Tongue pressure is a strong predictor of recommendation for gastrostomy in amyotrophic lateral sclerosis.

INTRODUCTION/AIMS: Objective and practical biomarkers to determine the need for gastrostomy in patients with amyotrophic lateral sclerosis (ALS) are lacking. Tongue pressure (TP) is a promising biomarker because it is associated with bulbar dysfunction. The aims of this study were to evaluate the association of TP with the need for gastrostomy, and to determine its optimal cut-off value. METHODS: This prospective observational study included participants with ALS taking nutrition orally. TP was evaluated using the Iowa Oral Performance Instrument. Need for gastrostomy as determined by a multidisciplinary team during a 12-month follow up period was recorded. Associations between TP and need for gastrostomy placement were performed. ROC curve analysis determined the optimal cut-off value of TP to predict gastrostomy. RESULTS: Of 208 screened participants, 119 were included. Gastrostomy was indicated in 45% (53), in a 12-month follow up period. TP of ≤20 kPA was a strong predictor of gastrostomy indication (OR 11.8, CI 95% [4.61, 34.7], p < .001). The association persisted even after adjustment for weight loss, pneumonia, prolonged feeding duration, Revised ALS Functional Rating Scale score, and American Speech-Language-Hearing Association scale score (OR 4.51, CI 95% [1.50, 14.9], p = .009). By receiver operating characteristic curve analysis, 20 kPA represented the optimal cut-off value (sensitivity 0.75, specificity 0.89). DISCUSSION: TP is a strong independent predictor of gastrostomy indication in the subsequent 12 months in patients with ALS, with good sensitivity and specificity at a cutoff value of ≤20 kPA, suggesting that it may be a promising biomarker in clinical practice.

Pancreatic Pseudocyst and Obesity: Video Case Report of Management with the One-Stage Procedure.

Reports of pancreatic pseudocyst drainage during metabolic bariatric surgery are extremely rare. Our patient is a 38-year-old female suffering from obesity grade IV and presents a persistent symptomatic pancreatic pseudocyst 8 months after an episode of acute biliary pancreatitis. After an extensive evaluation and considering other treatment options, our multidisciplinary team and the patient decided to perform a one-stage procedure consisting of laparoscopic cystogastrostomy, cholecystectomy, and one-anastomosis gastric bypass. After bringing the patient to the operating room, the surgeon performed an anterior gastrostomy to access the stomach's posterior wall, followed by a 6-cm cystogastrostomy on both the stomach's posterior wall and the cyst. Next, a cholecystectomy which involved dissecting the triangle of Calot was performed. Then, an 18-cm gastric pouch using a 36-Fr calibration tube was created. The cystogastrostomy was left in the remaining stomach. Finally, gastrojejunal anastomosis is done. The patient's postoperative course proceeded smoothly, leading to her home discharge on the third postoperative day. At the 1-year follow-up, the patient had lost 56 kg and was symptom-free; a computer tomography scan showed that the pancreatic pseudocyst had resolved. This case shows a video of a successful laparoscopic cystogastrostomy, cholecystectomy, and one-anastomosis gastric bypass (OAGB) used to treat persistent abdominal pain and obesity grade IV. We also conduct a bibliographic review.

Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy for enteral feeding: A systematic review and meta-analysis.

BACKGROUND: Percutaneous radiological gastrostomy (PRG) and percutaneous endoscopic gastrostomy (PEG) are minimally invasive gastrostomy techniques for individuals requiring prolonged enteral feeding. Recent meta-analyses concerning their efficacy and safety mainly included retrospective studies and yielded conflicting results. This meta-analysis of randomized controlled trials (RCTs) aimed to compare efficacy, safety, and procedure time between PRG and PEG for enteral feeding. METHODS: MEDLINE, Embase, and the Cochrane Library were searched for eligible RCTs comparing PRG and PEG for enteral feeding through February 23, 2024. The primary outcome was technical success. The secondary outcomes were (1) adverse events (AEs), (2) mortality, and (3) procedure time. We used the random-effects model to calculate pooled risk ratio (RR) and mean difference (MD) with corresponding 95% CIs for dichotomous and continuous outcomes, respectively. RESULTS: Five RCTs with 544 patients (268 PRG and 276 PEG) were included. There was similar technical success (RR = 1.02; 95% CI = 0.98-1.05; I² = 35%; moderate certainty of evidence because of inconsistency), overall mortality (RR = 1.25; 95% CI = 0.63-2.47; I² = 47%; very low certainty of evidence because of inconsistency, indirectness, and imprecision), and overall AEs risk (RR = 1.06; 95% CI = 0.63-1.76; I² = 81%; low certainty of evidence because of inconsistency and imprecision) between the two groups. However, compared with PEG, the procedure time was longer in the PRG group (MD = 19.35 min; 95% CI = 0.95-37.75 min; I² = 98%; very low certainty of evidence because of inconsistency and imprecision). CONCLUSION: PRG and PEG demonstrate similar efficacy and safety; however, the endoscopic technique may boast a shorter procedure time.

Operative Complications Following Gastrostomy Tube Placement After Cardiac Surgery During Infancy.

INTRODUCTION: Gastrostomy tube (GT) placement is common in infants following repair of congenital heart defects. We aimed to determine rate of operative complications and predictors of short-term GT use to counsel parents regarding the risks and benefits of GT placement. METHODS: We reviewed infants aged <1 y with congenital heart disease who underwent GT placement after cardiac surgery between 2018 and 2021. Demographics and clinical data were collected and analyzed. Comparisons were made between infants who required the GT for more than 1 y and those who required the GT for less than 1 y. RESULTS: One hundred thirty three infants were included; 35 (26%) suffered one or more complication including wound infection (4, 3%), granulation tissue (3, 2%), tube dislodgement (10), leakage from the tube (9), unplanned emergency department visit (15), and unplanned readmission (1). Thirty-four infants used the GT for feeds for 1 y or less (26%) including 17 (13%) who used it for 3 mo or less. Fifty-six infants had their GT removed during the study period (42%), 20 of whom required gastrocutaneous fistula closure (36%). Thirty-three infants had a GT placed on or before day of life 30, 17 (52%) used the GT for less than 1 y, and 10 (31%) used it for 3 mo or less. CONCLUSIONS: GT placement is associated with a relatively high complication and reoperation rate. GT placement in infants aged less than 30 d is associated with shorter duration of use. Risks, benefits, and alternatives such as nasogastric tube feeds should be discussed in the shared decision-making process for selected infants.

Sobrevida post instalación de gastrostomía: experiencia de un centro terciario / Survival post installation of gastrostomy: experience of a tertiary cente

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is one of the preferred methods for providing enteral feeding to patients whose oral intake nutrition is not feasible. There is limited evidence regarding post- PEG survival. Our primary objective is to evaluate long-term survival and identify main variables in a cohort of patients with PEG. Methodology: A retrospective study of patients who underwent PEG at Sótero del Río Hos- pital between 2013 and 2020 was conducted. Demographic data, indications for PEG, and time from placement to death, in applicable cases, were evaluated. Specific indications were classified into four groups: Neoplasia, Dementia, Stroke (CVA), and Other neurological causes. Kaplan-Meier curves were plotted to represent survival, and log-rank tests were used. Results: 635 patients were included, 53.5% male, with a median age of 69 years (IQR 55-79). Indications included Neoplasia (11.8%), Dementia (9.8%), Stroke (58.4%), and Other neurological causes (20.0%). The overall survival rate was 36%, with rates of 50.23% at one year and 3.94% at five years, and a median survival of 12 months (IQR 4-28). According to the previous diagnosis, the Other neurological causes group had a higher survival rate (p < 0.001), with a median survival of 16 months (IQR 4-35). Conclusions: PEG is an invasive technique where placement is influenced by multiple variables such as previous diagnosis and patient type. Our study demonstrated a survival rate consistent with the literature, where factors such as age and the type of disease that prompted indication are relevant to consider.

Introducción: La gastrostomía endoscópica percutánea (GEP) es uno de los métodos de elección para brindar alimentación enteral a pacientes que ven afectada su capacidad de nutrición por vía oral. Existe escasa evidencia respecto a la sobrevida post GEP, estudios describen un 40% al año, en relación a la gravedad inherente de la enfermedad de base de los pacientes. Nuestro objetivo principal es evaluar la sobrevida a largo plazo y cuáles serían las principales variables que podrían influir, en una cohorte de pacientes con GEP. Metodología: Estudio retrospectivo de pacientes a quienes se les instaló una GEP en el Hospital Sótero del Río, entre los años 2013- 2020. Se evaluaron datos demográficos, indicación de la GEP y tiempo transcurrido desde la instalación hasta el fallecimiento, en los casos correspondientes. Las indicaciones específicas fueron clasificadas en cuatro grandes grupos: Neoplasia, Demencia, Accidente Cerebrovascular (ACV) y Otras causas neurológicas. Se trazaron curvas de Kaplan-Meier para representar la supervivencia y se utilizaron pruebas de log-rank test. En el análisis estadísti- co se utilizó SPSS versión 25. Resultados: Se incluyeron 635 pacientes, 53,5% sexo masculino, con una mediana de edad 69 años (RIQ 55-79). Dentro las indicaciones: Neoplasia (11,8%), Demencia (9,8%), ACV (58,4%) y Otras causas neurológicas (20,0%). La tasa de sobrevida global fue del 36%, siendo al año 50,23 % y a los 5 años 3,94%; con una mediana de sobrevida de 12 meses (RIQ 4-28). Según diagnóstico previo, el grupo Otras causas neurológicos tuvo una mayor sobrevida (p < 0,001), con una mediana de 16 meses (RIQ 4-35). Conclusiones: La GEP es una técnica invasiva donde su instalación responde a múltiples variables como diagnóstico previo y tipo de paciente. Nuestro trabajo demostró una tasa de supervivencia acorde con la literatura, donde los factores como la edad y el tipo de enfermedad que originó indicación son relevantes a considerar.

Perfil de crianças e adolescentes dependentes de tecnologia em um hospital pediátrico do Sul do país / Perfil de niños e adolescentes dependientes de tecnología en un hospital pediátrico de referencia del sur del país / Profile of technology-dependent children and adolescents in a referral pediatric hospital in the south of the country

Resumo Objetivo identificar o perfil de crianças e adolescentes dependentes de tecnologia de um hospital de referência pediátrica do sul do país. Método estudo descritivo, com abordagem quantitativa. A coleta de dados ocorreu por meio da análise de prontuários, entre janeiro de 2016 e dezembro de 2019, armazenados em planilha Microsoft Excel para a análise estatística descritiva. Um projeto aprovado pelo Comitê de Ética sob o parecer 5.115.194. Resultados prevaleceu o sexo masculino (50,8%), em idade pré-escolar (30,8%), proveniente da Grande Florianópolis (60,1%). Os diagnósticos mais frequentes foram relacionados à prematuridade/período neonatal, anomalias congênitas/defeitos genéticos, doenças neurológicas e/ou neuromusculares, correspondendo a 37%, 33,2% e 18,5%. Os dispositivos tecnológicos mais utilizados foram gastrostomia (56,3%) e traqueostomia (36,6%). A utilização de medicamentos contínuos se deu em 93,4% e 49,2% utilizavam quatro ou mais medicamentos. As mães foram as principais cuidadoras (80,9%). Ocorreram 31 óbitos no período. Conclusão e implicação para a prática este grupo apresenta grande demanda de cuidados decorrentes do diagnóstico principal, dos dispositivos tecnológicos, das medicações e das possíveis complicações. A identificação do perfil das crianças e adolescentes dependentes de tecnologia contribuiu para ampliar a visibilidade de uma população que está em constante crescimento e, assim, prestar uma assistência integral, de acordo com suas especificidades e reais necessidades.

Resumen Objetivo identificar el perfil de niños y adolescentes dependientes de tecnología atendidos en un hospital de referência pediátrica del sur del país. Método estudio descriptivo con enfoque cuantitativo. La recolección de datos ocurrió através del análisis de las historias clínicas, desde enero de 2016 hasta diciembre de 2019, almacenadas en una hoja de cálculo de Microsoft Excel para el análisis estadístico descriptivo. El proyecto fue aprobado por el Comité de Ética bajo el parecer 5.115.194. Resultados predominaron varones (50,8%), en período de desarrollo preescolar (30,8%), la región más frecuentada de la Gran Florianópolis (60,1%). Los diagnósticos más frecuentes estuvieron relacionados con prematuridad/el período neonatal, anomalías congénitas/defectos genéticos, enfermedades neurológicas y/o neuromusculares, correspondiendo al 37%, 33,2% y 18,5%, respectivamente. Los dispositivos tecnológicos más utilizados fueron la gastrostomía (56,3%) y la traqueotomía (36,6%). El uso de medicación continua ocurrió en el 93,4% y el 49,2% utilizó cuatro o más medicamentos. Las madres fueron las principales cuidadoras en 80,9% de los casos, ocurriendo 31 óbitos en el período. Conclusión e implicación para la práctica este grupo tiene una alta demanda de atención debido al diagnóstico principal, dispositivos tecnológicos, medicamentos y posibles complicaciones. Identificar el perfil de niños y adolescentes dependientes de tecnología contribuye a aumentar la visibilidad de una población en constante crecimiento y, por lo tanto, calificar la asistencia, de acuerdo com sus especificidades y reales necesidades.

Abstract Objective to identify the profile of technology-dependent children and adolescents at a pediatric referral hospital in southern Brazil. Method a descriptive study with a quantitative approach. Data was collected by analyzing medical records between January 2016 and December 2019 and stored in a Microsoft Excel spreadsheet for descriptive statistical analysis. The project was approved by the Ethics Committee under protocol number 5.115.194. Results: The prevalence was male (50.8%), pre-school age (30.8%), from Greater Florianópolis (60.1%). The most frequent diagnoses were related to prematurity/neonatal period, congenital anomalies/genetic defects, and neurological and/or neuromuscular diseases, corresponding to 37%, 33.2%, and 18.5%. The most commonly used technological devices were gastrostomy (56.3%) and tracheostomy (36.6%). 93.4% used continuous medication and 49.2% used four or more medications. Mothers were the main caregivers (80.9%). There were 31 deaths during the period. Conclusion and implications for practice this group has a high demand for care due to the main diagnosis, technological devices, medications, and possible complications. Identifying the profile of technology-dependent children and adolescents has helped to increase the visibility of a population that is constantly growing and thus provides comprehensive care according to their specific needs.

Intususcepción por complicación de gastrostomía / Intussusception due to gastrostomy complication

Introducción: La oclusión intestinal constituye la segunda causa de abdomen agudo quirúrgico y el 20 por ciento de los ingresos en los servicios de urgencia; algunas revisiones muestran que se producen cada año más de 9000 muertes por esta causa. Objetivo: Presentar un paciente oncológico al cual se le realizó una gastrostomía y posteriormente se complicó con una intususcepción. Caso clínico: Paciente de 59 años de edad, al cual se le realizó una gastrostomía alimentaria al presentar disfagia. Días más tarde el paciente se complicó con una oclusión intestinal y falleció en un corto periodo. Conclusiones: La intususcepción es una enfermedad infrecuente en adultos, con una presentación clínica poco específica. Los síntomas cardinales son el dolor de tipo cólico, vómitos, distención abdominal y detención del tránsito intestinal(AU)

Introduction: Intestinal occlusion is the second leading cause of surgical acute abdomen and 20 percent of admissions to emergency services; some reviews show that they produce more than 9000 deaths each year from this cause. Objective: Report a case of an oncological patient who underwent a gastrostomy and subsequently becomes complicated by intussusception. Case presentation: A 59-year-old patient, who underwent an alimentary gastrostomy due to dysphagia. A few days later, the patient developed complications with intestinal occlusion and died within short time. Conclusions: Intussusception is an uncommon disease in adults, with a non-specific clinical presentation. The cardinal symptoms are cramping pain, vomiting, abdominal distension and intestinal transit arrest(AU)

[Start of enteral nutrition after an endoscopic gastrostomy, is it necessary to wait?] / Inicio de nutrición enteral luego de una gastrostomía endoscópica, ¿es necesario esperar?

Traditionally, the initiation of enteral nutrition after a percutaneous endoscopic gastrostomy (PEG) is performed between 12 and 24 hours. Different research suggests that early initiation might be a safe option. Our aim was to determine whether starting enteral nutrition 4 hours after performing PEG is a safe practice in terms of risk of intolerance, complications, or death, compared to starting it at 12 hours. We carried out a prospective, randomized, multicenter study in third and fourth level institutions in Bogotá and Cundinamarca, between June 2020 and May 2022, 117 patients were included who were randomized into 2 groups, group A with early nutrition initiation (4 hours), and standard group B (12 hours). The most frequent mechanism of dysphagia was cerebrovascular disease (43%), followed by complications of COVID19 infection (26%). There were no statistically significant differences between the groups evaluated regarding the percentage of intolerance to nutrition, RR = 0.93 (CI 0.30-2.90), there were also no differences in terms of postoperative complications, (RR) = 0.34 (CI 0.09-1.16), and no differences were found in mortality between the evaluated groups, (RR) = 1.12 (CI 0.59-2.15). In conclusion, early initiation of nutrition through the gastrostomy, 4 hours after performing the PEG, is a safe behavior that is not related to greater intolerance to nutrition, complications, or death, compared to later initiation.

Necrosis esofágica aguda (esófago negro) asociado a neoplasias digestivas / Acute esophageal necrosis (black esophagus) associated with digestive neoplasms

INTRODUCCIÓN. La necrosis esofágica aguda es un síndrome raro que se caracteriza endoscópicamente por una apariencia negra circunferencial irregular o difusa de la mucosa esofágica intratorácica, la afectación es generalmente del esófago distal y la transición abrupta de mucosa normal en la unión gastroesofágica, con extensión proximal variable. CASOS. Se presentan dos casos con diferentes comorbiliades, presentación de signos y síntomas, antecedentes y tratamiento, teniendo en común el diagnóstico a través de endoscopía digestiva alta. RESULTADOS. Caso clínico 1: tratamiento clínico basado en hidratación, suspensión de vía oral, omeprazol intravenoso y sucralfato; mala evolución clínica caracterizada por: disfagia, intolerancia oral y recurrencia del sangrado digestivo alto, se realiza colocación de gastrostomía endoscópica. Caso clínico 2: esófago con mucosa con fibrina y parches de necrosis extensa, se realiza compensación tanto de foco infeccioso pulmonar como hidratación y nutrición, en estudios complementarios se observa masa colónica, con estudio histopatológico confirmatorio de adenocarcinoma de colon en estado avanzado. DISCUSIÓN. La esofagitis necrotizante aguda es una entidad inusual, de baja prevalencia e incidencia, asociada con estados de hipoperfusión sistémica y múltiples comorbilidades que favorezcan un sustrato isquémico. Al revisar los reportes de casos que hay en la literatura médica, los casos que reportamos se correlaciona con las características clínicas, epidemiológicas, endoscópicas y factores de riesgo causales de la enfermedad. La presentación clínica más frecuente es el sangrado digestivo alto, que se debe correlacionar con el hallazgo endoscópico clásico. Nuestro primer caso reportado termina con la colocación de una gastrostomía para poder alimentarse. CONCLUSIÓN. El pronóstico de la necrosis esofágica aguda es malo y se requiere un alto índice de sospecha clínica y conocimiento de esta infrecuente patología para un diagnóstico temprano y un manejo oportuno. Se requiere una evaluación por endoscopia digestiva alta. Es una causa de sangrado gastrointestinal que conlleva tasas altas de mortalidad, principalmente en adultos mayores frágiles. El reconocimiento temprano y la reanimación agresiva son los principios fundamentales para un mejor resultado de la enfermedad.

INTRODUCTION. Acute esophageal necrosis is a rare syndrome that is characterized endoscopically by an irregular or diffuse circumferential black appearance of the intrathoracic esophageal mucosa, the involvement is generally of the distal esophagus and the abrupt transition of normal mucosa at the gastroesophageal junction, with variable proximal extension. CASES. Two cases are presented with different comorbidities, presentation of signs and symptoms, history and treatment, having in common the diagnosis through upper gastrointestinal endoscopy. RESULTS. Clinical case 1: clinical treatment based on hydration, oral suspension, intravenous omeprazole and sucralfate; poor clinical evolution characterized by: dysphagia, oral intolerance and recurrence of upper digestive bleeding, endoscopic gastrostomy placement was performed. Clinical case 2: esophagus with mucosa with fibrin and patches of extensive necrosis, compensation of both the pulmonary infectious focus and hydration and nutrition is performed, in complementary studies a colonic mass is observed, with a confirmatory histopathological study of colon adenocarcinoma in an advanced state. DISCUSSION. Acute necrotizing esophagitis is an unusual entity, with low prevalence and incidence, associated with states of systemic hypoperfusion and multiple comorbidities that favor an ischemic substrate. When reviewing the case reports in the medical literature, the cases we report correlate with the clinical, epidemiological, endoscopic characteristics and causal risk factors of the disease. The most common clinical presentation is upper gastrointestinal bleeding, which must be correlated with the classic endoscopic finding. Our first reported case ends with the placement of a gastrostomy to be able to feed. CONCLUSION. The prognosis of acute esophageal necrosis is poor and a high index of clinical suspicion and knowledge of this rare pathology is required for early diagnosis and timely management. Evaluation by upper gastrointestinal endoscopy is required. It is a cause of gastrointestinal bleeding that carries high mortality rates, mainly in frail older adults. Early recognition and aggressive resuscitation are the fundamental principles for a better outcome of the disease.

Elaboração e testagem de tecnologia de cuidado-educação para o manejo de complicações tardias em estomias intestinais / Development and testing of care-education technology for managing late complications in intestinal ostomies

Estomias possuem a finalidade de minimizar problemas que desabilitam temporariamente ou permanentemente um segmento do organismo, buscando manter a função do órgão afetado por patologias ou traumas. As estomias e a pele periestomia podem apresentar complicações, o que requer dos profissionais preparo técnico-científico para lidar com essa condição de saúde. Diante disso, são necessárias novas propostas de ensino e de difusão de conhecimento acerca do manejo das complicações. Objetivo: Elaborar uma tecnologia para a avaliação e manejo das complicações tardias relacionadas às estomias intestinais, com vistas a orientar as condutas dos enfermeiros frente ao paciente adulto com complicações. Método: Estudo de inovação tecnológica, desenvolvido em duas fases: na primeira, realizou-se uma revisão de escopo em bases de dados e sites especializados, cuja síntese e agregação dos dados possibilitou a elaboração do protótipo da tecnologia; a segunda, de testagem do protótipo e sua avaliação por quatro enfermeiras especialistas atuantes em um serviço de atendimento a pessoas com estomias. Após a sua utilização no serviço por 30 dias, a tecnologia foi avaliada quanto à aplicabilidade, conteúdo e aparência a partir de um questionário estruturado com o emprego de uma escala de Likert. Houve análise descritiva das respostas e das justificativas, a qual orientou a realização dos ajustes que originaram a versão final da tecnologia de cuidado-educação. Resultados: Com base nos 34 documentos captados na revisão, foram elencadas as complicações tardias: Dermatite periestomia; Prolapsos; Granulomas; Estomia retraída/plana; Hérnia paraestomal; Estenose; Foliculite periestomia; Alterações intestinais; Sangramentos; Fístulas enterocutâneas, Descolamento mucocutâneo e Traumas/Lesão por pressão periestomia. As sínteses das definições, das características clínicas das complicações e dos seus principais cuidados originou o protótipo da tecnologia, denominado "Guia de cuidados: identificação e manejo das complicações tardias das estomias intestinais". Na fase de avaliação pelas enfermeiras especialistas, as principais discordâncias das avaliadoras situaram-se na clareza do conteúdo, forma de organização das informações e apresentação das complicações, bem como na aplicação de algumas condutas na prática. A partir disso, foram realizados ajustes para facilitar a compreensão do usuário, reorganização dos tópicos, melhorias na diagramação da tecnologia, substituição de imagens e mudanças de condutas. Essas alterações resultaram na versão final da tecnologia educativa. Conclusão: O Guia de Cuidados tem potencial para auxiliar enfermeiros generalistas a manejar complicações tardias de pacientes com estomias intestinais de função eliminatória em diferentes contextos assistenciais e para reduzir os impactos das mesmas sobre a sua qualidade de vida, contribuindo também para minimizar as lacunas na formação/qualificação de enfermeiros sobre esse tema.

Higher Dose Noninvasive Transcutaneous Auricular Vagus Nerve Stimulation Increases Feeding Volumes and White Matter Microstructural Complexity in Open-Label Study of Infants Slated for Gastrostomy Tube.

OBJECTIVE: To determine whether transcutaneous auricular vagus nerve stimulation (taVNS) paired with twice daily bottle feeding increases the volume of oral feeds and white matter neuroplasticity in term-age-equivalent infants failing oral feeds and determined to need a gastrostomy tube. STUDY DESIGN: In this prospective, open-label study, 21 infants received taVNS paired with 2 bottle feeds for 2 - 3 weeks (2x). We compared 1) increase oral feeding volumes with 2x taVNS and previously reported once daily taVNS (1x) to determine a dose response, 2) number of infants who attained full oral feeding volumes, and 3) diffusional kurtosis imaging and magnetic resonance spectroscopy before and after treatment by paired t tests. RESULTS: All 2x taVNS treated infants significantly increased their feeding volumes compared with 10 days before treatment. Over 50% of 2x taVNS infants achieved full oral feeds but in a shorter time than 1x cohort (median 7 days [2x], 12.5 days [1x], P < .05). Infants attaining full oral feeds showed greater increase in radial kurtosis in the right corticospinal tract at the cerebellar peduncle and external capsule. Notably, 75% of infants of diabetic mothers failed full oral feeds, and their glutathione concentrations in the basal ganglia, a measure of central nervous system oxidative stress, were significantly associated with feeding outcome. CONCLUSIONS: In infants with feeding difficulty, increasing the number of daily taVNS-paired feeding sessions to twice-daily significantly accelerates response time but not the overall response rate of treatment. taVNS was associated with white matter motor tract plasticity in infants able to attain full oral feeds. TRIAL REGISTRATION: Clinicaltrials.gov (NCT04643808).

Does enteral nutrition through a percutaneous endoscopic gastrostomy, attenuate Helicobacter pylori colonization?: is it worth mentioning?

OBJECTIVE: In patients who experience difficulties in oral feeding, alimentary intake can be supported by creating direct access into the stomach through a percutaneous endoscopic gastrostomy. The present study purposed to compare naïve and exchanged percutaneous endoscopic gastrostomy tubes in terms of Helicobacter pylori infection and other clinical characteristics. METHODS: A total of 96 cases who underwent naïve or exchanged percutaneous endoscopic gastrostomy procedures with various indications were incorporated into the study. The patients' demographic data, such as age and gender, etiology of percutaneous endoscopic gastrostomy, anti-HBs status, Helicobacter pylori status, the presence of atrophy and intestinal metaplasia, biochemical parameters, and lipid profiles, had been analyzed. In addition, the anti-HCV and anti-HIV statuses had also been evaluated. RESULTS: The most common indication for percutaneous endoscopic gastrostomy placement was dementia in 26 (27.08%) cases (p=0.033). The presence of Helicobacter pylori positivity was significantly lower in the exchange group compared to the naïve group (p=0.022). Total protein, albumin, and lymphocyte levels were significantly higher in the exchange group compared to the naïve group (both p=0.001), and the mean calcium, hemoglobin, and hematocrit levels were statistically significantly higher in the exchange group (p<0.001). CONCLUSION: Preliminary outcomes of the present study revealed that enteral nutrition attenuates the incidence of Helicobacter pylori infection. Considering the acute-phase reactant, the significantly lower ferritin values in the exchange group suggest that there is no active inflammatory process in the patients and that immunity is sufficient.

Preparo dos pais para a desospitalização de crianças em uso de traqueostomia e gastrostomia / Preparación de los padres para la deshospitalización de niños en uso de traqueostomía y gastrostomía / Parents' preparation for the dehospitalization of children using tracheostomy and gastrostomy

RESUMO Objetivo: relatar a experiência de uma ação educativa para o preparo dos pais para a desospitalização de crianças em uso de traqueostomia e gastrostomia. Método: relato de experiência sobre uma ação educativa, que é parte de um Programa de Treinamento de um hospital público de alta complexidade referência em pediatria, no período de dezembro de 2017 a dezembro de 2018. Resultados: o preparo dos responsáveis para a desospitalização de crianças em uso de traqueostomia e gastrostomia foi feito a partir de 5 etapas: 1) Instruções aos pais; 2) Treinamento dos pais para manuseio do dispositivo utilizado pela criança; 3) Manipulação dos dispositivos pelos pais sob supervisão do enfermeiro; 4) Feedback oferecido pela Enfermagem; e 5) Avaliação da ação educativa. Considerações finais: Acredita-se que a educação terapêutica fornecida aos envolvidos contribuiu na qualificação do cuidado à criança em uso de traqueostomia e gastrostomia, favorecendo sua qualidade de vida e reduzindo as intercorrências domiciliares relacionadas ao manuseio inadequado dos dispositivos em questão.

resumen Objetivo: relatar la experiencia de una acción educativa para la preparación de los padres para la deshospitalización de niños en uso de traqueostomía y gastrostomía. Método: relato de experiencia sobre una acción educativa, que hace parte de un Programa de Entrenamiento de un hospital público de alta complejidad referencia en pediatría, en el período de diciembre de 2017 a diciembre de 2018. Resultados: la preparación de los responsables para la deshospitalización de niños en uso de traqueostomía y gastrostomía se hizo a partir de 5 etapas: 1) Instrucciones a los padres; 2) Entrenamiento de los padres para manejo del dispositivo utilizado por el niño; 3) Manipulación de los dispositivos por los padres bajo supervisión del enfermero; 4) Feedback ofrecido por la Enfermería; y 5) Evaluación de la acción educativa. Consideraciones finales: Se cree que la educación terapéutica proporcionada a los involucrados contribuyó en la calificación del cuidado del niño en uso de traqueostomía y gastrostomía, favoreciendo su calidad de vida y reduciendo las complicaciones domiciliarias relacionadas con el manejo inadecuado de los dispositivos en cuestión.

ABSTRACT Objective: to report the experience of an educational action for the preparation of parents for the dehospitalization of children using tracheostomy and gastrostomy. Method: experience report on an educational action, which is part of a Training Program of a public hospital of high complexity reference in pediatrics, from December 2017 to December 2018. Results: the preparation of those responsible for the dehospitalization of children using tracheostomy and gastrostomy was made from 5 stages: 1) Instructions to parents; 2) Training of parents to handle the device used by the child; 3) Manipulation of the devices by parents under the supervision of the nurse; 4) Feedback offered by Nursing; and 5) Evaluation of educational action. Final considerations: It is believed that the therapeutic education provided to those involved contributed to the qualification of care for children using tracheostomy and gastrostomy, favoring their quality of life and reducing home complications related to inadequate handling of the devices in question.

Antibiotic prophylaxis for percutaneous endoscopic gastrostomy in pediatric patients: a meta-analysis.

PURPOSE: To investigate if Antibiotic Prophylaxis (AP) can prevent wound and/or systemic infection in pediatric patients who underwent Percutaneous Endoscopic Gastrostomy (PEG). METHODS: PubMed, Embase, and Cochrane databases were searched for Randomized Controlled Trials (RCT) and Observational Studies that compared AP vs. no Intervention (NI) in children submitted to PEG. Odds ratios (OR) with 95% confidence intervals (CI) were pooled with random-effect models. Quality assessment and risk of bias were performed as outlined by Cochrane recommendations. RESULTS: Four studies, including one RCT, with a total of 568 patients were included, in which 230 (40.5%) individuals received AP. The use of AP during PEG reduced the incidence of systemic infection (OR 0.46; 95% CI 0.24-0.90; p = 0.02; I2 = 0). However, no statistical difference was found for wound infection (OR 0.85; 95% CI 0.43-1.69; p = 0.64; I2 = 12%) and for the composite outcome of any kind of infection (OR 0.74; 95% CI 0.13-4.06; p = 0.73; I2 = 67%). CONCLUSION: In this pooled analysis of 568 infants who underwent PEG, the use of AP reduced the incidence of systemic infection. Our results were compatible with findings obtained in the adult population. No differences were found regarding wound infection or the composite outcome of any kind of infection.

Evaluación de la gastrostomía percutánea con funduplicatura de Nissen mínimamente invasiva versus cirugía abierta, en ni-ños con parálisis cerebral infantil / Evaluation of minimally invasive percutaneous gastrostomy with Nissen fundoplication versus open surgery in children with infantile cerebral palsy

Introducción: Los niños con Parálisis Cerebral Infantil (PCI) tienen graves afec-ciones nutricionales por síntomas gastrointestinales como el reflujo gastroeso-fágico (RGE). El objetivo del presente estudio fue com-parar las técnicas de gas-trostomía Percutánea con Funduplicatura de Nissen (FN) mínimamente invasiva (FN-MI) versus cirugía abierta (FN-CA) para tra-tamiento de reflujo gas-troesofágico y trastornos de la deglución, en niños con parálisis cerebral infantil. Metodología: En este es-tudio observacional con muestreo no probabilístico se incluyeron niños con PCI con trastornos de deglución y RGE del Hospital de niños Dr. Roberto Gilbert Elizalde, en Guayaquil-Ecuador del período 2017 al 2022. Se registró la edad, tipo de cirugía, complicaciones, tiempo de inicio alimenta-ción, síntomas y comorbili-dades. Se realiza un análi-sis descriptivo. Un segundo análisis compara pacientes tratados con FN-MI + Gastrostomía Percutánea ver-sus FN-CA + gastrostomía tipo Stamm. Resultados: Se incluyeron 62 casos, 40 hombres (64.5%), <3 años 39 pacientes (62.9%); desnutrición severa en 27 casos (61.4%), 13 casos (29.5%) fueron ingresados por un episodio de neumonía; 52 pacientes con FN-CA y 10 con FN-MI. El inicio de la alimentación a las 48 horas en el grupo FN-MI 8 casos (80%), en FN-CA 3 casos (5.8%) P<0.0001. No hubo diferencias de edad y complicaciones entre los grupos. Conclusión: Con la técnica de gastrostomía Percutánea con FN-MI se presentaron un mínimo tiempo al cual los pacientes iniciaron la alimentación por la sonda de gastrostomía.

Introduction: Children with Infantile Cerebral Palsy (ICP) have severe nutritional disorders due to gastrointestinal symptoms such as gastroesophageal reflux (GER). The objective of the present study was to compare minimally invasive Percutaneous gastrostomy techniques with Nissen Funduplicature (MI-NF) versus open surgery (OS-NF) for the treatment of gastroesophageal reflux and swallowing disorders in children with child brain paralysis. Methodology: This observational study with non-probabilistic sampling included children with ICP swallowing disorders and GER at the Dr. Roberto Gilbert Elizalde Children's Hospital in Guayaquil-Ecuador from 2017 to 2022. Age, type of surgery, complications, feeding start time, symptoms, and comorbidities. A descriptive analysis is performed. A second analysis compares patients treated with MI-NF + Percutaneous Gastrostomy versus OS-NF + Stamm-type gastrostomy. Results: 62 cases were included, 40 men (64.5%), <3 years old 39 patients (62.9%); severe malnutrition in 27 cases (61.4%), 13 cases (29.5%) were admitted for an episode of pneumonia; 52 patients with OS-NF and 10 with MI-NF. The start of feeding at 48 hours in the MI-NF group was 8 cases (80%); in OS-NF, 3 cases (5.8%) P<0.0001. There were no differences in age and complications between the groups Conclusion: With the technique of percutaneous gastrostomy with MI-NF, there was a minimum time when the patients started feeding through the gastrostomy tube.

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.

Técnicas de Gastrostomia: Comparação quanto a custos e regiões em que são realizadas / Gastrostomy techniques: a comparison of costs and geographic regions where they are performed

Introdução: A gastrostomia é utilizada, principalmente, quando há indicação de nutrição enteral, mas não pode haver deglutição por mais de 30 dias ou quando há necessidade de descompressão gástrica. Este trabalho tem como objetivo comparar os custos das gastrostomias para o Sistema Único de Saúde e relacioná-los com as realizadas nas regiões no Brasil nos últimos 10 anos. Métodos: Foram coletadas informações de custos e número de realizações da plataforma DATASUS das seguintes gastrostomias: por laparotomia, laparoscópica, endoscópica percutânea e oncológica. Resultados: O método mais utilizado foi a por laparotomia (80,35%), seguido da endoscópica (16,71%) e a videolaparoscópica (2,92%). Essa porcentagem variou de acordo com a região analisada, sendo a endoscópica realizada predominantemente na Região Sul (26,78%) e Sudeste (18,69%). Nesse período, é possível notar uma crescente utilização da gastrostomia endoscópica e videolaparoscópica, tendo esses procedimentos aumentado 647,03% e 353,03%, respectivamente. Com relação ao custo, observa-se que a gastrostomia endoscópica tem um custo médio de R$ 590, se encaixando como AIH procedimento especial; já a por laparotomia tem custo médio da AIH principal de R$ 670, e a videolaparoscópica de R$ 530, porém as duas últimas, quando totalizado o valor da internação, resultam no valor de R$ 1.896 e R$ 1.539, respectivamente. Conclusão: Há uma tendência ao aumento da realização da gastrostomia endoscópica, pela redução de custos e tempo de realização. Já a videolaparoscópica tende a ser a segunda opção, sendo que a por laparotomia deverá ser usada apenas quando as outras forem contraindicadas.

Introduction: Gastrostomy is mainly used when there is indication for enteral nutrition but no swallowing for more than 30 days or when gastric decompression is required. This work aims to compare gastrostomy costs to the Unified Health Care and to relate them with procedures performed in different Brazilian regions in the last 10 years. Methods: We collected information on the costs and number of procedures from the DATASUS platform referring to the following types of gastrostomies: via laparotomy, laparoscopy, percutaneous endoscopy, and oncological procedures. Results: The most frequently used method was laparotomy (80.35%), followed by endoscopic (16.71%) and laparoscopic procedures (2.92%). This percentage varied according to geographic regions, and endoscopic procedures were predominantly performed in the South (26.78%) and Southeast regions (18.69%). During this period, we noticed a growing number of endoscopic and laparoscopic gastrostomies: the use of these procedures grew 647.03% and 353.03%, respectively. Regarding their costs, the endoscopic gastrostomy has a mean cost of R$ 590.00 when classified as IHA Special Procedure; the laparotomy procedure has a mean cost of main IHA of R$ 670.00; the laparoscopic procedure has a mean cost of R$ 530.00. Procedures performed via laparotomy and laparoscopy, however, result in total costs of R$ 1,896.00 and R$ 1,539.00, respectively, when considering hospitalization costs. Conclusion: There is an increasing trend of endoscopic gastrostomies due to their lower costs and shorter duration. Laparoscopic gastrostomies tend to be the second choice, whereas laparotomy procedures should be used only when the other two are contraindicated.

Gastrostomia endoscópica percutânea: perfil epidemiológico, indicações e complicações / Percutaneous endoscopic gastrostomy: epidemiological profile, indications, and complications

Introdução: A Gastrostomia Endoscópica Percutânea (GEP) é um procedimento de acesso à luz gástrica, descrito inicialmente em 1980, constituindo um grande avanço no manejo de pacientes com necessidade de nutrição enteral prolongada. Apresenta utilização em um largo espectro de doenças, em diversas faixas etárias e com baixo índice de complicações, sendo, portanto, uma ferramenta importante no cuidado aos pacientes. Objetivo: Descrever o perfil epidemiológico de pacientes submetidos à GEP, as indicações, os índices e tipos de complicações durante e após o procedimento. Métodos: Estudo de coorte retrospectiva, realizado por meio da coleta de laudos endoscópicos e em prontuários eletrônicos de pacientes atendidos em hospital terciário. Resultados: Foram incluídos 172 pacientes, com média de 69,9 anos (±16,6), maioria do sexo feminino (51,7%) e procedentes do município onde o estudo foi realizado (56,7%). A principal doença de base foi acidente vascular encefálico do tipo isquêmico (27,3%), seguido de outras doenças cérebro-vasculares, demenciais e neoplásicas. O tempo médio de uso prévio de sonda nasoentérica (SNE) foi de 32,2 dias (±45), sendo em 29,3% acima de 30 dias. Drogas antitrombóticas durante a internação foram usadas em 78,5% dos pacientes, tendo 45,9% realizado a GEP em vigência destas medicações. O índice de complicações intraoperatórias foi de 3,4% e o de pós-operatórias, de 3,5%. Conclusão: Destaca-se o tempo de uso prévio de SNE, maior do que o recomendado, e, principalmente, a presença de medicação antitrombótica durante o procedimento em boa parte da amostra. Os índices de complicações foram baixos, de modo semelhante à literatura.

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is a procedure to access the gastric lumen and was initially described in 1980, representing a major advance in the management of patients requiring prolonged enteral nutrition. It is used in a large number of diseases, in several age groups with low complication rates, thus being an important tool in patient care. Objective: To describe the epidemiological profile of patients undergoing PEG, its indications, and rates and types of complications during and after the procedure. Method: Retrospective, cohort study conducted through the collection of endoscopic reports and electronic medical records of patients seen in a tertiary hospital. Results: A total of 172 patients were included, with mean age of 69.9 years (±16.6), with a predominance of female patients (51.7%) and of those coming from the municipality where the study was conducted (56.7%). The main underlying disease was ischemic stroke (27.3%), followed by other cerebrovascular diseases, dementias, and neoplasms. Mean time of previous use of nasoenteric tube (NET) was 32.2 days (±45), being greater than 30 days in 29.3% of the cases. Antithrombotic drugs were used during hospitalization in 78.5% of patients, and 45.9% underwent PEG while they were using these medications. The rates of intra-operative and post-operative complications were 3.4% and 3.5%, respectively. Conclusions: It is worth noting the time of previous use of NET, which was greater than the recommended, and especially the use of antithrombotic therapy during the procedure by most of the sample. Rates of complication were low, in line with the literature.

Endoscopic Gastrojejunostomy in Infants and Children.

OBJECTIVE: To evaluate the feasibility of endoscopic gastrojejunal tube (GJT) placement in infants and children. STUDY DESIGN: All children undergoing endoscopic GJT placement between January 2010 and December 2019 were included in this single-center retrospective study. Difficulties with and failure of GJT placement, complication rates, and device longevity, efficacy, and duration were assessed. RESULTS: A total of 107 children, median age 10 months (IQR, 5.0-23.0 months) and median weight 6.6 kg (IQR, 5.3-9.5 kg), underwent endoscopic GJT placement using the gastric stoma to introduce the endoscope (one step: n = 36 of 107; 33.6%). Endoscopic placement was successful in 99%. Eight periprocedure complications occurred, including 1 pneumoperitoneum requiring exsufflation, 2 acute pulmonary hypertension episodes leading to death in 1 case, and 5 episodes of bronchospasm. Minor complications were frequent and mostly mechanical (79%), whereas major complications were rare (5.6%): intussusception (n = 4), intestinal perforation (n = 1), and pneumoperitoneum (n = 1). Ten patients died. Of the 97 patients who lived, 85 (87%) were weaned from jejunal feeding at a median of 179 days (IQR, 69-295 days) after initiation. Among them, 30 (35.2%) required fundoplication. Weight for age z-score was significantly higher at weaning. CONCLUSIONS: GJT placement is feasible in children, even low-weight infants. Complications are frequent but are mostly minor.