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Utilization of PEG in Diverse Clinical Practice Settings in the United States
Abstracts
M1377 Utilization of PEG in Diverse Clinical Practice Settings in the United States Adam E. Silverblatt, Leann Michaels, Nora Mattek, Glenn Eisen, David Lieberman
balloon endoscopy is a safe endoscopic technique with a high diagnostic yield in selected patients and excellent patient tolerability by our institutional experience. Moreover, Double over tube method is useful to examine more safely. Total number
Background/Aims: Percutaneous Endoscopic Gastrostomy (PEG) is performed when patients are or will be unable to maintain adequate nutritional intake. Recent events increased attention to artificial nutrition and hydration. Prior research describes single center experiences with PEG and mostly focuses on mortality or quality of life benefits. Our aim is to study PEG utilization in diverse practice settings to determine indications, patient demographics, and success rates. Methods: PEG tubes placed between July 2004 and June 2005 were reviewed from the Clinical Outcomes Research Initiative (CORI), an endoscopic database derived from 73 practice sites in 24 states. EGD reports for PEG insertion in patients over age 17 were included. Indication for PEG was reviewed manually from the CORI database when necessary. Results: 1269 PEG procedures (59% Male) are reported. 409 (32%) procedures were performed in patients over 80 years of age. The majority of patients were white non-hispanic (n Z 882, 69.5%) and received PEGs in community (n Z 770, 60.7%), academic (n Z 255, 20.1%), and VA/military (n Z 244, 19.2%) facilities. Procedures occurred in the hospital (n Z 1207, 95.1%) or in ambulatory endoscopy units (n Z 62, 4.9%) and were done in 595 (46.9%) inpatients and 378 (29.8%) outpatients (unidentified in 296 (23.3%) patients). The majority of patients had severe systemic illness (ASA III or IV) (n Z 622, 49%). Patient demographics and indications are shown in Table 1, with the most common reasons being neurologic conditions (35%) and cancer (16%). Success rate for PEG insertion was 98%. Immediate complications were reported in 35 (2.8%) patients, predominantly oxygen saturation less than 95% (n Z 12). One patient had a serious complication (perforation). Conclusions: This large study describes utilization of PEG in diverse clinical practice settings. The patients are elderly (mean age Z 70.3) and frail (ASA III-IV:57%). Neurologic conditions and cancer (usually ENT) account for almost one-half of procedures. Further study is needed to determine if PEG improves quality of life in these settings. Table 1. 1269 PEGs in Multi-Center Consortium Male Age: !50 50-69 70-79 R80 Inpatient status ASA III or IV
59%
Indications:
11% 29% 27% 32% 61%) 57%)
Neurologic Condition Stroke ALS Aspiration Risk Cancer Dementia Other Unknown
35% 9% 2% 5% 16% 4% 23% 4%
)When known.
M1378 Double-Balloon Enteroscopy: First One Year Experience and Modified Technique (Double-Over Tube Method) Akihiro Araki, Kiichiro Tsuchiya, Shigeru Oshima, Eriko Okada, Takanori Kanai, Mamoru Watanabe Background: The advent of the double-balloon enteroscopy (DBE, Fujinon Japan) enabling true full length endoscopy for the first time, tissue sampling and interventional therapies of the entire small intestine a major shortcoming of conventional methods has been surpassed. This new technique were investigated and that experience bring several modified techunique to prevent complication and to avoid discomfort of patient in procedure. Methods: Double-balloon enteroscopy was performed in 50 patients in the first year after introduction in our hospital in September 2004. Indication; 1. unidentified gastro-intestinal (Gl) blood loss. 2. unidentified ileus. 3. other disease of small intestin known by another method (GIST, crohn’s disease, eosinophilic gastroenteritis, lipoma).Pentazocine and hydroxyzine hydrochroride was used for sedation. Results: To 50 patients, 85 times prosedure were performed. 32 times approached orally were performed. 52 times approached via colon were performed. 33 times from both sides were performed. The average procedure duration was 99 min (range 63 to 179) via colon, 61 min (range 28 to 121) orally. The detected rate of a lesion was 64% (32/50). One complication occurred, the hemodialyzed patient became aspiration pneumonitis within maneuver orally. At the night of examination, patient had a fever and we predicted aspiration pneumonitis and prescribed antibiotics. Radiograph on the next day revealed pneumonia in chest, and aberration of inflammatory reaction was seen. We did antipyresis after 3rd, and inflammatory reaction was normalized, too. On this account we did a new modified techunique to reduce laryngeal discomfort while preventing aspiration. Double over tube method lets outward another exaggerated tube of an exaggerated tube for existing double balloons go through. Aspiration pneumonitis is not caused by this afterwards. Conclusion: Double
AB186 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
Duration time Detected rate of a lesion Rate of complication
50 patient orally via colon orally via colon 64% 2%
85 times 32 times 53 times 61 min (range 28 to 121) 99 min (range 63 to 179) 32/50 1/50
M1379 Differentiation of Small Bowel Strictures By Double-Balloon Endoscopy Hwang Choi, Kyu-Yong Choi, Bo-in Lee, Kyoung-Mee Kim, Hyong-Ju Kang, Jae-Myung Park, Tae-Ho Kim, Soo-Heon Park, Hiun-Suk Chae, Myung-Gyu Choi, Sok-Won Han, in-Sik Chung Background/Aims: The diagnosis of small bowel stricture was made by operation. Capsule endoscopy has been useful for diagnosis of small bowel diseases but is limited in use in cases with stricture. Double-balloon endoscopy is the useful method to visualize the entire small bowel. The aim of this study is to evaluate the usefulness of the double-balloon endoscopy in patient with small bowel stricture. Methods: Between March 2004 and November 2005, nine consecutive patients were referred for the evaluation of small bowel stricture. Small bowel strictures were suspected in small bowel series or CT in five patients. Capsule endoscopies were entrapped in two other patients. One patient (case #4) was resected small intestine for lymphoma, 3 years ago. Double-balloon endoscopy (EN-450P5/20, Fujinon, Japan) was performed with midazolam (median 5 mg, range 5-10 mg) and meperidine (median 50 mg, range 50-100 mg). Results: Endoscopic findings and clinical outcomes were summarized on table. All lesions were found within 60 minutes except one patient (case #2). Four patients confirmed to Crohn’s disease were relieved symptoms by 5-aminosalicylic acid with or without steroid. Entrapped capsules were easily removed by polypectomy snare. Four patients were diagnosed as 1 postoperative, 2 adhesive, and 1 NSAID-induced stricture. Abdominal pain and distention was developed after procedure in one patient (case #5) and relieved after 1 day with conservative care. But his obstructive symptom was recurred after 15 days of procedure and he was operated. Conclusions: Double-balloon endoscopy is a useful and safe method for diagnosis in patients with small bowel stricture and Clinical Outcomes of Double-Balloon Endoscopy.
Sex Age Route Findings
Histopathology
Diagnosis
Clinical outcomes
F
35 Anal
Granuloma
Crohn’s disease
Improved by 5-ASA
M
57 Anal
M
42 Oral
M
54 Oral
M
33 Anal
M
36 Anal
F
55 Anal
M
47 Oral
F
50 Anal
Irregularmarginated circular ulcer in ileum No narrowing
Infiltration of plasma cells, eosinophils, & mononuclear cells Chronic Ulcer scar wirth nodularity inflammation in jejunum Ischemic change Normal only mucosa in ileum Longitudinal Granuloma ulcer scar in ileum Round ulcer Chronic with concentric inflammation narrowing in ileum Rectangular Chronic large ulcer in inflammation jejunum Normal mucosa in ileum and cecal scar Longitudinal multiple ulcers in jejunum & ileum
Adhesive ileus Crohn’s disease
Relief after enteroscopy Capsule removal Improved by 5-ASA and steroid Postoperative Capsule stricture removal Symptom free Ischemic Operation injury Crohn’s disease
Improved by 5-ASA
NSAIDinduced stricture
No symptoms
Crohn’s disease
Improved by 5-ASA
Tuberculosis Spontaneously sequelae relieved
www.giejournal.org
M1377 Utilization of PEG in Diverse Clinical Practice Settings in the United States Adam E. Silverblatt, Leann Michaels, Nora Mattek, Glenn Eisen, David Lieberman
balloon endoscopy is a safe endoscopic technique with a high diagnostic yield in selected patients and excellent patient tolerability by our institutional experience. Moreover, Double over tube method is useful to examine more safely. Total number
Background/Aims: Percutaneous Endoscopic Gastrostomy (PEG) is performed when patients are or will be unable to maintain adequate nutritional intake. Recent events increased attention to artificial nutrition and hydration. Prior research describes single center experiences with PEG and mostly focuses on mortality or quality of life benefits. Our aim is to study PEG utilization in diverse practice settings to determine indications, patient demographics, and success rates. Methods: PEG tubes placed between July 2004 and June 2005 were reviewed from the Clinical Outcomes Research Initiative (CORI), an endoscopic database derived from 73 practice sites in 24 states. EGD reports for PEG insertion in patients over age 17 were included. Indication for PEG was reviewed manually from the CORI database when necessary. Results: 1269 PEG procedures (59% Male) are reported. 409 (32%) procedures were performed in patients over 80 years of age. The majority of patients were white non-hispanic (n Z 882, 69.5%) and received PEGs in community (n Z 770, 60.7%), academic (n Z 255, 20.1%), and VA/military (n Z 244, 19.2%) facilities. Procedures occurred in the hospital (n Z 1207, 95.1%) or in ambulatory endoscopy units (n Z 62, 4.9%) and were done in 595 (46.9%) inpatients and 378 (29.8%) outpatients (unidentified in 296 (23.3%) patients). The majority of patients had severe systemic illness (ASA III or IV) (n Z 622, 49%). Patient demographics and indications are shown in Table 1, with the most common reasons being neurologic conditions (35%) and cancer (16%). Success rate for PEG insertion was 98%. Immediate complications were reported in 35 (2.8%) patients, predominantly oxygen saturation less than 95% (n Z 12). One patient had a serious complication (perforation). Conclusions: This large study describes utilization of PEG in diverse clinical practice settings. The patients are elderly (mean age Z 70.3) and frail (ASA III-IV:57%). Neurologic conditions and cancer (usually ENT) account for almost one-half of procedures. Further study is needed to determine if PEG improves quality of life in these settings. Table 1. 1269 PEGs in Multi-Center Consortium Male Age: !50 50-69 70-79 R80 Inpatient status ASA III or IV
59%
Indications:
11% 29% 27% 32% 61%) 57%)
Neurologic Condition Stroke ALS Aspiration Risk Cancer Dementia Other Unknown
35% 9% 2% 5% 16% 4% 23% 4%
)When known.
M1378 Double-Balloon Enteroscopy: First One Year Experience and Modified Technique (Double-Over Tube Method) Akihiro Araki, Kiichiro Tsuchiya, Shigeru Oshima, Eriko Okada, Takanori Kanai, Mamoru Watanabe Background: The advent of the double-balloon enteroscopy (DBE, Fujinon Japan) enabling true full length endoscopy for the first time, tissue sampling and interventional therapies of the entire small intestine a major shortcoming of conventional methods has been surpassed. This new technique were investigated and that experience bring several modified techunique to prevent complication and to avoid discomfort of patient in procedure. Methods: Double-balloon enteroscopy was performed in 50 patients in the first year after introduction in our hospital in September 2004. Indication; 1. unidentified gastro-intestinal (Gl) blood loss. 2. unidentified ileus. 3. other disease of small intestin known by another method (GIST, crohn’s disease, eosinophilic gastroenteritis, lipoma).Pentazocine and hydroxyzine hydrochroride was used for sedation. Results: To 50 patients, 85 times prosedure were performed. 32 times approached orally were performed. 52 times approached via colon were performed. 33 times from both sides were performed. The average procedure duration was 99 min (range 63 to 179) via colon, 61 min (range 28 to 121) orally. The detected rate of a lesion was 64% (32/50). One complication occurred, the hemodialyzed patient became aspiration pneumonitis within maneuver orally. At the night of examination, patient had a fever and we predicted aspiration pneumonitis and prescribed antibiotics. Radiograph on the next day revealed pneumonia in chest, and aberration of inflammatory reaction was seen. We did antipyresis after 3rd, and inflammatory reaction was normalized, too. On this account we did a new modified techunique to reduce laryngeal discomfort while preventing aspiration. Double over tube method lets outward another exaggerated tube of an exaggerated tube for existing double balloons go through. Aspiration pneumonitis is not caused by this afterwards. Conclusion: Double
AB186 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
Duration time Detected rate of a lesion Rate of complication
50 patient orally via colon orally via colon 64% 2%
85 times 32 times 53 times 61 min (range 28 to 121) 99 min (range 63 to 179) 32/50 1/50
M1379 Differentiation of Small Bowel Strictures By Double-Balloon Endoscopy Hwang Choi, Kyu-Yong Choi, Bo-in Lee, Kyoung-Mee Kim, Hyong-Ju Kang, Jae-Myung Park, Tae-Ho Kim, Soo-Heon Park, Hiun-Suk Chae, Myung-Gyu Choi, Sok-Won Han, in-Sik Chung Background/Aims: The diagnosis of small bowel stricture was made by operation. Capsule endoscopy has been useful for diagnosis of small bowel diseases but is limited in use in cases with stricture. Double-balloon endoscopy is the useful method to visualize the entire small bowel. The aim of this study is to evaluate the usefulness of the double-balloon endoscopy in patient with small bowel stricture. Methods: Between March 2004 and November 2005, nine consecutive patients were referred for the evaluation of small bowel stricture. Small bowel strictures were suspected in small bowel series or CT in five patients. Capsule endoscopies were entrapped in two other patients. One patient (case #4) was resected small intestine for lymphoma, 3 years ago. Double-balloon endoscopy (EN-450P5/20, Fujinon, Japan) was performed with midazolam (median 5 mg, range 5-10 mg) and meperidine (median 50 mg, range 50-100 mg). Results: Endoscopic findings and clinical outcomes were summarized on table. All lesions were found within 60 minutes except one patient (case #2). Four patients confirmed to Crohn’s disease were relieved symptoms by 5-aminosalicylic acid with or without steroid. Entrapped capsules were easily removed by polypectomy snare. Four patients were diagnosed as 1 postoperative, 2 adhesive, and 1 NSAID-induced stricture. Abdominal pain and distention was developed after procedure in one patient (case #5) and relieved after 1 day with conservative care. But his obstructive symptom was recurred after 15 days of procedure and he was operated. Conclusions: Double-balloon endoscopy is a useful and safe method for diagnosis in patients with small bowel stricture and Clinical Outcomes of Double-Balloon Endoscopy.
Sex Age Route Findings
Histopathology
Diagnosis
Clinical outcomes
F
35 Anal
Granuloma
Crohn’s disease
Improved by 5-ASA
M
57 Anal
M
42 Oral
M
54 Oral
M
33 Anal
M
36 Anal
F
55 Anal
M
47 Oral
F
50 Anal
Irregularmarginated circular ulcer in ileum No narrowing
Infiltration of plasma cells, eosinophils, & mononuclear cells Chronic Ulcer scar wirth nodularity inflammation in jejunum Ischemic change Normal only mucosa in ileum Longitudinal Granuloma ulcer scar in ileum Round ulcer Chronic with concentric inflammation narrowing in ileum Rectangular Chronic large ulcer in inflammation jejunum Normal mucosa in ileum and cecal scar Longitudinal multiple ulcers in jejunum & ileum
Adhesive ileus Crohn’s disease
Relief after enteroscopy Capsule removal Improved by 5-ASA and steroid Postoperative Capsule stricture removal Symptom free Ischemic Operation injury Crohn’s disease
Improved by 5-ASA
NSAIDinduced stricture
No symptoms
Crohn’s disease
Improved by 5-ASA
Tuberculosis Spontaneously sequelae relieved
www.giejournal.org