President's column Vol.7

President's column

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「胃ろうは是か非か」なんてナンセンス 「胃ろうは是か非か」なんてナンセンス

Let’s say you have been using contact lenses, but your eyes got irritated so you started wearing glasses instead.
In this case, it is not the medical technology involving contact lenses that is to blame.
The irritation must have been caused as a result of your misuse of the contact lenses.
Therefore, you cannot argue the rights and wrongs of contact lenses.
The same applies to percutaneous endoscopic gastrostomy, or PEG.
This is the opinion of a famous gastroenterology surgeon with whom I totally agree.

Lately, PEG has frequently been featured in the media as a controversial topic.
While this is actually a good thing, considering that it hasn’t attracted much attention until now, those involved in the industry may have mixed feelings about the way it has been covered by the media.

There are two types of tube feeding: nasogastric feeding, where the tube is passed through the nostril into the stomach, and PEG feeding, where the tube is directly inserted through the abdomen into the stomach.
Very few media sources mention nasogastric feeding.
About 70% of patients receiving nutrition via tubes in Japan are fed through their noses.
Most of the problems concerned with nasogastric tube feeding are solved by PEG.
If I were to be fed by a tube and had a choice, I would definitely go with PEG.

A clinical study on gastrostomy conducted a few decades ago in the U.S. reported that the roles of tube feeding in patients with dementia are to prevent aspiration pneumonia, improve nutrition, prolong survival, reduce the risk of bedsores and infections and provide palliation. However, the report found no evidence that tube feeding benefited the patients in any way.
More often than not, it is reported that this is still the reality in Japan.
This is totally incorrect. The clinical performance of PEG has improved significantly in Japan over the years.
Japan is actually leading the world in making PEG a much safer feeding method by introducing a way of feeding semi-fluid nutrients in a shorter time period.
If the old report provided by the U.S. was totally true, we could argue that “PEG is wrong.”
However, just like the case of contact lenses mentioned earlier, this would be true only if something other than the medical technology was to be blamed for being wrong.

There are still many misunderstandings about PEG.
Many are losing sight of the root of the issue, as seen in the example of an ignorant politician that referred to a dementia patient fed through PEG tubes as "an alien".

Let’s take a look at the issue.
As the higher brain functions deteriorate due to dementia and other conditions, the swallowing mechanism becomes increasingly impaired.
It becomes harder to swallow food during regular meals so the food ends up entering the lungs and causes choking.
After experiencing difficulties for some time, eventually it starts to become hard to even choke, which ultimately causes pneumonia and fever repeatedly even after treatment.
This is when the doctor suggests a safer way to take in nutrients.
At this point, the level of consciousness of patients can vary to a great degree.
A lot of them actually fully recognize their own family members.
So what should be done?

There are a couple of different ways to receive nutrients non-orally: intravenously or through the digestive tract to the intestines. Here are some common methods.

Intravenous feeding

1. Total parenteral nutrition (TPN) –feeds medicinal substances

Nutrients are fed through a catheter inserted in the central vein just below the clavicle.

It is possible to introduce sufficient nutrients even if the digestive tract is not functioning properly.
Since it is necessary to prevent the risk of infection through the catheter, it is important to carry out the procedure under strict medical supervision or by taking sufficient measures.
Medical expenses can be high.
There is a risk of side effects since it does not involve the digestive tract.
2. Peripheral parenteral nutrition (PPN) –feeds medicinal substances

This is also known as an intravenous drip. Nutrients are fed by inserting the catheter into the veins of the extremities.

Operation is fairly easy and feeding becomes possible right away.
It is suitable for controlling the amount of water, electrolytes and medication.
It does not allow the administration of sufficient nutrients in one day.
When used alone, there is a risk of side effects associated with the fact that it does not involve the digestive tract.

Gastric feeding

1. Nasogastric (NG) feeding –feeds food or medicinal substances

A narrow tube is inserted through the nose to the stomach to feed fluids and nutrients.

Operation is fairly easy.
It makes it hard to eat because there is always a tube in the back of the throat.
It is necessary to ensure that the patient is not experiencing any pain during tube insertion and double check the location of insertion.
Administration takes two hours at a time, so it places constraints on the patients, taking a total of six hours a day.
It looks unattractive.
2. Percutaneous endoscopic gastrostomy (PEG) feeding –feeds food or medicinal substances

Using a gastric camera, a tube is inserted above the navel and attached to the stomach.

It is possible to supplement nutrients while undergoing rehabilitation for eating.
It is easy to clean the mouth area.
Blended food can be fed.
It requires surgery.
3. Semi-fluid short-period feeding method via PEG –feeds semi-fluid nutrients
Administration takes 15 minutes at a time, or 45 minutes a day, ensuring plenty of time for rehabilitation.
It has a lower risk of side effects such as aspiration pneumonia, diarrhea, and other complications frequently caused by feeding fluid nutrients.
Nutrients cannot be administered unless pressure is applied.

Despite the medical technology that makes nutrients available, there is the choice of forgoing all methods and waiting for death.
This choice can be made legitimately by following the guidelines on the end-of-life decision-making procedures provided by the Ministry of Health, Labour and Welfare.
This requires that the patient has already expressed his or her will in a clear manner or that the family members and the doctor or medical professional have agreed on the decision after thorough communication.

However, very rarely are there cases where this decision is made in Japan. It is said that this is attributable to the fact that most doctors do not recommend the option of not doing anything and that the patient’s family is reluctant to make that kind of decision.

This is what I think: Japan has a history of taking human life lightly during war. Seriously reflecting on such a past, one prime minister said “The value of human life is heavier than the weight of the earth.”
Perhaps this phrase has left a very strong impression on people, with it being etched in their mind.

I think it is wrong to think that Japanese people hesitate to make any decisions involving death because they are immature in their view of life and death based on their religion and philosophy.
After witnessing how people in the affected areas remained strong even after the devastating Great East Japan Earthquake that took the lives of more than 20,000 people, I believe Japan’s worldview and philosophy are more advanced than any other country in the world.

Holding your father or mother’s warm hand, you tell him or her that a nice cup of tea is on the way. The tea enters the stomach through a tube. You feel like you saw your parent smile.
I hope for a world where people can make such a decision without feeling awkward.

April 2012

Author : Susumu Kawaguchi

Chairman & CEO

Nutri Co., Ltd.

Illustrator : Nakajo Junichi