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1.
Medicine (Baltimore) ; 99(27): e20571, 2020 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-32629635

RESUMO

INTRODUCTION: Superior mesenteric artery syndrome (SMAS) is rare cause of small bowel obstruction and is characterized by an extrinsic vascular compression of the duodenum. The most common cause of SMAS is known as rapid and significant weight loss. PATIENT CONCERNS: A 61-year-old man who was diagnosed with amyotrophic lateral sclerosis and maintained a stable diet before admission. When the patient re-started feeding by gastrostomy tube after 5 days of therapeutic fasting due to gastric ulcer caused by gastrostomy tube irritation, he presented postprandial vomiting, abdominal distention, and tachycardia. Since fasting, his weight has been reduced by about 3 kg. DIAGNOSIS: Based on clinical symptoms and radiological findings, diagnose of SMAS was finally made. Abdomen computed tomography confirmed decreased aortomesenteric distance and tubography confirmed gastric and proximal duodenum distension above the compressed part. INTERVENTIONS: We performed jejunal tube insertion and the amount of feeding through the jejunal tube was gradually increased while maintaining parenteral nutrition. OUTCOMES: The presenting symptoms of the patient gradually improved. Follow-up abdomen computed tomography and tubography showed improvement in duodenal narrowing and stomach distension. CONCLUSION: SMAS should be considered when there is an abrupt observation of symptom of gastrointestinal obstruction in patients with predisposing condition such as a low body weight, even if the weight loss is relatively small.


Assuntos
Esclerose Amiotrófica Lateral/complicações , Jejum/efeitos adversos , Gastrostomia/efeitos adversos , Síndrome da Artéria Mesentérica Superior/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Úlcera Gástrica/etiologia , Perda de Peso
2.
Isr Med Assoc J ; 22(5): 315-319, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32378825

RESUMO

BACKGROUND: Buried bumper syndrome (BBS) mostly occurs as a late complication after percutaneous endoscopic gastrostomy (PEG) insertion; however, early BBS has been rarely reported, and the treatment of this condition is still unclear. OBJECTIVES: To evaluate the Seldinger technique for treatment of early BBS after PEG insertion. METHODS: We report two cases of early BBS in two consecutive patients who underwent PEG insertion to maintain oral intake. The first patient was an 83-year-old woman showing Alzheimer type dementia, while the other one was a 76-year-old man who presented with maxillary cancer and treated with radiotherapy followed by left maxillectomy. Post-surgery, he developed progressive difficulty of swallowing due to mouth deformation and treatment related nerve toxicity. The first patient presented with fever and purulent discharge from the gastrostomy insertion site, without ability to rotate or slide the tube through the stoma 10 days after the PEG insertion. The man was admitted to the hospital 5 days following PEG insertion due to a fever of 38°C and peritubal swelling with purulent discharge. In addition, the tube could not rotate or slide through the stoma. RESULTS: Buried bumper syndrome was demonstrated by computed tomography scan. Gastroscopy and gastrostomy tube replacement was performed successfully according to the Seldinger technique (replacement over guidewire) in both cases. Correct intragastric tube positioning was demonstrated radiographically before resuming tube feeding. The two patients were discharged in good physical condition several days later. CONCLUSIONS: External replacement over guide wire should be considered in such cases.


Assuntos
Nutrição Enteral/instrumentação , Gastrostomia/instrumentação , Complicações Pós-Operatórias/cirurgia , Idoso , Idoso de 80 Anos ou mais , Remoção de Dispositivo/métodos , Feminino , Humanos , Masculino , Sistemas Automatizados de Assistência Junto ao Leito , Retratamento , Fatores de Tempo
3.
Orv Hetil ; 161(18): 756-760, 2020 05 01.
Artigo em Húngaro | MEDLINE | ID: mdl-32338489

RESUMO

Despite the significant improvement in surgical and intensive care therapy, esophageal perforation is still a severe, life-threatening condition. As the underlying causes, the accompanying disorders, the localization and the extent of the inflammation vary, the surgeon may sometimes encounter unexpected situations. A 58-year-old female developed necrotizing mediastinitis due to esophageal perforation as the result of incarcerated thoracic hernia of the stomach, therefore, we had to perform esophagus extirpation and cervical esophagostomy. During the reconstruction of the intestinal tract, we found shrinkage of the complete esophageal stump with unknown cause. The gastric sleeve was joined to the hypopharynx. Insufficiency was solved with conservative therapy. The patient regained partial swallowing ability after complex dysphagia treatment. Hyophapharyngo-gastrostomy done due to non-malignant disease is extremely rare in the literature, however, it can be a surgical technique of choice if required as in our case. It should be followed by rehabilitation done by a team, with emphasis on dysphagia treatment. Orv Hetil. 2020; 161(18): 756-760.


Assuntos
Perfuração Esofágica/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Esofagectomia , Feminino , Gastrostomia , Humanos , Hipofaringe/cirurgia , Pessoa de Meia-Idade
4.
Arq Gastroenterol ; 57(1): 3-7, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32294728

RESUMO

BACKGROUND: Cerebral palsy is the most common cause of physical disability in childhood. Caregivers of patients presenting tetraparesis cerebral palsy (TCP) and gastrostomy tube feeding (GTF) were selected for this study because both conditions represent a great demand for their caregivers. OBJECTIVE: To describe the quality of life related to the state of health of caregivers of patients with TCP who were fed by gastrostomy, to assess the results linked to the mental health of these caregivers, to compare our data with data from other studies on children with cerebral palsy without gastrostomy and to evaluate the possible interference of gastrostomy in the quality of life. METHODS: A number of 30 major caregivers were interviewed and assessed. Quality of life and mental health tools applied and analyzed only for caregivers were: Medical Outcomes Study (MOS) 36-item Short Form Health Survey (SF-36), WHOQOL-BREF and Beck scales. Other information (age, gender, marital status, number of residents per household and psychological support) was evaluated. The Spearman's rank correlation coefficient was used to analyze. A 5% significance level was adopted. RESULTS: Results obtained through questionnaires are as follows: moderate hopelessness in 20% of caregivers (the higher the number of residents per household the higher the level of caregiver's hopelessness); moderate and severe anxiety in 33.33% of the sample studied; moderate and severe depression identified in 46.67% of interviewed caregivers; health-related quality of life of caregivers of patients with TCP were found to be below world averages; no significant figures for suicide potential were noted for the population under this study. CONCLUSION: The HRQOL of caregivers of TCP patients who were fed by gastrostomy is below the average of the general population. Our results are very similar to those found in other studies that evaluated caregivers of patients with cerebral palsy with different degrees of neurological impairment and no report of using GTF, suggesting that the presence of gastrostomy did not negatively interfere with the caregiver's HRQOL.


Assuntos
Cuidadores/psicologia , Paralisia Cerebral/enfermagem , Nutrição Enteral , Gastrostomia , Qualidade de Vida/psicologia , Adolescente , Adulto , Paralisia Cerebral/psicologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Inquéritos e Questionários , Adulto Jovem
6.
World Neurosurg ; 139: 97-100, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32305610

RESUMO

BACKGROUND: Ankylosing spondylitis (AS) is an inflammatory disease that involves above all the spine and the pelvis. In the spine, the inflammatory processes cause the formation of syndesmophytes between the vertebral bodies and the ossification of ligaments, with bony overgrowth. In this setting, dysphagia is a rare but severe complication and only a few cases have been reported in the literature. CASE DESCRIPTION: We describe the case of a 50-year-old man suffering from AS, with a 6-month history of severe dysphagia caused by bone compression of the esophagus at the C3-5 level. Because the patient underwent a 10-kg weight loss 2 months after clinical onset, a gastrostomy tube placement was needed. Complete surgical excision of the bone overgrowth via an anterior cervical approach was performed, but despite continuous intensive swallowing rehabilitation therapy, the patient failed to improve in the first following months. Surprisingly, the patient started to improve 18 months after the operation, with a complete recovery from dysphagia 24 months after. CONCLUSIONS: Among the 5 reports (including the present case) available in the current literature with a clear dysphagia recovery follow-up, the present case (the second one harboring gastrostomy) is associated with the slowest complete recovery published so far. This unusually late recovery suggests a possible role not only of the mechanical decompression of the esophagus but also of the degeneration/regeneration ratio of the myenteric plexus, along with local neurotransmitters sensitivity changes, to better understand the dysphagia recovery time course of this unique patient.


Assuntos
Vértebras Cervicais/cirurgia , Transtornos de Deglutição/cirurgia , Estenose Esofágica/cirurgia , Ligamentos Longitudinais/cirurgia , Ossificação Heterotópica/cirurgia , Recuperação de Função Fisiológica , Espondilite Anquilosante/cirurgia , Descompressão Cirúrgica , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/reabilitação , Nutrição Enteral , Estenose Esofágica/diagnóstico por imagem , Estenose Esofágica/etiologia , Gastrostomia , Humanos , Ligamentos Longitudinais/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Ossificação do Ligamento Longitudinal Posterior/diagnóstico por imagem , Ossificação Heterotópica/complicações , Ossificação Heterotópica/diagnóstico por imagem , Espondilite Anquilosante/complicações , Fatores de Tempo
7.
Muscle Nerve ; 62(1): 70-75, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32297335

RESUMO

INTRODUCTION: Radiologically inserted gastrostomy (RIG) placement in patients with amyotrophic lateral sclerosis (ALS) carries risks related to periprocedural sedation and analgesia. To minimize these risks, we used a paravertebral block (PVB) technique for RIG placement. METHODS: We retrospectively reviewed patients with ALS undergoing RIG placement under PVB between 2013 and 2017. RESULTS: Ninety-nine patients with ALS underwent RIG placement under PVB. Median (range) age was 66 (28 to 86) years, ALS Functional Rating Scale-Revised score was 27 (6 to 45), and forced vital capacity was 47% (8%-79%) at time of RIG placement. Eighty-five (85.9%) patients underwent RIG placement as outpatients, with a mean postanesthesia care unit stay of 2.3 hours. The readmission rate was 4% at both 1 and 30 days postprocedure. DISCUSSION: PVB for RIG placement has a low rate of adverse events and provides effective periprocedural analgesia in patients with ALS, the majority of whom can be treated as outpatients.


Assuntos
Esclerose Amiotrófica Lateral/diagnóstico por imagem , Esclerose Amiotrófica Lateral/cirurgia , Gastrostomia/métodos , Bloqueio Nervoso/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fluoroscopia/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Capacidade Vital/fisiologia
8.
9.
Tech Vasc Interv Radiol ; 23(1): 100659, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32192639

RESUMO

Aspiration therapy is a novel, endoscopic bariatric therapy that allows patients to remove a portion of an ingested meal through a modified percutaneous gastrostomy tube, called an A-Tube. Weight loss results from both fewer calories consumed, and from modifications in lifestyle and mealtime behaviors that patients make as a result of having the device installed. The first commercially available device for aspiration therapy, the AspireAssist (Aspire Bariatrics, King of Prussia, PA), was approved by the Food and Drug Administration in 2016 for weight loss for greater than 6 months duration in patients with a body mass index of 35-55. Multiple studies have demonstrated the effectiveness and safety of aspiration therapy, with low rates of adverse events related to the procedure, including no reported deaths, as well as no evidence of eating disorders developed during therapy. This chapter will describe our experience with aspiration therapy. We will describe how we select appropriate candidates for aspiration therapy, how we perform the procedure including a summary of the equipment used, and how we mitigate and manage complications of the procedure. This article will highlight the effectiveness of aspiration therapy as a novel and safe approach for weight loss in patients in obesity.


Assuntos
Cirurgia Bariátrica , Endoscopia Gastrointestinal , Gastrostomia , Obesidade/cirurgia , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/instrumentação , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/instrumentação , Ingestão de Energia , Desenho de Equipamento , Gastrostomia/efeitos adversos , Gastrostomia/instrumentação , Humanos , Obesidade/diagnóstico , Obesidade/fisiopatologia , Seleção de Pacientes , Medição de Risco , Fatores de Risco , Sucção , Resultado do Tratamento , Perda de Peso
10.
Can Assoc Radiol J ; 71(1): 68-74, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32062990

RESUMO

PURPOSE: Cone-beam computed tomography (CBCT) in interventional radiology allows volumetric imaging with open patient access. This work aimed to assess radiation dose metrics of CBCT in simulated image-guided retrograde gastrostomy (IGRG) tube insertions in pediatric anthropomorphic phantoms and to compare them to measured radiation dose metrics obtained using fluoroscopy during clinical IGRG tube insertions in children. METHODS: Radiation dose indices obtained from radiation dose structured reports of fluoroscopic IGRG tube insertions were retrospectively evaluated in a consecutive cohort of 30 children. Dose indices were fractionated into 3 clinical stages for each procedure (planning, insertion, and confirmation). These 3 stages in 30 patients (3 × 30 = 90 patient stages) were compared to dose indices measured from 4 CBCT acquisition protocols acquired in pediatric phantoms. RESULTS: The mean proportion of radiation dose during planning, insertion, and confirmation was 35%, 38% and 27%, with mean reference-point air kerma (range) measured to be 1.0 (0.02-6.0) mGy, 0.9 (0.03-4.1) mGy, and 0.7 (0.04-3.7) mGy, respectively. Cone-beam computed tomography dose varied greatly depending on technical parameters and protocol selection, ranging from 0.7 to 39.3 mGy. In 19% of patient stages, the most dose-sparing CBCT protocol evaluated on phantoms delivered less radiation than the radiation dose indices recorded from patient's fluoroscopy. CONCLUSIONS: From a dosimetric perspective, radiation delivered in CBCT can vary widely, yet can be appreciably low. With appropriate CBCT protocol selection, the radiation dose delivered may be sufficiently low to warrant consideration for use, if clinically needed during difficult IGRG tube insertions, and satisfy the interventionalist's benefit-risk assessment.


Assuntos
Tomografia Computadorizada de Feixe Cônico , Gastrostomia/métodos , Radiografia Intervencionista , Adolescente , Criança , Pré-Escolar , Estudos de Viabilidade , Feminino , Fluoroscopia , Humanos , Lactente , Masculino , Imagens de Fantasmas , Doses de Radiação , Estudos Retrospectivos
11.
Pediatrics ; 145(3)2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32107284

RESUMO

Medical decision-making in children is not a static process. In pediatrics, parents and health professionals actively participate in clinical decision-making. They always consider what is in the child's best interest and sometimes weigh that against other considerations. As children get older, the level of participation in this process may change according to their own cognitive development and maturity level. In this article, we present a case of an adolescent with a life-limiting condition at the end of life. He wants to participate in his health management and speak for himself. He does not always prefer interventions that his parents think are best. Health care practitioners must include mature minors in the decision-making process and be willing to listen to their voices.


Assuntos
Tomada de Decisões , Remoção de Dispositivo/ética , Gastrostomia/instrumentação , Direitos do Paciente/ética , Autonomia Pessoal , Recusa do Paciente ao Tratamento , Adolescente , Humanos , Masculino
12.
Nurs Stand ; 35(3): 60-65, 2020 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-32103650

RESUMO

Enteral feeding is defined as the intake of food directly into the gastrointestinal (GI) tract. Enteral feeding tubes can also be used to administer medicines. Patients who may require enteral feeding include those who are unconscious, or those with neurological swallowing disorders, upper GI obstruction, GI dysfunction or malabsorption. There are several routes that can be used for enteral feeding including gastrostomy, post-pyloric, nasogastric, continuous pump and bolus feeding. When undertaking enteral feeding, nurses and other healthcare professionals should be aware of the potential complications such as tube blockage and infection. This article examines the various enteral feeding routes, discusses the administration of medicines, and details the common complications associated with enteral feeding.


Assuntos
Nutrição Enteral , Gastrostomia , Intubação Gastrointestinal/enfermagem , Nutrição Enteral/enfermagem , Gastroenteropatias , Gastrostomia/enfermagem , Humanos , Estado Nutricional , Resultado do Tratamento
13.
Anticancer Res ; 40(2): 991-997, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32014944

RESUMO

AIM: To evaluate the efficacy of chemotherapy with itraconazole for advanced or recurrent gastric cancer. PATIENTS AND METHODS: Patients with human epidermal growth factor receptor 2 (HER2) negative unresectable gastric cancer referred to our hospital were included. The regimen comprised 160 mg/m2 nab-paclitaxel i.v. and 100 mg/m2 oxaliplatin i.v. on day 1, 60 mg/m2 S-1 orally on days 1-3, and 400 mg itraconazole orally on days -2 to 2, repeated every 2 weeks for 6-8 cycles. RESULTS: Twenty-three patients aged 40-80 years (median age=68 years) were enrolled, of whom 21 had stomach cancer and two gastroesophageal junction cancer. Regarding stage, two, one, and 20 patients had stage IIIA, IIIB, and IV, respectively. Among patients with liver metastases, 2/10 had simultaneous lung metastases. Nine patients had peritoneal dissemination, and five patients with stage IV disease developed recurrence after primary surgery followed by adjuvant S-1. The other 18 patients had no history of surgery or chemotherapy. The response rate was 70% (complete response in two; partial response in 14). Among 12 patients (67%) who underwent conversion surgery, R0 resection was conducted in eight, and no residual tumour was observed in two. For the population overall, the median overall survival was 24 months (95% confidence intervaI=21 months-not reached) and the 1-year overall survival rate was 95% (95% confidence intervaI=67-98%). Grade 3/4 neutropenia and grade 2 peripheral sensory neuropathy occurred in five (22%) and six (26%) patients, respectively, while no patient developed grade 3/4 thrombocytopenia. CONCLUSION: Chemotherapy with itraconazole is promising for patients with unresectable gastric cancer.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Gastrostomia , Neoplasias Gástricas/patologia , Neoplasias Gástricas/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Albuminas/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Combinação de Medicamentos , Feminino , Gastrostomia/efeitos adversos , Gastrostomia/métodos , Humanos , Itraconazol/administração & dosagem , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Estadiamento de Neoplasias , Oxaliplatina/administração & dosagem , Ácido Oxônico/administração & dosagem , Paclitaxel/administração & dosagem , Neoplasias Gástricas/mortalidade , Tegafur/administração & dosagem , Resultado do Tratamento
14.
Anticancer Res ; 40(2): 1167-1173, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32014970

RESUMO

BACKGROUND: A gastrostomy feeding tube is one method for long-term feeding support in patients undergoing radio(chemo)therapy for head and neck cancer (HNC). The aim of this study was to analyze the safety of prophylactic gastrostomy tube placement and usage in HNSCC patients. PATIENTS AND METHODS: HNC patients undergoing percutaneous endoscopic gastrostomy (PEG) or radiological percutaneous gastrostomy (RPG) tube placement prior to radio(chemo)therapy from 2010-2014 were retrospectively reviewed regarding procedural and long-term gastrostomy tube-related complications, usage of PEG/RPG, weight profile, pretreatment and posttreatment body mass index. RESULTS: A total of 212 patients underwent prophylactic feeding tube placement (71% RPG, 27% PEG and 2% surgical jejunostomy). A total of 173 patients utilized their gastrostomy tubes for either total or supplemental nutrition support. Despite this, 157 patients (74%) lost weight during therapy (mean weight loss=8 kg). The rate of severe tube-related complications (peritonitis/incorrect placement) was low and similar in both groups (PEG 2.7% vs. RPG 3.4%). CONCLUSION: Although a very high proportion of patients used their PEG/RPG during radio(chemo)therapy there was a high mean weight loss. Serious complications of tube placement were rare.


Assuntos
Gastrostomia , Neoplasias de Cabeça e Pescoço/dietoterapia , Intubação Gastrointestinal , Adulto , Idoso , Idoso de 80 Anos ou mais , Peso Corporal , Quimiorradioterapia , Nutrição Enteral/efeitos adversos , Nutrição Enteral/métodos , Feminino , Gastrostomia/efeitos adversos , Gastrostomia/métodos , Neoplasias de Cabeça e Pescoço/diagnóstico , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Intubação Gastrointestinal/efeitos adversos , Intubação Gastrointestinal/métodos , Jejunostomia , Masculino , Pessoa de Meia-Idade , Recidiva , Resultado do Tratamento
15.
Codas ; 32(2): e20180248, 2020.
Artigo em Português, Inglês | MEDLINE | ID: mdl-32074165

RESUMO

PURPOSE: The objective of the present study was to describe the total oral transit time (TOTT) of children with neurological impairment (CNI) and with an indication of gastrostomy. METHOD: A cross-sectional clinical study was conducted on 15 children (10 male and 5 female ranging in age from 1 to 14 years; mean 5.7 years) with CNI and gastrostomy indication. The patients were monitored by a Multidisciplinary Group of Pediatric Gastroenterology of Universidade de Marília - UNIMAR, which 13 of them with previous exclusive oral feeding and 2 fed by a nasogastric tube. Swallowing was analyzed by videofluoroscopy swallowing study and 19 images of TOTT were obtained using specific software, with analysis of pureed food (13 images) and liquid (six images). TTOT was categorized as short or long based on definitions already evidenced in the literature. RESULTS: The mean and standard deviation of TOTT values was 10.75 s and 11.76 s for pureed food and 4.22 s and 1.54 s for liquid food. CONCLUSION: The total oral transit time of pureed or liquid consistency was long in children with neurological involvement and with an indication of gastrostomy.


Assuntos
Transtornos de Deglutição/etiologia , Deglutição , Gastrostomia , Doenças do Sistema Nervoso/complicações , Adolescente , Criança , Pré-Escolar , Estudos Transversais , Transtornos de Deglutição/diagnóstico por imagem , Transtornos de Deglutição/cirurgia , Nutrição Enteral/métodos , Feminino , Fluoroscopia/métodos , Humanos , Lactente , Masculino
16.
Am J Surg ; 219(5): 828-830, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32057412

RESUMO

Low grade tumors located in the neck of the pancreas present a unique surgical challenge. Subtotal pancreatectomy results in significant loss of pancreatic gland and function, while pancreaticoduodenectomy may be too aggressive for these lesions. We present a case of a patient with a well differentiated neuroendocrine tumor in the neck of the pancreas who underwent a central pancreatectomy with pancreaticogastrostomy reconstruction. Patient selection and technical aspects of the procedure are described. The decision to perform a central pancreatectomy should not be made lightly as complications are frequent. Careful patient selection is imperative.


Assuntos
Gastrostomia/métodos , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Humanos , Neoplasias Pancreáticas/diagnóstico por imagem , Seleção de Pacientes , Tomografia Computadorizada por Raios X
18.
Einstein (Sao Paulo) ; 18: eAO4952, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31939524

RESUMO

OBJECTIVE: To define physician´s behavior in the face of a mentally capable elderly dysphagic patients at risk of pulmonary aspiration, who do not accept oral restriction. METHODS: Observational, cross-sectional study, presenting a clinical case of an independent elderly with clinical complaints of dysphagia and laryngotracheal aspiration by flexible endoscopic evaluation of swallowing who rejected the proposal to restrict oral diet. A questionnaire about the patient's decision-making process was used to assess whether the physician was sympathetic and justify their answer, and if they are aware of hierarchy of ethical principles (recognition of the person´s value, autonomy, beneficence, nonmaleficence and justice), in the decision-making process, and which was the main principle that guided their decision. RESULTS: One hundred participants were classified by time since graduation as Group I (less than 10 years) and Group II (more than 10 years). Of them, 60% agreed with the patient's decision, with no difference between the groups. The main reason was autonomy of patients, in both groups. Among those who were not sympathetic, the main argument was beneficence and nonmaleficence, considering the risk between benefit and harm. As to awareness about the hierarchy of principles, we did not find differences between the groups. Autonomy was the principle that guided those who were sympathetic with the patient's decision, and justice among those who didnot agree. CONCLUSION: Physicians were sympathetic with the patient's decision regarding autonomy, despite the balance between risks of beneficence and nonmaleficence, including death. We propose to formalize a non-compliance term.


Assuntos
Transtornos de Deglutição/complicações , Padrões de Prática Médica/estatística & dados numéricos , Aspiração Respiratória/etiologia , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Estudos Transversais , Transtornos de Deglutição/prevenção & controle , Gastroscopia/métodos , Gastrostomia/métodos , Humanos , Intubação Gastrointestinal/métodos , Masculino , Autonomia Pessoal , Relações Médico-Paciente , Aspiração Respiratória/prevenção & controle , Fatores de Risco , Inquéritos e Questionários , Fatores de Tempo
19.
Pediatrics ; 145(2)2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31996405

RESUMO

OBJECTIVES: Oropharyngeal dysphagia and aspiration may occur in infants and children. Currently, there is wide practice variation regarding when to feed children orally or place more permanent gastrostomy tube placement. Through implementation of an evidence-based guideline (EBG), we aimed to standardize the approach to these patients and reduce the rates of gastrostomy tube placement. METHODS: Between January 2014 and December 2018, we designed and implemented a quality improvement intervention creating an EBG to be used by gastroenterologists evaluating patients ≤2 years of age with respiratory symptoms who were found to aspirate on videofluoroscopic swallow study (VFSS). Our primary aim was to encourage oral feeding and decrease the use of gastrostomy tube placement by 10% within 1 year of EBG initiation; balancing measures included total hospital readmissions or emergency department (ED) visits within 6 months of the abnormal VFSS. RESULTS: A total of 1668 patients (27.2%) were found to have aspiration or penetration noted on an initial VFSS during our initiative. Mean gastrostomy tube placement in these patients was 10.9% at the start of our EBG implementation and fell to 5.2% approximately 1 year after EBG initiation; this improvement was sustained throughout the next 3 years. Our balancing measures of ED visits and hospital readmissions also did not change during this time period. CONCLUSIONS: Through implementation of this EBG, we reduced gastrostomy tube placement by 50% in patients presenting with oropharyngeal dysphagia and aspiration, without increasing subsequent hospital admissions or ED visits.


Assuntos
Medicina Baseada em Evidências , Gastrostomia/instrumentação , Melhoria de Qualidade , Aspiração Respiratória de Conteúdos Gástricos/terapia , Transtornos de Deglutição/complicações , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Gastrostomia/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Lactente , Intubação Gastrointestinal/instrumentação , Intubação Gastrointestinal/estatística & dados numéricos , Masculino , Aspiração Respiratória de Conteúdos Gástricos/diagnóstico por imagem , Fatores de Tempo
20.
J Surg Res ; 249: 156-162, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31958600

RESUMO

BACKGROUND: This study evaluates tube-specific outcomes after primary placement of low-profile buttons (LPBs) compared with long gastrostomy tubes (LGTs). MATERIALS AND METHODS: All surgically placed gastrostomy tubes from 2015 to 2017 from a single institution were reviewed. Primary outcomes were tube dislodgement and tube-related readmissions within 30 d. Secondary outcomes were resource utilization and minor complications within 6 mo. RESULTS: 53% (n = 253) of patients received an LGT and 47% (n = 228) received an LPB. Groups were similar with regard to operative indication and approach, but LPB patients were slightly older (9 versus 6 mo, P = 0.02). Tube dislodgement occurred overall in 6% of patients, with 23% and 41% experiencing leakage and granulation tissue, respectively. LGT patients experienced higher rates of tube dislodgement (9% versus 3%, P = 0.006), but no difference in tube-related readmissions (P = 0.38). LGT patients were also more likely to visit the ER for a tube-related concern (43.9% versus 31.6%, P = 0.01) and report problems of leakage around the tube (27.7% versus 17.5%, P = 0.01). No difference was found for issues of peristomal granulation tissue or in tube-related readmissions. CONCLUSIONS: Primary placement of low-profile gastrostomy buttons is safe and demonstrated superior tube-related outcomes compared with LGTs.


Assuntos
Nutrição Enteral/instrumentação , Gastrostomia/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Gastrostomia/efeitos adversos , Gastrostomia/instrumentação , Humanos , Lactente , Masculino , Readmissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Estudos Retrospectivos
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