Type Of Gastrostomy Research Articles

胃瘻部に転移した下咽頭癌例

Percutaneous endoscopic gastrostomy (PEG) tube emplacement is commonly used to feed those with head, neck, or esophageal cancer. An 80-year-old man with hypopharyngeal cancer underwent PEG before chemoradiotherapy. After 4 months, tissue granulation extended to the gastrostomy site. The pathological lesion findings showed squamous cell carcinoma, suspected to have metastasized from hypopharyngeal cancer. To avoid cancer cell implantation, it is important to select the type of gastrostomy carefully.

Attention to small details: big deal for gastrostomies

Gastrostomy tubes are used in the pediatric population when long-term enteral feeding is needed. A common method of placement is percutaneously with endoscopy (PEG, percutaneous endoscopic gastrostomy). Although PEG placement is a straightforward procedure most of the time, it can be associated with a significant rate of minor complications and a smaller but significantly important rate of major complications. Some of these complications may also occur after any type of gastrostomy. We will present representative case studies outlining major complications and discuss how we may be able to prevent them at the time of PEG insertion or during PEG to low-profile button gastrostomy exchange. The proposed guidelines apply to all types of gastrostomies.

Experience with a hybrid, minimally invasive gastrostomy for children with abnormal epigastric anatomy

Purpose This communication is an analysis of the experience with a new type of gastrostomy. It was developed for patients with pronounced epigastric anatomical abnormalities, such as dense adhesions, in whom the conventional “open” gastrostomy could prove difficult and the percutaneous endoscopic, the imaging-guided, and the laparoscopically assisted methods would be unsafe. Method A large, soft rubber catheter is inserted in the child's mouth and advanced into the stomach. A small epigastric incision is made. With the help of the catheter, the anterior gastric wall is identified and the stoma site chosen. One of the curved needles of a double-armed monofilament suture is passed through the gastric wall and through the catheter. The needle is then cut off. The other needle is passed through the abdominal wall, from the inside out at the most suitable skin stoma site. When the catheter (with the embedded suture) is withdrawn from the mouth, a tract is established. The suture is replaced by a guide wire, which allows a percutaneous endoscopic gastrostomy–type catheter to be placed by the percutaneous endoscopic gastrostomy “pull” technique. Results This approach was used in 15 patients (14 children—ages 1 month to 7 years and one 19 years old) with: status post (s/p) necrotizing enterocolitis and bowel loss (n = 4); s/p gastroschisis and short-gut syndrome (n = 3); cerebral palsy, s/p ventriculo-peritoneal shunt infections (n = 2); s/p complex omphalocele; dwarfism; morphologic abnormalities; repaired prune-belly syndrome; s/p duodenal atresia with malrotation; severe scoliosis with s/p multiple shunt infections (one each). There were no complications. The technique also proved useful in several other children in whom a laparotomy incision for unrelated conditions was remote from the gastrostomy site. Conclusion Using a very small incision, this hybrid method permits safe and precise gastric and abdominal wall site selection and gastrostomy catheter placement. Gastrotomy as well as purse-string and peritoneal fixation sutures are not needed, and the danger of accidental catheter dislodgement is minimized.

Persistence of gastrocutaneous fistula after removal of gastrostomy tubes in children: prevalence and associated factors.

The aims of this study were to determine the prevalence of gastrocutaneous fistula after removal of gastrostomy tubes in children and to identify associated risk factors. The records of children who had undergone removal of gastrostomy tubes between January 1992 and December 2002 were reviewed retrospectively. Persistent gastrocutaneous fistula was defined as the absence of closure of the gastrostomy 1 month after tube removal. Factors that might influence spontaneous closure of the gastrostomy were studied, including age, underlying disease, nutritional status, type of gastrostomy, replacement of the gastrostomy tube by a button, abdominal wall thickness, duration of gastrostomy tube or button placement, and complications related to the presence of the gastrostomy (infection, granulation tissue). A total of 44 patients were included in the study (mean age 20 months, range 1 day to 14 years). Of these, 28 had undergone percutaneous endoscopic gastrostomy and 16 surgical gastrostomy. The mean time to spontaneous closure was 6 +/- 7 days. Persistent gastrocutaneous fistula developed in 11 patients (25 %) and in seven of these patients this required surgical closure (16 %). The mean duration of gastrostomy placement was significantly longer in patients who went on to develop a gastrocutaneous fistula than in patients who did not develop a fistula (39 +/- 19 months vs. 22 +/- 23 months, respectively, P < 0.03). No other significant association was found between the time required for spontaneous closure and the characteristics of patients or the type of gastrostomy. Persistent gastrocutaneous fistula is common after removal of gastrostomy tubes in children. Surgical closure should be considered when a gastrostomy has not closed spontaneously 1 month after removal of the gastrostomy tube.

P1141 PERSISTENCE OF GASTROCUTANEOUS FISTULA AFTER REMOVAL OF GASTROSTOMY TUBE OR BUTTON IN CHILDREN: PREVALENCE AND ASSOCIATED FACTORS

Introduction: The aim of this study was 1) to determine the prevalence of gastrocutaneous fistula after removal of gastrostomy in children 2) to search for associated risk factors. Methods: Charts of children in whom gastrostomy was removed between January 1992 and December 2002 were reviewed retrospectively. Persistent gastrocutaneous fistula was defined as the absence of closure of gastrostomy 1 month after removal of material. Factors that could influence spontaneous closure including age, underlying disease, nutritional status, type of gastrostomy, replacement by a button, abdominal wall thickness, duration of time that gastrostomy tube and/or button were maintained in place, complications related to the presence of gastrostomy (infection, presence of granulation tissue) were studied. Results: Among 312 patients undergoing gastrostomy during the study period, 44 patients aged between 1 day and 14 years (median age: 20 months; percutaneous endoscopic gastrostomy, n=28; surgical gastrostomy, n=16) fulfilling the inclusion criteria were included. Mean time of spontaneous closure was 6±7 days. Persistent gastrocutaneous fistula was found in 11 patients (25%) and required surgical closure in 7/11 patients. The duration of time that gastrostomy was maintained in place was significantly longer in patients with gastrocutaneous fistula compared to patients with no fistula (39±19 versus 22±23 months respectively; p=0.03). No other significant association was found between the characteristics of patients, the type of gastrostomy and the time required for spontaneous closure. Conclusion: Persistent gastrocutaneous fistula appears frequent after removal of gastrostomy in children. Surgical closure should only be considered when gastrostomy does not close spontaneously beyond 1 month after removal of material.

Fibrin glue as adjuvant treatment for gastrocutaneous fistula after gastrostomy tube removal.

Gastrocutaneous fistulas are infrequent after gastrostomy tube removal. However, if the fistulous tract remains permeable, even low-volume output can produce significant cutaneous burns. The use of biodegradable adhesives has been described, where fibrin glue is applied directly over the fistulous tract or under the guidance of procedures such as upper or lower gastrointestinal endoscopy or fistuloscopy. We studied the use of fibrin glue in five consecutive adult patients with gastrocutaneous fistulas after gastrostomy tube removal, with no complications that might impede spontaneous closure. A comparison group included seven patients treated during the preceding 2 years with conservative medical management, who were not treated with fibrin glue. There was no difference between the two groups with regard to age and gender, nor with regard to type of gastrostomy (surgical or endoscopic). The mean output volume from the fistulas was 151.4 +/- 146.1 ml/24 h in the study group and 115.0 +/- 42.7 ml/24 h in the control group, which was not significantly different ( P = 0.80). The duration of previous conservative treatment was 93.8 +/- 85.1 days for the study group and 95.8 +/- 80.7 days for the control group and this also did not differ significantly ( P = 0.93). The time to achieve total fistula closure was 7.0 +/- 3.1 days in the study group and 32.7 +/- 15.7 days in the control group. This difference was statistically significant ( P < 0.004). The time required before oral feeding could be recommenced after spontaneous or induced closure was similar in the two groups, at 2.8 +/- 1.3 days and 4.71 +/- 2.36 days, respectively. Endoscopic guidance allows direct instillation of fibrin glue via the external opening through the whole fistulous tract. This procedure reduces the time required for the closure of gastrocutaneous fistulas.

Prospective Randomized Evaluation of Two Regimens for Converting from Continuous to Intermittent Feedings in Patients with Feeding Gastrostomies

Forty enterally fed male patients were randomized to one of two regimens designed to determine the better means of converting them from continuous to intermittent enteral feedings. All patients received a nutritionally complete iso-osmolal 1 kcal/cc formula containing 6 g of nitrogen/L beginning on the second postgastrostomy day. Half of the patients (20) were randomized to a discontinuous regimen abruptly changing from continuous to gradually increasing intermittent feedings until reaching their nutritional goals. Intravenous fluids were given to maintain normal fluid balance. The other 20 patients were randomized to an overlapping regimen, receiving continuous feedings at a decreasing rate while intermittent feedings were progressively increased. Intravenous fluids were used during the first three stages only. There were no significant differences (p less than 0.05) in major diagnosis, type of gastrostomy, age, weight, height, admission or discharge serum albumin concentration, calculated basal energy expenditure (BEE), or nutrient goals (1.5 X BEE, 1.5 g of protein/kg per day).(ABSTRACT TRUNCATED AT 250 WORDS)

Gastrostomy with antireflux properties

The need for feeding gastrostomy seems to be increasing in children with neurological impairment and swallowing incoordination. Because gastrostomy can cause or increase gastroesophageal reflux, an antireflux procedure has been advocated at the time of gastrostomy placement in neurologically impaired children. A gastrostomy in the lesser gastric curvature with antirefluxing properties was performed in nine neurologically impaired children. All had severe swallowing incoordination with aspiration and malnutrition. Postoperatively none of the nine patients have demonstrated clinical evidence of vomiting or gastroesophageal reflux. This type of gastrostomy prevents the development of gastroesophageal reflux by increasing the length of the intraabdominal esophagus and by increasing the acuity of the gastroesophageal angle of His. When compared with an antireflux procedure, it has less complications, shorter postoperative recovery, and is more economical.

The permanent gastrostomy. Use of the gastrointestinal anastomotic stapler.

A permanent feeding gastrostomy was quickly and simply constructed in 29 patients with low operative risk using the gastrointestinal anastomotic stapler. The technique consisted of a simple application of this stapler on a carefully selected section of the stomach to form a Janeway type of gastrostomy. Activation of the device placed two double rows of staples and cut between them. This left the mucosa in approximation both in the tube and in the body of the stomach. A few additional Lembert sutures was all that was necessary. There were no suture line leaks nor other complications peculiar to the method.

A new method of valvular gastrostomy

A method for valvular gastrostomy is presented. The tubular gastrostomy projects into the lumen of the stomach and is lined by stomach mucosa on both sides. This type of gastrostomy has been successfully performed on a patient with carcinoma of the esophagus. There was no leakage of gastric contents at any time. A rubber tube was used only during feeding periods.

Production of Gastric and Duodenal Ulcers in the Gat by Intramuscular Implantation of Histamine.

The finding of Code and Varco that prolonged stimulation of gastric secretion could be obtained by the injection of a histamine beeswax mixture into dogs offered a means of testing whether endogenous gastric secretion could produce ulcers of the stomach or duodenum. Cats were chosen for this investigation, because it had been found in a recent study in this laboratory that these animals developed erosions and ulcerations of the stomach and duodenum quite readily when 0.4% hydrochloric acid was instilled daily into the stomach through a fistula (Walpole). It seemed possible that a profitable comparison might be made between ulcer production in response to endogenous and exogenous acid. Experimental Procedure. The problem was approached by first studying the effects of single injections of the histamine beeswax mixture on gastric secretion and then observing the effects produced by chronic histamine administration. The effect of the histamine beeswax mixture upon gastric secretion was studied in 3 cats with a standard type of gastrostomy. Controls. Control observations were made with 2 of these animals some days prior to the injections of histamine. The continuous secretion of the fasting stomach was collected every 8 hours for 24 hours. Several days later each cat was given an intramuscular injection of plain beeswax mixture equivalent in amount to that in a dose of the histamine beeswax mixture and the continuous gastric secretion was collected every 8 hours for 24 hours. In addition, in 3 control cats beeswax alone was implanted daily intramuscularly over periods varying from 8 to 23 days. In each instance, the cat gained weight and its general health appeared satisfactory. One of these cats was killed and subjected to a careful necropsy. There was no ulcer.