⁎4741 Outcome after percutaneous endoscopic gastrostomy in patients with bulbar and spinal amyotrophic lateral sclerosis.

*4741 OUTCOME AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN PATIENTS WITH BULBAR AND SPINAL AMYOTROPHIC LATERAL SCLEROSIS. Etta Finocchiaro, Rosalba Galletti, Adriano Chio’, Marina Rivetti, Maurizio Fadda, Claudio De Angelis, Claudio Barletti, Alessandro Musso, Patrizia Carucci, Wilma Debernardi, Giorgio Saracco, Molinette Hosp, Torino, Italy. Background and aim: Dysphagia occurs in the last phase of the course of ASL and is associated with an adverse prognosis. PEG has been proposed as symptomatic treatment of dysphagia in patients with both bulbar and spinal ASL. The aim of our study was to evaluate the effects of PEG placement and to describe long-term nutritional status and survival of ASL patients. Methods: Since January 1993, 49 patients (19M/30F), mean age 61.7 years (range 33-77) with bulbar (25) and spinal (24) ASL were enrolled in the study and underwent PEG after a median time of 163 from dysphagia onset. Forced Vital Capacity (FVC), Norris scale, weight loss (WL), body mass index (BMI), serum prealbumin, albumin, trasnferrin, daily energy and protein intake were evaluated every two months in the follow-up period. Results: PEG was successfully placed in all patients. Three patients received a 9 Fr enteral tube, 38 a 14 Fr and 8 a 20 Fr. There were no procedure-related complications or 30-day mortality. The median body weight improved from 54.4+Kg at the time of PEG to 62.5+.8 Kg at six months follow-up. The median survival after PEG was 185 days (range 31-1080 days). Death was always related to respiratory failure. In univariate analysis factors influencing the survival after PEG were WL% (WL>10% median survival 116 days, WL<10% median survival 305 days, p=0.008) and FVC% (FVC<65% median survival 138 days, FVC>65% median survival 241 days, p=0.04). No statistically significant differences were observed in terms of survival in patients with bulbar and spinal ASL. In patients in whom PEG was placed within six months from the onset of dysphagia there was a trend toward a longer survival in comparison with patients who had PEG six months later than the onset of dysphagia. Conclusions: PEG represents a safe and effective method for the management of ASL patients who develop dysphagia. WL > 10% and FVC<65% at the time of PEG are related to a worse prognosis. No differences in survival were recorded between bulbar and spinal ASL. Early placement of PEG could improve survival in ASL patients who develop dysphagia. *4742 TECHNIQUE AND OUTCOME OF PERCUTANEOUS ENDOSCOPIC ENTEROSTOMY AFTER TOTAL GASTRECTOMY. Teruyuki Usuba, Yutaka Suzuki, Yoshio Ishibashi, Nobuo Omura, Fumiaki Yano, Hideyuki Kashiwagi, Nobuyoshi Hanyu, Hiroaki Suzuki, Teruaki Aoki, The JIkei Univ Sch of Medicine, Tokyo, Japan; Jikei Univ Sch of Medicine, Tokyo, Japan. Introduction: Since Ponsky, Gauderer first reported in 1980, PEG has spread rapidly in US and has now becomestandarde a procedure gastrostomy. However, in those d Europe cases that total gastrectomy have was performed, endoscopic jejunostomy was regarded contra-indication. As performed Percutaneous Endoscopic Enterostomy for those patients who underwent total gastrectomy we actively, we report success rate, preoperative tests, perioperative technique, complication, long term prognosis. Subject and Method: The subjects we have tried PEE are 30 cases (sex: 18 cases of male, 12 cases of female, age 64.5 yrs. Old (36~84 yrs. Old)). The purpose of making PEE was 18 cases of feeding, 12 cases of decompression. The reconstruction method of total gastrectomy was, 26 cases of Roux-en Y(posterior colon), 1 case of Roux-en Y (anterior colon), 2 cases of Ileo-colon interposition, 1 case of small intestine interposition. As a rule preoperative test included abdominal x-ray in supine positionand gastrography test of gastrointestine and abdominal CT test upon intubating stomach tube or injectinggastrographine. Similar to PEG procedure, PEE was made with the same kit (24 Fr One-Step Button) in the pull methodunder local anesthetic. In order to decide thepuncture site and to avoid erroneous puncture in enteral, we performed fiber light test(illumination) to observe the light emitted from endoscope through the abdominal wall, finger push test to see the pressureapplied onto the abdominal wall by finger at the expected puncturesite, water injection test to inject water throughendoscope and observe the enteral tract with extracorporeal ultrasonic. After the operation as a rule prophilactic antibiotec was administered for 3 days, and nutrition was started from the third day. 16 Fr N-G tube for decompression was intubated through the enterostomy button. Result: PEE procedure was possible in 23 cases (.7%), puncture of enteral tract were 21 cases in jejunum, 1 case of duodenum and 1 case of large bowel. The average operating time was 22.8 min. (16~42 min.) and complications were 6 cases of peristomal infection (26.1%), 4 cases of furyonikuge (17.4%) and 1 case of peristomal pain (4.3%) which were relatively minor kind and there was no serious complication. Average survival day was 192.5 days (20~565 days) and 14 patients (60.9%) were transferred to home care. Conclusion: With

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careful preoperative test and proper operating procedure, PEE is considered safe method and offers substantial clinical merits. *4743 PERCUTANEOUS ENDOSCOPIC GASTROSTOMY FEEDING TUBES IN HUNTINGTON’S DISEASE. Sushma Saksena, Stephanie White, Sue Clark, A. Torrance, Pat Bottrill, Margaret Atkins, Lynn Davison, W. Barker, Ken Matthewson, Royal Victoria Infirmary, Newcastle, United Kingdom; Collingwood Psychiatric Clin, Newcastle, United Kingdom. Percutaneous endoscopic gastrostomy (PEG) is widely used in patients with neurogenic dysphagia but there are no published series in patients with Huntington’s disease (HD). We retrospectively reviewed all patients with HD attending the department for PEG insertion or follow up by reviewing case records from endoscopy, psychiatry follow up clinics and nursing homes. 17 patients with HD were assessed. Carers of two refused permission while the third patient was capable of maintaining steady weight and kept under review. PEGS were inserted in 14 patients (6 males, 8 females, age range 33-65). The median interval between presentation and PEG insertion was 62 months (3-216 months). Indications for PEG insertion were significant weight loss in 10, difficult oral feeding in 11 and recurrent aspiration pneumonia in 1. Early complications included tube dislodgment in 5 of which 1 patient died of peritonitis on the first day, the other 4 settling on conservative treatment. Late complications included: granulation tissue around stoma (5), tube dislodgment with closure of the tract (1), peritoneal leak which settled on conservative therapy (1) and snapped PEG button (1). The first 11 patients had a “Corflo” PEG placed initially; and following tube displacement they were replaced with button type PEGS, none of which have been dislodged. The final 3 patients had one step buttons as their initial insertion and none have been dislodged. 10/14 patients and 9/ 13 carers felt their quality of life had improved following PEG. 3 patients died from aspiration pneumonia (7 months), perforated gastric ulcer (14 months) and pancreatitis (3 years). PEG placement was perceived beneficial by majority of patients and carers especially the button type, which had a lower risk of dislodgment. Appropriate timing of PEG placement may help in maximizing benefits and minimizing morbidity and mortality. *4744 ENDOSCOPIC SMALL INTESTINE BIOPSY: COMPARISON OF TWO TECHNIQUES. Rafael Amaro, Jack Lubin, Jamie S. Barkin, Univ of Miami, Miami Beach, FL; Dept of Pathology and Lab Medicine - U of Miami, Miami Beach, FL. Background: The importance of histologic interpretation to establish the diagnosis of diseases affecting the small bowel is well recognized. There is no consensus regarding enteroscopic biopsy technique and the number of biopsies required to enable an adequate histologic diagnosis. Purpose: To assess the utility of endoscopically obtained biopsies in the histologic evaluation of the small bowel and to compare the quality of biopsies obtained taking one piece (“single-bite”) versus two pieces (“double-bite”) with a single passage of the forceps. Methods: Patients undergoing push enteroscopy (Olympus SIF-100) requiring small bowel biopsies were included in the study. A standard biopsy forceps with serrated jaws and central needle (Boston Scientific/Microvasive, Watertown, MA) was utilized. A total of nine specimens were taken from each patient: three “single-bite” and three “double-bite” biopsies in alternative fashion. A specimen was considered adequate for interpretation if contained full thickness mucosa with two or more contiguous, complete, and well oriented villous-crypt gland complexes, and there was no interference due to squashing or fragmentation. Specimens from each patient were evaluated individually for the above criteria and as a group to assess suitability to make a histological diagnosis. Results: Thirty patients were included in the study for an expected total of 270 biopsy specimens. All 90 “single-bite” (100%) but only 153/180 (85%) expected “double-bite” specimens were recovered (p<0.005). 57/90 (63%) “single-bite” and 69/153 (45%) “double-bite” specimens were adequate for histologic interpretation (p<0.05). Biopsies were severely squashed/fragmented in 26/90 (28%) “single-bite” and 64/153 (42%) “double-bite” specimens (NS). Muscularis mucosa was present in 63/90 (70%) “single-bite” and 86/153 (56%) “double-bite” specimens (p<0.05). As a group, “singlebite” and “double-bite” specimens failed to give a diagnosis in 1/30 (3%) and 6/30 (20%) patients respectively (NS). A histologic diagnosis could be made in all patients, using combination of “single” and “double” bite biopsies. Conclusion: Enteroscopically obtained biopsies are adequate for evaluation of small bowel histology. “Single-bite” biopsy technique yields significantly better specimens for histologic interpretation with minimal loss of specimens versus “double-bite” technique. More than three specimens utilizing “single-bite” biopsy technique should be obtained to allow histologic evaluation of the small bowel.

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