Percutaneous endoscopic gastrostomy: a prospective audit of the impact of guidelines in two district general hospitals in the United Kingdom.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) is the accepted method for long-term enteral nutrition. Recent studies have suggested a higher mortality than was initially reported. The demands for gastrostomy insertion have risen, encompassing indications where the long-term outcomes are uncertain. We, therefore, constructed guidelines to try and improve the appropriateness of patient selection. Our aim was to prospectively assess the impact of guidelines for PEG insertion over a 1-yr period in a single center, Rotherham District General Hospital (hospital A) and compare against an adjacent center serving a similar population, Doncaster Royal Infirmary (hospital B) where guidelines had not been instituted. METHODS: Data were collected from June, 1998 to May, 1999. Indication for PEG was documented and survival analysis performed using the Kaplan-Meier survival method. RESULTS: The number of PEG insertions had been rising each year in both centers. After guidelines were introduced in hospital A, the number of procedures fell by 20, whereas in hospital B, the PEG insertion rate continued to rise (p = 0.02). There was a lower mortality observed in hospital A (at 1 month, 16%; at 3 months, 26%; at 6 months, 39%; and at 1 yr, 46%) than in hospital B (at 1 month, 26%; at 3 months, 44%; at 6 months, 58%; and at I yr, 68%), although this did not achieve statistical significance (log rank test, p = 0.1). CONCLUSIONS: This is the first study to prospectively assess the impact of guidelines and a proactive role in the decision for PEG insertion. Fewer procedures were performed, and there was a trend toward a reduction in mortality.

Percutaneous endoscopic gastrostomy: a prospective analysis of hospital support required and complications following discharge to the community.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is the commonest method of long-term enteral nutrition. In the UK there is no nationally funded framework to provide community support for patients with gastrostomies. OBJECTIVES: To assess the hospital support required and the complications occurring in a cohort of patients discharged into the community with a gastrostomy in-situ. DESIGN AND SETTING: We prospectively collected data between June and November 1998 regarding patients (n=87) with PEG complications in the community following discharge from two adjacent hospitals in South Yorkshire (Rotherham District General Hospital and the Royal Hallamshire Hospital). RESULTS: The mortality within this cohort during the study period was 17.2%. Of these 15 patients 10.3% (n=9) were thought to have died as a result of the progression of their disease, whilst in the other 6.9% (n=6) pneumonia was documented as the cause of death. Problems with gastrostomies requiring telephone advice occurred in 24.1% of patients and 65.5% necessitated a home visit. However during this period of 6 months, 23% of patients were admitted as an emergency, accounting for 61 in-patient days. All were from nursing or residential homes and the emergency occurred after normal surgery hours. General practitioners dealt with aspiration pneumonia in 25.2% of the cohort but other tube problems were referred to the endoscopy unit. DISCUSSION: This is the first study to specifically highlight the specialist intervention and support required by patients discharged into the community with PEGs, a group for whom there is often no formal aftercare. A specialist nurse or dietician could establish a liaison service focusing on primary care and using hospital resources when appropriate. This study provides further evidence to support the recommendations for tube feeding made by the British Association for Parenteral and Enteral Nutrition.

Course of hepatitis B and D virus infection in auxiliary liver grafts in hepatitis B-positive patients. A light-microscopic and immunohistochemical study.

Four patients who received an auxiliary partial liver graft for decompensated liver cirrhosis due to hepatitis B (HBV), associated in two cases with hepatitis D virus (HDV) superinfection, were studied. The sequential appearance of hepatitis B and D antigens in the grafts was investigated in serial liver biopsies by immuno-histochemical methods and compared with the viral antigenic profiles of the host livers. The histological changes in the liver grafts were studied in relation to the viral expression patterns. One week after transplantation, expression of HBsAg was already apparent in two grafts. HBcAg was found in the graft of the only patient with HBcAg in the host liver. HDAg was expressed in the grafts of both patients with HDV superinfection; in one of these cases HDAg was present without HBsAg. At 3 months, viral antigen expression was maximal. Expression of HBsAg and HBcAg in the grafts of the two HDV-positive patients was, however, less extensive than in the two HBV-positive patients. All patients developed a mild lobular hepatitis, histologically demonstrated between the 47th and 107th posttransplantation day. In the two HBV-positive, HDV-negative patients, cirrhotic transformation of the graft occurred within 1 year. In the HDV-positive patients only a mild chronic active hepatitis with slight or moderate fibrosis was observed after 1 year. We conclude that recurrence of HBV and HDV infection in auxiliary liver grafts is demonstrable within 1-3 weeks. HBV infection in liver grafts may be a rapidly progressive disease. Coinfection with HDV does not aggravate the acute hepatitis and may even suppress the progression of chronic HBV.

Graft regeneration and host liver atrophy after auxiliary heterotopic liver transplantation for chronic liver failure.

We studied the size of the liver graft and the host liver in six consecutive patients undergoing auxiliary heterotopic liver transplantation for chronic end-stage liver disease. In all cases, a liver reduced in size by left lateral hepatectomy was inserted. The sizes of the graft and host liver were estimated by planimetry of two-dimensional di-isopropyl iminodiacetic acid scintigrams taken 3, 7, 21, 90 and 180 days after surgery. Graft size increased from a mean of 12.2 cm2 (95% confidence interval = 10.2 to 14.1) on day 3 to a maximum of 14.8 cm2 (95% confidence interval = 13.4 to 16.1) on day 21 and remained stable thereafter; in contrast, the host liver decreased in size from 9.6 cm2 (95% confidence interval = 6.8 to 12.3) on day 3 to 3.9 cm2 (95% confidence interval = 3.0 to 4.8) at mo 6. We conclude that in patients with chronic liver failure, an auxiliary allograft reduced in size and placed adjacent to the host liver shows regenerative growth within 3 wk, whereas the host liver atrophies in 3 to 6 mo.

Infections after auxiliary partial liver transplantation. Experiences in the first ten patients.

In ten auxiliary partial liver transplant recipients selective bowel decontamination (SBD) was used to reduce infections due to gram-negative microorganisms and fungi. During SBD no gram-negative infections occurred. Candida peritonitis was observed in one patient. After discontinuation of SBD serious infections of gram-negative origin did occur and three fungal infections were seen. SBD seems to have a favourable effect in reducing infections by gram-negative microorganisms and fungi. Most striking was the number of enterococcal infections that occurred. Five out of ten patients developed enterococcal infections which in two cases contributed to a fatal outcome. These infections occurred after increase of the number of enterococci in faeces and concomitant positive cultures of bile, ascites or wound drains. This increase could be due to the use of SBD. Also, the kind of biliary anastomosis may play an important role in the relatively high incidence of enterococcal infections. In the postoperative period, recurrence of hepatitis B infection in the liver graft was observed in all patients with cirrhosis due to this virus. Problems caused by other viral infections or protozoal infections remained limited in these ten patients.

Auxiliary partial liver transplantation for end-stage chronic liver disease.

Auxiliary heterotopic liver transplantation is theoretically attractive because it leaves the recipient's liver in place. The surgical trauma of hepatectomy is avoided, and failure of the graft does not necessarily lead to the death of the patient or a second, emergency transplantation. Another advantage is that matching the body sizes of the donor and the recipient is not mandatory, which increases the number of possible donors. However, previous clinical results of auxiliary liver transplantation have been poor. We performed auxiliary partial liver transplantation in six consecutive patients with end-stage chronic liver disease who were not accepted for orthotopic liver transplantation because they had massive ascites, deficient clotting function, cachexia, or poor pulmonary reserve. The donor liver was transplanted to the right subhepatic region after removal of segments II and III, and it was provided with portal and arterial blood. There were no major changes in hemodynamic measurements during surgery. The mean hospital stay after transplantation was 22.7 days (range, 14 to 29). After a mean follow-up period of 14 months (range, 5 to 23), all patients were alive, with good graft function as demonstrated by scintigraphy, Doppler ultrasonography, and synthesis of clotting factors. From these observations we conclude that auxiliary partial liver transplantation is an attractive alternative to orthotopic liver transplantation in high-risk patients. Its role in other patients who need liver transplants remains to be defined.

Effect of sympathetic stimulation on inactive renin.

In the present study we investigated the effect of three manoeuvres known to be associated with enhanced sympathetic activity on plasma levels of active and inactive renin. To this end, active and trypsin-activatable renin were measured in blood drawn from 12 untreated essential hypertensive patients before, during and after any of the following tests: isometric exercise (handgrip), noise stimulation and 45 degrees head-up tilt. These studies were repeated after the patients had been treated with either atenolol (n = 6) or SL 77499 (n = 6), an alpha-1 adrenoceptor blocking agent for 10 days. The results indicate that active and inactive renin often change in an unpredictable way in response to sympathetic stimulation. There are, as yet, no conclusive explanations which describe the behaviour of both forms of renin during these manoeuvres.