Predictors of mortality post-gastrostomy in motor neuron disease patients.

INTRODUCTION/AIMS: Motor neuron disease (MND) is a progressive neurodegenerative condition with a limited life expectancy. There is very little data on mortality and its associated factors beyond 30 days following gastrostomy. We explored the demographic, clinical, and nutritional predictors for early mortality at 30, 90, and 180 days following gastrostomy in these patients. METHODS: This was a retrospective study involving 94 MND patients in Western Australia who underwent gastrostomy between 2015 and 2021. Patients were divided into two groups based on mortality at 30, 90, and 180 days post-gastrostomy. T-test (or Mann-Whitney), chi-square test and Fisher's exact test were used for detecting between-group differences in various factors. Multivariable logistic regression was used to identify factors associated with post-gastrostomy mortality at 90 and 180 days. RESULTS: No mortality was attributable to gastrostomy-related complications. Lower forced vital capacity (FVC) (p = .039) and greater weight loss (%) (p = .022) from diagnosis to gastrostomy were observed in those who died within 30 days post-gastrostomy. Older age (p = .022), male sex (p = .041), lower FVC (p = .04), requiring but not tolerating noninvasive ventilation (p = .035), and greater weight loss (%) (p = .012) were independent predictors of 90-day post-gastrostomy mortality. However, only older age (p = .01) and greater weight loss (p = .009) were predictors of mortality at 180 days post-gastrostomy. DISCUSSION: Our data indicated that mortality at 90 and 180 days was influenced by the weight loss (%) from diagnosis to gastrostomy, highlighting the importance of nutritional care in the MND population. Gastrostomy placement prior to substantial weight loss may reduce the risk of weight loss-associated mortality and warrants further investigation.

Open Gastrostomy Tube Placement is Associated With Higher Complications in Infants: A National Surgical Quality Improvement Program Database Analysis.

BACKGROUND: The purpose of this study was to compare outcomes between open versus laparoscopic gastrostomies in children aged ≤1 y. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Pediatric database was reviewed between 2012 and 2017. Chi-square analysis was performed on children aged ≤1 y to compare complication rates between open and laparoscopic procedures. RESULTS: A total of 7940 patients were aged ≤1 y. Of which, 20% underwent open gastrostomy (OGT), and 80% received laparoscopic gastrostomy (LGT). There were no differences in sex or race. However, OGT patients were younger (119 d versus 134 d; P = 0.0001), smaller at birth (1.84 kg versus 1.85 kg; P = 0.03), and were smaller at operation (4.6 kg versus 5 kg; P = 0.0001). Also, patients were more likely to be inpatient at the time of surgery and had more congenital malformations. Complications (OGT 6% versus LGT 4%; P = 0.001) and mortality were significantly higher in the open group (OGT 2.3% versus LGT 0.6%; P = 0.001). However, matched control analysis demonstrated OGT patients have more complications. CONCLUSIONS: OGT patients are smaller and with more significant comorbidities in this data set. In fact, even after matched control analysis, these patients experience more complications.

Improving All-Cause Inpatient Mortality After Percutaneous Endoscopic Gastrostomy.

BACKGROUND AND AIMS: Percutaneous gastrostomy (PEG) is a common inpatient procedure. Prior data from National Inpatient Sample (NIS) in 2006 reported a mortality rate of 10.8% and recommended more careful selection of PEG candidates. This study assessed for improvement in the last 10 years in mortality rate and complications for hospitalized patients. METHODS: A retrospective cohort analysis of all adult inpatients in the NIS from 2006 to 2016 undergoing PEG placement compared demographics and indication for PEG placement per ICD coding. Survey-based means and proportions were compared to 2006, and rates of change in mortality and complication rates were trended from 2006 through 2016 and compared with linear regression. Multivariable survey-adjusted logistic regression was used to determine predictors of mortality and complications in the 2016 sample. RESULTS: A total of 155,550 patients underwent PEG placement in 2016, compared with 174,228 in 2006. Mortality decreased from 10.8 to 6.6% without decreased comorbidities (p < 0.001). This trend was gradual and persistent over 10 years in contrast to a stable overall inpatient mortality rate (p = 0.113). Stroke remained the most common indication (29.7%). The majority of patients (64.6%) had Medicare. Indications for placement were stable. Complication rates were stable from 2006 (4.4%) to 2016 (5.1%) (p = 0.201). CONCLUSIONS: Inpatient PEG placement remains common. Despite similar patient characteristics, mortality has decreased by approximately 40% over the last 10 years without a decrease in complications likely reflecting improved patient selection.

Percutaneous endoscopic gastrostomy: dealing with the issue of dislodgement.

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is accepted as an efficient method to provide long-term enteral nutrition. PEG accidental dislodgement (device exteriorization confirmed by expert evaluation) rate is high and can lead to major morbidity.Objective: To identify independent risk factors for PEG accidental dislodgement.Methods: Retrospective, single-center study, including consecutive patients submitted to PEG procedure, for 38 consecutive months. Every patient had 12 months minimum follow-up after PEG placement. Univariate analysis selected variables with at least marginal association (p < .15) with the outcome variable, PEG dislodgement, which were included in a logistic regression multivariate model. Discriminative power was assessed using area under curve (AUC) of the receiver operating curve (ROC).Results: We included 164 patients, 67.7% (111) were female, mean age was 81 years. We report 59 (36%) PEG dislodgements, of which 13 (7.9%) corresponded to early dislodgements. The variables with marginal association were hypoalbuminemia (p = .095); living at home (p = .049); living in a nursing home (p = .074); cerebrovascular disease (CVD) (p = .028); weight change of more than 5 kg, either increase or decrease (p = .001); psychomotor agitation (p < .001); distance inner bumper-abdominal wall (p = .034) and irregular appointment follow-up (p = .149). At logistic multivariate regression, the significant variables after model adjustment were CVD OR 4.8 (CI 95% 2.0-11.8), weight change OR 4.7 (CI 95%1.6-13.9) and psychomotor agitation OR 18.5 (CI 95% 5.2-65.6), with excellent discriminative power (AUC ROC 0.797 [CI95% 0.719-0.875]).Conclusion: PEG is a common procedure and accidental dislodgement is a frequent complication. CVD, psychomotor agitation and weight change >5 kg increase the risk of this complication and should be seriously considered when establishing patients' individual care requirements.

Predictors for 30-day mortality and complications following radiologically inserted gastrostomies: a single centre, large cohort review.

AIM: To measure the 30-day mortality and delayed complication rates following radiologically inserted gastrostomy (RIG) placement and determine the predictive risk factors for 30-day mortality and delayed complications to aide pre-procedure informed consent. MATERIALS AND METHODS: Retrospective analysis was undertaken of RIG insertions between July 2012 and August 2017 at a single tertiary centre, which included 373 patients (56% male; median age: 65 years, range: 19-92 years). Data were collected from electronic databases on patient demographics, RIG indication, all-cause mortality, complication rates, patient co-morbidities, and biochemical/haematological parameters. Multivariate analysis was performed to identify predictive risk factors for complications and mortality. RESULTS: The RIG procedural success rate was 97.9%. The overall 30-day mortality rate was 7.8%; associated with pre-procedural haemoglobin <130 g/l in men (p=0.030, odds ratio [OR] 23.38), white cell count >11×109/l (p=0.001, OR 4.18), C-reactive protein >10 mg/l (p=0.003, OR 10.10) and international normalised ratio (INR) >1.2 (p=0.03, OR 4.63). Inpatient RIG referrals were associated with 10% 30-day mortality; compared to 1.1% for outpatients (p=0.028, OR 9.51). The incidence of immediate and delayed complications was 2.4% and 42.1%, respectively. Neuromuscular disease was associated with gastrostomy dislodgement (p=0.0001, OR 4.99) and fracture (p=0.0009, OR 13.45), cerebrovascular disease with gastrostomy dislodgement (p=0.009, OR 2.51), cardiovascular disease with sepsis 30-days post-RIG (p=0.02, OR 2.94), and diabetes mellitus with gastrostomy dislodgement (p=0.0001, OR 29.45), fracture (p=0.027, OR 5.63) and stoma site infections (p=0.0003, OR 7.16). CONCLUSION: RIG 30-day mortality was significantly associated with inpatient procedures compared to outpatient, and a range of biochemical/haematological parameters that suggest infection pre-intervention. It is advised that the markers of infection and catabolism are investigated pre-intervention, which may reduce mortality and complication rates.

Procedure-Related Complications and Survival after Gastrostomy: Results from a Japanese Cohort.

INTRODUCTION: In 2010, a large-scale multi-institutional study in Japan showed a good prognosis for percutaneous endoscopic gastrostomy (PEG). However, the function and efficacy of PEG are not fully understood by patients, families, and health-care professionals; thus, the number of PEG treatments in Japan has declined. Therefore, we aimed to investigate the safety of the PEG procedure and subsequent survival after PEG. METHODS: In total, 249 PEGs were performed at Juzenkai Hospital from 2005 to 2017. PEG was originally performed using the pull method and then by a modified introducer method from mid-2011. We examined procedure-related complications and survival rates after PEG. RESULTS: Fifty-one (20.5%) procedure-related complications occurred; emergency surgery was required in 4 cases. Infections accounted for 76.5% (39/51) of complications. More infections occurred with the pull method than with the modified introducer method. The 1-year survival rate was 66.8%; the median survival time was 678 days. Nine patients (3.6%) died within 30 days; no deaths were directly related to PEG. Sex, age, and albumin level before surgery significantly influenced the prognosis. CONCLUSION: Due to changes in the PEG insertion method and other factors, PEG has become a safer treatment method. Additionally, PEG-based nutritional supplementation is associated with adequate survival.

Complications and outcome of percutaneous endoscopic gastrostomy in a high-volume centre.

Introduction: Percutaneous endoscopic gastrostomy (PEG) is the method of choice for long-term enteral feeding for patients with swallowing disorders and normal gut function. There is limited data regarding the demographics and clinical characteristics of patients from whom PEG was removed. Patients and methods: We performed a retrospective analysis of all consecutive adult patients who underwent first placement of PEG between 1 August 2013 and 31 December 2015 at Karolinska University Hospital in Stockholm, Sweden. Results: In total, 495 PEG were inserted in 495 patients during the study period, 56% male, mean age at insertion 67 years (range 19-95). Most patients belonged to the neurologic group (52%), followed by the oncologic (32%), another diagnosis (9%) and trauma (7%). Major complications occurred in 10 (2.0%) patients. There were no differences in the age or BMI of patients with either minor or major complications but both parameters were risk factors in terms of survival. PEG was removed from 165 (33.3%) patients, most of them from the oncology group, due to the improvement of general status of patients after specific oncologic treatment. Conclusion: Increased age and low BMI were identified as risk factors for mortality but did not correspond with the rate of complications. Antibiotic prophylaxis with sulfamethoxazole and trimethoprim provides good protection for patients with PEG.

Percutaneous endoscopic gastrostomy in older patients with and without dementia: Survival and ethical considerations.

BACKGROUND AND AIM: Notwithstanding multiple recommendations in guidelines, percutaneous endoscopic gastrostomy (PEG)-tube placement is still performed in patients with dementia. In this study, we aim to investigate survival in patients with and without dementia after PEG-tube placement. METHODS: We conducted a retrospective multicenter study in four different hospitals in the Netherlands. Furthermore, we explored the ethical considerations that may play a role in the decision whether or not to insert a PEG tube in a patient with dementia. RESULTS: Three-hundred-and-three patients were included, mean age of 77.4 years. Forty-two (13.9%) patients had dementia. Short-term complications did not differ between patients with and without cognitive disorders (P 0.224). However, patients with dementia survived significantly shorter after PEG placement than did patients without dementia. Adjusted for age and sex, patients with dementia had a 49% increased risk of mortality (hazard ratio 1.49, 95% confidence interval 1.01-2.19). In our exploratory literature search, we found that several ethical concerns and considerations play a role in the decision process of PEG placement. These considerations are both medical and nonmedical and include beliefs regarding the benefits of a PEG tube, a lack of knowledge about the natural course of dementia in both professionals and family of patients, and a fear of letting a patient die hungry. CONCLUSIONS: Patients with dementia had higher mortality rates after PEG placement than patients without dementia. Although multiple ethical concerns and considerations play a role, insertion of a PEG tube in patients with dementia is not appropriate.

Timing of Direct Enteral Tube Placement and Outcomes after Acute Stroke.

BACKGROUND: Direct enteral feeding tube (DET) placement for dysphagia after stroke is associated with poor outcomes. However, the relationship between timing of DET placement and poststroke mortality and disability is unknown. We sought to determine the risk of mortality and severe disability in patients who receive DET at different times after stroke. METHODS: We used the Ontario Stroke Registry and linked administrative databases to identify patients with acute ischemic stroke or intracerebral hemorrhage between 2003 and 2013 who received DET (gastrostomy or jejunostomy) during their hospital admission. We grouped patients by week of DET placement and evaluated mortality at 30 days and 6 months after DET insertion, and disability at discharge. We used Cox proportional hazard models and multiple logistic regression to determine the association between time from admission to DET placement and outcomes, adjusting for patient and hospital factors. RESULTS: In the study sample of 1367 patients, the median time from admission to DET placement was 17 days. After adjustment, each week of delay to DET placement was associated with lower mortality at 30 days (adjusted hazard ratio [aHR] .88, 95% confidence interval [CI] .79-.98), but not at 6 months (aHR .98, 95% CI .91- 1.05), and a higher likelihood of severe disability at discharge (adjusted odds ratio 1.35, 95% CI 1.13- 1.60). CONCLUSIONS: Later DET placement after stroke was associated with lower 30-day mortality but higher severe disability at discharge. Further research is needed to understand the reasons for these observations and to optimize patient selection and timing of DET.

A Systematic Review and Meta-Analysis on Outcomes and Complications of Percutaneous Endoscopic Versus Radiologic Gastrostomy for Enteral Feeding.

BACKGROUND: The optimal technique for long-term enteral feeding has not yet been established. Both percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are widely used. Aim was to extensively review outcomes of PEG and PRG. MATERIALS AND METHODS: A systematic review using Medline, Embase, and Cochrane was performed, using standardized tools for assessing bias. Main outcomes were infectious and tube-related complications, procedure related and 30-day mortality. Pooled risk differences (RDs) with corresponding 95% confidence intervals (95% CIs) were calculated using random effects. Arcsine transformations were applied. RESULTS: In total, 344 studies were identified, of which 16 were included, reporting on 934 PEGs and 1093 PRGs. No differences were found for infectious complications [RD, 0.03 (-0.05 to 0.11)], procedure-related mortality [RD, 0.01 (-0.04 to 0.06)], or 30-day mortality [RD, 0.06 (-0.01 to 0.13)]. Tube-related complications were higher in PRG [RD, 0.16 (0.06-0.26)]. Subgroup analysis was performed for head and neck cancer (HNC) and motor neuron disease. In HNC, this revealed significantly lower tube-related complications and procedure-related mortality after PEG. In motor neuron disease, no differences were seen. The level of evidence appears sufficient considering the low degree of heterogeneity. CONCLUSIONS: No differences were found with regard to mortality or infectious complications. PEG showed lower risk of tube-related complications. Subgroup analysis revealed PEG to be favorable in HNC based on lower rates of procedure-related mortality and tube-related complications. Local experience and availability should be taken into account in the decision process.

Risk factors for complications and mortality of percutaneous endoscopic gastrostomy insertion.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure; however, acute and chronic complications of PEG have been reported. We aimed to determine risk factors associated with complications and 30-day mortality after PEG, based on 11 years of experience at a single tertiary hospital. METHODS: In total, 401 patients who underwent first PEG insertion at the Asan Medical Center, Seoul, Korea, between January 2005 and December 2015 were eligible. Medical records were retrospectively reviewed to determine clinical characteristics and outcomes of 139 and 262 patients who underwent pull-type and introducer-type PEG, respectively. RESULTS: The median age of the overall population was 68 years, and the median body mass index was 19.5 kg/m2. Acute and chronic complications developed in 96 (23.9%) and 105 (26.2%) patients. Acute ileus and chronic tube obstruction were significantly more frequent in the introducer-type PEG group (p = 0.033 and 0.001, respectively). The 30-day mortality rate was 5.0% (median survival: 10.5 days). Multivariate analysis revealed that underlying malignancy was a predictor of acute complications; age ≥ 70 years and diabetes mellitus were predictors of chronic complications. The median follow-up was 354 days. Neurologic disease and malignancy were the most common indications for PEG. Neurologic diseases were classified into two groups: stroke and the other neurologic disease group (including dementia, Parkinson's disease, neuromuscular disease, and hypoxic brain damage). Multivariate analysis showed that 30-day mortality was significantly lower in the other neurologic disease group and higher in patients with platelet count < 100,000/µL, and C-reactive protein (CRP) ≥ 5 mg/dL. CONCLUSIONS: PEG is a relatively safe and feasible procedure, but it was associated with significantly higher early mortality rate in patients with platelet count < 100,000/µL or CPR≥5mg/dL, and lower early mortality rate in neurologic disease group including dementia, Parkinson's disase, neuromuscular disease, and hypoxic brain damage. In addition, acute complications in patients with underlying malignancy, and chronic complications in patients aged ≥70 and those with diabetes mellitus should be considered during and after PEG.

Reduced 30-day gastrostomy placement mortality following the introduction of a multidisciplinary nutrition support team: a cohort study.

BACKGROUND: Percutaneous endoscopic gastrostomy feeding allows patients with dysphagia to receive adequate nutritional support, although gastrostomy insertion is associated with mortality. A nutrition support team (NST) may improve a gastrostomy service. The present study aimed to evaluate the introduction of a NST for assessment and follow-up of patients referred for gastrostomy. METHODS: We included adult inpatients referred for gastrostomy insertion consecutively between 1 October 2010 and 31 March 2013. During the first 6 months, a multidisciplinary NST assessment service was implemented. Patient characteristics, clinical condition, referral appropriateness and follow-up were documented prospectively. We compared the frequencies of appropriate referrals, 30-day mortality and mental capacity/consent assessment time spent between the 6 months implementation phase and 2 years following establishment of the assessment service ('established phase'). RESULTS: In total, 309 patients were referred for gastrostomy insertion and 199 (64%) gastrostomies placed. The percentage of appropriate referrals rose from 72% (61/85) during the implementation phase to 87% (194/224) during the established phase (P = 0.002). Thirty-day mortality reduced from 10% (5/52) to 2% (3/147) (P = 0.01), whereas time allocated to assessment of mental capacity and attainment of informed consent rose from mean 3 days (limits of normal variation 0-7) to mean 6 (0-13) days. CONCLUSIONS: The introduction of a NST to assess and select patients referred for gastrostomy placement was associated with a rise in the frequency of appropriate referrals and a decrease in 30-day mortality following gastrostomy insertion. Concomitantly, time spent on patient assessment and attainment of informed consent increased.

Increasing Serum Albumin Level Shortly After Gastrostomy Tube Insertion Predicts Longer Survival in Elderly Patients With Dementia.

GOAL: To identify factors influencing survival after percutaneous endoscopic gastrostomy (PEG) tube insertion in elderly patients with severe dementia. BACKGROUND: Use of PEG in patients with dementia raises medical and ethical questions. STUDY: The cohort included 189 patients aged ≥64 years with severe dementia who underwent PEG tube insertion in 2002 to 2011 at a tertiary hospital and were followed through 2014. Data were collected on background diseases, laboratory tests conducted 14 (±10) days before and 90 (±10) days after PEG, and date of death. Multivariate Cox regression analysis was performed and cumulative survival curves plotted. RESULTS: Mean baseline serum albumin level was significantly lower in patients who died ≤30 days after PEG (n=32, 16.9%) than patients who survived longer (2.9±0.5 vs. 3.3±0.5 g/dL, P<0.001), and significantly higher in patients who survived 1 year after PEG (n=96, 50.8%) than patients who died earlier (3.4±0.5 vs. 3.1±0.5 g/dL, P=0.002). No significant differences were found for the other laboratory parameters. After adjustment for background diseases, serum albumin level above the median (3.3 g/dL) was the only predictor of survival (hazard ratio 0.51; 95% confidence interval, 0.37-0.72; P<0.001). Patients with stable/increased serum albumin levels at 90 days after PEG (n=80, 42.3%) survived longer than patients with decreased levels. The only predictor of survival after adjustment for age and background diseases was a stable/increased albumin level at 90 days (hazard ratio 0.59; 95% confidence interval, 0.42-0.85; P=0.004). CONCLUSIONS: Survival after PEG tube insertion is associated with a higher serum albumin level at baseline and a stable/increased serum albumin level during follow-up.

PEG Insertion in Patients With Dementia Does Not Improve Nutritional Status and Has Worse Outcomes as Compared With PEG Insertion for Other Indications.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tubes are commonly utilized as a method of enteral feeding in patients unable to obtain adequate oral nutrition. Although some studies have shown improved mortality in select populations, the safety and effectiveness of PEG insertion in patients with dementia compared with those with other neurological diseases or head and neck malignancy remains less well defined. OBJECTIVE: To evaluate the nutritional effectiveness, rate of rehospitalization, and risk of mortality among patients with dementia compared with patients with other neurological diseases or head and neck cancers who undergo PEG placement. MATERIALS AND METHODS: We conducted a retrospective analysis from a prospective database of patients who underwent PEG placement at an academic tertiary center between 2008 and 2013. The following data were collected: indication for PEG, patient demographics, biochemical markers of nutritional status rehospitalization, and survival rates. RESULTS: During the study period, 392 patients underwent PEG tube placement. Indications for PEG were dementia (N=165, group A), cerebrovascular accident (N=124, group B), and other indications such as oropharyngeal cancers and motor neuron disease (N=103, group C). The mean follow-up time after PEG was 18 months (range, 3 to 36 mo). No differences in baseline demographics were noted. PEG insertion in the dementia (group A) neither reduced the rehospitalization rate 6 months' postprocedure compared with groups B and C (2.45 vs. 1.86 and 1.65, respectively; P=0.05), nor reduced the mortality rate within the first year post-PEG placement (75% vs. 58% and 38% for groups A, B, and C, respectively, P=0.001), as well, it did not improve survival at 1 month after the procedure (15% vs. 3.26% and 7.76%, for groups A, B, C, respectively, P<0.01). The presence of dementia was also associated with shorter mean time to death (7.2 vs. 8.85 and 8 mo for groups A, B, C, respectively, P<0.05). The rate of improvement of the nutritional biomarker albumin was lower in the dementia group [3.1. to 2.9 vs. 3.2 to 3.3 and 3 to 3.3 g/dL for groups A, B, and C, respectively (P<0.02)]. Multivariate regression analysis showed that the presence of dementia was an independent predictor for mortality rate within the first year and 1-month mortality rate in patients undergoing PEG insertion with odds ratio 3.22 (95% confidence interval, 1.52-4.32) and odds ratio 2.52 (95% confidence interval, 1.22-3.67). CONCLUSIONS: PEG insertion in patients with dementia neither improve both short-term and long-term mortality nor rehospitalization rate as compared with patients who underwent PEG placement for alternate indications such as other neurological diseases or head and neck malignancy and even was associated with shorter time to death. Furthermore, PEG insertion in patients with dementia did not improve albumin. Therefore, careful selection of patients with dementia is warranted before PEG placement weighing the risks and benefits on a personalized basis.

Effects of percutaneous endoscopic gastrostomy on survival of patients in a persistent vegetative state after stroke.

AIMS AND OBJECTIVES: To assess the effect of percutaneous endoscopic gastrostomy on short- and long-term survival of patients in a persistent vegetative state after stroke and determine the relevant prognostic factors. BACKGROUND: Stroke may lead to a persistent vegetative state, and the effect of percutaneous endoscopic gastrostomy on survival of stroke patients in a persistent vegetative state remains unclear. DESIGN: Prospective study. METHODS: A total of 97 stroke patients in a persistent vegetative state hospitalised from January 2009 to December 2011 at the Second Hospital, University of South China, were assessed in this study. Percutaneous endoscopic gastrostomy was performed in 55 patients, and mean follow-up time was 18 months. Survival rate and risk factors were analysed. RESULTS: Median survival in the 55 percutaneous endoscopic gastrostomy-treated patients was 17·6 months, higher compared with 8·2 months obtained for the remaining 42 patients without percutaneous endoscopic gastrostomy treatment. Univariate analyses revealed that age, hospitalisation time, percutaneous endoscopic gastrostomy treatment status, family financial situation, family care, pulmonary infection and nutrition were significantly associated with survival. Multivariate analysis indicated that older age, no gastrostomy, poor family care, pulmonary infection and poor nutritional status were independent risk factors affecting survival. Indeed, percutaneous endoscopic gastrostomy significantly improved the nutritional status and decreased pulmonary infection rate in patients with persistent vegetative state after stroke. Interestingly, median survival time was 20·3 months in patients with no or one independent risk factors of poor prognosis (n = 38), longer compared with 8·7 months found for patients with two or more independent risk factors (n = 59). CONCLUSION: Percutaneous endoscopic gastrostomy significantly improves long-term survival of stroke patients in a persistent vegetative state and is associated with improved nutritional status and decreased pulmonary infection. RELEVANCE TO CLINICAL PRACTICE: Percutaneous endoscopic gastrostomy is a promising option for the management of stroke patients in a persistent vegetative state.

[Complications after Percutaneous Endoscopic Gastrostomy Tube Placement - A Retrospective Analysis]. / Komplikationen nach Anlage einer perkutanen endoskopischen Gastrostomie - eine retrospektive Analyse.

BACKGROUND: Enteral nutrition is vital for patients with inadequate or absent oral food intake, as it can help to avoid catabolic metabolism. Enteral feeding can be secured by placing a percutaneous endoscopic gastrostomy tube (PEG-tube) which is an approved method. Several clinical studies could verify the superiority of this procedure compared to other options. Even though PEG-tube placement is regarded as less invasive surgery, a considerable rate of complications is reported in literature. MATERIAL/METHODS: Here, we report a retrospective analysis of PEG-tube placements in the Bonn University Hospital from January 2005 to December 2012. RESULTS: Overall, 641 PEG-tubes were placed with a complication rate of 9.4 %, which can be further divided in 5.5 % minor complications (mic) and 3.9 % major complications (mac). Two cases of death occurred in the context of PEG-tube placement. Endoscopically inserted PEG-tubes showed a complication rate of 8.6 % (4.8 % mic, 3.8 % mac). 63.2 % of mac consisted of perforations, 15.8 % of intra-abdominal abscesses and 15.8 % of buried bumper syndromes. The complication rate of CT-guided placement of PEG-tubes was 38.9 % (27.8 % mic, 11.1 % mac). In this group, all mac were perforations. Surgical PEG-tube placement was accompanied by no mac and 7.7 % mic. CONCLUSION: The amount of complications during PEG-tube placement is remarkable, therefore the indication of this procedure must be contemplated critically and careful follow-up is crucial.

Comparison of Modified Blumgart pancreaticojejunostomy and pancreaticogastrostomy after pancreaticoduodenectomy.

BACKGROUND: The aim of this study was to compare perioperative outcomes after Blumgart pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) for pancreatic-enteric reconstruction following pancreaticoduodenectomy. METHODS: Data of patients undergoing Blumgart PJ and PG were retrieved from prospectively-collected database. Matched patients in each surgical groups were included based on the Callery risk scoring system for clinically relevant postoperative pancreatic fistula (CR-POPF) (grades B and C). Surgical parameters and risks were compared between these two groups. RESULTS: A total of 206 patients undergoing PD were included. Blumgart PJ was associated with shorter postoperative hospital stay (median (range) 25 (10-99) vs. 27 (10-97) days, P = 0.022). There was no surgical mortality in the Blumgart PJ group, but a 4.9% perioperative mortality in the PG, P = 0.030. The CR-POPF by Blumgrt PG is significantly lower than that by PG for overall patients (7% vs. 20%, P = 0.007), especially for those in intermediate fistula risk zone (6% vs. 21%, P =0.048) and high fistula risk zone (14% vs. 47%, P=0.038). CONCLUSIONS: Blumgart PJ is superior to PG in terms of pancreatic leakage and surgical mortality. Blumgart PJ can be recommended for pancreatic reconstruction after PD for all pancreatic remnant subtypes.

Assessment of indications for percutaneous endoscopic gastrostomy--development of a predictive model.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) is used for long-term enteral nutrition in neurological patients with dysphagia (NEUR), in head and neck cancer patients prior to chemoradiation therapy (head and neck malignancy group [HNM]), or in cases of oropharyngeal or esophageal tumor obstruction or stricture (OBSTR). Considerable morbidity and overall mortality is reported. Aim was to analyze the complication rates and mortality with PEG and to identify subgroups with poor outcomes. MATERIAL AND METHODS: Patients underwent PEG (n = 401) in a single tertiary care center. Indications, characteristics, and causes of death were recorded. RESULTS: Number of patients in groups: HNM 135 (34%), OBSTR 74 (18%), and NEUR 192 (48%); follow-up time median (interquartile range): 17 (39) months; the time PEG used for feeding: 4 (7) months. A total of 91 patients (23%) had 110 complications, 31 patients (8%) had early (≤30 days) complications, and 49 patients (12%) major complications. Two deaths (0.5%, 2 peritonitis) were related to PEG. The 30-day mortality was 11% (n = 47). According to multivariate analysis, an increased 30-day mortality was associated with ≥75 years of age, American Society of Anesthesiologists (ASA) class IV, a Charlson comorbidity index (CCI) ≥4, body mass index (BMI) <18.5, and ongoing antibiotic therapy. With this model, 95% specificity was obtained in the 30-day survival figures. CONCLUSION: The presented predictive model derived from our analysis may recognize patients with poor outcome when referred for PEG. The parameters in the present model (age, ASA class, CCI score, BMI, and data of ongoing antibiotic treatment) are easily measurable, and it is possible to integrate them into everyday work.

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances.

BACKGROUND: A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT. OBJECTIVES: To evaluate the effectiveness and safety of PEG compared with NGT for adults with swallowing disturbances. SEARCH METHODS: We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to January 2014, and contacted the main authors in the subject area. There was no language restriction in the search. SELECTION CRITERIA: We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment). DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%. MAIN RESULTS: We included 11 randomised controlled studies with 735 participants which produced 16 meta-analyses of outcome data. Meta-analysis indicated that the primary outcome of intervention failure, occurred in lower proportion of participants with PEG compared to NGT (RR 0.18, 95% CI 0.05 to 0.59, eight studies, 408 participants, low quality evidence) and this difference was statistically significant. For this outcome, we also subgrouped the studies by endoscopic gastrostomy technique into pull, and push and not reported. We observed a significant difference favouring PEG in the pull subgroup (RR 0.07, 95% CI 0.01 to 0.35, three studies, 90 participants). Thepush subgroup contained only one clinical trial and the result favoured PEG (RR 0.05, 95% CI 0.00 to 0.74, one study, 33 participants) techniques. We found no statistically significant difference in cases where the technique was not reported (RR 0.43, 95% CI 0.13 to 1.44, four studies, 285 participants).There was no statistically significant difference between the groups for meta-analyses of the secondary outcomes of mortality (RR 0.86, 95% CI 0.58 to 1.28, 644 participants, nine studies, very low quality evidence), overall reports of any adverse event at any follow-up time point (ITT analysis, RR 0.83, 95% CI 0.51 to 1.34), 597 participants, 6 studies, moderate quality evidence), specific adverse events including pneumonia (aspiration) (RR 0.70, 95% CI 0.46 to 1.06, 645 participants, seven studies, low quality evidence), or for the meta- analyses of the secondary outcome of nutritional status including weight change from baseline, and mid-arm circumference at endpoint, although there was evidence in favour of PEG for meta-analyses of mid-arm circumference change from baseline (MD 1.16, 95% CI 1.01 to 1.31, 115 participants, two studies), and levels of serum albumin were higher in the PEG group (MD 6.03, 95% CI 2.31 to 9.74, 107 participants).For meta-analyses of the secondary outcomes of time on enteral nutrition, there was no statistically significant difference (MD 14.48, 95% CI -2.74 to 31.71; 119 participants, two studies). For meta-analyses of quality of life measures (EuroQol) outcomes in two studies with 133 participants, for inconvenience (RR 0.03, 95% CI 0.00 to 0.29), discomfort (RR 0.03, 95% CI 0.00 to 0.29), altered body image (RR 0.01, 95% CI 0.00 to 0.18; P = 0.001) and social activities (RR 0.01, 95% CI 0.00 to 0.18) the intervention favoured PEG, that is, fewer participants found the intervention of PEG to be inconvenient, uncomfortable or interfered with social activities. However, there were no significant differences between the groups for pain, ease of learning to use, or the secondary outcome of length of hospital stay (two studies, 381 participants). AUTHORS' CONCLUSIONS: PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT. There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration. Future studies should include details of participant demographics including underlying disease, age and gender, and the gastrostomy technique.

Clinical selection criteria can predict futile intervention in patients referred for percutaneous endoscopic gastrostomy insertion.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) placement is performed in a patient group with high mortality in the short and medium term. For a significant proportion of patients, the procedure provides no increase in survival. There are no standardised assessment tools available to determine the clinical appropriateness of PEG placement, nor any to predict clinical outcome. AIM: The study aims to determine whether clinical assessment, by a trained dietitian, of the appropriateness of PEG placement is predictive of mortality in the short and medium terms. METHODS: A prospective audit was undertaken of all requests for PEG placement at a single large, publicly funded Australian tertiary hospital. The clinical appropriateness of each request was assessed by a trained dietitian, and data on age, sex, reason for referral, comorbidities and satisfaction of assessment criteria were collected, and patient outcome and survival were compared for all patients according to whether a PEG was inserted or not. Main outcome measures were mortality at 30 and 150 days after referral. RESULTS: During the period 2005-2008, 198 patients were referred for PEG; 94 were assessed as appropriate referrals, 104 as inappropriate. Eighty-four patients who underwent gastrostomy, after being assessed as appropriate, had significantly reduced mortality at 30 days (96.4% vs 74.6%, P < 0.0001) and 150 days (82.1% vs 57.9%, P = 0.0001) compared with all other patients. Patients who received PEG despite contrary advice had no significant survival advantage, at 30 days or 150 days, over patients who did not receive PEG. CONCLUSION: The application of selection criteria by trained assessors improves patient selection for PEG insertion and predicts mortality at early and later time points, by identifying patients unlikely to benefit from PEG. The group of patients who received a gastrostomy despite an adverse assessment had no mortality benefit - in these patients, the procedure may have been futile.