Endoscopic gastrostomy: critical analysis in a regional referral hospital / Gastrostomía endoscópica: análisis crítico en un hospital referencial regional

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a safe and effective endoscopic surgical procedure for enteral access and gastrointestinal decompression, and it is an excellent alternative to surgical gastrostomy. There are various clinical indications and these mainly include the need for prolonged enteral nutritional support due to complications from neurological, geriatric and oncological diseases and decompression of the gastrointestinal tract. Although safe and effective, a number of possible complications relating to the time (early or late complications) and severity (minor or major complications) may occur. Objective: To evaluate the indications and complications relating to PEG among selected patients at the digestive endoscopy service of a regional referral hospital. Materials and methods: A retrospective study on patients who underwent PEG between May 2013 and April 2015 was conducted. The patients were identified through searching the medical records and using a standardized data form. Results: 53 cases were analyzed. The average age was 70.47 years and 60.37% of the patients were women. The main indication identified was the need for enteral nutritional support, and 73.58% of these indications were derived from neurological complications, 15.09% from geriatric complications and 9.43% from oncological complications and 1.88% were due to gastrointestinal decompression. Complications occurred in 24.52% of the cases: 23.07% were major and 76.93% were minor. Regarding the time, there were eight cases of late complications and five of early complications. Conclusion: PEG was shown to be an effective and safe method for enteral access. The indication and complication rates were similar to those reported in the literature.

Introducción: La gastrostomía endoscópica percutânea (GEP) es un procedimento endoscópico-quirúrgico seguro y efectivo para el acceso enteral y para la descompresión gastrointestinal, constituyéndose como una excelente alternativa a la gastrostomía quirúrgica. Las indicaciones clínicas son variadas y comprenden principalmente: necesidad de soporte nutricional enteral prolongado por complicaciones de las enfermedades neurológicas, geriátricas y oncológicas, así como la descompresión del tracto gastrointestinal. Aunque es segura y eficaz, se puede producir una serie de posibles complicaciones relacionadas al momento (precoz temprano o tardío) de la realización del procedimiento y a la gravedad (mayor o menor). Objetivo: Evaluar las indicaciones y complicaciones relacionadas a la realización de la GEP en pacientes seleccionados de un sector de endoscopia digestiva de un hospital regional de referencias. Materiales y métodos: Fue realizado un estudio retrospectivo de los pacientes sometidos a la GEP en el periodo de mayo de 2013 a abril de 2015. Los pacientes fueron identificados a partir de la investigación de los registros y formulario estándar de datos. Resultados: Fueron analizados 53 casos. La edad media fue de 70,47 años con un 60,37% del sexo femenino. La indicación principal verificada fue la necesidad de soporte nutricional enteral, siendo 73,58% por complicaciones neurológicas, 15,09% geriátricas, 9,43% oncológicas; y 1,88% de las indicaciones fueron para descomprensión gastrointestinal. Ocurrieron complicaciones en 24,52% de los pacientes: 23,07% mayores y 76,93% menores. En relación al momento, fueron verificados ocho casos de complicaciones tardías y cinco de complicaciones precoces (tempranas). Conclusión: La GEP se mostró como un método eficaz y seguro para el acceso enteral. Los índices de complicación fueron semejantes a los datos evidenciados en la literatura.

Embolismo pulmonar después de obturación de várices gástricas con N-butil-2-cianoacrilato / Pulmonary embolism after endoscopic injection with N-butyl-2-cyanoacrylate for gastric varices

Las várices gástricas están presentes en cerca de un tercio de los pacientes con hipertensión portal y el sangrado de las mismas representa una causa significativa de mortalidad. El tratamiento de primera línea es la obturación con N-butil-2-cianoacrilato, que si bien es seguro no está libre de complicaciones. Presentamos el caso de un paciente de 61 años de edad con antecedente de cirrosis criptogénica que se presentó a la consulta febril, taquicárdico e hipoxémico después de la obturación endoscópica con N-butil-2-cianoacrilato. Las imágenes mostraron embolia pulmonar bilateral del material obturante. El objetivo de este trabajo es destacar las manifestaciones clínicas y las imágenes de esta situación para ayudar a su diagnóstico precoz y diferenciarla de otras entidades que requieren un tratamiento específico.

Gastric varices occur in one-third of patients with portal hypertension. Bleeding from gastric varices remains a significant cause of death. Currently the first-line of treatment for gastric varices is endoscopic obliteration with N-butyl-2-cyanoacrylate. Though relatively safe, this option has several well-known complications. We report the case of a 61-year-old male patient with cryptogenic cirrhosis, who presented with fever, tachycardia and hypoxemia after endoscopic obliteration with N-butyl-2-cyanoacrylate. Radiographic findings were consistent with pulmonary embolism of the sclerosing substance. The aim of this case report is to emphasize the clinical and radiological findings of this complication in order to distinguish it from other similar medical conditions and prevent a delay in diagnosis.

Gastrostomía endoscópica -through como dispositivo de instalación / Endoscopic gastrostomy using the pull through kit as installation device

Background: The pull-through method to install endoscopic gastrostomies is not devoid of complications. Aim: To describe and show the results of a trans-abdominal method to perform endoscopic gastrostomies using the accessories available in any endoscopic facility. material and methods: The technique consists in installing an exchange tube using the pull kit, which acts as a tube installer. We attempted the procedure in 14 patients whose ages ranged from 15 days to 83 years in a regional hospital. results: In 13 patients, the tube was correctly installed using the trans-abdominal pathway and they could be fed two hours later. Three months later, 11 patients were alive and did not experience complications associated with the gastrostomy. Conclusions: This preliminary experience supports the use of the described technique to install gastrostomies.

Objetivo: Para evitar las complicaciones de la gastrostomía endoscópica (GE) hemos desarrollado un método transabdominal empleando accesorios disponibles en cualquier unidad de endoscopia y una técnica con la cual los endoscopistas están familiarizados. Describimos el método y mostramos sus resultados. material y método: Esta técnica consiste en instalar una sonda de recambio con la ayuda del kit Pull que actúa como instalador de la sonda. Hemos intentado este procedimiento en 14 pacientes con edades entre 15 días y ochenta y tres años. Esta experiencia se realizó en el Hospital de Iquique. resultados: En 13 pacientes se logró instalar la sonda por vía transabdominal y alimentar dos horas después. A los 3 meses, once permanecían vivos y no habían tenido complicaciones mayores relacionadas a su gastrostomía. Conclusión: Aunque se trata de una experiencia inicial, creemos que esta técnica de gastrostomía combinada presenta una alternativa a otras técnicas endoscópicas de acceso transabdominal.

Melanoma gástrico sin origen primario conocido / Gastric melanoma without well-known primary origin

El melanoma maligno es una neoplasia derivada de los melanocitos, que equivale al 5 por ciento de las neoplasias cutáneas. El 95 por ciento de los melanomas se desarrolla en la piel y menos de 3 por ciento corresponde a melanoma metastásico sin evidencia de tumor primario. En el tracto gastrointestinal, la afectación por melanoma es debido la mayoría de las veces a metástasis. El melanoma primario gastrointestinal está descrito que afecta a la zona anorrectal, seguido de esófago. El melanoma gástrico primario es un tumor excepcional, existen muy pocos casos documentados en la literatura. Presentamos el caso de un paciente con un melanoma en estómago como primera manifestación de la enfermedad y hacemos una revisión del estado actual(AU)

Malignant melanoma is a melanocyte-derived neoplasm and accounts for 5 percent of skin neoplasms. Ninety five percent of melanomas appear on the skin and less than 3 percent are metastasic melanoma without primary tumor evidence. In the gastrointestinal tract, most of cases of melanoma are metastasic. Primary gastrointestinal melanoma appears mostly in anorectal area followed by the esophageal area. Primary gastric melanoma is a very rare tumor, and there are very few cases reported in scientific literature. This is the report of a male patient with gastric melanoma as first sign of disease and a review of the present condition of the illness(AU)

Proton Pump Inhibitor Use before Percutaneous Endoscopic Gastrostomy Is Associated with Adverse Outcomes

BACKGROUND/AIMS: Knowledge of the risk factors associated with adverse outcomes after percutaneous endoscopic gastrostomy (PEG) may be helpful for developing PEG recommendations. The purpose of this study was to identify the clinical risk factors associated with adverse clinical outcomes after PEG, especially regarding the use of proton pump inhibitors (PPIs). METHODS: We retrospectively reviewed the data from PEG patients at seven university hospitals between June 2006 and January 2012. All patients were followed up through February 2012 after PEG, and the clinical risk factors for adverse clinical outcomes after PEG were analyzed. RESULTS: Data from 1,021 PEG patients were analyzed. PPI users were more frequently included in the complication group than the noncomplication group (p=0.040). PEG-related complications (p=0.040) and mortality (p=0.003) were more frequent in the PPI group than in the control group. In the subgroup analysis of complicated PEG cases, infectious complications were more frequently found in the PPI group than in the control group (35.8% vs 27.8%). After adjustment for multiple possible confounding factors, PPI users (odds ratio, 1.531; 95% confidence interval, 1.017 to 2.305) and diabetic patients had increased mortality after PEG. CONCLUSIONS: PPI use may be associated with adverse outcomes in patients with PEG; however, further prospective studies investigating this issue are warranted.

Endoscopic treatment for gastric perforation using T-tag and a plastic protection chamber: a short-term survival study / Tratamento endoscópico para perfuração gástrica por sutura utilizando dispositivos em T associados à câmara plástica protetora: estudo com curto tempo de sobrevida

CONTEXT: The endoscopic gastric perforation is a consequence of some endoscopic procedures and now a way to manage abdominal organs. This is the reason why endoscopists are studying a safe endoscopic repair. OBJECTIVE: To evaluate an endoscopic closure method for the gastric opening in natural orifice transenteric surgery DESIGN: Short-term survival animal study. METHODS: Ten White Landrace pigs underwent a gastric perforation of 1.8 cm in diameter under general anesthesia. The opening was repaired with stitch assembled in a T-tag anchor placed through the gastric wall with a needle. A plastic transparent chamber, adapted to the endoscope tip protected the abdominal organs from the needle puncture outside the stomach. Six T-tags were placed in most cases and the stitches were tied with a metallic tie-knot, forming three sutures. The animals received liquids in the same operative day. One shoot antibiotic was used. The leakage test was performed with a forceps and by air distention. RESULTS: No complication was detected in the postoperative course. One month later the endoscopy revealed a scar and some suture material was observed in all animals. The antral anterior gastric wall was clear with few adhesions in the laparotomy performed in the same time. The adhesions were intense in an animal in which a cholecystectomy was performed before the repair. CONCLUSION: The endoscopic repair using T-tag and a protector chamber is feasible, easy to perform and safe. Further studies are needed to show the real value of this kind of procedure.

CONTEXTO: A perfuração gástrica pode ser consequência de alguns procedimentos endoscópicos, atualmente, produzida intencionalmente para acesso a alguns órgãos com o advento da cirurgia transluminal endoscópica por orifícios naturais. Esta é a razão para que os endoscopistas estudem uma maneira segura de reparar estas lesões por via endoscópica. OBJETIVO: Avaliar um novo método de fechamento das perfurações gástricas utilizadas para acesso ao NOTES. MODELO DE ESTUDO: Pesquisa em modelos animais com curto tempo de sobrevida. MÉTODO: Dez porcos da raça White Landrace, foram submetidos a perfuração gástrica de 1,8 cm, monitorizados e sob anestesia geral. A abertura gástrica foi reparada com dispositivo especial constituído por agulha em forma de T montada com fio (T-tag), inserida, por via endoscópica, nas bordas do ferimento perfurando a parede gástrica e fixando-se a ela como uma âncora. Uma câmara plástica protetora, especialmente desenvolvida, foi adaptada à ponta do endoscópio para proteção dos órgãos subjacentes. Seis T-tags foram inseridos na maioria dos casos e os pontos foram amarrados e fixados com auxílio de outro dispositivo metálico de contenção do nó denominado “tie-knot”, formando três suturas. Um teste de vazamento do tipo manobra do borracheiro era realizado ao término do procedimento. Os animais recebiam líquido no pós-operatório imediato. Foi usada profilaxia antibiótica. RESULTADOS: Não houve complicações. Um mês depois, a endoscopia de controle revelou cicatriz e alguns restos de sutura. A laparotomia, feita no mesmo tempo, revelou poucas aderências na face anterior do antro. CONCLUSÃO: O reparo endoscópico com T-tags e câmara protetora parece ser efetiva, fácil e segura. Estudos maiores e com maior tempo são necessários para confirmar estes resultados e a utilidade deste procedimento.

Acute buried bumper syndrome: An endoscopic buried bumper syndrome:approach.

Acute buried bumper syndrome is an uncommon complication of percutaneous endoscopic gastrostomy (PEG) tube placement. If not recognized and treated appropriately, it can lead to serious complications including death. We report a case of an acute buried bumper syndrome, successfully managed with PEG tube repositioning through the original tract, without the need of replacement.

Effects of sedation during upper gastrointestinal endoscopy on endocrine response and cardiorespiratory function

Upper gastrointestinal endoscopy is often accompanied by tachycardia which is known to be an important pathogenic factor in the development of myocardial ischemia. The pathogenesis of tachycardia is unknown but the condition is thought to be due to the endocrine response to endoscopy. The purpose of the present study was to investigate the effects of sedation on the endocrine response and cardiorespiratory function. Forty patients scheduled for diagnostic upper gastrointestinal endoscopy were randomized into 2 groups. While the patients in the first group did not receive sedation during upper gastrointestinal endoscopy, the patients in the second group were sedated with intravenous midazolam at the dose of 5 mg for those under 65 years or 2.5 mg for those aged 65 years or more. Midazolam was administered by slow infusion. In both groups, blood pressure, ECG tracing, heart rate, and peripheral oxygen saturation (SpO2) were monitored during endoscopy. In addition, blood samples for the determination of cortisol, glucose and C-reactive protein levels were obtained from patients in both groups prior to and following endoscopy. Heart rate and systolic arterial pressure changes were within normal limits in both groups. Comparison of the two groups regarding the values of these two parameters did not reveal a significant difference, while a statistically significant reduction in SpO2 was found in the sedation group. No significant differences in serum cortisol, glucose or C-reactive protein levels were observed between the sedated and non-sedated group. Sedation with midazolam did not reduce the endocrine response and the tachycardia developing during upper gastrointestinal endoscopy, but increased the reduction in SpO2.

Entrapment of guide-wire during oesophageal dilation.

We report a patient who developed oesophageal stricture after accidental ingestion of acid. During one of the oesophageal dilation sessions, a Savary-Gillard guide-wire got entrapped in the stomach and had to be removed surgically. A Foley catheter, placed for feeding purposes, migrated into the proximal small intestine causing acute intestinal obstruction. The balloon of the Foley catheter had to be punctured using a sclerotherapy needle and the catheter withdrawn.

Gastrostomía endoscópica percutánea: una alternativa para la alimentación enteral a largo plazo / Percutaneous endoscopic gastrostomy: an alternative for long-term enteral feeding

This study shows that, in our environment, percutaneous endoscopic gastrostomy is feasible in most patients who need it, and at the same time it is a fast, safe and inexpensive procedure. The complication rate is low and most can be resolved rapidly medically or endoscopically. It also allows the placement of a permanent means for the administration of nutrients and for drainage of gastroduodenal secretions in those patients who warrant it