Percutaneous Gastrostomy Tube Research Articles

Impact of Intensity Modulated Radiotherapy on Weight Loss and Percutaneous Gastrostomy Tube Placement Rates in Advanced Head and Neck Cancer Patients

Impact of Intensity Modulated Radiotherapy on Weight Loss and Percutaneous Gastrostomy Tube Placement Rates in Advanced Head and Neck Cancer Patients

Concurrent Chemoradiotherapy Improves Survival in Patients With Hypopharyngeal Cancer

To retrospectively review our institutional experience with hypopharyngeal carcinoma with respect to treatment modality. A total of 70 patients with hypopharyngeal cancer treated between 1999 and 2009 were analyzed for functional and survival outcomes. The treatments included surgery alone (n= 5), surgery followed by radiotherapy (RT) (n= 3), surgery followed by chemoradiotherapy (CRT) (n= 13), RT alone (n= 2), CRT alone (n= 22), induction chemotherapy followed by RT (n= 3), and induction chemotherapy followed by CRT (n= 22). The median follow-up was 18 months. The median overall survival and disease-free survival for all patients was 28.3 and 17.6 months, respectively. The 1- and 2-year local control rate for all patients was 87.1% and 80%. CRT, given either as primary therapy or in the adjuvant setting, improved overall survival and disease-free survival compared with patients not receiving CRT. The median overall survival and disease-free survival for patients treated with CRT was 36.7 and 17.6 months vs. 14.0 and 8.0 months, respectively (p < .01). Of the patients initially treated with an organ-preserving approach, 4 (8.2%) required salvage laryngectomy for local recurrence or persistent disease; 8 (16.3%) and 12 (24.5%) patients were dependent on a percutaneous gastrostomy and tracheostomy tube, respectively. The 2-year laryngoesophageal dysfunction-free survival rate for patients treated with an organ-preserving approach was estimated at 31.7%. Concurrent CRT improves survival in patients with hypopharyngeal cancer. CRT given with conventional radiation techniques yields poor functional outcomes, and future efforts should be directed at determining the feasibility of pharyngeal-sparing intensity-modulated radiotherapy in patients with hypopharyngeal tumors.

Percutaneous Gastrostomy Tube Placement to Perform Transgastrostomy Endoscopic Retrograde Cholangiopancreaticography in Patients with Roux-en-Y Anatomy

Roux-en-Y gastric bypass (RYGB) surgery is one of the most commonly performed bariatric surgeries in the United States. Patients with prior RYGB are not amenable to conventional endoscopic retrograde cholangiopancreaticography (ERCP). Surgical gastrostomy (SG) tube placement enables transgastrostomy ERCP (TG-ERCP). Eleven patients with RYGB anatomy received open Stamm gastrostomy after which the tract was then allowed to mature for an average of 45days before therapeutic TG-ERCP. The success rate and procedure-related complications of both gastrostomy and ERCP were assessed. TG-ERCP was performed on eleven patients (median age 52years, range 37-61years) with prior RYGB and pancreatobiliary diseases. Indications for ERCP in these patients included suspected gallstone pancreatitis (n=4), ampullary/biliary strictures (n=5), pancreas divisum (n=1), and common bile duct clipping as a result of RYGB surgery (n=1). Two individuals developed post surgical complications with stomal-related infections. TG-ERCP with therapeutic intervention was successfully performed in all patients. Intervention included stone extractions (n=11), biliary stricture dilation (n=11), biliary sphincterotomy (n=11), biliary (n=3) and pancreatic (n=1) stent placement, ampullary biopsies (n=3), choledochoscopy (n=1), and pseudocyst drainage (n=1). Complications included post-ERCP pancreatitis (n=2), post-sphincterotomy bleeding (n=1), gastrostomy site bleed (n=1), and gastric perforation (n=1). The total number of ERCP sessions for the eleven patients was 15 (1 or 2 per patient). Median follow-up was 42days (range 7-123days). Surgical open gastrostomy followed by TG-ERCP enables therapeutic intervention but is associated with significant complications.

Management of Patients with Malignant Bowel Obstruction and Stage IV Colorectal Cancer

Malignant bowel obstruction (MBO), a serious problem in stage IV colorectal cancer (CRC) patients, remains poorly understood. Optimal management requires realistic assessment of treatment goals. This study's purpose is to characterize outcomes following palliative intervention for MBO in the setting of metastatic CRC. Retrospective review of a prospective palliative database identified 141 patients undergoing surgical (OR; n = 96) or endoscopic (GI; n = 45) procedures for symptoms of MBO. Median patient age was 58 years, median follow-up 7 months. Most (63%) had multiple sites of metastases. Computed tomography (CT) scan findings of carcinomatosis (p = 0.002), ascites (p = 0.05), and multifocal obstruction with carcinomatosis and ascites (p = 0.03) significantly predicted the need for percutaneous or open gastrostomy tube, or stoma. Procedure-associated morbidity for 81 patients with small bowel obstruction (SBO) was 37%; 7% developed an enterocutaneous fistula/anastomotic leak. Thirty-day mortality was 6%. Most (84%) patients were palliated successfully; some received additional chemotherapy (38%) or surgery (12%). Procedure-associated morbidity for 60 patients with large bowel obstruction (LBO) was 25%; 11 patients (18%) required other procedures for stent failure, with one death at 30 days. Symptom resolution was >97%. Patients with LBO had improved symptom resolution, shorter length of stay (LOS), and longer median survival than patients with SBO. Patients with MBO and stage IV CRC were successfully palliated with GI or OR procedures. Patients with CT-identified ascites, carcinomatosis, or multifocal obstruction were least likely to benefit from OR procedures. CT plays an important role in preoperative planning. Sound clinical judgment and improved understanding are required for optimal management of MBO.

Gastrostomía endoscópica percutánea: una actualización sobre indicaciones, técnica y cuidados de enfermería

There are numerous conditions and pathologies in which the patient's swallowing ability is diminished or prevented despite having working digestive system. These are the fundamental requirements for the placement of a percutaneous gastrostomy tube (PEG) as a method of choice to provide safe, effective, and prolonged enteral nutrition for the patient at home or when admitted to hospital. Due to its simplicity, safety and low cost, PEG offers several advantages over other feeding techniques, particularly nasogastric tube and parenteral feeding, although it does require simple and accurate knowledge and application of care that ensures low incidence of complications. The placement of a PEG tube should be contemplated in several clinical situations: a) for temporal use in those patients with potentially reversible diseases; b) in non-reversible diseases in which a long survival (of more than 6 months) is foreseeable, and c) in patients affected of terminal and debilitating illnesses in whom a relatively long survival is probable. In these last cases the indication and implementation for PEG should be individualized and agreed jointly. The appropriate training of care professionals and familiar supporters in charge of the patients carrying a PEG tube ensures its continuous functioning and reduces the risk of complications. This paper aims to review the indications and appropriate care for patients carrying a PEG tube and presents the most accurate care that should be provided by both the professional health carers and caregivers.

The effect of window rooms on critically ill patients with subarachnoid hemorrhage admitted to intensive care

IntroductionClinicians and specialty societies often emphasize the potential importance of natural light for quality care of critically ill patients, but few studies have examined patient outcomes associated with exposure to natural light. We hypothesized that receiving care in an intensive care unit (ICU) room with a window might improve outcomes for critically ill patients with acute brain injury.MethodsThis was a secondary analysis of a prospective cohort study. Seven ICU rooms had windows, and five ICU rooms did not. Admission to a room was based solely on availability.We analyzed data from 789 patients with subarachnoid hemorrhage (SAH) admitted to the neurological ICU at our hospital from August 1997 to April 2006. Patient information was recorded prospectively at the time of admission, and patients were followed up to 1 year to assess mortality and functional status, stratified by whether care was received in an ICU room with a window.ResultsOf 789 SAH patients, 455 (57.7%) received care in a window room and 334 (42.3%) received care in a nonwindow room. The two groups were balanced with regard to all patient and clinical characteristics. There was no statistical difference in modified Rankin Scale (mRS) score at hospital discharge, 3 months or 1 year (44.8% with mRS scores of 0 to 3 with window rooms at hospital discharge versus 47.2% with the same scores in nonwindow rooms at hospital discharge; adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 0.67 to 1.50, P = 0.98; 62.7% versus 63.8% at 3 months, aOR 0.85, 95% CI 0.58 to 1.26, P = 0.42; 73.6% versus 72.5% at 1 year, aOR 0.78, 95% CI 0.51 to 1.19, P = 0.25). There were also no differences in any secondary outcomes, including length of mechanical ventilation, time until the patient was able to follow commands in the ICU, need for percutaneous gastrostomy tube or tracheotomy, ICU and hospital length of stay, and hospital, 3-month and 1-year mortality.ConclusionsThe presence of a window in an ICU room did not improve outcomes for critically ill patients with SAH admitted to the ICU. Further studies are needed to determine whether other groups of critically ill patients, particularly those without acute brain injury, derive benefit from natural light.

Gastrocolic Fistula as a Cause of Persistent Diarrhea in a Patient With a Gastrostomy Tube

Joo YJ, Koo JH, Song SH. Gastrocolic fistula as a cause of persistent diarrhea in a patient with a gastrostomy tube. A 60-year-old man with a history of recurrent strokes secondary to moyamoya disease underwent insertion of a percutaneous radiologic gastrostomy tube because of severe dysphagia. Feeding was continued for 5 months after the procedure without complications. Persistent diarrhea began 2 weeks after admission for comprehensive rehabilitation. Conservative treatment was not effective. Sigmoidoscopy showed a U-shaped tube suggestive of a gastrocolic fistula in the transverse colon. This was confirmed by means of a tubogram obtained through a gastrostomy tube. The diarrhea resolved after changing the gastrostomy tube. This case report highlights the importance of considering other uncommon conditions, such as a gastrocolic fistula, in the differential diagnosis of persistent diarrhea in a patient with a gastrostomy tube.

Invited Commentary

Vocal cord paralysis after thoracic surgery remains an important problem worthy of further study. Vocal cord paralysis markedly impairs quality of life and leads to significant perioperative morbidity [1Schneider B. Bigenzahn W. End A. et al.External vocal fold medialization in patients with recurrent nerve paralysis following cardio-thoracic surgery.Eur J Cardiothorac Surg. 2003; 23: 477-483Crossref PubMed Scopus (38) Google Scholar]. Obviously the best treatment is prevention, which entails a detailed knowledge of the anatomy of the nerve, careful dissection when the nerve is in the field, judicious use electrocautery around the nerve, avoidance of traction injury on the nerve, and a weighing of the risk to benefit ratio when dissecting nodes out from the aortopulmonary window. Surgeons are slow at times to make this diagnosis postoperatively, perhaps because of a wish to avoid a painful discussion and acceptance of a technical problem with the procedure. Indeed prospective reports indicate this complication is underdiagnosed when a comparison is made with retrospective reports [2Filare M. Mom T. Laurent S. et al.Vocal cord dysfunction after left lung resection for cancer.Eur J Cardiothorac Surg. 2001; 20: 705-711Crossref PubMed Scopus (48) Google Scholar]. However, as this report indicates, ignoring this issue puts the patient at risk and is not recommended. Laccourreye and colleagues [3Laccourreye O. Malinvaud D. Delas B. et al.Early unilateral laryngeal paralysis after pulmonary resection with mediastinal dissection for cancer.Ann Thorac Surg. 2010; 90: 1075-1079Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar] reported 69 patients who had early recognition of vocal cord paralysis after lung cancer surgery. All patients had a poor voice quality and two thirds aspirated. Notably, 13% of patients recovered vocal cord function, which rose to 24% if the nerve was not reported to be cut in the operative note. As expected, 90% of the time the left vocal cord was involved due to the greater exposure of the left nerve to surgical injury. Vocal cord medialization was very effective at restoring voice quality and swallowing function. Early involvement of an ear nose and throat (ENT) surgeon and a speech therapist is prudent when confronted with a patient who likely has a vocal cord paralysis after thoracic surgery. Bedside inspection with a nasopharyngoscope can confirm the clinical suspicion of a vocal cord paralysis easily without any anesthesia. Bedside aspiration testing, which is usually followed by a modified barium swallow evaluation conducted by the speech therapist, completes the initial evaluation. Recent reports and my own preference is to have the ENT surgeon inject an absorbable substance in the vocal cord fold to medialize the cord in the early postoperative period. This can be done under local anesthesia at the bedside. The ENT surgeon can then follow the patient in the office to see if vocal cord function returns or not. My ENT surgeon waits at least 6 months (when it is not known if the nerve was irreversibly damaged) before recommending a medialization with a permanent implant, which seems prudent to me. This report indicates that the nerve did not recover function beyond 9 months, but does not elaborate on the pace of recovery of the recovered nerves, which would have been interesting to know. Repeat swallowing evaluation is typically done after any vocal cord intervention and periodically if function remains impaired. Early placement of a percutaneous gastrostomy tube is helpful to facilitate good nutrition in those patients with severe impairment of swallowing function. Most will regain adequate swallowing ability with time and swallowing therapy. Careful management of this sometimes unavoidable complication can prevent life-threatening aspiration and enhance the quality of the patient's life with vocal cord medialization procedures. Early Unilateral Laryngeal Paralysis After Pulmonary Resection With Mediastinal Dissection for CancerThe Annals of Thoracic SurgeryVol. 90Issue 4PreviewThe purpose of this study was to document the symptoms, evolution, management, and outcome in a large series of patients with an early unilateral laryngeal paralysis after mediastinal lymph node dissection and pulmonary resection for cancer. Full-Text PDF

Percutaneous Interventional Radiology Procedures in Patients With Epidermolysis Bullosa: Modifications and Challenges

The purpose of this study is to describe the role of interventional radiology in palliation and maintenance of nutritional support in children with epidermolysis bullosa, with a focus on safety and required procedural modifications. This was a retrospective study of all patients diagnosed with epidermolysis bullosa who underwent interventional radiology procedures between January 1991 and December 2008 at a pediatric tertiary care institution. The type of epidermolysis bullosa, the patient's age, the indication and type of interventional radiology procedure, modifications used, and complications were recorded. Fifteen patients (9 boys and 6 girls) with a diagnosis of epidermolysis bullosa underwent a total of 87 procedures during 82 different patient interventional radiology visits. Twenty-seven esophageal dilatations for symptoms of dysphagia, 11 percutaneous gastrostomy tube placements resulting from failure to thrive, 30 maintenance procedures, 15 central venous access device insertions, and three other procedures (nasojejunal tube insertion, liver biopsy, and inferior vena cava filter insertion) were performed. Modifications were related to anesthetic management, access, tissue handling, and dressings. Complications were categorized according to Society of Interventional Radiology grades: Minor A (n = 6), Minor B (n = 4), Major C (n = 7), Major D (n = 2), Major E (n = 0), and Major F (n = 0). Our experience suggests that interventional radiology procedures can be done successfully and safely when utmost care is given to skin and mucosal protection. Wound healing is adequate and should not deter intervention.

Nursing home-associated infections in Department of Veterans Affairs community living centers

Little is known about factors contributing to nursing home-associated infections (NHAIs). We conducted a survey of residents in 133 Department of Veterans Affairs community living centers to determine the roles of indwelling device use, bed locations, and treatment codes on NHAIs. A Web-based point prevalence survey of NHAIs using modified Centers for Disease Control and Prevention definitions for health care-associated infections was conducted on November 14, 2007. Among 10,939 residents, 575 had at least one NHAI, for a point prevalence rate of 5.3%. Urinary tract infection, skin infection, asymptomatic bacteriuria, and pneumonia were the most prevalent NHAIs. A total of 2687 residents had one or more indwelling devices; 290 of these also had an NHAI, for a prevalence of 10.8%. In contrast, the prevalence of NHAIs in residents without indwelling devices was 3.5% (P < .0001). Indwelling urinary catheters, percutaneous gastrostomy tubes, peripherally inserted central catheters, and suprapubic urinary catheters were the most commonly used devices. There were 4027 residents in designated units and 6912 residents in dispersed units. The rate of device use was 21.4% in the designated units and 26.4% in the dispersed units (P < .0001). The prevalence of NHAIs was 4.5% in the designated units and 5.7% in the dispersed units (P < .001). Rates of NHAIs and device use varied greatly among the various treatment codes; however, there was a positive correlation between the rates of NHAIs and device use. Stepwise logistic regression analysis of data from long-stay and short-stay skilled nursing care residents revealed that only the presence of an indwelling device, not length of stay or bed location, affected the rate of NHAIs. Indwelling device use, but not bed location or treatment code, was found to be associated with increased rate of NHAIs.

Laryngomalacia in the Setting of Vocal Cord Dysfunction

Objective: To describe the management and outcome of patients with clinically significant laryngomalacia (LM) and simultaneous vocal cord dysfunction (VCD). Methods: Children with LM and VCD treated at our tertiary referral center from 2003-2009 were reviewed retrospectively. Main outcome measures include resolution of VCD, polysomnography (PSG) parameter changes, and changes in breathing and swallowing after treatment. Results: Seven children were reviewed. Six patients had bilateral paresis and one patient had a paradoxical VCD. A third airway lesion was found in two patients. All patients were treated with reflux therapy. Five patients were treated with supraglottoplasty (SGP), and the patient with paradoxical VCD was treated with Botox injections. Two of the three patients with PSG studies preand post-SGP showed improvement in AHI and O2 nadir. The third patient had improved PSG parameters after an adenotonsillectomy. While breathing did improve in six patients, two patients required a tracheostomy for aspiration. Both patients treated without SGP and one patient treated with SGP required a percutaneous gastrostomy tube. Six (86%) patients were ultimately swallowing without aspiration (mean 11.4 months). VCD resolved completely in three patients, all of whom underwent SGP. Conclusion: The two most common causes of stridor in infants can occur simultaneously. While the management is often multifactorial, early SGP may improve airway obstruction without increasing the risk of aspiration in these patients. While breathing ultimately improved after primary treatment in all patients with vocal cord paresis, the patient with paradoxical VCD required a tracheostomy for ongoing airway obstruction after failing Botox injections. Four patients treated with SGP required additional surgeries: one child required a tracheotomy for respiratory distress and was decannulated within a year; another patient required a single-staged laryngotracheal reconstruction for subglottic stenosis; a third patient required an adenotonsillectomy; and a final patient required a gastrostomy tube for FTT. Of the three patients who underwent PSG preand post-SGP, two showed considerable improvement in AHI and O2 nadir. The third patient’s PSG parameters worsened postoperatively, which were thought to be due to adenotonsillar hypertrophy and obstruction. The patient’s PSG improved after an adenotonsillectomy. One patient who did not undergo SGP had more mild obstructive symptoms. Her gastroesophageal reflux was severe enough, however, to require a Nissen fundoplication and gastostomy tube.

Lingual protrusion dystonia: Frequency, etiology and botulinum toxin therapy

The purpose of this study was to examine lingual protrusion dystonia (LPD); its frequency, etiology and response to botulinum toxin therapy. Previous literature suggests that LPD is more frequently the result of heredodegenerative disease and that the use of botulinum toxin therapy in LPD is associated with significant adverse effects. This is a retrospective database and record review from a movement disorder clinic. Of 421 dystonia patients, we identified 17 with LPD (4%). Of these cases, the diagnoses were: primary cranial dystonia (5), primary generalized dystonia (2), tardive dystonia (7), heredodegenerative disease (1), multifactorial (1) and post-infectious (1). All primary cases had concomitant oromandibular dystonia. In some secondary cases the LPD was the only cranial feature. Nine received botulinum toxin injections and 55.6% sustained moderate or marked improvement. Of 89 total botulinum toxin sessions, 66.3% had an excellent response, and 92.1% had some response. 97.8% of the sessions resulted in no significant adverse effects. On one occasion one patient developed severe dysphagia requiring placement of a percutaneous gastrostomy (PEG) tube. We conclude that LPD is rare, most commonly the result of tardive and primary dystonia. Botulinum toxin therapy may be very effective but needs to be utilized with care because of the possibility for the development of dysphagia.

S1350 Efficacy of Nasal Bridles in Preventing Nasogastric Tube Displacement. the Royal Berkshire Experience

Introduction Rates of accidental removal of nasogastric feeding tubes (NGT) within hospital can reach up to 60% which exposes patients to risk from repeat procedures as well as consuming resources. Nasal bridles are not routinely used in the UK despite demonstrating a reduction in NGT removal rates, reducing the occurrence of unnecessary percutaneous gastrostomy (PEG) placements and increasing nutrition delivery. At the Royal Berkshire Hospital patients are deemed suitable for bridle placement if three or more NGT have been removed unintentionally, there is no history of nasal trauma and not so confused as to risk causing themselves nasal septal injury. All patients are assessed by a clinical nurse specialist. It is Trust policy to confirm all NGT placements with a chest x-ray. We audited our practice to assess whether bridles are effective and safe. Methods Database records for all patients referred for NG bridles between June 2007 and September 2009 were reviewed. Where additional information was required, case notes were obtained. Radiology exposure was also assessed. Results fifty-one patients were referred for bridle placement during the 27-month audit period. Median age was 72 years (range 36–90). Cerebrovascular accident was the most common reason for referral (82%). All patients had had at least 3 NGT placed prior to referral (median 3 range 3–8). 38 of the 51 patients (74.5%) had bridles attached using 39 devices in total. One patient required bridle replacement and only one experienced significant nasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 were already eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEG feeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1–32). Of these only two required long-term PEG feeding and 21 were able to have their bridles removed as they were no longer required. Fifteen patients with bridles died for reasons unrelated to their bridle. An additional 147 chest x-rays had been used prior to referral while only one additional x-ray was required to confirm NGT position after bridle placement. Conclusion Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helps to prevent delay of nutrition restoration. They also reduce repeated radiation exposure from recurrent x-rays and overall hospital costs. Bridles have a very low incidence of complication and help reduce unnecessary PEG insertions in high-risk groups if patients are assessed carefully by trained staff.

PTH-055 Efficacy of nasal bridles in preventing nasogastric tube displacement. The Royal Berkshire experience

<h3>Introduction</h3> Rates of accidental removal of nasogastric feeding tubes (NGT) within hospital can reach up to 60% which exposes patients to risk from repeat procedures as well as consuming resources. Nasal bridles are not routinely used in the UK despite demonstrating a reduction in NGT removal rates, reducing the occurrence of unnecessary percutaneous gastrostomy (PEG) placements and increasing nutrition delivery. At the Royal Berkshire Hospital patients are deemed suitable for bridle placement if three or more NGT have been removed unintentionally, there is no history of nasal trauma and not so confused as to risk causing themselves nasal septal injury. All patients are assessed by a clinical nurse specialist. It is Trust policy to confirm all NGT placements with a chest x-ray. We audited our practice to assess whether bridles are effective and safe. <h3>Methods</h3> Database records for all patients referred for NG bridles between June 2007 and September 2009 were reviewed. Where additional information was required, case notes were obtained. Radiology exposure was also assessed. <h3>Results</h3> fifty-one patients were referred for bridle placement during the 27-month audit period. Median age was 72 years (range 36–90). Cerebrovascular accident was the most common reason for referral (82%). All patients had had at least 3 NGT placed prior to referral (median 3 range 3–8). 38 of the 51 patients (74.5%) had bridles attached using 39 devices in total. One patient required bridle replacement and only one experienced significant nasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 were already eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEG feeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1–32). Of these only two required long-term PEG feeding and 21 were able to have their bridles removed as they were no longer required. Fifteen patients with bridles died for reasons unrelated to their bridle. An additional 147 chest x-rays had been used prior to referral while only one additional x-ray was required to confirm NGT position after bridle placement. <h3>Conclusion</h3> Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helps to prevent delay of nutrition restoration. They also reduce repeated radiation exposure from recurrent x-rays and overall hospital costs. Bridles have a very low incidence of complication and help reduce unnecessary PEG insertions in high-risk groups if patients are assessed carefully by trained staff.

Percutaneous transesophageal gastrostomy tube placement: an alternative to percutaneous endoscopic gastrostomy in patients with intra-abdominal metastasis

PEG/jejunostomy (PEG/J) is often placed in patients with metastatic gastric cancer for palliating bowel obstruction or for feeding. However, PEG/J placement may not always be possible for many reasons. We wish to bring attention to the percutaneous transesophageal gastrostomy/jejunostomy (PTEG/J) as a viable alternative to nasogastric decompression in patients who are not candidates for PEG/J. PTEG/J is a largely unknown technique in the United States that designed to gain access to the stomach and proximal small bowel in these patients. We describe the use of PTEG/J in 3 patients with metastatic gastric cancer by using resources and techniques readily available in a well-stocked interventional radiology suite. In the first case, percutaneous transesophageal gastrostomy (PTEG) was placed for palliation of intractable nausea and vomiting in a 37-year-woman with diffuse gastric cancer and peritoneal carcinomatosis. In the second case, PTEG was extended into the jejunum for feeding a 60-year-old woman with metastatic gastric cancer. In the third case, PTEG extending into the jejunum was placed in a 69-year-old man for palliation of bowel obstruction caused by metastatic gastric cancer and peritoneal carcinomatosis. After adequate sedation is administered, a 22 x 4-mm balloon catheter is passed into the esophagus over a guidewire just below the thoracic inlet. The balloon is ruptured with a needle passed through the neck under US guidance. A guidewire is then passed through the needle into the balloon and carried into the stomach or proximal small bowel by advancing the balloon catheter. The track is then dilated over the guidewire and a pigtail 45-cm-long 14F nephrostomy tube then passed into the stomach or into the proximal small bowel over the guidewire. The catheter is secured by suturing to the skin of the neck. PTEG/J was effective in achieving palliation or feeding in our patients. No complications occurred. PTEG/J is a safe and effective alternative to standard percutaneous gastrostomy/jejunostomy tube placement for decompression of bowel obstruction or feeding in appropriately selected patients.

Endoscopic-Assisted Closure of Persistent Gastrocutaneous Fistula With a Porcine Fistula Plug: Report of a New Technique

Persistent gastrocutaneous (GC) fistula is a rare but problematic complication of gastrostomy feeding tube removal. Several techniques for nonoperative fistula closure have been attempted with mixed results. None has proven both satisfactorily simple and consistently effective. The authors present a case of persistent GC fistula treated by a simple outpatient endoscopic-assisted procedure using a porcine anal fistula plug. The procedure requires only basic endoscopic skills, similar to percutaneous gastrostomy tube placement, and it involves minimal operative time and risk to the patient. This technique offers a potential solution to the troublesome problem of persistent GC fistula.

経皮経食道胃管挿入術(PTEG)後の自己抜去防止策としてのチューブ皮下トンネル埋没の試み

経皮経食道胃管挿入術(PTEG)後の自己抜去防止策としてのチューブ皮下トンネル埋没の試み

Long-term survival in older critically ill patients with acute ischemic stroke*

To compare survival in older patients with acute ischemic stroke admitted to intensive care units (ICUs) with those not requiring ICU care and to assess the impact of mechanical ventilation (MV) and percutaneous gastrostomy tubes (PEG) on long-term mortality. Multicentered retrospective cohort study. Administrative data from the Centers for Medicare and Medicaid Services covering 93 metropolitan counties primarily in the eastern half of the United States. 31,301 patients discharged with acute ischemic stroke in 2000. None. Mortality from the time of index hospitalization up to the end of the follow-up period of 12 months. Information was also gathered on use of mechanical ventilation, percutaneous gastrostomy, sociodemographic variables and a host of comorbid conditions. Of all patients with acute ischemic stroke, 26% required ICU admission. The crude death rate for ICU stroke patients was 21% at 30 days and 40% at 1-yr follow-up. At 30 days, after adjustment of sociodemographic variables and comorbidities, ICU patients had a 29% higher mortality hazard compared with non-ICU patients. MV was associated with a five-fold higher mortality hazard (hazard ratio 5.59, confidence interval [CI] 4.93-6.34). The use of PEG was not associated with mortality at 30 days. By contrast, at 1-yr follow up in 30-day survivors, ICU admission was not associated with mortality hazard (hazard ratio 1.01, 95% CI 0.93-1.09). MV still had a higher risk of death (hazard ratio 1.88, 95% CI 1.57-2.25), and PEG patients had a 2.59-fold greater mortality hazard (95% CI 2.38-2.82). Both short-term and long-term mortality in older patients with acute ischemic stroke admitted to ICUs is lower than previously reported. The need for MV and PEG are markers for poor long-term outcome. Future research should focus on the identification of clinical factors that lead to increased mortality in long-term survivors and efforts to reduce those risks.

Transoral robotic surgery for oropharyngeal squamous cell carcinoma: A prospective study of feasibility and functional outcomes

To investigate the feasibility of transoral robotic surgery as a method of surgical treatment of oropharyngeal squamous cell carcinoma. Prospective case study. Forty-five patients with previously untreated oropharyngeal squamous cell carcinoma underwent transoral robotic surgical removal of the tumor with or without neck dissection and with or without adjuvant therapy. Patients were observed and data were recorded on surgical time, blood loss, surgical complications, tracheostomy tube course, enteral feeding, and resumption of oral diet, speech outcomes, swallowing outcomes, and tumor recurrence. All 45 patients underwent complete transoral robotic surgical excision with simultaneous unilateral or bilateral neck dissection. Margins were negative for tumor. Mean operating time for tumor removal was 71.3 minutes for the last 35 cases. There were 15 stage T1 tumors, 18 T2 tumors, 3 T3 tumors, and 9 T4a tumors. Twenty-six patients had base of tongue primary tumors and 19 had tonsillar fossa tumors. Fourteen patients had a tracheostomy tube placed at surgery, and all patients had their tracheostomy tube removed (mean duration of use, 7.0 days). Twenty-two patients (48.9%) had a nasogastric feeding tube placed, and all patients had their feeding tube removed (mean duration of use, 12.5 days). Eight patients had percutaneous gastrostomy (PEG) tubes placed, and all eight eventually had their PEG tubes removed (mean duration of use, 140.3 days). Average hospital stay was 3.8 days. There were no major complications and no procedure was aborted because of an inability to remove the tumor. Transoral robotic surgery is a safe and efficacious method of surgical treatment of oropharyngeal neoplasms. Advantages of the technique include adequate ability to visualize and manipulate with two hands lesions in the base of tongue. Patients were able to retain or rapidly regain oropharyngeal function in the majority of cases.

Endoscopic Management of PEG Tube Perforation

Purpose: Background: Percutaneous endoscopical gastrostomy (PEG) tubes are a common means of providing enteral nutrition. Annually over 100,000 PEG tubes are placed with low complication rates. Minor events, such as tube dislodgement, peristomal wound infection, and bleeding occur in 10-15% of cases. Major complications, including intestinal perforation, are infrequent (1-3%) and often require open surgical repair. We describe an endoscopic repair of a PEG tube perforation through the transverse colon. Case: An 88 year old man with a history of refractory COPD and respiratory failure required tracheostomy and PEG placement. He had no previous history of abdominal surgeries or gastrointestinal disease, and was not receiving systemic steroids or anticoagulation. A PEG was placed without complications with initiation of tube feeds without event and he was discharged to a skilled nursing facility. Two weeks later, he was readmitted to another institution for worsening ventilatory failure. He was noted to have heme-positive brown stool with a decrease in hemoglobin. He had a benign abdominal exam that was notable for a functioning PEG tube. Colonoscopy demonstrated the PEG tube passing through the transverse colon causing a partial luminal obstruction. CT scan did not reveal pneumoperitoneum. Intervention: Upon repeat colonoscopy, a portion of PEG tubing was seen obliquely traversing the wall of the colon, without extending into the lumen. The surrounding colonic mucosa was completely normal without evidence of ischemia, ulceration, or necrosis. Boston Scientific Resolution® clips were used to close the defect. Sequentially, 4 clips were placed to completely oppose the mucosa around the PEG tube. The PEG itself was not visible at the completion of the procedure. Follow-up radiography again did not demonstrate any free air. A tube study confirmed the position of the PEG and failed to demonstrate extravasation of contrast. Resumption of tube feeds was well tolerated with no evidence of peritonitis. The patient's abdominal exam remained benign and he was discharged without further incident. Conclusion: While PEG placement is a common procedure with relatively low morbidity, complications can occur. Patients undergoing PEG placement are often poor surgical candidates, and visceral perforation often necessitates laparotomy for surgical repair. We describe the first report of a fully endoscopic approach to the closure of a colonic mucosal defect caused by PEG placement.