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Prophylactic gastrostomy for head & neck cancer: 5 year experience from a tertiary referral centre
Abstracts / Clinical Nutrition ESPEN 10 (2015) e174ee212
days. This equates to less than half of the prescribed volume of supplement being taken each day. This may have affected the outcomes of the study. This study reinforces that dietary counselling should remain first line treatment for undernourished children. There needs to be further studies done looking at factors (such as prescribed fluid volume and palatability) affecting ONS compliance in children. 1. A report by the University of Ulster, Nutrition screening week survey and audit, UK and Ireland, (2011) 2. Walton J (ED) 2012 National Children’s Nutrition Survey-Summary Report on: Food and Nutrient Intakes, Physical Measurements and Barriers to Healthy Eating OC59. PROPHYLACTIC GASTROSTOMY FOR HEAD & NECK CANCER: 5 YEAR EXPERIENCE FROM A TERTIARY REFERRAL CENTRE S. Fong 1, R. Donnelly 2, P. Lowe 2, H. Al-Hilou 1, K. Patel 1, T. Wong 1, P. Irving 1, J.P. Jeannon 3, R. Simo 3, M. McCarthy 1, J.M. Dunn 1. 1Department of Gastroenterology, Guys and St Thomas' Hospital NHS Trust, UK; 2 3 Department of Dietetics, GSTT, UK; Department of Otorhinolaryngology-Head & Neck Surgery, GSTT, UK Prophylactic gastrostomy placement remains controversial in H&N cancer, with conflicting evidence regarding quality of life (QoL), tube dependency and swallow outcomes. BSG guidance recommends gastropexy over Perctuaneous Endoscopic Gastrostomy (PEG) due to concerns of tumour seeding to PEG site. Guy’s and St Thomas’ Hospital is a tertiary centre for head and neck cancer. We have previously published on formal tumour assessment protocol that eliminated airway obstruction as a complication and reduced the potential for metastases at the gastrostomy site. We present data for prophylactic PEG and Radiologically Inserted Gastrostomy (RIG) insertions prior to chemo-radiotherapy (CRT) for H&N cancer over a 5 year period between 2007 and 2012. Data was obtained from patient records. Analysis was by independent t-tests for continuous variables and chi-squared tests for categorical variables. Gastrostomy insertions were successful in 286/324 (88%) patients. Overall 95% of patients used the tube for feeding. Demographic and outcome data are shown in Table 1. The 30 day mortality post gastrostomy insertion was zero. There were 2 major complications e one peritonitis and one GI bleed, both managed conservatively. Minor complications included mild stoma infections (19%) which all settled on a course of oral antibiotics, and pain (14% mild, 3.5% severe) treated with simple analgesia. No tumour seeding has been reported.
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OC60. INTRODUCTION OF A COMPLETE NUTRITION SUPPORT TEAM INCREASES APPROPRIATE PARENTERAL NUTRITION USE AND REDUCES ITS COMPLICATIONS C.L. Hvas 1, 4, K. Farrer 1, E. Donaldson 2, B. Blackett 3, H. Lloyd 3, C. Forde 3, P. Paine 3, S. Lal 1. 1Intestinal Failure Unit, Manchester M6 8HD, UK; 2Quality Improvement Directorate, Manchester M6 8HD, UK; 3Nutrition Support Team, Salford Royal NHS Foundation Trust, Manchester M6 8HD, UK; 4 Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, 8000 Aarhus C, Denmark Parenteral nutrition (PN) should be provided to malnourished hospitalised patients who cannot be safely fed using the oral or enteral route. A nutrition support team (NST) may improve the efficacy and safety of the PN service provided1-3. We compared the use and complications of hospital PN before and after implementation of a complete NST. From 2009-12, all hospitalised patients outside of intensive care who were referred for PN were consecutively registered in a clinical database. A complete NST was introduced in early 2010. Before introduction of the NST, a mean of 16 patients (limits of normal variation 4-28) were referred for PN each month. After introduction of the NST, this rose to a mean of 26 referrals per month (10-41). The percentage of referrals where PN was not started rose from 5.3% in 2009 to 10.1% in 2012 (p¼0.03). In 82% of these patients, oral or enteral nutrition could replace PN. The increase in referrals where PN was not started was only observed among specialty teams who infrequently referred for PN and in specialties other than gastrointestinal surgery and gastroenterology. Line sepsis rate dropped from 8% to 1% after NST implementation and remained low throughout the follow-up period (p<0.001). The 30-day mortality was unaffected by introduction of the NST (30- day mortality pre NST: 15%; 30day mortality post NST: 14%, p¼0.63) In this study, the introduction of a NST increased both the number of commenced PN courses and the percentage of referrals where enteral nutrition could replace PN. Appropriateness of referral for PN was associated with medical and surgical specialty. The line sepsis rate dropped, but overall 30-day mortality was unaffected after introduction of the NST. 1. Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total parenteral nutrition team improve patient outcomes? A systematic review. JPEN J Parenter Enteral Nutr 2004; 28: 251-8. 2. Kennedy JF, Nightingale JM. Cost savings of an adult hospital nutrition support team. Nutrition 2005; 21: 1127-33. 27. 3. Sriram K, Cyriac T, Fogg LF. Effect of nutritional support team restructuring on the use of parenteral nutrition. Nutrition 2010; 26: 735-9.
Table 1 Study outcomes (OC59).
Age (+/- SEM) Sex (Male) Stage IVA-C Mean BMI (+/- SEM) Median weight change (+/- IQR) Mean length tube in situ (+/- SEM) 30 day mortality (treatmentend date) 1 year mortality (treatment end date)
Total (n¼ 286)
PEG (n¼ 182)
RIG (n¼ 104)
P value
58.6 (+/- 0.64) 75% (214) 75% (286) 24.6 (+/- 0.56) -6.6% (-10.6% -2.7%) 11.8 months (+/- 0.77) 6.6% (19) 23% (66)
58.6(+/- 0.64) 75% (136) 75% (136) 25.2 (+/- 0.50) -6.9% (-11.2% -3.6%) 13.4 months (+/- 1.6) 6% (11) 19% (34)
58.2 (+/- 0.79) 75% (78) 74% (77) 23.6 (+/- 0.56) -6.2% (-10.4% -1.32%) 6.5 months (+/- 0.76) 8% (8) 30% (32)
ns ns ns ns ns 0.006 ns 0.028
This large cohort study supports gastrostomy insertion as a feasible and safe procedure for nutritional supplementation in patients with H&N cancer undergoing CRT. These data demonstrate a statistically significant improvement in 1 year mortality, and a statistically longer duration of tube in situ for PEG versus RIG. Our major and minor complications rates are lower than previous series. These data are limited to a single tertiary centre, with a dedicated team of dietitians, MDT approach to tumour assessment, and consultant led service for PEG or RIG placement.
OC61. USING A SERVICE IMPROVEMENT TECHNIQUE TO IMPROVE THE CARE OF PATIENTS REQUIRING NASOGASTRIC FEEDING TUBES R. Patel 1, A. Rochford 2. 1Department of Nutrition and Dietetics Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK; 2 Department of Gastroenterology, Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK
days. This equates to less than half of the prescribed volume of supplement being taken each day. This may have affected the outcomes of the study. This study reinforces that dietary counselling should remain first line treatment for undernourished children. There needs to be further studies done looking at factors (such as prescribed fluid volume and palatability) affecting ONS compliance in children. 1. A report by the University of Ulster, Nutrition screening week survey and audit, UK and Ireland, (2011) 2. Walton J (ED) 2012 National Children’s Nutrition Survey-Summary Report on: Food and Nutrient Intakes, Physical Measurements and Barriers to Healthy Eating OC59. PROPHYLACTIC GASTROSTOMY FOR HEAD & NECK CANCER: 5 YEAR EXPERIENCE FROM A TERTIARY REFERRAL CENTRE S. Fong 1, R. Donnelly 2, P. Lowe 2, H. Al-Hilou 1, K. Patel 1, T. Wong 1, P. Irving 1, J.P. Jeannon 3, R. Simo 3, M. McCarthy 1, J.M. Dunn 1. 1Department of Gastroenterology, Guys and St Thomas' Hospital NHS Trust, UK; 2 3 Department of Dietetics, GSTT, UK; Department of Otorhinolaryngology-Head & Neck Surgery, GSTT, UK Prophylactic gastrostomy placement remains controversial in H&N cancer, with conflicting evidence regarding quality of life (QoL), tube dependency and swallow outcomes. BSG guidance recommends gastropexy over Perctuaneous Endoscopic Gastrostomy (PEG) due to concerns of tumour seeding to PEG site. Guy’s and St Thomas’ Hospital is a tertiary centre for head and neck cancer. We have previously published on formal tumour assessment protocol that eliminated airway obstruction as a complication and reduced the potential for metastases at the gastrostomy site. We present data for prophylactic PEG and Radiologically Inserted Gastrostomy (RIG) insertions prior to chemo-radiotherapy (CRT) for H&N cancer over a 5 year period between 2007 and 2012. Data was obtained from patient records. Analysis was by independent t-tests for continuous variables and chi-squared tests for categorical variables. Gastrostomy insertions were successful in 286/324 (88%) patients. Overall 95% of patients used the tube for feeding. Demographic and outcome data are shown in Table 1. The 30 day mortality post gastrostomy insertion was zero. There were 2 major complications e one peritonitis and one GI bleed, both managed conservatively. Minor complications included mild stoma infections (19%) which all settled on a course of oral antibiotics, and pain (14% mild, 3.5% severe) treated with simple analgesia. No tumour seeding has been reported.
e203
OC60. INTRODUCTION OF A COMPLETE NUTRITION SUPPORT TEAM INCREASES APPROPRIATE PARENTERAL NUTRITION USE AND REDUCES ITS COMPLICATIONS C.L. Hvas 1, 4, K. Farrer 1, E. Donaldson 2, B. Blackett 3, H. Lloyd 3, C. Forde 3, P. Paine 3, S. Lal 1. 1Intestinal Failure Unit, Manchester M6 8HD, UK; 2Quality Improvement Directorate, Manchester M6 8HD, UK; 3Nutrition Support Team, Salford Royal NHS Foundation Trust, Manchester M6 8HD, UK; 4 Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, 8000 Aarhus C, Denmark Parenteral nutrition (PN) should be provided to malnourished hospitalised patients who cannot be safely fed using the oral or enteral route. A nutrition support team (NST) may improve the efficacy and safety of the PN service provided1-3. We compared the use and complications of hospital PN before and after implementation of a complete NST. From 2009-12, all hospitalised patients outside of intensive care who were referred for PN were consecutively registered in a clinical database. A complete NST was introduced in early 2010. Before introduction of the NST, a mean of 16 patients (limits of normal variation 4-28) were referred for PN each month. After introduction of the NST, this rose to a mean of 26 referrals per month (10-41). The percentage of referrals where PN was not started rose from 5.3% in 2009 to 10.1% in 2012 (p¼0.03). In 82% of these patients, oral or enteral nutrition could replace PN. The increase in referrals where PN was not started was only observed among specialty teams who infrequently referred for PN and in specialties other than gastrointestinal surgery and gastroenterology. Line sepsis rate dropped from 8% to 1% after NST implementation and remained low throughout the follow-up period (p<0.001). The 30-day mortality was unaffected by introduction of the NST (30- day mortality pre NST: 15%; 30day mortality post NST: 14%, p¼0.63) In this study, the introduction of a NST increased both the number of commenced PN courses and the percentage of referrals where enteral nutrition could replace PN. Appropriateness of referral for PN was associated with medical and surgical specialty. The line sepsis rate dropped, but overall 30-day mortality was unaffected after introduction of the NST. 1. Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total parenteral nutrition team improve patient outcomes? A systematic review. JPEN J Parenter Enteral Nutr 2004; 28: 251-8. 2. Kennedy JF, Nightingale JM. Cost savings of an adult hospital nutrition support team. Nutrition 2005; 21: 1127-33. 27. 3. Sriram K, Cyriac T, Fogg LF. Effect of nutritional support team restructuring on the use of parenteral nutrition. Nutrition 2010; 26: 735-9.
Table 1 Study outcomes (OC59).
Age (+/- SEM) Sex (Male) Stage IVA-C Mean BMI (+/- SEM) Median weight change (+/- IQR) Mean length tube in situ (+/- SEM) 30 day mortality (treatmentend date) 1 year mortality (treatment end date)
Total (n¼ 286)
PEG (n¼ 182)
RIG (n¼ 104)
P value
58.6 (+/- 0.64) 75% (214) 75% (286) 24.6 (+/- 0.56) -6.6% (-10.6% -2.7%) 11.8 months (+/- 0.77) 6.6% (19) 23% (66)
58.6(+/- 0.64) 75% (136) 75% (136) 25.2 (+/- 0.50) -6.9% (-11.2% -3.6%) 13.4 months (+/- 1.6) 6% (11) 19% (34)
58.2 (+/- 0.79) 75% (78) 74% (77) 23.6 (+/- 0.56) -6.2% (-10.4% -1.32%) 6.5 months (+/- 0.76) 8% (8) 30% (32)
ns ns ns ns ns 0.006 ns 0.028
This large cohort study supports gastrostomy insertion as a feasible and safe procedure for nutritional supplementation in patients with H&N cancer undergoing CRT. These data demonstrate a statistically significant improvement in 1 year mortality, and a statistically longer duration of tube in situ for PEG versus RIG. Our major and minor complications rates are lower than previous series. These data are limited to a single tertiary centre, with a dedicated team of dietitians, MDT approach to tumour assessment, and consultant led service for PEG or RIG placement.
OC61. USING A SERVICE IMPROVEMENT TECHNIQUE TO IMPROVE THE CARE OF PATIENTS REQUIRING NASOGASTRIC FEEDING TUBES R. Patel 1, A. Rochford 2. 1Department of Nutrition and Dietetics Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK; 2 Department of Gastroenterology, Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UK