Peritoneal Leakage Research Articles

Peritoneal scintigraphy and SPECT/TC in the diagnosis of leaks in patients on peritoneal dialysis

ObjectiveTo assess the usefulness of peritoneal cavity scintigraphy and the contribution of SPECT/CT in patients on peritoneal dialysis with suspected leak. MethodologyAn observational case series study is carried out. It consists of a longitudinal, retrospective and descriptive study. 11 patients on peritoneal dialysis were studied and it was realiced a peritoneal cavity scintigraphy test and SPECT/CT to evaluate a peritoneal leak. ResultsIn 54,5% of the patients, a positive study of peritoneal leak was obtained. The most frequent localitations were in the abdominal wall at the catheter entry level and the inguinal hernia. In the cases with sintomatology like pain and celullitis of the subcutaneous tract of the cateter the frequent of leak was 100%. There was a change in therapeutic management in patients with a positive study. There was not relevant changes in initial dialysis regimen in patients with a negative study. In this cases, except for one patient who required hemodialysis, all patients experienced clinical improvement. ConclusionsPeritoneal scintigraphy and SPECT/CT study are non-invasive techniques that allow an adequate diagnosis and subsequent management of peritoneal leak.

Complications and prognosis of patients diagnosed with autosomal recessive polycystic kidney disease in neonatal period.

There are no clinical guidelines for performing nephrectomy in patients with autosomal recessive polycystic kidney disease (ARPKD). Few reports have described the clinical course of ARPKD diagnosed in the neonatal period in detail. Here, we report seven patients diagnosed with ARPKD and treated at our center during the neonatal period. Two died within 48h of life due to pulmonary hypoplasia. Of the remaining five patients, three had anuria and required for kidney replacement therapy (KRT) within one week after birth, whereas two with a milder phenotype survived without KRT. All three patients who received KRT underwent unilateral nephrectomy and peritoneal dialysis (PD) catheter placement. To prevent fluid leakage, PD was initiated 7-14days after catheter placement. However, peritoneal leakage occurred in two patients, resulting in peritonitis and discontinuation of PD; one who required long-term hemodialysis contracted a catheter-related bloodstream infection as well as developed subdural and epidural hematomas. Meanwhile, two patients underwent a second nephrectomy within 6weeks after birth; one developed severe persistent hypotension and neurological complications, while the other died of bacteremia that may have resulted from cholangitis diagnosed on day 67 of life. A severe clinical course, life-threatening adverse events, and severe neurological sequalae may occur in patients with ARPKD who receive KRT in neonatal period.

Role of nuclear medicine in the diagnosis of peritoneal leaks in patients in dialysis: Experience of Hospital Universitario Son Espases

Role of nuclear medicine in the diagnosis of peritoneal leaks in patients in dialysis: Experience of Hospital Universitario Son Espases

Is endoscopy beneficial in pediatric laparoscopic gastrostomy insertion; A 9-year comparative study.

ObjectivesAdvancements in pediatric percutaneous endoscopic gastrostomy placement (PEG), laparoscopic-assisted gastrostomy (LAG) technique, and laparoscopic-assisted percutaneous endoscopic gastrostomy (LAPEG) procedure have opened up new options for gastrostomy tube placement. LAPEG utilizes endoscopy and laparoscopy for gastrostomy insertion. This review compares the outcomes and complications of LAG and LAPEG techniques in children.MethodsAll LAG and LAPEG gastrostomy tube placements in children from September 2010 to September 2019 were reviewed retrospectively. Patient demographic, along with procedural and 1-year complication data, were collected.ResultsIn total, 92/181 of gastrostomies were LAG and 89/181 were LAPEG. The mean age, weight and patient characteristics were comparable. Conversion rate was 1% in both groups (p = 0.74), there was no peritoneal leak in either group, a minor serosal injury to the stomach was seen in 1 patient in LAG with no bowel injury in LAPEG cohort (p = 0.51), need for re-operation was 1 and 2% in LAG and LAPEG, respectively (p = 0.49), early tube dislodgement was in 8 (9%) patients in LAG and 7 (6%) in LAPEG (p = 0.53) and wound infection was 13/92 in LAG and 11/89 in LAPEG (p = 0.8). The median operative time for LAPEG was less than LAG (p < 0.001) by 11 min but the median length of hospital stay was not significantly different (p < 0.096).ConclusionBoth LAG and LAPEG techniques in children are safe with comparable complication rates and length of hospital stay, the addition of endoscopy to LAG allowed for shorter operative time in the LAPEG technique.

A case of massive pancreatic fluid collection managed with percutaneous pigtail drainage as step-up approach

A 19-year-old male presented to us with complain of acute epigastric pain for 2 weeks duration. The pain was dull aching in nature, radiating to back. On examination he was of average built and nutrition, dysnoic and tachypnoic with pulse rate of 140 /min, respiratory rate 26 /min, blood pressure 140/80 mmHg, saturation on room air 90%, bilateral (b/l) pedal edema present. On per abdomen examination abdomen was distended, fullness was present in bilateral upper abdomen. So, after thorough investigation, diagnosis of acute necrotizing pancreatitis was made and subsequently planned for ultrasonography (USG) guided percutaneous pigtail drainage as step-up approach in view of multiple loculated collections. Nasojejunal tube was inserted for entral nutrition. First perihepatic collection was drained on day 1, then lesser sac and pelvis drainage was done on day 2. At times, the collections may extend into the subhepatic space from the lesser sac through foramen of Winslow. Such subhepatic collections are intraperitoneal rather than retroperitoneal and there is a significant risk of peritoneal leak during endoscopic transmural drainage that may cause peritonitis. The collections may extend to either or both paracolic gutters retroperitoneally and at times to pelvis. In these retroperitoneal collections where endoscopic transmural drainage that may cause peritonitis, percutaneous pigtail drainage as a step-up approach is a feasible option.

Robotic endoscopic cooperative surgery for colorectal tumors: a feasibility study (with video).

Laparoscopic endoscopic cooperative colorectal surgery (LECS-CR) is a promising technique to achieve full-thickness resection of colorectal tumors. This approach has shown good rates of complete resection and low local recurrence, especially for large laterally spreading tumors, which are difficult to remove via endoscopy alone. However, it is often difficult to prevent peritoneal leakage of intestinal content, causing infections and risks of cancer spreading. It was hypothesized that a robotic assistance could make the procedure easier and decrease intestinal fluid leakage. This preclinical trial aims to assess the feasibility of robotic and endoscopic cooperative colorectal surgery (RECS-CR). LECS-CR was performed in five female pigs and RECS-CR was also performed in five female pigs. With the animal under general anesthesia, pseudotumors were created on the colonic mucosa at a distance comprised between 20 and 25cm from the anal verge. Desired resection margins were marked endoscopically and two stay sutures were placed either robotically or laparoscopically. A mucosa-to-submucosa dissection was performed endoscopically along the markings. Complete full-thickness dissection was performed cooperatively. The specimen was withdrawn endoscopically. The colon was closed using a self-fixating running suture. Abdominal contaminations, operating times, complications, and complete resections were evaluated and compared between LECS-CR and RECS-CR. The mean number of colonies of Escherichia coli in the RECS group was significantly lower than in the LECS group (36.7 ± 30.2 vs. 142.2 ± 78.4, respectively, p < 0.05). Operating time was comparable (118 ± 11.2 vs. 98.6 ± 25.7, respectively, p = 0.22). Two stenoses occurred in the LECS group. R0 resection was achieved in all cases. This study suggests that RECS-CR is feasible and has the potential to reduce intestinal content leakage, potentially preventing postoperative infections.

P1232COMPUTED TOMOGRAPHIC PERITONEOGRAPHY - GUARANTYING SAFER SURGICAL STRATEGIES

Abstract Background and Aims Peritoneal Dialysis (PD) is currently the first option as renal replacement therapy to many patients, for several reasons, as personal flexibility, volemic management in cardiorenal patients, poor vascular access to dialysis, among others. Mechanical complications can be a drawback in these patients, which may occur during or after catheter placement. Abdominal wall hernias and dialysate leaks are relatively common and highly related to chronically increased intraperitoneal pressure. In this setting CT peritoneography is the technique of choice as it allows differentiation between a true hernia or a wall leakage. Method We describe a case of a 69-year-old man, with a personal history of polycystic kidney disease, colonic diverticulosis and hypertension, which opted for PD. The patient later developed a mechanical complication for which a proper diagnostic approach, namely through specific imaging, and surgical planning were essential. Results After 15 months without complications, it was detected a bulging in the periumbilical area, exacerbated by orthostatism. Changes in dialytic prescription included lower dialytic volumes during orthostatic period, with some improvements. The limitation of volumes and difficulty of drainage were limiting dialytic prescription and insufficient kt/V. An ultrasound (figure 1) and CT peritoneography (figure 2) were performed, revealing an hernial sac with peritoneal liquid leak, without any intestinal loop, approachable by minimally invasive surgery and local anesthesia. Mini-laparotomy was performed, hernial sac was removed, without peritoneum aperture, with only a 4-day pause on PD technique. Conclusion CT peritoneography allowed the differentiation between this true hernia and a wall leakage, by providing accurate anatomical detail, allowing proper planning of surgical intervention. In this case, the patient had additional predisposing factors, namely polycystic kidney disease. Moreover, only a short pause on PD was necessary. Although some limitations exist, such as the use of iodinated contrast material and ionizating radiations, CT peritoneography is currently the gold standard for the evaluation of mechanical complications in PD; in addition to those mentioned, it is also useful for complications related to the catheter (kinking, entrapment, malposition), intrabdominal adhesions or loculated fluid collections.

Intramesenteric dynamic contrast pediatric MR lymphangiography: initial experience and comparison with intranodal and intrahepatic MR lymphangiography

To report on our initial experience with intramesenteric (IM) dynamic contrast magnetic resonance lymphangiography (DCMRL) for evaluation of the lymphatics in patients with concern for mesenteric lymphatic flow disorders and to compare IM-DCMRL with intrahepatic (IH) and intranodal (IN) DCMRL. This is a retrospective review of imaging findings in 15 consecutive patients who presented with protein losing enteropathy (PLE) and/or ascites undergoing IM-DCMRL, IH-DCMRL, and IN-DCMRL. The IM-DCMRL technique involves the injection of a gadolinium contrast agent into the mesenteric lymphatic ducts or lymph nodes followed by imaging of the abdomen and chest with dynamic time-resolved MR lymphangiography. IM-DCMRL was successfully performed in 14/15 (93%) of the patients. When comparing IN-DCMRL with IM-DCMRL, there was a significant difference in the visualization of dermal backflow (p = 0.014), duodenal perfusion (p = 0.003), duodenal leak (p = 0.014), and peritoneal leak (p = 0.003). IM-DCMRL demonstrated peritoneal leak in 7 patients in contrast to IH-DCMRL which demonstrated leak in 4 patients and IN-DCMRL which did not demonstrate any peritoneal leaks. Duodenal leaks were seen by IH-DCMRL in 9 patients versus 5 with IM-DCMRL and none with IN-DCMRL. In one patient with congenital PLE, the three modalities showed different disconnected flow patterns with duodenal leak only seen by IM-DCMRL. There were no short-term complications from the procedures. IM-DCMRL is a feasible imaging technique for evaluation of the mesenteric lymphatics. In certain mesenteric lymphatic flow abnormalities, such as PLE and ascites, this imaging may be helpful for diagnosis and the planning of interventions and warrants further studies. • Intramesenteric dynamic contrast magnetic resonance lymphangiography (IM-DCMRL) is a new imaging technique to evaluate mesenteric lymphatic flow disorders such as ascites. • IM-DCMRL is able to image lymphatic leaks in patients with ascites and protein losing enteropathy not seen with intranodal (IN-DCMRL) imaging.

A single centre 10-year experience of Mitrofanoffs procedure for varied indications with its outcome

Background: To evaluate long term efficacy and complications of Mitrofanoffs procedure in patients with bladder dysfunction.Methods: Authors retrospectively reviewed the medical records of 51 patients who underwent construction of a continent catherisable channel (mitrofanoffs and monti) from 2009 till 2019 in our institution. Clinical findings and investigations result along with surgical techniques used were noted for these patients. Postoperative complications along with urinary continence and renal outcome were evaluated.Results: Mean age was 7 years and mean follow up was for 3 years. 27 patients were with neurogenic bladder and 24 with non-neurogenic bladder. The most common type of conduit was appendicovesicostomy (38) followed by illeal monti (12) and ureter (1). The most common stomal site was umbilicus (44) followed by right lower abdominal quadrant (6). Catherterizable conduit complications included stomal leakage in 3, mucosal prolapse at the stoma site in1 and an intra peritoneal leak requiring exploratory laprotomy and revision in1. Relative stomal continence was achieved in 98%. The preoperative serum creatinine &amp; blood urea nitrogen (BUN) at the time of mitrofanoffs procedure at the last follow up after the procedure were sought and compared using Chi square test showed statistically significant improvement (p&lt;0.01). No differences in outcome and complication rates were noted between different types of conduit, sites of implantation, or segments used for augmentation.Conclusions: Mitrofanoff is a safe and reliable procedure in children who are dependent on intermittent catherisation in developing countries. Appendicovesicostomy is our first option followed by yang -monti illeovesicostomy. While stomal continence is excellent patient education, family motivation and cost reduction are important factors for its lasting efficiency.

The application of a vascular closure device for closing a gastrostomy opening used for procedural access.

To study the feasibility of applying the Perclose ProGlide vascular closure device (PPVCD) in vitro for closing a gastrostomy opening for procedural access in the swine stomach in order to prevent peritoneal leakage. The study included four experimental groups: one manual suture (n = 10), two manual sutures (n = 10), one PPVCD suture (n = 10), and two PPVCD sutures (n = 5). In the two PPVCD sutures group, the "pre-close" technique was used. The leak pressure was measured, and statistical analysis was conducted to compare the leak pressures among the experimental groups. The gastrostomy openings were successfully closed in all experimental groups. The median (range) values of leak pressure (mmHg) for each experimental group were as follows: one manual suture, 86.0 (75.0-110.0); two manual sutures, 98.5 (44.0-130.0); one PPVCD suture, 96.5 (56.0-119.0); and two PPVCD sutures, 98.0 (66.0-104.0). The Mann-Whitney U test revealed no statistically significant difference in leak pressure between the manual (n = 20) and PPVCD (n = 15) suture groups. The Kruskal-Wallis test revealed no statistically significant difference in leak pressure among the four experimental groups. The Bonferroni post hoc test also revealed no statistically significant difference in the pairwise comparisons among the groups. Application of PPVCD is feasible for the closure of gastrostomy openings in an animal model and is as effective as a manual suture. In our in vitro study, percutaneous closure of gastrostomy opening using PPVCD was possible; animal survival studies and development of specific devices are needed before clinical application.

Lumen-apposing metal stents in management of pancreatic fluid collections: The nobody's land of removal timing.

Pancreatic fluid collections (PFCs) develop as a result of damage to the major or peripheral pancreatic ducts, complication due to acute or chronic pancreatitis, trauma or iatrogenic causes. PFCs include pancreatic pseudocysts (PPs) and walled-off necrosis (WON). PFCs usually resolve spontaneously and are asymptomatic, but if they persist, increase in dimension or became symptomatics, therapeutic intervention is required. Available therapeutic interventions include surgical, percutaneous, and endoscopic drainage. The endoscopic approach is nowadays considered the first line-treatment of PFCs due to various advantages when compared with surgical or percutaneous drainage: decreased morbidity, length of hospital stay, and reduced costs. In the last few years, the endoscopic ultrasound (EUS)-guided transmural drainage, initially with plastic stents, gained popularity. More recently, fully covered self-expanding lumen-apposing metal stents (LAMS) have been demonstrated to be both, safe and effective with high clinical and technical success, reducing the risk of perforation, peritoneal leakage, migration and facilitating the drainage of necrotic contents. In the last few years, several studies evaluating the safety and efficacy of LAMS and their differences with plastic stents have been performed, but literature on the removal timing of this device and associated complications is still limited. The aim of this review is to analyze studies reporting information about the retrieval timing of LAMS and the related adverse events.

A Rare Case of Unilateral Pleural Effusion in a Pediatric Patient on Chronic Peritoneal Dialysis: Is it a Pleuroperitoneal Leakage?

Non-infectious complications of peritoneal dialysis (PD) are relatively less common than infectious complications but are a potentially serious problem in patients on chronic PD. Here, we present a case of a non-infectious complication of PD in a 13-year- old boy on chronic PD who presented with symptoms such as hypertension, edema, dyspnea, and decreased ultrafiltration. Chest and abdominal radiography showed pleural effusion and migration of the PD catheter tip. Laparoscopic PD catheter reposition was performed because PD catheter malfunction was suspected. However, pleural effusion relapsed whenever the dialysate volume increased. To identify peritoneal leakage, computed tomography (CT) peritoneography was performed, and a defect of the peritoneum in the left lower abdomen with contrast leakage to the left rectus and abdominis muscles was observed. He was treated conservatively by transiently decreasing the volume of night intermittent PD and gradually increasing the volume. At the 2-year follow-up visit, the patient had not experienced similar symptoms. Patients on PD who present with refractory or recurrent pleural effusion that does not respond to therapy should be assessed for the presence of infection, catheter malfunction, and pleuroperitoneal communication. Thoracentesis and CT peritoneography are useful for evaluating pleural effusion, and timely examination is important for identifying the defect or fistula. Key words: Peritoneal dialysis; Pleuroperitoneal communication; Peritoneography; Pleural effusion; PD catheter

Laparoscopic Gastrostomy in Children: 10 Years of Experience.

Objectives:Laparoscopic gastrostomy is a widely used procedure in children with failure to thrive, feeding disorders, or neurologic impairment. Various methods of laparoscopic gastrostomy and fixing stomach to abdominal wall have been described. Trocar site primary gastrostomy under laparoscopic control is a simple and easy technique that does not require special instruments and a kit. The aim of this study was to present 10 years of experience in laparoscopic gastrostomy.Methods:The charts of 128 children who underwent laparoscopic gastrostomy between 2006 and 2016 were retrospectively reviewed. The data, including demographics, operative procedures, and complications, were recorded. All children underwent preoperative contrast imaging and 24-hour Ph monitorization. In all patients, the trocar site primary gastrostomy was done. A gastrostomy tube or a button was inserted into the stomach in the center of a purse–string suture loop, and the stomach was fixed to the anterior rectus sheath extracorporeally.Results:There were 49 girls (38.3%) and 79 boys (61.7%). The mean age was 50 months at surgery (1 day–18 years), and the average body weight was 13 kg (2300 gr–65 kg). Both laparoscopic Nissen fundoplication and gastrostomy were done in 116 (90.6%) patients, and 12 (9.4%) patients had only laparoscopic gastrostomy. Infection at the site of gastrostomy, which was treated by antibiotics, was the most common complication, observed in 14 (11%) patients. Peritoneal leakage within 30 days was seen in 9 (7%) patients. Severe dislodgement of gastrostomy resulting in operative intervention occurred in 5 (3.9%) patients. Granuloma developed in 4 (3.1%) patients and was treated with silver nitrate.Conclusion:The trocar site primary laparoscopic gastrostomy is a safe and easy technique with complication rates comparable to other gastrostomy methods.

Complications encountered during interventional endoscopic ultrasound - a tertiary care center experience

Background and Objectives:Interventional endoscopic ultrasound (EUS) includes fine needle aspiration (FNA), pancreatic cystogastrostomy, aspiration of cystic cavity or collection, hepaticogastrostomy, and coiling. It is considered safe. This study was undertaken to note frequency of various complications that arose with interventional EUS at our center.Methods:This was a retrospective cohort study done at a tertiary level referral center. Records of all patients who underwent EUS intervention over a period of 6 years (October 2010 to September 2016) were reviewed. Procedure-related minor adverse events such as throat pain and abdominal pain were noted. Complications were defined as acute pancreatitis, perforation, mucosal tear, hepatic encephalopathy, pneumomediastinum, pneumoperitoneum, peritoneal leak, bleeding, hematoma, and fever requiring hospital admission.Results:A total of 4654 EUS were done, of which 2030 intervention performed. Of these, 1780 were EUS FNA, 146 aspiration, 64 cystogastrostomy, and 40 others. Procedure-related minor adverse events were noted in 42% cases (throat pain - 31% and abdominal pain - 11%). Complications were observed in 35 patients (1.72%); minor mucosal bleeding (12), mild acute pancreatitis (5), asymptomatic duodenal hematoma (4), fever requiring hospitalization (3), duodenal perforations (2), cervical esophageal tear (2), mild hepatic encephalopathy (2), pneumomediastinum (1), pneumoperitoneum (1), bleeding from gastroduodenal artery (1), cystogastostomy site bleeding (1), and peritoneal leak (1). All the complications were managed conservatively except duodenal perforations which required surgery and peritoneal leak requiring drain placement percutaneously. On subgroup analysis, there were significant fewer complications with operator experience of >1000 EUS (P = 0.002).Conclusion:EUS intervention is a safe procedure, especially in experienced hands.

Postoperative complications and weight loss following jejunostomy tube feeding after total gastrectomy for advanced adenocarcinomas.

ObjectivePatients undergoing total gastrectomy for cancer are at risk of malnourishment. The aim of this self-controlled study was to examine the effect of jejunostomy tube feeding (JTF) and other factors on postoperative weight and the incidence of jejunostomy-related complications in patients undergoing total gastrectomy for cancer.MethodsAll consecutive patients who underwent total gastrectomy for gastric cancer with jejunostomy placement were included from a prospective single-center database (2003–2014). Jejunostomy-related complications and postoperative weight changes were evaluated up to 12 months after surgery. Multivariable linear regression analysis was performed to identify factors associated with weight loss 12 months after gastrectomy.ResultsOf 113 patients operated in the study period, 65 received JTF after total gastrectomy for a median duration of 18 d [interquartile range (IQR), 10–55 d]. Jejunostomy-related complications occurred in 11 (17%) patients, including skin leakage (n=3) and peritoneal leakage (n=2), luxation (n=3), occlusion (n=2), infection (n=1) and torsion (n=1). In 2 (3%) patients, a reoperation was needed due to jejunostomy-related complications. The mean preoperative weight of patients was 71.8 kg (100%), and remained stable during JTF (73.9 kg, 103%, P=0.331). After JTF was stopped, the mean weight of patients decreased to 64.9 kg (90%) at 12 months after surgery (P<0.001). A high preoperative body mass index (BMI) (≥25 kg/m2) was associated with high postoperative weight loss compared to patients with a low BMI (<25 kg/m2) (16.3% vs. 8.6%, P=0.016). ConclusionsJTF can prevent weight loss in the early postoperative phase. However, this is at the prize of possible complications. As weight loss in the long term is not prevented, routine JTF should be re-evaluated and balanced against the selected use in preoperatively malnourished patients. Special attention should be paid to patients with a high preoperative BMI, who are at risk of more postoperative weight loss.

Clinical efficiency of application of improved drain tube insertion in the prevention of greater omentum package in elderly patients with peritoneal dialysis

Objective To investigate the effects of improved dialysis catheter in the prevention of omental wrap in patients with postoperative dialysis catheter. Methods A total of 72 patients were divided into experimental group(37 cases)and control group(35 cases). The experimental group was treated by an improved dialysis catheter combined with traditional dialysis catheter.22 patients with a great quantity of greater omentum in experimental group were treated with improved dialysis catheter, namely, tying 3 to 5 knots with 7th line on the large greater omentum to draw the omentum.The control group was treated with traditional dialysis catheter.The routine dialysate measurement, blood routine, serum creatinine, urea nitrogen, C-reactive protein were compared between two groups, and complications such as omental wrapping, perioperative peritonitis, ileus, and peritoneal fluid leakage were observed. Results Compared with the control group, the incidence of greater omental wrap in the experimental group was significantly reduced(P<0.05). No significant differences in other parameters were found, including WBC, hemoglobin, Scr, BUN, hs-CRP, karyocyte count of peritoneal dialysate, over flow discharge of peritoneal dialysis. Conclusions For elderly peritoneal dialysis patients with a great quantity of greater omentum, the improved dialysis catheter can effectively prevent the occurrence of postoperative complication of omental wrapping.And it is simple to operate, which is of great clinical application value. Key words: Peritoneal dialysis; Nephrosis; Omentum

Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual

Lumen-apposing metal stents (LAMS) have been recently developed to improve treatment outcomes in the endoscopic management of pancreatic fluid collections (PFC), particularly in walled-off necrosis (WON), to facilitate better drainage...

Percutaneous endoscopic gastrostomy in children: a single center experience

The aim of this study was to evaluate the demographic data and complication rates in children who had undergone percutaneous endoscopic gastrostomy in a three-year period in our Division of Pediatric Gastroenterology and to interrogate parental satisfaction. The demographic data, complications and follow-up findings of the patients who had undergone percutaneous endoscopic gastrostomy between March 2011 and March 2014 were examined retrospectively using medical files. Forty seven percutaneous endoscopic gastrostomy and percutaneous endoscopic gastrostomy related procedures were performed in 34 children during a three-year period. The median age of the patients was 2.25 years (3 months-16 years, first and third quartiles=1.0-6.0) and the mean body weight was 13.07±8.6 kg (3 kg-47 kg). Before percutaneous endoscopic gastrostomy procedure, the mean weight z score was -2.26±1.2 (-5-0) and the mean height z score was -2.25±0.96 (-3.85-0.98). The follow-up mean height and weight Z scores at the 12(th) month after the percutaneous endoscopic gastrostomy procedure could be reached in 24 patients. A significant increase in the mean weight Z score from -2.41 to -1,07 (p=0.000) and in the mean height Z score from -2.29 to -1.99 (p=0.000) was found one year after percutaneous endoscopic gastrostomy catheter was placed in these 24 patients. Patients with neurological and metabolic diseases constituted the majority (64.7% and 26.5% respectively). Peritoneal leakage of food was detected in one patient and local stoma infections were detected in three patients after the procedure. During the follow up period, "Buried bumper syndrome" was observed in one patient. Following percutaneous endoscopic gastrostomy, the number of patients using anti-reflux medication increased from 16 (47.1%) to 18 (52.9%) (p=0.62). One patient with cerebral palsy who had aspiration pneumonia after percutaneous endoscopic gastrostomy insertion had undergone Nissen fundoplication. Percutaneous endoscopic gastrostomy tube was removed in a patient. The parents had positive views related with percutaneous endoscopic gastrostomy after the procedure. Percutaneous endoscopic gastrostomy is a substantially successful and reliable method in infants as well as in children and adolescents. The parents had positive views related with percutaneous endoscopic gastrostomy after the procedure.

Peritoneal Dialysis can be an Option for Dominant Polycystic Kidney Disease: An Observational Study

Autosomal dominant polycystic kidney disease (ADPKD) has been considered a relative contraindication for peritoneal dialysis (PD), although there are few specific studies available. A multicenter historical prospective matched-cohort study was conducted to describe the outcome of ADPKD patients who have chosen PD. All ADPKD patients starting PD (n = 106) between January 2003 and December 2010 and a control group (2 consecutive patients without ADPKD) were studied. Mortality, PD-technique failure, peritonitis, abdominal wall leaks and cyst infections were compared. Patients with ADPKD had similar age but less comorbidity at PD inclusion: Charlson comorbidity index (CCI) 4.3 (standard deviation [SD] 1.6) vs 5.3 (SD 2.5) p < 0.001, diabetes mellitus 5.7% vs 29.2%, p < 0.001 and previous cardiovascular events 10.4% vs 27.8%, p < 0.001. No differences were observed in clinical events that required transient transfer to hemodialysis, nor in peritoneal leakage episodes or delivered dialysis dose. The cyst infection rate was low (0.09 episodes per patient-year) and cyst infections were not associated to peritonitis episodes. Overall technique survival was similar in both groups. Permanent transfer to hemodialysis because of surgery or peritoneal leakage was more frequent in ADPKD. More ADPKD patients were included in the transplant waiting list (69.8 vs 58%, p = 0.04) but mean time to transplantation was similar (2.08 [1.69 - 2.47] years). The mortality rate was lower (2.5 vs 7.6 deaths/100 patient-year, p = 0.02) and the median patient survival was longer in ADPKD patients (6.04 [5.39 - 6.69] vs 5.57 [4.95 - 6.18] years, p = 0.024). Peritoneal dialysis is a suitable renal replacement therapy option for ADPKD patients.

Thinking Outside the Box of the Gastrostomy Kit: Stylet-Assisted Technique for Challenging Gastrostomy Tube Replacements

n 84-year-old man with dementia presented with Aa 6-hour history of unintended dislodgement of a percutaneous endoscopic gastrostomy (PEG) tube (24 Fr Pull PEG; US Endoscopy, Mentor, OH), placed 4 months earlier. Physical examination showed a PEG stoma that was partially closed in the epigastrium, preventing insertion of the balloon gastrostomy tube (PEG24-BRT-S; Cook Medical, Inc, Bloomington, IN). After confirming the permeability of the gastrocutaneous tract with a nasogastric tube (Figure A), replacement using a stylet-assisted technique was planned (Figure B). The balloon gastrostomy tube was strengthened by passing a stylet inside (Satin-Slip 10Fr Intubating Stylet; Mallinckrodt Medical, St. Louis, MO), providing increased stiffness while retaining some flexibility, and leaving 2.5 cm of free stylet distal to the balloon gastrostomy tube tip for guidance (Figure C). This stylet is composed of an outer plastic layer and an inner malleable metallic wire that was left 2 cm behind the plastic layer, enhancing its safety (Figure C). The stylet was introduced into the gastric lumen carefully until a minor resistance was felt, indicating contact of the stylet with the opposite gastric wall. The balloon gastrostomy tube then was smoothly advanced over the stylet (Figure D). After replacement of the balloon gastrostomy tube, the stylet was removed, and the balloon was inflated. Adequate positioning was confirmed by prompt aspiration of gastric fluid contents through the gastrostomy tube. Since its advent in 1980, PEG now is recognized as an efficient and successful means of providing long-term enteral nutrition. Despite its safety, PEG placement may result in complications, such as early and late unintentional removals, which occur in up to 5.3% of cases. Late dislodgements occur when the fistula has maturated, preventing peritoneal leakage, thus resulting in less morbidity and consequent underestimation in earlier studies when compared with early removals. A recent study reported a higher rate of late dislodgments of up to 12.8%. After tube displacement, the gastrocutaneous track is prone to closure within 12 to 24 hours. If the fistula has begun to close, insertion of the malleable PEG tube may be difficult, leading to bending of the tube when axial force is applied. The stylet-assisted technique appears to be a safe and useful approach for challenging gastrostomy tube replacements.