Gastrostomy Placement Research Articles

The Paired T-Fastener Technique: A Bolster-Free Gastropexy for Laparoscopic Gastrostomy Tube Placement.

Purpose: Gastropexy during laparoscopic gastrostomy tube (GT) insertion can be technically challenging. T-fasteners are an effective method of gastropexy. However, the use of external bolsters requires an additional procedure for removal and may cause skin complications due to pressure necrosis. We describe our experience utilizing T-fasteners in a novel way that eliminates external bolsters during laparoscopic GT placement. Methods: Pediatric patients requiring enteral access who underwent gastrostomy at a single institution using the paired T-fastener technique were reviewed. Gastropexy was achieved by passing pairs of T-fasteners, under laparoscopic and/or endoscopic guidance, through single stab incisions into the stomach in a square configuration, allowing the suture from one T-fastener to be tied subcutaneously to its paired suture. This eliminates the need for external bolsters. Operative time and 30-day postoperative complications, including local wound infection, granulation tissue formation, bleeding, and tube replacement, are reported. Results: Thirty patients underwent gastrostomy placement using the paired T-fastener technique. Mean age was 9.2 years (standard deviation [SD] 6.9) and mean weight 29.9 kg (SD 21.0). Mean tube length was 2.2 cm (SD 0.71). Eight patients underwent an additional procedure at the time of gastrostomy. Mean operative time was 74.4 minutes (SD 39.7). Five patients developed a local wound infection requiring antibiotics. Five developed granulation tissue. Seven patients underwent tube replacement within 30 days for dislodgment or stem upsize. Conclusion: The paired T-fastener technique is a safe and efficient method for primary button gastrostomy placement. This method eliminates the need for additional trocars or external bolsters and may be helpful in patients with thick abdominal walls.

A Multidisciplinary Approach to the Reactive Placement of Nasogastric Feeding Tubes in Clinic During Treatment for Head and Neck Cancer

Radiation therapy (RT) associated oral mucositis, xerostomia and loss of taste may result in significantly compromised oral intake in patients undergoing treatment for head and neck cancers (HNC). We sought to determine if reactive nasogastric tube (NGT) placement was an effective strategy for nutritional support in these patients and if invasive percutaneous endoscopic gastrostomy (PEG) tube insertion could be avoided.This is an IRB- approved study of patients treated for HNC using definitive or adjuvant RT with or without concurrent chemotherapy between June 2017 and December 2020. We evaluated the indications for NGT (Dobhoff) placement, time of placement during the course of RT, patient tolerance of NGT and median duration of NGT placement. In addition, we followed weight loss during treatment, treatment interruptions, and treatment related toxicities. Complications associated with having the NGT, if the NGT needed to be replaced during treatment, and if the patient had any hospitalization during the course of treatment was tracked. The indication for NGT placement is weight loss > 10% of baseline during the course of treatment, most often due to dysphagia and/or odynophagia unrelieved by pain medication. NGT placement is done in the radiation oncology outpatient clinic by the attending physician and/or nurse practitioner.Of the 441 patients treated during the time period of this study, 47 required reactive NGT placement for nutritional support. Patients included 40 with primary oropharynx, 3 oral cavity, 2 larynx, 1 nasopharyngeal, and 1 unknown. Chemotherapy was given concurrently with radiation in 87.2% (41/47) patients. The median time of NGT placement was during week 5.0 of the 6-7-week course of RT. The median percentage weight loss from baseline to the date of NGT placement was 12.9%. The median duration of NGT placement was 29 days (range, 5 to 151 days). There were no serious medical complications associated with having the NGT in place during treatment. 27.6% (13/47) of patients had the NGT dislodged or displaced and needed replacement. 4.3% (2/47) of patients had the NGT replaced due to clogging. 38.3% (18/47) of patients with an NGT had to be hospitalized during the course of RT, with the predominant symptoms being failure to thrive 22.2% (4/18) and nausea/vomiting 22.2% (4/18). 6.4% (3/47) of patients requested removal of the NGT due to local irritation. 76.6% (36/47) of patients did not require further nutritional support with the placement of a percutaneous endoscopic gastrostomy (PEG) tube.This study indicates clinic placement of an NGT for patients receiving RT for head and neck cancer is a safe and effective way to maintain nutrition during treatment. The rate of weight loss decreased after the patient had an NGT placed. The placement procedure is well tolerated and there were no complications associated with having the NGT during treatment. PEG tube insertion was avoided in 76.6% of the patients.

Direct endoscopic placement of percutaneous endoscopic gastrostomies with jejunal extension tubes (PEG-J) using ultra-thin endoscopes - long-term outcomes from a U.S. tertiary referral center.

Several techniques for PEG-J tube placement have been described, commonly requiring fluoroscopic guidance and/or fixation of the jejunostomy tube (J-tube) into the small intestine. We describe a modified technique for placing jejunostomy tubes under direct visualization through a PEG with the use of ultra-thin endoscopes and steel guidewire. A retrospective study at a single tertiary academic center evaluating patients who underwent PEG-J placement between 2010 and 2020. All PEG tubes were placed with a pull-through technique. The Olympus GIF-N180 endoscope was advanced through the PEG to the jejunum and a Savary-Gilliard guidewire was used for placement of the J-tube extension. Fifty-eight patients underwent PEG-J placement (median age 61years; women 52%). Surgically altered gastric anatomy was observed in 11 patients (19%). Median procedure time was 44min for new PEG-J tube placement (range 26-103) and 20min for placement of a J-tube extension through an existing PEG tube (range 9-86) or gastrostomy tract. Technical success rate was in 100%. Sixty-two repeat procedures were performed for J-tube exchange in 27 patients (46%, range 1-9 per patient), of which 51 procedures (82%) were done using the same technique. The most common indication for tube replacement was tube dysfunction (63%, n = 39). The median procedure time for tube exchange was 20min (range 2-62). No major adverse events were encountered. PEG-J tubes can be placed effectively, rapidly, and safely using an ultra-thin caliber endoscope and a stiff steel wire through the PEG tube or mature gastrostomy site, precluding the need for fluoroscopy or oral access. J-tubes can be easily replaced utilizing the same technique.

S2208 Primary Squamous Cell Carcinoma as a Long-Term Complication of Percutaneous Endoscopic Gastrostomy Placement

Introduction: Common complications associated with percutaneous endoscopic gastrostomy (PEG) placement include aspiration, bleeding, leakage, irritation, abdominal pain, and infection. Previous case reports have described the PEG site as a location for metastatic malignancy, especially in the setting of head and neck cancers (often an indication for PEG placement). We present a rare case of primary squamous cell carcinoma (SCC) which developed in the setting of long-term PEG placement. Case Description/Methods: Patient is a 51-year-old woman with developmental delay and dystonia secondary to DYT1 gene mutation. Given her developmental delay, a PEG was placed for nutritional support and had been in place for thirty-two years. She presented with a 2-cm abscess at her PEG site and was discharged with oral antibiotics following incision and drainage (I+D). She noted persistent leakage of bloody and foul-smelling drainage from her PEG tube (figure 1). She returned with worsening irritation surrounding the PEG site and was noted to have a 5x7 cm area of erythema with overlying fluctuant abscess. Again, she underwent I+D and was started on IV antibiotics. Cross sectional imaging demonstrated irregular soft tissue thickening involving the greater curvature of the stomach, adjacent to the PEG site, extending into the gastrostomy tube tract. A biopsy of the skin surrounding the PEG tube was performed and demonstrated well-differentiated and invasive SCC. A subsequent PET scan showed locally invasive disease with PEG site involvement extending into the abdominal wall. There were no additional areas concerning for malignancy (no indications of an alternative primary site). Given the burden of locally invasive disease, surgical resection was deferred and she was offered palliative radiation. Discussion: The development of SCC at the PEG site is an uncommon occurrence and previous case reports typically describe these events as metastasis from a head/neck primary site. There has been at least one additional documented case of primary SCC at the PEG site but this occurred in an immunosuppressed patient. Chronic irritation of the skin, which is a known complication of PEG placement, possibly contributed to the development of SCC in this patient. Aggressive wound care and close monitoring for suspicious mucosal changes should be considered in patients with long-term PEG placement.Figure 1.: Squamous Cell Carcinoma along the PEG site.

OEIS Syndrome: Omphalocele, Exstrophy of the Cloaca, Imperforate Anus, and Spinal Defects

OEIS Syndrome: Omphalocele, Exstrophy of the Cloaca, Imperforate Anus, and Spinal Defects

S617 Characteristics and Outcomes of Patients Consulted for Percutaneous Endoscopic Gastrostomy Tubes During the COVID-19 Pandemic: A Multicenter Experience

Introduction: COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, can result in critical illness and an unprecedented burden on the healthcare system. Severe cases can lead to prolonged hospitalizations, intubations and tracheostomy placements necessitating longer term nutrition planning including placement of percutaneous endoscopic gastrostomy (PEG) tubes. However, major uncertainties surround PEG tube placement in patients with COVID-19, including resources, exposure, and most importantly, the natural history of the disease, which we attempt to address through this study. Methods: We retrospectively analyzed all patients seen in consultation for PEG tube placement at two hospitals in New York City, considered an epicenter of the COVID-19 pandemic, between March 20, 2020 and May 15, 2020. Results: We identified 41 consecutive inpatients who were COVID+ and whose primary team consulted gastroenterology for PEG tube placement. The GI service placed PEG tubes in 24 patients (PEG cohort), and deferred placement in 17 others (noPEG cohort). Patients in the PEG cohort had higher Sheffield gastrostomy scores, Charlson comorbidity indices, and NUTRIC scores. Twelve of 41 (29%) of all consulted patients eventually tolerated per os (PO) intake by time of discharge/analysis, involving 53% of the noPEG cohort versus 13% of the PEG cohort (p=0.016). Average time from tracheostomy to PEG placement and from GI consult to PEG placement was 14±9 days and 3±3 days, respectively. PEG-related complications included bleeding (2), dislodgement (1), and colonic perforation (1). Conclusion: As many patients infected with COVID-19 become critically ill and develop prolonged hospitalizations, providing enteral feeding access via PEG tube placement is an increasingly common request. Some patients who were consulted for PEG tube were able to resume PO intake, and there were even requests to remove PEGs that were placed during the same hospitalization. While PEG tubes are generally safe, complications can occur, and careful selection of patients is essential to avoid unnecessary morbidity.Table 1.: Characteristics comparing COVID+ patients who had PEG tube placed by GI (PEG cohort) vs not placed by GI (noPEG cohort) *p = < 0.05 COVID+: positive for SARS-CoV-2 by nasopharyngeal swab; PEG: percutaneous endoscopic gastrostomy; GI: gastroenterology; BMI: body mass index; NUTRIC: nutrition risk in critically ill; SLP: speech-language pathology; NGT: nasogastric tube; OGT: orogastric tube; SNF: skilled nursing facility; PO: per os

S552 Outcomes of Inpatients With COVID Receiving Percutaneous Endoscopic Gastrostomy Placement as Compared to Inpatients Without COVID

S552 Outcomes of Inpatients With COVID Receiving Percutaneous Endoscopic Gastrostomy Placement as Compared to Inpatients Without COVID

A CASE OF SPONTANEOUS ESOPHAGEAL PERFORATION PRESENTING AS A RIGHT-SIDED PLEURAL EFFUSION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous esophageal perforation or Boerhaave's syndrome is characterized by rupture of the esophagus due to the rapid and spontaneous rise in intraluminal esophageal pressure. Only 14% of patients present with Meckler's triad, which includes severe vomiting, chest pain and subcutaneous emphysema. Approximately 90% of the perforations occur at the left lateral aspect of the distal esophagus, causing a left-sided pleural effusion. This case report describes an 85-year-old man who presented with Boerhaave's syndrome due to a right-sided effusion. CASE PRESENTATION: An 85-year-old male presented to the emergency department with 2 weeks of progressively worsening dyspnea, abdominal pain, nausea and vomiting. He denied a history of heavy lifting, chest trauma, alcohol or tobacco use. He was initially afebrile and hemodynamically stable. Jugular veins were not distended. Breath sounds were decreased on the right. There was no murmur and abdomen was soft nontender. ACS workup was negative. Subsequent CT scan revealed hydropneumothorax, subtle pneumomediastinum, and free intraperitoneal air. A chest tube was placed due to interval development of tachycardia & hypotension. Pleural fluid analysis yielded pH 4.23, WBC 2734, glucose 157, LDH <55, protein 2.0, amylase <26, and bilirubin <0.1. Gastrographin swallow demonstrated extravasation of contrast medium through a distal defect in the esophagus. Esophagogastroduodenoscopy showed esophageal perforation from 30 cm to 42 cm extending through the gastroesophageal junction into the cardia of the stomach with a dusky, friable, ischemic appearing distal esophageal mucosa. Rather than placing an esophageal stent as originally planned, the procedure was converted to an open esophagectomy with percutaneous endoscopic gastrostomy placement. His immediate postoperative course was largely uneventful and he was extubated post-op day 2. He was successfully discharged a few weeks later. DISCUSSION: This case is notable for a pleural fluid analysis which yielded a pH of 4.23. While pleural fluid pH is dependent on many factors and may be falsely low due to the presence of local anesthetic or heparin, exposure to air, or time delay, a pH of 4.23 in the setting of dyspnea, vomiting, and pneumomediastinum should raise concern for Boerhaave's syndrome. Another unique aspect of this case was the location of the pleural effusion. Nearly 90% of perforations are left-sided due to anatomical weakness in the left lateral aspect of the distal esophagus causing left-sided pleural effusions. This patient atypically presented with a right-sided pleural effusion. Prior literature indicates that this presentation contributes to a delay in diagnosis and subsequent increase in mortality. CONCLUSIONS: In the case presented here, vomiting, right-sided pleural effusion, and careful pleural fluid analysis aided in making the correct diagnosis and led to prompt surgical treatment. REFERENCE #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462217/ REFERENCE #2: https://www.ncbi.nlm.nih.gov/books/NBK430808/ REFERENCE #3: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153269/ DISCLOSURES: No relevant relationships by Matthew Bernens, source=Web Response No relevant relationships by Kari McCoy, source=Web Response No relevant relationships by Caroline Mears, source=Web Response No relevant relationships by David Pierce, source=Web Response

S3448 Percutaneous Endoscopic Gastrostomy Placement in Patients Infected with SARS-CoV-2, A Single Center Review

Introduction: Infection with SARS-CoV-2 can manifest with several gastrointestinal symptoms, specifically diarrhea, nausea, vomiting, gastrointestinal bleeding and loss of appetite. In patients requiring hospitalization, especially the critically ill, loss of appetite can quickly cause severe malnutrition, hindering the body’s ability to recover from illness. Severe disease also results in sequelae including prolonged mechanical ventilation and stroke, further limiting enteral nutrition and in many cases, creates a need for percutaneous endoscopic gastrostomy (PEG). We aim to characterize the demographics, timeline and severity of disease of patients with COVID-19 who required PEG placement at our institution. Methods: This was a single-center retrospective cohort study evaluating patients who tested positive for SARS-CoV-2 from March 2020 through January 2021, and had a percutaneous endoscopic gastrostomy (PEG) tube placed as an inpatient. Primary endpoints include the number of patients with COVID-19 requiring PEG, time from COVID-19 diagnosis to PEG placement, and severity of COVID-19 in those requiring PEG (measured by intensive care unit requirements, respiratory status, and medical treatment beyond supportive care). Secondary endpoints include demographics, past medical history of diabetes and stroke, and BMI. Results: 12,224 patients were COVID-19 positive from March 2020 - January 2021. 76 patients underwent inpatient PEG placement. 68/76 patients (89.5%) required ICU admission and 66/76 (86.8%) patients were considered to have severe or critical COVID infection. The average age of patients was 65, 46 were male, and 48.7% of patients were white. On average, PEG placement occurred 26.4 days after positive COVID test. Average BMI on admission was 30.5, serum protein on admission 6.7 and albumin 3.4. One third of patients had a history of DM, where 17% had a history of past or current stroke. Enteral access via nasogastric tube (NGT)/Dobhoff prior to PEG was noted in 71/76 patients. Conclusion: Our data suggests severity of COVID infection is the greatest predictor of patients that will require PEG placement. Nutritional status on admission, comorbidities, and demographic data is unlikely to help determine those that will require enteral access. As COVID-19 cases continue to present and patients recover, Gastroenterologists should be aware of the frequency and population in which PEGs were placed as management and decision for removal may fall in their purview.Figure 1.: Comparison made between those people who were admitted to the intensive care unit and underwent PEG placement and those that did not require the intensive care unit and received PEG placement.

S3441 High Rate of Percutaneous Gastrostomy Placement in COVID-19 Patients With Low Overall Complications

Introduction: The COVID-19 pandemic led to a significant increase in the number of ventilator-dependent patients requiring long-term enteral feeding with percutaneous gastrostomy tubes (G-tubes). Placement of G-tubes in these patients presents unique challenges as the procedure is aerosolizing and poses risk to staff via bodily fluid and fomite transmission. Overall, there has been minimal data on the rates, safety, and ideal methods of G-tube placement in COVID-19 patients. Our study aimed to determine the proportion of COVID-19 patients who required G-tube placements, procedural services utilized, rates of adverse events, and staff exposures in a large academic medical center. Methods: In this single-center retrospective cohort study, hospitalized patients admitted with positive COVID-19 PCR tests from 1/1/20 through 6/9/20 were reviewed. For patients who underwent G-tube placement, demographics, comorbidities, procedural details and associated adverse events were collected for 7 days post-procedurally and compared to the same period in 2019 as a control. Staff involved with the procedure were surveyed for any reported cases of COVID-19. Results: Of 710 COVID-19 positive patients, 36 (5.1%) underwent G-tube placement compared to 24 in 2019 (Table). G-tubes were placed for persistent dysphagia, tracheostomy-dependence, or inadequate oral nutrition. G-tubes were placed most often in the ICU at the bedside with sedation. Most placements were performed by Surgery (42%), followed by GI (22%) and IR (19%). No procedural staff subsequently tested positive for COVID-19. Adverse events occurred in 13.9% of placements (3 patients (8%) had an aspiration within 7 days, 1 had abdominal wall bleeding, and 1 had a wound infection). There were no occurrences of perforation, peritonitis, dislodgement, GI bleeding or death. Placement at bedside in the ICU was not associated with adverse events when compared to all other locations (5 total, P = 0.02). Conclusion: This study demonstrates that among COVID-19 patients admitted to a tertiary care center, there were high rates of G-tube placements with overall low complications for both patients and staff. The overall adverse event rate was 13.9%, within the range reported in the literature (10-16%). Given improved outcomes for patients, overall low complications, and no known staff COVID-19 infections after placement, bedside endoscopic placement of G-tubes for COVID patients in the ICU can be considered a safe first-line approach.Table 1.: Details of PEG Placement in 36 total COVID-19 patients.

Clinical characteristics and pathogens in percutaneous endoscopic gastrostomy site infection in patients with head and neck cancer: A 16-year retrospective study.

ObjectivesWound infection is the most common complication associated with percutaneous endoscopic gastrostomy (PEG) placement, with an incidence between 4% and 30%. In this study, we compared the characteristics of PEG site infection between the head and neck cancer (HNC) group and the non‐HNC group.MethodsThis study was conducted at Kangdong Sacred Heart Hospital at the Ilsong Head and Neck Cancer Center. We retrospectively collected and analyzed data on patients who underwent PEG insertion from October 2003 to May 2019 to evaluate the risk factors and microbiological etiologies of PEG site infection.ResultsA total of 316 (HNC group [n = 129] and non‐HNC group [n = 187]) patients undergoing PEG insertion were included in this study. Moreover, 67 episodes of PEG site infection were diagnosed, with an overall prevalence of 21.2%. PEG site infections were significantly higher in the HNC group than in the non‐HNC group (32.6% vs 13.4%, P <.001). Pseudomonas aeruginosa is the most common pathogen associated with a PEG site infection. Multidrug‐resistant (MDR) P aeruginosa was more frequent in the HNC group than in the non‐HNC group (78.6% vs 25.0%, P = .006).ConclusionsFor appropriate treatment, P aeruginosa, especially MDR P aeruginosa, should be considered when selecting empirical antibiotics for PEG site infection in patients with HNC.Level of Evidence: 4

Combined Percutaneous Endoscopic and Fluoroscopic Approach for Placement of Gastrostomy and Conversion to Gastrojejunostomy—A Novel Technique

Combined Percutaneous Endoscopic and Fluoroscopic Approach for Placement of Gastrostomy and Conversion to Gastrojejunostomy—A Novel Technique

Social Factors Predictive of Intensive Care Utilization in Technology-Dependent Children, a Retrospective Multicenter Cohort Study.

Objective: Technology-dependent children with medical complexity (CMC) are frequently admitted to the pediatric intensive care unit (PICU). The social risk factors for high PICU utilization in these children are not well described. The objective of this study was to describe the relationship between race, ethnicity, insurance status, estimated household income, and PICU admission following the placement of a tracheostomy and/or gastrostomy (GT) in CMC.Study Design: This was a retrospective multicenter study of children <19 years requiring tracheostomy and/or GT placement discharged from a hospital contributing to the Pediatric Health Information System (PHIS) database between January 2016 and March 2019. Primary predictors included estimated household income, insurance status, and race/ethnicity. Additional predictor variables collected included patient age, sex, number of chronic complex conditions (CCC), history of prematurity, and discharge disposition following index hospitalization. The primary outcome was need for PICU readmission within 30 days of hospital discharge. Secondary outcomes included repeated PICU admissions and total hospital costs within 1 year of tracheostomy and/or GT placement.Results: Patients requiring a PICU readmission within 30 days of index hospitalization for tracheostomy or GT placement accounted for 6% of the 20,085 included subjects. In multivariate analyses, public insurance [OR 1.28 (95% C.I. 1.12–1.47), p < 0.001] was associated with PICU readmission within 30 days of hospital discharge while living below the federal poverty threshold (FPT) was associated with a lower odds of 30-day PICU readmission [OR 0.7 (95% C.I. 0.51–0.95), p = 0.0267]. Over 20% (n = 4,197) of children required multiple (>1) PICU admissions within one year from index hospitalization. In multivariate analysis, Black children [OR 1.20 (95% C.I. 1.10–1.32), p < 0.001] and those with public insurance [OR 1.34 (95% C.I. 1.24–1.46), p < 0.001] had higher odds of multiple PICU admissions. Social risk factors were not associated with total hospital costs accrued within 1 year of tracheostomy and/or GT placement.Conclusions: In a multicenter cohort study, Black children and those with public insurance had higher PICU utilization following tracheostomy and/or GT placement. Future research should target improving healthcare outcomes in these high-risk populations.

Current practices and barriers in gastrostomy indication in amyotrophic lateral sclerosis: a survey of ALS care teams in The Netherlands

Objective To describe current practices and barriers and support needs in gastrostomy indication and decision-making amongst rehabilitation physicians of ALS care teams in the Netherlands. Methods: Cross-sectional online survey of rehabilitation physicians of ALS care teams in the Netherlands. Survey items covered current practices in timing of indication (i.e. indicators and criteria), goals, initiating discussion about gastrostomy, and criteria for preferred method of placement; and barriers and support needs in indication and decision-making. Descriptive analysis was used for quantitative responses, thematic, and content analysis for qualitative data. Results: Twenty-nine physicians (41%) of 27 ALS care teams (71%) responded. Timing of indication: physicians agreed on important indicators but not cutoff values/criteria. Goals: optimizing nutritional status (100%), ensuring safe food-intake (72%), and reducing effort of meals (59%). Initiating discussion about gastrostomy: 52% introduces the topic early after diagnosis, 48% at indication. Criteria for method of placement included physician preference (69%), availability of service (21%), lower complication risk (17%), contraindication (59%), and patient preference (24%). Reported barriers (69% of respondents) were: patient readiness (52%), timing of indication (31%), and organizational barriers (18%). Support needs (62%): evidence-based timing of indication (35%) and tailored patient education (31%). Conclusions: There is practice variation in the timing of first introduction of gastrostomy and preferred method of placement, but agreement on goals and indicators . More evidence on optimal timing of gastrostomy placement is needed. However, until then early and regular discussion of the topic of gastrostomy and better patient information may promote patient readiness and support patient choice.

Prophylactic versus reactive percutaneous endoscopic gastrostomy in oropharyngeal squamous cell carcinoma patients undergoing radical radiotherapy.

Radiotherapy (RT) for oropharyngeal squamous cell cancer (OPSCC) is associated with malnutrition due to treatment-related mucositis and dysphagia. While percutaneous endoscopic gastrostomy (PEG) feeding can improve nutrition, it has acute and late complications, including dependence on PEG feeding. We retrospectively evaluated patient outcomes by whether gastrostomy placement was prophylactic (P-G) or reactive to RT complications (R-G). Retrospective analysis of OPSCC patients undergoing curative-intent RT at Waikato Hospital between 2010 and 2015. Of 103 OPSCC patients treated with RT (+/- chemotherapy) 21 had P-G, 15 had R-G and 67 had none (No-G). P-G patients were significantly more likely to be female, older, have higher tumour stage and receive bilateral RT (all p< 0.05). P-G and No-G patients had similar rates and duration of hospital admission for complications during treatment, but both were significantly less than in R-G patients (admission rates 52.3%, 49.3% and 86.7%, and mean length of stay 3.5, 3.3 and 11.9 days, respectively; p< 0.001). R-G patients also had greater RT treatment delays than P-G or No-G patients (mean 1.1, 0.7 and 0.4 days, respectively, p< 0.05). No significant differences were noted between groups in PEG dependence or weight change during, or 1, 3 or 6months after, RT. Weight loss was not significantly different with P-G than R-G despite more frequent use of bilateral RT fields in the former group. P-G placement affords shorter and less frequent hospital admissions than R-G during RT for OPSCC, with no increased complications or gastrostomy-dependence rates.

Combined Percutaneous Tracheostomy and Endoscopic Gastrostomy Tubes in COVID-19: A Prospective Series of Patient Outcomes

Background: A significant number of patients with severe respiratory failure related to COVID-19 require prolonged mechanical ventilation. Minimal data exists regarding the timing, safety, and efficacy of combined bedside percutaneous tracheostomy and endoscopy gastrostomy tube placement in these patients. The safety for healthcare providers is also in question. This study's objective was to evaluate the effectiveness and safety of combined bedside tracheostomy and gastrostomy tube placement in COVID-19 patients. Design and Methods: This is a single arm, prospective cohort study in patients with COVID-19 and acute respiratory failure requiring prolonged mechanical ventilation who underwent bedside tracheostomy and percutaneous endoscopic gastrostomy placement. Detailed clinical and procedural data were collected. Descriptive statistics were employed and time to event curves were estimated and plotted using the Kaplan Meier method for clinically relevant prespecified endpoints. Results: Among 58 patients, the median total intensive care unit (ICU) length of stay was 29 days (24.7-33.3) with a median of 10 days (6.3-13.7) postprocedure. Nearly 88% of patients were weaned from mechanical ventilation postprocedure at a median of 9 days (6-12); 94% of these were decannulated. Sixty-day mortality was 10.3%. Almost 90% of patients were discharged alive from the hospital. All procedures were done at bedside with no patient transfer required out of the ICU. A median of 3.0 healthcare personnel total were present in the room per procedure. Conclusion: This study shows that survival of critically ill COVID-19 patients after tracheostomy and gastrostomy was nearly 90%. The time-to-event curves are encouraging regarding time to weaning, downsizing, decannulation, and discharge. A combined procedure minimizes the risk of virus transmission to healthcare providers in addition to decreasing the number of anesthetic episodes, transfusions, and transfers patients must undergo. This approach should be considered in critically ill COVID-19 patients requiring prolonged mechanical ventilation.

Days out of Institution after Tracheostomy and Gastrostomy Placement in Critically Ill Older Adults.

Rationale: Tracheostomy and gastrostomy tubes are frequently placed during critical illness for long-term life support, with most placed in older adults. Large knowledge gaps exist regarding outcomes expressed as most important to patients. Objectives: To determine the number of days alive and out of institution (DAOIs) and mortality after tracheostomy and gastrostomy placement during critical illness and to evaluate associations between health states before critical illness and outcomes. Methods: In this retrospective cohort study of Medicare beneficiaries admitted to an intensive care unit (ICU) who received a tracheostomy, gastrostomy, or both, we determined the number of DAOIs after procedure date; 90-day, 6-month, and 1-year mortality; hospital discharge destination; and hospital length of stay. We used claims from the year before admission to define eight mutually exclusive pre-ICU health states (permutations of one or more of cancer, chronic organ failure, frail, and robust) and assessed their association with DAOIs in 90 days and 1-year mortality. Results: Among 3,365 patients who received a tracheostomy, 6,709 patients who received a gastrostomy tube, and 3,540 patients who received both procedures, the median number of DAOIs in the first 90 days after placement was 3 (interquartile range, 0-46), 12 (0-61), and 0 (0-37), respectively. Over half died within 180 days. One-year mortality was 62%, 60%, and 64%, respectively. When compared with the robust state, all other pre-ICU health states were associated with loss of DAOIs and increased 1-year mortality; however, between the seven non-robust pre-ICU health states, there were no differences in outcomes. Conclusions: Medicare beneficiaries with prior comorbidity who received tracheostomy, gastrostomy tube, or both during critical illness spent few DAOIs and had high short- and long-term mortality.

The hypometabolic state: a good predictor of a better prognosis in amyotrophic lateral sclerosis

BackgroundMalnutrition and weight loss are negative prognostic factors for survival in patients with amyotrophic lateral sclerosis (ALS). However, energy expenditure at rest (REE) is still not included in clinical practice,...

Surgical treatment of esophageal atresia with lower tracheoesophageal fistula in an extremely preterm infant (510 g, 25 + 5 weeks): a case report

BackgroundThe surgical management of esophageal atresia in extreme-low-birth-weight infants (< 1000 g) is challenging. We report on an extreme-low-birth-weight infant who was extremely preterm (510 g, 25 + 5 weeks) and of prenatally unknown Gross type C esophageal atresia.Case presentationAfter resuscitation and intubation, the tracheoesophageal fistula was closed on the first day of life in the neonatal intensive care unit via an extrapleural approach using a titanium clip. On the sixth day of life, the Caucasian child was extubated. To minimize the operative trauma in the initial neonatal period, we prolonged gastrostomy placement until the 22nd day of life (weight 725 g). At the age of 3 months (weight 2510 g), thoracoscopic esophageal anastomosis was performed. The postoperative course was unremarkable. During the further clinical course, eight esophageal dilations were necessary. Currently, the patient swallows without difficulties at the age of 4 years and thrives well [15 kg (Percentile 28); 100 cm (Percentile 24)].ConclusionsOur case shows that minimized postnatal surgical trauma with primary tracheoesophageal fistula closure at the bedside, delayed gastrostomy, and minimally invasive esophageal repair after substantial weight gain (> 2.5 kg) is a good strategy for esophageal atresia/tracheoesophageal fistula in extreme-low-birth-weight infants.

Institutional Variation in Gastrostomy Tube Placement After Duodenal Atresia Repair in Children With Trisomy 21.

To compare institutional practice patterns for gastrostomy tube placement in neonates with duodenal atresia (DA) and trisomy 21. A retrospective review of the Pediatric Health Information System (PHIS) from 2015 to 2018 identified infants <10 days old with ICD-10 diagnostic codes for DA and trisomy 21, in addition to procedure codes for an intestinal bypass or duodenoduodenostomy. This cohort was then queried for gastrostomy tube procedure codes and diagnostic codes for associated co-morbidities. Two hundred and nine infants were identified with DA, trisomy 21, and an intestinal bypass. Fifty-seven (27%) underwent gastrostomy placement. Baseline characteristics of those with and without gastrostomy tubes were similar. Patients from 16 hospitals that placed no gastrostomy tubes (No-G-tube-Hospitals) were compared to children from 30 hospitals that placed at least one gastrostomy tube (G-tube-Hospitals). Open atresia repairs occurred more frequently at G-tube-Hospitals, but patients were otherwise similar. There was no difference in readmission at 12 months for gastrostomy placement between children from No-G-tube-Hospitals and those from G-tube-Hospitals that did not undergo gastrostomy during their index admission. One-third of institutions in this study did not place gastrostomy tubes during index admissions for neonates with trisomy 21 and DA, yet this did not negatively impact the length of stay or incidence of subsequent gastrostomy placement as a result. Future research is needed to determine factors that predispose patients to failure without gastrostomy, as well as best practices for post-operative management in these patients to reduce unnecessary tube placement.