Feeding Jejunostomy Research Articles

Impact of regular enteral feeding via jejunostomy during neo-adjuvant chemotherapy on body composition in patients with oesophageal cancer.

BACKGROUNDMalnourishment and sarcopenia are well documented phenomena in oesophageal cancer. Patients undergoing neo-adjuvant chemotherapy prior to oesophagectomy have complex nutritional needs.AIMTo examine the effect of regular nutritional support via feeding jejunostomy on overall body composition in patients undergoing neo-adjuvant chemotherapy prior to oesophagectomy for oesophageal cancer.METHODSRetrospective data were collected for 15 patients before and after neo-adjuvant chemotherapy. All patients had feeding jejunostomies inserted at staging laparoscopy prior to neo-adjuvant chemotherapy and underwent regular jejunostomy feeding. Changes in body composition were determined by analysis of computed tomography imaging.RESULTSPatient age was 61.3 ± 12.8 years, and 73% of patients were male. The time between start of chemotherapy and surgery was 107 ± 21.6 d. There was no change in weight (74.5 ± 14.1 kg to 74.8 ± 13.1 kg) and body mass index (26.0 ± 3.8 kg/m2 to 26.1 ± 3.4 kg/m2). Body composition analysis revealed a statistically significant decrease in lumbar skeletal muscle index despite regular feeding (45.8 ± 8.0 cm2/m2 to 43.5 ± 7.3 cm2/m2; P = 0.045). The proportion of sarcopenic patients increased (33.3% to 60%). Six patients (40%) experienced dose-limiting toxicity during chemotherapy.CONCLUSIONRegular jejunostomy feeding during neo-adjuvant chemotherapy can maintain weight and adipose tissue. Feeding alone is not sufficient to maintain muscle mass. Further insight into the underlying processes causing reduced muscle mass in cancer patients may help to provide targeted interventions.

Corrosive Poisoning Gastric Outlet Obstruction Treated by Early Definitive Surgery

Corrosive injury is common amongst young adults attempting suicide. Apart from oesophageal burns, many have predominant gastric injuries. Resulting gastric strictures need surgery in majority. Common practice is to do feeding jejunostomy followed by definitive surgery after a few months. But it is challenging in poor patients to maintain tube feeding. In view of this, we looked into alternative safe early definitive approach. This study was done in the Department of Surgical Gastroenterology in Medical College Kolkata. Over the last 8 years (January 2009 to April 2017), consecutive 74 patients with corrosive gastric strictures were included. Extent of gastric cicatrisation was assessed by endoscopy and barium study. Nutrition was maintained by oral, naso-jejunal or feeding jejunostomy. Early definitive surgery was preferred. Patients’ follow-up was evaluated. Patients presented with vomiting, weight loss and dysphagia. Out of 74 patients, 30 had associated oesophageal strictures which were amenable to dilatation. Pre-pyloric short strictures were found in 52 (70.27%) patients. Surgical procedures included stricturoplasty for short strictures (70%) and gastrojejunostomy for more severe gastric cicatrisation. Seventy-five per cent of the patients had definitive surgery within 3 months of injury. Complications included mortality in 3 (4.05%) patients and wound dehiscence, pneumonitis and ileus. All patients gained weight within 6 to 8 weeks and doing well during follow-up. Management of corrosive gastric injury depends on the extent of gastric involvement, associated oesophageal strictures and general condition of the patient. In majority, early definitive surgery like stricturoplasty, avoiding gastric resection or bypass provides very satisfactory and physiological outcomes.

A simple, novel laparoscopic feeding jejunostomy technique to prevent bowel obstruction after esophagectomy: the “curtain method”

Feeding jejunostomy (FJ) is a common treatment to support patients with esophageal cancer after esophagectomy. However, severe FJ-related complications, such as bowel obstruction, occasionally occur. We investigated the ability of our simple, novel FJ technique, the "curtain method," to prevent bowel obstruction. In laparoscopic surgery, the main mechanism of bowel obstruction involves torsion of the mesentery accompanied by migration of the intestine across the fixed FJ through the space surrounded by a triangle comprising the ligament of Treitz, fixed FJ, and spleen rather than adhesion. Our "curtain method" involves closure of this triangle zone with omentum, and the appearance of the lifted omentum resembles a curtain. Sixty patients treated with this modified FJ were retrospectively compared with 13 patients treated with conventional FJ in terms of the incidence of bowel obstruction, peritonitis, stoma site infection, and catheter obstruction. From 2013 to 2017, 60 patients underwent esophagectomy and gastric conduit reconstruction accompanied by modified laparoscopic FJ. The median observation period, including the period after tube removal, was 644days. No FJ-associated bowel obstruction, the prevention of which was the primary aim, occurred in any patient. Likewise, no peritonitis or dislodgement occurred. Eight patients (13%) developed a stoma site infection with granulation. The feeding tube became occluded in 11 patients (18%); however, a new feeding tube was reinserted under fluoroscopy for all of these patients. From 2003 to 2012, 13 patients underwent conventional FJ. The median observation period was 387days. Three patients (23%) developed bowel obstruction by torsion 71 to 134days after the first surgery, and all were treated by emergency operations. Other FJ-related complications were not different from those in the modified FJ group. Our simple, novel technique, the "curtain method," for prevention of laparoscopic FJ-associated bowel obstruction after esophagectomy is a safe additional surgery.

The decrease of BMI and albumin levels influences the rate of anastomotic leaks in patients following reconstruction after emergency diverting esophagectomy.

Diverting esophagectomies in cases of benign esophageal perforations remain rare but potentially life saving procedures. Usually, an esophagostoma and a feeding jejunostomy or gastrostomy are created, and patients are given time to recover from the emergency situation. However, little is known about morbidity and mortality as well as the optimal timing for a staged reconstruction. Patients with benign esophageal perforations were selected from our retrospective database. Perforations in esophageal malignancies were excluded to avoid bias on patients' general outcome. Clinical parameters and especially, the influence of the nutritional status indicated by the BMI (Body Mass Index) as well as serum albumin levels (g/l) were analyzed. A total of 24 patients with diverting esophagectomies were identified. Of these, 13 (54.2%) patients received a staged reconstruction after a median of 143.0days. Patients presenting for their staged reconstruction demonstrated a significantly decreased level of their BMI (p = 0.026) as compared to their prior hospitalization. Interestingly, the relative decrease of BMI (8.5kg/m2 vs. 4.3kg/m2) and albumin levels (6.5g/l vs. 0.0g/l) was significantly different in patients with or without anastomotic leaks between both surgeries (p = 0.021; p = 0.034, respectively). In addition, higher rates of overall complications were associated with an increased rate of malnutrition. The relative amount of malnutrition indicated by BMI or serum albumin levels influences the rate of anastomotic leaks and general complications in patients with staged reconstruction after diverting esophagectomy for non-malignant esophageal perforations. Hence, reconstruction should be done as fast as possible to reduce the amount of malnutrition and a frequent assessment of the nutritional status must be done during recovery from the emergency surgery.

Right paraduodenal hernia, rare cause of gangrene bowel: case report with review of literature

A right paraduodenal hernia includes small bowel trapped within a peritoneal sac between the right and transverse colon, positioned right of midline, with the hernia sac opening to the left at the ligament of treitz, with either the superior mesenteric or ileo-colic artery at the anterior aspect of the sac. Patients with PDH often present with signs and symptoms of obstruction and/or bowel gangrene. We report a case of a 50 year old male presenting with small bowel ischaemia due to right paraduodenal hernia. Patient presented with chief complaints of colicky abdominal pain since two days and abdominal distension, and altered sensorium since one day. Abdominal ultrasonography showed dilated small bowel loops, and CT scan of abdomen was suggestive of clustering of small bowel loops with proximal dilatation. Exploratory laparotomy revealed a right PDH with a strangulated loop of 160 cm of small bowel within. The peritoneum at the ligament of Treitz was lax. The DJ flexure showed gangrenous changes along the anti-mesenteric edge. Resection and anastomosis of small bowel was done along with wedge resection of the DJ flexure, followed by feeding jejunostomy. The sac was opened up wide and plicated over itself to prevent recurrences. Perioperative course was uneventful, and patient discharged on post op day 10. Jejunostomy tube was removed after one week. Patient is being followed up at OPD level with close surveillance to prevent nutritional deficiency due to short gut syndrome. A vigilant mind is of utmost importance to suspect and diagnose paraduodenal hernia to limit morbidity and mortality.

P223 BILATERAL RECURRENT LARYNGEAL NERVE LYMPHADENECTOMY DURING THORACOSCOPIC ESOPHAGECTOMY IN PRONE POSITION

Abstract Aim To present a video of a complete bilateral recurrent laryngeal nerve lymphadenectomy performed during minimally invasive esophagectomy using thoracoscopic video-assisted surgery in the prone position. Background and Methods Surgical treatment for esophageal cancer needs detailed lymphadenectomy. Indeed, the number of surgically dissected lymph nodes is important for staging accuracy and also determines patient’s prognosis, including those along the recurrent laryngeal nerve. However, recurrent laryngeal nerve dissection remains difficult and increases the appearance of postoperative complications. This is a video of a bilateral recurrent laryngeal nerve lymphadenectomy during thoracoscopic esophagectomy performed in the prone position in a female patient with esophageal cancer. Results A 75 year-old female was diagnosed with recurrent squamous cell middle third esophageal carcinoma. The patient had first been diagnosed eleven years ago, receiving chemoradiotherapy as a radical treatment. The patient achieved a complete response after treatment, which remained for eleven years. Eleven years later, during routine follow-up, tumor recurrence was identified in the middle third of the esophagus. After presentation in a Multidisciplinary Group the patient underwent minimally invasive McKeown esophagectomy. First, a video-assisted thoracoscopic surgery was performed in the prone position to mobilize the thoracic esophagus and complete a detailed mediastinal lymph node dissection, including infra-carinal lymph nodes, bilateral bronchial lymph nodes and also bilateral recurrent laryngeal nerve lymph nodes. Afterwards, the abdominal esophagus and lymph node dissection is performed using a laparoscopic approach, and also a left cervicotomy in the supine position. An assistance laparotomy was made to externalize the specimen and make the gastric conduit. A manual end-to end esophago-gastric anastomosis was executed and finally, a feeding jejunostomy tube was placed. The patient presented a benign postoperative course, introducing enteral nutrition and oral intake developing no complications, such as dysphonia, nor dysphagia and was discharged on the 8th postoperative day. The postoperative barium swallow radiography showed no leaks nor other complications and pathology report confirmed tumor free resection margins. Conclusion Detailed mediastinal lymph node dissection and exhaustive bilateral recurrent laryngeal nerve lymphadenectomy can be safely performed by minimally invasive surgery, as is shown in the video. The technique shown is feasible, achieves a complete lymph-node dissection and avoids postoperative complications such as dysphonia and recurrent laryngeal nerve palsy.

P133 INTRATORATHIC ANASTOMOSIS IN IVOR-LEWIS ESOFAGUECTOMY: TECHNICAL DESCRIPTION AND RESULTS

Abstract Aim Description of the technique of intrathoracic anastomosis in Ivor-Lewis esophagectomy in prone position with minimally invasive approach (MIE) by manual tobacco-bag suture and anastomosis with circular stapler and its results. Background & Methods Retrospective descriptive analysis of the intrathoracic anastomosis technique in prone of the cases performed in our Health Care Center by thoracoscopic and laparoscopic approach in Ivor-Lewis esophagectomy between April 2017 and December 2018. Patients who required conversion to thoracotomy due to pleural adhesions were excluded Results The median age of the 18 patients was 59 years (54-67 years). In the 18 analyzed (17 adenocarcinomas of 1/3 lower or gastro-esophageal junction and 1 benign stenosis post-RT) 12 were performed with mechanical anastomosis CEA 25, 2 with CEA 28 and 4 with Orvyl CEA 25. No leakage occurred during the postoperative period, performing in 16 a TEGD at 4-5º DPO. Three patients underwent feeding jejunostomy. In the postoperative period, 2 patients presented with ARDS, 2 with pneumonia, 2 with pleural effusion, and 1 with AF. In the follow-up performed until May 2019 1 patient presented stenosis of the anastomosis that was treated by endoscopic dilation. No leakage of the anastomosis has been recorded. The postoperative mortality (<30 days) was 0% Conclusion Compared with other technical variations, even with another type of anastomosis, the circular mechanical anastomosis, making the tobacco bag around the head by manual suture and reinforcing it by Endoloop is a safe and reproducible technique with a 0% leakage rate and stenosis of 5.88%. According to the literature, the rate of anastomotic leakage in the thoracoscopic approach is between 0-20% and that of anastomotic stenosis is 0-27.5%, without finding significant differences between the different types of anastomosis. It has been demonstrated in numerous series that the thoracoscopic approach is oncologically equal to or better than the approach by thoracotomy because it allows a better dissection with resection of a greater number of nodes and that provides benefits such as less postoperative pain, better patient ventilation, better ergonomics for the surgeon and better vision of the operative field. However, we believe that this new approach should not change the usual technique of performing the anastomosis or the indication of the Ivor-Lewis esophagectomy. Randomized studies with a larger number of cases are necessary to determine which anastomosis technique is safest and reproducible in MIE surgery of esophageal cancer.

O212 IVOR LEWIS ESOPHAGECTOMY AFTER SLEEVE GASTRECTOMY: THE USE OF GASTRIC CONDUIT IS STILL POSSIBLE

O212 IVOR LEWIS ESOPHAGECTOMY AFTER SLEEVE GASTRECTOMY: THE USE OF GASTRIC CONDUIT IS STILL POSSIBLE

P136 COMPARISON OF TOTALLY MINIMALLY AND HYBRID IVOR LEWIS ESOPHAGECTOMY FOR CANCER OF DISTAL ESOPHAGUS AND ESOPHAGOGASTRIC JUNCTION

Abstract Aim Aim of this retrospective study is the comparison of the short-terms outcomes and QoL of Hybrid Ivor Lewis (HIL) and Totally Minimally Invasive Ivor Lewis (TMIIL). Background & Methods Minimally invasive techniques for esophagectomy represents a challenging procedure with aiming to decrease cardiopulmonary complications and guarantee better quality of life (QoL) compared to open techniques, without compromising oncological radicality. Patients with cancer of distal esophagus and EGJ were included into (HIL) and (TMIIL) groups in the period January 2017 – March 2019. General features, intraoperative and postoperative results were analyzed. For all the patients a feeding jejunostomy was performed. The surgical radicality and number of resected nodes were also evaluated. QoL was determined preoperatively, at 7 and 90 days postoperatively with EORTC QLQ-C30 questionnaire. Results Eighteen and 24 patients were submitted to TMIIL and HIL respectively. General features were similar in the two groups. Median intervention duration was 360 minutes [range: 240-420] in TMIIL group and 335 minutes [range: 150-400] for HIL group (p=0.0647). Median blood losses were similar for TMIIL and HIL group, 100 ml [range:50-400] and 175 ml [50-350] respectively (p=0.0831). No differences were observed in terms of postoperative complications CD≥2. One exitus occurred in HIL group (CD=5), none in TMIIL group (p=n.s). No differences were evidenced for median number of lymphnodes harvested in the two group as well for rate of R0 and R1 resections. Results obtained from the QoL questionnaires evidenced a reduction of postoperative pain during the first 7 postoperative day for patients in the TMIIL group compared to HIL; these data were confirmed by the analysis conducted on postoperative day 90, as well for the global health status, physical functioning and role functioning. Conclusion Our experience evidenced TMIIL esophagectomy seems to give the similar results, of HIL influencing positively the QoL within 90-day after surgery. Duration of surgery and anastomotic leaks are the key elements influencing the learning curve. Randomized controlled trials are necessary to confirm the good results obtained and to give recommendations to avoid a high rate of complications

Fluoroscopic-guided nasogastric tube placement in patients with advanced head and neck cancers

Enteral feeding, mainly by using a nasogastric tube (NGT), is generally favored over parenteral supplementation in head and neck cancer (HNC) patients with dysphagia. However, the placement of a NGT, either blindly or by endoscopy, is technically challenging in these patients due to the obstructive mass and the altered regional anatomy. The aim of this retrospective study was to estimate the clinical feasibility and safety of fluoroscopic-guided NGT placement in patients with advanced HNC. Between January 2010 and June 2018, a total of 572 fluoroscopic-guided NGT placements were performed on 231 patients. Technical success was defined as successful insertion of the NGT into the stomach with proper positioning, which was verified by air injection into the NGT. Complications, including aspiration pneumonia, and the ones requiring intensive care, or procedure-related death, were recorded. Technical success was obtained in 558 (97.6%) procedures, and the other 14 (2.4%) procedures failed because of patient intolerance (n=1) and high-grade obstruction (n=13). Of the high-grade obstruction patients, eight (61.5%) were shifted to percutaneous radiological gastrostomy, two (15.4%) to surgical feeding jejunostomy, one (7.6%) to endoscopic balloon dilatation, and two (15.4%) to orogastric tube insertion. The average procedure time and fluoroscopy time were 11.7±7.4min and 3.1±3.1min, respectively. There were no major complications. Our results show that fluoroscopic-guided NGT placement is a highly safe and effective procedure for patients with advanced HNC requiring enteral feeding.

Paediatric enteral feeding at home: an analysis of patient safety incidents

AimsTo describe the nature and causes of patient safety incidents relating to care at home for children with enteral feeding devices.MethodsWe analysed incident data relating to paediatric nasogastric, gastrostomy or...

Management of leak after sleeve gastrectomy: outcomes of 73 cases, treatment algorithm and predictors of resolution.

IntroductionGastric leak post laparoscopic sleeve gastrectomy (LSG) is a severe complication that has been reported in 1.5–3% of cases. Management algorithms of leak exist; however, no known factors predict the time to resolution. This study aims to share outcomes of our management algorithm of post LSG leak, including the rate of resolution, complications, admission to the intensive care unit, conversion to other techniques, and mortality. To determine if any factors can predict the resolution time.MethodsA retrospective analysis of patients who had LSG leaks and was managed in the main tertiary center in Qatar (January 2012–December 2017).ResultsA total of seventy-three patients had post LSG leaks. Fifty-six (76.7%) underwent LSG outside our center. Thirteen leaks (17.8%) were after revisional LSG. Laparoscopic exploration was performed in twenty patients (27.4%) and feeding jejunostomy in nine patients (12.3%). Patients were followed up for 12 months. All healed within 8.8 ± 0.72 weeks. The resolution rate was (97.1%) without surgical conversion, while two patients required fistulo-jejunostomy. No patient died. Complications occurred; re-leak (14.9%) and splenic abscess (2.9%). Patients on jejunal feeding had shorter resolution time (HR = 2.7, P = 0.018), while patients on total parenteral nutrition and post-endoscopic dilatation had 66% and 50% increases in the resolution time; (HR = 0.34, P = 0.026) and (HR = 0.5, P = 0.047), respectively.ConclusionManagement of post-LSG leak is multimodal. Our clinical experience demonstrated less urge to perform extensive surgical interventions. Patients on enteral feeding had shorter resolution time while patients with sleeve stricture had a longer time to resolution.

Refractory Hyperemesis Gravidarum in a Patient with Type 1 Diabetes Treated with Laparoscopically Assisted Feeding Jejunostomy Tube Placement

Refractory Hyperemesis Gravidarum in a Patient with Type 1 Diabetes Treated with Laparoscopically Assisted Feeding Jejunostomy Tube Placement

RETROSPECTIVE AND PROSPECTIVE STUDY OF CORROSIVE POISONING AND ITS EFFECT ON UPPER GASTRO INTESTINAL TRACT AND SURGICAL MANAGEMENT IN TERTIARY CARE CENTRE

Background: Corrosive injury to the upper gastrointestinal tract is an insufferable experience for both the patient and surgeon. Corrosive ingestion may usually responsible for wide spread injury to the lips, oral cavity, oropharynx and the upper air way, upper gastrointestinal tract.
 Results: in our study more common patients were in the age group 21-30 years. Majority of the patients had consumed toilet cleaner. Majority of the patients had consumed substance of <=30 ml. Majority of the patients had consumed HCL. Majority of the patients had consumed the substance with a suicidal Intention, [ 42.9%] consumed corrosive under influence of alcohol, In 5 (14.3%) patients had oropharynx involvement, in 8 (22.9%) patients had lower esophagus involvement, in 8 (22.9%) patients had middle esophagus involvement and 17 (48.6%) patients had upper esophagus involvement. In 18 (51.4%) patients had pylorus (stomach) involvement and in 5 (14.3%) patients duodenum (first part) involvement. In 11 (31.4%) patients esophagus was involved at 2A level, in 17 (48.6%) patients esophagus was involved at 2B level and in 2 (5.7%) patients esophagus was involved at 3A level. In 9 (26.5%) patients dilatation was not possible, in 2 (5.9%) patients it was not done. In 9 (26.5%) dilatation was done 2 times and in 14 (41.1%) patients dilatation was done 3 times .In 34 (97.1%) patients feeding jejunostomy insertion was done in 1 (2.9%),most common sequels esophageal stricture [65.7%] and GOO[40%], patient laparotomy Bilroth II gastrectomy was done as a primary intervention. Majority of the patients complained of dysphagia and chest pain and cough at first visit. In 11 (32.4%) patients gastrojejunostomy was done, in 7 (20.6%) patients esophagectomy with gastric pull-up was done, in 4 (11.8%) patient’s thoracoscopic esophagectomy with colonic interposition was done. There were 3 (8.6%) deaths and 32 (91.4%) patients were discharged successfully in our study there was a significant improvement seen in the weight from follow-up at 2 months till the end of follow-up at 12 months (p<0.05).
 Conclusion: In our study corrosive ingestion common in young age decrees, with increase age, (HCL) toilet cleaner found to be the commonest corrosive chemical used esophags most common than pylorus affected by the ingestion, oropharynx and duodenum less likely,2Bgrade of injury was affected the most in esophagus, stomach or duodenum, with a very high incidence of stricture formation. Dysphagia, throatpain, excessive salivation and hoarseness of voice were the commonest presenting symptoms. The first line of performed surgery at presentation was insertion of feeding jejunostomy and improvement in diet intake and strength of feeding jejunotomy patients underwent gastrojejunostomy, esophagectomy with gastric pull-up or thoracoscopic esophagectomy with colonic interposition. Dilatation was required in majority of the patients. There was a significant improvement in the weight of these patients over various follow-up periods. The overall success rate of management of these patients was found to be very high with only a very few deaths recorded in our study.
 Keywords: Corrosive injury, Esophagealstricture, Gastric outlet obstruction, Upper GI endoscopy.

Routine use of feeding jejunostomy in oesophageal cancer resections: results of a survey in England.

Nutrition and post-operative feeding in oesophageal cancer resections for enhanced recovery remain a controversial subject. Feeding jejunostomy tubes (FJT) have been used post-operatively to address the subject but evidence to support its routine use is contentious. There is currently no data on FJT use in England for oesophageal cancer resections. Knowledge regarding current FJT usage, and rationale for its use may provide a snapshot of the trend and current standing on FJT use by resectional units in England. A standardised survey was sent electronically to all oesophageal resectional units in the United Kingdom (UK) between October 2016 and January 2018. In summary, the questionnaire probes into current FJT use, rationale for its usage, consideration of cessation of its use, and rationale of cessation of its use for units not using FJT. The resectional units were identified using the National Oesophago-Gastric Cancer Audit (NOGCA) progress report 2016 and 1 selected resectional unit from Northern Ireland, Scotland, and Wales, respectively. Performance data of those units were collected from the 2017 NOGCA report. Out of 40units that were eligible, 32 (80.0%) centres responded. The responses show a heterogeneity of FJT use across the resectional centres. Most centres (56.3%) still place FJT routinely with 2 of 18 (11.1%) were considering stopping its routine use. FJT was considered a mandatory adjunct to chemotherapy in 3 (9.4%) centres. FJT was not routinely used in 9 (28.1%) of centres with 5 of 9 (55.6%) reported previous complications and 4 of 9 (44.4%) cited using other forms of nutrition supplementation as factors for discontinuing FJT use. There were 5 (15.6%) centres with divided practice among its consultants. Of those 2 of 5 (40.0%) were considering stopping FJT use, and hence, a total of 4 of 23 (17.4%) of units are now considering stopping routine FJT use. In conclusion, the wider practice of FJT use in the UK remains heterogenous. More research regarding the optimal post-operative feeding regimen needs to be undertaken.

2725 Electrode Perforation Into Stomach Complicating Gastric Electrical Stimulation

INTRODUCTION: Gastric electrical stimulation is not FDA-approved, but available on a compassionate basis in the management of refractory gastroparesis. We describe a patient with refractory gastroparesis treated by gastric electrical stimulation who developed the rare complication of electrode migration into the lumen of the stomach. CASE DESCRIPTION/METHODS: A 31 year old female with idiopathic gastroparesis was refractory to maximal medical therapy including polypharmacy and feeding jejunostomy. Her gastric emptying was delayed with only 78% gastric emptying after 4 hours on gastric emptying scan (normal > 90%). A gastric electrical stimulator was placed 4 years prior to presentation, on a compassionate use basis. A battery change was required 2 years later. Settings were gradually increased to maximal, at 5 mA, pulse width of 360 us, rate 40 Hz, cycle on 2 seconds, cycle off 3 seconds. Two years later she complained of stabbing epigastric pain, and a recurrence of her gastroparesis symptoms, with nausea, vomiting, coffee ground emesis, and early satiety. On physical exam she was afebrile and non-toxic, with mild epigastric tenderness. CT showed a non-specific 3.7 cm fluid density adjacent to the stomach around the gastric pacemaker lead. Upper endoscopy revealed that two of the leads had penetrated into the gastric lumen. Gastric retention of food was also noted, even though the patient had been nothing by mouth for 12 hours prior to the procedure. Surgery confirmed that 2 of the gastric pacemaker leads had eroded into the stomach. The leads were removed, and new leads placed more proximally in the stomach. A surgical pyloroplasty was also performed. The patient did well in the 18 months of post-operative follow-up. DISCUSSION: Lead perforation into the stomach following gastric electrical stimulation is rare. As far as we are aware, there are 3 previously reported cases. In addition, there is one report of electrode perforation into the small bowel. We speculate that higher energy settings, and longer duration of cycles on may be a risk factor for this complication. Sudden epigastric pain, recurrence of gastroparesis symptoms, and a fluid collection at the electrode insertion site, may be clues as to the development of this rare complication.

1860 Use of NBT Gastrostomy Tubes as Replacement Jejunal Feeding Tubes

INTRODUCTION: For severely neurologically impaired patients, feeding tubes are a life-sustaining measure. While most patients can tolerate direct feeding into the stomach via nasogastric feeding tubes or gastrostomy feeding tubes, these options may be unhelpful or dangerous for patients with gastric retention or severe gastroesophageal reflux. For such patients, feeding through a jejunostomy may offer a safe alternative. However, when the tube needs to be replaced there are limited options. We review our experience of using non-balloon tip (NBT) gastrostomy replacement tubes as replacement jejunostomy tubes. CASE DESCRIPTION/METHODS: We searched procedure and follow-up reports from an individual gastroenterologist (JRE) from 03/2015 to 11/2018 for patients with jejunostomy feeding tubes at a single sub-acute nursing facility. All four jejunostomy patients on record had received 20 French NBT gastrostomy replacement tubes as replacement jejunostomy feeding tubes. The NBT tubes have a collapsible mushroom-shaped tip which is placed in the stoma with an obturator. We reviewed the patient records to determine if NBT replacement tubes effectively delivered nutrition and medication, whether they resulted in complications, and with what frequency the tubes needed replacement. DISCUSSION: The patients’ records show that the improvised replacement jejunal feeding tubes performed quite well. Available records show that the patients were fed jejunally for periods ranging from 47 to 168 weeks. Replacement NBT tubes lasted from 28 to 609 days. During this period, the only complication suffered was internal detachment of the mushroom tip, which occurred 5 times (4 of which in a single patient). In each of these cases however, the bowel remained unobstructed and the tips passed through the alimentary canal. Patients retained overall good health in spite of neurological impairment. For patients requiring feeding interventions, but lacking adequate gastric function, jejunostomy feeding is often needed if enteral feeding is to be maintained. While there is at present a dearth of equipment designed specifically for jejunal feeding tube replacement, our experience suggests that NBT gastrostomy tubes may constitute a viable option for patients with jejunostomy tubes. These mushroom-tip tubes remain in place without occluding the jejunum, they clog infrequently due to the wide lumen, and they represent a readily available and easy to place option for patients who need jejunostomy tube replacement.

1836 The Bougie Cap: A Novel Device for Treatment of Esophageal Strictures

INTRODUCTION: Treatment of high cervical esophageal strictures can be technically challenging. Placement of endoscopic balloons across the stricture may not be feasible due to their proximal location. Serial dilation with the use of Savary-Gilliard dilators is a well-established method for treatment of these strictures. However, this technique does not allow for direct optical feedback during dilation. We present a case of benign cervical esophageal stricture treated with a novel method utilizing the BougieCap (Ovesco Endoscopy AG). CASE DESCRIPTION/METHODS: A 62-year-old male presented with dysphagia. He had a prior history of peptic stricture at the gastroesophageal junction, treated with multiple balloon dilations that was complicated by an esophageal perforation. Patient underwent an emergent thoracotomy, esophagectomy, and gastric pull-up with placement of a feeding jejunostomy. Four months after surgery, he noted recurrence of dysphagia, with food getting lodged in the area below his throat and upper chest. Barium swallow revealed a tight stricture at the anastomosis that narrowed the lumen down to 5 mm in size. Upper endoscopy confirmed a stricture located 18 cm from the incisors. Using an endoscopic BougieCap the stricture was dilated serially from 7 to 12 mm in size with good results. Expected mucosal disruption was identified at the end of the procedure. On follow up, patient reported significant improvement in his symptoms without any complications. DISCUSSION: Use of Savary-Gilliard Dilators for stricture dilation provides only haptic control and often requires the use of fluoroscopic guidance. Our case highlights the use of a novel device - the BougieCap - for treatment of esophageal strictures which allows for direct visual control and optical feedback during the procedure. Ability to visualize the tension on the tissue while passing the stricture with the cap avoids overstretching and may help reduce the risk of complications, allowing for a more effective procedure. Moreover, by eliminating the need to switch instruments, the use of BougieCap can reduce procedure times. Additional prospective studies with a larger number of patients and long-term follow-up are necessary to determine its safety and long-term efficacy.

492 The Combination of a Tricyclic Antidepressant and Diaphragmatic Breathing Is an Effective Treatment for Rumination Syndrome

INTRODUCTION: Rumination syndrome (RS) is a functional gastrointestinal disorder that is characterized by effortless postprandial regurgitation, usually preceded by belching, and accompanied by epigastric abdominal wall pain and gastric visceral hypersensitivity. Almost invariably, the onset of symptoms is preceded by a psychologically stressful situation, and anxiety is often an accompanying complaint. In this background of gastric visceral hypersensitivity, anxiety, and psychological stress, we investigated the effectiveness of combining a tricyclic antidepressant (TCA) with the more standard approach of diaphragmatic breathing/relaxation techniques (DB/RT) for the treatment of RS, as well as highlight the clinical aspects of this entity. METHODS: Patients referred to an academic motility center for vomiting of unknown origin were prospectively identified. Those who fulfilled the Rome IV criteria for RS received hands-on instructions/coaching on diaphragmatic breathing techniques, were given relaxing auditory media, started on a TCA, and completed a follow-up symptoms questionnaire after undergoing a minimum of three months of this therapy. RESULTS: A total of 44 patients, 35 women; mean age 40.4 [range 20-71] were identified and completed the treatment protocol. Mean time from onset of symptoms to diagnosis was 36.0 months [range 6-180], weight loss ranged from 1.4 – 39.5 kg., six required a jejunostomy feeding tube (J-tube), and one was receiving total parenteral nutrition (TPN). 65.9% had a history of anxiety and/or depression, and 65.9% reported the onset of symptoms were chronologically related to an inciting event/psychological stressor. Moreover, half of the patients were taking opioid medications for abdominal wall pain at the time of initial evaluation (Table 1). After a mean follow-up period of 8.8 months, 90.9% of patients reported improvement in their symptoms, with a mean subjective improvement from baseline of 68.9%, and specifically, 45.5% of patients reported ≥80% improvement. Weight increased or stabilized in 80.6% of those initially reporting weight loss, all six patients with a J-tube were weaned off, and the patient on TPN was transitioned to a J-tube. Additionally, 81.8% of patients initially taking opioid medications were successfully tapered off by the time of follow-up (Table 2). CONCLUSION: The combination of a TCA with DB/RT is an effective treatment modality for the management of RS as it addresses the underlying factors identified in this entity.

A Prospective Randomized Trial Comparing Jejunostomy and Nasogastric Feeding in Minimally Invasive McKeown Esophagectomy

BackgroundEarly postoperative enteral nutrition is recommended for patients undergoing esophagectomy; however, the optimum method of tube feeding remains controversial. Thus, the aim of this study is to assess two common enteral nutrition methods after minimally invasive McKeown esophagectomy. MethodsA randomized controlled trial was performed with 120 patients who underwent minimally invasive McKeown esophagectomy from January 2017 to December 2018. The patients were randomly divided so that 58 patients were in the jejunostomy feeding (JF) group and 62 patients were in the nasogastric feeding (NF) group. The postoperative outcomes, including complications, nutritional status, quality of life, and survival rate, were studied and used as the main parameters to compare the abovementioned tube feeding methods. ResultsThe incidence of overall complications was equivalent between the two groups (P = 0.625), except for bowel obstruction (which occurred 4 times in the JF group but did not occur in the NF group). In the first month after surgery (postoperative month 1, POM1), a significantly higher body mass index (BMI) was observed in the JF group (23.6 ± 3.2) than in the NF group (20.9 ± 3.5, P = 0.032). The global quality-of-life scores were better in the JF group than in the NF group (P < 0.001). In addition, there were no significant differences between the two groups in terms of disease-free survival (DFS) (P = 0.816) and overall survival (OS) (P = 0.564). ConclusionsCompared with NF, JF provides more safety, efficacy, and utility as nutritional support for minimally invasive McKeown esophagectomy patients who have a high incidence of anastomotic leakage. However, the higher risk of intestinal obstruction after JF requires attention.