Comparison of Open Gastrostomy and Percutaneous Endoscopic Gastrostomy in Head and Neck Cancer Patients, Tertiary Care Hospital Experience

Objective: The current study was conducted to review and compare PEG and Gastrostomy in terms of early complications in head and neck cancer patients. Materials and Methods: This was prospective comparative study recruited total 60 patients as per the inclusion criteria, 30 in each group. Patients were assigned to the groups based on the surgeon’s choice. Ethical clearance was taken from ethical review board. Informed consent was taken from patients before enrolling them into the study. Non-probability consecutive sampling technique was used to enroll study participants. Data was collected on pre-designed performa and analyzed using SPSS version 16. Setting: Section of Otolaryngology, Department of Surgery, Aga Khan University Hospital Karachi. Results: The two groups did not differ on basis of age, gender and tumor site. The outcomes variables including pain and bleeding from post-operative day1 to day 5 were significantly lower in patients who underwent PEG placement as compared to patients whom we performed OPEN gastrostomy. None the patient had peristomal infection in PEG group throughout the study. However, difference between the groups was statistically significant from post-operative day 3 to day 5. Conclusion: In our study, PEG was associated with lesser complications than open gastrostomy. Recently clinicians are using newer modalities like radiological and laparoscopic gastrostomy at various centres in Pakistan as the first option for placing feeding gastrostomy. Therefore, future studies are warranted to compare their efficacy and post-operative complications PEG. Keywords: Head and neck cancer, Open gastrostomy, Percutaneous endoscopic gastrostomy, Complications, Pain, Peristomal infection, Bleeding

Radiologically Inserted Gastrostomy (RIG) at a Tertiary Center: Periprocedural Safety including Rationalization of Antibiotic Prophylaxis

Introduction Long-term percutaneous enteral nutrition forms an important part of treatment for patients with an inability to meet nutrient requirements orally. Radiologically inserted gastrostomy (RIG) is an alternative to the traditionally performed percutaneous endoscopic gastrostomy technique. However, there is marked heterogeneity in the way that RIG is performed. In addition, the role for antibiotic prophylaxis during RIG insertion is not clearly established. This study aimed to assess the safety of RIG insertion using our technique including the role of antibiotics in RIG insertion. Method Retrospective study over 5 years at a tertiary teaching hospital. Periprocedural or early complications within the first 2 weeks of the procedure were collected and correlated with the use of prophylactic antibiotics. Results A total of 116 patients met the inclusion criteria. 18-French tube was used in 96.6%. Note that 58.6% of procedures were done with intravenous sedation. Prophylactic 1 g cefazolin was used in 70 patients with 1 case of infection. Procedures were performed without antibiotics in 46 patients with 3 infections, p = 0.20.There were two major complications (1.7%) consisting of right gastric artery injury requiring embolization and gastric wall injury requiring laparotomy. There were 12 minor complications (10.3%) including 4 cases of infection, 3 of severe pain, 1 of minor bleeding, 2 of early dislodgement, and 2 of leak/bypass of gastric contents around the tube. Conclusion The technique used for RIG insertion at our institution results in a low complication rate. In addition, this study shows no significant difference in early peristomal infection rate with the use of antibiotic prophylaxis.

Long-term outcomes of catheterizable continent urinary diversion in children

Introduction/Objective. The use of bladder augmentation and/or continent urinary diversion has gained wide acceptance, particularly in children with small, abnormally developed bladder or high-pressure bladder that poses great risk for renal deterioration and incontinence. We discuss indications, results, and complications with various types of continent vesicostomy (CV) in children. Methods. Sixty-eight patients with CV are retrospectively reviewed (51 boys and 17 girls) 1987?2008. The median follow-up time was 17.8 years (3?22 years). CV included appendicovesicostomy in 31 (41.3%), vesicostomy with distal ureter in 27 (36.0%), and preputial CV in 10 (13.3%) patients. CV in patients with augmented bladder was in 18 (26.47%) children. The indications for performing CV were various types of neurogenic and myogenic dysfunctions of urine bladder with incontinence due to the following pathoanatomical substrates: anomalies of the brain?spine segment development (27), bladder exstrophy (10), posterior urethral valve (15), expansive processes (4), and other anatomical defects in 12 patients. Results. Continence was achieved in 94.64% of the cases, without statistically significant difference between particular types of the stoma (p = 0.065). Early complications included stoma necrosis, stoma bleeding, peristomal infection in 5/68 (7.35%) patients, and late complications included calculosis, in 20/68 (29.4%), stomal stenosis, in 8/68 (11.5%), and difficulties of catheterization, in 3/68 patients (4.08%). Calculosis was predominant in appendicovesicostomy (p = 0.012). Conclusion. CV is a safe procedure applied with the main purposes of achieving continence, preservation of renal function, and improvement of the quality of life, along with an acceptably low rate of complications.

How long do percutaneous endoscopic gastrostomy feeding tubes last? A retrospective analysis

BackgroundPercutaneous endoscopic gastrostomy (PEG) tubes allow for long-term enteral feeding. Disk-retained PEG tubes may be suitable for long-term usage without planned replacement, but data on longevity are limited. We aimed to assess the rates and predictors of PEG longevity and post-PEG mortality.DesignSingle-centred retrospective cohort study of patients with disk-retained (Freka) PEG tubes.MethodsAll patients undergoing PEG between 2010 and 2013 were identified, and retrospective analysis of outcomes until 2017 (median 1062 days) was performed. Time-to-event data were plotted using Kaplan-Meier curves, with predictors of survival derived from multivariate Cox-regression analyses.Results277patients were studied, with a median age of 74 years (IQR 59–82). PEG tube failure occurred in 17.4%, due to: buried bumper syndrome (7.0%), split/broken tube (6.3%), peristomal infection (1.8%) and dislodged tube (1.1%). PEG tube longevity was 95.1% (1 year) and 68.5% (5 year), with age <70 (HR 2.65, 95% CI 1.25 to 5.62, p=0.011) being predictive of PEG failure. Post-PEG mortality was 10.5% (30 day), 35.4% (1 year) and 59.7% (5 year). Age ≥70 was associated with mortality (HR 2.79, 95% CI 1.92 to 4.05, p<0.001), whereas PEG failure (HR 0.46, 95% CI 0.27 to 0.77, p=0.003) and elective PEG removal (HR 0.23, 95% CI 0.08 to 0.64, p=0.005) were associated with reduced mortality.Conclusions68.5% of PEG tubes remain intact after 5 years. Younger age was associated with earlier PEG failure, whereas younger age, PEG replacement and elective PEG tube removal were associated with improved survival. These data may inform future guidance for elective PEG tube replacements.

PEG TUBE

Objectives: To determine the efficacy of Cephalexin and Co-amoxiclave inpreventing Peristomal infection after PEG tube placement in head and neck and other cancerpatients. Study Design: Prospective, randomized clinical trial. Setting: Internal MedicineDepartment Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore. Period:February 2009 to September 2009. Material and Methods: A total of 160 patients includingboth males and females were selected by Non probability purposive sampling. Patients meetinginclusion and exclusion criteria were registered in the study from outpatient department afterinformed consent. These patients were randomly assigned into two groups. Group A was startedon Cephalexin 500mg q6h Per-orally started 24 hrs before the procedure with the 4th dosegiven one hour before the procedure and continued it as q6h for five days after the procedure.Group B was given Co-amoxiclav 1G Per-orally 12 hrs before the procedure with the seconddose of 1G, one hour before the procedure and then same dose advised q12h for five daysafter PEG tube placement. Results: Male to female ratio in both groups was 2:1 with 63.3%males and 33.8% females. Patients were aged between 19-80years, divided in four age groupswith 38.8% falling in age group 50-64 years. Mean age is 52.11+-13.59 years and median age54 years. The efficacy of Cephalexin and Co-amoxiclave was 84.7% and 78.6% respectivelywith no significant statistical difference among two groups. Conclusion: We concluded thatCephalexin and Co-amoxiclave were both equally effective in preventing peristomal infection.

Prophylactic Mesh Application during Colostomy to Prevent Parastomal Hernia: A Meta-Analysis

Background. Parastomal hernia is a common complication after stoma formation, especially in permanent colostomy. The present meta-analysis aimed to evaluate the effectiveness of prophylactic mesh application during permanent colostomy for preventing parastomal hernia. Methods. Randomized controlled trials comparing outcomes in patients who underwent colostomy with or without prophylactic mesh application were identified from PubMed, EMBASE, Science Citation Index, and the Cochrane Libraries. Results. This meta-analysis included 8 randomized controlled trials with 522 participants. Our pooled results showed that prophylactic mesh application (mesh group) reduced the incidence of clinically detected parastomal hernia (risk ratio [RR]: 0.22; 95% confidence interval [CI]: 0.13–0.38; P<0.00001), radiologically detected parastomal hernia (RR: 0.62; 95% CI: 0.47–0.82; P=0.0008), and surgical repair for herniation (RR: 0.34; 95% CI: 0.14–0.83; P=0.02) when compared with conventional permanent colostomy formation (control group). The incidence of complications, including wound infection, peristomal infection, mesh infection, stomal necrosis and stenosis, stoma site pain, and fistula, was not higher in the mesh group than in the control group. Conclusions. Our meta-analysis demonstrated that prophylactic mesh application at the time of primary colostomy formation is a promising method for the prevention of parastomal herniation.