Enteral Access Research Articles

AGA Clinical Practice Update on Endoscopic Enteral Access: Commentary.

The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update is to facilitate understanding and improve the clinical practice of endoscopic enteral access. This expert commentary was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology.

Complication Rates and Variability in Gastrojejunostomy Tube Usage in Infants and Children

BackgroundGastrojejunostomy tube (GJT) placement is commonly performed for enteral access and post-pyloric feeding in children with gastric feeding intolerance. Prior studies have suggested the risk of surgical complications is elevated in infants compared to older children. We aim to characterize GJT usage in children and investigate the risk factors for postoperative complications through two national databases. MethodsWe performed a multi-institutional retrospective cohort study on children who underwent GJT placement utilizing two national databases, the Pediatric American College of Surgeons National Surgical Quality Improvement Program (Ped-NSQIP) and the Pediatric Health Information System (PHIS). Analyses were performed within each cohort separately to determine differences in outcomes between infants (<1 year of age) and non-infants (≥ 1 year of age). Multivariable logistic regression was performed to determine associations with postoperative complications. ResultsInfants did not have an increased rate of surgical complications compared to non-infants in the Ped-NSQIP cohort (26.9% vs. 29.0%, p = 0.84) or PHIS cohort (35.3% vs. 30.7%, p = 0.07). There was an increased risk of complications in African American infants (OR 1.93, 95% CI 1.01-3.67) and non-infants (OR 1.64, 95% CI 1.27-2.10) and for urgent procedures or emergent procedures in both infants and non-infants (OR 5.42-6.46 and OR 2.12-2.61, respectively). GJT placement and complication rates significantly varied across institutions. ConclusionWe demonstrate substantial but similar overall complication rates of GJT placement between infants and non-infants. These findings suggest age alone should not negate placement of GJTs when indicated for enteral access in children. Level of Evidence3 Type of StudyMulti-institutional, retrospective, cohort study

Over-the-scope clip for closure of persistent gastrocutaneous fistula after gastrostomy tube removal: a multicenter pediatric experience

BackgroundPercutaneous endoscopic gastrostomy is commonly used for enteral nutritional access, but gastrocutaneous fistulae (GCF) may persist after tube removal, posing clinical challenges. The use of endoscopic closure devices, including over-the-scope clips (OTSC), has shown promise in managing non-healing fistulae, although data in the pediatric population are limited.MethodsA retrospective multicenter study analyzed pediatric patients who underwent GCF closure following gastrostomy tube removal. Data from seven centers across multiple countries were collected, including patient demographics, procedural details, complications, and outcomes. Closure techniques were compared between OTSC and surgical closure.ResultsOf 67 pediatric patients included, 21 underwent OTSC closure and 46 had surgical closure. Surgical closure demonstrated a higher success rate (100%) compared to OTSC closure (61.9%, P < 0.001). While procedural duration was shorter for OTSC closure (25 vs. 40 min, P = 0.002), complications, and scar quality were comparable between techniques. A subsequent sub-analysis did not reveal differences based on center experience.ConclusionOTSC closure is feasible and safe in pediatric patients, but surgical closure remains superior in achieving sustained GCF closure, although OTSC offers benefits, such as shorter procedural duration, potentially reducing the duration of general anesthesia exposure. Non-operative approaches, including OTSC, may be a valuable alternative to surgical closure.Graphical abstract

Initial experience and outcomes of per oral pyloromyotomy for the treatment of refractory gastroparesis.

Gastroparesis can be a debilitating disease process for which durable treatment options are lacking. While dietary changes and pharmacotherapy have some efficacy, symptoms frequently recur and some patients progress to needing supplemental enteral feeding access. Per oral pyloromyotomy (POP) has been shown to be a durable minimally invasive treatment option for refractory gastroparesis with a low side effect profile, and therefore has been performed at this institution for the past 6 years. This was a retrospective case series of all patients who underwent a POP at a single institution over a 6-year period (2018-2023). Patient demographics, preoperative symptomatology and subsequent workup, postoperative complications, and symptom recurrence were collected and analyzed. There were 56 patients included in the study. There was a 1.8:1 female:male ratio. The average patient age was 56 years old (range 23-85). The average duration of symptoms was 1-3 years. Thirty-eight percent of patients had undergone previous endoscopic therapy for gastroparesis (pyloric botox injection or pyloric dilation) and 16% of patients underwent multiple endoscopic therapies. Twenty-nine percent of patients were on a medication for gastroparesis. Past surgery was the most common gastroparesis etiology for POP (50% of patients). Diabetes (23%) and idiopathic (19%) were the other most common gastroparesis etiologies for POP. Nausea was the most common symptom at first follow-up (30%) but these patients continued to improve with 14% of patients continuing to endorse nausea at 6 months. Twenty-seven percent of patients developed symptom recurrence. Forty percent of patients with symptom recurrence underwent a repeat endoscopic or surgical therapy. In this present study, POP leads to durable results in approximately 75% of patients with minimal complications. Furthermore, the majority of patients who do develop symptom recurrence do not require additional gastroparesis interventions.

Pre-therapy Laparoscopic Jejunostomy Provides Safe, Reliable Nutrition for Trimodality GEJ Cancer Care

Background: Patients with locally advanced GEJ cancer may have severe obstruction and irreversible malnutrition requiring intervention such as TPN, stenting, or enteral access. Laparoscopic jejunostomy (LJ) is a reliable method of supplementing nutrition but is not widely used for fear of complications. At our institution we place LJ tubes preoperatively in such patients and aimed to evaluate their effectiveness. Methods: A retrospective review of patients undergoing neoadjuvant chemo-radiation and laparoscopic transhiatal esophagectomy (LTHE) from 2013 to 2022 was performed. Nutritional markers, weight, and height were recorded, LJ associated complications were recorded from placement time to removal. Thirty-day complications after LTHE were recorded using Clavien-Dindo classification. Results: Of 165 patients who underwent LTHE, twenty patients (12.1%) had LJ placement prior to neoadjuvant therapy due to obstructive symptoms and a median [IQR] weight loss of 13.6 kg [9.07, 16.74] despite dietary modification. LJs were placed a median [IQR] of 103.5 [93.3, 116.8] days prior to LTHE. Median [IQR] weight gain from LJ placement to LTHE was 2.09 kg [0.1, 5.03], P = .01. There were no major complications and 3 (15%) minor complications. There were no unplanned feeding interruptions greater than 48 hours or disruptions in neoadjuvant treatment. There was 1 (5%) 30-day complication after LTHE and there was no mortality. The median [IQR] hospital stay was 7 days [6.5, 9]. Conclusion: Jejunostomy feeding tube prior to neoadjuvant treatment consistently reverses weight loss with minor, manageable complications. Reliable pre-therapy nutrition in obstructed patients is associated with excellent esophagectomy results and should be considered the adjuvant nutritional treatment of choice.

Current surgical practice for central venous access to deliver chemotherapy and enteral access for nutritional support in pediatric patients with an oncological diagnosis.

Central venous access through tunneled central venous catheters (CVCs) are one of the cornerstones of modern oncologic practice in pediatric patients since CVCs provide a reliable access route for the administration of chemotherapy. Establishing best practices for CVC management in children with cancer is essential to optimize care. This article reviews current best practices, including types of devices, their placement, complications, and long-term outcomes. Additionally, nutrition status and nutritional support are also very important determinants of outcomes and care in pediatric surgical oncology patients. We review current nutritional assessment, support, access for enteral and parenteral nutrition delivery, and their complications, mainly from a surgical perspective. Overall, access surgery, whether for CVCs, or for enteral access can be challenging, and best practice guidelines supported by current though limited evidence are necessary to minimize complications and optimize outcomes.

A Nurse-Driven Protocol for Neonatal Enteral Access Device Placement Confirmation.

Preterm infants require the use of nasogastric and orogastric enteral access devices (EADs) to provide nutrition and medications. Confirmation of the location of the tip of the EAD is essential to minimize complications. At the study site, EAD location was limited to verifying the centimeter marking at the lip/nares and nonevidence-based methods of visual observation of aspirate and auscultation. Implement an evidenced-based EAD placement confirmation protocol, and by 90days post-education and implementation, achieve adherence of 90%. This quality improvement project implemented a nurse-driven evidence-based protocol for EAD verification. The intervention was based on the New Opportunities for Verification of Enteral Tube Location best practice recommendations. Prior to implementation, education sessions focused on insertion measurement technique and gastric pH measurement. Radiographs, insertion measurement technique, centimeter marking, and gastric pH measurement were used for EAD location confirmation. To determine compliance with the protocol, audits were conducted and questionnaires assessing current practice regarding EAD confirmation were administered pre- and postimplementation. The protocol increased nursing knowledge regarding evidence-based EAD insertion and verification procedures, incorporated pH measurement into practice, and reduced use of auscultation for confirmation. Nursing adherence to the protocol was 92%. This provides a model for how to successfully implement and achieve adherence to an evidence-based EAD placement confirmation nurse-driven protocol. Further research is needed to verify the effectiveness of the protocol and establish consensus on approaches specifically for the neonatal population.

Single-Center Randomized Trial Comparing Feeding Jejunostomy with Nasojejunal Tube Placement in Patients Undergoing Transhiatal Esophagectomy Post-Neoadjuvant Therapy for Esophageal Cancer.

Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus. This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up. In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001). Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.

A Technical Guide to Enteral Access and Complications

A Technical Guide to Enteral Access and Complications

Safety of elective enteral access in elderly patients: a comparative analysis of perioperative risk

BackgroundElderly patients can encounter torpid hospitalizations that are often characterized by malnutrition. In this setting, enteral feeding may facilitate improvement in nutritional status. The aim of this study is to compare perioperative outcomes of elderly (≥65 years-old) and non-elderly (<65 years-old) patients undergoing elective enteral access placement. MethodsAdult patients who underwent enteral access procedures between 2018-2020 at a tertiary care facility were reviewed retrospectively. Differences in baseline characteristics between non-elderly and elderly patients were adjusted using entropy-balanced weights. Subsequently, multivariable logistic and linear regressions were developed to evaluate the association between elderly status and outcomes of interest. Results914 patients with enteral access met inclusion criteria, of whom 471 (51.5%) were elderly. Compared to non-elderly patients, elderly individuals more commonly received percutaneous gastrostomy and had a higher burden of comorbidities as measured by the Charlson Index. Multivariable risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups. After adjustment, despite no significant association with in-hospital mortality, reoperation, or time to goal feeds, elderly status was linked to an approximately 8-day reduction in length of stay (95%CI -14.28 to -2.30, p=0.007), as well as significantly lower odds of total parenteral nutrition (AOR 0.59, 95%CI 0.37-0.94, p=0.026) and non-elective readmission (AOR 0.65, 95%CI 0.49-0.86, p=0.003). Elderly status was also associated with significantly greater odds of non-home discharge (AOR 1.58, 95%CI 1.17-2.13, p=0.003). ConclusionDespite having more comorbidities than their non-elderly counterparts, elderly patients experienced favorable nutritional and perioperative outcomes after enteral access placement.

Enteral Access Outcomes in Patients Hospitalized With Cardiac Disease: A Retrospective Cohort Study

IntroductionPatients admitted with principal cardiac diagnosis (PCD) can encounter difficult inpatient stays that are often marked by malnutrition. In this setting, enteral feeding may improve nutritional status. This study examined the association of PCD with perioperative outcomes after elective enteral access procedures. MethodsAdult patients who underwent enteral access procedures between 2018 and 2020 at a tertiary care institution were reviewed retrospectively. Differences in baseline characteristics between patients with and without PCD were adjusted using entropy balancing. Multivariable logistic and linear regressions were subsequently developed to evaluate the association between PCD and nutritional outcomes, perioperative morbidity and mortality, length of stay, and nonelective readmission after enteral access. Results912 patients with enteral access met inclusion criteria, of whom 84 (9.2%) had a diagnosis code indicating PCD. Compared to non-PCD, patients with PCD more commonly received percutaneous endoscopic gastrostomy by general surgery and had a higher burden of comorbidities as measured by the Charlson comorbidity index. Multivariable risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups (standardized differences ranged from −2.45 × 10−8 to 3.18 × 108). After adjustment, despite no significant association with in-hospital mortality, percentage change prealbumin, length of stay, or readmission, PCD was associated with an approximately 2.25-day reduction in time to meet goal feeds (95% CI -3.76 to −0.74, P = 0.004) as well as decreased odds of reoperation (adjusted odds ratio 0.28, 95% CI 0.09-0.86, P = 0.026) and acute kidney injury (adjusted odds ratio 0.24, 95% CI 0.06-0.91, P = 0.035). ConclusionsDespite having more comorbidities than non-PCD, adult enteral access patients with PCD experienced favorable nutritional and perioperative outcomes.

Metformin for sepsis-associated AKI: a protocol for the Randomized Clinical Trial of the Safety and FeasibiLity of Metformin as a Treatment for sepsis-associated AKI (LiMiT AKI)

IntroductionAcute kidney injury (AKI) is a common complication of sepsis associated with increased risk of death. Preclinical data and observational human studies suggest that activation of AMP-activated protein kinase, an...

Esophageal perforation after anterior cervical spine surgery

ObjectiveTo report our updated experience in the management of esophageal perforation resulting from anterior cervical spine surgery, and to compare two wound management approaches. MethodsThis is a retrospective review of patients managed for esophageal perforations resulting from anterior cervical spine surgery (2007-2020). We examine outcomes based on 2 wound management approaches: closed (closed incision over a drain) versus open (left open to heal by secondary intention). We collected data on demographics, operative management, resolution (resumption of oral intake), time to resolution, number of procedures needed for resolution, microbiology, length of stay, and neck morbidity. ResultsA total of 13 patients were included (10 men). Median age was 52 years (range, 24-74 years). All patients underwent surgical drainage, repair, or attempted repair of perforation, hardware removal, and establishment of enteral access. Wounds were managed closed versus open (6 closed, 7 open). There were 2 early postoperative deaths due to acute respiratory distress syndrome and aspiration (open group), and 1 patient was lost to follow-up (closed group). Among the remaining 10 patients: resolution rate was 80% versus 100%, resolution in 30 days was 20% versus 100%, median number of procedures needed for resolution was 3 versus 1, and median hospital stay was 23 versus 14 days, for the closed and open groups, respectively. ConclusionsEsophageal perforation following anterior cervical spine surgery should be managed in a multidisciplinary fashion with surgical neck drainage, primary repair when feasible, hardware removal, and establishment of enteral access. We advocate open neck wound management to decrease the time-to-resolution, number of procedures, and length of stay.

Nutritional Assessment in Patients after Gastric Electrical Stimulation (GES).

Gastric electrical stimulation (GES) is used for patients with drug-refractory gastroparesis (Gp) symptoms. Approximately two-thirds of patients with Gp symptoms are either overweight or obese. We aimed to assess symptoms and nutritional status pre-GES and post-GES placement in a large sample of drug-refractory Gp patients. We conducted a chart review of 282 patients with drug-refractory Gp who received temporary followed by permanent GES at an academic medical center. Gastrointestinal symptoms were collected by a traditional standardized PRO (0-4, 0 being asymptomatic and 4 being worst symptoms), baseline nutritional status by BMI plus subjective global assessment (SGA score A, B, C, for mild, moderate, and severe nutritional deficits), ability to tolerate diet, enteral tube access, and parenteral therapy were assessed at baseline and after permanent GES placement. Comparing baseline with permanent, GES was found to significantly improve upper GI symptoms in all quartiles. Of the 282 patients with baseline body mass index (BMI) information, 112 (40%) patients were severely malnourished at baseline, of which 36 (32%) patients' nutritional status improved after GES. Among all patients, 76 (68%) patients' nutritional status remained unchanged. Many patients with high BMI were malnourished by SGA. We conclude that symptomatic patients of different BMIs showed improvement in their GI symptoms irrespective of baseline nutritional status. Severely malnourished patients were found to have an improvement in their nutritional status after GES therapy. We conclude that BMI, even if high, is not by itself a contraindication for GES therapy for symptomatic patients.

Malnutrition and Refeeding Syndrome: Report of Three Patients on Jejunostomy Feeding Following Corrosive Oesophageal Injury

Abstract Patients with alternative enteral access for corrosive oesophageal stricture are a particularly sensitive group of patients requiring dedicated nutritional care. The COVID-19 pandemic and the resulting lockdown, restrictions, financial constraints and delayed surgeries have resulted in nutritional deprivation. Many of these patients present late to healthcare institutions with severe malnutrition. Refeeding should be done carefully in them to prevent refeeding syndrome. Here, we describe the clinical course of three patients who were on jejunostomy feeds for corrosive injury of the oesophagus, developed feeding tube-related complications and presented with severe malnutrition during the COVID-19 pandemic.

Safety and efficacy of direct percutaneous endoscopic jejunostomy tube placement compared with surgical jejunostomy: a tertiary care analysis

Background and AimsJejunostomy tube placements provides enteral access for feeding in eligible patients who cannot meet the nutritional needs by mouth. They can be surgically placed laparoscopically (lap-J) or using conventional open laparotomy (open-J) approach. Recently, direct percutaneous endoscopic jejunostomy (DPEJ) has emerged as an alternative because of its low cost and shorter recovery times. We sought to retrospectively compared the procedural success rates and complications of these methods. MethodsPatients were identified by a querying of our health system patient database and the departmental database of patients who underwent DPEJ. The patients were divided into three cohorts based on the procedure: DPEJ, lap-J, and open-J. Patient age and BMI, procedure success rate, and complications rate were compared among the three groups. Results201 patients met inclusion criteria (65 DPEJ, 111 lap-J and 25 open-J). Procedural success rates were similar between the 3 groups (DPEJ 96.9%, Lap-J 99.1%, Open-J 100%, p=0.702). Rates of infection and bleeding were also similar between the 3 groups. There were no cases of GI perforation. Tube dysfunction for any reason that required complete removal and/or replacement within 90 days occurred more often in the surgical groups than in the DPEJ group (DPEJ 0%, lap-J 35.1%, open-J 40.0%, p<0.001). This was driven largely by increased rates of tube clogging and tube dislodgement in the surgical groups. ConclusionDPEJ is a safe and effective alternative to surgical jejunostomy in eligible patients and may be associated with decreased complication rates at 90-days.

Medication delivery errors in outpatients with percutaneous endoscopic gastrostomy: effect on tube feeding replacement

Patients with enteral access usually receive oral drugs via feeding tubes and correct drug administration remains a challenge. The aim of this study was to identify common medication delivery errors (MDEs) in outpatients with percutaneous endoscopic gastrostomy (PEG) and evaluate their association with the need for tube replacement due to deterioration or clogging. A 2-year retrospective study that comprised adult outpatients with a placed/replaced PEG tube and whose electronic medical record included home medication was carried out. Treatment with medication that should not be crushed and administered through an enteral feeding tube was considered an MDE. We included 269 patients and 213 MDEs (20% of oral prescriptions) were detected in 159. Ninety-two percent of the medications associated with MDEs could be substituted by appropriate formulations. Tube replacement due to obstruction was needed in 85 patients. MDEs were associated with increased risk for tube replacement (OR 2.17; 95% CI 1.10–4.27). Omeprazole enteric-coated capsules were associated with the greatest risk (OR 2.24; 95% CI 1.01–4.93). PEG outpatients are highly exposed to MDEs, leading to a significant increase in the odds of tube replacement, mainly when treated with omeprazole. The use of appropriate alternative therapies would prevent unnecessary adverse events.

Immediate-use strategy is as safe and effective as delayed-use strategy following percutaneous endoscopic gastrostomy tube placement: A retrospective cohort study.

Percutaneous endoscopic gastrostomy (PEG) tube placement is the most common enteral access for long-term feeding. The aim of our study is to assess the feasibility and safety of immediate PEG tube use after initial placement. We conducted a single-center retrospective cohort study between August 2006 and August 2016. Prior to August 2011, tube feedings were delayed for ≥4 h after initial PEG placement, compared with immediate use (<1 h) after August 2011. Primary outcomes were complication rates within 30 days of placement. Secondary outcomes were impact of morbidity, mortality, length of stay, and need for repeat PEG placement. Our study included 1296 patients during the 10-year period, of which 704 underwent delayed use and 592 underwent immediate use (744 inpatient and 552 outpatient). There were no significant differences between the delayed-use and immediate-use PEG with regard to complications (3.4% vs 4.4%; P = 0.76). Subgroup analysis also reflected no significant differences in complications between inpatient and outpatient groups. For inpatients, there were no substantial differences in inpatient mortality (3.9% vs 3.3%; P = 0.70), mortality within 30 days of discharge (13.8% vs 13.1%; P = 0.15), readmissions (38.2% vs 34.3%; P = 0.23), repeat PEG placement (0.7% vs 1.5%; P = 0.46), and length of stay (13.3 vs 13.9 days; P = 0.99). Patients who received immediate enteral nutrition after PEG tube placement did not have any increased complications, morbidity, or mortality; and it is just as safe when compared with patients who received delayed feeding.

EPID-30. DYSPHAGIA-RELATED HEALTHCARE UTILIZATION AMONG OLDER PATIENTS WITH PRIMARY AND METASTATIC BRAIN TUMORS: A NATIONAL STUDY OF MEDICARE BENEFICIARIES

Abstract BACKGROUND Swallowing dysfunction is common among older adults and the presence of a malignant brain tumor (primary or metastatic) may compound the existing burden of dysphagia in this population. We aimed to characterize the dysphagia-specific healthcare utilization among Medicare beneficiaries with malignant brain tumors. METHODS Using a Medicare 5% limited dataset (2013-2018) and ICD-9/10 codes, we identified beneficiaries (≥ 65 years) with primary malignant brain tumors (PMBTs) as well as the five most common solid tumors metastasizing to the brain (lung, breast, melanoma, renal, and colorectal). Those with disorders predisposing to dysphagia were excluded. Healthcare utilization was quantified using CPT codes for hospitalizations, gastroenterology services (endoscopy [EGD]), nutrition consultation, speech language management, radiographic testing, and enteral feeding access, occurring after cancer diagnosis. Comparisons of utilization by dysphagia status were made using chi-square and Wilcoxon rank-sum tests. RESULTS Among 79,926 beneficiaries, we identified 3,184 (4.0%) with malignant PBTs and 1,033 (1.3%) with brain metastases. Of the total cohort, 4.7% (n=3,777) experienced dysphagia. Whereas, 11.0% (n=349) of those with PMBTs and 7.9% (n=82) with brain metastases experienced dysphagia. Those with PMBTs were diagnosed with dysphagia significantly earlier in their disease course compared to other groups (median 20 vs. 36 vs. 58 days for PMBTs, brain metastases, and no brain metastases, respectively; p&amp;lt; 0.01). Speech pathology services use was highest among PMBT patients compared other groups (36.1%; n=126; p&amp;lt; 0.001). Gastroenterology services utilization overall was high among all groups and enteral feeding tube placement was significantly higher among PMBTs (p&amp;lt; 0.001). CONCLUSIONS Dysphagia increases with age and older patients with brain malignancies are at particularly high risk. Those with PMBTs experience dysphagia earlier in their disease course and dysphagia-related healthcare utilization is higher when compared to other cancers. Our findings have important implications as the number of Medicare beneficiaries is expected to increase.

Feeding after congenital heart surgery: a mixed-methods study of the caregiver experience.

Feeding difficulties after congenital heart surgery are a common concern for caregivers of children with CHD. Insight into the intricacies of their experience is lacking. With a better understanding, healthcare providers can continue to optimize the approach and support mechanisms for these families. This study will explore the psychosocial impacts on caregivers, define barriers to care, and identify areas to improve their care. This mixed-methods study combined semi-structured interviews with surveys. Purposive sampling targeted caregivers of a child who underwent heart surgery and was discharged with alternative enteral feeding access. A hybrid inductive-deductive methodology was used to analyse interview transcripts. Survey scores were compared to interview content for concordance. Fifteen interviews were conducted with socio-demographically diverse caregivers. Feeding difficulties were often identified as their greatest challenge, with the laborious feeding schedule, sleep deprivation, and tube management being common contributors. Most caregivers described feeling overwhelmed and worried. Time-intensive feeding schedules and lack of appropriate childcare options precluded caregivers' ability to work. Barriers to care included imperfect feeding education, proximity of specialist clinics, and issues with medical supply companies. Caregiver proposals for improved care addressed easing the transition home, improving emotional support mechanisms, and intensifying feeding therapy for expedited tube removal. This study describes the psychosocial toll on the caregiver, typical barriers to care, and ideas for improved provision of care. These themes and ideas can be used to advance the family-centered approach to feeding difficulties after heart surgery.