A new large-caliber trocar for percutaneous endoscopic gastrostomy by the introducer technique in head and neck cancer patients.

BACKGROUND AND STUDY AIMS: In many patients, percutaneous endoscopic gastrostomy (PEG) can be limited by digestive tract stenosis. PEG placement using an introducer is the safest alternative for this group of patients, but the available devices are difficult to implement and require smaller-caliber tubes. The aim of this study was to evaluate the modification of an introducer technique device for PEG placement with regard to the following: procedure feasibility, possibility of using a 20-Fr balloon gastrostomy tube, tube-related function and problems, complications, procedure safety, and mortality. PATIENTS AND METHODS: Between March 2007 and February 2008, 30 consecutive patients with head and neck malignancies underwent introducer PEG placement with the modified device and gastropexy. Each patient was evaluated for 60 days after the procedure for the success of the procedure, infection, pain, complications, mortality, and problems with the procedure. RESULTS: The procedure was successful in all cases with no perioperative complications. No signs of stomal infection were observed using the combined infection score. The majority of patients experienced mild-to-moderate pain both in the immediate postoperative period and at 72 hours. One major early complication (3.3%) and two minor complications (6.7%) were observed. No procedure-related deaths occurred during the first 60 days after the procedure. CONCLUSION: The device modification for PEG using the introducer technique is feasible, safe, and efficient in outpatients with obstructive head and neck cancer. In this series, it allowed the use of a larger-caliber tube with low complication rates and no procedure-related mortality.

Fístulo-papilotomia endoscópica: uma alternativa à papila de difícil cateterizaçäo / Is the endoscopic fistulo-papilotomy an alternative to the difficult papilary cannulation?

A fistulizaçäo cirúrgico-endoscópica no contorno papilar superior é um procedimento destinado a facilitar a cateterizaçäo da porçäo terminal do ducto colédoco, pela impossibilidade do acesso habitual pelo óstio, tendo em vista a fibrose, tumores ou cálculo impacatado. Esse procedimento foi denominado por Schapira (19982) como fístulo-esfincterotomia endoscópica, embora tenha recebido outras denominações inapropriadas, como fistulotomia suprapapilar ou infundibulotomia. Tal intervençäo endoscópica viabiliza a catererizaçäo emcasos difíceis, ampliando o acesso ao colédoco terminal ao nível da ampola hepatopancreática. E difere do procedimento denominado pré-corte, porquanto o óstio da papila é poupado com o intuito de prevenir a pancreatite aguda. Essa intervençäo cirúrgico-endoscópica, com base anatômica, é denominada fístulo-papilotomia no Serviço de Endoscopia Digestiva do HC-FMUSP. No período de outubro de 1999 a dezembro de 2000, foram realizadas 451 papilotomias, sendo indicadas 65 (14,5por cento) fístulo-papilotomias, cuja indicaçäo miais frequente foi a coledocolitíase. Ocorreram nove (13,8por cento) complicações: pancreatite aguda em cinco (7,6por cento) casos, hemoragia em um (1,5por cento), colangite em dois (3por cento) e perfuraçäo retroduodenal em um (1.5por cento). Em todos esses casos houve resoluçäo espontânea através do tratamento conservador. Considerando-se o insucesso da cateterizaçäo do óstio da papila de forma convencional, a fístulo-papilotomia for a opçäo que demonstrou ser um procedimento viável e seguro

Endoscopic sclerosis versus cyanoacrylate endoscopic injection for the first episode of variceal bleeding: a prospective, controlled, and randomized study in Child-Pugh class C patients.

BACKGROUND AND STUDY AIMS: Despite the recognized efficacy of sclerotherapy and elastic band ligation in controlling variceal hemorrhage, the results of endoscopic treatment in Child-Pugh class C patients remain poor. The aim of this prospective, controlled, and randomized study was to compare conventional sclerotherapy with injection of the tissue adhesive N-butyl-2-cyanoacrylate in controlling the first episode of rupturing of esophageal varices. PATIENTS AND METHODS: From January 1994 to June 1997, 36 consecutive Child-Pugh class C cirrhotic patients were admitted with an initial episode of esophageal variceal bleeding. They were randomly assigned to receive sclerotherapy with a 3% ethanolamine oleate solution (group 1, 18 patients) or injection of tissue adhesive (group 2, 18 patients). Episodes of recurrent bleeding were managed after the randomization procedure. After bleeding had been controlled, patients in both groups received weekly sessions of conventional sclerotherapy to eradicate any remaining esophageal veins. RESULTS: The patients in the two treatment groups had similar characteristics on entry into the study. More than 80% of the patients were admitted with moderate or severe hemorrhage. Approximately half of them presented with active bleeding during the index endoscopy. Early recurrent bleeding was observed in ten of the 18 patients in group 1 (55.6%) and in two of the 18 in group 2 (11.1%; P = 0.01). The hospital mortality rates were 72.2% in group I and 33.3% in group II (P = 0.04). CONCLUSION: These findings support the view that cyanoacrylate injection is superior to conventional sclerosis for controlling esophageal variceal bleeding in Child-Pugh class C patients. It is also highly probable that the better bleeding control achieved using the cyanoacrylate tissue adhesive treatment led to a lower hospital mortality rate.

Endosonographic diagnosis of intraluminal diverticulum.

After a long symptom period of 19 years a submucosal tumor was suspected on endoscopy to account for the patient's intermittent nausea and abdominal pain. Duodenal waterfilling during endoscopic ultrasound led to the endosonographic diagnosis of an intraluminal duodenal diverticulum which was removed surgically. The patient became completely asymptomatic.