- Email: [email protected]
Percutaneous endoscopic duodenostomy
into the end of a standard nasogastric tube placed through the nose and exiting via the mouth. Following transnasal placement, a large blunt-tipped needle is inserted and secured into the cut end of the feeding tube. Correct feeding tube position is documented by abdominal x-ray, and enteral feeding is begun.
SUMMARY
A technique for expeditious and safe placement of nasoenteric feeding tubes under direct vision is described. Adult patients undergo feeding tube placement with intravenous sedation and topical anesthesia. Endoscopic tube placement requires an average of 10 min and eliminates many risks associated with blind passage. REFERENCES
Figure 2. Artist's depiction of the biopsy brush being advanced in the channel, pushing the feeding tube out the distal end of the scope. As the feeding tube is expelled, the endoscope is gradually withdrawn from the patient. Proper tube position is confirmed by continuous direct vision.
Percutaneous endoscopic duodenostomy Juan J. Alberti-Flor, MD Joseph L. Cochran, MD Steve Vaughan, GIA G. Dewey Dunn, MD
Esophagectomy with cervical esophagogastrostomy for esophageal carcinoma may be associated with a high rate of postoperative complications of which reflux and aspiration of gastric content are among the most common. The patient reported here had this operation performed 2 years previously and then developed recurrent bouts of aspiration due to the absence of the lower esophageal shincter and pull-through of the stomach into the chest cavity. In this patient, percutaneous endoscopic duodenostomy (PED) with a jejunal feeding tube (duodenojejunostomy) was successfully performed. This procedure may prove useful in patients with this operation who require long-term nutritional support. Received June 17, 1986. Accepted July 31, 1986. From the Department of Medicine (Gastroenterology), VanderbiLt University ScJwoL of Medicine, and Veterans Administration MedicaL Center, NashviLle, Tennessee. Reprint requests: Juan J. ALberti-FLor, MD, 951 SW 42 Avenue, Suite 302, Miami, Florida 33134.
350
1. Heymafield SB, Bethel RA, Ansley JD, et al. Enteral hyperalimentation: an alternative to central venous hyperalimentation. Ann Intern Med 1979;90:63-71. 2. Liston SL, Dickinson PB. Nasogastric intubation under fiberoptic endoscopic control. Laryngoscope 1984;94:258-9. 3. Schorlemmer GR, Battaglini JW. An unusual complication of naso-enteral feeding with small-diameter feeding tubes. Ann Surg 1984;199:104-6. 4. Hand RW, Kempster M, Levy JH, Rogol PR, Spirn P. Inadverent transbronchial insertion of narrow-bore feeding tubes into the pleural space. JAMA 1984;251(18):2396-7.
CASE REPORT
A 67-year-old man was admitted to the hospital for evaluation of aspiration and to consider the possibility of a percutaneous endoscopic feeding route. Past medical history was remarkable for esophagectomy with cervical esophagogastrostomy with pull-through of the stomach into the chest for esophageal carcinoma 2 years previously. Recently, the patient suffered recurrent bouts of reflux associated with aspiration. Physical examination revealed a well-developed, cachectic, chronically ill patient with a blood pressure of 120/70 mm Hg and no fever. Pertinent findings were confined to the abdomen. There was a well healed midabdominal scar without masses, ascites, or organomegaly. Laboratory tests revealed a hemoglobin level of 11.3 g and hematocrit of 33.6%. Platelet count, prothrombin time, and partial thromboplastin time were normal. Upper endoscopy was performed using pharyngeal anesthesia. The examination revealed that the area of the anastomosis of the esophagogastrostomy was located at approximately 15 em from the incisors. The anastomosis appeared normal. The stomach, pylorus, and duodenum were normal as well. Because of recurrent bouts of aspiration it was decided that the patient might benefit from percutaneous endoscopic gastrostomy (PEG) with a feeding jejunostomy tube. However, with the history of cervical esophagogastrostomy, the whole stomach had been pulled into the chest, and performing a PEG would have been impossible. For this reason, we GASTROINTESTINAL ENDOSCOPY
performed a percutaneous endoscopic duodenostomy (PED) with a jejunal feeding tube placed through the mushroom catheter (duodenojejunostomy). PED was performed as described by Ponsky and Gauderer l for PEG. A 16 F mushroom catheter was used, and the distal tip of the mushroom head was cut off. An internal rubber bumper was not used. After the mushroom catheter was placed in the anterior wall of the duodenal bulb at about 2 em from the pylorus (Fig. 1), an 8 F, 42-inch long feeding tube was introduced through the mushroom catheter using a 3 F guide wire. The 8 F feeding tube was grabbed inside the duodenal bulb with the biopsy forceps and advanced into the second and third portions of the duodenum (Fig. 2). The location of the
Figure 1. Endoscopic photograph of the mushroom head in the anterior wall of the duodenal bulb. Note that the tip of the mushroom head has been cut ott. The 8 F feeding jejunostomy tube with the guide wire is seen coming through the duodenostomy tube into the small bowel.
Figure 2. Endoscopic photograph showing the 8 F feeding tube with the guide wire in the third portion of the duodenum. VOLUME 32, NO.5, 1986
placement of the duodenostomy tube was made by transillumination and palpation. Abdominal x-ray revealed that the feeding tube was in the jejunum, and enteral alimentation was started with Vital® High Nitrogen (Ross Laboratories). There were no complications encountered, and aspiration of liquid feeding did not occur. After 6 weeks of follow-up the tube was still working.
DISCUSSION
Since the first description of PEG,! other reports have addressed the diverse methods for placing feeding tubes using the percutaneous endoscopic technique. 2,3 Most of the literature dealing with percutaneous endoscopic placement of feeding tubes has advocated gastrostomy tube placement with or without small jejunal feeding tubes. However, none of these reports have examined the placement of feeding tubes in the duodenum using the percutaneous endoscopic technique. Our patient had a cervical esophagogastrostomy 2 years previously for esophageal carcinoma and developed recurrent bouts of aspiration. Technically speaking, PEG could not be performed due to the fact that the stomach was in the chest cavity. Furthermore, even if it were possible to perform a PEG, this patient had no lower esophageal sphincter and reflux with aspiration of liquid feeding would have been a problem. The use of the stomach for esophageal reconstruction in patients with resectable esophageal carcinoma has been infrequently required. In order to perform a cervical esophagogastrostomy, the stomach has to be mobilized so that it can be pulled up in the chest or neck. Furthermore, mobilization of the duodenum (Kocher maneuver) should also be performed to provide a greater length of stomach to be pulled up. This maneuver will prevent kinking of the duodenum and will allow the proximal duodenum to be displaced medially and upward. However, it should be kept in mind that the Kocher maneuver may bring the transverse colon anteriorly and, if entered, may be associated with the formation of a duodenocolonic fistula when the duodenostomy tube is placed percutaneously. Placement of the mushroom catheter in the anterior wall of the duodenal bulb at about 2 cm from the pylorus was accomplished using the same technique as that described by Ponsky and Gauderer for PEG.! However, we did not use an internal rubber bumper. The location of the end of the duodenostomy tube was made by transillumination and palpation. Despite the presence of a competent pylorus we decided that infusion of liquid feeding into the duodenal bulb still carried a risk for aspiration, so that an 8 F jejunostomy feeding tube was introduced through the duodenostomy tube into the small bowel. PEG following previous abdominal surgery has been described. 4 Stellato et al. 4 reported their experience 351
with PEG in 25 patients with previous abdominal surgery. However, none of the cases reported had a cervical esophagogastrostomy with the stomach pulled into the chest cavity. To our knowledge, there are no previous reports of PED. Certainly, the placement of duodenal feeding tubes using the percutaneous endoscopic technique is a procedure that should be performed by an experienced endoscopist and in selected cases such as the one described here.
REFERENCES 1. Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 1981;27:9-11. 2. Ponsky JL, Aszodi A. Percutaneous endoscopic jejunostomy. Am J GastroenteroI1984;79:113-6. 3. Gottfried EB, Plumser AB. Endoscopic gastrojejunostomy: a technique to establish small bowel feeding without laparotomy. Gastrointest Endosc 1984;30:355-7. 4. Stellato TA, Gauderer MWL, Ponsky JL. Percutaneous endoscopic gastrostomy following previous abdominal surgery. Ann Surg 1984;200:46-50.
Case Reports The endoscopic appearance of Burkitt's lymphoma involving the stomach and colon W. Michael Priebe, MD
Burkitt's lymphoma, a distinct histopathological entity, l seems to primarily involve the gastrointestinal tract in American patients2 - 4 and less commonly in African patients in whom jaw tumors predominate. 1 ,4, 5 The Epstein-Barr virus probably has etiologic significance in Africans, but the role of this virus in causing American Burkitt's lymphoma is less clear. 4 ,6 Because of the rarity of this undifferentiated malignant lymphoma of the B cell type, endoscopic descriptions are lacking. Colonoscopic and upper gastrointestinal endoscopic findings in a case of Burkitt's lymphoma involving the colon and stomach are presented.
CASE REPORT A 27-year-old welder noted episodic, severe, crampy, left upper quadrant and lower abdominal pain in June 1981. For the preceding 2 weeks he had also noted the passage of bright red blood with stools and a small volume of red blood between bowel movements. An outpatient barium enema demonstrated a 5-cm sessile, rounded mass filling the lumen in the splenic flexure and a second similar lesion in the proximal sigmoid colon. An upper gastrointestinal series was reported as normal. Physical examination on an August hospital admission was unremarkable. The hemoglobin was 10.3 gjdl. Colonoscopy revealed a smooth, polypoid, friable mass, 4 cm in diameter, in the proximal sigmoid colon. The surface was hard with shallow lobulation and a central umbilication; From St. Joseph Hospital and Health Care Center, Tocoma, Washington. Reprint requests: W. Michael Priebe, MD, Gastroenterology, 721 Fawcett, Suite 103, Tocoma, Washington 98402.
there was a light green hue to the tumor (Fig. 1). A second, slightly larger lesion with a similar appearance could be seen in the splenic flexure. The remainder of the colon was normal. Biopsies of both lesions revealed an undifferentiated small cell malignant tumor of uncertain etiology along with extensive superficial necrosis. A laparotomy demonstrated intussusception of the sigmoid colon lesion, but no evidence of extraintestinal tumor. An unexpected finding was a large mass involving the midbody of the stomach. Since resection would have resulted in a near total gastrectomy, the stomach was left in place and a left hemicolectomy was performed (Fig. 2). Histologic sections of both colonic lesions revealed monotonous sheaths of malignant round cells with interspersed histocytes giving the classical "starry sky" appearance of Burkitt's lymphomaS (Fig. 3). Mesenteric lymph node histology was normal. Upper gastrointestinal endoscopy postoperatively demonstrated a single "doughnut-shaped" mass, 6 cm in diameter, involving the mid-gastric body along the greater curvature with extension onto the anterior wall (Fig. 4). The margin was heaped up, irregular, and friable. A large, central, excavated ulcer crater was covered with a greenish yellow exudate. The mucosa proximal and distal to the mass was normal, as was the duodenum to the third portion. Biopsies of the tumor confirmed the presence of gastric Burkitt's lymphoma, but specimens proximal and distal to the mass showed only normal gastric epithelium. Over the ensuing months the patient received combination chemotherapy including cyclophosphamide, doxorubicin, vincristine, prednisone, intrathecal cytosine arabinoside, and high dose methotrexate with leucovorin rescue. At repeat upper gastrointestinal endoscopy in November 1981, the gastric mass had melted away, leaving only a small residual ulcer crater 0.5 cm in diameter with radiating gastric folds (Fig. 5). Biopsies of the ulcer margin showed only mild nonspecific gastritis. Follow-up endoscopy in March 1982, after completion of chemotherapy, revealed re-epithelization of the previous ulcer crater and persistent radiating gastric
Figure 1. Colonoscopic view of a 4-cm sessile mass in the sigmoid colon with a distinctive olive green color. The mass was later shown to be Burkitt's lymphoma. Figure 2. Left hemicolectomy specimen showing polypoid masses of Burkitt's lymphoma involving the splenic flexure and sigmoid colon. 352
GASTROINTESTINAL ENDOSCOPY
SUMMARY
A technique for expeditious and safe placement of nasoenteric feeding tubes under direct vision is described. Adult patients undergo feeding tube placement with intravenous sedation and topical anesthesia. Endoscopic tube placement requires an average of 10 min and eliminates many risks associated with blind passage. REFERENCES
Figure 2. Artist's depiction of the biopsy brush being advanced in the channel, pushing the feeding tube out the distal end of the scope. As the feeding tube is expelled, the endoscope is gradually withdrawn from the patient. Proper tube position is confirmed by continuous direct vision.
Percutaneous endoscopic duodenostomy Juan J. Alberti-Flor, MD Joseph L. Cochran, MD Steve Vaughan, GIA G. Dewey Dunn, MD
Esophagectomy with cervical esophagogastrostomy for esophageal carcinoma may be associated with a high rate of postoperative complications of which reflux and aspiration of gastric content are among the most common. The patient reported here had this operation performed 2 years previously and then developed recurrent bouts of aspiration due to the absence of the lower esophageal shincter and pull-through of the stomach into the chest cavity. In this patient, percutaneous endoscopic duodenostomy (PED) with a jejunal feeding tube (duodenojejunostomy) was successfully performed. This procedure may prove useful in patients with this operation who require long-term nutritional support. Received June 17, 1986. Accepted July 31, 1986. From the Department of Medicine (Gastroenterology), VanderbiLt University ScJwoL of Medicine, and Veterans Administration MedicaL Center, NashviLle, Tennessee. Reprint requests: Juan J. ALberti-FLor, MD, 951 SW 42 Avenue, Suite 302, Miami, Florida 33134.
350
1. Heymafield SB, Bethel RA, Ansley JD, et al. Enteral hyperalimentation: an alternative to central venous hyperalimentation. Ann Intern Med 1979;90:63-71. 2. Liston SL, Dickinson PB. Nasogastric intubation under fiberoptic endoscopic control. Laryngoscope 1984;94:258-9. 3. Schorlemmer GR, Battaglini JW. An unusual complication of naso-enteral feeding with small-diameter feeding tubes. Ann Surg 1984;199:104-6. 4. Hand RW, Kempster M, Levy JH, Rogol PR, Spirn P. Inadverent transbronchial insertion of narrow-bore feeding tubes into the pleural space. JAMA 1984;251(18):2396-7.
CASE REPORT
A 67-year-old man was admitted to the hospital for evaluation of aspiration and to consider the possibility of a percutaneous endoscopic feeding route. Past medical history was remarkable for esophagectomy with cervical esophagogastrostomy with pull-through of the stomach into the chest for esophageal carcinoma 2 years previously. Recently, the patient suffered recurrent bouts of reflux associated with aspiration. Physical examination revealed a well-developed, cachectic, chronically ill patient with a blood pressure of 120/70 mm Hg and no fever. Pertinent findings were confined to the abdomen. There was a well healed midabdominal scar without masses, ascites, or organomegaly. Laboratory tests revealed a hemoglobin level of 11.3 g and hematocrit of 33.6%. Platelet count, prothrombin time, and partial thromboplastin time were normal. Upper endoscopy was performed using pharyngeal anesthesia. The examination revealed that the area of the anastomosis of the esophagogastrostomy was located at approximately 15 em from the incisors. The anastomosis appeared normal. The stomach, pylorus, and duodenum were normal as well. Because of recurrent bouts of aspiration it was decided that the patient might benefit from percutaneous endoscopic gastrostomy (PEG) with a feeding jejunostomy tube. However, with the history of cervical esophagogastrostomy, the whole stomach had been pulled into the chest, and performing a PEG would have been impossible. For this reason, we GASTROINTESTINAL ENDOSCOPY
performed a percutaneous endoscopic duodenostomy (PED) with a jejunal feeding tube placed through the mushroom catheter (duodenojejunostomy). PED was performed as described by Ponsky and Gauderer l for PEG. A 16 F mushroom catheter was used, and the distal tip of the mushroom head was cut off. An internal rubber bumper was not used. After the mushroom catheter was placed in the anterior wall of the duodenal bulb at about 2 em from the pylorus (Fig. 1), an 8 F, 42-inch long feeding tube was introduced through the mushroom catheter using a 3 F guide wire. The 8 F feeding tube was grabbed inside the duodenal bulb with the biopsy forceps and advanced into the second and third portions of the duodenum (Fig. 2). The location of the
Figure 1. Endoscopic photograph of the mushroom head in the anterior wall of the duodenal bulb. Note that the tip of the mushroom head has been cut ott. The 8 F feeding jejunostomy tube with the guide wire is seen coming through the duodenostomy tube into the small bowel.
Figure 2. Endoscopic photograph showing the 8 F feeding tube with the guide wire in the third portion of the duodenum. VOLUME 32, NO.5, 1986
placement of the duodenostomy tube was made by transillumination and palpation. Abdominal x-ray revealed that the feeding tube was in the jejunum, and enteral alimentation was started with Vital® High Nitrogen (Ross Laboratories). There were no complications encountered, and aspiration of liquid feeding did not occur. After 6 weeks of follow-up the tube was still working.
DISCUSSION
Since the first description of PEG,! other reports have addressed the diverse methods for placing feeding tubes using the percutaneous endoscopic technique. 2,3 Most of the literature dealing with percutaneous endoscopic placement of feeding tubes has advocated gastrostomy tube placement with or without small jejunal feeding tubes. However, none of these reports have examined the placement of feeding tubes in the duodenum using the percutaneous endoscopic technique. Our patient had a cervical esophagogastrostomy 2 years previously for esophageal carcinoma and developed recurrent bouts of aspiration. Technically speaking, PEG could not be performed due to the fact that the stomach was in the chest cavity. Furthermore, even if it were possible to perform a PEG, this patient had no lower esophageal sphincter and reflux with aspiration of liquid feeding would have been a problem. The use of the stomach for esophageal reconstruction in patients with resectable esophageal carcinoma has been infrequently required. In order to perform a cervical esophagogastrostomy, the stomach has to be mobilized so that it can be pulled up in the chest or neck. Furthermore, mobilization of the duodenum (Kocher maneuver) should also be performed to provide a greater length of stomach to be pulled up. This maneuver will prevent kinking of the duodenum and will allow the proximal duodenum to be displaced medially and upward. However, it should be kept in mind that the Kocher maneuver may bring the transverse colon anteriorly and, if entered, may be associated with the formation of a duodenocolonic fistula when the duodenostomy tube is placed percutaneously. Placement of the mushroom catheter in the anterior wall of the duodenal bulb at about 2 cm from the pylorus was accomplished using the same technique as that described by Ponsky and Gauderer for PEG.! However, we did not use an internal rubber bumper. The location of the end of the duodenostomy tube was made by transillumination and palpation. Despite the presence of a competent pylorus we decided that infusion of liquid feeding into the duodenal bulb still carried a risk for aspiration, so that an 8 F jejunostomy feeding tube was introduced through the duodenostomy tube into the small bowel. PEG following previous abdominal surgery has been described. 4 Stellato et al. 4 reported their experience 351
with PEG in 25 patients with previous abdominal surgery. However, none of the cases reported had a cervical esophagogastrostomy with the stomach pulled into the chest cavity. To our knowledge, there are no previous reports of PED. Certainly, the placement of duodenal feeding tubes using the percutaneous endoscopic technique is a procedure that should be performed by an experienced endoscopist and in selected cases such as the one described here.
REFERENCES 1. Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 1981;27:9-11. 2. Ponsky JL, Aszodi A. Percutaneous endoscopic jejunostomy. Am J GastroenteroI1984;79:113-6. 3. Gottfried EB, Plumser AB. Endoscopic gastrojejunostomy: a technique to establish small bowel feeding without laparotomy. Gastrointest Endosc 1984;30:355-7. 4. Stellato TA, Gauderer MWL, Ponsky JL. Percutaneous endoscopic gastrostomy following previous abdominal surgery. Ann Surg 1984;200:46-50.
Case Reports The endoscopic appearance of Burkitt's lymphoma involving the stomach and colon W. Michael Priebe, MD
Burkitt's lymphoma, a distinct histopathological entity, l seems to primarily involve the gastrointestinal tract in American patients2 - 4 and less commonly in African patients in whom jaw tumors predominate. 1 ,4, 5 The Epstein-Barr virus probably has etiologic significance in Africans, but the role of this virus in causing American Burkitt's lymphoma is less clear. 4 ,6 Because of the rarity of this undifferentiated malignant lymphoma of the B cell type, endoscopic descriptions are lacking. Colonoscopic and upper gastrointestinal endoscopic findings in a case of Burkitt's lymphoma involving the colon and stomach are presented.
CASE REPORT A 27-year-old welder noted episodic, severe, crampy, left upper quadrant and lower abdominal pain in June 1981. For the preceding 2 weeks he had also noted the passage of bright red blood with stools and a small volume of red blood between bowel movements. An outpatient barium enema demonstrated a 5-cm sessile, rounded mass filling the lumen in the splenic flexure and a second similar lesion in the proximal sigmoid colon. An upper gastrointestinal series was reported as normal. Physical examination on an August hospital admission was unremarkable. The hemoglobin was 10.3 gjdl. Colonoscopy revealed a smooth, polypoid, friable mass, 4 cm in diameter, in the proximal sigmoid colon. The surface was hard with shallow lobulation and a central umbilication; From St. Joseph Hospital and Health Care Center, Tocoma, Washington. Reprint requests: W. Michael Priebe, MD, Gastroenterology, 721 Fawcett, Suite 103, Tocoma, Washington 98402.
there was a light green hue to the tumor (Fig. 1). A second, slightly larger lesion with a similar appearance could be seen in the splenic flexure. The remainder of the colon was normal. Biopsies of both lesions revealed an undifferentiated small cell malignant tumor of uncertain etiology along with extensive superficial necrosis. A laparotomy demonstrated intussusception of the sigmoid colon lesion, but no evidence of extraintestinal tumor. An unexpected finding was a large mass involving the midbody of the stomach. Since resection would have resulted in a near total gastrectomy, the stomach was left in place and a left hemicolectomy was performed (Fig. 2). Histologic sections of both colonic lesions revealed monotonous sheaths of malignant round cells with interspersed histocytes giving the classical "starry sky" appearance of Burkitt's lymphomaS (Fig. 3). Mesenteric lymph node histology was normal. Upper gastrointestinal endoscopy postoperatively demonstrated a single "doughnut-shaped" mass, 6 cm in diameter, involving the mid-gastric body along the greater curvature with extension onto the anterior wall (Fig. 4). The margin was heaped up, irregular, and friable. A large, central, excavated ulcer crater was covered with a greenish yellow exudate. The mucosa proximal and distal to the mass was normal, as was the duodenum to the third portion. Biopsies of the tumor confirmed the presence of gastric Burkitt's lymphoma, but specimens proximal and distal to the mass showed only normal gastric epithelium. Over the ensuing months the patient received combination chemotherapy including cyclophosphamide, doxorubicin, vincristine, prednisone, intrathecal cytosine arabinoside, and high dose methotrexate with leucovorin rescue. At repeat upper gastrointestinal endoscopy in November 1981, the gastric mass had melted away, leaving only a small residual ulcer crater 0.5 cm in diameter with radiating gastric folds (Fig. 5). Biopsies of the ulcer margin showed only mild nonspecific gastritis. Follow-up endoscopy in March 1982, after completion of chemotherapy, revealed re-epithelization of the previous ulcer crater and persistent radiating gastric
Figure 1. Colonoscopic view of a 4-cm sessile mass in the sigmoid colon with a distinctive olive green color. The mass was later shown to be Burkitt's lymphoma. Figure 2. Left hemicolectomy specimen showing polypoid masses of Burkitt's lymphoma involving the splenic flexure and sigmoid colon. 352
GASTROINTESTINAL ENDOSCOPY