Are same day PEG’s a viable option for Head and Neck Patients at Lister Hospital? Maria O’Donnell Macmillan Head and Ne

1. Are same day PEG’s a viable option for Head and Neck Patients at Lister Hospital? Maria O’Donnell Macmillan Head and Neck Dietitian The Lister Hospital • Current practice • At the Lister Hospital patients with head and neck cancer requiring a Percutaneous Endoscopic Gastrostomy (PEG) pre treatment are kept in overnight on the day of insertion. It has been proposed that this group of people are ideal candidates for out-patient PEG’s as contrary to the stereotype they tend to be eating well, have a good body mass index and are ‘clinically well’ for such a procedure. • Out-Patient PEG’s • Carrying out this procedure as an outpatient has the obvious advantage of avoiding admission to hospital and the cost savings associated with this. But how safe is it for patients and how practical is it for health professionals? These were questions I needed to investigate when asked to be involved in putting together a protocol for selective head and neck patients lead by our endoscopy sister. • What is the evidence for the safety of out-patient PEG’s? • There are three main studies. • De Souzae Mello GF et al (2009) prospective cohort study of 139 patients in Brazil concluded “ambulatory placement of gastrostomy tubes is viable and safe in head and neck cancer patients in good clinical condition” (Ref 1). • Mandala A et al(2000) a retrospective auditof 36 patients concluded that “PEG can be performed as a day-case procedure in stable patients with no increase in complication rate, morbidity, or mortality “ (Ref 2). • Wilhelm S et al (2010), looked at the complication rates of 100 consecutive PEG’s 74 inpatient vs. 26 outpatient. Conclusion “outpatientPEG placement is safe and feasible in carefully selected patients. It requires a care path–driven team approach” (Ref 3). • Are there any enteral feeding clinical guidelines? • Relevant guidelines looked at:- • NICE Clinical Guideline 32 • ESPEN (European Society of Enteral and parenteral nutrition). • CREST enteral feeding guidelines 2004 • NPSA 72hr warning post gastrostomy 2011 • Outcome = no evidence to say that anything more than a flush of the PEG 4hrs after being placed is required before discharging the patient. • Are there many units carrying out same day PEG’s and what are their protocols? • Four hospitals have been identified so far • All have nutrition nurses who do the majority of the organisational work (n.b. this trust does not have a nutrition nurse) • All just flush the feeding tube before discharging the patient if all ok • None of the nutrition nurses/dietitians spoken to report concerns of complications • All have protocols and policies in place • How would it work at the Lister? • The Dietitian will provide pre PEG information as usual. Post PEG patients will go to a gastro day unit with nursing staff trained to give post PEG advice and a feeding company nurse can visit the patient the day after in the community. It will require ongoing auditing to identify any problems in complication rates. • The endoscopy sister is currently putting a policy together for trust boards. • In conclusion • Same day PEG’s are a viable option for patients with head and neck cancer at the Lister Hospital as long as the pre and post gastrostomy support is in place. References 1. Souza e Mello et al (2009) Outpatient percutaneous endoscopic gastrostomy in selected head and neck cancer patients. Surgical Endoscopy, Volume 23 (7) Jul . 2. Mandala A et al (2000) Day-case percutaneous endoscopic gastrostomy: a viable proposition? Postgrad Med J ;76:157-159 doi:10.1136/pmj.76.893.157. 3. Wilhelm S et al (2010) Guidelines for identification and management of outpatient percutaneous endoscopic gastrostomy tube placement The American Journal of Surgery. Volume 199, Issue 3 , Pages 396-400.