Israel Medical Association Journal

Background: Despite its wide use, evidence is inconclusive regarding the effect of percutaneous endoscopic gastrostomy (PEG) in patients with chronic diseases and dementia among hospitalized patients with malnutrition.

Objectives: To examine the effect of PEG insertion on prognosis after the procedure.

Methods: This retrospective analysis of medical records included all adult patients who underwent PEG insertion between 1 January 2009 and 31 December 2013 during their hospitalization. For each PEG patient, two controls similar in age, sex, referring department, and underlying condition were randomly selected from the entire dataset of patients admitted. The effect of PEG on mortality and repeated admissions was examined.

Results: The study comprised 154 patients, 49 referred for PEG insertion and 105 controls (mean age 74.8 ± 19.8 years; 72.7% females; 78.6% admitted to internal medicine units). Compared to controls, the PEG group had a higher 2-year mortality rate (59.2% vs. 17.1%, P < 0.001) but the 2-year readmission rate did not differ significantly (44.9% vs. 56.2% respectively, P = 0.191). Regression analysis showed PEG was  associated with increased risk of the composite endpoint of death or readmission (hazard ratio 1.514, 95% confidence interval 1.016–2.255, P = 0.041). No specific characteristic of admission was associated with increased likelihood of death or readmission. Among readmitted patients, reasons for admission and baseline laboratory data, including albumin and cholesterol, did not differ between the PEG patients and controls.

Conclusions: In-hospital PEG insertion was associated with increased mortality at 2 years but had no effect on readmissions.

Background: Buried bumper syndrome (BBS) mostly occurs as a late complication after percutaneous endoscopic gastrostomy (PEG) insertion; however, early BBS has been rarely reported, and the treatment of this condition is still unclear.

Objectives: To evaluate the Seldinger technique for treatment of early BBS after PEG insertion.

Methods: We report two cases of early BBS in two consecutive patients who underwent PEG insertion to maintain oral intake. The first patient was an 83-year-old woman showing Alzheimer type dementia, while the other one was a 76-year-old man who presented with maxillary cancer and treated with radiotherapy followed by left maxillectomy. Post-surgery, he developed progressive difficulty of swallowing due to mouth deformation and treatment related nerve toxicity. The first patient presented with fever and purulent discharge from the gastrostomy insertion site, without ability to rotate or slide the tube through the stoma 10 days after the PEG insertion. The man was admitted to the hospital 5 days following PEG insertion due to a fever of 38°C and peritubal swelling with purulent discharge. In addition, the tube could not rotate or slide through the stoma.

Results: Buried bumper syndrome was demonstrated by computed tomography scan. Gastroscopy and gastrostomy tube replacement was performed successfully according to the Seldinger technique (replacement over guidewire) in both cases. Correct intragastric tube positioning was demonstrated radiographically before resuming tube feeding. The two patients were discharged in good physical condition several days later.

Conclusions: External replacement over guide wire should be considered in such cases.

Background: Children dependent on gastrostomy tube feeding and those with extremely selective eating comprise the most challenging groups of early childhood eating disorders. We established, for the first time in Israel, a 3 week intensive weaning and treatment program for these patients based on the "Graz model."

Objectives: To investigate the Graz model for tube weaning and for treating severe selective eating disorders in one center in Israel. 

Methods: Pre-program assessment of patients’ suitability to participate was performed 3 months prior to the study, and a treatment goal was set for each patient. The program included a multidisciplinary outpatient or inpatient 3 week treatment course. The major outcome measures were achievement of the target goal of complete or partial tube weaning for those with tube dependency, and expansion of the child's nutritional diversity for those with selective eating. 

Results: Thirty-four children, 28 with tube dependency and 6 with selective eating, participated in four programs conducted over 24 months. Their mean age was 4.3 ± 0.37 years. Of all patients, 29 (85%) achieved the target goal (24 who were tube-dependent and 5 selective eaters). One patient was excluded due to aspiration pneumonia. After 6 months follow-up, 24 of 26 available patients (92%) maintained their target or improved. 

Conclusions: This intensive 3 week program was highly effective in weaning children with gastrostomy tube dependency and ameliorating severe selective eating. Preliminary evaluation of the family is necessary for completion of the program and achieving the child’s personal goal, as are an experienced multidisciplinary team and the appropriate hospital setup, i.e., inpatient or outpatient. 

 

Background: Peritonitis is a major complication of chronic peritoneal dialysis therapy. It is recommended that each center monitor infection rates in order to define the local microbiological profile and implement an appropriate empiric antibiotic regimen.

Objectives: To analyze the microbiological profile of peritonitis in our pediatric dialysis unit and identify local predisposing factors.

Methods: In this retrospective study we reviewed the files of children treated with chronic PD[1] during the 10 year period 1997–2007.

Results: Eighty peritonitis episodes were recorded in 29 children (20 male, 9 female) aged 0.1–18.5 years (median 11.75) treated with peritoneal dialysis for 6–69 months (median 19) for a total of 578 patient-months. The annual peritonitis rate was 1.66/patient. The main pathogens were coagulase-negative Staphyloccocus (32.5%) and Pseudomonas spp. (16%), which were also cultured in most cases (64–69%) from the exit site during the 3 months preceding peritonitis. No peritonitis occurred in 31% of the patients (median age 12.5 years). All patients less than 5 years old had at least one peritonitis episode. Contaminating conditions (gastrostomy, enuresis, diaper use), found in 44% of the study group, and first infection within 6 months from starting PD were significantly associated with an increased peritonitis rate (P = 0.01, P = 0.009, respectively). Recurrent peritonitis led to a switch to hemodialysis in 18% of patients. There were no deaths.

Conclusions: The risk factors for peritonitis in our study were: first infection within less than 6 months from starting treatment, Pseudomonas exit-site colonization, and contaminating conditions (gastrostomies, diaper use, enuresis). These susceptible subgroups as well as very young age (< 5 years) at starting PD should be especially targeted during training of caregivers and follow-up to prevent later complications.  

[1] PD = peritoneal dialysis

Background: The frequency of performing percutaneous endoscopic gastrostomy in demented older people has increased in recent years. Several reports indicate flaws in the criteria for performing PEG[1] and in the decision-making process, raising concerns about the adequacy of the consent.

Objectives: To examine knowledge and attitudes of referring doctors and gastroenterologists, and to evaluate attitudes and feelings of family members concerning PEG insertion.

Methods: We conducted a survey of 72 doctors who referred 126 demented patients for PEG, as well as 126 family members and 34 gastroenterologists. Closed-ended questionnaires were designed for each study group, completed by the participants, and computer analyzed.

Results: Approximately 50% of family members expressed dissatisfaction with the decision-making process. Referring physicians reported that PEG insertion was often dictated by the need to transfer patients to a nursing home, with 50% admitting institutional pressure. Most of the referring physicians believed that PEG improved quality of life and longevity, whereas gastroenterologists did not expect an improved quality of life and thought that administrative demands should not intervene in the decision to insert PEG.

Conclusions: The decision-making process in the patient's families regarding PEG insertion for their demented relative is unsatisfactory, often takes place under pressure, and does not provide sufficient information about the procedure or its complications. Interpersonal communication between the patient's family and the medical team need to be improved and institutional demands should not play a major role in the medical decision to insert PEG. Gastroenterologists should take a more active role in the deliberations regarding PEG.

Background: Thyroidectomy for goiter is a common surgical procedure performed in most hospitals in Israel. Both general and ear, nose and throat surgeons are familiar with thyroidectomy for cervical goiters. In about 1–15% of thyroidectomies, the goiter is intrathoracic and requires somewhat different management. This topic has not been reviewed in the literature recently.

Objective: To evaluate the clinical presentation, preoperative workup, surgical complications and risk of malignancy in retrosternal goiters.

Methods: We retrospectively reviewed the records of 75 patients who underwent thyroidectomy for retrosternal goiter in the General Thoracic Surgical Department of our institution during a 15 year period, January 1990 to January 2005.

Results: All the patients (41 women and 34 men) were symptomatic at presentation, with choking and dyspnea being the most common complaint. Computerized tomography scan of the neck and chest were obtained before the operation in 71 patients (95%). Ten patients (13%) had a previous partial thyroidectomy. A cervical approach was used in 68 patients (91%). Seven patients (9%) required median sternotomy to complete the operation. One patient (1.3%) died from postoperative respiratory failure. Transient recurrent laryngeal nerve palsy occurred in 5 patients (7%) and permanent RLNP[1] in 3 (4%). The incidence of transient and permanent hypoparathyroidism was 10% and 2.6% respectively. Sixty-six lesions (88%) were benign and 9 (12%) were malignant.

Conclusions: Choking and dyspnea are the most common presenting symptoms of retrosternal goiter. CT scan is an important component of the preoperative evaluation and operative planning. Surgical removal of the thyroid is the treatment of choice and most patients have symptomatic improvement following the operation. Since a substernal thyroidectomy may be technically different from cervical thyroidectomy, a surgical team familiar with its unique pitfalls should perform the procedure.

Background: Trauma is the leading cause of death in children. In abdominal lesions the spleen is the most commonly involved organ. During the last two decades much effort has focused on spleen tissue conservation.

Objectives: To analyze the rationale of a multimodality management policy that includes autotransfusion and mesh wrapping.

Methods: Data gathered over 14 years illustrate the introduction of new techniques and their impact on cases of severe spleen rupture.

Results: A total of 122 children were treated during the 14 year period, 1985-98. In 16 children an absorbable mesh wrapping, alone or in combination with other techniques, was used to obtain hemostatis and save spleen tissue.

Conclusions: Mesh wrapping, partial splenectomy and autotransfusion can be used, alone or in combination, to preserve severely injured spleens. According to our records, all children survived with a functional spleen. There were no cases of rebleeding. In only one case of prolonged postoperative fever could the cause be traced to an infected spleen hematoma that was drained transcutaneously. Autotransfusion is performed simply and without the use of a "cell saver." Its use can be crucial in small or field hospitals or in a situation of mass casualty.

Background: Previous studies have published controversial results regarding a connection between Helicobacter pylori infection and colorectal cancer. One possible mechanism is increased gastrin secretion in subjects infected with H. pylori, insofar as gastrin is known to be a trophic factor for the colonic mucosa.

Objectives: To investigate a possible role of gastrin secretion in H. pylori infection associated with colorectal cancer, and determine whether H. pylori infection is a factor in this disease.

Methods: The serum gastrin levels and the presence of H. pylori IgG antibodies were measured in 51 colorectal cancer patients and 51 control subjects. The cancer patients were also tested for carcinoembryonic antigen and CA 19-9.

Results: H. pylori IgG antibodies were found in the serum of 41 (80.4%) of the cancer patients compared to 32 (62.7%) of the control subjects (P=0.05). A significant correlation was found between CA 19-9 (γ=0.3432, n=49, P=0.01) and seropositive H. pylori IgG antibodies in the serum of the cancer patients (odds ratio 2.43, and 95% confidence limit 0.99-5.95), but none between CEA and H. pylori IgG antibodies nor between the serum gastrin level and the presence of colorectal cancer.

Conclusions: The results of this study indicate a significant association between seropositive H. pylori IgG antibodies and elevated CA 19-9 in colorectal cancer patients, but no correlation between the serum gastrin level and the presence of this cancer. H. pylori seropositivity is more prevalent in patients with colorectal cancer.