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Charlson Comorbidity Index As a Predictor of Percutaneous Endoscopic Gastrostomy (PEG) Placement in 21,558 Noncancer Medicare Patients with Alzheimer's Dementia
Abstracts
under conscious sedation. It was developed a trocar system consisting of an external sheath with a lateral cleft. The pointed end of the internal shaft of the trocar system is conic shaped in order to reduce the trauma to the abdominal and gastric walls. Two points of gastropexy were placed under endoscopic view by using a double-needle puncturing device. The trocar system was advanced through a 10 mm skin incision into the transilluminated and inflated stomach under endoscopic view. The internal shaft was removed and a 20 Fr ballooned tube was introduced through the lateral cleft. Once the tube was in place the balloon was inflated and the external sheath of the trocar was pulled out as the feeding tube was slid out through the lateral cleft. Long-term function, replacement or removal of the PEG and complications were evaluated. Results: the PEG procedure was successful in all patients. The mean procedural time was 18min (range 15 - 22 min). The follow up period was two months with any death. One patient developed acute abdominal pain in the immediate postoperative period. The presence of a massive pneumoperitoneum was the indication for surgical revision. No abnormality was found at laparotomy. One patient (4.8%) presented a periostomal dermatite in the 30th postoperative day. There were three (14.28%) cases of tube disfunction. Conclusion: the introducer PEG technique with this new device is efficient and safe for long term enteral access in patients with obstructive head and neck cancer.
T1613 Endoscopic and Histopathologic Characteristics Suggesting Coexisting Focus of High Grade Adenoma Or Cancer in the Cases Diagnosed As Low Grade Gastric Adenoma By Forceps Biopsy Byung-Hoon Min, Eun Ran Kim, Jae J. Kim, Hoi Jin Kim, Jun Haeng Lee, Dong Kyung Chang, Young-Ho Kim, Hee Jung Son, Poong-Lyul Rhee, Jong Chul Rhee Background and study aims: We have been experiencing the cases which were initially diagnosed as low grade gastric adenoma by forceps biopsy but finally diagnosed as having coexisting focus of high grade adenoma or cancer by endoscopic mucosal resection (EMR). Therefore if EMRs are not performed for all the cases diagnosed as low grade gastric adenoma by forceps biopsy, there can be the risk of missing the high grade adenoma or cancer which is the absolute indication of resection. However, EMR can cause serious complications such as perforation or bleeding and it is still controversial whether low grade gastric adenoma should be resected or not. Therefore, it is necessary to identify the endoscopic and histopathologic characteristics suggesting coexisting focus of high grade adenoma or cancer in the cases diagnosed as low grade gastric adenoma by forceps biopsy. Patients and methods: From January 2004 to June 2007, a total of 235 lesions in 219 patients were diagnosed as low grade gastric adenoma by forceps biopsy and resected using EMR. The still photographs of endoscopic findings were reviewed for the location, gross shape, size, red color change and nodular change of the surface of the lesions. Pathology slides were reviewed for the presence of coexisting focus of high grade adenoma or cancer and histological type of the lesions. Results: After EMR, 194 lesions (82.6%) were finally diagnosed as low grade adenoma, 37 lesions (15.7%) as having focus of high grade adenoma, and 4 lesions (1.7%) as having focus of cancer. In the univariate analysis, no significant difference was found in the location or nodular change of the surface between the low grade adenoma group and the high grade adenoma or cancer group. However, non-IIa lesions (I, IIaþIIc, IIcþIIa, or IIc), lesions with size R1 cm, lesions with red color change on the surface, and lesions with tubulovillous or villous histology were significantly more frequently found in high grade adenoma or cancer group than in low grade adenoma group. In the multivariate analysis, lesion size R1 cm and tubulovillous or villous histology were identified as the independent risk factors suggesting coexisting focus of high grade adenoma or cancer in the cases diagnosed as low grade gastric adenoma by forceps biopsy (OR 3.202, 95% CI 1.172-8.745; OR 3.453, 95% CI 1.003-11.952). Conclusions: Complete resection by EMR should be performed for the cases diagnosed as low grade gastric adenoma by forceps biopsy if the lesions are R1 cm in size or have tubulovillous or villous histology.
T1614 Racial Disparities in Utilization and Timing of Percutaneous Endoscopic Gastrostomy (PEG) Placement in 21,558 Noncancer Medicare Patients with Alzheimer’s Dementia Joshua D. Novak, Tzuyung D. Kou, Gregory S. Cooper, Richard C. Wong Background: PEG placement is a common method for delivering artificial nutrition and hydration (ANH) to patients with Alzheimer’s dementia who are unable to
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sustain sufficient oral intake. We have previously shown that the incident rate of PEG placement has nearly tripled from 1992 to 2003. It is unclear whether racial differences impact on the timing and utilization of PEG placement. Objective: To describe racial characteristics associated with PEG placement in patients with Alzheimer’s dementia. Methods: Both inpatient MEDPAR and outpatient (NCH and SAF) files from 1992 to 1999 from a 5% random sample of cancer-free Medicare beneficiaries age 66 years and older with a new diagnosis of Alzheimer’s dementia were examined. Patients were followed-up for 5 years. Patients who were enrolled in Medicare Part A and were in fee-for-service arrangements were included. Chisquare analysis was used for descriptive statistics. A multivariate logistic model estimated the association of race with PEG placement and a Cox model was used to evaluate time to PEG placement. Results: Of the 21,558 patients with Alzheimer’s dementia, 1,741 received a PEG. Of these, 1,206 (69.2%) were Caucasian, 419 (24%) were African American, and 116 (6.6%) were of other minority descent, compared with 85.8%, 8.8%, and 5.4%, respectively, in the study population (p ! 0.0001). African Americans with Alzheimer’s dementia were more likely to receive PEG placement compared to Caucasians (OR 3.04, CI 2.56-3.61). Members of other racial groups were also more likely to undergo PEG placement than were Caucasians (OR 1.46, CI 1.13-1.88). In addition, compared to Caucasians, African Americans had PEG placement significantly earlier after their dementia diagnosis (Hazard ratio 2.05, CI: 1.83-2.31), which was also observed in other minority groups (Hazard ratio 1.28, CI: 1.06-1.56). Conclusions: Not only is PEG utilization disproportionately greater in African Americans, but PEG placement occurs significantly earlier after their dementia diagnosis. Further research is needed to explore the underlying causes of these observed disparities and to assess long-term outcome.
T1615 Charlson Comorbidity Index As a Predictor of Percutaneous Endoscopic Gastrostomy (PEG) Placement in 21,558 Noncancer Medicare Patients with Alzheimer’s Dementia Joshua D. Novak, Tzuyung D. Kou, Gregory S. Cooper, Richard C. Wong Background: PEG placement is an increasingly common means of providing artificial nutrition and hydration (ANH) in patients with Alzheimer’s dementia who are no longer able to sustain sufficient oral intake. We have previously shown that the Charlson comorbidity index predicts mortality following PEG placement. Whether the Charlson index can be used to predict subsequent PEG placement following the diagnosis of dementia is unknown. Objective: Analysis of Charlson comorbidity index as a predictor of PEG placement in noncancer patients with Alzheimer’s dementia. Methods: Both inpatient MEDPAR and outpatient (NCH and SAF) files from 1992 to 1999 from a 5% random sample of cancer-free Medicare beneficiaries age 66 years and older with a new diagnosis of Alzheimer’s dementia were examined. Patients were followed-up for 5 years. Patients who were enrolled in Medicare Part A and were in fee-for-service arrangements were included. All comorbid conditions within a year prior to PEG placement were used to calculate the Charlson comorbidity index. Chisquare analysis was used for descriptive statistics. Results: Of the 21,558 patients with Alzheimer’s dementia, 1,741 received a PEG. 458 (2.4%) of those patients who had a Charlson comorbidity index score of 0 had a PEG placed. A PEG was placed in 455 (43%), 411 (49.7%), and 417 (61.5%) of those patient’s with Charlson comorbidity index scores of 1, 2 and O3, respectively (p ! 0.0001). Conclusions: Patients with Alzheimer’s dementia who score a Charlson index of one or greater have a significantly increased incidence of PEG placement. The higher the Charlson index, the greater the likelihood of PEG placement. In this noncancer population, the Charlson comorbidity index can be used to evaluate the probability that a patient with Alzheimer’s dementia will require PEG placement.
T1616 New Glycogel Wound Dressing Modality for Peristomal PEG Dressing: A Simple, Convenient, Economical and Better Option Dietmar Borger, Loitsch Stefan Marcel, Yogesh Shastri, Angelika Tessmer, Franz Hartmann, Ju ¨ Rgen Stein Background and aims: Peristomal PEG (Percutaneous endoscopic gastrostomy) site infection is clearly the commonest post procedure complication. Despite prophylactic antibiotics, the routinely performed ‘pull’ type PEG placement technique has been associated with high peristomal infectious complications (430%). Conventional wound care following PEG placement requires daily change of the wound dressing initially. New glycerin hydro gel wound dressing has been proposed to possess more effective antimicrobial properties; also it can be kept for up to 7 days, eliminating the need for daily change of dressings of the PEG wound. The aim of the present study was to compare the occurrence of peristomal infections, and frequency of change of wound dressing between the groups of patients offered conventional vs. the new glycogel wound dressing. Patients and Methods: SondoFixÒ (Medi-Globe Gmbh, Germany) is a triangular glycogel wound dressing (gel on glycerin basis), equipped with a pre-cut slit which facilitates its easy fixation around the PEG catheter. A hypo-allergenic, semi-transparent and cushioned plaster is gelled allowing easy application and wound inspection. 41 patients undergoing PEG were prospectively evaluated, 20 patients received a conventional wound dressing while 21 were offered the SondoFix wound dressing. Both patient groups were equally matched for age, sex, and weight. The
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB261
under conscious sedation. It was developed a trocar system consisting of an external sheath with a lateral cleft. The pointed end of the internal shaft of the trocar system is conic shaped in order to reduce the trauma to the abdominal and gastric walls. Two points of gastropexy were placed under endoscopic view by using a double-needle puncturing device. The trocar system was advanced through a 10 mm skin incision into the transilluminated and inflated stomach under endoscopic view. The internal shaft was removed and a 20 Fr ballooned tube was introduced through the lateral cleft. Once the tube was in place the balloon was inflated and the external sheath of the trocar was pulled out as the feeding tube was slid out through the lateral cleft. Long-term function, replacement or removal of the PEG and complications were evaluated. Results: the PEG procedure was successful in all patients. The mean procedural time was 18min (range 15 - 22 min). The follow up period was two months with any death. One patient developed acute abdominal pain in the immediate postoperative period. The presence of a massive pneumoperitoneum was the indication for surgical revision. No abnormality was found at laparotomy. One patient (4.8%) presented a periostomal dermatite in the 30th postoperative day. There were three (14.28%) cases of tube disfunction. Conclusion: the introducer PEG technique with this new device is efficient and safe for long term enteral access in patients with obstructive head and neck cancer.
T1613 Endoscopic and Histopathologic Characteristics Suggesting Coexisting Focus of High Grade Adenoma Or Cancer in the Cases Diagnosed As Low Grade Gastric Adenoma By Forceps Biopsy Byung-Hoon Min, Eun Ran Kim, Jae J. Kim, Hoi Jin Kim, Jun Haeng Lee, Dong Kyung Chang, Young-Ho Kim, Hee Jung Son, Poong-Lyul Rhee, Jong Chul Rhee Background and study aims: We have been experiencing the cases which were initially diagnosed as low grade gastric adenoma by forceps biopsy but finally diagnosed as having coexisting focus of high grade adenoma or cancer by endoscopic mucosal resection (EMR). Therefore if EMRs are not performed for all the cases diagnosed as low grade gastric adenoma by forceps biopsy, there can be the risk of missing the high grade adenoma or cancer which is the absolute indication of resection. However, EMR can cause serious complications such as perforation or bleeding and it is still controversial whether low grade gastric adenoma should be resected or not. Therefore, it is necessary to identify the endoscopic and histopathologic characteristics suggesting coexisting focus of high grade adenoma or cancer in the cases diagnosed as low grade gastric adenoma by forceps biopsy. Patients and methods: From January 2004 to June 2007, a total of 235 lesions in 219 patients were diagnosed as low grade gastric adenoma by forceps biopsy and resected using EMR. The still photographs of endoscopic findings were reviewed for the location, gross shape, size, red color change and nodular change of the surface of the lesions. Pathology slides were reviewed for the presence of coexisting focus of high grade adenoma or cancer and histological type of the lesions. Results: After EMR, 194 lesions (82.6%) were finally diagnosed as low grade adenoma, 37 lesions (15.7%) as having focus of high grade adenoma, and 4 lesions (1.7%) as having focus of cancer. In the univariate analysis, no significant difference was found in the location or nodular change of the surface between the low grade adenoma group and the high grade adenoma or cancer group. However, non-IIa lesions (I, IIaþIIc, IIcþIIa, or IIc), lesions with size R1 cm, lesions with red color change on the surface, and lesions with tubulovillous or villous histology were significantly more frequently found in high grade adenoma or cancer group than in low grade adenoma group. In the multivariate analysis, lesion size R1 cm and tubulovillous or villous histology were identified as the independent risk factors suggesting coexisting focus of high grade adenoma or cancer in the cases diagnosed as low grade gastric adenoma by forceps biopsy (OR 3.202, 95% CI 1.172-8.745; OR 3.453, 95% CI 1.003-11.952). Conclusions: Complete resection by EMR should be performed for the cases diagnosed as low grade gastric adenoma by forceps biopsy if the lesions are R1 cm in size or have tubulovillous or villous histology.
T1614 Racial Disparities in Utilization and Timing of Percutaneous Endoscopic Gastrostomy (PEG) Placement in 21,558 Noncancer Medicare Patients with Alzheimer’s Dementia Joshua D. Novak, Tzuyung D. Kou, Gregory S. Cooper, Richard C. Wong Background: PEG placement is a common method for delivering artificial nutrition and hydration (ANH) to patients with Alzheimer’s dementia who are unable to
www.giejournal.org
sustain sufficient oral intake. We have previously shown that the incident rate of PEG placement has nearly tripled from 1992 to 2003. It is unclear whether racial differences impact on the timing and utilization of PEG placement. Objective: To describe racial characteristics associated with PEG placement in patients with Alzheimer’s dementia. Methods: Both inpatient MEDPAR and outpatient (NCH and SAF) files from 1992 to 1999 from a 5% random sample of cancer-free Medicare beneficiaries age 66 years and older with a new diagnosis of Alzheimer’s dementia were examined. Patients were followed-up for 5 years. Patients who were enrolled in Medicare Part A and were in fee-for-service arrangements were included. Chisquare analysis was used for descriptive statistics. A multivariate logistic model estimated the association of race with PEG placement and a Cox model was used to evaluate time to PEG placement. Results: Of the 21,558 patients with Alzheimer’s dementia, 1,741 received a PEG. Of these, 1,206 (69.2%) were Caucasian, 419 (24%) were African American, and 116 (6.6%) were of other minority descent, compared with 85.8%, 8.8%, and 5.4%, respectively, in the study population (p ! 0.0001). African Americans with Alzheimer’s dementia were more likely to receive PEG placement compared to Caucasians (OR 3.04, CI 2.56-3.61). Members of other racial groups were also more likely to undergo PEG placement than were Caucasians (OR 1.46, CI 1.13-1.88). In addition, compared to Caucasians, African Americans had PEG placement significantly earlier after their dementia diagnosis (Hazard ratio 2.05, CI: 1.83-2.31), which was also observed in other minority groups (Hazard ratio 1.28, CI: 1.06-1.56). Conclusions: Not only is PEG utilization disproportionately greater in African Americans, but PEG placement occurs significantly earlier after their dementia diagnosis. Further research is needed to explore the underlying causes of these observed disparities and to assess long-term outcome.
T1615 Charlson Comorbidity Index As a Predictor of Percutaneous Endoscopic Gastrostomy (PEG) Placement in 21,558 Noncancer Medicare Patients with Alzheimer’s Dementia Joshua D. Novak, Tzuyung D. Kou, Gregory S. Cooper, Richard C. Wong Background: PEG placement is an increasingly common means of providing artificial nutrition and hydration (ANH) in patients with Alzheimer’s dementia who are no longer able to sustain sufficient oral intake. We have previously shown that the Charlson comorbidity index predicts mortality following PEG placement. Whether the Charlson index can be used to predict subsequent PEG placement following the diagnosis of dementia is unknown. Objective: Analysis of Charlson comorbidity index as a predictor of PEG placement in noncancer patients with Alzheimer’s dementia. Methods: Both inpatient MEDPAR and outpatient (NCH and SAF) files from 1992 to 1999 from a 5% random sample of cancer-free Medicare beneficiaries age 66 years and older with a new diagnosis of Alzheimer’s dementia were examined. Patients were followed-up for 5 years. Patients who were enrolled in Medicare Part A and were in fee-for-service arrangements were included. All comorbid conditions within a year prior to PEG placement were used to calculate the Charlson comorbidity index. Chisquare analysis was used for descriptive statistics. Results: Of the 21,558 patients with Alzheimer’s dementia, 1,741 received a PEG. 458 (2.4%) of those patients who had a Charlson comorbidity index score of 0 had a PEG placed. A PEG was placed in 455 (43%), 411 (49.7%), and 417 (61.5%) of those patient’s with Charlson comorbidity index scores of 1, 2 and O3, respectively (p ! 0.0001). Conclusions: Patients with Alzheimer’s dementia who score a Charlson index of one or greater have a significantly increased incidence of PEG placement. The higher the Charlson index, the greater the likelihood of PEG placement. In this noncancer population, the Charlson comorbidity index can be used to evaluate the probability that a patient with Alzheimer’s dementia will require PEG placement.
T1616 New Glycogel Wound Dressing Modality for Peristomal PEG Dressing: A Simple, Convenient, Economical and Better Option Dietmar Borger, Loitsch Stefan Marcel, Yogesh Shastri, Angelika Tessmer, Franz Hartmann, Ju ¨ Rgen Stein Background and aims: Peristomal PEG (Percutaneous endoscopic gastrostomy) site infection is clearly the commonest post procedure complication. Despite prophylactic antibiotics, the routinely performed ‘pull’ type PEG placement technique has been associated with high peristomal infectious complications (430%). Conventional wound care following PEG placement requires daily change of the wound dressing initially. New glycerin hydro gel wound dressing has been proposed to possess more effective antimicrobial properties; also it can be kept for up to 7 days, eliminating the need for daily change of dressings of the PEG wound. The aim of the present study was to compare the occurrence of peristomal infections, and frequency of change of wound dressing between the groups of patients offered conventional vs. the new glycogel wound dressing. Patients and Methods: SondoFixÒ (Medi-Globe Gmbh, Germany) is a triangular glycogel wound dressing (gel on glycerin basis), equipped with a pre-cut slit which facilitates its easy fixation around the PEG catheter. A hypo-allergenic, semi-transparent and cushioned plaster is gelled allowing easy application and wound inspection. 41 patients undergoing PEG were prospectively evaluated, 20 patients received a conventional wound dressing while 21 were offered the SondoFix wound dressing. Both patient groups were equally matched for age, sex, and weight. The
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB261