Time trends and outcomes of gastrostomy placement in a Swedish national cohort over two decades.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) and laparoscopically inserted gastrostomy have become the gold standard for adult patients and children, respectively, requiring long-term enteral nutrition support. Procedure-related mortality is a rare event, often reported to be zero in smaller studies. National data on 30-d mortality and long-term survival rates after gastrostomy placement are scarce in the literature. AIM: To study the use of gastrostomies in Sweden from 1998-2019 and to analyze procedure-related mortality and short-term (< 30 d) and long-term survival. METHODS: In this retrospective, population-based cohort study, individuals that had received a gastrostomy between 1998-2019 in Sweden were included. Individuals were identified in the Swedish National Patient Register, and survival analysis was possible by cross-referencing the Swedish Death Register. The cohort was divided into three age groups: Children (0-18 years); adults (19-64 years); and elderly (≥ 65 years). Kaplan-Meier with log-rank test and Cox regression were used for survival analysis. RESULTS: In total 48682 individuals (52% males, average age 60.9 ± 25.3 years) were identified. The cohort consisted of 12.0% children, 29.5% adults, and 58.5% elderly. An increased use of gastrostomies was observed during the study period, from 13.7/100000 to 22.3/100000 individuals (P < 0.001). The use of PEG more than doubled (about 800 to 1800/year), with a corresponding decrease in open gastrostomy (about 700 to 340/year). Laparoscopic gastrostomy increased more than ten-fold (about 20 to 240/year). Overall, PEG, open gastrostomy, and laparoscopic gastrostomy constituted 70.0% (n = 34060), 23.3% (n = 11336), and 4.9% (n = 2404), respectively. Procedure-related mortality was 0.1% (n = 44) overall (PEG: 0.05%, open: 0.24%, laparoscopic: 0.04%). The overall 30-d mortality rate was 10.0% (PEG: 9.8%, open: 12.4%, laparoscopic: 1.7%) and decreased from 11.6% in 1998-2009 vs 8.5% in 2010-2019 (P < 0.001). One-year and ten-year survival rates for children, adults, and elderly were 93.7%, 67.5%, and 42.1% and 79.9%, 39.2%, and 6.8%, respectively. The most common causes of death were malignancies and cardiovascular and respiratory diseases. CONCLUSION: The annual use of gastrostomies in Sweden increased during the study period, with a shift towards more minimally invasive procedures. Although procedure-related death was rare, the overall 30-d mortality rate was high (10%). To overcome this, we believe that patient selection should be improved.

Inoperable malignant bowel obstruction: palliative interventions outcomes - mixed-methods systematic review.

BACKGROUND: Parenteral nutrition (PN) and palliative venting gastrostomies (PVG) are two interventions used clinically to manage inoperable malignant bowel obstruction (MBO); however, little is known about their role in clinical and quality-of-life outcomes to inform clinical decision making. AIM: To examine the impact of PN and PVG on clinical and quality-of-life outcomes in inoperable MBO. DESIGN: A mixed-methods systematic review and narrative synthesis. DATA SOURCES: The following databases were searched (from inception to 29 April 2021): MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Bielefeld Academic Search Engine, Health Technology Assessment and CareSearch for qualitative or quantitative studies of MBO, and PN or PVG. Titles, abstracts and papers were independently screened and quality appraised. RESULTS: A total of 47 studies representing 3538 participants were included. Current evidence cannot tell us whether these interventions improve MBO survival, but this was a firm belief by patients and clinicians informing their decision. Both interventions appear to allow patients valuable time at home. PVG provides relief from nausea and vomiting. Both interventions improve quality of life but not without significant burdens. Nutritional and performance status may be maintained or improved with PN. CONCLUSION: PN and PVG seem to allow valuable time at home. We found no conclusive evidence to show either intervention prolonged survival, due to the lack of randomised controlled trials that have to date not been performed due to concerns about equipoise. Well-designed studies regarding survival for both interventions are needed. PROSPERO REGISTRATION NUMBER: CRD42020164170.

Tumor Seeding Post Nutritional Support Implementation: A Rare Complication; A Scoping Review.

Patients with cancer are at risk of malnutrition because of reduced food intake, thus making oral intake challenging. Thus, nutritional support is used to provide the nutrient requirements. Feeding tube site implantation among patients with cancer has been reported after endoscopic feeding gastrostomy installation. This manuscript aims to further explore this phenomenon using a structured database review. Among 33 seeding cases included in this review, case reports (70 %) were the most common study design, predominantly using percutaneous endoscopic gastrostomy via the pull method. The duration between tube implantation and seeding detection ranged from 7.12 ± 3.7 months, with some missing data among the included studies. The most common primary cancer diagnosis was head and neck cancer. Tumor seeding was higher among male patients than that in female patients. However, large-scale, statistically powered studies are needed to further investigate this complication.

Evaluation of community nurse-led traumatic tube displacements.

Home enteral tube feeding (HEF) has many benefits and is largely safe practice. Some complications have historically required intervention in the acute setting, including traumatic displacement of feeding tubes (i.e. internal bumper/balloon removed intact), and evidence to support the safe replacement of these tubes in the community is lacking. To address this, a service enabling community homecare nurses (CHN) to replace traumatically displaced feeding tubes was designed and evaluated. Adult patients presenting with a traumatically displaced feeding tube over 29 months were included in the service evaluation. Baseline characteristics and outcomes at day 1, 7 and 6 months post-replacement were recorded. A total of 71 tube replacements were performed by CHNs in 60 patients. No clinical complications were recorded at any follow-up points. A simple cost analysis estimated savings of £235 754.40. These results suggest that nurse-led replacement of traumatically displaced feeding tubes in adults in the community is low-risk and offers potential cost savings.

Head and neck cancer patients treated with concomitant chemoradiotherapy involving the oral cavity and oropharynx: is another choice possible than prophylactic gastrostomy?

PURPOSE OF REVIEW: Recent recommendations on cachexia highlight, in head and neck cancers, the heterogeneity of studies, focusing on weight loss and sequelae including swallowing disorders. The current national guidelines emphasize that, in cases of concurrent chemoradiotherapy (cCRT) involving the oral cavity and oropharynx, prophylactic gastrostomy placement should be carried out systematically. We review why this technique is particularly relevant in this specific location for the feasibility of cCRT. RECENT FINDINGS: A randomized trial is underway on swallowing disorders and the quality of life of patients after prophylactic vs. reactive gastrostomy in advanced oropharyngeal cancer patients treated with CRT. Concurrently, recent literature reviews emphasize the importance of the cumulative dose of chemotherapy for local control and survival. In cases of cCRT involving the oral cavity or the oropharynx, nutritional support could have a beneficial or detrimental impact on chemotherapy. SUMMARY: Specifically for patients treated with cCRT involving the oral cavity and oropharynx, prophylactic gastrostomy would be able to fulfill the three objectives of local control, survival, and quality of life, minimizing complications related to nutritional support. Studies need to be more homogeneous. In clinical practice, nutrition should primarily assist in carrying out cancer treatment when survival is the main goal.

Prophylactic anti-reflux procedure for children undergoing laparoscopic gastrostomy: Rethinking of the routine practice.

AIM: Laparoscopic gastrostomy is a frequently performed procedure in children requiring long-term enteral nutrition. The role of prophylactic anti-reflux surgery during gastrostomy placements is controversial. The current study aims to evaluate the role of prophylactic anti-reflux procedures during gastrostomy placement. METHODS: A retrospective single-center analysis of all children without reflux receiving laparoscopic gastrostomy from January 2005 through December 2021 was performed. Demographics and clinical outcomes were compared between patients receiving gastrostomy placement alone and patients receiving gastrostomy with prophylactic anti-reflux surgery. RESULTS: A total of 79 patients had a confirmed absence of reflux by a 24-h pH/impedance study before operation. Thirty-six of these patients underwent prophylactic anti-reflux surgery (PAR) while 43 received gastrostomy (PG) alone. The operative time and conversion rate were significantly higher in the PAR group (140.5 ± 67.5 vs. 80.2 ± 66.8 min, p = 0.0001 and 8.3% vs. 0%, p = 0.04). There were no major complications in either group. De novo reflux was detected in five patients (11.6%) in the PG group. None of these patients progressed to require anti-reflux surgery. CONCLUSION: The occurrence of de novo reflux after laparoscopic gastrostomy was low and could be managed without anti-reflux surgery. A routine pre-operative pH study is helpful for appropriate patient selection to avoid unnecessary anti-reflux surgery, which lengthens operative time and increases the conversion rate.

Gastrostomy Tubes: Indications, Types, and Care.

Gastrostomy tube insertion has become a more common practice in pediatric patients. An increasing number of children both in health-care facilities and at home are relying on temporary or long-term enteral feeding. Gastrostomy tube placement can be accomplished by various methods and by a variety of specialists. Despite the overall safety of these procedures, both early and late complications can occur. It is important for pediatricians and pediatric subspecialists to be familiar with and aware of the indications, safety, and management of gastrostomies. This paper provides a comprehensive overview of the topic.

[Chinese expert consensus on clinical application of percutaneous endoscopic gastrostomy / jejunostomy (2024 edition)].

Percutaneous endoscopic gastrostomy / jejunostomy (PEG/J) is a relatively safe and effective minimally invasive surgical approach to establish long-term enteral nutrition (EN) channels. Due to the good compliance and the reduced incidence of reflux and aspiration pneumonia, PEG/J is the preferred way for long-term EN and has been widely used in clinical applications. However, few technical guidelines or expert consensus guiding the clinical practice of PEG/J have been published. The formation of "Chinese expert consensus on clinical application of percutaneous endoscopic gastrostomy / jejunostomy (2024 edition)" is led by the Committee of Parenteral and Enteral Nutrition, Chinese Research Hospital Association. This consensus is based on the latest clinical evidence as well as the clinical experience of Chinese experts. This consensus is divided into PEG/J indications and contraindication, perioperative management, operational techniques, prevention, and treatment of related complications and other issues. All recommendations and their strengths were carried out by expert-voting method and presented as the basic framework of "Recommended Opinions (level of evidence and strength of recommendation) and Summary of Evidence". This consensus is registered on the International Practice Guide Registration Platform (IPGRP-2022CN329).

Timing and impact of percutaneous endoscopic gastrostomy insertion in patients with amyotrophic lateral sclerosis: a comprehensive analysis.

Dysphagia is common in amyotrophic lateral sclerosis (ALS) patients, often requiring percutaneous endoscopic gastrostomy (PEG) for enteral nutrition. We retrospectively analyzed data from 188 Korean patients with ALS who underwent PEG tube insertion at five-time points: symptom onset (t1), diagnosis (t2), recommended time for gastrostomy (t3), PEG insertion (t4), and one-year post-insertion (t5). The recommended time point for gastrostomy (T-rec for gastrostomy) was defined as the earlier time point between a weight loss of more than 10% and advanced dysphagia indicated by the ALSFRS-R swallowing subscore of 2 or less. The T-rec for gastrostomy was reached at 22 months after symptom onset, followed by PEG insertion at 30 months, resulting in an 8-month delay. During the delay, the ALSFRS-R declined most rapidly at 1.7 points/month, compared to 0.8 points/month from symptom onset to diagnosis, 0.7 points/month from diagnosis to T-rec for gastrostomy, and 0.6 points/month after the PEG insertion. It is crucial to discuss PEG insertion before significant weight loss or severe dysphagia occurs and minimize the delay between the recommended time for gastrostomy and the actual PEG insertion. A stratified and individualized multidisciplinary team approach with careful symptom monitoring and proactive management plans, including early PEG insertion, should be prioritized to improve patient outcomes.

Utility of gastrostomy tube placement at the time of pancreaticoduodenectomy.

PURPOSE: The aim of this study is to investigate the utility of gastrostomy tube (G-tube) placement in reducing delayed gastric emptying (DGE) among patients undergoing pancreaticoduodenectomy (PD). METHODS: We retrospectively reviewed consecutive patients undergoing PD from 2015 to 2020 at our institution. Thirty-day patient outcomes including DGE, length of stay (LOS), reoperation rates, and morbidity were analyzed in patients with or without G-tube placement. RESULTS: 128 patients with resectable pancreatic head cancer (54 females, median age 68.50 [59.00-74.00]) underwent PD (66 had G-tube placement and 62 did not). There was no significant difference in the incidence of DGE (n = 17 vs. n = 17, p = 0.612), and LOS between the groups. Postoperative ileus (p = 0.007) was significantly lower while atrial fibrillation (p = 0.037) was higher among the G-tube group. Gastrostomy-related complications (p = 0.001) developed in ten patients: skin-related complications (n = 6), tube dislodgement (n = 3) and clogging (n = 1). Nine patients required reoperation during index admission (n = 4 vs. n = 5, p = 1.000). There was no difference in 30-day readmissions (n = 7 vs. n = 5, p = 0.471) and no difference in 30 or 90-day mortality. CONCLUSION: Gastrostomy tube placement during index PD did not affect the incidence of DGE. However, patients experienced significant morbidities due to G-tube-related complications. Placement of gastrostomy tubes at the index PD offers no clinical benefits.

Safety and efficacy of stoma site selection in CT-guided percutaneous gastrostomy: a retrospective analysis.

PURPOSE: To compare the safety and efficacy of CPG in the rectus abdominis and intercostal regions. MATERIALS AND METHODS: This retrospective study included 226 patients who underwent CPG at a single center, with the stoma placed in the rectus abdominis or intercostal region. Surgical outcomes and complications, such as pain and infection within 6 months postoperatively, were recorded. RESULTS: The surgical success rate was 100%, and the all-cause mortality rate within 1 month was 0%. An intercostal stoma was placed in 56 patients; a rectus abdominis stoma was placed in 170 patients. The duration of surgery was longer for intercostal stoma placement (37.66 ± 14.63 min) than for rectus abdominis stoma placement (30.26 ± 12.40 min) (P = 0.000). At 1 month postsurgery, the rate of stoma infection was greater in the intercostal group (32.1%) than in the rectus abdominis group (20.6%), but the difference was not significant (P = 0.077). No significant difference was observed in the infection rate between the two groups at 3 or 6 months postsurgery (P > 0.05). Intercostal stoma patients reported higher pain scores during the perioperative period and at 1 month postsurgery (P = 0.000), but pain scores were similar between the two groups at 3 and 6 months postsurgery. The perioperative complication rates for intercostal and rectus abdominis surgery were 1.8% and 5.3%, respectively (P = 0.464), with no significant difference in the incidence of tube dislodgement (P = 0.514). Patient weight improved significantly at 3 and 6 months postoperatively compared to preoperatively (P < 0.05). CONCLUSION: Rectus abdominis and intercostal stomas have similar safety and efficacy. However, intercostal stomas may result in greater short-term patient discomfort.

Successful Conservative Management of Hepatic Portal Venous Gas Following Percutaneous Endoscopic Gastrostomy: A Case Report.

BACKGROUND Hepatic portal venous gas (HPVG) is a rare radiologic finding mostly associated with life-threatening diseases like bowel necrosis, but can also be benign; its overall mortality rate is 39-75%. In rare cases HPVG is associated with endoscopic procedures such as percutaneous endoscopic gastrostomy (PEG) placement. However, due to the rarity of this condition, there is no recommendation about its management. The aim of this case report was to describe a successful conservative management of HPVG without antibiotic administration based on the clinical presentation. CASE REPORT A 78-year-old male patient known for a history of esophageal cancer treated with radio- and chemotherapy, complicated by a post-radiation esophageal stenosis requiring a PEG tube placement 1 month prior was admitted to our Emergency Department for vomiting and abdominal pain. A contrast-enhanced abdominal CT scan showed small-bowel dilatation without obstruction, as well as gastric wall pneumatosis and HPVG. We opted for a conservative approach. The PEG was put to suction for 2 days. The clinical evolution was favorable, with resolution of abdominal pain and a restored transit on day 2. A follow-up CT scan at day 5 showed resolution of HPVG. Nutrition through the PEG was restored at day 6 without complication. CONCLUSIONS HPVG can be a benign finding after a PEG tube placement. Conservative management without antibiotics can be used in oligosymptomatic and hemodynamically stable patients after life-threatening associated diseases like bowel necrosis have been ruled out.

The Association of Social Determinants of Health With Short Term Pediatric Gastrostomy Tube Outcomes.

INTRODUCTION: Social determinants of health (SDH) have been found to be important contributors to postoperative outcomes, especially those related to procedures that require significant postoperative resources. The association between short-term gastrostomy tube (GT) outcomes and SDH in the pediatric population is unknown. METHODS: A retrospective review was performed of all patients less than 18 y old who received a GT between January 2018 and December 2020 at a single institution. Data including demographics, area deprivation index (ADI), and perioperative information were collected. Patient characteristics were compared in those that did and did not have an unexpected emergency department (ED) visit within 6 wk of discharge from GT placement. Statistical analysis was performed using Wilcoxon sum-rank, Chi-squared test, and Fisher's exact test where applicable, and univariable and multivariable logistic regression. RESULTS: Of the 541 children who underwent GT placement, 112 (20.7%) returned to the ED within 6 wk postdischarge. In univariable analysis, Black children had 1.64 the odds of an unexpected ED visit compared to White children (95% confidence interval [CI] 1.04-2.60, P = 0.03). When controlling for ethnicity, primary language, insurance, ADI and comorbidities, Black children had 1.80 the odds of an unexpected ED visit compared to White children (95% CI 1.10-2.97, P = 0.02). Final model fit which added a race by ADI interaction term revealed Black children had 2.52 the odds of an unexpected ED visit compared to White children in the low (1-6) ADI group (95% CI 1.41-4.60, P = 0.002). Within advantaged neighborhoods (ADI 1-6), the probability of unplanned ED visits for White children was 17.3% (95%CI 8.9% - 31.1%), which was significantly lower than that for Black children (34.6%, 95% CI 18.8% - 54.7%; P value = 0.006). CONCLUSIONS: Race and neighborhood disadvantage can be associated with unexpected ED visits within 6 wk of discharge from GT placement in the pediatric population. For procedures that require significant postdischarge resources it is important to study the effect of SDH on return to the healthcare system as they can be an important driver of disparities in outcomes.

Health Literacy and Health-care Resource Utilization Following Gastrostomy Tube Placement in Pediatric Patients.

INTRODUCTION: Parental health literacy and neighborhood socioeconomic disadvantage are associated with adverse health outcomes and increased health-care resource utilization in children. We sought to evaluate the association between community-level health literacy and neighborhood socioeconomic disadvantage and their relationships with outcomes of pediatric patients undergoing gastrostomy tube (GT) placement. METHODS: Pediatric patients who underwent GT placement from 2000 to 2019 were identified using the IBM MarketScan Research database. Claims data were merged with the health literacy index (HLI) and area deprivation index (ADI), measures of community-level health literacy and neighborhood socioeconomic disadvantage, respectively. We used multivariate logistic regression to estimate factors associated with postoperative 30- and 90-day ED visits (EVs) and 30-day readmissions. RESULTS: A total of 4374 pediatric patients underwent GT placement. In this cohort, 6.1% and 11.4% had 30-day and 90-day EV; and 30-day readmissions in 19.75%. HLI was lower in those with 30-(244.6 ± 6.1 versus 245.4 ± 6.1; P = 0.0482) and 90-(244.5 ± 5.8 versus 245.5 ± 6.1; P = 0.001) day EV, and 30-day readmission (244.5 ± 5.56 versus 245.4 ± 6.1; P = 0.001) related to GT. ADI was lower in those with 90-day EV (55.1 ± 13.1 versus 55.9 ± 14.6; P = 0.0244). HLI was associated with decreased odds of 30- (adjusted odds ratio: 0.968; 95% confidence interval: 0.941-0.997) and 90-day (adjusted odds ratio: 0.975; 95% confidence interval: 0.954-0.998) EV following GT placement. ADI was also significantly associated with 30 and 90-day EV following GT placement. CONCLUSIONS: In pediatric patients undergoing GT placement, higher ecologically-measured health literacy and neighborhood socioeconomic disadvantage are associated with decreased health-care resource utilization, as evidenced by decreased ED visits. Future studies should focus on the role of individual parental health literacy in outcomes of pediatric surgical patients.

Anthropometric parameters as a predictor for abdominal wall thickness in a patient with gastrostomy.

BACKGROUND: Enteral feeding tubes play essential roles in clinical management and nutritional support. Knowledge of the abdominal wall is beneficial in surgical practice and safe for gastrostomy. Anthropometric parameters are currently used for clinical assessment in many clinical applications. That might be beneficial if we applied anthropometric measurement for thickness prediction of the abdominal wall to the schedule of patients' gastrostomy care. This study aimed to evaluate the anthropometric parameters of abdominal wall thickness (AWT). METHODS: We conducted a cross-sectional study with anthropometric parameters and CT-measured anterior AWT were assessed and analyzed. RESULTS: The data are collected from January 2020 to March 2021. Arm circumference and body mass index were strongly correlated with AWT at left upper quadrant area and anterior AWT at middle area. The data was created in an TAWT (Thammasat AWT) chart to represent body parameters to AWT. CONCLUSIONS: Arm circumference is related to AWT. A TAWT chart is designed to help medical personnel evaluate the thickness of the abdominal wall and could guide estimating the gastrostomy tube length.

Home enteral nutrition does not decrease oral feeding in children during the first year of nutritional support.

BACKGROUND: Enteral nutrition is necessary when nutritional status is poor and oral intake is insufficient or impossible. Although it has been suspected to reduce spontaneous oral feeding, no study has formally assessed the influence of enteral nutrition on pediatric oral intake. The present study aimed to evaluate variation in oral feeding intake after enteral nutrition initiation, and to identify factors influencing oral feeding. METHODS: This retrospective cohort study included 149 pediatric patients from two French tertiary care hospitals, who received home enteral nutrition from 2009 to 2022. The patients were aged 2 months to 17 years (median age 3 years, interquartile range 1.3-9.2). Oral and enteral intakes were assessed when enteral nutrition was initiated (M0), and again at M3 (n = 123), M6 (n = 129), and M12 (n = 134) follow-ups, based on dieticians' and home services' reports. Oral feeding and body mass index z score variations during follow-ups were evaluated using a linear mixed regression model, including "time" as a fixed effect and "patient" as a random effect. Factors associated with oral feeding changes were assessed using a model interaction term. RESULTS: Oral intake did not vary significantly (P = 0.99) over time and accounted for 47.4% ± 27.4%, 46.9% ± 27.4%, 48.4% ± 28.2%, and 46.6% ± 26.9% of the ideal recommended daily allowance (calculated for the ideal weight for height) at M0, M3, M6, and M12, respectively. Delivery method (nasogastric tube versus gastrostomy), prematurity, underlying disease, history of intrauterine growth retardation, and speech therapy intervention did not influence oral intake. Administration (i.e., exclusively continuous nocturnal infusion versus daytime bolus) led to different oral intake development, although oral intake also differed at M0. CONCLUSIONS: Enteral nutrition, although increasing total energy intake, does not alter oral feeding during the first year of administration. Only the mode of administration might influence oral intake.