[The frequency of wound infections after PEG-placement and utilization of glycogel wound dressing: a randomized controlled trial]. / Häufigkeit von Wundinfektionen bei Verwendung eines Glycogelverbandes nach PEG-Anlage: Ergebnisse einer kontrollierten Studie.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is the method of choice for long- term artificial enteral feeding. Standardized wound management such as daily dressing changes and local disinfection of the exit site helps to keep complication rates low. New bacteriostatic glycogel wound dressing has not yet been tested. We compared glycogel dressing to the usual method of wound aftercare with regard to wound infections. METHODS: The standard wound management was compared to glycogel dressing. 100 consecutive patients were investigated in a prospective randomized trial from Aug. 2004 to Jan. 2006 regarding wound infections. We also compared indications for PEG placement, complications other than wound infection, and mortality. The exit site was examined and scored daily using a specific wound scoring system. After 30 days, the patients were followed up by phone calls to determine if any infection had occurred after discharge. RESULTS: During our study, 98 out of 100 patients had a successful PEG procedure performed. Out of these 98 patients, 48 patients received standard wound dressing care and 50 patients used glycogel dressing. The indications for PEG placement were not significantly different between the two groups. A total of 88% of patients (n = 42) with standard wound care had no relevant infection (50%, n = 24 with score 0 or 1; 38%, n = 18 had score 2), 10% (n = 5) presented with serious local infection (score 3) and one patient (2%) had severe infection necessitating PEG removal (score 4). In the group using glycogel dressing, 88% of the patients (n = 44) did not show any relevant sign of infection (54%, n = 27 with score 0 or 1; 34%, n = 17 had score 2), 8% (n = 4) had serious local infection (score 3), 2% (n = 1) had severe infection (score 4) and 2% (n = 1) were lost to follow up. CONCLUSION: Regarding wound infection rates after PEG placement, glycogel wound dressing was found to be as effective as standard wound dressing. Thus, omitting daily changes of regular wound dressings by using glycogel dressing instead may be advantageous for patients and generally help to decrease overall cost.

Long-term outcome following placement of percutaneous endoscopic gastrostomy in younger and older patients.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) is the method of choice in maintaining enteral nutrition in patients with swallowing and nutritional disorders of different etiology. The aim of this study was to assess the long-term outcome of patients following placement of a PEG. MATERIAL AND METHODS: All patients who received a PEG between October 1999 and September 2000 were included in this prospective study. Long-term function, replacement or removal of the PEG, complications and survival of the patients were analyzed in group A (younger than 75 years) and group B (75 years or older). RESULTS: The indications for PEG placement in group A (54 patients, mean age 54.5 years) were neurological (66.7%) and malignant (31.5%) disorders, whereas in group B (40 patients, mean age 81 years) the indications were predominantly neurological diseases (87.5%). The majority of patients (91 of 94 patients; 96.8%) could be followed long term or until death. In group A, 46 patients (85.2%) had uncomplicated long-term function of their PEG and interventions were necessary in only 8 patients. Removal of the PEG was possible during the course in 17 patients (31.5%). In group B, uncomplicated long-term function was observed in 34 patients (85%) and interventions were required in only 6 patients. Removal of the PEG was not possible in group B. Survival rates for 1-, 2- and 5 years in group A were 73.9%, 61.8% and 43.9%, respectively, and in group B 41.4%, 31.9% and 15.9%, respectively; the difference was statistically significant (p=0.002). CONCLUSIONS: Excellent long-term function of PEG was seen in this study of 94 consecutive patients, and interventions were necessary only in a minority of patients. The prognosis for older patients was worse; however, the 2-year survival rate of 32% justified the PEG insertion.

ERCP is safe and effective in patients 80 years of age and older compared with younger patients.

BACKGROUND: Biliary disease frequently occurs in the elderly, but there are limited data on ERCP in the elderly population. PATIENTS: A total of 502 patients (group A, 97; group B, 405) underwent 724 ERCP procedures. MAIN OUTCOME MEASUREMENTS: All consecutive ERCPs performed between 2000 and 2002 at a single center were retrospectively reviewed for patients >/=80 years old (group A) and patients <80 years old (group B) to evaluate endoscopic findings, interventions, complications, and mortality related to complications. RESULTS: The number of important chronic concomitant diseases was significantly higher in the older group (average per patient 1.08 vs 0.57, P < .001). Successful cannulation was achieved in 88% in group A versus 86% in group B, and endoscopic sphincterotomy was performed in 63.2% versus 51.4%. Periampullary diverticulum was found significantly more often in patients of group A (39.2%) than of group B (14.1%, P < .001). Stents were used in 24.1% of ERCP procedures in group A and in 22.9% in group B. There was no significant difference in the complication rate between group A (6.8%) and group B (5.1%) and in early mortality (1.03% vs 0.25%), respectively. CONCLUSION: ERCP is a safe and effective intervention in the elderly because complication and early mortality rates are comparable to those of younger patients, although comorbidity is significantly higher.

Colorectal cancer in geriatric patients: endoscopic diagnosis and surgical treatment.

AIM: To investigate the prevalence of colorectal cancer in geriatric patients undergoing endoscopy and to analyze their outcome. METHODS: All consecutive patients older than 80 years who underwent lower gastrointestinal endoscopy between January 1995 and December 2002 at our institution were included. Patients with endoscopic diagnosis of colorectal cancer were evaluated with respect to indication, localization and stage of cancer, therapeutic consequences, and survival. RESULTS: Colorectal cancer was diagnosed in 88 patients (6% of all endoscopies, 55 women and 33 men, mean age 85.2 years). Frequent indications were lower gastrointestinal bleeding (25%), anemia (24%) or sonographic suspicion of tumor (10%). Localization of cancer was predominantly the sigmoid colon (27%), the rectum (26%), and the ascending colon (20%). Stage Dukes A was rare (1%), but Dukes D was diagnosed in 22% of cases. Curative surgery was performed in 54 patients (61.4%), in the remaining 34 patients (38.6%) surgical treatment was not feasible due to malnutrition and asthenia or cardiopulmonary comorbidity (15 patients), distant metastases (11 patients) or refusal of operation (8 patients). Patients undergoing surgery had a very low in-hospital mortality rate (2%). Operated patients had a one-year and three-year survival rate of 88% and 49%, and the survival rates for non-operated patients amounted to 46% and 13% respectively. CONCLUSION: Nearly two-thirds of 88 geriatric patients with endoscopic diagnosis of colorectal cancer underwent successful surgery at a very low perioperative mortality rate, resulting in significantly higher survival rates. Hence, the clinical relevance of lower gastrointestinal endoscopy and oncologic surgery in geriatric patients is demonstrated.

Severe malabsorption due to refractory celiac disease complicated by extensive gastric heterotopia of the jejunum.

Refractory celiac disease denotes that patients considered to have celiac disease fail to respond histologically to treatment with a gluten-free diet. Among several causes of nonresponsiveness, enteropathy-type T-cell lymphoma is most important because of its almost invariably rapid lethal outcome. We present the case of a 44-year-old patient with refractory celiac disease complicated by unusually severe malabsorption. Repeated duodenal biopsies disclosed normal and slightly shortened villi, focal crypt hypertrophy, and a moderate increase of intraepithelial lymphocytes consistent with celiac disease, but unable to explain the severe malabsorption. To rule out cryptic lymphoma, push enteroscopy was done providing 21 biopsies taken along the entire jejunum. Surprisingly, about 70% of the biopsies were composed of gastric glands covered by nonabsorptive-type, strongly periodic acid-Schiff-positive surface epithelium and showed a villous architecture. Alternating with the gastric mucosa, there were areas of flat mucosa with elongated crypts and occasional erosions. Irrespective of the type of surface epithelium, intraepithelial lymphocytes were increased with counts up to 80/100 epithelial cells. Despite harboring an aberrant immunophenotype, overt T-cell lymphoma was ruled out histologically and by lack of monoclonality, as tested by polymerase chain reaction. To the best of our knowledge, this is the first case of refractory celiac disease complicated by extensive jejunal gastric heterotopia, which might have contributed to the severe malabsorption.

Systemic embolism from a large descending aortic thrombus.

With the advent of transesophageal echocardiography (TEE), thrombi of the aorta are becoming increasingly recognized as possible sources of systemic emboli. This report describes a 58-year-old woman with multiple unexplained peripheral emboli. A giant thrombus of the descending aorta has been identified as the source of systemic thromboembolism. The patient refused surgery and was treated successfully with long-term anticoagulation.

[Indications and complications of percutaneous endoscopic gastrostomy]. / Indikationen und Komplikationen der perkutanen endoskopischen Gastrostomie.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) plays an important role in maintaining enteral nutrition in patients with swallowing disorders of different etiologies. The aim of our study was to record indications and complications of PEG-placement in a one-year period. METHODS: All patients were investigated prospectively regarding indications, wound infections, other complications and mortality between 1999-10-01 and 2000-09-30. The exit site was examined daily, after 30 days a follow-up by telephone was carried out. RESULTS: The PEG-procedure was performed in 93 patients, one patient received a percutaneous endoscopic jejunostomy. The mean age of the patients was 65.4 years (range 7 months--92 years). The most frequent indications were neurological diseases (n = 61, 65%). 21 patients had a PEG-placement because of malignancies (22%), 9 patients following brain injury (10%) and 3 patients (3%) due to other benign swallowing disorders. 63 patients (67%) had no complications, 28 patients (30%) had wound infections, and in two patients hemorrhage was observed (small hematoma requiring no further intervention). One patient had laparotomy because of suspected perforation--however, laparotomy was negative. In 7 patients (7%) wound infections (n = 28) were mild and needed only local or no therapy. In 18 patients (19%) we found a relevant infection that required systemic antibiotic therapy. 2 patients had serious local infections that caused further interventions. One patient died from sepsis caused by wound infection. Patients receiving antibiotic therapy at the time of PEG-placement suffered from wound infections in 25%. Patients with malignant diseases more often had wound infections. 8 patients died after 7 days and 19 patients after 30 days (8% and 19%, respectively) from their underlying disease. CONCLUSIONS: PEG is regarded as a small intervention with low morbidity and mortality. However, our analysis of daily practice shows a remarkable rate of complications. The high mortality in our study reflects the seriousness of the comorbidities. Antibiotic therapy failed to prevent wound infection in 25% of our patients.