S1351 Predictors of Length of Stay and Mortality in Hospital TPN Patients
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causing themselves nasal septal injury. All patients are assessed by a clinical nurse specialist. It is Trust policy to confirm all NGT placements with a chest X-ray. We audited our practice to assess whether bridles are effective and safe. Methods: Database records for all patients referred for NG bridles between June 2007 and September 2009 were reviewed. Where additional information was required, case notes were obtained. Radiology exposure was also assessed. Results: Fifty one patients were referred for bridle placement during the 27 month audit period. Median age was 72 years (range 36-90). Cerebrovascular accident was the most common reason for referral (82%). All patients had had at least 3 NGT placed prior to referral (median 3 range 3-8). 38 of the 51 patients (74.5%) had bridles attached using 39 devices in total. 1 patient required bridle replacement and only 1 experienced significant nasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 were already eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEG feeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1-32). Of these only 2 required long term PEG feeding and 21 were able to have their bridles removed as they were no longer required. 15 patients with bridles died for reasons unrelated to their bridle. An additional 147 chest X-rays had been used prior to referral whilst only 1 additional X-ray was required to confirm NGT position after bridle placement. Conclusion: Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helps to prevent delay of nutrition restoration. They also reduce repeated radiation exposure from recurrent x-rays and overall hospital costs. Bridles have a very low incidence of complication and help reduce unnecessary PEG insertions in high risk groups if patients are assessed carefully by trained staff. S1351 Predictors of Length of Stay and Mortality in Hospital TPN Patients Emily F. Shen, Taufique Ahmed, Aivee Lim, Kavita Sundaram, Mei Yee Loo Aim: To assess which factor/s increase mortality, length of stay (LOS) and complications in hospital patients commenced on total parenteral nutrition (TPN). Method: Data was prospectively collected from patients commenced on TPN and managed by the Nutrition Support Team in an Asian Tertiary Hospital during the period January 2007 to September 2009. The primary outcome measure was mortality; secondary outcome measures included LOS and TPN related complications. Data was analysed using Strata Results: 251 patients were commenced on TPN during this period with a total of 260 episodes. Average age of patients was 66.4 years (23-95), 82.2% were Chinese. Indication for commencement of TPN were: non-functioning GI tract 18.46% , disrupted GI tract 51.92% post operative 20.38% and others 6.15%. 19% of patients died during their hospital admission. TPN complication rate was 14.7%. The average length of stay was 29 days (5-339 days). Patients who were started on TPN postoperatively for anticipated prolonged fast had a significantly shorter length of stay -2.35 days (p = 0.02) and reduction in mortality with an odds ratio 0.24 (p = 0.043). Those with a Subjective Global Assessment (SGA) score C had significantly increased mortality with odds ratio of 14.3 (p< 0.005), and longer length of stay 1.85 days . Conclusion: We found that both indication for commencement of TPN and SGA score of C significantly influenced both hospital mortality and length of stay of hospital TPN patient S1352 Comparison of Customized Versus Standardized Peripheral Parenteral Nutrition in an Asian Academic Hospital Emily F. Shen, Mei Yee Loo, Stephen Tsao, Bengyi Sia Aim: To determine if standardised peripheral parenteral nutrition is safer and more nutri- tionally adequate than customized peripheral parenteral nutrition in an Asian Academic hospital Method: During the time period 5 /10/2008 to 11/03/2009 patients admitted under the general surgery department who were nil by mouth and required pPN were recruited. Data was collected prospectively including patient characteristics, total caloric count, types of calories, length of stay, days of pPN and complications of pPN. After collecting data, feedback and education on use and prescription of pPN was given to the general surgery department. Result: Total of 73 patients on pPN were recruited, 74.0% were prescribed customized pPN and 26.0% standardized pPN. The average age of patients on pPN was 63.7 years (19-100 years), majority male. Patients prescribed standardized pPN received significantly more calories (57.5% of required calories, p<0.01) than those on customized pPN (19.0%). Patients on standardized pPN received an appropriate balance of calories as compared to those on customized pPN. Majority of the customized pPN patients received dextrose solution alone (n=39). There was a lower complication rate for patients on standard- ized pPN (15.8%) compared to patients on customized pPN (27.8%). The most common complication for patients on customized pPN was thrombophlebitis (18.0%) in patients prescribed standardized the most common complication was raised triglycerides (10.5%). After the doctors education session, there was a significant increase in the prescription of standardized pPN from 0% to 70% (p<0.01). Conclusion: We found that prescription of standardized pPN resulted in increased appropriate calories to patients with fewer complica- tions. S1353 Pexact®: Analysis of 319 Procedures Performed at the Digestive Diseases Unit, University Hospital Aintree Suhail Ahmed, Katherine Bowering, Naveen Polavarapu, Roger Nicholson, Paul Thomas, Richard Sturgess Introduction Patients with head and neck cancers can require nutritional support during and after treatment of their cancers, commonly done via a gastrostomy. The ‘pull though' PEG has an increased risk of tumour implantation at the PEG site. We changed to direct puncture gastrostomy insertion in 2004, using the PEXACT® (fresenius) gastrostomy system, for all head and neck cancer patients. We have previously reported our first year experience of 89 cases. We report our practice since then. Methods:All PEXACTS® performed in the unit between November 2005 and November 2009 were identified, using endoscopy S-235 AGA Abstracts reporting system and referral register. Information regarding each patient (readmissions, complications and mortality) was obtained from the hospital patient administration system. Results:According to data available to date, 319 PEXACT® insertions were identified in 317 patients. 79% of patients were male (n=251). Average age 58y, 99% (n316) patients had a head and neck cancer as the indication. Insertion was successful in 99% (n316) and unsuccessful in 3 (0.9%) patients: 2 cases due to poor access and 1 due to gastric intramucosal haematoma. All patients had pre-procedure antibiotics on the ward. 6 patients died within 30 days (1.9%), 1 within 7 days (0.3%). Of the 30 day deaths, 3 were due to disease progression, one neutropenic sepsis following chemotherapy and two had no record of the cause of death available. 2 patients had major procedure related complications (0.6%). 1 of the patients had splenic injury during the procedure and required emergency surgery, the second patient had intra-abdominal haematoma due to laceration of gastric wall which was managed conservatively. 10(3.1%) patients had unplanned admissions within 30 days of their proced- ure. 4 patients were admitted within7 days (1.3%). Causes of readmission included displaced or blocked gastrostomy tube n2(0.6%), disease progression n2(0.6%), gastrostomy site infection n3 (0.9%) and n1(0.3%) patient developed aspiration pneumonia due to alcohol excess. There have been no cases of tumour implantation to date. Late displacement of the gastrostomy tube (over 30 days after insertion) was common (6.6%). Most were replaced at the bedside. Conclusions:PEXACT® is a safe and reliable method of gastrostomy tube placement. Overall, our complication rate has fallen, with only 2 major procedure related complications during this period. There have been no procedure related deaths. There have been no cases of tumour implantation. S1354 The Impact of Prophylactic Percutaneus Endoscopic Gastrostomy to Nutritional Status and Quality of Life in Locally Advanced Head and Neck Cancer Patients Receiving Chemoradiotherapy Oya Yonal, Beste M. Atasoy, Birsen Demirel, Yusuf Yilmaz, Faysal Dane, Ufuk Abacioglu, Cem Kalayci, Nese Imeryuz Aim: To investigate the impact of prophylactic percutaneous endoscopic gastrostomy (PEG) on nutritional status and quality of life (QOL) of locally advanced head and neck cancer (LAHNC) patients treated with chemoradiotherapy (CRT). Materials and Methods: Twenty- three patients (F/M:6/17, median age: 53 (19-79 years) with LAHNC on free diet were enrolled into this prospective study. PEG tube was inserted in all patients 3 to 7 days before the initiation of CRT prophylactically. Nutritional status and QOL were evaluated by anthropometric indices and by the University of Washington QOL (UW-QOL) question- naire at the beginning and at the end of CRT The median radiation dose was 70Gy (n=17) for primary and 60Gy (n=6) for adjuvant radiotherapy (RT). Concurrent cisplatin was administered either 60mg/m2 weekly or 75-80mg/m2 in every 21 days. Side effects were evaluated by Common Toxicity Criteria (CTC) v2.0. Data was analysed by chi-square and Mann Whitney U tests. Results: All patients completed RT as scheduled in median 7 weeks. The concurrent chemotherapy was stopped in 35% of patients due to grade 3 oral mucositis (65%) and/or grade 3 pharyngeal dysphagia (56%). There was no grade 3 weight loss observed. Grade 0 weight loss was seen 56.5% of patients whereas grade 1 was in 21.7% and grade 2 was in 21.7% of patients, respectively. The median time the first tube feeding after the first RT session was 3 weeks. At the end of CRT, one patient had normal oral feeding, 7 had combined oral and PEG feeding, and the remaining 15 (65%) patients received PEG feeding only. Median duration of PEG tube feeding was 5 months (range: 3 to 7). Compliance to PEG tube feeding was 67% in patients who lost weight and 87.5% in patients who did not. At the time of analysis tube feeding was stopped and PEG tube was removed in 6 patients. The only serious PEG complication was the burried bumper syndrome in 1 patient necessitated removal. Minor complications of PEG were local infection in 2 patients, leakage from the gastrostomy site (requiring tube replacement) in 1 patient, and nausea in 2 patients. Prospective analysis of QOL showed that at the end of the study swallowing (P<0.001), chewing (P<0.001), saliva (P<0.001) and composite mean scores (p=0.008) has significantly become worse due to CRT. Conclusion: Concomittant chemoradiotherapy is the standard treatment in LAHNC in favor of survival rates. However, the toxicity reduces the patients` quality of life and may restrict the completeness rates of the full courses of combined regimens. Elective PEG tube is a safe and effective way of providing adequate enteral nutrition in LAHNC patients receiving CRT. S1355 Percutaneous Gastrostomy in Patients With Dementia: A Survey of Family Members Matt Atkinson, Marty M. Meyer, Nathan Schmulewitz Introduction: Percutaneous gastrostomies (PGs) are often placed in patients with end-stage dementia despite retrospective data showing no survival advantage or improvement in nutritional parameters. Nevertheless, family members might consent for PG placement for a variety of social, ethical, psychological, or medical reasons. Little is known about whether family members gain benefit from the PG in their relative. Aims: To determine family member experience with PG tubes in end-stage dementia. Methods: All PGs placed at the University of Cincinnati endoscopy unit and interventional radiology unit and all PGs placed at the Ohio State University endoscopy unit were reviewed for indication. Chart review was performed on those PGs placed for dementia and they were included if no other indication was identified (e.g., acute stroke or malignancy). The person who signed consent was asked to participate in the telephone survey. Results: From June 2003 to July 2008, 2159 PG tubes were reviewed, of which 125 (5.8%) were placed for dementia. Twenty three (18%) of family members were willing to undergo telephone survey. Mean time between PG placement and telephone survey was 35 months. Of family members surveyed, 78% believed they were provided with enough information prior to PG placement, 74% believed the PG prolonged life, 83% believed the tube was helpful, 83% would have agreed to the PG if they could do it over, 57% believed their relative would have wanted the PG, and 61% would recommend the PG to another family in a similar situation. Problems with the PG occurred in 52% of the 23 patients including tube discomfort (4), tube pulled out (4), tube dysfunction (4), infections (2), and aspiration pneumonia (2) leading to death in one patient. Conclusions: A majority AGA Abstracts
Transcript of S1351 Predictors of Length of Stay and Mortality in Hospital TPN Patients
causing themselves nasal septal injury. All patients are assessed by a clinical nurse specialist.It is Trust policy to confirm all NGT placements with a chest X-ray. We audited our practiceto assess whether bridles are effective and safe. Methods: Database records for all patientsreferred for NG bridles between June 2007 and September 2009 were reviewed. Whereadditional information was required, case notes were obtained. Radiology exposure was alsoassessed. Results: Fifty one patients were referred for bridle placement during the 27 monthaudit period. Median age was 72 years (range 36-90). Cerebrovascular accident was themost common reason for referral (82%). All patients had had at least 3 NGT placed priorto referral (median 3 range 3-8). 38 of the 51 patients (74.5%) had bridles attached using39 devices in total. 1 patient required bridle replacement and only 1 experienced significantnasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 werealready eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEGfeeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1-32).Of these only 2 required long term PEG feeding and 21 were able to have their bridlesremoved as they were no longer required. 15 patients with bridles died for reasons unrelatedto their bridle. An additional 147 chest X-rays had been used prior to referral whilst only1 additional X-ray was required to confirm NGT position after bridle placement. Conclusion:Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helpsto prevent delay of nutrition restoration. They also reduce repeated radiation exposure fromrecurrent x-rays and overall hospital costs. Bridles have a very low incidence of complicationand help reduce unnecessary PEG insertions in high risk groups if patients are assessedcarefully by trained staff.
S1351
Predictors of Length of Stay and Mortality in Hospital TPN PatientsEmily F. Shen, Taufique Ahmed, Aivee Lim, Kavita Sundaram, Mei Yee Loo
Aim: To assess which factor/s increase mortality, length of stay (LOS) and complicationsin hospital patients commenced on total parenteral nutrition (TPN). Method: Data wasprospectively collected from patients commenced on TPN and managed by the NutritionSupport Team in an Asian Tertiary Hospital during the period January 2007 to September2009. The primary outcome measure was mortality; secondary outcome measures includedLOS and TPN related complications. Data was analysed using Strata Results: 251 patientswere commenced on TPN during this period with a total of 260 episodes. Average age ofpatients was 66.4 years (23-95), 82.2% were Chinese. Indication for commencement ofTPN were: non-functioning GI tract 18.46% , disrupted GI tract 51.92% post operative20.38% and others 6.15%. 19% of patients died during their hospital admission. TPNcomplication rate was 14.7%. The average length of stay was 29 days (5-339 days). Patientswho were started on TPN postoperatively for anticipated prolonged fast had a significantlyshorter length of stay -2.35 days (p = 0.02) and reduction in mortality with an odds ratio0.24 (p = 0.043). Those with a Subjective Global Assessment (SGA) score C had significantlyincreased mortality with odds ratio of 14.3 (p< 0.005), and longer length of stay 1.85 days. Conclusion: We found that both indication for commencement of TPN and SGA score ofC significantly influenced both hospital mortality and length of stay of hospital TPN patient
S1352
Comparison of Customized Versus Standardized Peripheral ParenteralNutrition in an Asian Academic HospitalEmily F. Shen, Mei Yee Loo, Stephen Tsao, Bengyi Sia
Aim: To determine if standardised peripheral parenteral nutrition is safer and more nutri-tionally adequate than customized peripheral parenteral nutrition in an Asian Academichospital Method: During the time period 5 /10/2008 to 11/03/2009 patients admitted underthe general surgery department who were nil by mouth and required pPN were recruited.Data was collected prospectively including patient characteristics, total caloric count, typesof calories, length of stay, days of pPN and complications of pPN. After collecting data,feedback and education on use and prescription of pPN was given to the general surgerydepartment. Result: Total of 73 patients on pPN were recruited, 74.0% were prescribedcustomized pPN and 26.0% standardized pPN. The average age of patients on pPN was63.7 years (19-100 years), majority male. Patients prescribed standardized pPN receivedsignificantly more calories (57.5% of required calories, p<0.01) than those on customizedpPN (19.0%). Patients on standardized pPN received an appropriate balance of calories ascompared to those on customized pPN. Majority of the customized pPN patients receiveddextrose solution alone (n=39). There was a lower complication rate for patients on standard-ized pPN (15.8%) compared to patients on customized pPN (27.8%). The most commoncomplication for patients on customized pPN was thrombophlebitis (18.0%) in patientsprescribed standardized the most common complication was raised triglycerides (10.5%).After the doctors education session, there was a significant increase in the prescription ofstandardized pPN from 0% to 70% (p<0.01). Conclusion: We found that prescription ofstandardized pPN resulted in increased appropriate calories to patients with fewer complica-tions.
S1353
Pexact®: Analysis of 319 Procedures Performed at the Digestive DiseasesUnit, University Hospital AintreeSuhail Ahmed, Katherine Bowering, Naveen Polavarapu, Roger Nicholson, Paul Thomas,Richard Sturgess
Introduction Patients with head and neck cancers can require nutritional support duringand after treatment of their cancers, commonly done via a gastrostomy. The ‘pull though'PEG has an increased risk of tumour implantation at the PEG site. We changed to directpuncture gastrostomy insertion in 2004, using the PEXACT® (fresenius) gastrostomy system,for all head and neck cancer patients. We have previously reported our first year experienceof 89 cases. We report our practice since then. Methods:All PEXACTS® performed in theunit between November 2005 and November 2009 were identified, using endoscopy
S-235 AGA Abstracts
reporting system and referral register. Information regarding each patient (readmissions,complications and mortality) was obtained from the hospital patient administration system.Results:According to data available to date, 319 PEXACT® insertions were identified in 317patients. 79%of patients weremale (n=251). Average age 58y, 99% (n316) patients had a headand neck cancer as the indication. Insertion was successful in 99% (n316) and unsuccessful in3 (0.9%) patients: 2 cases due to poor access and 1 due to gastric intramucosal haematoma.All patients had pre-procedure antibiotics on the ward. 6 patients died within 30 days(1.9%), 1 within 7 days (0.3%). Of the 30 day deaths, 3 were due to disease progression,one neutropenic sepsis following chemotherapy and two had no record of the cause of deathavailable. 2 patients had major procedure related complications (0.6%). 1 of the patientshad splenic injury during the procedure and required emergency surgery, the second patienthad intra-abdominal haematoma due to laceration of gastric wall which was managedconservatively. 10(3.1%) patients had unplanned admissions within 30 days of their proced-ure. 4 patients were admitted within7 days (1.3%). Causes of readmission included displacedor blocked gastrostomy tube n2(0.6%), disease progression n2(0.6%), gastrostomy siteinfection n3 (0.9%) and n1(0.3%) patient developed aspiration pneumonia due to alcoholexcess. There have been no cases of tumour implantation to date. Late displacement of thegastrostomy tube (over 30 days after insertion) was common (6.6%). Most were replacedat the bedside. Conclusions:PEXACT® is a safe and reliable method of gastrostomy tubeplacement. Overall, our complication rate has fallen, with only 2 major procedure relatedcomplications during this period. There have been no procedure related deaths. There havebeen no cases of tumour implantation.
S1354
The Impact of Prophylactic Percutaneus Endoscopic Gastrostomy toNutritional Status and Quality of Life in Locally Advanced Head and NeckCancer Patients Receiving ChemoradiotherapyOya Yonal, Beste M. Atasoy, Birsen Demirel, Yusuf Yilmaz, Faysal Dane, Ufuk Abacioglu,Cem Kalayci, Nese Imeryuz
Aim: To investigate the impact of prophylactic percutaneous endoscopic gastrostomy (PEG)on nutritional status and quality of life (QOL) of locally advanced head and neck cancer(LAHNC) patients treated with chemoradiotherapy (CRT). Materials and Methods: Twenty-three patients (F/M:6/17, median age: 53 (19-79 years) with LAHNC on free diet wereenrolled into this prospective study. PEG tube was inserted in all patients 3 to 7 daysbefore the initiation of CRT prophylactically. Nutritional status and QOL were evaluatedby anthropometric indices and by the University of Washington QOL (UW-QOL) question-naire at the beginning and at the end of CRT The median radiation dose was 70Gy (n=17)for primary and 60Gy (n=6) for adjuvant radiotherapy (RT). Concurrent cisplatin wasadministered either 60mg/m2 weekly or 75-80mg/m2 in every 21 days. Side effects wereevaluated by Common Toxicity Criteria (CTC) v2.0. Data was analysed by chi-square andMann Whitney U tests. Results: All patients completed RT as scheduled in median 7 weeks.The concurrent chemotherapy was stopped in 35% of patients due to grade 3 oral mucositis(65%) and/or grade 3 pharyngeal dysphagia (56%). There was no grade 3 weight lossobserved. Grade 0 weight loss was seen 56.5% of patients whereas grade 1 was in 21.7%and grade 2 was in 21.7% of patients, respectively. The median time the first tube feedingafter the first RT session was 3 weeks. At the end of CRT, one patient had normal oralfeeding, 7 had combined oral and PEG feeding, and the remaining 15 (65%) patients receivedPEG feeding only. Median duration of PEG tube feeding was 5 months (range: 3 to 7).Compliance to PEG tube feeding was 67% in patients who lost weight and 87.5% in patientswho did not. At the time of analysis tube feeding was stopped and PEG tube was removedin 6 patients. The only serious PEG complication was the burried bumper syndrome in 1patient necessitated removal. Minor complications of PEG were local infection in 2 patients,leakage from the gastrostomy site (requiring tube replacement) in 1 patient, and nausea in2 patients. Prospective analysis of QOL showed that at the end of the study swallowing(P<0.001), chewing (P<0.001), saliva (P<0.001) and composite mean scores (p=0.008) hassignificantly become worse due to CRT. Conclusion: Concomittant chemoradiotherapy isthe standard treatment in LAHNC in favor of survival rates. However, the toxicity reducesthe patients` quality of life and may restrict the completeness rates of the full courses ofcombined regimens. Elective PEG tube is a safe and effective way of providing adequateenteral nutrition in LAHNC patients receiving CRT.
S1355
Percutaneous Gastrostomy in Patients With Dementia: A Survey of FamilyMembersMatt Atkinson, Marty M. Meyer, Nathan Schmulewitz
Introduction: Percutaneous gastrostomies (PGs) are often placed in patients with end-stagedementia despite retrospective data showing no survival advantage or improvement innutritional parameters. Nevertheless, family members might consent for PG placement fora variety of social, ethical, psychological, or medical reasons. Little is known about whetherfamily members gain benefit from the PG in their relative. Aims: To determine family memberexperience with PG tubes in end-stage dementia. Methods: All PGs placed at the Universityof Cincinnati endoscopy unit and interventional radiology unit and all PGs placed at the OhioState University endoscopy unit were reviewed for indication. Chart review was performed onthose PGs placed for dementia and they were included if no other indication was identified(e.g., acute stroke or malignancy). The person who signed consent was asked to participatein the telephone survey. Results: From June 2003 to July 2008, 2159 PG tubes were reviewed,of which 125 (5.8%) were placed for dementia. Twenty three (18%) of family memberswere willing to undergo telephone survey. Mean time between PG placement and telephonesurvey was 35 months. Of family members surveyed, 78% believed they were providedwith enough information prior to PG placement, 74% believed the PG prolonged life, 83%believed the tube was helpful, 83% would have agreed to the PG if they could do it over,57% believed their relative would have wanted the PG, and 61% would recommend thePG to another family in a similar situation. Problems with the PG occurred in 52% of the23 patients including tube discomfort (4), tube pulled out (4), tube dysfunction (4), infections(2), and aspiration pneumonia (2) leading to death in one patient. Conclusions: A majority
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