Jorge Fonseca

Percutaneous endoscopic gastrostomy for nutritional palliation of upper esophageal cancer unsuitable for esophageal stenting

CONTEXT Esophageal cancer is often diagnosed at an advanced stage and has a poor prognosis. Most patients with advanced esophageal cancer have significant dysphagia that contributes to weight loss and malnutrition. Esophageal stenting is a widespread palliation approach, but unsuitable for cancers near the upper esophageal sphincter, were stents are poorly tolerated. Generally, guidelines do not support endoscopic gastrostomy in this clinical setting, but it may be the best option for nutritional support. OBJECTIVE Retrospective evaluation of patients with dysphagia caused advanced esophageal cancer, no expectation of resuming oral intake and with percutaneous endoscopic gastrostomy for comfort palliative nutrition. METHOD We selected adult patients with unresecable esophageal cancer histological confirmed, in whom stenting was impossible due to proximal location, and chemotherapy or radiotherapy were palliative, using gastrostomy for enteral nutrition. Clinical and nutritional data were evaluated, including success of gastrostomy, procedure complications and survival after percutaneous endoscopic gastrostomy, and evolution of body mass index, albumin, transferrin and cholesterol. RESULTS Seventeen males with stage III or IV squamous cell carcinoma fulfilled the inclusion criteria. Mean age was 60.9 years. Most of the patients had toxic habits. All underwent palliative chemotherapy or radiotherapy. Gastrostomy was successfully performed in all, but nine required prior dilatation. Most had the gastrostomy within 2 months after diagnosis. There was a buried bumper syndrome treated with tube replacement and four minor complications. There were no cases of implantation metastases or procedure related mortality. Two patients were lost and 12 died. Mean survival of deceased patients was 5.9 months. Three patients are alive 6, 14 and 17 months after the gastrostomy procedure, still increasing the mean survival. Mean body mass index and laboratory parameters were roughly stable 1 and 3 months after the gastrostomy procedure. CONCLUSIONS In patients with advanced upper esophageal cancer where only palliative treatment is possible, nutritional support is easily achieved with percutaneous endoscopic gastrostomy, allowing patients to be at homes, surviving a significant period of time. Percutaneous endoscopic gastrostomy feeding should be considered as standard definitive nutritional palliation in patients with upper esophageal cancer, unsuitable for esophageal stenting.

ORAL MUCOSA LESIONS AND ORAL SYMPTOMS IN INFLAMMATORY BOWEL DISEASE PATIENTS

BACKGROUND Inflammatory Bowel Disease is known for its extra intestinal manifestations, the oral cavity is no exception. OBJECTIVES The aim of this study was to evaluate the association between Inflammatory Bowel Disease and oral mucosa lesions and symptoms, and complementary to evaluate their possible relation with oral hygiene, smoking habits, drug therapy, duration and activity of the disease. METHODS Patients were selected from the Gastroenterology Clinic of a Portuguese tertiary referral hospital. This sample consisted of 113 patients previously diagnosed with ulcerative colitis or Crohns disease along with a control group of 58 healthy individuals that were accompanying the study group patients to their appointments. Clinical interviews and clinical examinations were performed for data collection. RESULTS The patients in the study group were more affected by oral symptoms (P=0.011), and showed a trend towards a higher incidence of oral mucosal lesions, even though statistical significance was not reached (8.8% versus 3.4% in the control group; P=0.159). Patients in active phase were the most affected. No differences were detected between Crohns disease and ulcerative colitis, or concerning smoking habits. The corticosteroid and immunosuppressant therapy seemed to increase the incidence of oral symptoms (P=0.052). The oral mucosa lesions increased and the oral symptoms decreased over the course of the disease, however without statistical significance. CONCLUSION Oral mucosas lesions and oral symptoms were positively associated with Inflammatory Bowel Disease, mainly during disease activity periods and conceivably, associated with corticosteroid and immunosuppressant therapy.

Noise-induced gastric lesions: a light and electron microscopy study of the rat gastric wall exposed to low frequency noise

CONTEXT Only a few studies evaluated the digestive alterations caused by low frequency noise (LFN) and most focused only on mucosal alterations. OBJECTIVES To investigate the morphological injury of LFN-exposed gastric wall, beyond the epithelial layer. METHODS Wistar rats were exposed to low frequency noise (LFN), during increasing periods, 1 to 13 weeks. A control group was kept in silence. Gastric specimens were studied using: (i) light microscopy with hematoxylin-eosin and immunostaining for collagens; (ii) transmission electron microscopy; (iii) morphometry allowing statistical analysis. RESULTS Submucosa of all LFN-exposed animals exhibit increased thickness with fibrous proliferation. Transmission electron microscopy showed massive collagen deposition. Immunostaining identified collagen IV as responsible for the increased thickness. Morphometry allowed the demonstration of a significant difference of thickness between control and exposed groups. Vascular alterations included: i) intima proliferation and thickening, rupture of the internal elastic lamina, thrombotic changes; ii) thickening of the media; iii) after 9 weeks of LFN-exposure, we found new formed vessel presenting tortuous and twisted. There is a significant difference of arterial wall thickness between control and exposed groups. CONCLUSIONS Deeper layers of gastric wall undergo alterations, including fibrosis of the submucosa caused by collagen IV deposition, an early marker of neoangiogenesis. Vascular alterations included thickening and thrombotic phenomena, but also images of newly formed vessels. This study suggests that, at least in the stomach, LFN-induced fibrosis could be linked with neoangiogenesis.

Predicting survival of endoscopic gastrostomy candidates using the underlying disease, serum cholesterol, albumin and transferrin levels.

BACKGROUND Endoscopic gastrostomy (PEG) is the gold standard for long-term enteral feeding. An adequate PEG candidate must have life expectancy longer than a few weeks. Patients surviving less than three weeks should have a nasogastric tube, and gastrostomy should be avoid. There are few studies looking to prognostic factors and fewer attempts of creating a predictor model for PEG patients survival. AIM The aim of this study was creating a predictive survival model for PEG candidates, using underlying disease, cholesterol, albumin and transferrin. METHODS Data was obtained from records of adult patients that underwent PEG between 1999 and 2011. Patients surviving < 3 weeks were considered short survivors; surviving ≥ 3 weeks were considered adequate survivors. A full logistic regression model was used to classify future cases into one of the two groups of survival. RESULTS An equation for the probability of future cases was generated, in order to obtain a P value. In the future, patients with a P ≥ 0,88 will have a 64,7% probability of adequate surviving; patients with a P < 0,88 will have a 70.3% probability of short surviving. CONCLUSIONS When clinical evaluation alone does not display a clear prognosis, this equation should be included in the evaluation of gastrostomy candidates, avoiding useless gastrostomy.

Serum Zn levels in dysphagic patients who underwent endoscopic gastrostomy for long term enteral nutrition

BACKGROUND AND AIMS Dysphagic patients who underwent endoscopic gastrostomy (PEG) usually present protein-energy malnutrition, but little is known about micronutrient malnutrition. The aim of the present study was the evaluation of serum zinc in patients who underwent endoscopic gastrostomy and its relationship with serum proteins, whole blood zinc, and the nature of underlying disorder. METHODS From patients that underwent gastrostomy a blood sample was obtained minutes before the procedure. Serum and whole blood zinc was evaluated using Wavelength Dispersive X-ray Fluorescence Spectroscopy. Serum albumin and transferrin were evaluated. Patients were studied as a whole and divided into two groups: head and neck cancer (HNC) and neurological dysphagia (ND). RESULTS The study involved 32 patients (22 males), aged 43-88 years: HNC = 15, ND = 17. Most (30/32) had low serum zinc, 17/32 presented normal values of whole blood zinc. Only two, with traumatic brain injury, presented normal serum zinc. Serum zinc levels showed no differences between HNC and ND patients. There was no association between serum zinc and serum albumin or transferrin. There was no association between serum and whole blood zinc. CONCLUSIONS Patients had low serum zinc when gastrostomy was performed, similar in HNC and ND, being related with prolonged fasting and unrelated with the underlying disease. Decrease serum zinc was unrelated with low serum proteins. Serum zinc was more sensitive than whole blood zinc for identifying reduced zinc intake. Teams taking care of PEG-patients should include zinc evaluation as part of the nutritional assessment, or include systematic dietary zinc supply.

Malnutrition and Clinical Outcome of 234 Head and Neck Cancer Patients who Underwent Percutaneous Endoscopic Gastrostomy

ABSTRACT Head and neck cancer (HNC) patients who underwent percutaneous endoscopic gastrostomy (PEG) present malnutrition risk and speech impairments. Their assessment relies on objective anthropometric/laboratory data. Focusing on HNC PEG patients, our aims were to evaluate: 1) outcome; 2) nutritional status when the patients underwent PEG; and 3) association of nutritional status/outcome, creating a survival predictive model. We evaluated the outcome based on NRS 2002, dietary assessment, body mass index (BMI), mid-upper arm circumference (MUAC), triceps skinfold thickness (TSF), mid-arm muscle circumference (MAMC), albumin, transferrin, and cholesterol on the day of gastrostomy. Using BMI, TSF, MAMC, and laboratory data, a survival predictive model was created. Of the 234 patients (cancer stages III–IV), 149 died, 33 were still PEG-fed, and 36 resumed oral intake (NRS-2002≥3, caloric needs <50% in all). BMI was 12.7–43. 189, 197, and 168 patients displayed, respectively, low MUAC, TSF, and MAMC. 91, 155, and 119 patients displayed low albumin, transferrin, and cholesterol. Albumin, cholesterol, and transferrin were strongly associated with the outcome. A predictive model was created, discriminating between short-term survivors (<4 months) and long-term survivors. HNC patients were malnourished. Using anthropometric/laboratory parameters, a predictive model provides discrimination between patients surviving PEG for <4 months and long-term survivors. Teams taking care of PEG patients may provide special support to potential short-term survivors.

Scored patient-generated subjective global assessment, albumin and transferrin for nutritional assessment of gastrostomy fed head or neck cancer patients

INTRODUCTION Gastrostomy fed head or neck cancer patients frequently have impaired speech capacities. Enteral feeding teams frequently depend on laboratorial or anthropometrical parameters for nutritional assessment. AIMS In these patients, this study aimed to evaluate: (1) the practicability of Scored - Patient-Generated Subjective Global Assessment (PG-SGA); (2) their nutritional status using the Scored-PG-SGA; (3) association of serum albumin and transferrin values to the nutritional status rating using PG-SGA. METHODS On adult outpatients with head or neck cancer under prolonged (> 1 month) gastrostomy feeding, Scored-PGSGA, albumin and transferrin were evaluated during the same appointment. RESULTS Scored-PG-SGA was easily feasible in 42 patients, even in patients with speech difficulties. Twenty-five patients were moderately/severely undernourished (PG-SGA/B+C). Scored-PG-SGA rated 41 patients as ≥ 2, thus needing nutritional/ pharmacologic intervention. Albumin was low in 13 patients. Transferrin was low in 19 patients. Average albumin and transferrin in moderately/severely undernourished patients (PG-SGA/B+C) was significantly lower than in well-nourished (PG-SGA/A). There was association between Scored- PG-SGA rating, albumin and transferrin. CONCLUSIONS In PEG fed head or neck cancer patients, PGSGA was practicable and useful, even in patients with impaired speaking skills. Most patients displayed moderate/severe malnutrition (PG-SGA/B+C). Scored-PG-SGA rated 41 patients as needing for nutritional/pharmacological intervention. Scored-PG-SGA should be systematically included in the evaluation of these patients. In these patients, albumin and transferrin levels showed relation with Scored-PG-SGA and should be considered as nutritional biomarkers.

Nonvariceal upper gastrointestinal bleeding in Portugal, A multicentric retrospective study in twelve Portuguese hospitals

BACKGROUND Nonvariceal upper gastrointestinal bleeding (NVUGIB) is associated with important mortality. More information is needed in order to improve NVUGIB management. The aims of this study were: (a) characterizing Portuguese patients and clinical approaches used in NVUGIB, (b) comparing management used in Portugal with management globally used in European countries, (c) identify factors associated with management options, and (d) identify factors associated with adverse outcome. METHODS ENERGiB was an observational, retrospective cohort study, on NVUGIB with endoscopic evaluation, carried across Europe. This study focuses on Portuguese patients of the ENERGiB study. Patients were managed according to routine care. Later, data were collected from files. Multivariate/univariate analyses were conducted on predictive factors of poor outcome and clinical decisions. RESULTS Patients (n=404) were mostly men (66.8%), mean age 68, with co-morbidities (72%), frequently on NSAIDs/aspirin. Most were assisted by general medical (57.8%) or surgical team (20.6%), only 19.4% by gastroenterology/GI-bleeding team. PPI was largely used. Gastric/duodenal ulcers, erosive gastritis and esophagitis were the main bleeding causes. 10% had bleeding persistence/recurrence. Death occurred in 24 patients, 20 from a non-bleeding related cause. Poor outcomes were related with age >65, co-morbidities, fresh blood haematemesis, shock/syncope, bleeding through previous nasogastric tube, massive fluid replacement or transfusions besides erythrocytes. CONCLUSIONS This study contributed to characterization of Portuguese patients and NVUGIB episodes in real clinical setting and identified factors associated with a poor outcome. It also identified differences, especially in the organization of GI bleeding teams, which might help us to improve the management of these patients.

Peristomal infection after percutaneous endoscopic gastrostomy: a 7-year surveillance of 297 patients

CONTEXT Healthcare-associated infection represents the most frequent adverse event during care delivery. Medical advances like percutaneous endoscopic gastrostomy have brought improvement on quality of life to patients but an increased risk of healthcare-associated infection. Predictive risk factors for peristomal wound infection are largely unknown but evidence suggests that antibiotic prophylaxis and preventive strategies related to infection control may reduce infection rates. OBJECTIVES The primary aim was to evaluate the global prevalence rate of peristomal infection. Secondary objectives were to characterise the positive culture results, to evaluate the prophylactic antibiotic protocol and to identify potential risk factors for peristomal infection. METHODS Retrospective study of 297 patients with percutaneous endoscopic gastrostomy performed at a general hospital between January 2004 and September 2010. Patients received prophylactic cefazolin before the endoscopic gastrostomy procedure. Medical records were reviewed for demographic data, underling disease conditions to percutaneous endoscopic gastrostomy and patient potential intrinsic risk factors. Statistical analysis was made with the statistical program SPSS 17.0. RESULTS A total of 297 percutaneous endoscopic gastrostomy tubes were inserted. Wound infection occurred in 36 patients (12.1%). Staphylococcus aureus methicillin resistant was the most frequently isolated microorganism (33.3%) followed by Pseudomonas aeruginosa (30.6%). The incidence rate had been rising each year and differ from 4.65% in 2004/2007 to 17.9% in 2008/2010. This finding was consistent with the increasing of prevalence global infection rates of the hospital. Most of the infections (55.6%) were detected in the first 10 days post procedure. There was no significant difference in age, body mass index values, mean survival time and duration of percutaneous endoscopic gastrostomy feeding between patients with and without periostomal infection. Institutional factors, namely global prevalence infection rates and the endemic character of Staphylococcus aureus methicillin resistant, play an important role in peristomal infection rates. Traditional antibiotic prophylaxis with cefazolin is not adequate due to the prevalence of resistant organisms. CONCLUSIONS Peristomal infection is a frequent problem with clinical impact in percutaneous endoscopic gastrostomy patients and should be considered a healthcare associated infection. The antimicrobial prophylaxis regimens using cephalosporins are not adequate and need to be reviewed due to the high prevalence of Staphylococcus aureus methicillin resistant and other resistant organisms in hospitals and nursing homes.

Ostomy metastasis after pull endoscopic gastrostomy: a unique favorable outcome

Head and neck cancer (HNC) patients tend to develop dysphagia. In order to preserve the nutritional support, many undergo endoscopic gastrostomy (PEG). In HNC patients, ostomy metastasis is considered a rare complication of PEG, but there are no reports of successful treatment of these metastatic cancers. We report the case of a 65 years old pharyngeal/laryngeal cancer patient who underwent a PEG before the neck surgery. He was considered to be cured, resumed oral intake and the PEG tube was removed. Ten months after, he returned with a metastasis at the ostomy site. A block resection of the stomach and abdominal wall was performed. Two years after the abdominal surgery, he is free of disease. Although usually considered a rare complication of the endoscopic gastrostomy, ostomy metastasis may be more frequent than usually considered and the present case report demonstrates that these patients may have a favourable outcome.