In April’s blog we take a close look at two papers published recently in BMJOG. The first of these papers looks at a very interesting topic, lacking specific evidence- when to replace PEG tubes in patients with long-term requirements. Secondly, we discuss a really interesting and controversial topic, laryngopharyngeal reflux, and specifically the symptoms attributed, perhaps wrongly, to this condition. Finally, we examine an interesting article published recently in Frontline Gastroenterology, and closely linked to our first manuscript from this blog- the experience and practical management of buried bumpers in patients with PEGs.
In their article on the experience of replacing percutaneous gastrostomy feeding tubes, Cha et al retrospectively examined the 5-year experience of patients having gastrostomy tubes placed both endoscopically and via radiological procedures. They examined both the frequencies of tube changes and the costs associated with this, alongside basic demographics. Interestingly they also looked at the specifics associated with the tube type and materials. Over the time period just under 600 procedures were performed. The tubes with the greatest longevity were pull-type gastrostomy, specifically compared to balloon-type. Larger tubes tended to last longer. As expected, procedures involving an endoscopic procedure were more expensive than simple changes in the community. The authors conclude that pull-type tubes require replacement less often than balloon-type tubes, but the latter are more cost-effective largely due to the ease of replacement in the community. These data provide an interesting foundation for prospective work detailing the best strategy for specific patient groups in order to minimise tube failure, minimise unneeded changes and maximise safety.
Multiple symptoms are attributed to reflux. A frequent presentation to both primary and secondary care is the concept of ‘laryngopharyngeal reflux’, often felt to the cause of symptoms such as dysphonia, ‘globus’, throat clearing, postnasal secretions and cough. Despite this, the actual prevalence of reflux leading to these symptoms is poorly elucidated and there is little evidence to rationalise diagnosis and treatment. In their article, O’Hara et al seek to rationalise the diagnosis of ‘Persistent throat symptoms’ versus ‘laryngopharyngeal reflux’. Here the authors analysed data from participants in the ‘Trial Of Proton-Pump Inhibitors in Throat Symptoms’, specifically data at baseline referring to which symptoms they had and a number of reflux symptom scores including Endoscopic-‘Reflux Finding Score’, ‘Reflux Symptom Index’ and ‘Comprehensive Reflux Symptom Score’. Overall, 344 patients were included. There was no relationship between endoscopic reflux findings and any symptoms or symptom scores. The authors performed exploratory analysis and recommend that general terms are used to describe ‘persistent throat symptoms’ and point that these data further question the role of reflux in the aetiology of these symptoms. It may be that current treatment of these symptoms groups with PPIs is pointless, and renaming these constellations of symptoms will help to point patients and clinicians towards new treatments.
Finally, we come back to feeding tubes and a relatively common problem affecting the long-term use and viability of tubes- buried bumpers. In their article in Frontline Gastroenterology Kitchin et al present the experience and recommendations of tube replacement following MDT adoption, compared to prior to this specialist service. Overall, the team found a buried bumper rate of 2.4% and reported 30 cases. Following adoptions of the specialist MDT approach there were fewer surgical procedures (more endoscopic replacement), reduced length of stay and reduced overall complication rates. The use of the specialist MDT resulted in better decision making and pushed replacement towards endoscopic resolution whenever possible, with improved patient outcomes.