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Long-term outcome of patients treated with home enteral nutrition
A772 AGA ABSTRACTS
GASTROENTEROLOGY Vol. 118, No.4
4138
4140
EFFICACYOF ANTmIOTIC-LOCK TECHNIQUE WITH TElCOPLANIN IN STAPHYLOCOCCUS EPIDERMIDIS CATHETERRELATED SEPSIS DURING LONG-TERM PARENTERAL NUTRITION.
PERCUTANEOUS ENDOSCOPIC GASMOSTOMY (PEG) - EVALUATION OF NUTRITION AND QUALITY OF LIFE. J. Klose, W. Heldwein, F. Sernetz, B. Otto, M. Gross, K. Loeschke, Clin
Claire Guedon, Olivier Lalaude, Michele Nouvellon, Eric Lerebours, Grad, Rouen, France; Bacteriology unit. Rouen Univ Hosp, Rouen, France. Catheter-related sepsis (CRS) is a serious complication of long-term parenteral nutrition (PN) but its true incidence and the prevalence of staphylococcus epidermidis (SE) infection remain controversial. Antibiotic-lock technique (ALT) has been proposed as an alternative to catheter removal. The aim of this study was to determine a) the incidence of CRS, b) the SE prevalence infection rate c) the efficacy of teicoplanin-Al.T, Patients and methods : This two-years (1997-98) retrospective study enrolled 196 consecutive gastroenterological patients receiving PN via a catheter, either at hospital (n= 156) or at home (n=40). Infectious diagnosis of CRS was carried out on drawn back and peripheral blood. All suspicious CRS were treated by in-situ teicoplanin (5 mg/2ml infused in catheter and rinced after 12 hours) in ALT. After blood cultures results. catheter was immediately removed in case of non-SE infecting organism and secondly removed in SE-CRS if fever persists after 48 hours of ALT. Systemic antibiotics were added in cases of bacteriemia. Results : in all inserted catheters, 28 CRS occurred in 15 patients : 20 SE (13 meticillin susceptible : metiS, 7 meticillin resistant: metiR) and 8 non-SE : 3 S. aureus, 1 bacillus circulans, 1 streptococcus B, 1 candida, 1 pseudomonas, 1 corynebacteria. With regard to PN duration, CRS incidence was not significantly different between home and hospital PN (0.52/100 vs 0.37/100 days). Five out of 15 patients had 2 or more CRS. First infection median delay was 27 days (range: 2-342) at hospital and 115 days (range: 16-1950) at home (NS), median reinfection delay was 193 days (range: 115-342). In 4 patients, metiS infection treated with ALT was followed by SE metiR reinfection. For SE metiS infection (n = 13), ALT allowed a short-term salvage of the catheter in 6/6 cases when it was a first infection. ALT allowed a salvage of the catheter in 1/7 cases, when the metiS SE infection was a reinfection. In 6/7 cases of metiR infection, teicoplanin-Al.T did not avoid catheter removal with persistant fever after 48 hours. Conclusion: In our study, incidence of CRS was low and not different at home and at hospital. Prevalence of SE-CRS was 71% of CRS. Meti resistance was a predictive factor of inefficacy of teicolpanin-Al.T, At short term, teicoplanin-ALT was efficacious suggesting its use as a treatment of choice in SE-CRS in short-term PN.
4139
LONG·TERM OUTCOME OF PATIENTS TREATED WITH HOME ENTERAL NUTRITION. Stephane M. Schneider, Claire Raina, Pascal Pugliese, Isabelle Pouget, Patrick Rampal, Xavier Hebuterne, Hosp de I' Archet, Nice, France. The aim of this study was to prospectively analyze the long-term outcome of home enteral nutrition (HEN) patients in order to determine the benefits of this treatment. Methods: Between 1990 and 1996, 417 patients (195 men, 185 women, and 37 children, mean age: 64 ::!: 25 years) were discharged from our hospital on HEN because of neurological disorders (39.6%), digestive diseases (16.5%), head and neck cancers (15.1%), anorexia (15.1%), AIDS (4.1%), head injuries (2.4%), or other diseases (7.4 %). The main reasons for HEN were dysphagia (58%), anorexia (30%), or moderate intestinal failure (12%). Patients were prospectively studied and followed up until December 31, 1998. A physician independent from the nutritional team recorded the final outcome. Survival probabilities were estimated from Kaplan-Meier survival curves and compared by the log-rank test. Hazard ratios and 95% confidence intervals (95% CI) were calculated by multiple logistic regression model. Results: The mean duration of HEN was 242 ::!: 494 days (mean ::!: SD). After a follow-up of 24 to 103 months, 300 of the 417 patients (71.9%) had died, 109 (26.2%) were alive, and 8 (1.9%) had been lost to follow-up. Probabilities of being alive at one and five years were 41.7% and 25%, respectively. The five-year survival rate was 80.8% for children, 34.3% for patients aged 16-70 years, and 10.7% for patients over 70 years; it was 70% for patients with head injury, 48% for patients with digestive diseases, 32% for patients with miscellaneous diseases, and between 18% and 23% for the other diagnosis groups. Independent factors associated with death were neurological disease (RR: 2,39, 95%CI: 1.19 - 4.78), head and neck cancer (RR 2.50, 95%CI: 1.10 - 5.67), AIDS (RR 5.18, 95%CI: 1.37 - 19.59), and age over 70 (RR 3.36, 95%CI: 1.91 - 5.92). After initiation of HEN, 5.5% of patients were definitely dependent on HEN. 32.6% were discharged of HEN; survival probabilities one and five years after discharge were 65% and 43%, respectively. 20.2% of patients died during the first month of HEN, and 35% died while on HEN after more than one month of treatment (219 ::!: 257 days). In 6.7% of patients HEN was stopped after a mean of one year because of rehospitalization (3.8%), intolerance to HEN (1.9%), or because they moved to another region (1%). Conclusion: HEN provides well-tolerated long-term nutritional support in most patients. However, because of their age and underlying disease, these patients have a poor prognosis. To determine the true impact of HEN, measurement of the quality of life is needed in a large cohort of patients.
Innenstadt Ludwig Maximilians Univ, Munich, Germany. Percutaneous endoscopic gastrostomie (PEG) is an established method for enteral nutrition of patiens with dysphagia but few data exist about possible nutritional deficits and quality of life. We therefore followed both aspects before and after PEG placement. Methods: 60 patients (22 f, 38 m; 73:!:14 years) with dysphagia (67% neurologic disease, 33% cancer) were followed up for a period of 12 month. Before as well as 1,2,3,6,9, 12 month after PEG blood sampling for minerals and vitamins and bioelectric impedance analysis (BIA) were performed. A validated questionnaire (GLQI) was regularly used to document quality of life. Results: Because of the severity of the underlying disease, II patients (18%) died during the initial hospitalization in which the PEG tube was placed (day 1-30). Dependent on the duration of dysphagia a number of nutritional deficits were noted which improved during PEG feeding: for albumin 48% before PEG placement vs. 2 1 % after PEG placement; protein 24% vs. 9%; calcium 14% vs. 3%; magnesium 16% vs. 5%; vitamin A 69% vs. 14%; folate 14% vs. 2%). Before PEG placement 36% had a BMI below 20 vs. 24% after PEG placement, and 90% had low body cell mass at BIA measurement (ecml bcm-index>l) vs. 50% under PEG nutrition. Quality of life scores remained unchanged despite progressing underlying disease (GLQI 85:!:3 SD of 144 possible points before PEG placement, 87:!:5 after PEG placement). Conclusions: Enteral nutrition by PEG provides a minimum supply of minerals and vitamins. Quality of life is preserved. In some cases PEG should be employed earlier to reduce the mortality during initial hospitalization. This research was funded by Fresenius, Germany.
4141 INULIN AND FOS FEEDING MODIFY COLONIC MUCOSAL BACTERIA IN VIVO. S. J. Langlans, M. 1. Hopkins, J. H. Cummings, Watford Gen Hosp, London, United Kingdom; Ninewells Hosp & Med Sch, Univ of Dundee, Dundee, United Kingdom. Aims: to assess the effect of adding fermentable short chain carbohydrate s to the diet on the colonic mucosal flora background: prebiotics including the fructose polymers inulin and oligofructose are fermentable carbohydrates that benefit the host by stimulating the growth of specific bacteria, in this case, the bifidobacteria. Several studies have confirmed this prebiotic action of these foodstuffs (contained in wheat, onions, artichokes, chicory and garlic) on faecal bacteriology although the effect on the mucosal flora is unknown. In a model fermentation system, we have shown that the prebiotic effect is more pronounced on the surface associated bacteria and have carried out a human feeding study to investigate this effect in vivo. Methods: 15 healthy (no history of diarrhoea, inflammatory bowel disease or colorectal carcinoma) subjects were selected from the colonoscopy waiting list and supplemented their usual diet with 15g/day inulin/fos mixture for 2 weeks before their colonoscopy. At the procedure biopsies of mucosa were removed for culture, hisological analysis and measurement of proliferative indices. Anaerobic cultures were identified according to their pattern of cellular fatty acids( midi system). A group of age and sex matched healthy subjects attending for colonoscopy were used as controls results:the added carbohydrate was well tolerated by the majority of subjects the main side effects of supplementation being wind and bloating. The effect on the mucosal flora was to increase both bifidobacterial and lactobacilli counts on the mucosa significantly. This was by 1 log cfulg mucosa and 0.5 log CFU/g mucosa respectively without affecting overall figures. Discussion: this small feeding study has shown that adding fermentable carbohydrate to the diet will cause a favourable alteration in the bacterial populations associated with the colonic mucosa. Further studies are planned to study this effect in more detail.
4142 APPROPRIATENESS OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) IN A HOSPITALSERVING REGIONALENT, NEUROSURGERY & ONCOLOGY. Steven D. Mann, Susan Evans, Marta S. Carpani de Kaski, Andrew V. Thillainayagam, Imperial Coli Sch of Medicine, London, United Kingdom; Chafing Cross Hosp, London, United Kingdom; ICSM, Chafing Cross Hosp, London, United Kingdom. Introduction: Currently available guidelines recommend placement of a PEG if planned enteral feeding is likely to exceed 2-4 weeks. It is generally agreed that it would be inappropriate to place a PEG in a patient with incurable or rapidly progressive disease which is likely to be fatal. Nevertheless, rates of inappropriate PEG placement approaching 27% have been reported. Therefore, we have reviewed the appropriateness of PEG placement in our hospital over a 3-year period. Results: PEG placement was carried out in 309 patients (mean age 63 y, 197 male; mean duration of feeding = 94.9 days) between October 1996 and September 1999 inclusive. These patients were referred from oncology (32.7%), ENT 20.7%), neurosurgery (14.2%), other medical specialties (17.1%), and other surgical specialties (7.5%). PEG insertion was considered inappropriate if the patients died for non-procedure related reasons or had elective removal of the PEG within 28 days of its placement. At the time of our audit, 33 patients (10.7%) were still on a home PEG feeding program. One
GASTROENTEROLOGY Vol. 118, No.4
4138
4140
EFFICACYOF ANTmIOTIC-LOCK TECHNIQUE WITH TElCOPLANIN IN STAPHYLOCOCCUS EPIDERMIDIS CATHETERRELATED SEPSIS DURING LONG-TERM PARENTERAL NUTRITION.
PERCUTANEOUS ENDOSCOPIC GASMOSTOMY (PEG) - EVALUATION OF NUTRITION AND QUALITY OF LIFE. J. Klose, W. Heldwein, F. Sernetz, B. Otto, M. Gross, K. Loeschke, Clin
Claire Guedon, Olivier Lalaude, Michele Nouvellon, Eric Lerebours, Grad, Rouen, France; Bacteriology unit. Rouen Univ Hosp, Rouen, France. Catheter-related sepsis (CRS) is a serious complication of long-term parenteral nutrition (PN) but its true incidence and the prevalence of staphylococcus epidermidis (SE) infection remain controversial. Antibiotic-lock technique (ALT) has been proposed as an alternative to catheter removal. The aim of this study was to determine a) the incidence of CRS, b) the SE prevalence infection rate c) the efficacy of teicoplanin-Al.T, Patients and methods : This two-years (1997-98) retrospective study enrolled 196 consecutive gastroenterological patients receiving PN via a catheter, either at hospital (n= 156) or at home (n=40). Infectious diagnosis of CRS was carried out on drawn back and peripheral blood. All suspicious CRS were treated by in-situ teicoplanin (5 mg/2ml infused in catheter and rinced after 12 hours) in ALT. After blood cultures results. catheter was immediately removed in case of non-SE infecting organism and secondly removed in SE-CRS if fever persists after 48 hours of ALT. Systemic antibiotics were added in cases of bacteriemia. Results : in all inserted catheters, 28 CRS occurred in 15 patients : 20 SE (13 meticillin susceptible : metiS, 7 meticillin resistant: metiR) and 8 non-SE : 3 S. aureus, 1 bacillus circulans, 1 streptococcus B, 1 candida, 1 pseudomonas, 1 corynebacteria. With regard to PN duration, CRS incidence was not significantly different between home and hospital PN (0.52/100 vs 0.37/100 days). Five out of 15 patients had 2 or more CRS. First infection median delay was 27 days (range: 2-342) at hospital and 115 days (range: 16-1950) at home (NS), median reinfection delay was 193 days (range: 115-342). In 4 patients, metiS infection treated with ALT was followed by SE metiR reinfection. For SE metiS infection (n = 13), ALT allowed a short-term salvage of the catheter in 6/6 cases when it was a first infection. ALT allowed a salvage of the catheter in 1/7 cases, when the metiS SE infection was a reinfection. In 6/7 cases of metiR infection, teicoplanin-Al.T did not avoid catheter removal with persistant fever after 48 hours. Conclusion: In our study, incidence of CRS was low and not different at home and at hospital. Prevalence of SE-CRS was 71% of CRS. Meti resistance was a predictive factor of inefficacy of teicolpanin-Al.T, At short term, teicoplanin-ALT was efficacious suggesting its use as a treatment of choice in SE-CRS in short-term PN.
4139
LONG·TERM OUTCOME OF PATIENTS TREATED WITH HOME ENTERAL NUTRITION. Stephane M. Schneider, Claire Raina, Pascal Pugliese, Isabelle Pouget, Patrick Rampal, Xavier Hebuterne, Hosp de I' Archet, Nice, France. The aim of this study was to prospectively analyze the long-term outcome of home enteral nutrition (HEN) patients in order to determine the benefits of this treatment. Methods: Between 1990 and 1996, 417 patients (195 men, 185 women, and 37 children, mean age: 64 ::!: 25 years) were discharged from our hospital on HEN because of neurological disorders (39.6%), digestive diseases (16.5%), head and neck cancers (15.1%), anorexia (15.1%), AIDS (4.1%), head injuries (2.4%), or other diseases (7.4 %). The main reasons for HEN were dysphagia (58%), anorexia (30%), or moderate intestinal failure (12%). Patients were prospectively studied and followed up until December 31, 1998. A physician independent from the nutritional team recorded the final outcome. Survival probabilities were estimated from Kaplan-Meier survival curves and compared by the log-rank test. Hazard ratios and 95% confidence intervals (95% CI) were calculated by multiple logistic regression model. Results: The mean duration of HEN was 242 ::!: 494 days (mean ::!: SD). After a follow-up of 24 to 103 months, 300 of the 417 patients (71.9%) had died, 109 (26.2%) were alive, and 8 (1.9%) had been lost to follow-up. Probabilities of being alive at one and five years were 41.7% and 25%, respectively. The five-year survival rate was 80.8% for children, 34.3% for patients aged 16-70 years, and 10.7% for patients over 70 years; it was 70% for patients with head injury, 48% for patients with digestive diseases, 32% for patients with miscellaneous diseases, and between 18% and 23% for the other diagnosis groups. Independent factors associated with death were neurological disease (RR: 2,39, 95%CI: 1.19 - 4.78), head and neck cancer (RR 2.50, 95%CI: 1.10 - 5.67), AIDS (RR 5.18, 95%CI: 1.37 - 19.59), and age over 70 (RR 3.36, 95%CI: 1.91 - 5.92). After initiation of HEN, 5.5% of patients were definitely dependent on HEN. 32.6% were discharged of HEN; survival probabilities one and five years after discharge were 65% and 43%, respectively. 20.2% of patients died during the first month of HEN, and 35% died while on HEN after more than one month of treatment (219 ::!: 257 days). In 6.7% of patients HEN was stopped after a mean of one year because of rehospitalization (3.8%), intolerance to HEN (1.9%), or because they moved to another region (1%). Conclusion: HEN provides well-tolerated long-term nutritional support in most patients. However, because of their age and underlying disease, these patients have a poor prognosis. To determine the true impact of HEN, measurement of the quality of life is needed in a large cohort of patients.
Innenstadt Ludwig Maximilians Univ, Munich, Germany. Percutaneous endoscopic gastrostomie (PEG) is an established method for enteral nutrition of patiens with dysphagia but few data exist about possible nutritional deficits and quality of life. We therefore followed both aspects before and after PEG placement. Methods: 60 patients (22 f, 38 m; 73:!:14 years) with dysphagia (67% neurologic disease, 33% cancer) were followed up for a period of 12 month. Before as well as 1,2,3,6,9, 12 month after PEG blood sampling for minerals and vitamins and bioelectric impedance analysis (BIA) were performed. A validated questionnaire (GLQI) was regularly used to document quality of life. Results: Because of the severity of the underlying disease, II patients (18%) died during the initial hospitalization in which the PEG tube was placed (day 1-30). Dependent on the duration of dysphagia a number of nutritional deficits were noted which improved during PEG feeding: for albumin 48% before PEG placement vs. 2 1 % after PEG placement; protein 24% vs. 9%; calcium 14% vs. 3%; magnesium 16% vs. 5%; vitamin A 69% vs. 14%; folate 14% vs. 2%). Before PEG placement 36% had a BMI below 20 vs. 24% after PEG placement, and 90% had low body cell mass at BIA measurement (ecml bcm-index>l) vs. 50% under PEG nutrition. Quality of life scores remained unchanged despite progressing underlying disease (GLQI 85:!:3 SD of 144 possible points before PEG placement, 87:!:5 after PEG placement). Conclusions: Enteral nutrition by PEG provides a minimum supply of minerals and vitamins. Quality of life is preserved. In some cases PEG should be employed earlier to reduce the mortality during initial hospitalization. This research was funded by Fresenius, Germany.
4141 INULIN AND FOS FEEDING MODIFY COLONIC MUCOSAL BACTERIA IN VIVO. S. J. Langlans, M. 1. Hopkins, J. H. Cummings, Watford Gen Hosp, London, United Kingdom; Ninewells Hosp & Med Sch, Univ of Dundee, Dundee, United Kingdom. Aims: to assess the effect of adding fermentable short chain carbohydrate s to the diet on the colonic mucosal flora background: prebiotics including the fructose polymers inulin and oligofructose are fermentable carbohydrates that benefit the host by stimulating the growth of specific bacteria, in this case, the bifidobacteria. Several studies have confirmed this prebiotic action of these foodstuffs (contained in wheat, onions, artichokes, chicory and garlic) on faecal bacteriology although the effect on the mucosal flora is unknown. In a model fermentation system, we have shown that the prebiotic effect is more pronounced on the surface associated bacteria and have carried out a human feeding study to investigate this effect in vivo. Methods: 15 healthy (no history of diarrhoea, inflammatory bowel disease or colorectal carcinoma) subjects were selected from the colonoscopy waiting list and supplemented their usual diet with 15g/day inulin/fos mixture for 2 weeks before their colonoscopy. At the procedure biopsies of mucosa were removed for culture, hisological analysis and measurement of proliferative indices. Anaerobic cultures were identified according to their pattern of cellular fatty acids( midi system). A group of age and sex matched healthy subjects attending for colonoscopy were used as controls results:the added carbohydrate was well tolerated by the majority of subjects the main side effects of supplementation being wind and bloating. The effect on the mucosal flora was to increase both bifidobacterial and lactobacilli counts on the mucosa significantly. This was by 1 log cfulg mucosa and 0.5 log CFU/g mucosa respectively without affecting overall figures. Discussion: this small feeding study has shown that adding fermentable carbohydrate to the diet will cause a favourable alteration in the bacterial populations associated with the colonic mucosa. Further studies are planned to study this effect in more detail.
4142 APPROPRIATENESS OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) IN A HOSPITALSERVING REGIONALENT, NEUROSURGERY & ONCOLOGY. Steven D. Mann, Susan Evans, Marta S. Carpani de Kaski, Andrew V. Thillainayagam, Imperial Coli Sch of Medicine, London, United Kingdom; Chafing Cross Hosp, London, United Kingdom; ICSM, Chafing Cross Hosp, London, United Kingdom. Introduction: Currently available guidelines recommend placement of a PEG if planned enteral feeding is likely to exceed 2-4 weeks. It is generally agreed that it would be inappropriate to place a PEG in a patient with incurable or rapidly progressive disease which is likely to be fatal. Nevertheless, rates of inappropriate PEG placement approaching 27% have been reported. Therefore, we have reviewed the appropriateness of PEG placement in our hospital over a 3-year period. Results: PEG placement was carried out in 309 patients (mean age 63 y, 197 male; mean duration of feeding = 94.9 days) between October 1996 and September 1999 inclusive. These patients were referred from oncology (32.7%), ENT 20.7%), neurosurgery (14.2%), other medical specialties (17.1%), and other surgical specialties (7.5%). PEG insertion was considered inappropriate if the patients died for non-procedure related reasons or had elective removal of the PEG within 28 days of its placement. At the time of our audit, 33 patients (10.7%) were still on a home PEG feeding program. One