Frederick A. Slezak

Predictive factors for early mortality after percutaneous endoscopic gastrostomy

BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is a safe access procedure for enteral nutrition. The purpose of this investigation is to identify predictive factors for early mortality after PEG. METHODS A retrospective review of the hospital records of 416 patients undergoing PEG from June 1, 1989, through December 31, 1991, was conducted. Patient demographics, admitting diagnosis, indication for PEG, risk factors for early mortality, and cause and date of death were reviewed. Logistic regression analysis was used to develop a model to predict early mortality after PEG. The follow-up period ranged from 1 to 30 months. RESULTS The overall mortality rate in this review was 227 of 416 patients (54.6%). The 7- and 30-day case fatality rates were 39 of 416 (9.4%) and 97 of 416 (23.3%), respectively. Logistic regression analysis showed that urinary tract infection (odds ratio (OR) = 3.05; 95% confidence interval (CI) = 1.45-6.43) and previous aspiration (OR = 6.86; 95% CI = 3.27-14.4) were predictive factors for death at 1 week after PEG. Patients who had both risk factors had a 48.4% probability of dying within 7 days after PEG insertion, whereas those who had no risk factors had a 4.3% probability of death. Urinary tract infection (OR = 2.00; 95% CI = 1.17-3.41), previous aspiration (OR = 3.62; 95% CI = 2.00-6.55), and age greater than 75 years (OR = 2.49; 95% CI = 1.47-4.21) were predictive factors for death at 1 month after PEG. Patients who had all three risk factors had a 67.1% probability of death at 1 month while those who had no risk factors had a 10% probability of death. CONCLUSIONS A subgroup of patients exists that has a very high mortality rate after PEG. Less invasive ways of nutritionally supporting these high-risk patients should be evaluated.

Arterial thromboembolic complications of inflammatory bowel disease: Report of three cases

Extraintestinal manifestations of inflammatory bowel disease are legion and are demonstrated in one-third of those afflicted. In general, they do not mandate surgery. Three patients with active pancolonic ulcerative colitis developed arterial thromboembolic complications prior to surgical treatment. Thromboembolic complications are not fully understood, as is evidenced by the paucity of information in the literature, and only sporadic cases of arterial thromboemboli are found. These have been described primarily in the postsurgical patient. To ascertain whether others have encountered similar cases, a survey form was distributed to members of The American Society of Colon and Rectal Surgeons, yielding an additional 54 patients with thromboembolic complications. Approximately two-thirds were deep venous thromboses and/or pulmonary emboli. Ten patients had cerebrovascular accidents, and eight had arterial emboli. Eleven patients, over 21 percent, suffered multiple events. There were four resultant mortalities. An arterial thromboembolic event in a patient with ulcerative colitis is usually associated with pancolonic disease, has a poor long-term prognosis, and is an indication for colectomy.

Inflammatory Polyps: A Cause of Late Bleeding in Stapled Hemorrhoidectomy

PurposeStapled hemorrhoidectomy has become a popular treatment of hemorrhoids, mainly because of the benefits of greatly reduced postoperative pain. However, complications unique to the new procedure have been reported. This study was designed to review our series of 82 patients with a focus on complications, with particular focus on late bleeding caused by inflammatory polyps at the staple line.MethodsA review of 82 patients who underwent stapled hemorrhoidectomy was conducted. Indications included bleeding in 29 patients, prolapse in 19, combined bleeding and prolapse in 31, and pain in 3. The procedure was performed in an outpatient setting with the Ethicon® ILS 33 stapler in the standard fashion.ResultsLate bleeding as a result of inflammatory polyps was encountered in nine patients (11 percent). Bleeding was mild, and all cases resolved after excision of the polyps. Other complications occurred with the following frequency: urinary retention (4.9 percent), submucosal hematoma (2.4 percent), early bleeding (1.2 percent), recurrent hemorrhoids (2.4 percent), thrombosed external hemorrhoids (2.4 percent), and fecal urgency (3.7 percent).ConclusionsBleeding from inflammatory polyps occurs in a significant number of patients undergoing stapled hemorrhoidectomy. Mild bleeding several weeks or months after the procedure should prompt a search for inflammatory polyps at the staple line. Simple excision of the polyps was adequate treatment and has not resulted in rebleeding.

Pneumoperitoneum following percutaneous endoscopic gastrostomy : does the timing of panendoscopy matter?

SummaryPercutaneous endoscopic gastrostomy (PEG) has had a significant impact on enteral alimentation in patients unable to maintain adequate oral caloric intake. PEG avoids the morbidity and mortality associated with the traditional feeding gastrostomies placed by celiotomy. Several authors have documented benign, self-limiting pneumoperitoneum following PEG placement. No study has addressed whether the timing of panendoscopy in relation to gastric puncture has an effect on the incidence of post-PEG pneumoperitoneum. The authors prospectively studied 30 patients undergoing PEG. Panendoscopy was either performed before or after gastric puncture, and each patient then had abdominal radiographs to determine the presence of pneumoperitoneum. Four of 16 patients (25%) having panendoscopy prior to gastric puncture had radiographic evidence of pneumoperitoneum compared to three of 14 patients (23%) having panendoscopy following gastric puncture. The authors conclude that the timing of panendoscopy in relation to gastric puncture does not significantly effect the incidence of post-PEG pneumoperitoneum.

Combined tracheostomy and percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy is rapidly becoming the preferred method of long-term enteral access with minimal complications obviating the need for prolonged nasogastric or orogastric intubation. Tracheostomy is the accepted technique for long-term airway control, especially for protection against upper airway secretions and respiratory failure. Over a 14 month period, 73 percutaneous gastrostomies were inserted in 71 patients. Nine patients (12.6 percent) had previously undergone tracheostomy, and 13 patients (18.3 percent) underwent a percutaneous endoscopic gastrostomy immediately after tracheostomy. All procedures were performed under local anesthesia. The concomitant percutaneous endoscopic gastrostomy added little time to the total procedure and was not associated with additional complications. Early experience with percutaneous gastrostomy indicates that a substantial number of patients (30.9 percent in the present study) also required tracheostomy. The tracheostomy and percutaneous endoscopic gastrostomy combination completely frees the nasopharynx of indwelling tubes. Concomitant percutaneous gastrostomy should be considered in patients undergoing tracheostomy.

Repeat percutaneous endoscopic gastrostomy (PEG) : an outpatient procedure

SummaryPatients who have previously undergone percutaneous endoscopic gastrostomy (PEG) with subsequent PEG removal occasionally require elective repeat PEG. Adhesion of the stomach to the abdominal wall after the original PEG allows repeat PEG to be performed as an outpatient procedure and full-volume tube feeding to be started immediately. Elective repeat PEG was performed in ten patients. Repeat PEG was performed at the site of the original PEG in all cases. Six of the ten repeat PEGs were performed as an outpatient procedure. No complications were attributed to repeat PEG, and full-volume tube feedings were tolerated in all cases when attempted. To obviate the need for repeat PEG, we recommend immediate replacement after inadvertent PEG removal and avoiding elective removal of PEGs used in patients with long-term neurologic impairment for at least 6 months.