Carga del cuidador y calidad de vida referida en pacientes neurológicos portadores de sonda de gastrostomía / Caregiver burden and reported quality of life in neurological patients with gastrostomy tubes

Objetivo: el objetivo del estudio es determinar si el uso de nutrición enteral domiciliaria (NED) por gastrostomía endoscópica percutánea (PEG) reduce la carga del cuidador y mejora la calidad de vida de los pacientes referida por los cuidadores. Material y métodos: se llevó a cabo un estudio observacional, descriptivo, prospectivo de una cohorte única de 30 pacientes. Resultados: los resultados mostraron una mejoría del estado nutricional y parámetros analíticos. Se observaron reducción de los ingresos (1,50 ± 0,90 vs 0,17 ± 0,38; p < 0,001) y estancia hospitalaria tras la colocación de la PEG a los 3 meses (10,2 ± 8,02 días vs 0,27 ± 0,69 días; p < 0,001). Los minutos que le dedicaban los cuidadores a la administración de NED disminuyeron tras la colocación de la PEG en 28,5 minutos por toma, lo que supone a lo largo de un día y 5 tomas diarias casi 150 minutos. Hubo una reducción de la percepción de sobrecarga de 13,5 puntos según el test de Zarit. El 56,6 % de los cuidadores refirieron que la calidad de vida había mejorado “bastante”, frente al 6,7 % que respondieron poca mejoría y el 36,7 % que contestaron mucha mejoría. Asimismo, se obtuvo una puntuación de 3,40 puntos superior en la escala QoL-AD tras la colocación de la PEG. Conclusiones: El uso de NED por sonda PEG reduce el tiempo que el cuidador le dedica a la administración de NE, dando lugar a una reducción de la carga. Además, mejora la calidad de vida de los pacientes referida por los cuidadores. (AU)

Objective: the aim of the study is to determine if the use of home enteral nutrition (HEN) by percutaneous endoscopic gastrostomy (PEG) reduces the burden on the caregiver and improves the patients' quality of life reported by the caregivers. Material and methods: a prospective, cross-sectional, descriptive, and observational study of a single cohort of 30 patients was conducted. Results: the results showed an improvement in nutritional status and analytical parameters. Fewer admissions (1.50 ± 0.90 vs 0.17 ± 0.38; p < 0.001) and hospital stays were reported at 3 months after gastrostomy (10.2 ± 8.02 days vs 0.27 ± 0.69 days; p < 0.001). The minutes spent by caregivers administering NEDs decreased after PEG placement by 28.5 minutes per feeding, which amounts to almost 150 minutes over a day and 5 feedings per day. In the Zarit questionnaire, there was a reduction of 13.5 points in the perception of overload. A total of 56.6 % of caregivers reported that quality of life had improved "quite a lot", compared to 6.7 % who reported little improvement, and 36.7 % who reported a lot of improvement. In the QoL-AD questionnaire, a higher score of 3.40 points was obtained. Conclusion: the use of HEN by PEG tube reduces the time spent by the caregiver administering EN, which results in a reduced burden. In addition, the quality of life of patients reported by caregivers improved. (AU)

[Caregiver burden and reported quality of life in neurological patients with gastrostomy tubes.] / Carga del cuidador y calidad de vida referida en pacientes neurológicos portadores de sonda de gastrostomía.

Introduction: Objective: the aim of the study is to determine if the use of home enteral nutrition (HEN) by percutaneous endoscopic gastrostomy (PEG) reduces the burden on the caregiver and improves the patients' quality of life reported by the caregivers. Material and methods: a prospective, cross-sectional, descriptive, and observational study of a single cohort of 30 patients was conducted. Results: the results showed an improvement in nutritional status and analytical parameters. Fewer admissions (1.50 ± 0.90 vs 0.17 ± 0.38; p < 0.001) and hospital stays were reported at 3 months after gastrostomy (10.2 ± 8.02 days vs 0.27 ± 0.69 days; p < 0.001). The minutes spent by caregivers administering NEDs decreased after PEG placement by 28.5 minutes per feeding, which amounts to almost 150 minutes over a day and 5 feedings per day. In the Zarit questionnaire, there was a reduction of 13.5 points in the perception of overload. A total of 56.6 % of caregivers reported that quality of life had improved "quite a lot", compared to 6.7 % who reported little improvement, and 36.7 % who reported a lot of improvement. In the QoL-AD questionnaire, a higher score of 3.40 points was obtained. Conclusion: the use of HEN by PEG tube reduces the time spent by the caregiver administering EN, which results in a reduced burden. In addition, the quality of life of patients reported by caregivers improved.

Introducción: Objetivo: el objetivo del estudio es determinar si el uso de nutrición enteral domiciliaria (NED) por gastrostomía endoscópica percutánea (PEG) reduce la carga del cuidador y mejora la calidad de vida de los pacientes referida por los cuidadores. Material y métodos: se llevó a cabo un estudio observacional, descriptivo, prospectivo de una cohorte única de 30 pacientes. Resultados: los resultados mostraron una mejoría del estado nutricional y parámetros analíticos. Se observaron reducción de los ingresos (1,50 ± 0,90 vs 0,17 ± 0,38; p < 0,001) y estancia hospitalaria tras la colocación de la PEG a los 3 meses (10,2 ± 8,02 días vs 0,27 ± 0,69 días; p < 0,001). Los minutos que le dedicaban los cuidadores a la administración de NED disminuyeron tras la colocación de la PEG en 28,5 minutos por toma, lo que supone a lo largo de un día y 5 tomas diarias casi 150 minutos. Hubo una reducción de la percepción de sobrecarga de 13,5 puntos según el test de Zarit. El 56,6 % de los cuidadores refirieron que la calidad de vida había mejorado "bastante", frente al 6,7 % que respondieron poca mejoría y el 36,7 % que contestaron mucha mejoría. Asimismo, se obtuvo una puntuación de 3,40 puntos superior en la escala QoL-AD tras la colocación de la PEG. Conclusiones: El uso de NED por sonda PEG reduce el tiempo que el cuidador le dedica a la administración de NE, dando lugar a una reducción de la carga. Además, mejora la calidad de vida de los pacientes referida por los cuidadores.

Manipulación de fármacos para su administración por gastrostomía endoscópica percutánea en pacientes con esclerosis lateral amiotrófica y nutrición enteral / Handling of drugs for administration by percutaneous endoscopic gastrostomy in patients with amyotrophic lateral sclerosis and enteral nutrition

Introducción: la esclerosis lateral amiotrófica (ELA) es una enfermedad neurodegenerativa. Entre sus síntomas destaca la disfagia, que hace necesaria la colocación de una gastrostomía endoscópica percutánea (PEG) para alimentarse. La administración de fármacos por la PEG puede obstruirla, disminuir la eficacia del tratamiento y aumentar el riesgo de toxicidad, al alterar la forma farmacéutica original. Objetivo: describir y analizar el grado de adecuación de la prescripción de fármacos administrados por PEG en pacientes con ELA y con nutrición enteral (NE). Material y métodos: se revisó la prescripción del tratamiento farmacológico de los pacientes con ELA que ingresaban para la colocación de una PEG. Se analizó el grado de adecuación de los fármacos prescritos según los criterios de pérdida de eficacia, toxicidad, riesgo para el manipulador y compatibilidad con la NE, consultando la evidencia científica disponible. Resultados: se revisaron las prescripciones médicas de los tratamientos de 34 pacientes, con un total de 307 medicamentos (mediana de 9 fármacos por paciente; rango, 2-17). Se pautaron por la PEG 267 medicamentos de administración oral (mediana de 8 por paciente; rango, 2-15). El 81,65 % fueron formas sólidas y se modificó la forma farmacéutica en el 43 % por riesgo de oclusión de la sonda, toxicidad o pérdida de eficacia, afectando al 97 % de los pacientes. Conclusiones: los pacientes con ELA y con PEG tienen riesgo de presentar problemas de seguridad y de pérdida de eficacia del tratamiento relacionados con la alteración de la forma farmacéutica original y de la interacción con la NE. Palabras clave: Esclerosis lateral amiotrófica; Gastrostomía endoscópica percutánea; Interacción fármaco-nutriente; Medicamentos peligrosos; Nutrición enteral; Sondas digestivas (AU)

Introduction: amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease. Its symptoms include dysphagia that may make it necessary to place a percutaneous endoscopic gastrostomy (PEG) for feeding. The administration of drugs by PEG can obstruct it, decrease the effectiveness of treatment, and increase the risk of toxicity by altering the original pharmaceutical form. Objective: to describe and analyze the degree of adequacy of the prescription of drugs administered by PEG in patients with ALS and with enteral nutrition (EN). Material and methods: the prescription of pharmacological treatment for patients with ALS who were admitted for placement of a PEG was reviewed. The degree of adequacy of the prescribed drugs was analyzed according to criteria of loss of efficacy, toxicity, risk for handler, and compatibility with EN by consulting the available scientific evidence. Results: the medical prescriptions of the treatments of 34 patients were reviewed, with a total of 307 medications (median of 9 drugs per patient, range 2-17). Via PEG 267 oral medications (median 8 per patient, range 2-15) were prescribed; 81.65 % were solid forms, and the pharmaceutical form was modified in 43 %, due to the risk of catheter occlusion, toxicity or loss of efficacy, affecting 97 % of the patients. Conclusions: patients with ALS and PEG are at risk of presenting safety problems and loss of treatment efficacy related to alteration of the original pharmaceutical form and the interaction with EN (AU)

Exploratory study on gastrostomy in patients with neurological diseases: usefulness and impact.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is a useful intervention for patients with impaired swallowing and a functional gastrointestinal system. Neurological diseases that cause neuromotor dysphagia, brain tumors, and cerebrovascular disease are the most frequent indications; complications are rare, and morbidity and mortality rates are low. OBJECTIVE: To describe the usefulness of PEG in patients with neurological diseases, and its impact on care, survival, and costs and benefits. MATERIAL AND METHODS: We performed a retrospective observational study, reviewing clinical files of patients hospitalised at the National Institute of Neurology and Neurosurgery (years 2015-2017) who underwent PEG placement. RESULTS: The sample included 51 patients: 62.7% were women and the mean (SD) age was 54.4 (18.6) years (range, 18-86). Diagnosis was tumor in 37.3% of cases and cerebrovascular disease in 33.3%. Sixteen patients (33.3%) died and 11 presented minor complications. The PEG tube remained in place for a mean of 9.14 months; in 52.9% of patients it was removed due to lack of improvement and/or tolerated oral intake, with removal occurring after a mean of 5.1 (4.4) months. Among patients' family members, 78.4% reported a great benefit, 43.1% reported difficulty caring for the PEG, and 45.1% reported complicated care in general. The monthly cost of maintaining the PEG was €175.78 on average (range, 38.38-293.45). DISCUSSION AND CONCLUSIONS: This preliminary study reveals that PEG was well indicated in patients with neurological diseases, with survival rates similar to those reported in other studies with long follow-up periods. In patients with cerebrovascular disease, the PEG tube remained in place a mean of 9.14 months, during recovery of swallowing function; however, the cost is high for our population.

Estudio exploratorio sobre gastrostomía en pacientes con enfermedades neurológicas: utilidad e impacto / Exploratory study on gastrostomy in patients with neurological diseases: usefulness and impact

Introducción: La gastrostomía endoscópica percutánea (GEP) es útil para personas con problemas de la vía oral con viabilidad de la vía gástrica. Las enfermedades neurológicas que producen disfagia neuromotora, tumores cerebrales y enfermedad vascular cerebral son las que tienen mayor indicación; las complicaciones son escasas y baja la morbimortalidad. Objetivo: Describir la utilidad de la GEP en pacientes con enfermedades neurológicas y el impacto en el cuidado, sobrevida y coste-beneficio. Material y métodos: Estudio observacional retrospectivo, mediante revisión de expedientes clínicos de pacientes hospitalizados en el Instituto Nacional de Neurología y Neurocirugía (años 2015-2017) que se realizó GEP. Resultados: Se incluyeron 51 pacientes: 62,7% mujeres, edad promedio 54,4 ± 18,6 años (rango; 18 a 86). Diagnósticos: tumor del SNC 37,3% y EVC 33,3%. Mortalidad 33,3% (16 pacientes): 11 presentaron complicaciones menores. Permanencia de la GEP: promedio 9,14 meses. Al 52,9% se le retiró por mejoría y/o toleró la VO, con tiempo promedio 5,1 ± 4,4 meses. El 78,4% de los familiares reportó gran beneficio, el 43,1% percibió difícil el cuidado de la GEP y el 45,1% refirió complicado el cuidado en general. El coste de mantener la GEP mensual fue de 175,78 € en promedio (rango de 38,38 a 293,45 €). Discusión y conclusiones: Este primer estudio revela que la GEP fue bien indicada en pacientes con enfermedades neurológicas, con sobrevida similar a la reportada en otras investigaciones con seguimiento prolongado. En pacientes con EVC la permanencia de la GEP fue de 9,14 meses en promedio, por recuperación de la vía oral; sin embargo, el coste es elevado para nuestra población. (AU)

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a useful intervention for patients with impaired swallowing and a functional gastrointestinal system. Neurological diseases that cause neuromotor dysphagia, brain tumors, and cerebrovascular disease are the most frequent indications; complications are rare, and morbidity and mortality rates are low. Objective: To describe the usefulness of PEG in patients with neurological diseases, and its impact on care, survival, and costs and benefits. Material and methods: We performed a retrospective observational study, reviewing clinical files of patients hospitalised at the National Institute of Neurology and Neurosurgery (years 2015-2017) who underwent PEG placement. Results: The sample included 51 patients: 62.7% were women and the mean (SD) age was 54.4 (18.6) years (range, 18-86). Diagnosis was tumor in 37.3% of cases and cerebrovascular disease in 33.3%. Sixteen patients (33.3%) died and 11 presented minor complications. The PEG tube remained in place for a mean of 9.14 months; in 52.9% of patients it was removed due to lack of improvement and/or tolerated oral intake, with removal occurring after a mean of 5.1 (4.4) months. Among patients’ family members, 78.4% reported a great benefit, 43.1% reported difficulty caring for the PEG, and 45.1% reported complicated care in general. The monthly cost of maintaining the PEG was €175.78 on average (range, 38.38-293.45). Discussion and conclusions: This preliminary study reveals that PEG was well indicated in patients with neurological diseases, with survival rates similar to those reported in other studies with long follow-up periods. In patients with cerebrovascular disease, the PEG tube remained in place a mean of 9.14 months, during recovery of swallowing function; however, the cost is high for our population. (AU)

[Handling of drugs for administration by percutaneous endoscopic gastrostomy in patients with amyotrophic lateral sclerosis and enteral nutrition]. / Manipulación de fármacos para su administración por gastrostomía endoscópica percutánea en pacientes con esclerosis lateral amiotrófica y nutrición enteral.

Introduction: Introduction: amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease. Its symptoms include dysphagia that may make it necessary to place a percutaneous endoscopic gastrostomy (PEG) for feeding. The administration of drugs by PEG can obstruct it, decrease the effectiveness of treatment, and increase the risk of toxicity by altering the original pharmaceutical form. Objective: to describe and analyze the degree of adequacy of the prescription of drugs administered by PEG in patients with ALS and with enteral nutrition (EN). Material and methods: the prescription of pharmacological treatment for patients with ALS who were admitted for placement of a PEG was reviewed. The degree of adequacy of the prescribed drugs was analyzed according to criteria of loss of efficacy, toxicity, risk for handler, and compatibility with EN by consulting the available scientific evidence. Results: the medical prescriptions of the treatments of 34 patients were reviewed, with a total of 307 medications (median of 9 drugs per patient, range 2-17). Via PEG 267 oral medications (median 8 per patient, range 2-15) were prescribed; 81.65 % were solid forms, and the pharmaceutical form was modified in 43 %, due to the risk of catheter occlusion, toxicity or loss of efficacy, affecting 97 % of the patients. Conclusions: patients with ALS and PEG are at risk of presenting safety problems and loss of treatment efficacy related to alteration of the original pharmaceutical form and the interaction with EN.

Introducción: Introducción: la esclerosis lateral amiotrófica (ELA) es una enfermedad neurodegenerativa. Entre sus síntomas destaca la disfagia, que hace necesaria la colocación de una gastrostomía endoscópica percutánea (PEG) para alimentarse. La administración de fármacos por la PEG puede obstruirla, disminuir la eficacia del tratamiento y aumentar el riesgo de toxicidad, al alterar la forma farmacéutica original. Objetivo: describir y analizar el grado de adecuación de la prescripción de fármacos administrados por PEG en pacientes con ELA y con nutrición enteral (NE). Material y métodos: se revisó la prescripción del tratamiento farmacológico de los pacientes con ELA que ingresaban para la colocación de una PEG. Se analizó el grado de adecuación de los fármacos prescritos según los criterios de pérdida de eficacia, toxicidad, riesgo para el manipulador y compatibilidad con la NE, consultando la evidencia científica disponible. Resultados: se revisaron las prescripciones médicas de los tratamientos de 34 pacientes, con un total de 307 medicamentos (mediana de 9 fármacos por paciente; rango, 2-17). Se pautaron por la PEG 267 medicamentos de administración oral (mediana de 8 por paciente; rango, 2-15). El 81,65 % fueron formas sólidas y se modificó la forma farmacéutica en el 43 % por riesgo de oclusión de la sonda, toxicidad o pérdida de eficacia, afectando al 97 % de los pacientes. Conclusiones: los pacientes con ELA y con PEG tienen riesgo de presentar problemas de seguridad y de pérdida de eficacia del tratamiento relacionados con la alteración de la forma farmacéutica original y de la interacción con la NE.

Effect of the type of specialized nutrition support on the course of the patient with amyotrophic lateral sclerosis (ALS). Interhospital registry SCLEDyN.

INTRODUCTION: Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disease in which specialized nutritional support is essential. The objectives of our study were to describe nutritional support at the beginning of follow-up and its impact on anthropometry and survival. METHODS: An interhospital registry was created for the hospitals of Castilla-León through a web platform designed for this purpose. An anamnesis was carried out on the evolution and nutritional history of the disease; and classical anthropometry was determined. The prescribed nutritional treatment was recorded. The parameters were measured at the beginning, at six and twelve months of nutritional follow-up. RESULTS: A total of 93 patients [49 (52.7%) spinal; 44 (47.3%) bulbar)] were analyzed. The nutritional support route at the beginning was oral diet in 36 (38.7%) patients; oral nutritional supplementation (SON) in 46 (49.5%) patients; and in 11 (11.8%) patients percutaneous endoscopic gastrostomy (PEG). A decrease in the body mass index (BMI) was observed between the first and second visit [Start: 24.18 (3.29) kg/m2; 6 months: 23.69 (4.12) kg/m2; P < .05]. Less weight loss was observed at 6 months compared to the start of nutritional follow-up [Start: 8.09 (8.72)%; 6 months: 1.4 (6.29)%; P < .01]. 36 (38.7%) patients died but with no differences according to when nutritional support was started. Survival from the onset of symptoms was higher in the group of patients with artificial nutrition, although without reaching statistical significance [Oral: 28 (20.25) months; SON: 30 (16.75-48.25) months; PEG: 39 (27-52) months; P = .90]. CONCLUSIONS: Patients with ALS present a severe deterioration in nutritional status before the start of nutritional support. After the nutritional intervention, a slowdown in weight loss and nutritional deterioration was observed.

Gastrostomia endoscópica percutânea em crianças e adolescentes: 15 anos de experiência em um hospital terciário / Percutaneous endoscopic gastrostomy in children and adolescents: 15-years' experience of a tertiary center

ABSTRACT BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is an important option for enteral nutrition for both children and adults. It is considered a safe, effective, and advantageous technique in comparison to other complementary feeding routes. It allows continuous feeding, the feeding of patients with swallowing disorders due to neurological causes or others, and the administration of non-palatable diets or medications, all with low rates of complications and mortality. OBJECTIVE: This study aimed to evaluate the main indications and complications of PEG in pediatric patients. In addition, the impact on the nutritional status of patients undergoing PEG was also compared with weight, body mass index (BMI), and height according to references from the World Health Organization. METHODS: This observational and retrospective study included 152 children and adolescents who underwent PEG between January/2003 and December/2018. Patients up to 18 years of age at the time of the procedure were included. Complications related to the procedure were classified as minor or major. Patients with PEG indication for nutritional supplementation were evaluated for weight gain, height, and BMI, using the Z score at the day of the procedure and six months, 1 year, and 2 years after the procedure. RESULTS: Indications for PEG were: swallowing disorder of neurological cause (67.1%), need for nutritional supplementation (25%), swallowing disorder of mechanical origin (6.6%), and indication of gastric decompression (1.3%). Minor complications occurred in 57.8% of patients and major complications in 9.8% of patients. The traction technique corresponded to 92.1% and puncture to 7.9%. The death rate was 1.3%. Thirty-eight patients had an indication for nutritional supplementation. In these patients, there was a gradual increase in both BMI and weight, reaching statistically significant differences (P=0.0340 and P= 0.0105, respectively). These differences were more evident in chronic renal disease patients. Height did not vary significantly (P=0.543). CONCLUSION: PEG proved to be an advantageous option as an auxiliary feeding method in pediatric patients. Dysphagia of neurological origin was the main indication followed by the need for nutritional supplementation. PEG has low frequency of major complications and mortality. This study also showed the importance of PEG in patients who need nutritional supplementation, as it enabled patients to move from undernutrition to normal weight ranges.

RESUMO CONTEXTO: A gastrostomia endoscópica percutânea (GEP) é uma importante opção de nutrição enteral para crianças e adultos, sendo considerada uma técnica segura, eficaz e vantajosa em comparação às outras vias de alimentação complementar. Permite a alimentação contínua, a alimentação em pacientes com distúrbios de deglutição de causa neurológica ou outros, a administração de dietas ou medicamentos não palatáveis, todos com baixos índices de complicações e mortalidade. OBJETIVO: Avaliar as principais indicações e complicações de pacientes pediátricos submetidos à GEP e o impacto no estado nutricional de pacientes submetidos à GEP para suplementação nutricional, comparando peso, índice de massa corporal (IMC) e estatura com referências da Organização Mundial de Saúde. MÉTODOS: Estudo observacional e retrospectivo de 152 crianças e adolescentes submetidos à GEP, no período de janeiro/2003 a dezembro/2018. Foram incluídos pacientes até 18 anos de idade na época do procedimento. As complicações relacionadas ao procedimento foram divididas em menores e maiores. Pacientes com indicação de GEP para suplementação nutricional foram avaliados quanto ao ganho de peso, altura e IMC, por meio do escore Z no dia do procedimento e 6 meses; 1 ano; e 2 anos após o procedimento. RESULTADOS: As indicações para GEP foram distúrbio de deglutição de causa neurológica (67,1%), necessidade de suplementação nutricional (25%), distúrbio de deglutição de origem mecânica (6,6%), e indicação de descompressão gástrica (1,3%). Complicações menores ocorreram em 57,8% dos pacientes e complicações maiores em 9,8%. A técnica de tração correspondeu a 92,1% e a punção, 7,9%. A taxa de mortalidade foi de 1,3%. Trinta e oito pacientes tinham indicação de suplementação nutricional. Nestes, houve aumento gradativo tanto do IMC quanto do peso, com variação estatisticamente significativa da mediana P=0,0340 e P=0,0105, respectivamente, mais evidente nos pacientes renais crônicos. A altura não variou significativamente (P=0,543). CONCLUSÃO: A GEP mostrou-se uma opção vantajosa como forma auxiliar de alimentação em pacientes pediátricos, tendo como principais indicações a disfagia de causa neurológica e a necessidade de suplementação nutricional, com baixa prevalência de complicações maiores e mortalidade. Este estudo também mostrou a importância da GEP em pacientes com necessidade de suplementação nutricional, possibilitando a passagem dos pacientes desnutridos para escores nutricionais de peso adequados à idade.

Effect of the type of specialized nutrition support on the course of the patient with amyotrophic lateral sclerosis (ALS). Interhospital registry SCLEDyN. / Efecto del tipo de soporte nutricional especializado sobre la evolución del paciente con esclerosis lateral amiotrófica (ELA). Registro interhospitalario SCLEDyN.

INTRODUCTION: Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disease in which specialized nutritional support is essential. The objectives of our study were to describe nutritional support at the beginning of follow-up and its impact on anthropometry and survival. METHODS: An interhospital registry was created for the hospitals of Castilla-León through a web platform designed for this purpose. An anamnesis was carried out on the evolution and nutritional history of the disease; and classical anthropometry was determined. The prescribed nutritional treatment was recorded. The parameters were measured at the beginning, at six and twelve months of nutritional follow-up. RESULTS: A total of 93 patients [49 (52.7%) spinal; 44 (47.3%) bulbar)] were analyzed. The nutritional support route at the beginning was oral diet in 36 (38.7%) patients; oral nutritional supplementation (SON) in 46 (49.5%) patients; and in 11 (11.8%) patients percutaneous endoscopic gastrostomy (PEG). A decrease in the body mass index (BMI) was observed between the first and second visit [Start: 24.18 (3.29) kg/m2; 6 months: 23.69 (4.12) kg/m2; P<.05]. Less weight loss was observed at 6 months compared to the start of nutritional follow-up [Start: 8.09 (8.72)%; 6 months: 1.4 (6.29)%; P<.01]. 36 (38.7%) patients died but with no differences according to when nutritional support was started. Survival from the onset of symptoms was higher in the group of patients with artificial nutrition, although without reaching statistical significance [Oral: 28 (20.25) months; SON: 30 (16.75-48.25) months; PEG: 39 (27-52) months; P=.90]. CONCLUSIONS: Patients with ALS present a severe deterioration in nutritional status before the start of nutritional support. After the nutritional intervention, a slowdown in weight loss and nutritional deterioration was observed.

Pancreatitis aguda: una complicación infrecuente de las gastrostomías por migración del balón interno. Reporte de un caso y revisión de literatura / Acute pancreatitis: A rare complication of gastrostomy due to intragastric balloon migration. Case report and literature review

Resumen La pancreatitis aguda secundaria a la obstrucción de la papila mayor causada por la migración del balón interno es uno de los efectos secundarios poco frecuentes, pero potencialmente graves relacionados con el uso de gastrostomías endoscópicas percutáneas (PEG). Hasta ahora solo existen 15 casos reportados en el mundo, presentamos el que para nuestro conocimiento sería el caso número 16 en la literatura internacional.

Abstract Acute pancreatitis secondary to major papilla obstruction caused by intragastric balloon migration is one of the rare but potentially severe side effects associated with the use of percutaneous endoscopic gastrostomy (PEG). To date, there are only 15 cases reported worldwide. This article presents a case that, to the best of our knowledge, is the sixteenth case reported in the international literature.

Feasibility, safety and outcome of endoscopic gastrostomy in patients with esophageal cancer.

INTRODUCTION: Background and aims: esophageal cancer (EC) is an important health problem worldwide with high morbidity and mortality. EC patients are likely to develop malnutrition. The aim of this study was to assess the feasibility and safety of endoscopic gastrostomy (PEG) feeding in EC cancer, and to identify risk factors associated with poor prognosis. Methods: a retrospective observational study was performed using records from EC patients referred for PEG. Age, gender, cancer histologic subtype, indication for gastrostomy, and mortality data were recorded. NRS 2002, body mass index (BMI), hemoglobin, serum albumin, transferrin and total cholesterol were collected at the day of PEG. An association between anthropometric, clinical and laboratorial data with patient survival was assessed. Results: data were obtained for forty-one EC patients (36 men and 5 women) aged 39-88 years (mean, 62 years). Gastrostomy was possible in all patients referred to PEG (27 patients selected for curative treatment and 14 patients for palliative nutrition). No major complications occurred. Mean survival after PEG was 18.1 months, and mortality rate at 3 months was 31.7 %. Most patients (34; 82.9 %) died under PEG feeding. Mean BMI was 21.3 kg/m2 and 14 patients (34.1 %) patients had low BMI. Serum albumin, transferrin and total cholesterol were low in 10 (24.4 %), 20 (48.8 %) and 18 (43.9 %) patients, respectively. Higher BMI (R = 0.30), serum albumin (R = 0.41) and transferrin (R = 0.47) tended to be positively correlated with survival (p < 0.005). Conclusions: PEG is a feasible and safe technique for enteral feeding in EC patients. Higher BMI, serum albumin and transferrin levels at admission predict a better outcome. Enteral feeding through PEG should be considered early in EC patients due to their higher risk of malnutrition, which is associated with shorter survival.

INTRODUCCIÓN: Introducción y objetivos: los pacientes con EC presentan una elevada probabilidad de desarrollar desnutrición. El objetivo de este estudio fue evaluar la viabilidad y seguridad de la alimentación por gastrostomía endoscópica (PEG) en los EC e identificar los factores de riesgo asociados con un peor pronóstico. Métodos: estudio observacional retrospectivo utilizando registros de pacientes con EC remitidos para PEG. Se registraron edad, género, subtipo histológico del cáncer, indicación de gastrostomía y datos de mortalidad. El NRS 2002, el índice de masa corporal (IMC), la hemoglobina, la albúmina sérica, la transferrina y el colesterol total se recogieron el día de la PEG. Se evaluó la asociación de los datos antropométricos, clínicos y de laboratorio con la supervivencia del paciente. Resultados: se obtuvieron datos de 41 pacientes con EC (36 hombres y 5 mujeres), con edades entre 39 y 88 años (media 62 años). La gastrostomía fue posible en todos los pacientes remitidos a PEG (27 pacientes seleccionados para tratamiento curativo y 14 pacientes para nutrición paliativa). No ocurrieron complicaciones mayores. La supervivencia media después de la PEG fue de 18,1 meses y la tasa de mortalidad a los 3 meses fue del 31,7 %. La mayoría de los pacientes (34; 82,9 %) murieron bajo alimentación con PEG. El IMC medio fue 21.3 kg/m2 y 14 pacientes (34,1 %) pacientes presentaron un IMC bajo. La albúmina sérica, transferrina y colesterol total fueron bajos en 10 (24,4 %), 20 (48,8 %) y 18 (43,9 %) pacientes, respectivamente. El IMC alto (R = 0,30), la albúmina sérica (R = 0,41) y transferrina (R = 0,47) tienden a correlacionarse positivamente con la supervivencia (p < 0,005). Conclusiones: la PEG es una técnica factible y segura para la alimentación enteral de los pacientes con EC. Los niveles más altos de IMC, albúmina sérica y transferrina al ingreso predicen un mejor resultado. La alimentación enteral a través de PEG debe considerarse temprano en pacientes con EC debido al mayor riesgo de desnutrición, que se asocia a supervivencia más corta.

Prevalence of diabetes mellitus in patients with home enteral nutrition.

BACKGROUND: There are few data available in the literature on the prevalence of diabetes mellitus (DM) in patients with home enteral nutrition (HEN) via tube feeding. The objective was to analyze the prevalence of DM in patients receiving HEN, as well as evaluating the complications, the prescribed antidiabetic treatments and the nutrition regimen selected. DESIGN: This was a retrospective, single-center, observational study reviewing clinical histories. The population consisted of patients over 18 years of age who started HEN by tube between January 2016 and January 2018. Sociodemographic variables were recorded, as well as variables related to HEN. Additional variables were recorded in patients with DM. RESULTS: In the 198 study patients, followed up for a median of 104 days, the prevalence of DM was 31.8%, and patients with DM were older (71.3±11.5 vs. 64.2±15.8; p=0.002) than those without DM. There were no differences between patients with and without DM as regards the prescription of HEN, its route and form of administration, and its complications. One hundred and thirty-two patients (66.7%) died during follow-up. The presence of DM did not increase the risk of death during follow-up (after adjusting for age, gender, and diagnosis). More than 85% of patients with DM received a specific formula for diabetes, and 84.1% of these patients received drug treatment. CONCLUSION: The prevalence of DM was high in patients receiving HEN, most of whom were prescribed specific enteral nutrition formulas. The presence of DM was not associated with greater morbidity and mortality or with differences in HEN regimens or indications.

Exploratory study on gastrostomy in patients with neurological diseases: usefulness and impact. / Estudio exploratorio sobre gastrostomía en pacientes con enfermedades neurológicas: utilidad e impacto.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is a useful intervention for patients with impaired swallowing and a functional gastrointestinal system. Neurological diseases that cause neuromotor dysphagia, brain tumors, and cerebrovascular disease are the most frequent indications; complications are rare, and morbidity and mortality rates are low. OBJECTIVE: To describe the usefulness of PEG in patients with neurological diseases, and its impact on care, survival, and costs and benefits. MATERIAL AND METHODS: We performed a retrospective observational study, reviewing clinical files of patients hospitalised at the National Institute of Neurology and Neurosurgery (years 2015-2017) who underwent PEG placement. RESULTS: The sample included 51 patients: 62.7% were women and the mean (SD) age was 54.4 (18.6) years (range, 18-86). Diagnosis was tumor in 37.3% of cases and cerebrovascular disease in 33.3%. Sixteen patients (33.3%) died and 11 presented minor complications. The PEG tube remained in place for a mean of 9.14 months; in 52.9% of patients it was removed due to lack of improvement and/or tolerated oral intake, with removal occurring after a mean of 5.1 (4.4) months. Among patients' family members, 78.4% reported a great benefit, 43.1% reported difficulty caring for the PEG, and 45.1% reported complicated care in general. The monthly cost of maintaining the PEG was €175.78 on average (range, 38.38-293.45). DISCUSSION AND CONCLUSIONS: This preliminary study reveals that PEG was well indicated in patients with neurological diseases, with survival rates similar to those reported in other studies with long follow-up periods. In patients with cerebrovascular disease, the PEG tube remained in place a mean of 9.14 months, during recovery of swallowing function; however, the cost is high for our population.

Nutritional profile and mortality in patients undergoing percutaneous endoscopic gastrostomy.

INTRODUCTION: Background: malnutrition is a common problem in hospitalized patients, being associated with increased morbidity, mortality and costs. Multiple factors contribute to a deficient nutritional status, making malnutrition the cause or consequence of severe diseases. Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure indicated for long-term administration of enteral nutrition in patients with limited ability for oral intake who have an intact, functional gastrointestinal tract. The aim of this study was to determine the profile of patients undergoing PEG in a tertiary hospital in southern Brazil. Methods: single-center retrospective study of all patients who underwent PEG from January 1st to December 31st, 2016, in a private tertiary hospital located in southern Brazil. Data were collected retrospectively from the patients' medical records, including nutritional status, indications, complications and outcomes. Results: one hundred and thirty-three patients underwent PEG at our institution and were eligible for inclusion in the study. Median patient age was 82 years, and 57.9% were females. The main indication for PEG was dementia syndrome, followed by stroke. As much as 68.4% were diagnosed as severely malnourished and 23.0% had procedure-related complications. Conclusions: PEG tubes are being increasingly used for enteral nutrition in patients with dysphagia or inability to maintain adequate nutritional intake. The findings of the present study highlight the importance of regular nutritional risk screening by a multidisciplinary team, paying special attention to the patient's nutritional status and conditions that may place the patient at risk of developing dysphagia, with the implementation of measures to minimize malnutrition in hospitalized patients.

INTRODUCCIÓN: Introducción: la desnutrición es común en pacientes hospitalizados y se está convirtiendo en causa o consecuencia de enfermedades graves, asociándose a morbilidad, mortalidad y costos aumentados. Múltiples factores contribuyen a un estado nutricional deficiente. La gastrostomía endoscópica percutánea (PEG) es un procedimiento mínimamente invasivo para la administración de nutrición enteral en pacientes con capacidad limitada de ingesta oral que tengan el tracto gastrointestinal intacto y funcional. El objetivo de este estudio fue determinar el perfil de pacientes sometidos a PEG en un hospital terciario del sur de Brasil. Métodos: estudio retrospectivo unicéntrico de todos los pacientes sometidos a PEG del 1 de enero al 31 de diciembre de 2016 en un hospital terciario privado del sur de Brasil. Se recolectaron los datos retrospectivamente en los registros médicos, incluyendo estado nutricional, indicaciones, complicaciones y evolución. Resultados: ciento treinta y tres pacientes se sometieron a PEG en nuestra institución y fueron elegibles para el estudio. La edad mediana fue de 82 años y el 57,9% eran mujeres. Las principales indicaciones para PEG fueron demencia y accidente cerebrovascular. El 68,4% fueron diagnosticados con desnutrición grave y el 23,0% presentaron complicaciones relacionadas al procedimiento. Conclusiones: se utilizan cada vez más tubos de PEG para nutrición enteral en pacientes disfágicos o incapaces de mantener una ingesta nutricional adecuada. Nuestros hallazgos señalan la importancia del cribado para riesgo nutricional por un equipo multidisciplinario, con atención especial al estado nutricional del paciente y a condiciones que pueden ponerlo en riesgo para disfagia y la implementación de medidas para minimizar la desnutrición.

Percutaneous endoscopic gastrostomy in patients with amyotrophic lateral sclerosis: Mortality and complications. / La gastrostomía endoscópica percutánea en pacientes diagnosticados de esclerosis lateral amiotrófica: mortalidad y complicaciones.

INTRODUCTION: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that causes severe dysphagia and weight loss. Percutaneous endoscopic gastrostomy (PEG) is currently the technique of choice for the enteral nutrition of these patients. OBJECTIVES: To analyse mortality and complications in a series of patients diagnosed with ALS who underwent PEG, and to evaluate factors related to patient survival after the procedure. MATERIAL AND METHODS: We performed a prospective, observational study including all patients diagnosed with ALS and treated by our hospital's Gastroenterology Department in the period 1997-2013. We studied mortality, complications, and clinical and biochemical parameters, and correlated these with the survival rate. RESULTS: The study included a total of 57 patients, of whom 49 were ultimately treated with PEG. ALS onset was bulbar in 30 patients and spinal in 19. Mortality during the procedure and at 30 days was 2% (n = 1). Six patients (12.2%) experienced major complications; 17 (34.7%) experienced less serious complications which were easily resolved with conservative treatment. No significant differences were observed in forced vital capacity, albumin level, or age between patients with (n = 6) and without (n = 43) major complications. CONCLUSIONS: PEG is an effective, relatively safe procedure for the enteral nutrition of patients with ALS, although not without morbidity and mortality. Neither forced vital capacity nor the form of presentation of ALS were associated with morbidity in PEG.

Percutaneous endoscopic gastrostomy. Indications, care and complications. / Gastrostomía endoscópica percutánea. Indicaciones, cuidados y complicaciones.

Percutaneous endoscopic gastrostomy (PEG) is an effective and safe method for nutritional support in patients with malnutrition and impossibility of oral intake with an estimated survival higher than the months that require enteral nutrition beyond four weeks. The main indications include neoplasms of the upper air-digestive tract and neurological diseases, with dementia currently considered a controversial indication. Anatomical alterations and infectious diseases are the most frequent contraindications. There are different endoscopic techniques; the most widely used being the "pull" method, with a low mortality. Complications are more frequent in patients with multiple pathologies and the elderly. Wound infection, extraction of the tube, tube blockage and bronchoaspiratory pneumonia are the most prevalent complications. Adequate prior preparation of the patient and exhaustive maintenance of the tube can reduce the appearance of these.

Hemorragia masiva: una complicación tardía del reemplazo de la gastrostomía endoscópica percutánea. A propósito de un caso / Massive hemorrhage: a late complication of replacement percutaneous endoscopic gastrostomy: case report

La gastrostomía endoscópica percutánea (GEP) se utiliza como alternativa de la alimentación enteral/nasoenteral en situaciones en las que la alimentación por vía oral a largo plazo no es eficaz o no se tolera. Se prefiere principalmente en pacientes con afecciones neurológicas y, además, como apoyo de la nutrición en pacientes con enfermedades cardíacas congénitas, fibrosis quística, enfermedad intestinal inflamatoria y diversas enfermedades orofaríngeas. Si bien la colocación es sencilla en comparación con muchos procedimientos invasivos, presenta complicaciones, que incluyen desde la infección de la herida hasta la muerte. La GEP exige personal médico experimentado, antibióticos profilácticos adecuados e información exhaustiva para los pacientes o sus familias sobre el procedimiento y los cuidados posteriores. Presentamos una complicación rara, aunque importante, que surgió durante el reemplazo de la sonda de gastrostomía después del método de "corte y empuje". El tope, que debe llegar hasta el extremo distal del estómago, se desplazó hacia arriba, hasta el esófago proximal, y causó una úlcera profunda en la mucosa esofágica y una hemorragia masiva.

Percutaneous endoscopic gastrostomy (PEG) is used as an alternative to enteral/nasoenteral feeding in situations where long-term oral feeding is ineffective or not tolerated. It is mostly preferred in patients with neurological conditions and also to support nutrition in patients with congenital heart diseases, cystic fibrosis, inflammatory bowel disease, and various oropharyngeal diseases. Although it is easily applicable compared to many invasive procedures, it has complications ranging from wound infection to death. PEG requires experienced medical personnel, appropriate prophylactic antibiotics and exhaustive information to the patients or their families about the procedure and subsequent care. We present a rare but important complication during the replacement of the gastrostomy tube subsequent to the "cut and push" method. The bumper portions, which should move to the distal end of the stomach, moved upwards to the proximal esophagus, caused a deep ulcer in the esophageal mucosa and a massive hemorrhage.

[Non-invasive mechanical ventilation with a facial interface during sedation for a percutaneous endoscopic gastrostomy in a patient with amyotrophic lateral sclerosis]. / Ventilación mecánica no invasiva con interfase facial durante la sedación para una gastrostomía endoscópica percutánea en un paciente con esclerosis lateral amiotrófica.

Amyotrophic lateral sclerosis is a chronic neurodegenerative disease of the central nervous system which affects the motor neurons and produces a progressive muscle weakness, leading to atrophy and muscle paralysis, and ultimately death. Performing a percutaneous endoscopic gastrostomy with sedation in patients with amyotrophic lateral sclerosis can be a challenge for the anesthesiologist. The case is presented of a 76-year-old patient who suffered from advanced stage amyotrophic lateral sclerosis, ASA III, in which a percutaneous endoscopic gastrostomy was performed with deep sedation, for which non-invasive ventilation was used as a respiratory support to prevent hypoventilation and postoperative respiratory complications.

Gastrostomía endoscópica percutánea en ancianos: indicaciones, seguridad y desenlaces / Percutaneous Endoscopic Gastrostomy in elderly, indications, safety and outcomes

Introducción: la gastrostomía endoscópica percutánea (GEP) se ejecuta cada vez con mayor frecuencia en ancianos con alteraciones deglutorias, sin importar su condición física, mental o funcional. En nuestro medio se desconocen sus complicaciones y desenlaces. Objetivo: el propósito del estudio es determinar las indicaciones, tasa de complicaciones y desenlaces a corto y largo plazo en el seguimiento de hasta de 5 años. Pacientes y métodos: estudio descriptivo retrospectivo de pacientes mayores de 60 años de edad hospitalizados con indicación de gastrostomía endoscópica percutánea y atendidos en la Clínica Fundadores en el período comprendido entre enero de 2008 y junio del 2013; fueron excluidos pacientes menores de 60 años, realización de gastrostomía abierta o GEP fallida. Se realizó revisión de historias clínicas y seguimiento telefónico de los pacientes. Resultados: de los 135 pacientes con indicación de GEP, 96 fueron incluidos, media de edad 77,5±9 años, 38 hombres (39,5%). La indicación para la GEP fue la incapacidad para la deglución por evento cerebrovascular (32,89%), demencia (30,26%) u otras causas (36,85%). La hipertensión arterial fue la comorbilidad más frecuente. La complicación más común asociada con la GEP fueron los síntomas gastrointestinales (32,9%). No hubo mortalidad asociada con el procedimiento. Conclusiones: la GEP es segura para el aporte enteral a los pacientes ancianos, sin embargo, no demostró beneficio en aquellos pacientes asociados con demencia. Es importante un manejo interdisciplinario previo para definir la alimentación por gastrostomía en ancianos.

Introduction: Percutaneous endoscopic gastrostomies (PEG) are performed more and more frequently in elderly patients suffering from problems with swallowing. The procedure is used regardless of patients’ physical, mental and functional status, but little is known about complications and outcomes here in Colombia. Objective: The purpose of the study is to determine indications for performance of PEG, rate of complications, and outcomes in short and long term follow-ups (five years). Patients and methods: This is a retrospective and descriptive study of patients over the age of 60 who were hospitalized for percutaneous endoscopic gastrostomy at the Clínica Fundadores between January 2008 and June 2013. Patients younger than 60 years of age, those who had open gastrostomies, and those whose PEG procedure failed were excluded. Patients medical records were reviewed and telephone follow-ups of patients were conducted. Results: Of the 135 patients with indications for PEG, 96 patients were included. The mean age was 77.5 ± 9 years, and 38 of the patients were men (39.5%). The reasons for performance of PEG were inability to swallow due to a cerebrovascular event (32.89%), dementia (30.26 %) and other causes (36.85). Hypertension was the most common comorbidity. The most common complications associated with PEG were gastrointestinal symptoms (32.9%). There was no mortality associated with the procedure. Conclusions: PEG is a safe way for elderly patients to receive enteral tube feeding (ETF), but we found no benefit for patients with dementia. Interdisciplinary management prior to the procedure is important to determine whether or not ETF should be used for elderly patients.