Early Percutaneous Endoscopic Gastrostomy Research Articles

Timing and impact of percutaneous endoscopic gastrostomy insertion in patients with amyotrophic lateral sclerosis: a comprehensive analysis

Dysphagia is common in amyotrophic lateral sclerosis (ALS) patients, often requiring percutaneous endoscopic gastrostomy (PEG) for enteral nutrition. We retrospectively analyzed data from 188 Korean patients with ALS who underwent PEG tube insertion at five-time points: symptom onset (t1), diagnosis (t2), recommended time for gastrostomy (t3), PEG insertion (t4), and one-year post-insertion (t5). The recommended time point for gastrostomy (T-rec for gastrostomy) was defined as the earlier time point between a weight loss of more than 10% and advanced dysphagia indicated by the ALSFRS-R swallowing subscore of 2 or less. The T-rec for gastrostomy was reached at 22 months after symptom onset, followed by PEG insertion at 30 months, resulting in an 8-month delay. During the delay, the ALSFRS-R declined most rapidly at 1.7 points/month, compared to 0.8 points/month from symptom onset to diagnosis, 0.7 points/month from diagnosis to T-rec for gastrostomy, and 0.6 points/month after the PEG insertion. It is crucial to discuss PEG insertion before significant weight loss or severe dysphagia occurs and minimize the delay between the recommended time for gastrostomy and the actual PEG insertion. A stratified and individualized multidisciplinary team approach with careful symptom monitoring and proactive management plans, including early PEG insertion, should be prioritized to improve patient outcomes.

Timing and Outcomes of Percutaneous Endoscopic Gastrostomy After Ischemic Stroke.

Guidelines recommend using percutaneous endoscopic gastrostomy (PEG) for dysphagia after 2 weeks of stroke onset. We aimed to study the impact of PEG timing on outcomes in patients with ischemic stroke. In this retrospective study of patients with ischemic stroke and PEG between 2014 and 2019, early PEG was defined as PEG tube placed within 14 days of stroke and late PEG after 14 days. Outcomes of 30-day mortality, PEG-related complications, and functional swallow recovery were compared between early and late PEG. Logistic regression model assessed factors associated with PEG timing. The median time of PEG tube placement after stroke was 10.9 days. Of the 161 included patients, 60.9% had early PEG, and its associated patient factors were nursing facility discharge (adjusted odds ratio (OR): 3.4, confidence interval (CI): 1.48 - 7.82) and infection (OR: 0.32, CI: 0.139 - 0.178). Late PEG had 3.27 times greater odds of swallowing recovery, but mortality and complications were not significantly different between early and late PEG. Skilled nursing facility disposition and lack of infection were predictors of early PEG, constituting the majority of PEG placed for ischemic stroke-related dysphagia. Although better odds of swallowing recovery were seen with late PEG, likely implicating better patient selection, overall, the timing of PEG tube placement did not impact short-term mortality and complications.

Increasing incidence of early percutaneous endoscopic gastrostomy (PEG) tube dislodgements in hospitalized patients

Increasing incidence of early percutaneous endoscopic gastrostomy (PEG) tube dislodgements in hospitalized patients

To push or to pull? A clinical audit on the efficacy and safety of the pull and push percutaneous endoscopic gastrostomy techniques in oncological patients.

The peroral "pull" technique and the direct "push" procedure are the two main methods for percutaneous endoscopic gastrostomy (PEG) placement. Although pull-PEG is generally recommended as the first-line modality, many oncological patients require a push-PEG approach to prevent tumor seeding or overcome tumor-related obstruction. We aimed to compare the efficacy and safety of both PEG procedures in cancer patients. We retrospectively analyzed all consecutive PEG procedures within a tertiary oncological center. Patients were followed up with the hospital databases and National Cancer Registry to assess the technical success rate for PEG placement, the rate of minor and major adverse events (AEs), and 30-day mortality rates. We compared those outcomes between the two PEG techniques. Finally, risk factors for PEG-related adverse events were analyzed using a multivariable Cox proportional-hazard regression model adjusted for patients' sex, age, performance status (ECOG), Body Mass Index (BMI), diabetes, chemoradiotherapy (CRT) status (pre-/current-/post-treatment), and type of PEG. We included 1055 PEG procedures (58.7% push-PEG/41.4% pull-PEG) performed in 994 patients between 2014 and 2021 (mean age 62.0 [±10.7] yrs.; 70.2% males; indication: head-and-neck cancer 75.9%/other cancer 24.1%). The overall technical success for PEG placement was 96.5%. Although the "push" technique had a higher rate of all AEs (21.4% vs. 7.1%, Hazard Ratio [HR] =2.9; 95% CI=1.9-4.3, p<0.001), most of these constituted minor AEs (71.9%), such as tube dislodgement. The methods had no significant difference regarding major AEs and 30-day mortality rates. Previous CRT was associated with an increased risk of major AEs (hazard ratio=2.7, 95% CI=1.0-7.2, p=0.042). The risk of major AEs was comparable between the push- and pull-PEG techniques in cancer patients. Due to frequent tube dislodgement in push-PEG, the pull technique may be more suitable for long-term feeding. Previous CRT increases the risk of major AEs, favoring early ("prophylactic") PEG placement when such treatment is expected.

"Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes": Commentary.

In this commentary, we summarize some of the key points of the original paper "Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes" and offer support for the proposed results. Specifically, we address how early percutaneous endoscopic gastrostomy (PEG) tube placement may reduce hospital length of stay and costs. We also discuss topics related to the article including PEG weaning and post-stroke nutritional formulation. However, we note that concerns purported by previous studies that early PEG placement may worsen outcomes are not fully addressed, and further research is needed.

Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes.

BACKGROUNDPercutaneous Endoscopic Gastrostomy (PEG) tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake. The 2011 ASGE guidelines recommend delaying PEG tube placement for two weeks, as half of patients with dysphagia improve within 2 wk. There are few studies comparing outcomes based on timing of PEG tube placement, and there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehab and skilled nursing facilities. AIMTo assess the safety of early (≤ 7 d post stroke) vs late (> 7 d post stroke) PEG tube placement and evaluate whether pre-procedural risk factors could predict mortality or complications. METHODSWe performed a retrospective study of patients undergoing PEG tube placement for dysphagia following a stroke at two hospitals in Saint Louis, MO between January 2011 and December 2017. Patients were identified by keyword search of endoscopy reports. Mortality, peri-procedural complication rates, and post-procedural complication rates were compared in both groups. Predictors of morbidity and mortality such as protein-calorie malnutrition, presence of an independent cardiovascular risk equivalent, and presence of Systemic inflammatory response syndrome (SIRS) criteria or documented infection were evaluated by multivariate logistic regression.RESULTS154 patients had a PEG tube placed for dysphagia following a stroke, 92 in the late group and 62 in the early group. There were 32 observed deaths, with 8 occurring within 30 d of the procedure. There was an increase in peri-procedural and post-procedural complications with delayed PEG placement which was not statistically significant. Hospital length of stay was significantly less in patients with early PEG tube placement (12.9 vs 22.34 d, P < 0.001). Protein calorie malnutrition, presence of SIRS criteria and/or documented infection prior to procedure or having a cardiovascular disease risk equivalent did not significantly predict mortality or complications.CONCLUSIONEarly PEG tube placement following a stroke did not result in a higher rate of mortality or complications and significantly decreased hospital length of stay. Given similar safety outcomes in both groups, early PEG tube placement should be considered in the appropriate patient to potentially reduce length of hospital stay and incurred costs.

Percutaneous Endoscopic Gastrostomy Tube Timing in Head and Neck Cancer Surgery.

To examine outcomes and complications in patients receiving a percutaneous endoscopic gastrostomy (PEG) tube on the same day of head and neck cancer (HNC) surgery versus later in hospitalization. The 2003-2014 Nationwide Inpatient Sample was queried for patients undergoing ablative HNC procedures who had a PEG tube placed. Cases were stratified by PEG tube timing into an early (on the same day as ablative procedure) and late (later in hospitalization) group. Demographics and outcomes were compared using univariate analysis and multivariate regression modeling. A total of 4,068 cases were included, of which 2,206 (54.23%) underwent early PEG and 1,862 (45.77%) received a late PEG tube. Late PEG tube patients were more likely to have a diagnosis of malnutrition (18.0% vs. 15.3%, p=0.018) or renal failure (4.7% vs. 3.0%, p=0.006). On multivariate regression analysis, patients receiving late PEG tubes were more likely to experience aspiration pneumonia, acute pulmonary disease, infectious pneumonia, sepsis, hematoma, wound disruption, surgical site infection, and fistula formation (all p < 0.05). The mean length of stay and hospital charges in the late PEG group were significantly greater (17.1 vs. 12.6 days, p < 0.001) and ($159,993 vs. $125,705, p < 0.001), respectively. Patients undergoing HNC surgery who received a PEG tube on the day of ablative surgery had lower complication rates, shorter length of stay, and decreased hospital costs compared to those who had a PEG tube placed later during hospitalization. Further research is needed to determine the causal relationships behind these findings. 3 Laryngoscope, 133:109-115, 2023.

Comparison of Pull and Introducer Techniques for Percutaneous Endoscopic Gastrostomy.

ObjectiveTo compare indications, success rates and complications of pull [P] and introducer [I] techniques for percutaneous endoscopic gastrostomy (PEG).MethodsIn this retrospective study, inpatients who underwent primary PEG tube insertion between January 2015 and February 2020 at the Endoscopy Center of the First Affiliated Hospital of Fujian Medical University were included.ResultsA total of 103 inpatients were included in this study (P group, n = 67; I group, n = 36). The rates of tube replacement within first six months in the P and I groups were 1.5% and 11.1%, respectively (P = 0.049). The most common primary indication of PEG was malignancy. The proportion of patients with esophageal cancer was significantly lower in the P group (24.4% vs 54.2%, P = 0.015). No significant difference was found in the overall, major, or minor complications between the two groups. In patients with esophageal stenosis, the pull method was a risk factor for complications (P = 0.03; odds ratio [OR] = 12, 95% confidence interval [CI]: 1.164–123.684). Logistic regression analysis showed that the risk factors for major and minor complications were the admission-to-gastrostomy interval (OR = 1.078, 95% CI: 1.016–1.145, P = 0.014) and lack of antibiotic use (OR = 4.735, 95% CI: 1.247–17.979, P = 0.022), respectively.ConclusionBoth PEG techniques have high clinical success rates. The introducer technique is more suitable for patients with esophageal stricture, which has lower minor complications, but higher rate of tube replacement compared to the pull technique. Use of antibiotics may reduce minor complications following PEG. Early PEG insertion may help to reduce post-PEG major complications.

Percutaneous Endoscopic Gastrostomy

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure for establishing enteral access for nutrition. There is a paucity of literature on PEG from the Indian subcontinent. With the rate of complications in the literature showing a downward trend, we aimed to analyze the same in our institute following a standard procedure of PEG tube placement. Methods: The prospective study was conducted including patients referred for PEG placement from August 2017 to December 2019. Data were recorded on a proforma. The primary aim of the study was to determine the rate of complications in patients undergoing PEG, whereas the secondary aim was to determine whether early feeding was associated with increased rate of infection or other complications. Patients were reviewed after 3 days, 1 month, and every 3 months thereafter later with clinical examination. Results: Sixty-seven (83.75%) males and 13 (16.25%) females with a median age of 51 years (range 1–85) were included in the study. Forty-one (51.25%) patients had comorbidities with hypertension being the most common (n = 28). Postoperative placement of the PEG tube was done in 47 (58.75%) patients. Seventy-four patients had underlying neurological or neurosurgical conditions. At the time of PEG placement, 59 (73.75%) had tracheostomy. All procedures were performed in the endoscopic suite, of which two were performed as day care procedures. There were no intraprocedural complications. Feed was started within 2 h in 45 (56.25%) patients and all tolerated feed well. There were no major postprocedural complications. Thirteen patients had clinically suspected PEG site infection, of which 11 patients had a culture-positive organism. All responded to conservative management. Thirty-two patients were on follow-up at a median follow-up period of 2 years. Conclusion: The incidence of complications following PEG tube placement is low. With the standardization of the PEG technique, no major complications were seen in our study. Early PEG feeding was not associated with an increase in the rate of complications.

Endoscopic rescue of early percutaneous endoscopy gastrostomy tube dislodgement.

Percutaneous endoscopic gastrostomy (PEG) tube placement is one of the most common methods for establishing durable enteral access. Early PEG dislodgement occurs in < 5% of cases but typically prompts urgent surgical intervention to reestablish the gastrocutaneous tract and prevent intra-abdominal sepsis. To date, there is a single case report in the literature where successful endoscopic "rescue" of an early dislodged PEG tube negated the need for operative intervention. Here, we report our experience with a series of endoscopic PEG rescues for early dislodged PEG tubes. A retrospective analysis of cases was reviewed from two institutions. Patients with early PEG dislodgements underwent PEG rescue using a gastroscope and standard Ponsky "Pull" PEG techniques through the original tract. Eleven patients were identified from the database and underwent PEG rescue after early PEG dislodgement. Mean operative time was 68min, and there were no complications related to PEG rescue. PEG rescue permitted safe re-establishment of the gastrostomy tract while avoiding laparoscopic or open surgical intervention in hemodynamically stable patients. All patients tolerated the procedure well and were able to resume use of the PEG tubes shortly after intervention. Endoscopic rescue represents a feasible noninvasive option for PEG tube replacement following early inadvertent PEG tube dislodgement in appropriate clinical settings.

Relationship of early acute complications and insertion site in push method percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG), which is frequently used for nutrition management in patients having difficulty with oral intake, is considered a safe procedure. However, serious complications may occur depending on site of the puncture. This study aimed to clarify whether push method PEG construction at the posterior wall (PW) of the greater curvature (GC) had a higher risk of complications. We retrospectively investigated the relationship between puncture site at the PW of the GC and early acute complications in 540 patients receiving PEG. Early acute complications were defined as bleeding or perforation within 30 days after the PEG procedure. PEG-related complications were observed in 80 patients in total, with early acute complications detected in 42 patients. PEG construction at the PW of the GC in 12 cases exhibited a significantly higher occurrence of early acute complications versus PEG at other sites (41.7% vs. 7.0%, p = 0.001). Further, multivariate analysis revealed PW at the GC to be independently associated with early acute complications (OR 9.59, 95% CI 2.82–32.61; p = 0.0003). It may be desirable to avoid PEG at the PW of the GC. If performed, clinicians should pay careful attention to early acute complications.

S0553 Early vs Late Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Post-Stroke Patients: Mortality, Predictors of Mortality, Complications, and Outcomes

INTRODUCTION: PEG tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake. There are no studies comparing outcomes based on timing of PEG tube placement. We aimed to assess the safety of early (7 days post stroke) versus late ( >7 days post stroke) PEG tube placement in this population by evaluating post procedure mortality, peri-procedural complications, and post procedural complications. METHODS: We performed a retrospective longitudinal study at two hospitals in Saint Louis, MO between January 2011 to December 2017 of patients who had PEG tube placement for dysphagia following a stroke. Patients were identified by keyword search of upper endoscopy reports and individual reports and patient charts were manually reviewed for data collection. Mortality, peri-procedural complications, and post-procedural complication rates were compared in both groups. Predictors of morbidity and mortality such as protein-calorie malnutrition, having an independent cardiovascular risk equivalent, and presence of SIRS criteria or documented infection were evaluated by multivariate logistic regression. RESULTS: 154 patients had PEG tube placed for dysphagia following a stroke, 92 in the late group and 62 in the early group. There were 32 observed deaths, however only 8 occurred within 30 days of the procedure. Peri-procedural complications (within 24 hours of the procedure) and post procedural complications (occurring >1 day to 3 months post procedure) were noted to be higher with delayed PEG placement, however the differences were not statistically significant (Table 1A). Hospital length of stay was significantly less in patients with early PEG tube placement (12.9 vs 22.34 days, P < 0.001). Protein calorie malnutrition, presence of SIRS or documented infection prior to procedure, or having a cardiovascular disease risk equivalent did not seem to significantly predict mortality or complications (Table 1B). CONCLUSION: Our study found that early PEG tube placement following a stroke did not result in a higher risk of mortality or complications when compared to delayed PEG placement. Although not statistically significant, there were less deaths and complications when a PEG tube was placed early. Hospital length of stay was significantly less in patients with early PEG tube placement. Given similar safety outcomes in both groups, we should consider early PEG tube placement to decrease length of hospital stay and incurred costs.Table 1.: PEG: percutaneous endoscopic gastrostomy; OR: odd's ratio; CI: confidence interval; SIRS: systemic inflammatory response syndrome; CV: cardiovascularFigure 1.: Assembly of study cohort based on exclusion and inclusion criteria and manual chart review CVA: cerebrovascular accident.Figure 2.: Kaplan Meier Curve: Time to Death within 90 days of follow up in Early vs Late PEG placement Groups.

Alexis St. Martin Gastropexy: A Novel Technique for Gastropexy During Percutaneous Endoscopic Gastrostomy Tube Placement.

Percutaneous endoscopic gastrostomy (PEG) is a preferred method of long-term enteral nutritional support. Despite its ease of placement, it has a 4% major complication rate, requiring surgical intervention or hospitalization. Early PEG tube dislodgment can cause peritonitis, requiring emergent laparotomy at significant morbidity and cost. T-fasteners have been used as an adjunct gastropexy, but nearly one third migrate into the abdominal wall within the first 2 weeks. We describe a low-cost, minimally invasive technique using widely available surgical instruments to appose the gastric and abdominal walls. All PEG procedures were performed in our 60-bed surgical intensive care unit. Institutional IRB approval was obtained along with procedure specific consent for all patients. The adjunctive gastropexy procedure was performed on four patients at high risk for early PEG tube dislodgment. Following routine PEG tube placement, both ends of four 2-0 polyglactin ties were brought through the gastric and abdominal walls through separate stab incisions adjacent to the PEG tube exit site in the 3, 6, 9, and 12 o'clock positions. These were tied in the subcutaneous tissue, securing the gastric wall to the abdominal wall. No PEG tube complications occurred. All patients were discharged to long-term care facilities with PEG tubes intact or electively removed. We describe the results of a pilot study for a cost-effective, easily implementable, adjunct technique, named after the namesake of our institution, to decrease the incidence and severity of complications associated with PEG tube dislodgment. It was used in 4 patients at high risk for PEG tube dislodgment with satisfactory early results in all 4. Further recruitment of larger numbers of patients using this technique is ongoing to determine if this technique is truly effective at reducing PEG tube complications.

Re-PEGing: An Endoscopic Approach to Inadvertent Early PEG Tube Withdrawal

Introduction: Percutaneous endoscopic gastrostomy (PEG) is the modality of choice for enteral feeding access in patients with dysphagia. A common complication is inadvertent removal of the tube. If it occurs early after placement, there is a potential for leak of gastric contents through the gastric wall defect, and a risk of peritonitis and sepsis. The standard approach to this problem has been either observation, or, in patients with peritoneal signs, surgical exploration. An alternative approach, “re-PEGing”, which patches the gastric wall defect to the anterior abdominal wall, was described by Galat in 1990, but did not gain acceptance. We adopted this approach, and report our successful experience with seven patients. Methods: The records of 352 patients who underwent PEG placement between January 2015 and March 2018 in a 528-bed hospital were reviewed. Seven patients with removal of PEG tube within four weeks of placement, who were treated with re-PEGing, were identified. Clinical data were collected and analyzed. Results: Seven patients had PEG tube withdrawal within a range of one to 25 days after placement. In five patients, there was evidence of violation of the peritoneal cavity either on physical exam or on imaging studies showing peritoneal air or fluid. In two of these patients, an attempt had been made for direct replacement of the tube through the gastro-cutaneous tract with a balloon-catheter, resulting in intraperitoneal placement. All patients received a short course of broad spectrum antibiotics, and underwent re-PEGing within 24 hours. In five patients, the post-procedural course was uneventful. Two patients had sepsis attributed to a pulmonary source, and were managed conservatively. All patients recovered without residual peritoneal infection. Conclusion: Early PEG tube withdrawal results in the anatomical equivalent of gastric perforation, as well as loss of enteral feeding access. Immediate re-PEGing addresses these two issues non-surgically. So why has this safe, efficient, and minimally invasive procedure not been widely adopted? The most likely explanation is the clinician’s ‘gestalt’ that gastric perforation is a contraindication to upper endoscopy, and should rather be approached surgically. However, our successful experience with re-PEGing, even in cases with peritoneal violation, supports a paradigm shift in the perception and practice of replacing early PEG tube withdrawal.496_A Figure 1. Summary of “re-PEGed” patients, with time to removal from original placement, comment on peritoneal violation, and if a second PEG was placed to improve gastric and abdominal patching (double PEG). Direct tube replacement (DTR). Early Removal of PEG Tube (ERPT).496_B Figure 2. CT abdomen with contrast through PEG tube, demonstrating the dome of the tube within the abdominal wall (white arrow), with contrast spreading between the muscle layers of the abdominal wall (yellow arrow).496_C Figure 3. Endoscopic view of a double-PEG, placed to improve the apposition and patching of the gastric and abdominal walls.

Trends and Outcomes of Early Versus Late Percutaneous Endoscopic Gastrostomy Placement in Patients With Traumatic Brain Injury: Nationwide Population-based Study

Oral intake for traumatic brain injury (TBI) patients is often not an option because of facial trauma, swallowing dysfunctions, altered consciousness, etc. These patients often require percutaneous endoscopic gastrostomy (PEG) placement for nutrition support. To date, there is lack of studies examining the relationship between the timing of PEG placement and patient outcome in the TBI group. We conducted a population-based study in a retrospective cohort of TBI patients undergoing PEG, using the national inpatient sample for years 2011 to 2013. A total of 96,625 patients were identified for TBI and 3343 of those patients received PEG. TBI patients who undergo an early or late PEG placement had a higher rate of in-hospital mortality, when compared with patients with a standard timing of PEG placement. Late PEG was preferably placed in patients with higher Charlson index and trauma-related comorbidities, and these patients had a higher incidence of complications, that is, sepsis, urinary tract infection, acute respiratory distress syndrome/pneumonia, and deep vein thrombosis/pulmonary embolism. When stratified by mortality-risk groups, early PEG was associated with higher rates of in-hospital mortality while standard PEG was associated with best mortality outcomes in low-mortality-risk group and moderate-mortality-risk group. The results of this study suggest that if a PEG placement is indicated for a TBI patient, a standard (7 to 14 d) timing may be associated with better patient outcomes. However, secondary to limitations associated with the use of administrative databases, further prospective studies are needed to establish clear guidelines regarding the optimal timing of placing PEG in TBI patients.

Prospective experience of percutaneous endoscopic gastrostomy tubes placed by otorhinolaryngologist-head and neck surgeons:safe and efficacious.

Percutaneous endoscopic gastrostomy (PEG) is often the treatment of choice in head and neck cancer (HNC) patients needing long-term nutritional support. Prospective studies on PEG tube placement in an otorhinolaryngologist service are lacking. At our hospital, otolaryngologist-head and neck (ORL-HN) surgeons-have performed PEG insertions for HNC patients since 2008. We prospectively analyzed 127 consecutive HNC patients who received their PEG tubes at the Department of Otorhinolaryngology-head and neck surgery, and evaluated the outcome of PEG tube insertions performed by ORL-HN surgeons. To compare time delays before and after, PEG placement service was transferred from gastrointestinal surgeons to ORL-HN surgeons, and we retrospectively analyzed a separate group of 110 HNC patients who had earlier received PEG tubes at the Department of Gastrointestinal Surgery. ORL-HN surgeons' success rate in PEG insertion was 97.6%, leading to a final prospective study group of 124 patients. Major complications occurred in four (3.2%): two buried bumper syndromes, one subcutaneous hemorrhage leading to an abscess in the abdominal wall, and one metastasis at the PEG site. The most common minor complication was peristomal granulomatous tissue affecting 23 (18.5%) patients. After the change in practice, median time delay before PEG insertion decreased from 13 to 10days (P<0.005). The proportion of early PEG placements within 0-3days increased from 3.6 to 14.6% (P<0.005). PEG tube insertion seems to be a safe procedure in the hands of an ORL-HN surgeon. Independence from gastrointestinal surgeons' services reduced the time delay and improved the availability of urgent PEG insertions.

Abstract WP181: Timing of Percutaneous Endoscopic Gastrostomy (PEG) for Acute Ischemic Stroke Inpatients in the United States

Background and Purpose: Stroke guidelines recommend time-limited trials of nasogastric feeding prior to placement of percutaneous endoscopic gastrostomy (PEG) tubes. We sought to describe timing of PEG placement and identify factors associated with early PEG for acute ischemic stroke. Methods: We designed a retrospective observational study to examine time to PEG for ischemic stroke admissions in the Nationwide Inpatient Sample, 2001-2011. We defined early PEG placement as 1-7 days from admission. Using multivariable regression analysis, we identified the effects of patient and hospital characteristics on time to PEG. Results: We identified 34,623 admissions receiving a PEG from 2001-2011, 53% of which received the PEG early. Among hospitals placing ≥10 PEG tubes, median time to PEG for individual hospitals ranged from 3 days to over 3 weeks (interquartile range: 6-8.5 days). Older adult age groups were associated with early PEG placement (≥85 years vs. 18-54 years: Adjusted Odds Ratio [AOR] 1.68, 95% CI 1.50-1.87). Those receiving a PEG tube and tracheostomy were less likely to receive the PEG early (vs. no tracheostomy; AOR 0.27, 95% CI 0.24-0.29), and these patients were more often younger compared to PEG only recipients ( Figure ). Those admitted to high volume hospitals were more likely to receive their PEG early (≥350 vs. &lt;150 hospitalizations; AOR 1.26, 95% CI 1.17-1.35). Conclusions: More than half of PEG recipients received their surgical feeding tube within 7 days of admission. The oldest old, who may be the most likely to benefit from time-limited trials of nasogastric feeding, were most likely to receive a PEG early.

Risk factors for the onset and progression of Huntington disease

Huntington’s disease (HD) is an autosomal dominant neurodegenerative disorder characterized by chorea, behavioural and psychiatric manifestations, and dementia, caused by a CAG triplet repeat expansion in the huntingtin gene. Systematic review of the literature was conducted to determine the risk factors for the onset and progression of HD. Multiple databases were searched, using terms specific to Huntington disease and to studies of aetiology, risk, prevention and genetics, limited to studies on human subjects published in English or French between 1950 and 2010. Two reviewers independently screened the abstracts and identified potentially relevant articles for full-text review using predetermined inclusion criteria. Three major categories of risk factors for onset of HD were identified: CAG repeat length in the huntingtin gene, CAG instability, and genetic modifiers. Of these, CAG repeat length in the huntingtin gene is the most important risk factor. For the progression of HD: genetic, demographic, past medical/clinical and environmental risk factors have been studied. Of these factors, genetic factors appear to play the most important role in the progression of HD. Among the potential risk factors, CAG repeat length in the mutant allele was found to be a relatively consistent and significant risk factor for the progression of HD, especially in motor, cognitive, and other neurological symptom deterioration. In addition, there were many consistent results in the literature indicating that a higher number of CAG repeats was associated with shorter survival, faster institutionalization, and earlier percutaneous endoscopic gastrostomy.

Comparison of Percutaneous Endoscopic Gastrostomy and Surgical Gastrostomy in Severely Handicapped Children.

PurposeGastrostomy is commonly used procedures to provide enteral nutrition support for severely handicapped patients. This study aimed to identify and compare outcomes and complications associated with percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy (SG).MethodsA retrospective chart review of 51 patients who received gastrostomy in a single tertiary hospital from January 2000 to May 2016 was performed. We analyzed the patients and the complications caused by the procedures.ResultsAmong the 51 patients, 26 had PEG and 25 had SG. Four cases in the SG group had fundoplication for gastroesophageal reflux disease. PEG and SG groups were followed up for an average of 29 months and 44 months. Major complications occurred in 19.2% of patients in the PEG group and 20.0% in the SG group, but significant differences between the groups were not observed. Minor complications occurred in 15.4% of patients in the PEG group and 52.0% in the SG group. Minor complications were significantly lower in the PEG group than in the SG group (p=0.006). The average use of antibiotics in the PEG and SG groups was 6.2 days and 15.7 days (p=0.002). Thirteen patients died of underlying disease but not related to gastrostomy, and only one patient died due to complications associated with general anesthesia.ConclusionThe duration of antibiotics use and incidence of minor complications were significantly lower in the PEG group than those in the SG group. Early PEG could be recommended for nutritional supports.

Timing of Percutaneous Endoscopic Gastrostomy for Acute Ischemic Stroke: An Observational Study From the US Nationwide Inpatient Sample.

Stroke guidelines recommend time-limited trials of nasogastric feeding prior to percutaneous endoscopic gastrostomy (PEG) tube placement. We sought to describe timing of PEG placement and identify factors associated with early PEG for acute ischemic stroke. We designed a retrospective observational study to examine time to PEG for ischemic stroke admissions in the Nationwide Inpatient Sample, 2001 to 2011. We defined early PEG placement as 1 to 7 days from admission. Using multivariable regression analysis, we identified the effects of patient and hospital characteristics on PEG timing. We identified 34 623 admissions receiving a PEG from 2001 to 2011, 53% of which received the PEG 1 to 7 days from admission. Among hospitals placing ≥10 PEG tubes, median time to PEG for individual hospitals ranged from 3 days to over 3 weeks (interquartile range 6-8.5 days). Older adult age groups were associated with early PEG (≥85 years versus 18-54 years: adjusted odds ratio 1.68, 95% confidence interval 1.50-1.87). Those receiving a PEG and tracheostomy were more likely to receive the PEG beyond 7 days, and these patients were more often younger compared with PEG only recipients. Those admitted to high-volume hospitals were more likely to receive their PEG early (≥350 versus <150 hospitalizations; adjusted odds ratio 1.26, 95% confidence interval 1.17-1.35). More than half of the PEG recipients received their surgical feeding tube within 7 days of admission. The oldest old, who may benefit most from time-limited trials of nasogastric feeding for ≥2 to 3 weeks, were most likely to receive a PEG within 7 days.