Removal Of Feeding Tube Research Articles

The nasal bridle: A useful approach to prevent the dislodgement of feeding tubes

The reported incidence of nasogastric feeding tube dislodgement is 40%. In many cases, repeated tube dislodgements result in having to initiate gastrostomy feeding or total parenteral nutrition. To address this problem we sourced a tube-securing device (nasal bridle) and commenced its insertion. In a prospective study we aimed to measure the success of bridle insertion and to assess its effectiveness in preventing inadvertent feeding tube removal. 26 patients with a history of repeated tube dislodgement had their nasogastric feeding tube secured with a bridle. In addition, 2 patients commencing nasojejunal feeding had their tubes secured as a prophylactic measure against dislodgement. Subjects were selected based on clinical judgement by the dietitian and doctor. A DVD demonstrating insertion technique was viewed by the practitioner prior to insertion. The majority of tubes (84.8%) were successfully secured. In those with a history of tube dislodgement, the mean number of dislodged tubes prior to bridle insertion was 3.6 (range 1–6). Bridle insertion prevented further tube dislodgement in 85.8% of cases. Minor bleeding occurred in 18.2% of insertions. Bridles can be safely used to secure feeding tubes and can reduce the incidence of tube dislodgement. Bridle use has the potential to save valuable hospital resources.

Endoscopic-Assisted Closure of Persistent Gastrocutaneous Fistula With a Porcine Fistula Plug: Report of a New Technique

Persistent gastrocutaneous (GC) fistula is a rare but problematic complication of gastrostomy feeding tube removal. Several techniques for nonoperative fistula closure have been attempted with mixed results. None has proven both satisfactorily simple and consistently effective. The authors present a case of persistent GC fistula treated by a simple outpatient endoscopic-assisted procedure using a porcine anal fistula plug. The procedure requires only basic endoscopic skills, similar to percutaneous gastrostomy tube placement, and it involves minimal operative time and risk to the patient. This technique offers a potential solution to the troublesome problem of persistent GC fistula.

Gastrointestinal Tract Recovery in Patients Undergoing Bowel Resection

To investigate the efficacy and safety of alvimopan, 12 mg, administered orally 30 to 90 minutes preoperatively and twice daily postoperatively in conjunction with a standardized accelerated postoperative care pathway for managing postoperative ileus after bowel resection. This multicenter, randomized, placebo-controlled, double-blind, phase 3 trial enrolled adult patients undergoing partial bowel resection with primary anastomosis by laparotomy and scheduled to receive intravenous, opioid-based, patient-controlled analgesia. A standardized accelerated postoperative care pathway including early ambulation, oral feeding, and postoperative nasogastric tube removal was used to facilitate gastrointestinal (GI) tract recovery in all of the patients. The primary end point was time to GI-2 recovery (toleration of solid food and first bowel movement). Secondary end points included time to GI-3 recovery (toleration of solid food and first flatus or bowel movement), hospital discharge order written, and actual hospital discharge. Postoperative length of hospital stay based on calendar day of hospital discharge order written, opioid consumption, and overall postoperative ileus-related morbidity were recorded. Alvimopan, 12 mg, was well tolerated and significantly accelerated GI-2 recovery, GI-3 recovery, and actual hospital discharge compared with a standardized accelerated postoperative care pathway alone (hazard ratio = 1.5, 1.5, and 1.4, respectively; P < .001 for all). Time to hospital discharge order written as measured by hazard ratio (1.4) and by postoperative calendar days (mean for alvimopan, 5.2 days; mean for placebo, 6.2 days) was also accelerated. Opioid consumption was comparable between groups, and alvimopan was associated with reduced postoperative ileus-related morbidity compared with placebo. Alvimopan, 12 mg, administered 30 to 90 minutes before and twice daily after bowel resection is well tolerated, accelerates GI tract recovery, and reduces postoperative ileus-related morbidity without compromising opioid analgesia.

Acupuncture for dysphagia in acute stroke

Dysphagia after acute stroke is associated with poor prognosis, particularly if prolonged. Acupuncture has been widely used for this complication in China. However, its therapeutic effect is unclear. To determine the therapeutic effect of acupuncture for dysphagia after acute stroke compared with placebo, sham or no acupuncture intervention. We searched the Cochrane Stroke Group Trials Register (last searched September 2007), the Chinese Stroke Trials Register and the Trials Register of the Cochrane Complementary Medicine Field (last searched January 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2007). In January 2007 we searched the following databases from the first available date; MEDLINE, EMBASE, CINAHL, AMED, CISCOM, BIOSIS Previews, ProQuest Digital Dissertations, Science Citation Index, ISI Proceedings, ACUBRIEFS, ACP Journal Club, Books@Ovid and Journals@Ovid, Chinese Biological Medicine Database, Chinese scientific periodical database of VIP INFORMATION, China periodical in China National Knowledge Infrastructure, Chinese Evidence-Based Medicine Database, Science China, Chinese Social Science Citation Index, and the Chinese Science and Technology Document Databases. We also searched databases of ongoing trials, conference proceedings, and grey literature, handsearched three Chinese journals and contacted authors and researchers. We included all truly randomised controlled trials that evaluated the effect of acupuncture, irrespective of type, in patients with dysphagia within 30 day after the onset of ischaemic or haemorrhagic stroke. All types of acupuncture interventions were eligible. The control intervention could be placebo acupuncture, sham acupuncture, or no acupuncture. The primary outcome was recovery of normal feeding. The secondary outcomes were case fatality, deterioration, late disability, length of hospital stay, quality of life, feeding tube removal, aspiration pneumonia and nutritional measures. Two review authors independently selected trials, assessed trial quality, and extracted data. Disagreements were resolved by a third review author. Only one trial of 66 participants was included. In the acupuncture group, 12 out of 34 participants recovered to normal feeding (35.3%). In the control group, seven out of 32 participants recovered to normal feeding (21.9%). The relative risk of recovery was 1.61 with a 95% confidence interval of 0.73 to 3.58. No statistical significance was detected. There is not enough evidence to make any conclusion about the therapeutic effect of acupuncture for dysphagia after acute stroke. High quality and large scale randomised controlled trials are needed.

A Child With Feeding Aversion Corrected by Acupuncture

Background: Acupuncture has been shown to be effective in the treatment of nausea and vomiting. In addition, pediatricians are becoming aware of acupuncture as a useful adjunctive treatment modality. Objective: To describe the use of acupuncture in a young child with feeding intolerance with vomiting. Design, Setting, and Patient: A 14-month-old boy seen at a midwestern pain clinic for months-long feeding intolerance, resulting in drastic reduction in weight percentile. Intervention: Bilateral needling at PC 6, ST 34, ST 36, LR 3, and abdominal points CV 12 and ST 25. The procedure was repeated weekly for 3 weeks, then continued every other week for 3 months, combined with his behavioral program of feeding therapy. Main Outcome Measure: Cessation of vomiting and ability to take food orally (removal of feeding tube). Results: The patient cried and vomited during quick placement of needles, but then played with toys for 45 minutes in the pain clinic with needles in place. Needles were withdrawn and he did not vomit all the following week and actually put rice in his mouth at day care. The patient continued to gradually increase his oral intake to eventually taking 80% of food orally, with an 11-g/d weight gain. Acupuncture therapy was stopped, with occasional resumption of 1–2 treatments if vomiting resumed. His feeding tube was surgically removed. Conclusions: The successful use of acupuncture for vomiting and feeding intolerance in this patient should encourage pediatricians to consider acupuncture for related conditions.

Enteral Nutrition in Critically Ill Children: Are Prescription and Delivery According to Their Energy Requirements?

The purpose of this study was to compare the differences between prescribed and delivered energy among critically ill children and to identify the factors that impede the optimal delivery of enteral nutrition in the first 5 days of nutrition support. In a prospective cohort study, we evaluated 55 critically ill children aged 8.2 +/- 11.4 months (0-162.3 months), who were fed for > or =2 days through a gastric or postpyloric tube. The patients were followed from admission until day 10 of enteral nutrition. Prescribed and delivered energy were recorded daily and compared with each other and with the estimated basal metabolic rate (BMR). The Paediatric Index of Mortality 2 (PIM 2) was used to estimate illness severity. The ratio of delivered:required energy was <90% in 55.7% of the enteral nutrition days. Low prescription was the main reason for not achieving the energy goal in the first 5 days of enteral nutrition. Discrepancies between prescribed and delivered: energy were attributable to interruptions in feeding caused by clinical instability, airway management, radiologic and surgical procedures, and accidental feeding tube removal. The other factors associated with the delivery of less than required energy were PIM 2 > or =15%, gastrointestinal complications, dialysis, and use of alpha-adrenergic vasoactive drugs. The latter was the only variable in multivariate analysis that was associated with not ultimately achieving energy goal. The prescription and delivery of energy were not adequate in >50% of enteral nutrition days. The gap between the effective administration and energy requirements can be explained by both underprescription and underdelivery. Administration of vasoactive drugs was the only variable independently associated with a low energy supply.

Early activity is feasible and safe in respiratory failure patients*

To determine whether early activity is feasible and safe in respiratory failure patients. Prospective cohort study. From June 1, 2003, through December 31, 2003, we assessed safety and feasibility of early activity in all consecutive respiratory failure patients who required mechanical ventilation for >4 days admitted to our respiratory intensive care unit (RICU). A majority of patients were treated in another intensive care unit (ICU) before RICU admission. We excluded patients who required mechanical ventilation for < or =4 days. Eight-bed RICU at LDS Hospital. We assessed patients for early activity as part of routine respiratory ICU care. We prospectively recorded activity events and adverse events. We defined three activity events as sit on bed, sit in chair, and ambulate. We defined six activity-related adverse events as fall to knees, tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, oxygen desaturation <80%, and extubation. During the study period, we conducted a total of 1,449 activity events in 103 patients. The activity events included 233 (16%) sit on bed, 454 (31%) sit in chair, and 762 (53%) ambulate. In patients with an endotracheal tube in place, there were a total of 593 activity events, of which 249 (42%) were ambulation. There were <1% activity-related adverse events, including fall to the knees without injury, feeding tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, and desaturation <80%. No patient was extubated during activity. We conclude that early activity is feasible and safe in respiratory failure patients. A majority of survivors (69%) were able to ambulate >100 feet at RICU discharge. Early activity is a candidate therapy to prevent or treat the neuromuscular complications of critical illness.

P077 Swallowing Outcomes Following Supracricoid Partial Laryngectomy in the Setting of Adjuvant Therapy

Objective: To evaluate swallowing recovery following supracricoid partial laryngectomy. Design: Retrospective review. Setting: Major comprehensive cancer center. Patients: Twenty-seven patients treated with supracricoid partial laryngectomy for primary or recurrent larynx cancer. Intervention: Functional swallowing strategies, maneuvers, and therapies based on objective modified barium swallow (MBS) study results. Main Outcome Measures: Hospital recovery (length of stay, decannulation rates, complications), swallowing outcomes (physiology, symptoms), and nutritional results (time to oral intake, tube dependency, final diet). Results: Supracricoid partial laryngectomy included 1 arytenoid cartilage in 8 of 27 patients. The mean (SD) length of hospitalization was 8 days (9.23 days [median, 6 days; range, 3-53 days]) with a mean (SD) number of weeks to decannulation of 5 (8.23 weeks [median, 1 week; range, 1-30 weeks]). One patient required permanent tracheostomy. The most common complications were pneumonia and subcutaneous emphysema (7 [26%] of 27 complications). Pneumonia occurred more often in patients who had received radiation therapy (P=.02). Twenty-two patients had MBS studies. Initially, all patients aspirated thin liquids and 55% (12 of 22) aspirated pureed consistencies owing to neoglottic incompetency. Diet modifications alone did not alleviate aspiration; 64% (14 of 22) of patients needed to use swallowing strategies. The supraglottic swallow maneuver was most effective in reducing or eliminating aspiration. Eighty-one percent (22 of 27) of patients returned to complete oral intake with mean (SD) time to feeding tube removal of 10 weeks (8.33 weeks [median, 6 weeks; range, 1-29 weeks]); 7 of these patients used swallowing strategies. Nineteen percent of patients (5 of 27) remained partially (4 of 27) or fully (1 of 27) tube dependent. Arytenoid resection did not significantly affect hospital course or swallowing outcomes. Conclusion: Supracricoid partial laryngectomy initially produces severe swallowing dysfunction but most patients return to oral intake following targeted dysphagia intervention.

Neck dissection following organ preservation protocols prolongs feeding tube dependence in patients with advanced head and neck cancer

5525 Background: Organ preserving strategies employed in the treatment of advanced stage head and neck cancer frequently result in significant organ dysfunction including dysphagia and feeding tube dependence. While the acute and chronic effects of radiation and chemotherapy are known to contribute to swallowing impairment, the effect of a neck dissection, performed 6–8 weeks following the completion of treatment is unknown. Methods: Retrospective review of Stage III/IV squamous carcinoma patients treated with primary radiation with/without chemotherapy and a post-treatment neck dissection, who remain free of locoregional or distant failure for a minimum of two years. Predictors of prolonged feeding tube dependence (&gt;24 months following the completion of treatment) were evaluated using univariate and multivariate analysis. To determine the independent effect of neck dissection on length of feeding tube dependence, patients matched for covariates were also compared. Results: 79 patients treated at the Fox Chase Cancer Center between 1992 to 2003 were included in this study. 61 (77.2%) received chemotherapy and 37 (46.8%) underwent a neck dissection. The surgical specimen was positive for residual carcinoma in 12 patients (33%). 57 patients (71.3%) underwent placement of a feeding tube. The median time to removal of feeding tubes was 12 months [7–17 months, 95% CI]. Feeding tube-free status at 24 months was associated with use of standard radiotherapy (p = 0.031), N0 vs N+ neck stage (p = 0.041) and management without a neck dissection (p = 0.003). There was no association with age, T-stage, tumor site or use of chemotherapy. On multiple regression, only neck dissection remained a predictor of retained feeding tube at 24 months (p = 0.013). In patients matched for N-stage and treatment selection, those who underwent a neck dissections required a feeding tube a median of 36 months compared with 10 months for those without a neck dissection [32–57 months versus 7–13 months, 95% CI, p = 0.021]. The two year frequency of feeding tube dependence was 14/34 (41%) versus 3/30 (10%), respectively (p = 0.005). Conclusions: Neck dissection may contribute dysphagia experienced by head and neck cancer patients treated with organ preservation protocols. No significant financial relationships to disclose.

Does It Have to be hESC? A Note on War, Embryo, and the Disabled

In the spring semester of 2006, in my previous university position, I offered a course entitled: "Does it have to be hESC? Ethics and debate of stem cell research and cloning." As part of the course assignment, my students, divided into small groups, had to conduct group research on either a nation (or state within it) or a religious/political movement and its position on human embryonic stem cell research to present to the class. Groups elected to present on Israel, California, Canada, Vatican, the Bush-Kerry 2004 Presidential campaign, and South Korea. Outstanding presentations brought to the foreground how difficult it would be to reach any kind of complete agreement on ethical standards of human embryonic stem cell (hESC) research on an international level, yet at the same time, nearly all emphasized how important such an agreement would be, on the basis that hESC research concerns precisely what we see as life or non-life. Here, life's national specificity and human universality clashed head on. * * * Debates on hESC research are multi-directional, including the precise point of life's beginning, the moral status of embryo, and how to reconcile [End Page 509] with the existing practice of discarding and destroying not insignificant portions of spare embryos that are produced from IVF (in vitro fertilization), diverse religious views on what embryo is, and so on. Paralleling these discussions, (industrialized) national-states' efforts to participate in global competition, mixed with individual scientists' dreams and ambitions, creates an enormously complex terrain in which to observe debates about what life is and how it should be treated. These debates on life, involving individual, cultural, political, national, and international actors, curiously, are also about death—notably, the question of of whether non-life=death. It is here that the most salient, yet characteristically unspoken, points are contained. For, as I shall argue below, societies (including our own) are constantly making decisions about who can survive and who can be killed. If any society in a certain period of history under certain conditions does not necessarily see an individual life belonging exclusively to an individual, then this individual's death may not result in death. More concretely: in the current rhetoric of the US government with regard to the American soldier's death in Iraq, references to the eternity of life prevail—the deceased soldier being not dead, but alive, eternally with us. If so, in the US, under the current national emergency, individual lives are not the exclusive property of individuals—they belong, at least in part, to the nation. As long as the nation survives, the dead soldier never dies. As another example, many nations, including the US, allow brain death to be deemed as death proper and, as we witnessed in the 2005 removal of Terry Schiavo's feeding tube, the political and judiciary institution such as courts and the congress interfered directly and exercised their authority to endorse or disputing the death ("Schiavo's feeding tube removed" 2005, see also Lock 2002 for a comparative study). Often, on the other hand, the brain-dead person's fully functioning organs or even, as in the recent transplantion in France, a face ("Woman has first face transplant" 2006). Body parts are donated to needy persons and, in this practice, the donated organ, part of the life of the deceased, continues to live, fused with someone else's life. These instances evoke the concept of sacrifice. Individual sacrifices for a larger and supposedly more meaningful collectivity are often not seen as death. Humans have done this since primordial times, both in myths and rituals: Adonis's sacrifice for the vegetation god, offers of virgin sexuality for the temple of Ishtar, and other such instances are abundantly recorded (Frazer 1922, Herodotus 1954). From Hollywood movie themes to pious martyrdoms, [End Page 510] sacrificial tales continue to surround us today. If a soldier's death...

Terri Schiavo and the use of artificial nutrition and fluids: Insights from the Catholic tradition on end-of-life care

The recent events surrounding the case of Terri Schiavo have highlighted the moral implications of end-of-life care. Among the issues raised by Terri's parents against the withdrawal of her feeding tube was that doing so would be “euthanasia” and, as such, would violate their daughter's Roman Catholic religious beliefs. The emotionally charged rhetoric and the political posturing in this case drowned out both rational discourse and historical memory. Politicians and even a few bishops and cardinals were quick to join the parents in denouncing the removal of Terri Schiavo's feeding tube as “euthanasia” or “murder.” However, the interpretation of the Catholic position on the sanctity of life that led to that moral judgment is not in line with the centuries-long Catholic position on end-of-life care.

Fluoroscopically Guided Feeding Tube Insertion for Relief of Postoperative Gastrointestinal Anastomotic Obstruction and Leakage

To evaluate the feasibility and effectiveness of feeding tube insertion and enteral feeding for the treatment of postoperative gastrointestinal anastomotic obstruction and leakage. From June 1999 to June 2002, thirty-four cases of postoperative gastrointestinal anastomotic obstruction and leakage after surgery for gastric carcinoma were treated by insertion of a feeding tube under fluoroscopic guidance. Twenty-one patients were male and 13 were female. The patients' ages ranged from 39 to 74 years (mean age: 61 years). All the patients experienced vomiting, and 15 patients had anastomotic site or duodenal stump leakage. We evaluated the feasibility of feeding tube insertion for enteral feeding to improve the obstruction and facilitate leakage site closure, and the patients' nutritional benefit was also evaluated by checking the serum albumin level between pre- and post-enteral feeding via the feeding tube. Thirty-two patients (94%) were successfully managed by feeding tube insertion, but the remaining two were not managed, and this was due to severe angulations at the anastomotic site. The procedure times for feeding tube insertion ranged from 15 to 60 minutes (mean time: 45 minutes). Twenty-eight patients experienced symptomatic relief of gastrointestinal obstruction, and they were able to resume a normal regular diet after feeding tube removal. Three patients underwent stent insertion due to recurrent symptoms, and one patient underwent jejunostomy feeding due to the presence of a persistent leakage site. Eleven patients achieved leakage site closure after enteral feeding via a feeding tube. The serum albumin level was significant, increased from pre-enteral feeding (2.65 +/- 0.37 g/dL) to the post-enteral feeding (3.64 +/- 0.58 g/dL) via the feeding tube (p < 0.001). The duration of follow-up ranged from one to 53 months (mean: 23 months). The insertion of a feeding tube for enteral feeding under fluoroscopic guidance is safe, and it provides effective relief from gastrointestinal anastomotic site obstruction and leakage after gastric surgery. Moreover, our findings indicate that feeding tube insertion for enteral feeding may be used as the primary procedure to treat postoperative anastomotic obstruction and leakage.

On Feeding Tubes

During the early spring of 2005, debates in the United States about the right to centered on a single solitary figure in a Florida hospice-Terri Schiavo. Schiavo collapsed in 1990 from a potassium imbalance that her doctors believe resulted from an eating disorder; Schiavo lost consciousness, and blood flow to her brain was severely diminished for around five minutes. When she was revived, doctors found her significantly brain damaged, and declared her to be in a permanent vegetative state. Over the course of the next 15 years, Schiavo's husband and parents became involved in a bitter debate about whether or not she should be allowed to After numerous attempts to adjudicate continuing lifesupport, in March 2005 Schiavo's parents finally lost their appeals to the Supreme Court. Within days, the feeding tube that provided water and nourishment to Schiavo was removed, and around 9:oo A.M. on 31 March, Terri Schiavo died. In the period between the removal of Schiavo's feeding tube and the signing of her death certificate, the Florida hospice where Schiavo was housed became the geographical battleground where pro-life activists and right to advocates staged their conflict. The scene was highly publicized in the national media, and the space outside the hospice was quickly converted into an outdoor theatre: a staging area was set for press releases and statements from family members and doctors; small tents were constructed where religious activists could publicly sing and pray; and an array of picket signs and enlarged photographs created by representatives from both camps circulated slogans and images pleading either for the reinsertion of the tube or for support of her husband's decision to remove it. Hundreds of cameras captured the scene and reproduced it for newspapers and TV. The rhetoric of morbidity was transposed onto the body of Terri Schiavo; translated through the various images of her released to the public; and transfixed on the question of what it could possibly mean, in Schiavo's case, to choose to die. The Schiavo case epitomizes the complicated nature of hunger as it functions at the very heart of mortality-or, in Freud's words, of the drive to die in one's own way (1961). The intensity of the question of hunger is especially strong at the site of the alternately lionized and demonized medical apparatus at the center of the controversy: the feeding tube. In standard medical practice, the feeding

In Respect of People Living in a Permanent Vegetative State - And Allowing Them to Die

This article considers the controversy surrounding the removal of Terri Schiavo's feeding tube and argues for a new approach in determining treatment decisions for people in a permanent vegetative state. Examination of the duty to respect living people as persons rather than as objects reveals that people in a permanent vegetative state are particularly vulnerable under our current statutory and case law to being kept alive only in service to the interests of others. The article proposes that we replace the current legal presumption in favor of continued life support with a presumption to discontinue it for those in a permanent vegetative state and that judicial or quasi-judicial review be brought to bear on decisions in favor of continued life support, particularly tube feeding.

“Culture of Life” Politics at the Bedside — The Case of Terri Schiavo

The parents of Terri Schiavo, a Florida woman who was in a persistent vegetative state, objected to her husband's decision to discontinue artificial nutrition, and a protracted legal battle ensued. The Florida courts ordered the removal of Schiavo's feeding tube to provide care consistent with her wishes. The judicial decisions in the Schiavo case were consistent with legal precedent, but the interference in the case by the legislative and executive branches of the Florida and U.S. governments was unprecedented.

Knotting of feeding tube used for bladder drainage in hypospadias repair

In a 5-year-old child who had undergone hypospadias repair, removal of an over-catheterized 6F infant feeding tube was met with resistance and required lubrication inand-around the tube with 2% lignocaine jelly while maintaining a constant and gentle traction. The tube successfully removed was found knotted distally [Figure 1]. There was no bleeding or urethral disruption and the subsequent urinary stream was straight and thick.

Supracricoid partial laryngectomy with cricohyoidopexy and cricohyoidoepiglottopexy: functional and oncological results

Sixty-eight patients who presented with glottic and glottosupraglottic squamous cell carcinoma and who were managed in this department with supracricoid partial laryngectomy (SCPL) with either cricohyoidoepiglottopexy (CHEP) or cricohyoidopexy (CHP), were retrospectively reviewed. The authors analysed the functional and oncological results of the patients. The median follow-up period was 62 months. The average times until decannulation and nasogastric feeding tube removal were 27.7 and 26.4 days, respectively. All patients were successfully decannulated. All patients were able to swallow, but one patient was unable to swallow and had recurrent aspiration. Better functional results were achieved in patients managed with CHEP procedure than the patients managed with CHP procedure. The five-year absolute and cause-specific actuarial survival rates (Kaplan-Meier method) were 78.6 per cent and 93.9 per cent, respectively. The five-year actuarial local control and nodal control rates were 89.5 per cent and 90.4 per cent, respectively. Local recurrence was statistically more likely in patients with positive resection margins (p <0.006). Overall, local control and laryngeal preservation were achieved in 95.6 per cent and 89.7 per cent, respectively. Supracricoid partial laryngectomy procedures (CHEP and CHP) are possible alternatives to total laryngectomy in the treatment of selected advanced glottic and glottosupraglottic carcinomas.

Implications of the Papal Allocution on Feeding Tubes

The recent papal allocution To the International Congress on Life-Sustaining Treatment and Vegetative State. Scientific Advances and Ethical Dilemmas has been the occasion for much discussion concerning the use of artificial feeding tubes for nutrition and hydration. Briefly, the Pope stated in the March address that such tubes were a medical act and that their use represents a natural means of preserving life and is part of normal care. Therefore, their use is to be morally evaluated as ordinary and obligatory. If done knowingly and willingly, the removal of such feeding tubes is euthanasia by omission. The person's medical condition is not relevant in making a determination about the use of feeding tubes because the food and water delivered through such tubes is ordinary care and provides a benefit--nourishment to the patient and alleviation of his suffering. (1) What is interesting about this papal allocution is that it seems to represent a significant departure from the Roman Catholic bioethical tradition with respect to both the method and the basis upon which such decisions are made. The method announced by Pope John Paul II seems to be deontological. The use of feeding tubes to deliver artificial nutrition and hydration is declared ordinary, and such an intervention apparently ought not be forgone or withdrawn. Historically, the method for making a determination about the use of a medical intervention was to consider the proportional benefits and its harms to the individual, family, and community. The method is a teleological balancing of the impact of the intervention. This has been the central teaching of the tradition from the mid-1600s through Pope Plus XII and the 1987 Declaration on Euthanasia by the Congregation for the Doctrine of the Faith. (2) The examples of disproportionately harmful impacts in the Roman Catholic tradition range from the use of expensive medications, food beyond the budget of the individual, and interventions that are painful in both the short and long term, to the refusal of a physical examination if that will cause excessive embarrassment to the individual. Included in such a listing and specifically noted in the Declaration on Euthanasia is the financial impact on both the patient and family. Interventions that will provide a significant financial hardship need not be utilized. The question of the use of artificial feeding tubes has been much debated in Roman Catholic bioethics, especially when used for patients in persistent vegetative state. (3) One early statement was from the revered Jesuit moral theologian Gerald Kelly: I see no reason why even the most delicate professional standard should call for their [oxygen and intravenous nutrition and hydration for a patient in a terminal coma] use. In fact, it seems to me that, apart from very special circumstances, the artificial means not only need not but also should not be used, once the coma is reasonably diagnosed as terminal. Their use creates expense and nervous strain without conferring any real benefit. (4) There were further arguments made on both sides of the issue by theologians, bishops, and bishop conferences. Over time a consensus seemed to develop that the forgoing or withdrawal of artificial feeding tubes could be judged morally optional in some circumstances. The reason the papal statement is so startling to many is that it came out of the blue. It seems to depart from the tradition of Roman Catholic bioethics on how to analyze such questions and substitutes a deontological principle for the traditional weighing of benefits to burdens. Thus it raises a number of very practical questions for patients, theologians, medical personnel, and Catholic hospital administrators. One question concerns the authority of the statement. Traditionally, allocutions are given to a variety of groups that meet in Rome, but they have not always been seen as the locus for announcing a major policy shift. …

At Law: Schiavo: A Hard Case Makes Questionable Law

Since the 1970s Quinlan case, decisions about life-sustaining interventions have been a major focus of bioethics inquiry. By the end of the 1990s, however, professionals and the general public were paying less attention to this topic. After the U.S. Supreme Court rulings on physician-assisted suicide, it seemed that most of the major issues about end-of-life choices had been settled. But appearances can be deceiving. In the final months of 2003, another end-of-life controversy captured the nation's attention. This new dispute over life-sustaining treatment demonstrated that sharp disagreements persist regarding the acceptable conditions for forgoing treatment. The dispute over Terri Schiavo's care triggered heavy media coverage and actions by officials in all three branches of Florida's state government. Thanks to the extensive publicity, most readers are familiar with the facts of the case. In 1990, Terri Schiavo's heart stopped. Paramedics revived her, but oxygen deprivation had already produced severe brain damage. Later that year, her husband, Michael Schiavo, was appointed her guardian. For several years, he and his wife's parents, the Schindlers, remained friendly. But their cooperative relationship ended after malpractice litigation produced an award of about one million dollars, which went into a trust fund to cover the patient's care. By the mid-1990s, Michael Schiavo concluded that his wife would not recover. In 1998, he asked a court to permit removal of the patient's feeding tube. The Schindlers opposed this request. By 2003, various challenges and counter-challenges had been considered in numerous court proceedings. The courts, applying Florida statutes and case law, determined that Michael Schiavo's request to withdraw treatment should be honored. (1) The Schindlers continued to oppose treatment withdrawal, however, and certain organizations and state officials expressed support for their position. In October 2003, at the behest of Governor Jeb Bush, the Florida legislature passed a law authorizing the governor to block the court order to remove the tube, pending additional testing to ascertain whether the patient could ingest food orally. This laws constitutionality then became an issue for the courts. In the meantime, Governor Bush issued a stay keeping the tube in place and a guardian ad litem was appointed to prepare a case summary and recommendations on whether the stay should be continued. Last December, the guardian ad litem, Jay Wolfson, submitted his report. (2) It is a detailed and thoughtful account that concludes by recommending further testing to evaluate the patient's swallowing ability. It also urges the parties to agree in advance about the effect test results should have on the treatment decision. As the report notes, Given the history of this case, [the testing] would not, in and of itself, assure a resolution, and is not, therefore, deemed either feasible or of value to Theresa Schiavo without prior agreement. Source of Disagreement At least five points underlie the family dispute that is responsible for keeping this case in the legal spotlight. One is whether Terri Schiavo is in a persistent vegetative state. An evidentiary hearing in 2002 focused on this question. Three neurologists, including one appointed by the court and two chosen by Michael Schiavo, said that she met the criteria for PVS. A neurologist and a radiologist selected by the Schindlers said that her condition was less severe than that. Though the court found clear and convincing evidence that Terri Schiavo met the criteria for PVS, the parents believe that more tests are needed to evaluate her current capacities. Terri Schiavo's prognosis is another point of contention. At the earlier evidentiary hearing, the physicians testifying for the parents said that they thought she could be helped by certain interventions (hyperbaric therapy or vasodilatation therapy). …

Our own experience in supracricoid laryngectomy with CHP and CHEP type of reconstruction due to larynx cancer

The results of the surgical treatment of larynx cancer (glottic–supraglottic) by supracricoid laryngectomy with CHP and CHEP type of reconstruction are presented. The material consists of 160 cases (88 after CHP and 72 after CHEP). A 5-year survival rate was obtained in over 71% of cases in all material. Decannulation was possible in 126 (79%) patients. Feeding tube removal before 4 weeks after operation was performed in 139 (87%) cases. In subjective assessment, all patients had social efficient speech. Favorable results of the treatment encourage wider application of supracricoid laryngectomy.