Direct percutaneous endoscopic jejunostomy through a mature gastrostomy tract.
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Adult↗
Biomedical subjects
Todd H Baron
Publications and source records attributed to Todd H Baron.
Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension.
BACKGROUND: Jejunostomy tubes can be placed endoscopically by means of percutaneous gastrostomy with jejunal extension (PEG-J) or by direct percutaneous jejunostomy. These 2 techniques were retrospectively compared in patients requiring long-term jejunal feeding. METHOD: An endoscopy database was used to identify all patients who underwent endoscopic jejunal feeding tube placement from January 1996 to May 2001. Patients with a history of upper GI surgery were excluded. There were 56 patients with a direct percutaneous jejunostomy and 49 with a percutaneous gastrostomy with jejunal extension. Patients in the direct percutaneous jejunostomy group received a 20F direct jejunostomy tube; a 20F PEG tube with a 9F jejunal extension was used in the percutaneous gastrostomy with jejunal extension group. Medical records for the period of 6 months after establishment of jejunal access were reviewed. Complications and need for further endoscopic intervention within this time frame were recorded. The duration of feeding tube patency (number of days from established jejunal access to first endoscopic reintervention) was compared for both groups. RESULTS: Feeding tube patency was significantly longer in patients who had a direct percutaneous jejunostomy compared with those with a percutaneous gastrostomy with jejunal extension. Within the 6-month period, 5 patients with a direct percutaneous jejunostomy required endoscopic reintervention for tube dysfunction compared with 19 patients who had a percutaneous gastrostomy with jejunal extension (p < 0.0001). CONCLUSIONS: For patients who require long-term jejunal feeding, a direct percutaneous jejunostomy with a 20F tube provides more stable jejunal access compared with a percutaneous gastrostomy with jejunal extension with a 9F extension and has a lower associated rate of endoscopic reintervention.
Adult↗
Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients.
OBJECTIVE: Malignant gastric outlet obstruction is seen in the setting of a variety of cancers, most commonly pancreatic. Self-expanding metal stents can be used to palliate these patients and restore the ability to eat. METHODS: We reviewed the Mayo Clinic experience in the endoscopic treatment of malignant gastric outlet obstruction. Thirty-six patients (26 male, 10 female) were treated between October, 1998 and January, 2001. Data were collected from charts, endoscopy reports, x-rays, and telephone calls. A scoring system was created to grade the ability to eat. RESULTS: All procedures were successful. Thirty-one of 36 patients (86%) required one stent at initial endoscopy, and 5/36 patients (14%) required two or more stents. Pretreatment, 19/36 patients (53%) were nil per os, 15/36 (42%) drank liquids, and 2/36 were able to eat soft solids. After stent placement, only 1/36 (3%) was still nil per os, 13/36 (36%) drank liquids, 13/36 (36%) ate soft solids, and 9/36 (25%) ate a full diet. The improvement in ability to eat using the scoring system was statistically significant (p < 0.0001). Nine of 36 patients (25%) required reintervention for recurrent symptoms. Sixteen of 36 patients (44%) had concomitant or subsequent development of biliary obstruction, of which 15 were successfully decompressed. CONCLUSIONS: Self-expanding metal stents are a safe and efficacious method for palliating malignant gastric outlet obstruction. The majority of patients do not require reintervention, and those that do can usually be managed nonoperatively.
Adult↗
The variable stiffness colonoscope: a scope for all seasons?
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Colonoscopes↗
Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction.
OBJECTIVE: Acute colonic pseudoobstruction (ACPO) most commonly develops after surgery, with narcotic administration, or in association with severe illness. Most cases resolve with conservative management. Colonoscopic decompression may be required in patients failing to respond to conservative treatment. Neostigmine has been proposed as an effective treatment for ACPO as an alternative to colonoscopic decompression. We sought to identify factors associated with spontaneous resolution of ACPO and to identify variables associated with a response to i.v. administration of neostigmine for the treatment of ACPO. METHODS: Retrospective analysis of Mayo Clinic's diagnostic index revealed all patients who developed ACPO between July, 1999 and September, 2001 at the Mayo Clinic Medical Center. We separately analyzed those patients who did not resolve ACPO with conservative management and to whom i.v. neostigmine was administered. Patient records were abstracted for demographic data, etiology of ACPO, management, and response to treatment. RESULTS: A total of 151 patients were identified with ACPO between July, 1999 and September, 2001; 117 patients (77%) had spontaneous resolution of symptoms. Of the 34 "nonresolvers," 18 patients received neostigmine, whereas 16 did not receive neostigmine. Of those 16 patients, 11 required colonoscopic decompression, two underwent surgery, and three died of underlying illness. "Spontaneous resolvers" were less likely to be taking narcotics (59% vs 74%, p = 0.08). Of the 16 nonresolvers who did not receive neostigmine, only one had a contraindication to neostigmine use. Of the 18 patients that who received neostigmine, 16 patients (89%) had prompt evacuation (<30 min) of flatus or stool. Sustained clinical response to neostigmine was noted in 11 of 18 (61%); the remaining seven patients (39%) required colonoscopic decompression or surgery for recurrent or persistent colonic dilation. Neostigmine-responders were more likely to be older (mean age, 76 yr vs 54 yr, p = 0.03), than nonresponders. Preneostigmine cecal diameter did not differ significantly between responders (median, 12 cm) and nonresponders (median, 13 cm), p = 0.9. Median time to resolution of ACPO in spontaneous resolvers was 4 days compared to 2 days in patients responding to neostigmine; p = 0.038. CONCLUSIONS: Most patients with ACPO respond to conservative treatment. Female gender and older age are associated with a response to neostigmine in those patients who do not respond to conservative management. Neostigmine appears to be under-used in patients with ACPO who do not have a true contraindication to its use.
Acute Disease↗
Combined tracheal and esophageal stenting for palliation of tracheoesophageal symptoms from mediastinal lymphoma.
Mediastinal lymphoma as a cause of tracheobronchial obstruction is uncommon, and a malignant tracheoesophageal fistula in the setting of mediastinal lymphoma is rare. Malignant tracheoesophageal fistulas are associated with pronounced morbidity and mortality. We describe a patient with mediastinal lymphomatous infiltration resulting in tracheal obstruction, esophageal obstruction, and tracheoesophageal fistula that were successfully palliated with combined airway and esophageal stent placement.
Esophagoscopy↗
Past, present, and future of endoscopic retrograde cholangiopancreatography: perspectives on the National Institutes of Health consensus conference.
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Abdominal Pain↗
Evaluation of indeterminate bile duct strictures by intraductal US.
BACKGROUND: Cholangiography and tissue sampling (brush cytology, biopsy) are the standard nonsurgical techniques for determining whether a bile duct stricture is benign or malignant. The aim of this study was to determine whether intraductal US is of assistance in distinguishing benign from malignant biliary strictures. METHODS: A retrospective review was undertaken of 30 patients with indeterminate bile duct strictures who underwent ERCP and tissue sampling from September 1999 to November 2000. A 20 MHz over-the-guidewire intraductal US catheter probe was used during ERCP for further examination of the strictures. Final diagnoses of malignant strictures (18 patients) were confirmed histopathologically; confirmation of benign stricture (12 patients) was based on negative tissue sampling plus extended clinical follow-up. RESULTS: Based on retrospective blinded review, the diagnosis by ERCP was correct in 67% of patients, by tissue sampling in 68%, by combined ERCP/tissue sampling in 67%, and by intraductal US in 90% (p = 0.04 vs. ERCP/tissue sampling) of cases. No complication of intraductal US or ERCP was recorded. CONCLUSIONS: Intraductal US is safe and can improve on the ability at ERCP to distinguish benign from malignant biliary strictures.
Adolescent↗
Indications and results of endoscopic rectal stenting.
Self expandable metal stents (SEMS) are a useful option to diverting colostomy for the palliation of malignant rectal obstruction. SEMS can be successfully placed in approximately 90% of cases with acceptable complication rates. Covered SEMS allow closure of malignant rectovaginal and rectovesical fistulae associated with rectal obstruction. The main drawback to these devices is the inability to palliate bleeding.
Colonoscopy↗
Direct percutaneous endoscopic jejunostomy placement in a patient with intracorporeal left ventricular assist device.
We present a case involving a patient who required enteral feeding after implantation of an abdominally positioned left ventricular assist device. The position of the device occupied most of the abdomen, precluding percutaneous endoscopic gastrostomy tube placement. However, in the case presented, direct percutaneous endoscopic jejunostomy (DPEJ) tube placement was achieved without interfering with the intracorporeal device. To our knowledge, there are no previous reports in the literature of successful DPEJ placement in a patient with an abdominally positioned heart assist device. DPEJ should be considered as a long-term enteral feeding route when structural barriers prevent percutaneous gastric access.
Abdominal Cavity↗
Percutaneous endoscopic gastrostomy placement without skin incision: results of a randomized trial.
BACKGROUND: During percutaneous endoscopic gastrostomy (PEG) placement, skin incision is performed as standard practice. We suspected that this time-honored principle is unnecessary. METHODS: In a prospective, randomized trial, 50 adults undergoing PEG placement were randomized to skin incision omission PEG (IOPEG) and standard PEG (SPEG). Two- and 7-day PEG site evaluations were performed to grade stomal infection, bleeding, pain, and overall satisfaction using a standardized scoring system. Median stomal evaluation scores were compared between groups using a Wilcoxon rank-sum test. Completion rates were compared using a t-test. RESULTS: Placement success for the IOPEG and SPEG technique was 22/25 (88%) and 24/25 (96%), respectively (p = NS). Three failed IOPEG attempts required an incision to complete due to increased pull force encountered. One SPEG failed due to inability to transilluminate. Stomal evaluation scores of infection, bleeding, pain, leakage, and patient satisfaction were not significantly different at 2 or 7 days. No serious complications occurred as a result of skin incision omission. CONCLUSIONS: Omitting the skin incision does not significantly alter the placement success rate, patient satisfaction, or the rate of stomal complications, thus dispelling the dogma that a skin incision is mandatory for PEG placement and the myth that incisions reduce infectious complications.
Adult↗