Percutaneous Endoscopic Gastrostomy Research Articles

Thirst Distress in Palliative Care Patients.

Objective: It has been reported that chronically critical patients and patients at high risk of death have moderate to high levels of thirst distress. It was planned as a descriptive and cross-sectional study to determine thirst distress in palliative care patients. Methods: A Patient Information Form, the Thirst Severity Form, and the Thirst Distress Scale were used for data collection. The research was carried out between March 2023 and July 2023 with 157 patients hospitalized in the palliative care services of a state hospital and a training and research hospital in Istanbul, Turkey. Results: Of the patients, 51.6% were female. The mean thirst distress score of the patients was 23.96 ± 5.096. Of the patients, 0.6% had no thirst distress; 7.6% had mild, 48.4% had moderate, 38.9% had high, and 4.5% had severe thirst distress. Thirst scores of patients who were illiterate and did not smoke or drink alcohol were high (P < .05). The thirst distress score of patients fed with percutaneous endoscopic gastrostomy was higher than that of patients fed with total parenteral nutrition. There was a positive weak correlation between age and thirst distress score, a negative very weak correlation between fluid balance and thirst distress score, and a positive moderate correlation between Visual Analog Scale and thirst distress. Conclusion: Thirst distress was found to be at moderate and high levels in palliative care patients. In patients, thirst should be routinely assessed, and necessary interventions should be planned.

Improvement of glycemic control after initiation of enteral nutrition through percutaneous endoscopic gastrostomy (PEG)

Improvement of glycemic control after initiation of enteral nutrition through percutaneous endoscopic gastrostomy (PEG)

The principles of enhanced recovery after percutaneous endoscopic gastrostomy (ERaPEG): a UK tertiary center experience.

Enhanced recovery after surgery (ERAS) pathways have been shown to improve surgical outcomes and patient satisfaction. The aim of the study was to assess whether the implementation of a perioperative enhanced recovery after percutaneous endoscopic gastrostomy (ERaPEG) pathway based on ERAS principles was safe, satisfactory to parents and improved outcomes. Following a quality improvement project, a multimodal ERaPEG pathway was introduced as standard practice within the department and children undergoing elective same-day admission percutaneous endoscopic gastrostomy (PEG) at a single UK tertiary center were prospectively enrolled. Exclusion criteria were patients undergoing other concurrent procedures and those who underwent a laparoscopic assisted/open procedure. Data included patient demographics, underlying diagnosis, indication, length of stay (LOS) and 30-day readmission. Parental experience and satisfaction were determined using a questionnaire including 5-point Likert scales. A retrospective cohort was used for comparison. Data were analyzed using Chi-Square test and Mann-Whitney U tests. Ninety-five patients met the inclusion criteria: 50 pre and 45 post the implementation of ERaPEG. Median age was 3 and 2years, respectively. Neurodisability was the underlying diagnosis in most patients (84%-pre-ERaPEG; 76%-post-ERaPEG). Most common PEG indication was medication/nutritional supplementation (52%-pre-ERaPEG; 51%-post-ERaPEG). The LOS significantly decreased from a median of 51.5h (pre-ERaPEG) to 32h (post-ERaPEG) (p < 0.001). Thirty-day readmission rates were similar (6% vs 11%). Most parents felt that the educational material was easy to access and understand. Post-operatively the majority of parents (≥ 80%) were confident in managing the gastrostomy device, setting up/giving the feeds and also felt that the LOS was appropriate. This study shows that the implementation of an ERaPEG pathway significantly reduced LOS following PEG. In addition, the pathway was satisfactory to parents and offered the benefit of improved resource utilization.

The impact of radiation therapy in patients with systemic sclerosis and head and neck cancer

ObjectiveSystemic sclerosis (SSc) is considered a relative, or in some cases, absolute contraindication for radiation therapy for various cancers; however, radiation is standard of care and the best option for tumor control for locally advanced head and neck (H&N) cancer. We present a case series to document the post-radiation outcomes in patients with SSc and H&N cancer. MethodsPatients with SSc and H&N cancer treated with radiation were identified from two large Scleroderma Center research registries. Through chart review, we identified whether patients developed pre-determined acute and late side effects or changes in SSc activity from radiation. We further describe therapies used to prevent and treat radiation-induced fibrosis. ResultsThirteen patients with SSc who received radiation therapy for H&N cancer were included. Five-year survival was 54%. Nine patients (69%) developed local radiation-induced skin thickening and seven (54%) developed reduced neck range of motion. Two patients required long-term percutaneous endoscopic gastrostomy use due to radiation therapy complications. No patients required respiratory support related to radiation therapy. Regarding SSc disease activity among the patients with established SSc prior to radiation therapy, none experienced interstitial lung disease progression in the post-radiation period. Following radiation, one patient had worsening skin disease outside the radiation field, however, this patient was within the first year of SSc when progressive skin disease is expected. Treatment strategies to prevent radiation fibrosis included pentoxifylline, amifostine and vitamin E, while intravenous immunoglobulin (IVIG) was used to treat it. ConclusionWhile some patients with SSc who received radiation for H&N cancer developed localized skin thickening and reduced neck range of motion, systemic flares of SSc were uncommon. This observational study provides evidence to support the use of radiation therapy for H&N cancer in patients with SSc when radiation is the best treatment option.

Percutaneous Endoscopic Gastrostomy Goals of Care Conversations with Hospitalized Patients after Severe Stroke

Percutaneous Endoscopic Gastrostomy Goals of Care Conversations with Hospitalized Patients after Severe Stroke

Why People Still Choose PEG Tube at End of Life-Do Religion, Culture, Race, or Ethnicity Play a Role?

Why People Still Choose PEG Tube at End of Life-Do Religion, Culture, Race, or Ethnicity Play a Role?

Modified Frailty Index Associates With Transoral Robotic Surgery Complications and Survival: A National Database Study.

The modified frailty index (mFI-5) is a National Surgical Quality Improvement Program-derived 5-factor index that has been proven to reflect frailty and predict morbidity and mortality. We hypothesize that mFI-5 is a valid predictive measure in the transoral robotic surgery (TORS) population. Retrospective study utilizing the TriNetX US-collaborative health records network querying for TORS patients. Cohorts were stratified by mFI-5 score which uses five ICD-10 codes: nonindependent functional status, hypertension, obstructive respiratory disease, heart failure, and diabetes mellitus. Cohorts were matched by age using propensity score matching. Outcome measures included survival, infection, pneumonia, tracheostomy dependence, and percutaneous endoscopic gastrostomy dependence. Reported odds ratios were normalized to mFI-5 = 0. A total of 9,081 patients were included in the final analysis. Greater mFI-5 scores predicted decreased survival and increased incidence of postoperative infection and pneumonia. Odds of 5-year mortality were 1.93 (p = 0.0003) for mFI-5 = 2 and 1.90 (p = 0.0002) for mFI-5 = 3. Odds of 2-year mortality were 1.25 (p = 0.0125) for mFI-5 = 1, 1.58 (p = 0.0002) for mFI-5 = 2, and 1.87 (p = 0.003) for mFI-5 = 3. Odds of postoperative infection were 1.51 (p = 0.02) for mFI-5 = 2 and 1.78 (p = 0.05) for mFI-5 = 3. Two-year odds of developing pneumonia were 1.69 (p = 0.0001) for mFI-5 = 2 and 2.84 (p < 0.0001) for mFI-5 = 3. Two-month odds of pneumonia were 1.50 (p = 0.0259) for mFI-5 = 2 and 2.55 (p = 0.0037) for mFI-5 = 3. mFI-5 = 4 or 5 had too few patients to analyze. Using polynomial regression to model age versus incident 5-year post-TORS death (R2 = 0.99), mFI-5 scores better predicted survival than age alone. This study demonstrates that mFI-5 predicts mortality, pneumonia, and postoperative infection independently of age. 4 Laryngoscope, 2024.

The Arabic EAT-10 and FEES in dysphagia screening among cancer patients: a comparative prospective study.

Head and neck cancer treatments, such as radiotherapy, chemotherapy, and surgery, have diverse effects on patients, leading to dysphagia as a significant post-treatment issue. This study aims to evaluate the effectiveness of the Arabic version of the EAT-10 screening instrument (A-EAT-10) using Fiber-Optic Endoscopic Evaluation of Swallowing (FEES) as an imperfect gold standard. Additionally, we seek to establish a correlation between A-EAT-10 and PEG tube insertion in head and neck cancer (HNC) patients. Our sample comprised 130 head and neck cancer patients with varying cancer types at King Hussein Cancer Center (KHCC). We followed these patients throughout their distinct treatment plans up to one month after their final treatment session. During follow-up visits, we administered the A-Eat-10 instrument to monitor dysphagia. FEES were conducted at the initial and concluding visits to compare results with A-EAT-10 scores. The results in our tests, assuming independence or dependence, demonstrated excellent agreement. A-EAT-10 exhibited outstanding predictive capabilities with an AUC ranging from 93 to 97%. A-EAT-10 tended to slightly overestimate dysphagia at later treatment stages by approximately 20% compared to FEES, with an RR of 1.2 (95% CI 0.91, 1.56, p-value = 0.21), indicating statistical insignificance. In conclusion, A-EAT-10 is an excellent option for dysphagia evaluation, offering non-invasive, straightforward, and cost-effective advantages compared to FEES. Its utility extends to predicting the need for PEG tube insertion at initial patient visits, making it a valuable tool for informed treatment decisions. Notably, A-EAT-10 demonstrates a diminishing correlation with FEES over time.

Dysphagia in Ischaemic Stroke Patients: One Centre Retrospective Study.

The aim of this study was to examine the frequency of dysphagia in patients with ischaemic stroke. It was crucial to evaluate the relationship between swallowing disorders and selected demographic and clinical indicators. Additionally, the association between various patient feeding methods and selected demographic and clinical factors was assessed. Based on the analysis of medical documentation, we identified the most important clinical parameters, including demographic data, the frequency of stroke risk factors, the location of the ischaemic lesion, cortical involvement, stroke severity as measured by the NIHSS (Nationale Institutes of Health Stroke Scale), and the methods of feeding post-stroke patients. Dysphagia was observed in 65.9% of the patients in the study group. Hypertension was the most common chronic illness in the studied population of ischemic stroke patients (91.8% of patients). Diet modification (35.7%) and PEG (25%) were the frequent methods of feeding in patients with confirmed dysphagia. Age played a significant role in determining the feeding methods in patients with dysphagia. Patients with a PEG (Percutaneous Endoscopic Gastrostomy) tube were the oldest (79.37 ± 10.80) and 75% of them had pneumonia. Early identification of swallowing difficulties in stroke patients is critical in determining an appropriate and safe feeding plan, as well as initiating logopedics therapy to improve swallowing efficacy and minimize pulmonary complications.

Spontaneous duodenocutaneous fistula: a rare presentation of perforated duodenal ulcer

Abstract Objectives Fistula formation between the duodenum and the skin of the anterior abdominal wall is a rare complication and reported most often following surgery. To the best of our knowledge, the development of a spontaneous duodenocutaneous fistula in association with duodenal ulcer has only been reported once. Case presentation A 52-year-old female patient presented at the emergency department with a painful ulcer and erythema on the right abdominal wall. On admission, she was in extremely poor general and nutritional condition. Laboratory analysis revealed inflammation. An empiric antibiotic therapy was initiated; parenteral nutrition, fluid, and electrolyte resuscitation were started. An enterocutaneous fistula was postulated and confirmed by endoscopy identifying a perforated duodenal ulcer. Surgery was not a valuable option and a Foley catheter was inserted through the fistula. During further endoscopic interventions, the Foley catheter was first replaced by a jejunal tube and later by a percutaneous endoscopic gastrostomy with a jejunal limb for enteral nutrition. The fistula output decreased, the local infection was controlled and the nutritional status improved. Conclusions Three months later the fistula was closed and the gastrostomy tube was removed. After 2 years the patient was in good general and nutritional condition.

Effect of Percutaneous Endoscopic Gastrostomy Tube Placement on Confusion/Delirium in Stroke Patients with Dysphagia (P7-5.007)

Effect of Percutaneous Endoscopic Gastrostomy Tube Placement on Confusion/Delirium in Stroke Patients with Dysphagia (P7-5.007)

Supplemental tube feeding: qualitative study of patient perspectives in advanced pancreatic cancer

ObjectivesMalnutrition is associated with poor quality of life and survival outcomes for patients with cancer, but is challenging to prevent or treat in pancreatic cancer due to the multifactorial drivers...

Oncological and functional outcome after laryngectomy for laryngeal and hypopharyngeal cancer: a population-based analysis in Germany from 2001 to 2020

Prognostic factors for overall survival (OS), percutaneous endoscopic gastrostomy (PEG) dependency, and long-term speech rehabilitation via voice prosthesis (VP) after laryngectomy for laryngeal or hypopharyngeal cancer were investigated in a retrospective population-based study in Thuringia, Germany. A total of 617 patients (68.7% larynx; hypopharynx; 31.3%; 93.7% men; median age 62 years; 66.0% stage IV) from 2001 to 2020 were included. Kaplan–Meier and Cox multivariable regression analyses were performed. 23.7% of patients received a PEG. 74.7% received a VP. Median OS was 131 months. Independent factors for lower OS were stage IV (compared to stage II; hazard ratio [HR] = 3.455; confidence interval [CI] 1.395–8.556) and laryngectomy for a recurrent disease (HR = 1.550; CI 1.078–2.228). Median time to PEG removal was 7 months. Prior partial surgery before laryngectomy showed a tendency for independent association for later PEG removal (HR = 1.959; CI 0.921–4.167). Postoperative aspiration needing treatment was an independent risk factor (HR = 2.679; CI 1.001–7.167) for later definitive VP removal. Laryngectomy continuously plays an important role in a curative daily routine treatment setting of advanced laryngeal or hypopharyngeal cancer in Germany. Long-term dependency on nutrition via PEG is an important issue, whereas use of VP is a stable long-term measure for voice rehabilitation.

Health Factors Associated With Development and Severity of Poststroke Dysphagia: An Epidemiological Investigation.

Dysphagia after stroke is common and can impact morbidity and death. The purpose of this population-based study was to determine specific epidemiological and health risk factors that impact development of dysphagia after acute stroke. Ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review from the GCNKSS (Greater Cincinnati Northern Kentucky Stroke Study), a representative sample of ≈1.3 million adults from southwestern Ohio and northern Kentucky. Dysphagia status was determined on the basis of clinical assessments and necessity for alternative access to nutrition via nasogastric or percutaneous endoscopic gastrostomy tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and premorbid conditions. Multivariable logistic regression determined factors associated with increased risk of dysphagia. Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed that increased age, Black race, higher National Institutes of Health Stroke Scale score at admission, having a hemorrhagic stroke (versus infarct), and right hemispheric stroke increased the risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower prestroke modified Rankin Scale score, and white matter disease. This study replicated previous findings of variables associated with dysphagia (older age, worse stroke, right-sided hemorrhagic lesions), whereas other variables identified were without clear biological rationale (eg, Black race, history of high cholesterol, and presence of white matter disease) and should be investigated in future studies to determine biological relevance and potential influence in stroke recovery.

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

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

Choosing Optimal Feeding Method in Head–Neck Cancer Patients Receiving Radiation: Percutaneous Endoscopic Gastrostomy Versus Nasogastric Tube—Is It Pertinent?

The current standard of care for locally-advanced head–neck cancer is multidisciplinary, using bimodality or trimodality therapy as appropriate. These patients are frequently malnourished either due to disease or due to treatment related toxicities. Both chemotherapy and radiotherapy are associated with acute and late toxicities which in turn exacerbate malnutrition in these patients. Malnutrition is found to be associated with poor survival outcomes. To maintain nutrition in such patients, enteral feeding can be done using either percutaneous endoscopic gastrostomy tube (PEG) or a nasogastric tube (NGT). Both PEG and NGT have been found effective in adequate maintenance of weight; however, both have their own set of advantages and disadvantages. Nutritional counselling forms an integral part of weight management during treatment and oral feeding should be encouraged in all unless contra-indicated.

[Chinese expert consensus on clinical application of percutaneous endoscopic gastrostomy / jejunostomy (2024 edition)].

Percutaneous endoscopic gastrostomy / jejunostomy (PEG/J) is a relatively safe and effective minimally invasive surgical approach to establish long-term enteral nutrition (EN) channels. Due to the good compliance and the reduced incidence of reflux and aspiration pneumonia, PEG/J is the preferred way for long-term EN and has been widely used in clinical applications. However, few technical guidelines or expert consensus guiding the clinical practice of PEG/J have been published. The formation of "Chinese expert consensus on clinical application of percutaneous endoscopic gastrostomy / jejunostomy (2024 edition)" is led by the Committee of Parenteral and Enteral Nutrition, Chinese Research Hospital Association. This consensus is based on the latest clinical evidence as well as the clinical experience of Chinese experts. This consensus is divided into PEG/J indications and contraindication, perioperative management, operational techniques, prevention, and treatment of related complications and other issues. All recommendations and their strengths were carried out by expert-voting method and presented as the basic framework of "Recommended Opinions (level of evidence and strength of recommendation) and Summary of Evidence". This consensus is registered on the International Practice Guide Registration Platform (IPGRP-2022CN329).

Dysphagia Assessments as Criteria in the 'Decision-Making Process' for Percutaneous Endoscopic Gastrostomy Placement in People with Amyotrophic Lateral Sclerosis: A Systematic Review.

To review the assessment methods of dysphagia as a criterion for the decision-making process for Percutaneous Endoscopic Gastrostomy (PEG) placement in patients with Amyotrophic Lateral Sclerosis (ALS). Systematic review. A search was conducted in three databases (EMBASE, CINAHL, PUBMED) in December 2022 and updated in July 2023. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools. Systematic review registration number in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42022385461. The searches identified 240 records. The 10 eligible studies included 2 case reports, 4 retrospective studies, 3 prospective studies, and 1 cohort observational study. Study quality was low, with most studies having moderate to high risk of bias. Dysphagia is a common criterion for decision-making. Dysphagia assessment is usually in the form of either self-reports, objective instrumental assessments, or both. Dysphagia is a common criterion for the decision-making process, yet is missing in clinical guidelines. Establishing the optimal means of dysphagia assessment is important for timely decision-making procedures, so that life-threatening consequences of dysphagia are minimized.

Speech and Language Development, Hearing, and Feeding in Patients With Genetically Confirmed Crouzon Syndrome With Acanthosis Nigricans: A 36-Year Longitudinal Retrospective Review of Patients at the Oxford Craniofacial Unit.

Crouzon syndrome with acanthosis nigricans (CAN) is caused by the specific mutation c.1172C>A (p.Ala391Glu) in the fibroblast growth factor receptor 3 gene, and has an estimated prevalence of 1:1,000,000 births. Most cases occur de novo; however, autosomal dominant inheritance may occur. The clinical presentation typically includes craniosynostosis, midface and maxillary hypoplasia, choanal atresia/stenosis, hydrocephalus, and intracranial hypertension. Patients develop acanthosis nigricans, a hyperkeratotic skin disorder. The authors present the first known study to investigate the speech, language, hearing, and feeding of patients with CAN. A retrospective case-note review of patients with a genetically confirmed diagnosis of CAN attending the Oxford Craniofacial Unit during a 36-year period (1987-2023) was undertaken. Participants were 6 patients with genetically-confirmed CAN (5 females, 1 male), all cases arose de novo. All patients had craniosynostosis (n = 5/6 multisuture synostosis, n = 1/6 left unicoronal synostosis). Hydrocephalus was managed through ventriculoperitoneal shunt in 67% (n = 4/6) of patients, and 67% (n = 4/6) had a Chiari 1 malformation. Patients had a complex, multifactorial feeding history complicated by choanal atresia/stenosis (100%; n = 6/6), and significant midface hypoplasia. All patients required airway management through tracheostomy (83%; n = 5/6); and/or continuous positive airway pressure (67%; n = 4/6). All patients underwent adenotonsillectomy (100%; n = 6/6). Initial failure to thrive, low weight, and/or height were seen in 100% (n = 6/6) patients; 80% (n = 4/5) had reflux; 100% (n = 6/6) had nasogastric, or percutaneous endoscopic gastrostomy based feeding during their treatment journey. All patients had hearing loss (100%; n = 6/6). Early communication difficulties were common: receptive language disorder (50%; n = 3/6); expressive language disorder (50%; n = 3/6); and speech sound disorder in 50% (n = 3/6)-necessitating the use of Makaton in 80% of patients (n = 3/5). Patients with CAN experience significant respiratory, neurological, and structural obstacles to hearing, speech, language, and feeding. The authors present a recommended pathway for management to support patients in these domains.

Osteo-cutaneous microvascular free-flaps are a viable option for reconstructing the temporomandibular joint

BackgroundThere are multiple reconstructive options after mandibular resection and disarticulation of the condyle. The purpose of this study was to assess the clinical outcomes and functionality of osteocutaneous free flaps in the reconstruction of mandibular defects that involve the Temporo-Mandibular Joint (TMJ). MethodsOur study is a retrospective cohort study involving subjects who underwent mandibular resection and needed TMJ reconstruction with vascularized bony-free flaps from February 2016 to June 2018. Data gathered included patient demographics, post-operative function, maximum interincisal opening (MIO), occlusion status, deviation on opening, and TMJ symptoms. Data points collected from postoperative CT imaging included the following: position of the flap in relation to the glenoid fossa and articular eminence, and closest point of contact. ResultsEight out of the nine patients who underwent free flap reconstruction of mandibular defects involving the TMJ qualified for the study. The mean age was 39.7 years old. In all 8 cases, virtual surgical planning (VSP) was used. The mean follow-up time was 18.75 months. The flap success rate was 100%. The mean MIO was 37.37 mm. Six patients resumed their premorbid diet, and one patient developed dysphagia and was peg tube dependent. In seven cases the occlusion was intact and reproducible, one case was without sufficient teeth for occlusion. On imaging, the mean distance from the neo-condyle to the glenoid fossa was 14 mm and to the articular eminence 8.68 mm. The point of closest contact in all cases appeared to be the articular eminence. ConclusionVascularized Osteocutaneous-flaps such as FFFs and DCIA flaps provide a good option for the reconstruction of mandibular defects that involve the TMJ. Ipsilateral deviation on opening does not negatively affect clinical outcomes or function. Placing patients in Maxillomandibular fixation for 4–6 weeks may help to prevent condylar sag and provide stable post-operative occlusion.