Bourdel-Marchasson I, Dumas F, Pinganaud G, Emeriau J P, Decamps A
Centre de Gériatrie, CHU de BORDEAUX, Hôpital Xavier Arnozan, Pessac, France.
Int J Qual Health Care. 1997 Aug;9(4):297-302. doi: 10.1093/intqhc/9.4.297.
Percutaneous endoscopic gastrostomy (PEG) is now easily used in the event of long-term enteral nutrition. Tolerance of long-term enteral feeding has been documented in different populations but the documentation is incomplete in the case of older and frail people. Our aim was to describe early and late tolerance in this population, and to propose ways in which it could be improved.
Retrospective study in two parts: tolerance and quality of care; case-control study for tolerance.
A nursing home with 240 beds in south-west France. who had undergone PEG insertion between January 1990 and June 1994. Fifty-eight patients were involved, 12 under 65 years (48 +/- 10.6), and 46 over 65 (80.7 +/- 9.3). The gastrostomy insertion was performed because of a vegetative state in 6 patients, swallowing difficulties in 31 and anorexia in 21. A control group was gathered in December 1996, which included all patients for whom the question of nutritional support was mentioned books but where no artificial nutrition had been implemented due to the patients' or families' refusal or to a staff decision. This group included 50 patients, 5 younger than 65 years (54 +/- 8.3), and 45 older (84.7 +/- 7.6). In 22 cases the nutritional problem was swallowing difficulties and in 28 cases anorexia. Pressure ulcers were present before insertion in 34 patients in the PEG group and in 7 of the control group (p < 0.001).
Prognosis, early and late cutaneous digestive (ileus, vomiting, gastroesophageal reflux) and pulmonary (bronchorrhea, dyspnea and aspiration pneumonia) complications for PEG and control groups, and patients with signs of poor behavioural tolerance of PEG were recorded in the chart. Audit of quality of care was performed in the PEG group using eight criteria: two concerned the pre-insertion period, two the early follow-up and four the long-term follow-up.
Early mortality (4 weeks) was 13.8% in PEG (vs 10%, NS), mid-term mortality (between 4 and 8 weeks) was 12.1% (vs 14%, NS) and late mortality was 19.0% (vs 42.0%, length of follow-up 63.4 +/- 42.1 weeks compared to 53.1 +/- 63.8 weeks, NS). The duration of follow-up of the living patients was 71.6 +/- 61.8 weeks in PEG compared to 48.0 +/- 70.5 in the control group. Only 20% in PEG were free of any cutaneous complication around the insertion site, and 8 abscesses occurred during the first week. Pulmonary complications occurred in 39% of the PEG group (vs 30.0, NS). Aspiration pneumonia was significantly associated with swallowing difficulties in both groups (p < 0.05). Vomiting occurred for 15.5% of the PEG group (vs 12%, NS), ileus in 13.8% (vs 6%, NS). Gastroesophageal reflux was found in 2 PEG patients, compared to 1 case among the control patients. Pressures sores were healing in 20 out of 34 patients in the PEG group (vs 2 out of 7) and new ulcers appeared in 6 out of 24 (vs 8 out of 43). Fifteen (25.8%) of the PEG patients attempted to withdraw the tube.
经皮内镜下胃造口术（PEG）目前已广泛应用于长期肠内营养的情况。不同人群对长期肠内喂养的耐受性已有记录，但在老年人和体弱人群中记录并不完整。我们的目的是描述该人群的早期和晚期耐受性，并提出改善耐受性的方法。
分两部分的回顾性研究：耐受性和护理质量；耐受性的病例对照研究。
法国西南部一家拥有240张床位的养老院。研究对象为1990年1月至1994年6月期间接受PEG置入术的患者。共纳入58例患者，其中12例年龄在65岁以下（48±10.6岁），46例年龄在65岁以上（80.7±9.3岁）。胃造口术置入的原因包括6例植物人状态、31例吞咽困难和21例厌食。1996年12月收集了一个对照组，包括所有在病历中提及营养支持问题但因患者或家属拒绝或工作人员决定未实施人工营养的患者。该组包括50例患者，5例年龄小于65岁（54±8.3岁），45例年龄较大（84.7±7.6岁）。22例患者存在营养问题为吞咽困难，28例为厌食。PEG组34例患者和对照组7例患者在置入前即存在压疮（p<0.001）。
PEG组和对照组的预后、早期和晚期皮肤消化系统（肠梗阻、呕吐、胃食管反流）和肺部（支气管溢液、呼吸困难和吸入性肺炎）并发症，记录PEG行为耐受性差迹象的患者情况。对PEG组进行护理质量审核，采用八项标准：两项涉及置入前期，两项涉及早期随访，四项涉及长期随访。
PEG组早期死亡率（4周）为13.8%（对照组为10%，无统计学差异），中期死亡率（4至8周）为12.1%（对照组为14%，无统计学差异），晚期死亡率为19.0%（对照组为42.0%，PEG组随访时间为63.4±42.1周，对照组为53.1±63.8周，无统计学差异）。PEG组存活患者的随访时间为71.6±61.8周，对照组为48.0±70.5周。PEG组只有20%的患者置入部位周围无任何皮肤并发症，第一周内发生了8例脓肿。PEG组39%的患者发生肺部并发症（对照组为30.0%，无统计学差异）。两组中吸入性肺炎均与吞咽困难显著相关（p<0.05）。PEG组15.5%的患者发生呕吐（对照组为12%，无统计学差异），13.8%的患者发生肠梗阻（对照组为6%，无统计学差异）。PEG组有2例患者出现胃食管反流，对照组有1例。PEG组34例患者中有20例压疮正在愈合（对照组7例中有2例），24例中有6例出现新的溃疡（对照组43例中有8例）。15例（25.8%）PEG患者试图拔出胃管。
