Metachronous lesions after gastric endoscopic submucosal dissection: first assessment of the FAMISH prediction score.

BACKGROUND: Surveillance after gastric endoscopic submucosal dissection (ESD) is recommended for all patients owing to the persistent risk of metachronous gastric lesions (MGLs). We developed and validated a prediction score to estimate MGL risk after ESD for early neoplastic gastric lesions, to define an individualized and cost-saving approach. METHODS: Clinical predictors and a risk score were derived from meta-analysis data. A retrospective, single-center, cohort study including patients with ≥ 3 years of standardized surveillance after ESD was conducted for score validation. Predictive accuracy of the score by the area under the receiver operating characteristic curve (AUC) was assessed and cumulative probabilities of MGL were estimated. RESULTS: The risk score (0-9 points) included six clinical predictors (scored 0-3): positive family history of gastric cancer, older age, male sex, corpus intestinal metaplasia, synchronous gastric lesions, and persistent Helicobacter pylori infection (FAMISH). The study population included 263 patients. The MGL rate was 16 %. The score diagnostic accuracy for predicting MGL at 3 years' follow-up, measured by the AUC, was 0.704 (95 %CI 0.603-0.806). At 3 years and a cutoff < 2, the score achieved maximal sensitivity and negative predictive value; 15 % of patients could be assigned to a low-risk group, in which the progression to MGL was significantly lower than for the high-risk group (P = 0.04). CONCLUSION: The FAMISH score might be a useful tool to accurately identify patients with low-to-intermediate risk for MGL at 3 years of follow-up who could have surveillance intervals extended to reduce the burden of care.

Direct endoscopic full-thickness resection for submucosal tumors with an intraluminal growth pattern originating from the muscularis propria layer in the gastric fundus.

BACKGROUND AND AIMS: Endoscopic full-thickness resection (EFTR) is difficult to perform in a retroflexed fashion in the gastric fundus. The present study aims at exploring whether direct EFTR can be a simple, effective and safe procedure to treat intraluminal-growth submucosal tumors originating from the muscularis propria. METHODS: The patients with intraluminal-growth submucosal tumors originating from the muscularis propria in gastric fundus treated by direct EFTR between 01 January 2017 and 01 September 2018 were retrospectively reviewed. In addition, we analyzed the patients with intraluminal-growth submucosal tumors originating from the muscularis propria in gastric fundus treated by traditional EFTR. The differences in tumor resection time, cost-effectiveness, and complication rate were evaluated. RESULTS: Forty patients were enrolled in the present study, 20 patients of which were in the direct EFTR group and 20 patients of which were in the traditional EFTR group. En-bloc resections of gastric tumors were successfully performed in all 40 cases. There was no significant difference in the average tumor size of the two groups (24.3 ± 2.9 mm in direct EFTR group verus 24.0 ± 2.6 mm in the traditional group, p = 0.731), but significant difference existed in the operative time between two groups (35.0 ± 8.2 min in direct EFTR group verus 130.6 ± 51.9 min in the traditional group, p<0.05). No complications, such as postoperative bleeding and perforation, occurred in any groups. CONCLUSIONS: Direct EFTR is a safe, simple and cost-effective procedure for SMTs with an intraluminal growth pattern originating from the muscularis propria layer in the gastric fundus.

Is the Reinitiation of Antiplatelet Agents Safe at 1 Week after Gastric Endoscopic Submucosal Dissection? Assessment of Bleeding Risk Using the Forrest Classification.

BACKGROUND/AIMS: Delayed bleeding after gastric endoscopic submucosal dissection (ESD) commonly occurs within 3 days, but it may also occur after 1 week following ESD, especially in antiplatelet agent users. We evaluated the risk of delayed bleeding in post-ESD ulcers using the Forrest classification. METHODS: Registry data on the Forrest classification of post-ESD ulcers (n=371) at 1 week or 2 weeks after ESD were retrospectively evaluated. The Forrest classification was categorized into two groups: increased risk (Forrest Ia to IIc) or low risk (Forrest III). The odds ratios (ORs) were calculated using logistic regression analysis. RESULTS: Among 371 post-ESD ulcers, one ulcer (0.3%) was classified as Forrest Ib, two (0.5%) as Forrest IIa, 17 (4.6%) as Forrest IIb, 172 (46.4%) as Forrest IIc, and 179 (48.2%) as Forrest III. The proportion of increased-risk ulcers was 72.2% (140/194) at 1 week after ESD, which decreased to 29.4% (52/177) at 2 weeks after ESD (p<0.001). In the multivariate analysis, a post-ESD ulcer at 1 week after ESD (OR, 7.54), younger age (OR, 2.17), and upper/middle ulcer location (OR, 2.05) were associated with increased-risk ulcers. CONCLUSIONS: One week after ESD, ulcers still have an increased risk of bleeding when assessed using the Forrest classification. This risk should be considered when resuming antiplatelet therapy.

Cost of detecting gastric neoplasia by surveillance endoscopy in atrophic gastritis in Italy: A low risk country.

BACKGROUND: Atrophic gastritis (AG) is at increased risk of gastric neoplasia, thus surveillance gastroscopy has been proposed. AIMS: To assess cost of detecting gastric neoplasias by surveillance endoscopy according to identified risk factors in Italy. METHODS: Post-hoc analysis of a cohort study including 200 AG-patients from Italy followed up for a mean of 7.5 (4-23.4) years was done. Considered risk factors were: age >50years, extensive atrophy, pernicious anaemia, OLGA-OLGIM scores 3-4 at diagnosis. The number of 4-year-surveillance endoscopies needed to be performed to detect one gastric neoplasia (NNS) was calculated. RESULTS: In 19 patients neoplasias (4 gastric cancers, 8 type 1 gastric carcinoids, 7 dysplasias) were detected at the 361 surveillance gastroscopies, corresponding to NNS of 19 and a cost per gastric neoplastic lesion of €2945. By restricting surveillance to pernicious anaemia patients, reduction of NNS and cost per neoplasia to 13.8 and €2139 may be obtained still detecting 74% of neoplasias. By limiting the surveillance to pernicious anaemia patients and OLGA 3-4, 5 (26.3%) neoplasias would have been detected with a corresponding NNS of 5.4 and a cost per lesion of €837. CONCLUSION: Risk factors may allow an efficient allocation of financial and medical resources for endoscopic surveillance in AG in a low risk country.

Antibacterial gauzes are effective in preventing infections after percutaneous endoscopic gastrostomy placement: a retrospective analysis.

OBJECTIVES: The most common complication after percutaneous endoscopic gastrostomy (PEG) placement is peristomal wound infection (up to 40% without antibiotic prophylaxis). Single-dose parenteral prophylactic antibiotics as advised by current guidelines decrease the infection rate to 9-15%. We assume a prolonged effect of local antibiotic treatment with antibacterial gauzes. This study is the first to describe the effect of antibacterial gauzes in preventing infections in PEG without the use of antibiotics. METHODS: A retrospective data analysis was carried out of all patients with PEG insertion between January 2009 and October 2014 in the Catharina Hospital Eindhoven. Data include placement and the period of the first 2 weeks after PEG placement, and long-term follow-up. All patients received a locally applied antibacterial gauze polyhexamethylene biguanide immediately following PEG insertion for 3 days. No other antibiotics were administered. The main outcomes were wound infection, peritonitis, and necrotizing fasciitis; secondary outcomes included other complications. RESULTS: A total of 331 patients with only antibacterial gauzes were analyzed. The total number of infections 2 weeks after PEG insertion was 9.4%, including 8.2% minor and 1.2% major infections (peritonitis). No wound infection-related mortality or bacterial resistance was found. Costs are five times lower than antibiotics, and gauzes are more practical and patient friendly for use. CONCLUSION: Retrospectively, antibacterial gauzes are at least comparable with literature data on parenteral antibiotics in preventing peristomal wound infection after PEG placement, with an infection rate of 9.4%. Rates of other complications found in this study were comparable with current literature data.

Endoscopic Resection Versus Surgical Resection for Early Gastric Cancer: A Systematic Review and Meta-Analysis.

Endoscopic resection (ER) has been widely accepted to treat early gastric cancer (EGC) in place of surgical resection (SR). The aim of this meta-analysis was to conduct a comprehensive comparison between the two methods.Four literature databases, including PubMed, Web of Science, the Cochrane Library, and EMBASE, were searched for studies that compared ER with SR to treat EGC. In this meta-analysis, primary and secondary endpoints were compared between the two groups. Primary endpoints included overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and recurrence-free survival (RFS). Secondary endpoints included operation-related death, local recurrence, metachronous lesions, procedure-related complication, bleeding, hospital stay, operation time, and cost.Nineteen studies consisting of a total of 6118 patients were identified and selected for evaluation. Meta-analysis showed that long-term outcomes of ER versus SR for EGC were comparable in terms of 5-year OS (risk ratio [RR] 1.00, 95% confidence interval [CI] 0.98-1.02), DSS (RR 0.98, 95% CI 0.89-1.08), DFS (RR 0.95, 95% CI 0.86-1.05), and RFS (RR 0.98, 95% CI 0.94-1.01). However, ER had shorter operation time (standardized mean difference [SMD] -3.39, 95% CI -3.58 to 3.20), hospital stay (SMD -2.86, 95% CI -4.02 to -1.69), lower costs (SMD -5.30, 95% CI -10.37 to -0.22), and fewer procedure-related complications (RR 0.43, 95% CI 0.28-0.65) compared to SR. Nevertheless, ER had higher incidences of local recurrence (risk difference 0.01, 95% CI 0.00-0.02) and metachronous lesions (RR 6.81, 95% CI 3.80-12.19).Endoscopic resection was associated with similar long-term outcomes and considerable advantages concerning operation time, hospital stay, costs, and complications, compared with SR, and was also associated with disadvantages such as higher incidence of local recurrence and metachronous lesions. Further high-quality studies from more countries are required to confirm these results.

Endoscopic submucosal dissection for gastric cancer in elderly Japanese patients: an observational study of financial costs of treatment based on a national administrative database.

OBJECTIVE: There is currently little information on the medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer (GC) in elderly patients. This study therefore aimed to investigate the medical economic outcomes of ESD in elderly patients with GC using a national administrative database. METHODS: A total of 27 385 patients treated with ESD for GC were referred to 867 hospitals in Japan from 2009 to 2011. We collected data from the national administrative database and divided them into two groups according to age: elderly patients (≥80 years; n = 5525) and non-elderly patients (<80 years; n = 21 860). We compared ESD-related complications, risk-adjusted length of stay (LOS) and medical costs during hospitalization between elderly and non-elderly patients. RESULTS: There was no significant difference in ESD-related complications between elderly and non-elderly patients (4.3% vs 3.9%, P = 0.152). However, significant differences were observed in mean LOS and medical costs during hospitalization between the two groups (P < 0.001). Multiple linear regression analysis showed that elderly patients experienced a significantly longer LOS and higher medical costs. The unstandardized coefficient for LOS in elderly patients was 2.71 days (95% confidence interval [CI] 2.59-2.84, P < 0.001), while that for medical costs during hospitalization was USD952.1 (95% CI 847.7-1056.5, P < 0.001). CONCLUSIONS: LOS and medical costs during hospitalization were significantly higher in elderly patients undergoing ESD for GC than in non-elderly patients, although there was no difference in the incidence of ESD-related complications.

Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is performed to provide nutrition to patients with swallowing difficulties. A multicenter study was conducted to evaluate the predictors of complications and mortality after PEG placement. METHODS: This study retrospectively analyzed patients who underwent initial PEG placement between January 2004 and December 2011 at seven tertiary hospitals in the Republic of Korea. RESULTS: All 1,625 patients underwent PEG placement by the pull-string method. The median age of the patients was 66 years, and 1,108 of the patients were men. The median follow-up period was 254 days. The common indications were stroke (31.6%) and malignancy (18.9%). The complication rate was 13.2%. The prophylactic use of antibiotics (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.38-0.88; p = 0.010) reduced the PEG-related infection rate, but the actual usage rate was 81.1%. The use of anticoagulants (OR, 7.26; 95% CI, 2.23-23.68; p = 0.001) and the presence of diabetes mellitus (OR, 4.02; 95% CI, 1.49-10.87; p = 0.006) increased the risk of bleeding, but antiplatelet therapy did not. The procedural, 30-day, and overall mortality rates were 0.2, 2.4 and 14.0%, respectively. Serum albumin levels lower than 31.5 g/L (OR, 8.55; 95% CI, 3.11-23.45; p < 0.001) and C-reactive protein levels higher than 21.5 mg/L (OR, 3.01; 95% CI, 1.27-7.16; p = 0.012) increased the risk of 30-day mortality, and the patients who had both risk factors had a significantly shorter median survival time than those who did not (1,740 vs 3,181 days) (p < 0.001, log-rank). CONCLUSIONS: The findings showed PEG to be a safe and feasible procedure, but the patient's nutritional and inflammatory status should be considered in predicting the outcomes of PEG placement.

Basic geriatric assessment does not predict in-hospital mortality after PEG placement.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is an established procedure for long-term nutrition. However, studies have underlined the importance of proper patient selection as mortality has been shown to be relatively high in acute illness and certain patient groups, amongst others geriatric patients. Objective of the study was to gather information about geriatric patients receiving PEG and to identify risk factors associated with in-hospital mortality after PEG placement. METHODS: All patients from the GEMIDAS database undergoing percutaneous endoscopic gastrostomy in acute geriatric wards from 2006 to 2010 were included in a retrospective database analysis. Data on age, gender, main diagnosis leading to hospital admission, death in hospital, care level, and legal incapacitation were extracted from the main database of the Geriatric Minimum Data Set. Self-care capacity was assessed by the Barthel index, and cognitive status was rated with the Mini Mental State Examination or subjectively judged by the clinician. Descriptive statistics and group comparisons were chosen according to data distribution and scale of measurement, logistic regression analysis was performed to examine influence of various factors on hospital mortality. RESULTS: A total of 1232 patients (60.4% women) with a median age of 82 years (range 60 to 99 years) were included. The mean Barthel index at admission was 9.5 ± 14.0 points. Assessment of cognitive status was available in about half of the patients (n = 664), with 20% being mildly impaired and almost 70% being moderately to severely impaired. Stroke was the most common main diagnosis (55.2%). In-hospital mortality was 12.8%. In a logistic regression analysis, old age (odds ratio (OR) 1.030, 95% confidence interval (CI) 1.003-1.056), male sex (OR 1.741, 95% CI 1.216-2.493), and pneumonia (OR 2.641, 95% CI 1.457-4.792) or the diagnosis group 'miscellaneous disease' (OR 1.864, 95% CI 1.224-2.839) were identified as statistical risk factors for in-hospital death. Cognitive status did not have an influence on mortality (OR 0.447, CI 95% 0.248-1.650). CONCLUSION: In a nationwide geriatric database, no component of the basic geriatric assessment emerged as a significant risk factor for mortality after PEG placement, emphasizing individual decision-making.

The clinical diagnostic reasoning process determining the use of endoscopy in diagnosing peptic ulcer disease.

OBJECTIVE: To evaluate the clinical diagnostic reasoning process as a tool to decrease the number of unnecessary endoscopies for diagnosing peptic ulcer disease. tudy DESIGN: Cross-sectional KAP study. PLACE AND DURATION OF STUDY: Shifa College of Medicine, Islamabad, from April to August 2010. METHODOLOGY: Two hundred doctors were assessed with three common clinical scenarios of low, intermediate and high pre-test probability for peptic ulcer disease using a questionnaire. The differences between the reference estimates and the respondents' estimates of pre-test and post test probability were used for assessing the ability of estimating the pretest probability and the post test probability of the disease. Doctors were also enquired about the cost-effectiveness and safety of endoscopy. Consecutive sampling technique was used and the data was analyzed using SPSS version 16. RESULTS: In the low pre-test probability settings, overestimation of the disease probability suggested the doctors' inability to rule out the disease. The post test probabilities were similarly overestimated. In intermediate pre-test probability settings, both over and under estimation of probabilities were noticed. In high pre-test probability setting, there was no significant difference in the reference and the responders' intuitive estimates of post test probability. Doctors were more likely to consider ordering the test as the disease probability increased. Most respondents were of the opinion that endoscopy is not a cost-effective procedure and may be associated with a potential harm. CONCLUSION: Improvement is needed in doctors' diagnostic ability by more emphasis on clinical decision-making and application of bayesian probabilistic thinking to real clinical situations.

Effect of lansoprazole versus roxatidine on prevention of bleeding and promotion of ulcer healing after endoscopic submucosal dissection for superficial gastric neoplasia.

BACKGROUND: Proton pump inhibitors have been reported to be more useful than histamine-2 receptor antagonists for the prevention of bleeding after endoscopic submucosal dissection (ESD) for superficial gastric neoplasia. The aim of this study was to assess the effects of the proton pump inhibitor lansoprazole and the histamine-2 receptor antagonist roxatidine for the prevention of bleeding and the promotion of ulcer healing after ESD and to compare the cost-effectiveness of these two drugs. METHODS: The study subjects were 129 patients who underwent ESD for superficial gastric neoplasia. The patients were randomly assigned to the lansoprazole group (L group) or the roxatidine group (R group). Either drug was administered intravenously from the morning of the ESD day to the day after the ESD, followed by oral treatment for an additional 8 weeks. A second-look endoscopy was performed on the day after the ESD, and a repeat endoscopy was performed at 8 weeks after the ESD. The incidence of bleeding and the ulcer-healing rate at 8 weeks after the ESD were analyzed, as well as the total cost of treatment with these antisecretory agents. RESULTS: Three patients in each group were excluded from the analysis, leaving 62 patients in L group and 61 in R group. Two of the 62 patients (3.2%) in L group and three of the 61 patients (4.9%) in R group showed bleeding after ESD ; there was no significant difference between the two groups (P = 0.68). The ulcer-healing rate was 93.5% (58/62) in L group and 93.4% (57/61) in R group (P = 1). The total cost of treatment with the antisecretory agent from the day of the ESD to day 56 after the ESD was Yen 13,212 for lansoprazole and Yen 5,841 for roxatidine. CONCLUSIONS: Roxatidine appears to have high cost-effectiveness in the prevention of bleeding and in the promotion of ulcer healing after ESD for superficial gastric neoplasia.

An approach to the assessment and management of the laparoscopic adjustable gastric band patient in the emergency department.

OBJECTIVE: As the number of obese people in Australia continues to increase, laparoscopic adjustable gastric banding (LAGB) surgery will become increasingly common. It is important for practitioners involved in the care of such patients to be able to accurately diagnose, and initially manage, pathology relating to the LAGB. METHODS: A retrospective review of 56 presentations in 41 patients with LAGB, who presented to the ED of a major tertiary hospital, was performed. Note was made of presenting symptoms, investigations undertaken, subsequent diagnosis, and initial and definitive management. RESULTS AND DISCUSSION: The commonest presenting symptoms included abdominal pain, nausea, vomiting and dysphagia. The ultimate diagnosis was food bolus obstruction (18 presentations; 32.1%), port infection (11 presentations; 19.6%), band prolapse (9 presentations; 16.1%), band erosion (2 presentations; 3.6%) and subacute bowel obstruction (1 presentation; 1.8%). Food bolus obstruction was best diagnosed clinically. Plain abdominal X-ray was useful to identify prolapse. Infection was best diagnosed with the combination of clinical picture and wound swab. CT scan was helpful when suspecting a deep source of infection. From these data, two algorithms were developed, which can be used as a clinical aide to help practitioners in diagnosing and treating such complications appropriately. CONCLUSION: It is important that health-care professionals are aware of the common presentations of problems following LAGB and have a basic paradigm for initial care. The present study identifies the presenting picture of various complications that can arise postoperatively, and describes an approach to the assessment and management of the LAGB patient in the ED.

[Alleged malpractice claims related to gastrointestinal endoscopy. Analysis of casuistics over 22 years]. / Reclamaciones por presunta negligencia relacionadas con endoscopia digestiva. Análisis de una casuística de 22 años.

We reviewed the records of patients filing alleged malpractice claims related to gastrointestinal endoscopy to the Professional Responsibility Section of the Medical Council of Catalonia from 1987 to 2009 to determine the frequency of medical errors or substandard care in the practice of this procedure and the result of complaints according to whether malpractice might have been involved or not. There were a total of 66 complaints, 46 (70%) after colonoscopy, 12 (18%) after endoscopic retrograde cholangiography and eight (12%) after gastroscopy. In 18 (27%) cases, we considered malpractice to have been probable, due to lack of informed consent in four, delayed treatment of complications in six, substandard sedation in five, misdiagnosis in two and substandard practice in one, which would justify the complaints. Of the 48 cases we considered not to have involved malpractice, a guilty verdict was secured in one and an out-of-court settlement was reached in six with regard to the disproportionate and permanent harm experienced by the patients. Among the 66 claims, an out-of-court settlement was reached with the complainant on 19 occasions (28.7%) and a civil or penal trial was held in 39 (59%), resulting in a guilty verdict in only 10% of cases. In eight cases (15.3%), the complainant took no further action after receiving the response of the Professional Responsibility Section. The number of complaints progressively increased over the study period. There were a greater number of complaints in private clinics than in public hospitals. Endoscopists with more than one complaint were more frequently found guilty or reached an out-of-court settlement than those with only one complaint against them (100% versus 28%). Analysis of complaints of alleged malpractice is useful to identify areas requiring improved patients safety and to reduce the number of these complaints.

The effect of an information brochure on patients undergoing gastrointestinal endoscopy: a randomized controlled study.

OBJECTIVE: The aim of the present study was to test the potential beneficial effects of an information brochure on undergoing a gastrointestinal endoscopy for the first time. The information provided was based on self-regulation theory, and patients could restrict themselves to reading the summary only. METHODS: Patients were randomly assigned to an experimental group receiving the brochure at least 1 day before the gastroscopy (N=47), or to a control group not receiving the brochure (N=48). RESULTS: The results show that all experimental subjects, except one, fully read the brochure. Those receiving the brochure experienced less anxiety before the gastroscopy and, afterwards, they reported greater satisfaction with the preparation for it. With regard to coping style there were some small moderating effects into the direction expected: low blunters (those not seeking distraction under impending threat) as compared to high blunters showed extra reduced anxiety after reading the brochure. They also tended to read the brochure more often. High monitors (those seeking information under impending threat) receiving the brochure showed reduced anxiety during the gastroscopy as compared to low monitors (tendency). CONCLUSION: We conclude that providing patients with the developed brochure constitutes an efficient, beneficial intervention. PRACTICE IMPLICATIONS: The brochure could easily be implemented in standard practice without the necessity to take the patient's coping style into account.

A national inpatient cost estimate of percutaneous endoscopic gastrostomy (PEG)-associated aspiration pneumonia.

OBJECTIVE: To present national estimates of the prevalence and costs of inpatient admissions for aspiration pneumonia (AP) associated with percutaneous endoscopic gastrostomies (PEGs) inserted before or during an admission. STUDY DESIGN: Retrospective analysis using medical claims. PATIENTS AND METHODS: National estimates of the prevalence of inpatient admissions associated with AP and mortality rates were developed, using data from the Nationwide Inpatient Sample of the Hospital Cost and Utilization Project (HCUP-3) Database. The MEDSTAT Group's MarketScan Private Pay Fee-for-Service (FFS) and Medicare FFS databases were used to calculate the percentage of admissions for AP that were preceded by a PEG or that entailed a PEG placement. Associated statistics, such as average length of stay and mean payments for these admissions, also were estimated. RESULTS: Approximately 300,000 inpatient admissions for AP took place in the United States in 1995, of which roughly 70,000 (23.9%) resulted in death. Approximately 10% of all AP admissions occurred after or entailed a PEG placement. After adjusting for differences in patients' age, gender, and health status, the total mean payments were estimated to be $26,618 per patient. This per-patient estimate translates into a national estimate of the cost of PEG-associated AP of approximately $808.2 million. CONCLUSION: The cost of PEG-associated AP is relatively high, as estimated in this study. The high inpatient mortality rates of AP imply that future efforts should be directed toward preventing AP.

[Percutaneous endoscopic gastrostomy: cost/benefit analysis in patients with carcinoma of the upper aero-digestive tract]. / Technique de gastrostomie percutanée radiologique: évaluation coût/bénéfice chez les patients porteurs d'un cancer des voies aérodigestives supérieurs.

The aim of this retrospective study was to evaluate the cost and benefit of percutaneous fluoroscopic gastrostomy feeding (PFG) in 70 cancer patients with advanced stage disease of the upper-aero digestive tract; we retrospectively analyzed the consequences in terms of nutritional status (evaluated by weight and body mass index), the possibility to lead a treatment by high dose chemo-radiotherapy to the end of the therapeutic schedule, the feasibility, complications and cost ratios. Three weeks after the procedure, no major complication was observed, the initial nutritional threshold was conserved. PFG is a safe and effective technique; the additional cost is low (2%) compared with the total cost of hospitalization.

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

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

Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: a prospective, randomized comparison.

PURPOSE: To compare the efficacy of radiologic guided placement of percutaneous gastrojejunostomy (PGJ) and percutaneous endoscopic gastrostomy (PEG). MATERIALS AND METHODS: Patients were randomized to PGJ (n = 66) or PEG (n = 69). Indications for gastrostomy were need for prolonged enteral nutrition (97%) or gastrointestinal decompression (3%), with etiologies of neurologic impairment (81%), head and neck neoplasm (12%), bowel obstruction (3%), or other (4%). Mean follow-up was 202 days and 30-day follow-up was obtained for 85% of patients. RESULTS: PEG was successful in 63 of 69 (91%) patients, while PGJ established access in all of 66 attempts (100%) (P = .014). Average procedural time was 53 minutes for PGJ and 24 minutes for PEG (P = .001). At 30-day follow-up, there were 33 and 45 complications in the PGJ and PEG groups, respectively. This difference was due to the greater incidence of pneumonia in the PEG group (P = .013). Long-term tube-related complications occurred with 17 PGJs and four PEGs (P = .007). The PGJ cost more than PEG, but this advantage was offset by the cost of complications. CONCLUSION: PGJ had higher success rate and fewer complications, due to a lower incidence of pneumonia. PEG took less time to perform, cost less, and required less tube maintenance.

Postpyloric enteral feeding costs for patients with severe head injury: blind placement, endoscopy, and PEG/J versus TPN.

This study describes the advantages and disadvantages of several forms of enteral nutrition for patients with severe head injury (Glasgow Coma Scale Score [GCS], <12). Included in the study are nasoenteric nutrition delivery using blind, endoscopic, percutaneous endoscopic gastrostomy (PEG) and PEG with jejeunostomy (PEG/J), and open jejeunostomy tube placement methods. These methods are compared with parenteral delivery of nutrition. The study constituted a retrospective analysis of the success rate of early enteral feedings by blind, endoscopic PEG and PEG/J and by open jejeunostomy placement of small-bowel feeding tubes for 57 patients with severe head injury. The delivery cost of enteral nutrition per intensive care unit day was compared to the delivery cost of parenteral nutrition per intensive care unit day in the same group of patients. Fifty-three percent of patients were adequately maintained nutritionally with nasoenteric delivery alone and did not require parenteral feeding. The average number of days for initiation of either enteral or parenteral feedings was 1.8 +/- 0.2 days from injury [standard error of mean (SEM); range, 0-10 days]. An average of 3.3 days (range, 0-23 days) was required for feeding tube placement in all patients. For 70% of patients, tube placement was completed within 48 h after injury. Full-strength, full-rate enteral feedings were achieved by a mean of 4.9 days after injury. A total of 128 feeding tubes were placed while the patients were in the intensive care unit (ICU; 2.2 +/- 0.2 tubes per patient). Blind placement of feeding tubes into the small bowel was rarely achieved without repositioning. Endoscopic tube placement into the duodenum was achieved in 50% of patients, into the jejunum for 33% of patients, and into the stomach for 18% of patients. While in the intensive care unit, patients received an average of 77 +/- 2% of their measured energy expenditure (range, 57-114%). Eleven percent of patients experienced severe gastrointestinal problems. Other problems were associated with the inability to achieve or maintain access: dislodged tubes (30%), clogged or kinked tubes (21%), and mechanical access problems (7 %). Seventy-one percent of patients in barbiturate coma were able to tolerate early nasoenteric feedings. Aspiration pneumonitis occurred equally among patients fed nasogastrically and those fed nasoenterically. The overall aspiration rate was 14%. The cost of acute enteral feeding was $170 per day and that for parenteral feeding, $308 per day. We conclude that blind transpyloric feeding tube placement is difficult to achieve in patients with severe head injury; endoscopically guided placement is a better option. Endoscopic feeding tube placement most consistently allows for early enteral nutritional support in severe head injured patients. Limitations include the inability to establish and/or maintain enteral access, increased intracranial pressure, unstable cervical spinal injuries, facial fractures, and dedication of the physician to tube placement and monitoring.

Identification of factors that influence tolerance of upper gastrointestinal endoscopy.

OBJECTIVE: Unsedated gastroscopy is unpleasant for some patients. The identification of factors related to tolerance would permit the selection of patients for sedation. The aim of the present study was to identify these factors. METHODS: Five hundred and nine patients underwent diagnostic gastroscopy after the administration of topical pharyngeal anaesthesia, without sedation. Patients were grouped as to whether they had undergone prior examinations or not. Tolerance was assessed with a visual analogue scale and a questionnaire. RESULTS: Two hundred and seventy-three (54%) patients underwent gastroscopy for the first time, and 236 (46%) patients had prior experience. Patient tolerance was poor in 84 of 273 (31%) patients undergoing gastroscopy for the first time, and in 61 of 236 (26%) patients with prior experience. Logistic regression analysis identified the following variables related to poor tolerance: (a) in patients undergoing gastroscopy for the first time: presence of gag reflex (odds ratio (OR) = 3.42, 95% confidence interval (CI) 1.90-6.17), apprehension (OR = 2.57, CI 1.33-4.95), young age (OR = 0.95, CI 0.93-0.98) and high level of anxiety (OR = 1.91, CI 0.96-3.89); (b) in patients with prior experience: apprehension (OR = 4.21, CI 1.93-9.20), poor tolerance of prior examinations (OR = 4.92, CI 1.93-12.5) and female (OR = 2.23, CI 1.09-4.57). CONCLUSIONS: The above-mentioned factors are predictive of poor tolerance, and may enable the identification of those patients who might benefit more from sedation for gastroscopy.