Gastrostomy Tube Placement In Patients Research Articles

Efficacy of enteral feeding by gastrostomy tube placement in patients with Lennox-Gastaut syndrome on body weight and days of hospitalization: A retrospective case series.

Lennox-Gastaut syndrome (LGS) is a severe form of drug-resistant epilepsy that begins during childhood and frequently leads to significant neurological impairments. Patients with LGS are likely to receive improper oral nutrition because of issues such as dysphagia and aspiration risk, potentially resulting in long-term tube feeding and eventual gastrostomy tube placement. Therefore, we investigated the effects of gastrostomy tube placement on nutrition outcomes and frequency of hospitalization in LGS. We retrospectively examined 67 patients diagnosed with LGS who had undergone gastrostomy tube placement between January 2005 and August 2022. Comprehensive clinical data and complications arising from the procedure were collected. Patients' nutrition condition and frequency of hospitalizations were analyzed before and after gastrostomy tube placement. Gastrostomy tube placement was performed for the following reasons: high risk of aspiration (50 out of 67, 74.6%), dysphagia (13 out of 67, 25.4%), persistent nasogastric tube feeding (2 out of 67, 3.0%), and severe malnutrition (2 out of 67, 3.0%). After the procedure, z scores for weight-for-age improved significantly, shifting from -3.35 ± 3.57 to -2.54 ± 2.70 over a 2-year interval (P < 0.001). Additionally, the total days of hospitalization and days of hospitalization due to respiratory symptoms reduced significantly from 41.94 ± 51.76 to 15.27 ± 26.68 (P < 0.001) and from 23.75 ± 36.92 to 10.52 ± 22.98 (P = 0.009), respectively. Among the patients, 50 (74.6%) experienced complications resulting from gastrostomy, with a relatively small proportion of major complications (11 out of 67, 16.4%) and no mortality. Gastrostomy tube placement is a relatively safe procedure with favorable effects on nutrition status and hospitalization rates in patients with LGS.

Nutritional disorders as a predictor of rapid diagnosis and disease progression in patients with amyotrophic lateral sclerosis

Background: One of the symptoms of amyotrophic lateral sclerosis (ALS) is progressive loss of body weight. Moreover, in various forms of ALS, regardless of the presence of dysphagia at the onset of the disease, there are similar changes in nutritional status. The problem of nutritional support in patients with ALS, as well as monitoring nutritional status over time in this group of patients remains relevant. Purpose: to evaluate the severity and rate of increase in nutritional disorders in patients with ALS and their relationship with the rate of disease progression, as well as the life expectancy of these patients. Materials and methods: The study included 49 patients diagnosed with ALS who died from 2018 to 2023. All participants underwent a neurological examination, measurement of anthropometric parameters, and laboratory blood tests; 61 % (n=30) of the patients underwent bioimpedance analysis of body composition over time. Results: The highest rate of body weight loss was recorded in the group of patients with quickly diagnosed ALS: it accounted for 1.9 (1.6; 2.2) kg/month. The highest rate of loss of skeletal muscle mass was noted in the same group of patients at 0.4 (0.38;0.46) kg/month. In the group with a quickly diagnosed disease, only 20 % of the patients underwent gastrostomy insertion; in the group with a slow diagnosis rate, 25 % of the patients underwent gastrostomy; only 50 % of the patients received special therapeutic nutrition. Conclusions: Patients with rapid disease progression have a short period of ALS diagnosis and rapidly increasing nutritional disorders, reflected in higher rates of losing weight and skeletal muscle mass. However, patients with rapid diagnosis of the disease had the lowest level of nutritional support. Lack of time to make the difficult decision to insert a gastrostomy tube and perform the necessary preoperative examination is the main reason for the low rate of gastrostomy tube placement in patients with rapidly progressing disease. In this regard, the development of new measures and algorithms for dynamic monitoring of the nutritional status of patients with ALS, as well as increasing awareness of the need for timely gastrostomy, is required. Bioimpedance analysis of body composition can be one of the methods for monitoring the patient’s nutritional status, allowing one to assess the dynamics of decrease in skeletal muscle mass as the most labile component of body composition in patients with ALS.

Prophylactic vs. Reactive Gastrostomy Tube Placement in Patients Treated with Radiotherapy for Head and Neck Cancer

Radiotherapy (RT) for head and neck cancer (HNC) can cause acute toxicities resulting in weight loss warranting alterative enteral access. Some institutions favor prophylactic gastrostomy tube (GT) placement to prevent malnutrition at the forefront, while others choose to reactively place tubes if nutritional deficits arise. Though prophylactic GT placement may limit on-treatment weight loss, this approach may result in unneeded GT placement and may potentially impact long-term swallowing function. Patients with HNC treated with CRT from 2018-2021 were reviewed. GT placement prior to CRT (prophylactic [ppx] tube) was performed at the discretion of the treating radiation oncologist. The remainder of patients were treated with reactive (rx) GT placement in the event of on-treatment weight loss approaching 10-15%. Patient, disease and treatment factors were abstracted from the medical record. Primary endpoints were placement of GT in the rx group, weight change at the end of RT, and time to tube removal. In total, 278 patients were identified; 35 GT-dependent patients and 22 patients with nasal cavity/paranasal sinus cancers were excluded, yielding 221 for analysis. Baseline factors associated with GT group included age, ECOG, baseline swallowing function, primary site, T and N stage, stage group, and treatment year. Treatment factors associated with GT group were: neck target (bilateral v. unilateral/none), concurrent chemotherapy, and total dose. Of the 118 patients in the rx group, 14 (12%) required rx GT placement during or within 30 days of CRT. RT completion rates were similar between groups (95-96%, p = 1). GT was removed at last follow-up in 57% of patients in both groups (p = 1). Percent on-treatment weight loss was -8.9% (SD 6.7) and -7.2% (SD 6.1) for the ppx and rx groups, respectively (p = 0.04). Median Kaplan-Meier estimate of time to GT removal was 7.7 months (95% CI 6.0-11.3) and did not differ between groups (log-rank p = 0.87). Factors associated with the placement of rx GT include: concurrent chemotherapy (yes 20% vs. No 0%, p.0007) and baseline FOIS (5 or less 40% vs. 6 or more 9%, p = 0.02). T stage, N stage, overall stage, postoperative RT, degree of neck irradiation were not associated. Reactive gastrostomy tube placement in patients treated with chemoradiotherapy for head and neck cancer patients is feasible and results in low rates of gastrostomy tube placement. There are no observed differences in on-treatment weight loss between patients treated using a prophylactic versus reactive approach. No differences in time to gastrostomy tube removal were observed.

Early feeding after percutaneous endoscopic gastrostomy tube placement in patients who require trauma and surgical intensive care: A retrospective cohort study.

Critically ill patients experience interruptions in enteral nutrition (EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy (PEG) tube placement, postprocedure fasting times vary from 1 to 24 h depending on the surgeon's preference. There is no evidence to support delayed feeding (DF) after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with early feeding (EF) after PEG. 150 adult ventilated patients in the trauma and surgical intensive care unit (TSICU) at a level I trauma center underwent PEG placement in March 2015 through May 2018 by one of six surgical intensivists. Retrospective review revealed variable post-PEG fasting practices: one started EN at 1 h, two started at 4 h, two started at 6 h, and one started at 24 h. Time to initiation of EN and complication rates were assessed. Patients were divided into EF (<4) and DF (≥4 h) groups. Median postprocedure fasting time was 5.5 h. The overall complication rate was 3.3%, with a feeding intolerance rate of 0.7% and aspiration rate of 0%. There was no difference in complication rate for EF (3.1%) as compared with DF (3.4%) (odds ratio, 0.92; 95% CI, 0.10-8.52; P = 0.7). Complication rates following PEG placement in ventilated TSICU patients are low and do not change with EF compared with DF. EF is probably safe.

Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks confrontation

Background For children with neurological impairment (NI) and swallowing incoordination feeding gastrostomy is usually required. This procedure may cause or aggravate preexisting gastroesophageal reflux disease (GERD). Fundoplication has been advocated at the time of gastrostomy placement in these patients. The purpose of this study is to evaluate clinical impact and risk-benefit balance of fundoplication and gastrostomy tube placement in patients with NI due to cerebral palsy, Hypoxic ischemic encephalopathy, brain tumors, and Dandy-Walker syndrome. Methods This study is a ten-year retrospective analysis including 180 cases of gastric tube placement in neurologically impaired children performed in a single institution. Results One hundred eighty patients underwent gastrostomy tube (GT)placement (94 open versus 86 laparoscopic). Concomitant fundoplication was performed in 44 cases. Three different types of tube were used during the procedures. There were differences between the two groups in gender but not in age distribution or comorbidity. Fundoplication was laparoscopic in 29 cases (33.7%) and open in 15 (16.0%). Postoperative diarrhea was more frequently observed with the Mickey tube (p=0.008). the hospital stay was longer after Mic tube placement (p=001). Sequelae after gastrostomy tube placement were observed in 21 cases (p=0.015). five postoperative cases of death were noted (p=0.015). The recurrence rate of reflux was 71% and mortality rate was 63% on long term follow-up. Conclusions In this study on NI and swallowing disorder unresponsive to medical treatment, open or laparoscopic fundoplication and gastrostomy reduced nausea and pain after feeding, but not Apparent life-threatening event in infancy (ALTE). Potential increased risk of complications and the procedure results instability may indicate the implementation of new management guidelines. Key words Fundoplication; Gastrostomy; Neurological impairment; Children, Outcome.

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.

Safety of Gastrostomy Tube Placement in Patients with Advanced Amyotrophic Lateral Sclerosis With Noninvasive Ventilation.

In patients with amyotrophic lateral sclerosis (ALS), bulbar muscle dysfunction can occur, which eventually requires the initiation of enteral tube feeding. However, there is no consensus on the optimal timing for the gastrostomy or the proper ventilator support method during the procedure. We aimed to investigate the safe range of gastrostomy according to respiratory support status and forced vital capacity (FVC)% of predicted values classification and to compare the safety of noninvasive and invasive mechanical ventilation during the procedure in ALS patients with FVC < 30% of predicted. A total of 477 patients diagnosed with ALS at our institution from January 1, 2009, to December 31, 2018, were evaluated, and 105 patients were enrolled in this study. All medical records covering ventilation status and complications within 6 months to 1 year after the initial gastrostomy were gathered and reviewed. The gastrostomy procedure was considered safe regardless of FVC status or modality of respiratory support. There were complications related to the gastrostomy procedure in 6 of 105 patients and all were managed through conservative care. The incidence of complications, including respiratory ones, for noninvasive and invasive positive pressure ventilation was 5.5% and 9.6%, respectively, which were not statistically significantly different (P = .294). The procedure and tube placement of a gastrostomy can be safely performed in ALS patients with minimal FVC regardless of ventilation invasiveness. We suggest that there should be a new standard for FVC% of predicted to facilitate performing gastrostomy in ALS patients.

Safety and outcome of gastrostomy tube placement in patients with Loeys-Dietz syndrome

BackgroundLoeys-Dietz syndrome (LDS) is a systemic connective tissue disease (CTD) associated with a predisposition for intestinal inflammation, food allergy, and failure to thrive, often necessitating nutritional supplementation via gastrostomy tube. Poor wound healing has also been observed in in some patients with CTD, potentially increasing the risk of surgical interventions. We undertook to determine the safety and efficacy of gastrostomy tube placement in this population.MethodsWe performed a retrospective cohort study of 10 LDS patients who had a total of 12 gastrostomy tubes placed.ResultsNo procedural complications occurred, although one patient developed buried bumper syndrome in the near post-procedural time period and one patient had a small abscess at a surgical stitch. Most patients exhibited improvements in growth, with a median immediate improvement in BMI Z-score of 0.2 per month following the institution of gastrostomy tube feedings. Those with uncontrolled inflammation due to inflammatory bowel disease or eosinophilic gastrointestinal disease showed the least benefit and in some cases failed to demonstrate significant weight gain despite nutritional supplementation.ConclusionsGastrostomy tube placement (surgical or endoscopic) is a generally safe and a reasonable therapeutic option for patients with LDS despite their underlying CTD.

3:09 PM Abstract No. 219 Feasibility of percutaneous gastrostomy tube placement in patients with neuromuscular dysfunction using only local anesthesia

3:09 PM Abstract No. 219 Feasibility of percutaneous gastrostomy tube placement in patients with neuromuscular dysfunction using only local anesthesia

Percutaneous Endoscopic Gastrostomy Tube Placement in Patients with Head and Neck Cancer Treated with Radiotherapy.

Background and aimThe primary aim of our study was to evaluate percutaneous endoscopic gastrostomy (PEG) tube placement depending on body weight and body mass index in patients undergoing radiotherapy (RT) for head and neck cancer (HNC). A secondary aim was to evaluate the course of weight change following PEG placement.MethodsWe retrospectively reviewed the medical records of 186 patients with HNC undergoing radiotherapy (RT) or chemoradiotherapy (CRT) at our institution between January 2010 and August 2017. Initial weight and nutritional intake were analyzed prior to RT initiation and then followed throughout treatment until completion. Based on these data, the indication of PEG placement was determined. Medical records were also reviewed to analyze PEG-related acute toxicities.ResultsA total of 186 patients met inclusion criteria. Patients were most commonly male (n=123, 66.1%) with squamous cell carcinoma (n=164, 88.2%). Patients who had dysphagia prior to treatment initiation as well as patients with a BMI <18.5 kg/m2 needed PEG placement earlier during the treatment course. Low-grade toxicities related to PEG insertion were observed in 10.7% patients, with peristomal pain and redness adjacent to the PEG tube insertion site being most common. High-grade toxicities, such as peritonitis and organ injury, were found in 4.9% of patients.ConclusionUnderweight patients and those with preexisting dysphagia should be closely screened during RT for weight loss and decreased oral intake. For weight loss greater than 4.5% during the treatment of HNC, early PEG-tube placement should be considered. Further prospective studies are needed to confirm these findings, and delineate a scoring system for timing of PEG use (prophylactic vs reactive) as well as assess the quality of life in patients with HNC who receive PEG placement.

2950 Gastrostomy Tube Placement in Patients With Ascites: A National Inpatient Sample Analysis

INTRODUCTION: As the treatment of liver diseases progress, patients with cirrhosis are living longer, and physicians are facing an increasing need for gastric feeding tube placement to provide enteral nutritional support to these patients. Cirrhotic patients are usually considered as a poor surgical risk candidates, making a surgically placed gastrostomy tube an undesirable option; thus, percutaneous endoscopic gastrostomy (PEG) is often considered to an alternate route to provide enteral nutrition. Cirrhotic patients with portal hypertension often have varices or ascites and are inherently more prone to procedural complications. There is limited data on the safety of the gastrostomy tube in patients with ascites. The aim of our study is to assess the outcomes of gastrostomy tube placement in patients with ascites. METHODS: We conducted a retrospective review of patients with ascites who underwent gastrostomy tube placement using the largest all-payer database, national inpatient sample (NIS) from 2007-2014 using validated ICD-9 codes. Primary and secondary outcomes included in-patient mortality, length of stay (LOS) and total hospital charges, respectively. We adjusted for confounding factors including age, gender, insurance, zip income, and hospital size and location by using multivariate regression. RESULTS: Out of total 2,603,539 hospitalizations for adult patients with ascites, 29,001 patients underwent gastrostomy tube on that hospitalization. Mean age of patients with ascites with gastrostomy 64 ± 2 years with male predominance (55% vs. 45%). The patients with ascites who had gastrostomy tube placed were more likely to die in the hospital (adjusted OR 1.84; 95% CI 1.7-1.9, P = 0.00) as compared to ascites patients without gastrostomy tube. Also, we found a significant increase in mean LOS (28.83 days vs 8.34 days) and mean total charges ($277,404.5 vs $71,874.73). CONCLUSION: Our study is the largest evaluation to date of cirrhotic patients who have undergone PEG. This study suggests that patients with ascites who undergo gastrostomy tube placement have increased mortality, length of stay, and hospital charges. The results of this study point towards caution for the use of PEG in patients with ascites.

Fluoroscopic and Endoscopic Gastrostomy Tube Placement: Regional Variation and Their Prevalence

Abstract Objective This study aims to assess the regional variation and overall longitudinal prevalence of approaches to gastrostomy tube placement in patients covered by Medicare or Medicaid. Background Gastrostomy tubes are most commonly inserted endoscopically given the approaches’ demonstrated safety, success, and patient outcomes as compared with laparoscopic approaches. Recently, the growth of interventional radiology services has provided patients with an alternative percutaneous approach. The safety and efficacy of this approach as opposed to endoscopic approaches has yet to be determined. Methods From 2005 to 2014, Medicare Standard Analytic Files derived from Medicare parts A and B, which contain 100% of inpatient and outpatient facility records billed to Medicare, were retrospectively analyzed. Age, sex, year of placement, region, comparative quarterly ratio, regional cost variation, and overall financial cost were compared between both cohorts. Results Our population included a total of 336,021 patients; of those, 30,327 patients underwent fluoroscopic guided procedures, and 305,694 patients underwent endoscopic procedures. Age (p &lt; 0.001), region (p = 0.043), and year of placement (p &lt; 0.001) varied significantly between these populations. Fluoroscopic-guided procedures were found to have a statistically significantly lower average cost of treatment compared with endoscopic gastrostomies ($2,018.62 vs. $2,471.33, respectively, p = 0.03). Conclusion This study demonstrates an increasing prevalence of fluoroscopically placed gastrostomy tubes as compared with those placed endoscopically.

Image-Guided Percutaneous Gastrostomy Tube Placement is Safe in Patients Requiring Aspirin 325 mg

Requests for gastrostomy tube placement in patients on aspirin (ASA) 325 mg are common, particularly in patients following reconstructive surgery for head and neck cancer, but periprocedural guidelines and recommendations regarding management of high dose aspirin are inconsistent. The purpose of this study was to assess the bleeding risk of percutaneous gastrostomy tube placement in patients on ASA 325 mg. This retrospective study of 213 patients who underwent image-guided "push" percutaneous gastrostomy tube placement compared rates of significant bleeding and other secondary outcomes (including all-cause mortality within 30 days, procedure-related mortality, bowel perforation, abdominal abscess, peritonitis, aspiration pneumonia, intraprocedural airway complications, and tube dislodgement) between patients maintained on ASA 325 mg and patients not on antiplatelet or anticoagulation therapy. No significant bleeding episodes occurred in patients on ASA 325 mg, compared to three episodes in patients not on ASA 325 mg (p = 0.37). A patient in each group had aspiration pneumonia possibly related to tube placement. There were no other notable secondary outcomes, including intraprocedural airway complications in this population with complex head and neck anatomy. These findings suggest that holding ASA 325 mg in patients undergoing percutaneous gastrostomy tube placement is not necessary, especially in patients in whom holding ASA would pose considerable risk. Further multi-institutional longitudinal study is warranted to validate these results.

03:27 PM Abstract No. 309 Safety and feasibility of percutaneous gastrostomy tube placement on patients receiving antiplatelet therapy after cerebral vascular accident

Dysphagia occurs in 50% of patients following a cerebrovascular accident (CVA), which can lead to aspiration and pulmonary complications. Gastrostomy tubes are often placed in the interventional radiology department to mitigate these complications. However, following a CVA, patients are routinely treated with antiplatelet therapy (APT) to prevent further thromboembolic events. This study aims to identify the safety and feasibility of performing gastrostomy tube placement in patients on APT. Retrospective analysis was performed on 154 consecutive patients following gastrostomy tube placement from August 2017 to August 2018. Demographics, procedure indication, APT regimen, and gastrostomy tube type (push vs pull) were compared with short-term outcomes. Complications were categorized based on SIR Clinical Practice Guidelines. CVA was the indication in 102 patients. Of the 154 gastrostomy tubes, 72 were performed while on APT (31 on dual antiplatelet therapy). Gastrostomy tube placement was successful in all patients. Of the 154 patients receiving gastrostomy tube placement, a total of 12 complications were observed (10 minor complications and 2 major complications). Bleeding-specific complications occurred in 6 patients (4 minor/2 major). The most common complication was minimal bleeding around the incision site (n=4). Both major bleeding complications occurred in patients not receiving APT. No difference in complication rate was noted based on indication (p=0.17), gastrostomy tube type (p=0.21), single APT (p=0.42), or DAPT (p=0.26). In the CVA cohort, no difference in complication rate was identified between gastrostomy tube type (p=0.29), ASA use (p=0.96), Plavix use (p=0.69), single APT (p=0.24), or DAPT (p=0.45). Of the 6 bleeding-specific complications, recent CVA was associated with increased risk (6% vs 0%, p=0.01). However, no difference in bleeding rate complications were present in patients on DAPT (6.5% vs 3.3%, p=0.44) or single APT (0% vs 5.3%, p=0.14). Antiplatelet therapy can be safely maintained in patients following recent CVA for gastrostomy tube placement without increased risk of bleeding.

Perioperative management of gastrostomy tube placement in Duchenne muscular dystrophy adolescent and young adult patients: A role for a perioperative surgical home.

In past decades, Duchenne muscular dystrophy patients have been living longer and as the disease advances, patients experience multisystemic deterioration. Older patients often require gastrostomy tube placement for nutritional support. For optimizing the perioperative care, a practice of multidisciplinary team can better anticipate, prevent, and manage possible complications and reduce the overall perioperative morbidity and mortality. The aim of this study was to review our experience with perioperative care of adolescent and young adults with Duchenne muscular dystrophy undergoing gastrostomy by various surgical approaches in order to identify challenges and improve future perioperative care coordination to reduce morbidity. We retrospectively examined cases of gastrostomy tube placement in patients of ages 15years and older between 2005 and 2016. We reviewed preoperative evaluation, anesthetic and surgical management, and postoperative complications. Twelve patients were identified; 1 had open gastrostomy, 3 laparoscopic gastrostomies, 5 percutaneous endoscopic guided, and 3 radiologically inserted gastrostomy tubes. All patients had preoperative cardiac evaluation with 6 patients demonstrating cardiomyopathy. Nine patients had preoperative pulmonary consultations and the pulmonary function tests reported forced vital capacity of ≤36% of predicted. Eight patients were noninvasive positive pressure ventilation dependent. General anesthesia with tracheal intubation was administered in 8 patients, and intravenous sedation in 4 patients; 1 received sedation supplemented with regional anesthesia and 3 received deep sedation. One patient had a difficult intubation that resulted in trauma and prolonged tracheal intubation. Three patients developed postoperative respiratory complications. Two patients' procedures were postponed due to inadequate preoperative evaluation and 1 because of disagreement between anesthesia and procedural services as to the optimal approach for airway management. Optimal management of the perioperative care of Duchenne muscular dystrophy patients requires input from relevant medical specialists, proceduralist and anesthesiologist. This complexity of care coordination presents an opportunity for anesthesiologists to lead a collaborative perioperative team in management of advanced Duchenne patients coming for gastrostomy.

P.059 Predictors of gastrostomy tube placement in patients with dysphagia after acute stroke

Background: In patients with acute stroke, nasogastric (NG) tubes are commonly inserted for feeding when dysphagia is identified, and percutaneous endoscopic gastrostomy (PEG) tubes are placed for severe or persistent dysphagia. However, little is known regarding predictors of PEG insertion. Methods: We used the Ontario stroke registry from 2003-2013 to identify baseline characteristics of all patients with NG or PEG tube insertion after stroke. We used multiple logistic regression with backwards selection to determine variables that were independent predictors of PEG tube insertion during admission. Results: 4002 patients with NG and 1903 patients with PEG were included in the analysis. Independent predictors of PEG were: Age (80+ vs. &lt;60; odds ratio [OR] 1.70), past history of stroke (OR 1.17), higher stroke severity (severe vs. mild stroke; OR 1.37), stroke unit admission (OR 1.46), and dysphagia screening (OR 1.52). Factors associated with reduced odds of PEG insertion were: Prior history of peptic ulcer disease (OR 0.70), prior independence (OR 0.78), dementia (OR 0.76), palliative status (OR 0.49), and thrombolysis (OR 0.66). *All p&lt;0.01 Conclusions: The strongest predictors of PEG were older age, higher stroke severity, stroke unit admission and dysphagia screening. Patients with dementia had reduced odds of PEG. Thrombolysis also reduced odds of PEG and may be protective.

GP.03 Outcomes after gastrostomy tube placement in patients with acute stroke: A 10-year population-based study using the Ontario Stroke Registry

Background: Dysphagia is a common and devastating complication after acute stroke. Percutaneous endoscopic gastrostomy (PEG) tubes are often placed for persistent dysphagia. However, little is known regarding outcomes after PEG tube placement. Methods: We used a 10-year Ontario Stroke Registry to shed light on the clinical outcomes of patients with PEG tube insertion after ischemic stroke or intracranial hemorrhage compared to patients with only NG tubes, including rate of pneumonia, disability, and mortality. Results: Using propensity score matching, 1,793 patients were successfully matched and had similar baseline characteristics. Compared with NG, patients with PEG had a higher rate of pneumonia (32.6% vs. 20.6%; RR 1.59), higher disability at discharge (modified Rankin Scale Score 3-5; 74.0% vs. 65.4%; RR 1.13), and higher rate of long-term care placement (27.1% vs. 9.3%; RR 2.9). &gt;From stroke onset, there was a lower rate of death in patients with PEG compared to NG at 30 days (15.3% vs. 34.3%; RR 0.45) but no difference at 2 years (52.8% vs. 53.5%; RR 0.99, p=0.71). *All significant p &lt;0.0001. Conclusions: In conclusion, PEG tube placement after stroke may prolong survival in patients with poor outcomes. Our study provides a framework for discussions between physicians, patients, and families with regards to expected prognosis after PEG tube placement.

Safety of percutaneous endoscopic gastrostomy tube placement in patients with continuous-flow ventricular assist devices

In this retrospective study, the safety of percutaneous endoscopic gastrostomy (PEG) tube placement was evaluated as maintaining adequate nutritional support for patients with left ventricular assist devices is crucial. Nineteen...

Clinical Ethics and Nutrition Support Practice: Implications for Practice Change and Curriculum Development

Clinical ethics awareness involving nutrition support has increased during the past 4 decades because of media attention and public discussion of several landmark cases, including Karen Ann Quinlan, Nancy Beth Cruzan, and Theresa Marie Schiavo, and the results of subsequent court decisions. 1 Schwartz D.B. Ethical considerations in the critically ill patient. in: Cresci G. Nutritional Therapy for the Critically Ill Patient: A Guide to Practice. 2nd ed. Taylor & Francis, Boca Raton, FL2015: 635-652 Crossref Google Scholar Yet decisions to start or stop nutrition support for specific individuals remain challenging. Withholding or withdrawing nutrition support is appropriate if the risks and burdens outweigh the potential benefits as perceived by the informed individual, family, or surrogate decision maker. Despite advancements in the field of nutrition support practice, a practice gap remains between appropriate use of nutrition support and other advanced life-sustaining treatments, such as mechanical ventilation and cardiopulmonary resuscitation, based on the individual’s wishes. 2 Geppert C.M.A. Barrocas A. Schwartz D.B. Ethics and law. in: Mueller C. McClave S.A. Schwartz D.B. Kovacevich D. Miller S.J. The A.S.P.E.N. Adult Nutrition Support Core Curriculum. 2nd ed. American Society for Parenteral and Enteral Nutrition, Springfield, MD2012: 656-676 Google Scholar , 3 Raijmakers N.J.H. van Zuylen L. Costantini M. et al. on behalf of OPCARE9Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol. 2011; 22: 1478-1486 Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar , 4 Teno J.M. Gozalo P.L. Bynum J.P.W. et al. Change in end-of-life care for beneficiaries. JAMA. 2013; 309: 470-477 Crossref PubMed Scopus (753) Google Scholar , 5 Schwartz D.B. Barrocas A. Wesley J.R. et al. A.S.P.E.N. Special report: Gastrostomy tube placement in patients with advanced dementia or near end of life. Nutr Clinc Pract. 2014; 29: 829-840 Crossref PubMed Scopus (35) Google Scholar , 6 Institute of Medicine. Dying in America Improving Quality and Honoring Individual Preferences Near the End of Life, Key Findings and Recommendations. https://iom.nationalacademies.org/∼/media/Files/Report%20Files/2014/EOL/Key%20Findings%20and%20Recommendations.pdf. Published 2014. Accessed October 26, 2015. Google Scholar

Radiologic Percutaneous Gastrostomy in Nondistended Stomach: A Modified Approach.

Gastrostomy tube placement for patients requiring long-term nutritional support may be performed using different techniques including endoscopic, surgical, and percutaneous radiologically guided methods. Radiologically inserted gastrostomy (RIG), typically performed when percutaneous endoscopic gastrostomy is not possible, requires proper gastric distension that is achieved by insufflating air through a nasogastric tube. We describe a simple technique to prevent air escape from the stomach during gastrostomy tube placement. To the best of our knowledge, this technique has not yet been described in the literature. Four patients with unsuccessful percutaneous endoscopic gastrostomy were referred for fluoroscopic-guided gastrostomy. One patient had a pyriform sinus tumor and three had an ischemic stroke causing dysphagia. Gastric distention was not achieved in the patients due to air escaping into the bowel during the standard RIG procedure. A modified approach using a balloon catheter inflated in the pylorus to avoid air passing into the duodenum permitted successful RIG. The modified RIG procedure was successfully carried out in all cases without complications. Inadequate air distension of the stomach is an unusual event that causes a failure of gastrostomy tube placement and an increased risk of both major and minor complications. The use of a balloon catheter inflated in the first part of the duodenum prevents the air passage into the bowel allowing the correct positioning of the gastrostomy.