Endoscopic guided percutaneous tracheostomy: early results of a consecutive trial

Percutaneous tracheostomy is increasingly being used for patients needing prolonged ventilatory support. The purpose of this study was to assess the feasibility of widespread application of endoscopic guided percutaneous tracheostomy. Sixty-one consecutive ICU patients requiring prolonged mechanical ventilation underwent bedside endoscopic guided percutaneous tracheostomy. Using a modified Ciaglia technique, a #6-10 tracheostomy tube was introduced between the second and third tracheal rings. Bronchoscopic transillumination facilitated identification of the appropriate tracheostomy site, and verified satisfactory placement of dilators and tracheostomy tube. There was one procedure-related death due to arrhythmia. Procedure-related complications included (n = 7): bleeding (controlled with local pressure), two infections, two cuff tears, and two obstructions of the tracheal tube. The tracheostomy was eventually removed in 13 patients. Bronchoscopic evaluation of three patients at 4 months post-tracheostomy removal was normal and there has been no clinical evidence suggestive of tracheal stenosis in the remaining ten extubated patients. There was a 50% reduction in cost when compared to operative tracheostomy. Percutaneous tracheostomy is a simple, safe, cost-effective bedside procedure for critically ill ventilator-dependent patients. Endoscopic guidance appears to increase the safety of this procedure and may prevent complications of pneumothorax, subcutaneous emphysema, and paratracheal false passage previously reported with blinded percutaneous methods.

Percutaneous endoscopic tracheostomy

Bedside percutaneous tracheostomies are increasingly performed. This avoids patient transport to the operating room. Complications of this procedure are largely related to the blind nature of the technique. After laboratory studies, 4 patients underwent percutaneous endoscopic guided tracheostomy in a selective clinical trial. There were no procedure-related complications. Endoscopic guidance ensures precise low tracheostomy position, prevents paratracheal tube misplacement, and avoids inadvertent injuries.

Analysis of 5-OH-indoles in human gut biopsy tissues by reversed-phase high-performance liquid chromatography with fluorimetric detection

A method was devised for the rapid simultaneous determination of major indoles in human gut tissues. Analysis with picomol detection limits was done by HPLC on a C(18) reversed-phase column with fluorimetric detection at 276/350 nm. This simple method for which there is no necessity of derivatization or purification was validated for routine analysis of small mucosa samples (less than 4 mg fresh weight) obtainable during endoscopy. A comprehensive list of 5-OH-indole compounds in human gut tissue is presented.

Analysis of tryptophan, tyrosine and related dipeptides in mouse brain by isocratic high-performance liquid chromatography with switchable wavelength fluorescence detection

Tryptophan (Trp) and tyrosine (Tyr) are pharmacologically active compounds which, after administration of adequate doses, are increased in level in the brain, and stimulate neurotransmitter synthesis. Trp and Tyr containing dipeptides were tested as possible substitutes with regard to the effect on precursor level in the brain. Glycyltryptophan, alanyl-tryptophan and glycyl-tyrosine were intravenously applied to young female mice and the brain levels of dipeptides, Trp and Tyr measured 30 min after application. Neurotransmitter precursor levels in the brain increased similarly in all cases. The results suggest that the dipeptides are as effective as the single amino acids and may be superior because of their better solubility.

Percutaneous endoscopic duodenostomy (PED). Case report

Surgeons are increasingly using endoscopy to place transabdominal feeding tubes for enteral nutrition or gastric decompression. A possible extension for the application of this new technique is the direct placement of the feeding tube into the duodenal bulb. Two patients are presented in whom percutaneous endoscopic duodenostomy was successfully performed, although percutaneous endoscopic gastrostomy was not possible. It shows that this new method is technically possible. In both patients the positive influence of this technique on the patient's quality of life could be shown using the Spitzer Quality of Life Index and the Karnofsky Performance Status. Enteral nutrition was maintained for more than 6 weeks.

Quality of life: an important endpoint both in surgical practice and research

Surgery asks patients to trade present discomfort and risk for future gains. Although research reports on the effectiveness of surgery have largely focused on mortality, length of hospital stay, major complications, and laboratory analyses, the principal criteria guiding surgeons' clinical decisions and patients' acceptance of treatment are most often the patients' subjective feelings and capabilities, the quality of their lives. This is true for both major and minor surgical procedures. We discuss the role of information on functional capacity, overall well-being, and quality of life in the assessment of surgical outcomes. Broadening the choice of endpoints beyond traditional, so-called "hard" variables in surgical studies has advantages for both surgeons and patients.

Long-term results of Troidl's technique of endoscopic pneumatic dilatation for achalasia of the esophagus. A prospective clinical trial

In a prospective clinical trial, 26 consecutive patients underwent endoscopic pneumatic dilatation over a 10-year period. Dilatation was achieved by means of a balloon attached to a normal gastrointestinal fiberscope. With the endoscope in an inverse position, the device was placed in the cardia and the dilatation process was monitored macroscopically. Before dilatation, patients suffered from dysphagia (92%), reduced speed of swallowing (100%), symptom aggravation under stress (73%), weight loss (50%), aspiration, pain, regurgitation, and vomiting. After dilatation and long-term follow-up (mean of 5 years), symptoms could be markedly reduced, especially the speed of eating and symptom aggravation under stress. Excellent and good results (Visick scale) were achieved in 76%. Fair results were achieved in 20%. To date, perforation and other complications have not occurred. Mortality was zero. Our series was an uncontrolled trial, so the results are hardly comparable to other studies. Furthermore, the small number of patients in our study represents a weak point with regard to complications. We conclude that the main advantages of the procedure are its simplicity and practicability. The simple procedure may be the method of choice in elderly patients. Of course, no final decision can be made until a well-designed controlled trial has been carried out.

[Gastric outlet stenosis (benign): definition, incidence, therapy?]

According to a strict definition of a benign gastric outlet obstruction i.e. delayed vomiting, changing of symptoms, weight loss and intraoperative test by Hegardilators (less than 14), 2.2% real stenoses among 619 operative treated duodenal ulcer patients were found. All patients were treated by SPV and digital dilatation of the stenosis through a gastrotomy. During up to a 10 year follow-up no reoperation was necessary. All patients showed Visick-classification of I and II. In conclusion SPV with digital dilatation showed good clinical results for patients with benign gastric outlet obstruction in long-term follow up.

[Dissociation behavior of peptide diets]

The solution stability of different diets (Peptisorb, Salvipeptid, Survimed and Survimed neutral) was investigated. All diets exert a more or less cream formation. Additionally in some of them one can observe the sedimentation of particulates. When these diets were pumped out of the nutrient bag, as usually done in clinical practice during enteral nutrition, some of them produce an effluent, which contains a high portion of sedimenting particulates at the beginning of the infusion. All of them show a very high colloidal portion in the last pumping fraction. The question is raised, whether these phenomena may lead to an osmotic burden of the bowel, thus in consequence, causing the often observed diarrhoea in tube fed patients.

[Modern technics of tube feeding]

A prospective study was done in 101 patients and clinical usefulness of a fine needle-catheter-jejunostomy was investigated; this procedure was modified according to the procedure devised by Delany (2). The instruments used were two split canules and a polyurethane catheter (inner diameter 2.1 mm); these instruments are simple, safe and can be applied quickly. Formation of fistulae, peritonitis, ileus or deaths caused by the procedure could not be observed. The catheter needs to have certain mechanical qualities as e.g. sufficient rigidity. Percutaneous endoscopic gastrostomy is an alternative to corresponding surgery procedure. The stomach is punctured under sight and a Foley catheter is applied immediately. We performed this procedure without major complications in seven cases, and found it to be very useful. The techniques described here are essentially important if the advantages of the enteral as compared to the parenteral nutrition are to be made use of. As soon as the problems of diarrhea and belching are solved, tube feeding will offer in the near future a real alternative to parenteral nutrition, especially in patients who need long time artificial nutrition.

[Effect of immunoglobulin and antibiotic in E. coli infection of malnourished mice]

Malnourished mice, which exert a greater susceptibility to E.coli induced intraperitoneal infection than standard fed animals, cannot be protected by application of immunoglobulin (2 X 10(5) cells/animal). If, however, an antibiotic (mezlocillin, 500 mg/kg s.c.) is given shortly after infection, the surviving rate increases dramatically to 42%. This effect is enhanced to 63% survival, if the infected animals receive an additional dose of immunoglobulin.