyzed. Duration of need for g-tube was also analyzed in patients undergoing CS. RESULTS: The CS group had 144 patients, and the non-CS group had 677 patients. CS patients had a higher incidence of feeding intolerance (18.8% versus 5.6%, P < 0.001) and took longer to attain full feeds (median of 2 versus 1 d, P < 0.001), and this was confirmed on propensity matched analysis. In addition, technical g-tube complications were similar in the two groups. No mortality in CS was attributed to the g-tube. 58% of patients undergoing CS were able to wean from g-tube feeding by 6-12 mo after g-tube placement. CONCLUSIONS: G-tube placement in patients undergoing CS by any technique is safe without increased complications. A significant portion of these patients was able to wean off supplemental enteral feeding assistance by a year after g-tube placement.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Nutrición Enteral/efectos adversos , Gastrostomía/efectos adversos , Intubación Gastrointestinal/efectos adversos , Complicaciones Posoperatorias/epidemiología , Preescolar , Nutrición Enteral/instrumentación , Nutrición Enteral/métodos , Nutrición Enteral/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Gastrostomía/instrumentación , Gastrostomía/estadística & datos numéricos , Cardiopatías Congénitas/cirugía , Humanos , Lactante , Intubación Gastrointestinal/instrumentación , Intubación Gastrointestinal/métodos , Intubación Gastrointestinal/estadística & datos numéricos , Masculino , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Background Use of inpatient brain magnetic resonance imaging (MRI) in patients with acute ischemic stroke is highly institution dependent and has been associated with increased length and cost of hospital stay. We examined whether inpatient brain MRI in patients with acute ischemic stroke is associated with improved clinical outcomes to justify its resource requirements. Methods and Results The National Inpatient Sample database was queried retrospectively to find 94 003 patients who were admitted for acute ischemic stroke and then received inpatient brain MRI between 2012 and 2014. Multivariable regression analysis was performed with respect to a control group to assess for differences in the rates of inpatient mortality and complications, as well as the length and cost of hospital stay based on brain MRI use. Inpatient brain MRI was independently associated with lower rates of inpatient mortality (1.67% versus 3.09%; adjusted odds ratio [OR], 0.60; 95% CI, 0.53-0.68; P<0.001), gastrostomy (2.28% versus 2.89%; adjusted OR, 0.82; 95% CI, 0.73-0.93; P<0.001), and mechanical ventilation (1.97% versus 2.82%; adjusted OR, 0.68; 95% CI, 0.60-0.77; P<0.001). Brain MRI was independently associated with ≈0.32 days (8%) and $1131 (11%) increase in the total length (P<0.001) and cost (P<0.001) of hospital stay, respectively. Conclusions Inpatient brain MRI in patients with acute ischemic stroke is associated with substantial decrease in the rates of inpatient mortality and complications, at the expense of marginally increased length and cost of hospitalization.
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Hospitalización , Accidente Cerebrovascular Isquémico , Imagen por Resonancia Magnética , Neuroimagen , Anciano , Correlación de Datos , Costos y Análisis de Costo , Femenino , Gastrostomía/estadística & datos numéricos , Mortalidad Hospitalaria , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Humanos , Accidente Cerebrovascular Isquémico/complicaciones , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/epidemiología , Accidente Cerebrovascular Isquémico/terapia , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Imagen por Resonancia Magnética/métodos , Imagen por Resonancia Magnética/estadística & datos numéricos , Masculino , Neuroimagen/métodos , Neuroimagen/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Infants with congenital heart disease (CHD) often require the placement of a gastrostomy button to ensure proper nutrition. Some also require a Nissen fundoplication (NF) to further improve nutrition capabilities in the setting of reflux, however, the clinical and diagnostic imaging characteristics that support NF are variable. The aims of this study were as follows: (1) identify the factors associated with NF in patients with CHD and (2) determine the incidence of NF complications in patients with CHD. METHODS: All patients with CHD who underwent cardiac repair and subsequent creation of a gastrostomy at a single institution between 6/1/2013 and 9/1/2018 were included. We then identified which patients underwent NF. RESULTS: Two-hundred fifty-seven CHD patients who had a gastrostomy button placed after CHD repair, with 17% undergoing a simultaneous NF or an NF at a later time. The presence of acyanotic heart disease, neurologic comorbidities, and vocal cord dysfunction was not univariately associated with a higher likelihood of NF. On multivariable model, only prematurity was significantly associated with NF (P = 0.022). Abnormal findings on imaging studies (upper gastrointestinal series, gastric emptying studies, motility studies, upper endoscopies, swallow studies, and pH probe studies) were not associated with an NF (all P's > 0.05). The overall complication rate was 23%. CONCLUSIONS: Prematurity was the only factor associated with an NF. Surprisingly, cyanotic heart disease, neurologic comorbidities, age at first cardiac surgery, and vocal cord dysfunction were not associated with an NF. We identified an area for quality improvement at our institution given the lack of standardized work-up for the NF in this high-risk population.
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Nutrición Enteral/efectos adversos , Fundoplicación/efectos adversos , Reflujo Gastroesofágico/terapia , Gastrostomía/efectos adversos , Cardiopatías Congénitas/terapia , Complicaciones Posoperatorias/epidemiología , Puente Cardiopulmonar/estadística & datos numéricos , Nutrición Enteral/instrumentación , Nutrición Enteral/métodos , Nutrición Enteral/estadística & datos numéricos , Femenino , Fundoplicación/estadística & datos numéricos , Reflujo Gastroesofágico/diagnóstico , Reflujo Gastroesofágico/etiología , Gastrostomía/estadística & datos numéricos , Edad Gestacional , Cardiopatías Congénitas/complicaciones , Humanos , Incidencia , Recién Nacido , Recien Nacido Prematuro , Intubación Gastrointestinal/efectos adversos , Intubación Gastrointestinal/métodos , Intubación Gastrointestinal/estadística & datos numéricos , Masculino , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Medición de Riesgo/estadística & datos numéricos , Factores de RiesgoRESUMEN
BACKGROUND: Positive health outcomes have been observed following gastrostomy insertion in children with intellectual disability, which is being increasingly used at younger ages to improve nutritional intake. This study investigated the effect of gastrostomy insertion on survival of children with severe intellectual disability. METHODS: We used linked disability and health data of children and adolescents who were born in Western Australia between 1983 and 2009 to compare survival of individuals with severe intellectual disability by exposure to gastrostomy status. For those born in 2000-2009, we employed propensity score matching to adjust for confounding by indication. Effect of gastrostomy insertion on survival was compared by pertinent health and sociodemographic risk factors. RESULTS: Compared with children born in the 1980s-1990s, probability of survival following first gastrostomy insertion for those born in 2000-2009 was higher (2 years: 94% vs. 83%). Mortality risk was higher in cases than that in their matched controls (hazard ratio 2.9, 95% confidence interval 1.1, 7.3). The relative risk of mortality (gastrostomy vs. non-gastrostomy) may have differed by sex, birthweight and time at first gastrostomy insertion. Respiratory conditions were a common immediate or underlying cause of death among all children, particularly among those undergoing gastrostomy insertion. CONCLUSIONS: Whilst gastrostomy insertion was associated with lower survival rates than children without gastrostomy, survival improved with time, and gastrostomy afforded some protection for the more vulnerable groups, and earlier use appears beneficial to survival. Specific clinical data that may be used to prioritise the need for gastrostomy insertion may be responsible for the survival differences observed.
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Nutrición Enteral/estadística & datos numéricos , Gastrostomía/estadística & datos numéricos , Discapacidad Intelectual/mortalidad , Discapacidad Intelectual/terapia , Adolescente , Peso al Nacer , Niño , Femenino , Humanos , Masculino , Índice de Severidad de la Enfermedad , Australia Occidental/epidemiologíaRESUMEN
Gastrostomy tubes (G-tubes) are frequently used in children for feeding and nutrition. Complications related to G-tubes (and G-buttons) in children represent a common presentation to the emergency department (ED). G-tube replacement is usually performed by pediatric emergency medicine physicians. Misplacement may lead to tract disruption, perforation, fistula tract formation, or feeding into the peritoneum. Contrast-enhanced radiographs are traditionally used for confirmation. In addition to a longer length-of-stay, repeat ED visits result in repeated radiation exposure. The use of point-of-care ultrasound (POCUS) instead of radiography avoids this exposure to ionizing radiation. Here, we describe three patients who presented with G-tube complications in whom POCUS alone performed by pediatricians was used for confirmation of the tubes' replacement. Two children presented to the ED with G-tube dislodgement, and one child presented with a ruptured balloon. In all three cases, a new G-tube was replaced at the bedside using POCUS guidance without the need for further radiographic studies. There were no known ED or clinic returns for G-tube complaints over the next 30 days. This is the first report of pediatricians using POCUS to guide and confirm G-tube replacement in children. The success of these cases suggests the technique's feasibility. Future prospective studies are needed to evaluate the learning curves, diagnostic accuracy, ED length-of-stay, and use of confirmatory imaging.