Gastrostomía por minilaparotomía / PERCUTANEOUS GASTROSTOMY WITHOUT LAPAROTOMY

Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares. Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares.

Introduction: Percutaneous surgery is undoubtedly the preferred technique to perform a gastrostomy for enteral feeding. Despite its advantages, it requires expensive sets and a complex procedure, which are not always available in our locations. All this led us to look for a safe alternative, easy to manage at home, and economically viable in all cases that occur in our locations. Material and Method: This is a retrospective study that includes 18 patients treated between 2005 and 2008 using the technique of minimal laparotomy (3 cm) for left median below the costal ridge, detection of the ascending portion of the stomach, placement of a Foley tube No. 18 and fixation of the stomach to the wall during the closure of the incision. Results: No serious complications were observed in the patients included in this study, except for some peri-tube reflux dermatitis and a mucous membrane prolapse. Easy home management and good patient tolerance were also observed. Discussion: Although this procedure is not the first-line treatment of choice, it is a safe and low-cost technique, which allows the placement of a safe, low-cost enteral feeding route with similar results in areas with scarce economic means like ours.

Gastrostomy tube placement via a laparotomic procedure in growing conventional piglets to perform multi-dose preclinical paediatric drug studies.

The use of juvenile conventional pigs as a preclinical animal model to perform pharmacokinetic (PK), pharmacodynamic (PD) and safety studies for the paediatric population is increasing. Repetitive oral administration of drugs to juvenile pigs is however challenging. A representative method which can be used from birth till adulthood is necessary. The current study presents the placement and use of a gastrostomy button in pigs with a weight ranging from 2.4 to 161 kg. The surgical placement was performed via a laparotomic procedure on, each time, 12 pigs (six male, six female) of 1 week, 4 weeks, 8 weeks and 6-7 months old. For every age category, eight pigs were part of a PK study with a non-steroidal anti-inflammatory drug (NSAID) and four pigs served as a control group. No severe complications were observed during surgery. The button remained functional for 10 days in 40 out of 48 pigs. No significant differences in body temperature or white blood cell count were observed during the trial. Three control pigs showed signs of inflammation indicating a NSAID might be warranted. Autopsy revealed minimal signs of major inflammation in the abdominal cavity or the stomach. A limited number of pigs showed mucosal inflammation, ulcers or abscesses in the stomach or around the fistula. These results indicate that the laparotomic placement of a gastrostomy button might be considered safe and easy in growing pigs to perform repetitive oral dosing preclinical studies. However, the method is not advised in pigs weighing more than 100 kg.

Aspiration therapy for the treatment of obesity: 4-year results of a multicenter randomized controlled trial.

BACKGROUND: The AspireAssist is the first Food and Drug Administration-approved endoluminal device indicated for treatment of class II and III obesity. OBJECTIVES: We earlier reported 1-year results of the PATHWAY study. Here, we report 4-year outcomes. SETTING: United States-based, 10-center, randomized controlled trial involving 171 participants with the treatment arm receiving Aspiration Therapy (AT) plus Lifestyle Therapy and the control arm receiving Lifestyle Therapy (2:1 randomization). METHODS: AT participants were permitted to continue in the study for an additional year up to a maximum of 5 years providing they maintained at least 10% total weight loss (TWL) from baseline at each year end. For AT participants who continued the study, 5 medical monitoring visits were provided at weeks 60, 68, 76, 90, and 104 and thereafter once every 13 weeks up to week 260. Exclusion criteria were a history of eating disorder or evidence of eating disorder on a validated questionnaire. Follow-up weight, quality of life, and co-morbidities were compared with the baseline levels. In addition, rates of serious adverse event, persistent fistula, withdrawal, and A-tube replacement were reported. All analyses were performed using a per-protocol analysis. RESULTS: Of the 82 AT participants who completed 1 year, 58 continued to this phase of the trial. Mean baseline body mass index of these 58 patients was 41.6 ± 4.5 kg/m2. At the end of first year (at the beginning of the follow-up study), these 58 patients had a body mass index of 34.1 ± 5.4 kg/m2 and had achieved an 18.3 ± 8.0% TWL. On a per protocol basis, patients experienced 14.2%, 15.3%, 16.6%, and 18.7% TWL at 1, 2, 3, and 4 years, respectively (P < .01 for all). Forty of 58 patients (69%) achieved at least 10% TWL at 4 years or at time of study withdrawal. Improvements in quality of life scores and select cardiometabolic parameters were also maintained through 4 years. There were 2 serious adverse events reported in the second through fourth years, both of which resolved with removal or replacement of the A tube. Two persistent fistulas required surgical repair, representing approximately 2% of all tube removals. There were no clinically significant metabolic or electrolytes disorders observed, nor any evidence for development of any eating disorders. CONCLUSIONS: The results of this midterm study have shown that AT is a safe, effective, and durable weight loss alternative for people with class II and III obesity and who are willing to commit to using the therapy and adhere to adjustments in eating behavior.

Case Report of gastroparesis healing: 16 years of a chronic syndrome resolved after proximal intercessory prayer.

A male infant at two weeks of age was hospitalized vomiting forcefully. He had a pyloromyotomy. He did not improve with medical therapy. The diagnosis of gastroparesis was made after a nuclear medicine gastric emptying study and intestinal manometry. He required a gastrostomy tube (g-tube) and a jejunostomy tube (j-tube) for feeding. At 11 months of age, the j-tube was converted into a feeding jejunostomy with Roux-en-Y limb. For 16 years he was completely dependent on j-tube feeding. In November 2011, he experienced proximal-intercessory-prayer (PIP) at a church and felt an electric shock starting from his shoulder and going through his stomach. After the prayer experience, he was unexpectedly able to tolerate oral feedings. The g- and j-tube were removed four months later and he did not require any further special treatments for his condition as all symptoms had resolved. Over seven years later, he has been free from symptoms. This article investigates a case of PIP as an alternative intervention for resolving severe idiopathic gastroparesis when maximal medical management is not effective.

Unsedated Outpatient Percutaneous Endoscopic Gastrostomy in Stroke Patients: Is It Feasible and Safe?

Percutaneous endoscopic gastrostomy (PEG) is an established practice for long-term nutrition in dysphagia-suffering stroke patients. This study sought to determine the feasibility and safety of outpatient, unsedated PEG implementation in stroke patients. This retrospective cohort study involved stroke victims who underwent unsedated outpatient PEG insertion from 2014 to 2017 at our Surgical Endoscopy Unit. Patients were given pharyngeal anesthesia with lidocaine 10% spray, while the PEG tube was placed under local anesthesia. The incidence of intraprocedural and postprocedural complications and 30-day mortality rate were recorded. Data from 127 cases were analyzed. The procedures were performed with minor, transient complications, which resolved after rescue maneuvers. No intraprocedural and postprocedural major complications or death were observed. During the 30-day follow-up, the most important complication involved a single case of accidental PEG removal that was successfully resolved surgically. Unsedated PEG insertion appears to be a feasible, well-tolerated, and safe option for stroke-related dysphagia.

Non-vascular interventional radiology in the paediatric alimentary tract.

Paediatric interventional radiology is an evolving speciality which is able to offer numerous minimally invasive treatments for gastrointestinal tract pathologies. Here we describe interventions performed by paediatric interventional radiologists on the alimentary tract from the mouth to the rectum. The interventions include sclerotherapy, stricture management by dilation, stenting and adjunctive therapies such as Mitomycin C administration and enteral access for feeding, motility assessment and administration of enemas.

Rendezvous endoscopic recanalization for complete esophageal obstruction.

BACKGROUND AND STUDY AIM: Complete esophageal obstruction after (chemo)radiation for head and neck cancers is rare. However, inability to swallow one's own saliva strongly inflicts upon quality of life. Techniques for endoscopic recanalization in complete obstruction are not well established. We assessed the efficacy and safety of rendezvous recanalization. PATIENTS AND METHODS: We performed a retrospective review of all patients who underwent endoscopic recanalization of complete proximal esophageal obstruction after radiotherapy between January 2009 and June 2016. Technical success was defined as an ability to pass an endoscope across the recanalized lumen, clinical success by changes in the dysphagia score. Adverse events were recorded prospectively. RESULTS: 19 patients with complete obstruction (dysphagia IV°), all of whom had failed at least one trial of conventional dilatation, underwent recanalization by endoscopic rendezvous, a combined approach through a gastrostomy and perorally under fluoroscopic control. Conscious sedation was used in all patients. In 18/19 patients (94.7%), recanalization was technically successful. In 14/18 patients (77.8%), the post-intervention dysphagia score changed to ≤ II. Three patients had their PEG removed. Factors negatively associated with success were obstruction length of 50 mm; and tumor recurrence for long-term success. No severe complications were recorded. CONCLUSIONS: Rendezvous recanalization for complete esophageal obstruction is a reliable and safe method to re-establish luminal patency. Differences between technical and clinical success rates highlight the importance of additional functional factors associated with dysphagia. Given the lack of therapeutic alternatives, rendezvous recanalization is a valid option to improve dysphagia.

SERUM ELECTROLYTES AND OUTCOME IN PATIENTS UNDERGOING ENDOSCOPIC GASTROSTOMY.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a gold standard for long term enteral feeding. Neurologic dysphagia and head/neck cancer are the most common indications for PEG as they can lead to protein-energy malnutrition and serum electrolyte abnormalities, with potential negative impact on metabolic balance. Refeeding syndrome may also be related with severe electrolyte changes in PEG-fed patients and contribute to poor prognosis. OBJECTIVE: This study aims to evaluate the changes in serum concentrations of the main electrolytes and its possible association with the outcome. METHODS: Retrospective study of patients followed in our Artificial Nutrition Clinic, submitted to PEG from 2010 to 2016, having head/neck cancer or neurologic dysphagia, who died under PEG feeding. Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium and phosphorus) were evaluated immediately before the gastrostomy procedure. Survival after PEG until death was recorded in months. RESULTS: We evaluated 101 patients, 59 with electrolyte alterations at the moment of the gastrostomy. Sodium was altered in 32 (31.7%), magnesium in 21 (20.8%), chlorine in 21 (20.8%), potassium in 14 (13.8%), calcium in 11 (10.9 %) and phosphorus in 11 (10.9%). The survival of patients with low sodium (<135 mmol/L) was significantly lower when compared to patients with normal/high values, 2.76 months vs 7.80 months, respectively (P=0.007). CONCLUSION: Changes in serum electrolytes of patients undergoing PEG were very common. More than half showed at least one abnormality, at the time of the procedure. The most frequent was hyponatremia, which was associated with significantly shorter survival, probably reflecting severe systemic metabolic distress.

Eletrólitos séricos e prognóstico em doentes submetidos a gastrostomia endoscópica / Serum electrolytes and outcome in patients undergoing endoscopic gastrostomy

ABSTRACT BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a gold standard for long term enteral feeding. Neurologic dysphagia and head/neck cancer are the most common indications for PEG as they can lead to protein-energy malnutrition and serum electrolyte abnormalities, with potential negative impact on metabolic balance. Refeeding syndrome may also be related with severe electrolyte changes in PEG-fed patients and contribute to poor prognosis. OBJECTIVE: This study aims to evaluate the changes in serum concentrations of the main electrolytes and its possible association with the outcome. METHODS: Retrospective study of patients followed in our Artificial Nutrition Clinic, submitted to PEG from 2010 to 2016, having head/neck cancer or neurologic dysphagia, who died under PEG feeding. Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium and phosphorus) were evaluated immediately before the gastrostomy procedure. Survival after PEG until death was recorded in months. RESULTS: We evaluated 101 patients, 59 with electrolyte alterations at the moment of the gastrostomy. Sodium was altered in 32 (31.7%), magnesium in 21 (20.8%), chlorine in 21 (20.8%), potassium in 14 (13.8%), calcium in 11 (10.9 %) and phosphorus in 11 (10.9%). The survival of patients with low sodium (<135 mmol/L) was significantly lower when compared to patients with normal/high values, 2.76 months vs 7.80 months, respectively (P=0.007). CONCLUSION: Changes in serum electrolytes of patients undergoing PEG were very common. More than half showed at least one abnormality, at the time of the procedure. The most frequent was hyponatremia, which was associated with significantly shorter survival, probably reflecting severe systemic metabolic distress.

RESUMO CONTEXTO: A gastrostomia endoscópica percutânea (PEG) é a via de eleição preferencial para a nutrição entérica de longa duração. A disfagia neurológica e as neoplasias cervico-faciais constituem as principais indicações para PEG por poderem conduzir a desnutrição energético-proteica e alterações hidroeletrolíticas, com potencial impacto negativo no equilíbrio metabólico. A síndrome de realimentação pode também estar associada a alterações hidroeletrolíticas graves em doentes alimentados por PEG e contribuir para um mau prognóstico. OBJETIVO: Avaliar as alterações das concentrações séricas dos principais eletrólitos e a eventual associação entre os valores séricos alterados e o prognóstico dos doentes gastrostomizados. Métodos - Estudo retrospetivo realizado em doentes seguidos na Consulta de Nutrição Artificial do Hospital Garcia de Orta, propostos e submetidos a PEG, de 2010 a 2016 e que faleceram sob nutrição por PEG. Consideraram-se os valores séricos dos iões em estudo avaliados imediatamente antes do procedimento endoscópico de gastrostomia, obtidos por consulta do processo clínico. A sobrevida, após a realização da PEG até à morte foi registrada em meses. RESULTADOS: Avaliaram-se 101 doentes. A sobrevida média pós-gastrostomia foi 6,55 meses. Destes, 59 apresentaram alterações de alguns iões no momento da realização da PEG. O sódio estava alterado em 31 (30,6%), magnésio em 20 (19,8%), cloro em 19 (18,8%), potássio em 14 (13,8%), cálcio em 10 (9,9%) e o fósforo em 9 (8,9%). Quando comparada a sobrevida dos doentes com valores de sódio baixo (<135 mmol/L) com a dos doentes com valores normais/elevados, esta foi 2,76 meses vs 7,80 meses, respectivamente (P=0,007). CONCLUSÃO: As alterações dos eletrólitos séricos nos doentes submetidos a PEG foram muito frequentes, com mais de metade dos doentes a apresentarem pelo menos uma alteração aquando da realização do procedimento. A alteração mais frequente foi a hiponatrémia, associando-se a pior prognóstico com sobrevida significativamente mais curta, refletindo provavelmente um grave compromisso metabólico sistêmico.

Nutrition and Swallowing Therapy in Head and Neck Cancer: Utilization of Care and Preventative Efficacy.

PURPOSE: To examine the impact of ethnicity, Spanish language preference, socioeconomic status, and treatment setting on utilization of supportive services before radiotherapy (RT) among head and neck cancer patients and to determine whether a lack of these services is associated with an increased rate of adverse events. METHODS AND MATERIALS: Demographic, staging, and treatment details were retrospectively collected for patients treated at a safety-net hospital (n = 56) or adjacent private academic hospital (n = 183) from January 1, 2014, to June 30, 2016. Supportive care services evaluated were limited to speech/swallowing therapy and nutrition therapy. Adverse events and performance measures examined included weight loss during RT, gastric tube placement, emergency department visits, hospital admissions, and missed RT days. RESULTS: On multivariable analysis, patients receiving treatment at the safety-net hospital were less likely to receive speech/swallowing services. Receiving speech/swallowing therapy before treatment was associated with less weight loss during treatment, and in conjunction with nutrition therapy, was associated with fewer missed RT days. CONCLUSION: Safety-net hospital treatment was associated with a lack of utilization of pre-RT speech/swallowing therapy which in turn was associated with increased weight loss. Interventions aimed at improving utilization of these services would improve treatment tolerance and patient outcomes.

Preoperative Educational Intervention Decreases Unplanned Gastrostomy-Related Health Care Utilization.

Apprehension in taking independent care of children with medical devices may lead to unnecessary visits to the ED and/or acute clinic (AC). To address these concerns, our institution implemented a gastrostomy tube (GT) class in 2011 for caretakers. We hypothesized that inappropriate GT-related ED/AC visits would be lower in preoperatively educated caregivers. We performed a retrospective cohort study of all patients aged 0 to 18 who received GT (surgical or percutaneous) at our institution between 2006 and 2015 (n = 1340). Class attendance (trained vs untrained) and unscheduled GT-related ED/AC visits one year after GT placement were reviewed. Gastrostomy-related ED/AC visits were classified as appropriate (hospital-based intervention) or inappropriate (site care and education/reassurance). Occurrence of ED/AC visits was compared between trained and untrained cohorts. We found that 59 per cent of patients had an unscheduled GT-related ED/AC visit within one year of placement. The trained cohort had 27 per cent less unplanned ED/AC visits within one year (mean 1.21 (SD 1.82) vs untrained 1.65 (2.24), P < 0.001). On multivariate analysis, GT education independently decreased one-year GT-related health care utilization (Odds Ratio 0.75, 95% Confidence Interval 0.59-0.95). Formal education seems to decrease GT-related health care utilization within one year of placement and should be integrated into a comprehensive care plan to improve caregiver self-efficacy.

Clinical use of metal and plastic calipers for nutritional assessment of patients under long-term enteral feeding through endoscopic gastrostomy / Utilización clínica de adipómetros metálicos y plásticos para la evaluación nutricional de pacientes en nutrición enteral de larga duración por gastrostomía endoscópica

Background: Endoscopic gastrostomy (PEG) fed patients, including those with neurologic disorders (ND) or head and neck cancer (HNC) present high malnutrition risk and speech difficulties. Teams taking care of these patients need to rely on anthropometric data. Skinfold thickness (TSF) is used to assess nutritional status, but the use of heavy, large and expensive metal calipers may become a limitation. This study aimed to compare and correlate TSF measurements using a metal caliper and a plastic caliper in PEG fed patients. Methods: Prospective observational study on adult PEG fed patients. TSF was measured using plastic Ross and Lange metal calipers. Paired measurements were compared and correlated. Results: Fifty-one patients, 37 men (72.5%), 14 women (27.5%): 28 (54.9%) ND patients; 23 (45.1%) with HNC. In total, 94 TSF measurements were performed using both plastic and metal calipers. Significant association was found between TSF measurements with the two equipments (rs = 0.94; p < 0.001). High correlation was observed between TSF measurements using both calipers for both genders (men: rs = 0.93; p < 0.001; women: rs = 0.96; p < 0.001), age (< 65 years: rs = 0.98; p < 0.001; ≥ 65 years: rs = 0.88; p < 0.001), underlying condition (ND: rs = 0.91; p < 0.001; HNC: rs = 0.95; p < 0.001) and time of TSF evaluation (before PEG: rs = 0.95; p < 0,001; after PEG: rs = 0.92; p < 0.001). Conclusions: TSF measurements obtained with small, light and cheap plastic Ross caliper were equivalent to those obtained with larger, heavier and more expensive metal caliper. For everyday clinical practice, plastic calipers may be suitable for teams taking care of PEG fed patients in hospital wards, outpatient clinic and home visits (AU)

Introducción: los pacientes alimentados por gastrostomía endoscópica (PEG), incluyendo aquellos con enfermedades neurológicas o cáncer de cabeza y cuello, presentan un riesgo elevado de desnutrición. Los equipos que cuidan a estos pacientes se basan frecuentemente en datos antropométricos. El pliegue cutáneo del tríceps (TSF) se utiliza para evaluar el estado nutricional, pero la utilización de adipómetros metálicos pesados, grandes y costosos puede convertirse en una limitación. El presente estudio pretende comparar y correlacionar las mediciones de la TSF usando un adipómetro metálico y de plástico en pacientes alimentados por PEG. Métodos: estudio observacional prospectivo en pacientes alimentados por PEG. La TSF se midió utilizando el adipómetro metálico de Lange y el adipómetro plástico de Ross. Las mediciones emparejadas se compararon y correlacionaron. Resultados: cincuenta y un pacientes, 37 hombres (72,5%), 14 mujeres (27,5%): 28 (54,9%) pacientes neurológicos; 23 (45,1%) con cáncer de cabeza y cuello. En total, se efectuaron 94 mediciones utilizando ambos los adipómetros (de plástico y metálico). Se encontró una asociación significativa entre las mediciones de TSF con los dos tipos de adipómetros (rs = 0,94; p < 0,001). Se observó también una correlación fuerte entre las mediciones de TSF utilizando ambos adipómetros para ambos los géneros (hombres: rs = 0,93; p < 0,001; mujeres: rs = 0,96; p < 0,001), edad (< 65 años: rs = 0,98; p < 0,001; ≥ 65 años: rs = 0,88; p < 0,001), enfermedad de base (neurológicos: rs = 0,91; p < 0,001, cáncer: rs = 0,95; p < 0,001) y tiempo de evaluación (antes de PEG: rs = 0,95; p < 0,001; después de PEG: rs = 0,92; p < 0,001). Conclusiones: las mediciones de TSF obtenidas con adipómetros de plástico Ross, pequeños, ligeros y menos costosos, fueron equivalentes aquellos en que se utilizaron adipómetros metálicos grandes, pesados y más caros. Los adipómetros de plástico pueden ser más adecuados para la práctica clínica diaria de los equipos que abordan pacientes alimentados por PEG en régimen de ambulatorio o internamiento (AU)

A retrospective matched cohort study evaluating the effects of percutaneous endoscopic gastrostomy feeding tubes on nutritional status and survival in patients with advanced gastroesophageal malignancies undergoing systemic anti-cancer therapy.

BACKGROUND: Many patients with cancer or other systemic illnesses can experience malnutrition. One way to mitigate malnutrition is by insertion of a percutaneous endoscopic gastrostomy feeding tube (PEG tube). The goal of this retrospective matched cohort study is to evaluate if PEG tube placement improved nutritional status and overall survival (OS) in advanced gastroesophageal (GE) cancer patients who are undergoing anti-neoplastic therapy. METHODS: GE cancer patients who were treated and evaluated by a nutritionist and had at least 2 nutritionist follow-up visits were identified. Patients with PEG tube were matched to patients that did not undergo PEG placement (non-PEG). Clinical characteristics, GE symptoms reported at nutrition follow-up visits, and OS were recorded. RESULTS: 20 PEG and 18 non-PEG cases met criteria for further analyses. After correction for multiple testing, there were no OS differences between PEG and non-PEG, treatment naive and previously treated. However, PEG esophageal carcinoma has statistically significant inferior OS compared with non-PEG esophageal carcinoma. PEG placement did not significantly reduce the proportion of patients with weight loss between the initial nutrition assessment and 12-week follow-up. CONCLUSIONS: In this small study, PEG placement had inferior OS outcome for GE esophageal carcinoma, no improvement in OS for other evaluated groups, and did not reduce weight loss between baseline and 12-week follow-up. Unless there is prospective randomized trial that can show superiority of PEG placement in this population, PEG placement in this group cannot be endorsed.

ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient.

The value of nutrition therapy for the adult hospitalized patient is derived from the outcome benefits achieved by the delivery of early enteral feeding. Nutritional assessment should identify those patients at high nutritional risk, determined by both disease severity and nutritional status. For such patients if they are unable to maintain volitional intake, enteral access should be attained and enteral nutrition (EN) initiated within 24-48 h of admission. Orogastric or nasogastric feeding is most appropriate when starting EN, switching to post-pyloric or deep jejunal feeding only in those patients who are intolerant of gastric feeds or at high risk for aspiration. Percutaneous access should be used for those patients anticipated to require EN for >4 weeks. Patients receiving EN should be monitored for risk of aspiration, tolerance, and adequacy of feeding (determined by percent of goal calories and protein delivered). Intentional permissive underfeeding (and even trophic feeding) is appropriate temporarily for certain subsets of hospitalized patients. Although a standard polymeric formula should be used routinely in most patients, an immune-modulating formula (with arginine and fish oil) should be reserved for patients who have had major surgery in a surgical ICU setting. Adequacy of nutrition therapy is enhanced by establishing nurse-driven enteral feeding protocols, increasing delivery by volume-based or top-down feeding strategies, minimizing interruptions, and eliminating the practice of gastric residual volumes. Parenteral nutrition should be used in patients at high nutritional risk when EN is not feasible or after the first week of hospitalization if EN is not sufficient. Because of their knowledge base and skill set, the gastroenterologist endoscopist is an asset to the Nutrition Support Team and should participate in providing optimal nutrition therapy to the hospitalized adult patient.

A prospective study comparing prophylactic gastrostomy to nutritional counselling with a therapeutic feeding tube if required in head and neck cancer patients undergoing chemoradiotherapy in Thai real-world practice.

BACKGROUND: Concurrent chemoradiotherapy (CRT) is the standard treatment for head and neck (HN) cancer patients. Most patients experience malnutrition and weight loss during treatment because of mucositis and difficulty in swallowing. Prevention of malnutrition may allow more patients to complete their treatment. The present study aimed to examine whether prophylactic gastrostomy tube (PGT) could reduce treatment interruption, prevent malnutrition and maintain quality of life, especially in Thai patients who generally do not accept feeding tubes. METHODS: A prospective study was performed on HN cancer patients undergoing CRT at a tertiary hospital in Thailand (n = 95). Before starting CRT, all patients received nutritional assessment and were counselled about the risks and benefits of PGT. According to patient discretion, they chose to have a PGT (experimental group) or only nutritional counselling with a therapeutic feeding tube if required (control group). During CRT, weight, degree of mucositis, delayed chemotherapy and/or radiotherapy, and nutritional status were recorded. Quality of life (Functional Assessment of Cancer Therapy - Head and Neck Scale; FACT-H&N) was compared between two groups. RESULTS: There was no significant difference in the rates of delayed treatment. Mean weight loss was 3.1 and 4.8 kg in the experimental and control groups, respectively (P = 0.04). A higher proportion of patients in the control group experienced ≥10% weight loss (24% versus 4%; P = 0.03). In terms of quality of life, no significant difference in FACT-H&N score was found. CONCLUSIONS: The results of the present study suggest that PGT provided similar quality of life without a reduction in treatment interruption. However, patients with PGT had significantly less weight loss (P = 0.04) during CRT.

The Effects of Glucose Therapy Agents-Apple Juice, Orange Juice, and Cola-on Enteral Tube Flow and Patency.

To develop evidence-based hypoglycemia treatment protocols in patients receiving total enteral nutrition, this study determined the effect on enteral tube flow of glucose therapy agents: apple juice, orange juice, and cola, and it also examined the effects of tube type and feed type with these glucose therapy agents. For this study, 12 gastrostomy tubes (6 polyethylene and 6 silicone) were set at 50 mL/h. Each feeding set was filled with Isosource HN with fibre or Novasource Renal. Each tube was irrigated with 1 glucose therapy agent, providing approximately 20 g of carbohydrate every 4 h. Flow-rate measurements were collected at 2 h intervals. The results showed that the glucose therapy agent choice affected flow rates: apple juice and cola had higher average flow rates than orange juice (P = 0.01). A significant difference was found between tube type and enteral formula: polyethylene tubes had higher average flow rates than silicone tubes (P < 0.0001), and Isosource HN with fibre had higher flow rates than Novasource Renal (P = 0.01). We concluded that apple juice and cola have less tube clogging potential than orange juice, and thus may be considered as primary treatment options for hypoglycemia in enterally fed patients. Polyethylene tubes and Isosource HN with fibre were less likely to clog than silicone tubes and Novasource Renal.

Antegrade transverse or sigmoid colonic enema through a percutaneous endoscopic gastrostomy tube is an option in the treatment of colorectal dysfunction.

BACKGROUND: Antegrade colonic enemas are used in patients with colorectal dysfunction resistant to conservative therapy. A number of different operative techniques are applied, but their effectiveness is by and large unknown. We therefore evaluated the long-term usefulness of the left-sided percutaneous endoscopic gastrostomy (PEG) tube method in adult patients. METHODS: Twenty-one patients with colorectal dysfunction underwent insertion of a PEG tube colostomy by laparotomy between 1997 and 2006. In 2014, we evaluated how many of the patients had the tube still in place, how the patients coped with the tube, and what the reasons for the removal were. RESULTS: The main indications were severe constipation or fecal incontinence mainly related to neurological diseases. In 2014, 5 out of 21 patients had the tube still in use (median follow-up 14 years, range 11-17 years) and 4 out of 5 deceased patients had had the tube in use until their death, unrelated to this treatment (median follow-up 7 years, range 0-8 years). Four out of the 5 living patients considered the benefit of the tube to be good or excellent. Tubes were removed in 11 (52%) patients for various reasons, local skin irritation being the most common. CONCLUSIONS: A left-sided PEG tube colostomy was removed in over half of the patients, but despite that, it still seems to be a viable long-term option in the treatment of individual patients with colorectal dysfunction, when conservative methods are ineffective.

Efficacy of percutaneous endoscopic gastrostomy on unplanned treatment interruption and nutritional status in patients undergoing chemoradiotherapy for advanced head and neck cancer.

OBJECTIVE: Efficacy of percutaneous endoscopic gastrostomy (PEG) on unplanned treatment interruption and nutritional status was examined in patients undergoing chemoradiotherapy (CRT) for advanced head and neck cancer. METHODS: We retrospectively reviewed hospital charts of 44 patients with advanced head and neck cancer who were treated with CRT. RESULTS: CRT-induced mucositis of grade 3 or worse and inadequate oral intake of less than one third of their usual intake developed in 33 patients who were recommended PEG placement, but not in 11 patients. Thirteen patients accepted PEG placement and then completed CRT (compliant group). However, among 20 patients who refused both PEG and nasogastoric tube (NGT) placements (non-compliant group), 10 required unplanned interruptions of CRT at a radiation dose around 30-40 Gy (UI-CRT group) while 10 others could complete CRT without interruption (C-CRT group) CRT. Total serum protein levels were significantly decreased after CRT in all patients. DISCUSSION: It is suggested that therapeutic PEG placement is useful for preventing unplanned interruption of CRT in patients with advanced head and neck cancer. After severe mucositis and inadequate oral intake have developed during CRT, PEG placement should be considered before the radiation therapy dose of 30 Gy.