Percutaneous biliary drainage into the jejunum via a tube gastrostomy in patients with complete biliary obstruction: a report of two cases

In recent years, percutaneous gastrostomy has been used to return bile draining from percutaneous transhepatic drainage catheters in patients with complete biliary obstruction that could not be bypassed surgically or stented either percutaneously or endoscopically. We report our initial experience with two patients in whom the combined percutaneous and endoscopic technique was used to divert the bile back into the jejunum.

Contamination of a prefilled ready-to-use enteral feeding system compared with a refillable bag

The contamination of a refillable bag enteral feeding system was compared with a prefilled, ready-to-use system on four stable patients with gastrostomies in a longterm care facility. Samples were taken from the distal end of the tubing attached to the formula reservoir three times (just before administration to the patient, during the morning medication pass, and just before the reservoir change) during 24 hours for 3 days with use of the refillable bag, the ready-to-use system, and the ready-to-use system with a Y-port added. A Y-port was added to the ready-to-use system to facilitate administration of water, medications, residual checks, and specimen collection without disconnection of the gastrostomy tube from the formula reservoir tubing when it was apparent that the contamination levels of the refillable bag and the ready-to-use system were not different. Forty-one (65%) of the 63 specimens collected while the Y-port was not being used exceeded the acceptable contamination level for grade A pasteurized milk. Five (28%) of the 18 specimens collected while the Y-port was in use exceeded this level. Use of a Y-port is suggested when a prefilled ready-to-use system is used to decrease contamination as well as save nursing time.

Long-term effects of feeding high carbohydrate diet in pre-weaning period by gastrostomy: a new rat model for obesity

In the present study, we report the long-term metabolic consequences of feeding a milk substitute formula that is high in carbohydrate-derived calories during the suckling period. Male Sprague-Dawley rat pups were raised by gastrostomy on a high carbohydrate (HC) formula or a high fat (HF) formula (which mimicked rat milk composition in macronutrients) during the pre-weaning period (day 4 to 24). These rats were then weaned to a laboratory stock diet and subsequently challenged with a high sucrose diet to augment the development of obesity. The pups receiving the HC formula developed obesity in later life, even though there was no change in the body weight of this group compared to mother-fed (MF) controls or HF formula fed animals during the pre-weaning period. The HC rats were hyperinsulinemic and their growth rates were greater than MF rats starting at day 55. The lipogenic capacity of liver as well as adipose tissues (epididymal and omental) was higher in HC animals compared to MF control animals, as reflected by increases in two key lipogenic enzymes (fatty acid synthase and glucose-6-phosphate dehydrogenase) and in vitro synthesis of lipids. An analysis of adipose tissue morphology in adult rats showed an increase in cell size in epididymal adipose tissue of HC rats compared to the MF group. However, there was no significant difference in cell size in omental adipose tissue between the MF and HC rats. The HF group behaved similarly to the MF control group in growth pattern and measured metabolic parameters.

Evaluation of the benefits of gastric tube feeding in an elderly population

OBJECTIVE

To assess the benefits of gastric tube feeding in an elderly community hospital population.

SUBJECTS

One hundred consecutive patients who required feeding gastrostomies from July 1984 through June 1987.

SETTING

Durham (NC) Regional Hospital, a 380-bed community hospital.

METHODS

Patients were evaluated using a quality of life scale (QL scale) adapted from Spitzer's QL Index. The evaluation was based on hospital records at the time of tube placement and interviews with patients or family members at follow-up between June 1991 and March 1992. Subjective evaluation of the benefits of gastric tube feeding were obtained in interviews with patients or their families at follow-up.

RESULTS

Overall there was no significant change in the objective evaluation of quality of life at follow-up. Men, patients over 76 years of age, and patients with chronic illnesses such as multiple strokes or dementia showed the poorest response on the QL scale. Subjective evaluation by patients or their family members was positively correlated with objective evaluation on the QL scale. Family members of patients who showed the poorest response on the QL scale were more likely than other family members to respond no to the question, "Would you want this done to you if you were in his/her situation?"

CONCLUSIONS

Our QL scale provides a good indication of patients' and family members' subjective evaluation of the benefits of gastrostomy tube feeding after 4 to 8 years. Thus, the scale should be helpful to physicians who must consult with patients and their families and make decisions about the use of this procedure. The significant discrepancy between family members' evaluations of the benefit of the procedure to the patient and their refusal of the procedure for themselves if they were in the patient's situation confirms the need for advance directives and the importance of conscientious implementation of the Patient Self Determination Act of 1990.

Pure esophageal atresia: outlook in the 1990s

Eleven newborns with pure esophageal atresia were treated between 1980 and 1989 inclusive; there were six girls and five boys. Their gestational age ranged from 31 to 40 weeks (average, 37 weeks) and weight from 1.1 to 3.0 kg (average, 2.2). The only associated anomalies were Down's syndrome, respiratory distress syndrome, and patent ductus arteriosus. All babies received an immediate gastrostomy. Several radiologic studies were done to see if the distance between the two esophageal pouches was decreasing. Dilatations of the upper pouch were carried out in two patients. After a wait of 1 to 7 months (average, 3 1/2) a primary anastomosis was attempted; the weight of six babies doubled during this time. Eight neonates had a primary repair (two were aided by a circular myotomy). Two had a staged gastric tube constructed, and one baby had a gastric pull-up procedure. Three of the infants with a primary anastomosis required a subsequent antireflux operation, and one needed her anastomosis resected 16 months later. Ten of these 11 newborns are alive and well; one of the gastric tube children died from an adhesive small bowel obstruction at age four years.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of supportive nutritional therapy via percutaneous endoscopically guided gastrostomy on the quality of life of cancer patients

Between April 1987 and May 1990 a total of 212 consecutive patients with tumours in the head and neck region were admitted to a prospective study comparing planned prospective enteral nutrition via percutaneous endoscopically guided gastrostomy (PEG; n = 47) and oral nutrition (n = 134). The nutritional status (anthropometric and laboratory chemical parameters) and the quality-of-life index according to Padilla et al. [Res Nurs Health 6:117-126 (1983)] were determined prior to radiotherapy, 2, 4, 6 weeks later during radiotherapy and 6, 12 and 18 weeks after completion of radiotherapy. The quality-of-life score of the orally nourished patients decreased quickly during radiotherapy and improved only slowly afterwards. Although PEG patients had a worse starting score, their quality-of-life index did not deteriorate during therapy (statistically significant difference between the two groups). The same applies to the nutritional status. These results show that an early and constant enteral nutrition by PEG can stabilize the nutritional state and the quality of life of patients with tumours of the head and neck area during radiotherapy.

Double percutaneous endoscopic gastrostomy fixation: an effective treatment for recurrent gastric volvulus

A lady with recurrent gastric volvulus (and a poor surgical risk) was treated by insertion of two percutaneous endoscopic gastrostomy tubes to anchor the stomach to the anterior abdominal wall. The tubes were removed 5 months later, and she remained asymptomatic.

Laryngo-tracheo-oesophageal cleft: a plea for early diagnosis

Congenital laryngeal clefts are rare. This paper reports on the management of 3 patients with Type 2 laryngo-tracheo-oesophageal cleft. One patient died following tracheopexy after successful cleft closure. Prognosis is related to the presence of other major anomalies, the early diagnosis of the lesion and institution of appropriate respiratory and nutritional care prior to correction of the defect. A greater awareness of the condition combined with aggressive diagnostic endoscopy should result in early diagnosis and improved survival.

Surgical management of duodenal obstruction in older children in Kaduna, Nigeria

Twenty children, aged between six years and fourteen years were seen and treated for duodenal obstruction at the Department of Surgery, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria, between 1st January 1990 and 31st December, 1990. Both extrinsic and intrinsic factors caused the duodenal obstruction. All the patients were surgically treated and all survived. The main presenting clinical features, diagnosis and treatment are discussed. Follow up on some of the patients has been erratic because of patients defaulting on clinic appointments. In spite of successful surgical treatment and relief of symptoms, growth retardation, as shown by height and weight measurements, persisted relatively in patients in whom it was present at the time of diagnosis and treatment.

[Technical aspects of rehydration]

Rehydration of terminally ill patients is from a technical point of view not more difficult than fluid treatment of any other patient. The difficulty lies in the balanced decision between the appropriate method on one hand and the desirability of a rehydration on the other hand. The route of choice in terms of burden for the patient as well as from a logistic point of view is the oral one. If it fails fluid can be administered via transnasal gastric tube. Percutaneous endoscopic gastrostomy and other types of gastrostomy do not provide any advantage over gastric tube for patients with imminent early mortality and those in a hospital. Subcutaneous infusions provide at least for a short time a suitable method for rehydration also and in particular for terminally ill patients. Peripheral venous catheters are suitable for rehydration, however only for a period of few days until another solution is found.

[Post-cholestatic hypercholeresis in a patient with malignant obstruction of the bile ducts]

Increased choleresis of up to 4950 ml per day was observed after positioning of a PTCD in a patient with complete biliary obstruction due to a malignant tumor. Bile secretion could be temporarily reduced to 15% of the initial flow rate by intravenous administration of somatostatin. Simultaneously, the concentration of bile acids increased from 1.2 to 6.2 mmol/l, whereas the concentrations of electrolytes remained constant. Cholic acid had no influence on bile secretion. To safeguard the patient from excessive loss of fluid and electrolytes, the drained bile was reinfused into the duodenum via a PEG.

Nutrition support of a pregnant comatose patient via percutaneous endoscopic gastrostomy

A pregnant woman was comatose after a motor vehicle accident at 13 weeks' gestation. The nutritional needs of the patient were supported by tube feedings after percutaneous endoscopic gastrostomy. Clinical management was required for nutrition support, infection, and fetal development. At 37 weeks' gestation, a normal 3640-g male infant was delivered by cesarean section. This represents the first case report of a successful pregnancy outcome after percutaneous endoscopic gastrostomy for enteral nutrition support of a pregnant comatose patient.

Chronic pulmonary aspiration in children

According to established diagnostic and therapeutic guidelines for chronic pulmonary aspiration, clinical suspicion is raised by coughing and choking with feeding, coughing during sleep, recurrent pneumonia, failure to thrive, and radiologic signs of chronic lung injury. The upper gastrointestinal series accurately defines anatomy and function, can differentiate between direct and reflux aspiration, and identifies conditions that predispose to aspiration. Gastroesophageal scintigraphy lacks anatomic detail but increases observation time, may differentiate between direct and reflux aspiration, and identifies delayed gastric emptying and gastroesophageal reflux. The lipid-laden macrophage index improves identification of aspiration, but cannot differentiate between direct and reflux aspiration. The esophageal pH probe identifies gastroesophageal reflux. Treatment options include medical therapy (thickened feedings, prone positioning, and metoclopramide) and surgical intervention (gastrostomy, fundoplication, and definitive correction of predisposing conditions). Therapy is determined by severity of illness and results of diagnostic evaluation.

Safety of percutaneous endoscopic gastrostomy in patients with a ventriculoperitoneal shunt

The placement of percutaneous endoscopic gastrostomy tubes in patients with a ventriculoperitoneal shunt implicitly raises concerns about the potential for infection, shunt malfunction, and neurological decompensation. As there is no detailed information on this subject, the safety of percutaneous endoscopic gastrostomy was prospectively studied in 15 consecutive patients who had a ventriculoperitoneal shunt. Ten shunts entered the right upper abdomen, and five were on the left. A percutaneous gastrostomy tube was placed in the left upper abdomen for a minimum of 1 week (mean, 2.2 weeks) after shunt insertion. In the immediate postoperative period, no wound or intra-abdominal complications occurred. One patient developed acute neurological decompensation because of proximal shunt malfunction, and one patient died from cardiopulmonary complications unrelated to the placement of shunts or gastrostomy tubes. Among the 14 survivors, there have been no shunt malfunctions or septic complications during a mean follow-up period of 8.6 months. It would appear that percutaneous endoscopic gastrostomy tubes can be placed in patients with a ventriculoperitoneal shunt without undue concern for short- or long-term infectious or neurological sequelae. In addition, the presence of a shunt on the left side does not necessarily interfere with the safe placement of a percutaneous endoscopic gastrostomy tube.