- Email: [email protected]
⁎4740 The mucosal clip assisted method for the placement of percutaneously placed jejunal enteral tubes is safe and effective.
*4737 OUTCOME OF DIRECT PERCUTANEOUS ENDOSCOPIC JEJUNOSTOMY TUBE PLACEMENT FOR NUTRITIONAL SUPPORT IN CRITICALLY-ILL, MECHANICALLY VENTILATED PATIENTS. Mark A. Schattner, Seth J. Richter, Rafael Barrera, Samuel Adeyeye, Michael Ahdoot, Alan Ahdoot, Moshe Shike, Memorial Sloan-Kettering Cancer Ctr, New York, NY; Memorial Sloan-Kettering Cancer Ctr, New Yok, NY. Background: Gastrointestinal function is adversely affected in critically-ill, mechanically ventilated patients. The most common abnormality is delayed gastric emptying. This may lead to intolerance of gastric enteral feedings despite the presence of a functioning small bowel, and may predispose to aspiration pneumonia. Placement of a direct percutaneous endoscopic jejunostomy tube (PEJ) provides direct access to the small bowel and may therefore be the preferred route of access in critically-ill, mechanically ventilated patients who require enteral nutrition support. Methods: A review of the records of all patients who underwent direct PEJ tube placement while mechanically ventilated in the ICU was undertaken. For each patient the following factors were identified: age, indication for ICU admission and PEJ placement, nutritional support prior to and after PEJ placement, calories received, complications (aspiration, diarrhea, infection, bleeding, abdominal pain, leakage, or any procedural complications), and outcome. Results: 17 patients were studied. All had successful placement of direct PEJ tubes. The mean age was 64 years with a range of 25-83 years. Indications for PEJ placement included: aspiration pneumonia =9, intolerance of gastric enteral feedings =4, anastomotic leak after esophagectomy/gastric pull-up =3, duodenal obstruction =1. There was a single complication (colonic perforation). 15/17 patients tolerated jejunal feedings within 24 hours of PEJ placement. The mean daily caloric intake through the PEJ tube was 1994 cal (range 1440-2700) and all were able to progress to their established nutritional goals. There were no cases of aspiration of PEJ feeds. 13 patients required total parenteral nutrition (TPN) prior to PEJ placement. In all these patients TPN was not required once PEJ tubes were placed. 12 patients were discharged to home or a rehabilitation facility with jejunal feeds, 3 expired in the ICU, 1 was able to resume oral intake, and 1 remains hospitalized with continued enteral feedings. Conclusions: Direct PEJ is a safe and effective method to provide enteral nutrition support to critically-ill, mechanically ventilated patients who may not tolerate gastric enteral feeds and who might otherwise require TPN.
tant to give a specific treatment in order to provide a global assistance to the terminally ill patient.
*4738 EVALUATION OF QUALITY OF LIFE IN THE PALLIATIVE TREATMENT WITH PERCUTANEOUS ENDOSCOPIC GASTROSTOMY OF INTESTINAL OCCLUSION CAUSED BY GYNECOLOGICAL TUMORS. Renato Cannizzaro, Maria A. Annunziata, Elio Campagnutta, Nadia Dal Bo’, Giovanni De Piero, Ettore Bidoli, Roberto Sigon, Barbara Piani, Carlo Scarabelli, Ctr Riferimento Oncologico, Aviano, Italy. Obstruction of upper gastrointestinal tract is a frequent consequence of gynecological tumors metastatic in the peritoneal cavity. Such condition requires chronic gastric decompression that is possible to obtain by PEG. The effectiveness of PEG in reducing severe symptoms as nausea, vomiting and abdominal relaxation has been assessed in previuos study (Endoscopy ‘95).AIM of the study is to evaluate the global QoL of PEG pts. METHODS: Since 1998 until today, 25 consecutive pts (median age 58 years;range 32-79), have been interwieved prior and seven day after the placing of PEG, in order to assess their QoL. All pts showed an intestinal occlusion. The QoL was evaluated by Symptom Distress Scale (SDS) of Mc Corkle and Young. The SDS assesses both psychological symptoms, as they are experienced by the patient, and their variation due to the course of the disease or the association with specific medical or psychological interventions. Lower scores are associated with a better QoL. Some symptoms such as fatigue, insomnia and appetite have been classified as somatopsychic since they are easily affected by the organic and the psychological components. RESULTS: As to the global QoL, of the 25 pts, 16 (64 %) have recovered (41 vs 32.6,pre and post PEG median scores respectively, p=0.003), 2 (8%)have shown the same scores as at baseline, and 7 (28 %) have worsened (30.85 vs 36.14,p= 0.18). Of the 16 pts showing an improvement in the QoL, 9/16 reported a reduction in symptoms at a physical (19.16 vs 14.75 , p=0.004), psychological (10.1 vs 7.3, p= 0.03), and somatopsychic level (11.25 vs 9.2, p=0.03). Of the remaining 7/16 pts, 1 reported a physical impairment, 3 a psychological worsening and 3 a somatopsychic impairment.The worsening of global QoL found in 7/25 pts was determined particularly by the persistence of the physical symptoms - pain, nausea, intestinal activity, breathing and cough - (14.57 vs 20, p= 0.02). CONCLUSIONS: Our results suggest that PEG in pts with obstruction of the upper gastrointestinal tract improves their global QoL. It effectively affects the physical and, less specifically the psychological symptoms. However, as these two aspects are so closely linked together in this phase of the disease, we can report an improvement also at the psychological level. It is impor-
*4740 THE MUCOSAL CLIP ASSISTED METHOD FOR THE PLACEMENT OF PERCUTANEOUSLY PLACED JEJUNAL ENTERAL TUBES IS SAFE AND EFFECTIVE. Jose M. Nieto, John R. Evans, Meghel Parikh, Daniel Leckemby, Western Univ Health Sci, Pomona, CA; San Bernardino, CA; Arrowhead Regional Med Ctr, Colton, CA. Jejunal enteral tubes (JET) are often placed as an extension of the percutaneous gastrostomy tube in debilitated patients(pts) who are at high risk for aspiration. Proximal migration into the stomach due to friction between the endoscope (EGD) and the JET often occurs. Thus, procedural time may be increased and repeat EGDs may be required. The literature is sparse regarding the MCAM technique. A total of 9 pts; 8 had naso-jejunal tubes and 1 a JET/PEG with successful placement in 83% and an average procedure time of 30 minutes (GIE 1994;40:220-22 & JPEN 1996;20:306-8). The objective is to determine if MCAM: 1) is effective in delivering and keeping the JET in place in the descending duodenum (DD), 2) involves less procedural time, 3) prevented less proximal migration of the JET and 4) is safe and without complications. We prospectively used this method in 31 pts. There were 19 males. 34 total EGDs were performed. The major indications were: neurologic deficits, cancer and dysphagia. A Bard or Microvasive 20F G-tube was placed using the Ponsky-Pull Method. A 9F JET with a distal suture was then placed through the G-tube. The suture was grasped with the Olympus mucosal clip (MC) device, closed and pulled back into the standard upper EGD. The EGD and the JET were placed as far down in the DD. The MC was deployed between the suture loop and fastened to the duodenal wall. X-rays (KUB) were obtained to confirm placement. The procedure time, number of attempts, timing of feeding and complications were assessed. Results: The mean procedure time was 23.5 minutes. Only 1 attempt was required in 94% (32/34) and 2 attempts in 6%(2/34). Feeding was initiated within 24 hrs in 44% (15/34) and after 24 hrs in 56% (19/34) pts. JET migration occurred in only 2 pts requiring repeat EGD. 24/34 cases had at least 2 KUBs confirming JET placement. Conclusion: The MCAM method is technically simple, well tolerated and is a reliable method of performing a JET/PEG. In addition to lowering the aspiration risk by securing the JET to the duodenal wall, feedings may be initiated on the same day. No complications of ulcerations, bleeding or perforation occurred. A randomized trial comparing the MCAM with the conventional method is required to determine its true efficacy, costs and ease of use.
AB218
GASTROINTESTINAL ENDOSCOPY
*4739 REMOVAL OF PEG-TUBES BY CUTTING-THE-TUBE: SHORTAND LONG-TERM COMPLICATIONS. Dieter Schwab, Winfried Melzner, Steffen M. Muehldorfer, Eckhart G. Hahn, Dept of Medicine I, Erlangen, Germany. Background: For removal of PEG-tubes, two different techniques exist: 1. an endoscopic approach and 2. the natural passage after cutting the tube at skin level. Although the second possibility is preferred by most of the patients, complications like bowel obstruction with the need of surgery have been reported. Additionally, the long-term complications of this procedure are unknown. Methods: We performed a combined retrospective and prospective study to investigate the complications of removal of PEG-tubes by cutting. Duration of tube-passage was documented, and if natural passage was not noticed by the patient, an x-ray-examination was offered. Additionally, the further outcome of the patients was evaluated. Every patient was advised to drink at least 2000mls fluid per day, and to ensure deliberate oral food intake Results: Of 62 patients investigated (30 prospective, 32 retrospective; age: 2677 years, mean: 46.5 years; 82% male, 18% female; indication for PEG: Headand-Neck-Tumor: 89%, Esophagus-Tumor: 3%, Others: 8%), only 3 exhibited complications: 1 patient had abdominal pain until passage of the PEG after 4 days, and two had gastro-cutaneuos fistulas for 6 and 12 months respectively. Reasons for PEG-removal was sufficient oral intake without further need for the PEG-tube in 59/62 (95%) patients, and PEG-defect in 3 patients (5%) resulting in Button-PEG placement. Passage was noted only by 34/62 patients (55%) with a mean passage-time of 2.4 days (range: 0.5-13 days). In 11 of 28 patients, who did not notice PEG-passage, an x-ray was performed for control, but PEG-tubes could not found in any of the plain abdominal radiographs. After a mean follow-up of 38 months (range: 1-94 months), 46/59 patients (78%) are still doing well without PEG, 7 (12%) had died (4 because of the underlying disease, 3 because of other illnesses), and 6 (10%) needed a PEG-tube again because of inability of sufficient oral intake. Conclusions: Cutting-the-tube is not only easy to perform, it also seems to be safe, even if no passage of the tube is noticed by the patient. Providing bowel movements is essential to avoid bowel obstruction. In the long-term, 10% of the patients need a PEG-tube again. Therefore, indication for PEG-removal should be considered very carefully.
VOLUME 51, NO. 4, PART 2, 2000
tant to give a specific treatment in order to provide a global assistance to the terminally ill patient.
*4738 EVALUATION OF QUALITY OF LIFE IN THE PALLIATIVE TREATMENT WITH PERCUTANEOUS ENDOSCOPIC GASTROSTOMY OF INTESTINAL OCCLUSION CAUSED BY GYNECOLOGICAL TUMORS. Renato Cannizzaro, Maria A. Annunziata, Elio Campagnutta, Nadia Dal Bo’, Giovanni De Piero, Ettore Bidoli, Roberto Sigon, Barbara Piani, Carlo Scarabelli, Ctr Riferimento Oncologico, Aviano, Italy. Obstruction of upper gastrointestinal tract is a frequent consequence of gynecological tumors metastatic in the peritoneal cavity. Such condition requires chronic gastric decompression that is possible to obtain by PEG. The effectiveness of PEG in reducing severe symptoms as nausea, vomiting and abdominal relaxation has been assessed in previuos study (Endoscopy ‘95).AIM of the study is to evaluate the global QoL of PEG pts. METHODS: Since 1998 until today, 25 consecutive pts (median age 58 years;range 32-79), have been interwieved prior and seven day after the placing of PEG, in order to assess their QoL. All pts showed an intestinal occlusion. The QoL was evaluated by Symptom Distress Scale (SDS) of Mc Corkle and Young. The SDS assesses both psychological symptoms, as they are experienced by the patient, and their variation due to the course of the disease or the association with specific medical or psychological interventions. Lower scores are associated with a better QoL. Some symptoms such as fatigue, insomnia and appetite have been classified as somatopsychic since they are easily affected by the organic and the psychological components. RESULTS: As to the global QoL, of the 25 pts, 16 (64 %) have recovered (41 vs 32.6,pre and post PEG median scores respectively, p=0.003), 2 (8%)have shown the same scores as at baseline, and 7 (28 %) have worsened (30.85 vs 36.14,p= 0.18). Of the 16 pts showing an improvement in the QoL, 9/16 reported a reduction in symptoms at a physical (19.16 vs 14.75 , p=0.004), psychological (10.1 vs 7.3, p= 0.03), and somatopsychic level (11.25 vs 9.2, p=0.03). Of the remaining 7/16 pts, 1 reported a physical impairment, 3 a psychological worsening and 3 a somatopsychic impairment.The worsening of global QoL found in 7/25 pts was determined particularly by the persistence of the physical symptoms - pain, nausea, intestinal activity, breathing and cough - (14.57 vs 20, p= 0.02). CONCLUSIONS: Our results suggest that PEG in pts with obstruction of the upper gastrointestinal tract improves their global QoL. It effectively affects the physical and, less specifically the psychological symptoms. However, as these two aspects are so closely linked together in this phase of the disease, we can report an improvement also at the psychological level. It is impor-
*4740 THE MUCOSAL CLIP ASSISTED METHOD FOR THE PLACEMENT OF PERCUTANEOUSLY PLACED JEJUNAL ENTERAL TUBES IS SAFE AND EFFECTIVE. Jose M. Nieto, John R. Evans, Meghel Parikh, Daniel Leckemby, Western Univ Health Sci, Pomona, CA; San Bernardino, CA; Arrowhead Regional Med Ctr, Colton, CA. Jejunal enteral tubes (JET) are often placed as an extension of the percutaneous gastrostomy tube in debilitated patients(pts) who are at high risk for aspiration. Proximal migration into the stomach due to friction between the endoscope (EGD) and the JET often occurs. Thus, procedural time may be increased and repeat EGDs may be required. The literature is sparse regarding the MCAM technique. A total of 9 pts; 8 had naso-jejunal tubes and 1 a JET/PEG with successful placement in 83% and an average procedure time of 30 minutes (GIE 1994;40:220-22 & JPEN 1996;20:306-8). The objective is to determine if MCAM: 1) is effective in delivering and keeping the JET in place in the descending duodenum (DD), 2) involves less procedural time, 3) prevented less proximal migration of the JET and 4) is safe and without complications. We prospectively used this method in 31 pts. There were 19 males. 34 total EGDs were performed. The major indications were: neurologic deficits, cancer and dysphagia. A Bard or Microvasive 20F G-tube was placed using the Ponsky-Pull Method. A 9F JET with a distal suture was then placed through the G-tube. The suture was grasped with the Olympus mucosal clip (MC) device, closed and pulled back into the standard upper EGD. The EGD and the JET were placed as far down in the DD. The MC was deployed between the suture loop and fastened to the duodenal wall. X-rays (KUB) were obtained to confirm placement. The procedure time, number of attempts, timing of feeding and complications were assessed. Results: The mean procedure time was 23.5 minutes. Only 1 attempt was required in 94% (32/34) and 2 attempts in 6%(2/34). Feeding was initiated within 24 hrs in 44% (15/34) and after 24 hrs in 56% (19/34) pts. JET migration occurred in only 2 pts requiring repeat EGD. 24/34 cases had at least 2 KUBs confirming JET placement. Conclusion: The MCAM method is technically simple, well tolerated and is a reliable method of performing a JET/PEG. In addition to lowering the aspiration risk by securing the JET to the duodenal wall, feedings may be initiated on the same day. No complications of ulcerations, bleeding or perforation occurred. A randomized trial comparing the MCAM with the conventional method is required to determine its true efficacy, costs and ease of use.
AB218
GASTROINTESTINAL ENDOSCOPY
*4739 REMOVAL OF PEG-TUBES BY CUTTING-THE-TUBE: SHORTAND LONG-TERM COMPLICATIONS. Dieter Schwab, Winfried Melzner, Steffen M. Muehldorfer, Eckhart G. Hahn, Dept of Medicine I, Erlangen, Germany. Background: For removal of PEG-tubes, two different techniques exist: 1. an endoscopic approach and 2. the natural passage after cutting the tube at skin level. Although the second possibility is preferred by most of the patients, complications like bowel obstruction with the need of surgery have been reported. Additionally, the long-term complications of this procedure are unknown. Methods: We performed a combined retrospective and prospective study to investigate the complications of removal of PEG-tubes by cutting. Duration of tube-passage was documented, and if natural passage was not noticed by the patient, an x-ray-examination was offered. Additionally, the further outcome of the patients was evaluated. Every patient was advised to drink at least 2000mls fluid per day, and to ensure deliberate oral food intake Results: Of 62 patients investigated (30 prospective, 32 retrospective; age: 2677 years, mean: 46.5 years; 82% male, 18% female; indication for PEG: Headand-Neck-Tumor: 89%, Esophagus-Tumor: 3%, Others: 8%), only 3 exhibited complications: 1 patient had abdominal pain until passage of the PEG after 4 days, and two had gastro-cutaneuos fistulas for 6 and 12 months respectively. Reasons for PEG-removal was sufficient oral intake without further need for the PEG-tube in 59/62 (95%) patients, and PEG-defect in 3 patients (5%) resulting in Button-PEG placement. Passage was noted only by 34/62 patients (55%) with a mean passage-time of 2.4 days (range: 0.5-13 days). In 11 of 28 patients, who did not notice PEG-passage, an x-ray was performed for control, but PEG-tubes could not found in any of the plain abdominal radiographs. After a mean follow-up of 38 months (range: 1-94 months), 46/59 patients (78%) are still doing well without PEG, 7 (12%) had died (4 because of the underlying disease, 3 because of other illnesses), and 6 (10%) needed a PEG-tube again because of inability of sufficient oral intake. Conclusions: Cutting-the-tube is not only easy to perform, it also seems to be safe, even if no passage of the tube is noticed by the patient. Providing bowel movements is essential to avoid bowel obstruction. In the long-term, 10% of the patients need a PEG-tube again. Therefore, indication for PEG-removal should be considered very carefully.
VOLUME 51, NO. 4, PART 2, 2000