Introduction
A gastrostomy can be life-extending; however it is also associated with an increase in morbidity and mortality. This research aims to describe current gastrostomy practices and associated mortality, and understand the factors involved in the gastrostomy decision-making process.
Methods
1. A retrospective study using the national endoscopy database (NED) and a national survey to understand clinical practice around gastrostomies.
2. Analysis of multicentre hospital records to determine how 30-day gastrostomy mortality varies and assess the validity of the Sheffield gastrostomy score (SGS).
3. Evaluation of factors influencing gastrostomy-tube removal.
4. Semi-structured interviews with doctors to understand what influences gastrostomy decision-making.
Results
1. The survey response was 69%. There was a 60% reduction in percutaneous endoscopic gastrostomy (PEG) insertions compared to previous estimates, this was validated with NED (≈6,500 vs 17,000 in 2010 (p<0.01)). Survey responses also revealed that consultant involvement in gastrostomy decision making, MDTs and aftercare provision had significantly increased.
2. PEGs =5% 30-day mortality, radiologically inserted gastrostomies (RIGs) =5.5%, per-oral image guided gastrostomies (PIGs) =7.2% (p=0.215). SGS was validated in PEGs, RIGs and PIGs. (n=1977)
3. Gastrostomy removal was associated by age, residence and head and neck cancer (p<0.05). 31.2% of gastrostomies were removed within 3 years. (n=251)
4. Eighteen doctors were interviewed and 4 themes derived: Strengths and weaknesses, process and influences, problems, and factors optimising decision-making.
Conclusions
This thesis shows that there are still areas that can be improved in gastrostomy selection and emphasises the importance of discussions amongst colleagues, patients, and families. Data suggests that MDT discussions have improved but do not occur for everyone. Information on mortality, including validated scoring systems, may be useful in the consent process. Some hospitals still lack effective referral systems for gastrostomy insertion, having these correctly in place should improve the selection process.
