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Autopsy findings after PEG
poor candidates for surgery or in whom surgery cannot be performed. The risk of developing this serious complication and the necessity for urgent, extensive surgical debridement to reduce mortality2 must encourage one to carefully examine the risk-benefit factors in patients undergoing PEG. Jacob Korula, MD, FRCPC
Harry E. Rice, MD Hepatology and Pulmonary Units University of Southern California School of Medicine Rancho Los Amigos Medical Center Downey, California
REFERENCES 1. Greif JM, Ragland JJ, Ochsner MG, Riding R. Fatal necrotizing fasciitis complicating percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:292-4. 2. Majeski JA, Alexander JW. Early diagnosis, nutritional support and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg 1983;145:784-7.
Autopsy findings after PEG To the Editor:
Figure 1. A, chest x-ray showing subcutaneous emphysema (arrows). Note the infiltrate of pulmonary tuberculosis in right mid-zone. B, Gastrografin~ study through the gastrostomy tube showing contrast within the stomach and without extragastric leak.
all of which were sensitive to the antibiotics administered. His condition deteriorated and he died 10 days after PEG placement. Permission for autopsy was refused. Gastrografin@ study on the eighth postoperative day demonstrated a satisfactory location of the gastrostomy, (Fig. IB) without evidence of a leak or fistula. Surgical debridement was not an option because both he and his family were opposed to his undergoing any surgical procedure. A number of important points emerge from this case. Necrotizing fasciitis is now a recognized complication and must be included as a serious and potentially fatal complication in the informed consent, especially in high risk patients such as the elderly with arteriosclerosis and obesity.2 It is conceivable that hypochlorhydria and the presence of bacteria in the stomach may have contributed to this septic complication. More importantly, in our patient, the same organisms isolated from the gastrostomy site were cultured from the urine some days prior to PEG placement; this urinary tract infection was incompletely treated. Bacteremia probably contributed to the development of this necrotizing infection where ischemia and impaired defense mechanisms related to renal failure were concurrent factors. PEG is particularly advantageous in patients who are 336
Percutaneous endoscopic gastrostomy (PEG) is rapidly becoming a major technique for the placement of gastrostomy tubes. 1 . 2 A major anatomic difference between PEG and standard surgical gastrostomy (Stamm) is the method by which the stomach is apposed to the anterior abdominal wall. Apposition in PEG results from pressure created by cross pieces attached to the gastrostomy tube. In surgical gastrostomy, the stomach is attached with four quadrant sutures. Thus, a major potential difference in anatomic result between these two procedures is the short- and longterm nature and strength of the fibrous adhesions at the point of apposition. We describe a patient who had undergone PEG and had a careful dissection of his PEG site at autopsy. A 71-year-old man underwent PEG for feeding. He had longstanding, severe, progressive Parkinson's disease and dementia. PEG was performed under light intravenous sedation and local anesthesia. A modified Ponsky technique was used to place an 18 F Sachs-Vine tube (Microvasive, Milford, Mass.). The patient tolerated the procedure well. There were no complications and the tube functioned properly. The patient died 130 days later of pneumonia and underwent autopsy. Particular attention was paid to the gastrostomy site at autopsy (Fig. 1). In addition to finding significant fibrous adherence, strong traction on the tube tract demonstrated that it was extremely difficult to physically separate the stomach from the anterior abdominal wall. The size and strength of adherence was similar to that seen in patients with Stamm gastrostomy undergoing autopsy. The results in this case suggest that fibrous adhesions of adequate strength develop after performance of PEG. This concept is supported by reports of favorable results of clinical experience. 2.3 The nature and time course of fibrous adherence after PEG and its comparison with surgically placed gastrostomy tubes will require further study. GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without a laparotomy: a percutaneous endoscopic technique. J Ped Surg 1980;15:872-5. 2. Foutch PG, Haynes WC, Bellapravalu S, Sanowski RA. Percutaneous endoscopic gastrostomy (PEG). A new procedure comes of age. J Clin GastroenteroI1986;8:1O-5. 3. Tanker MS, Scheinfeldt BD, Steerman PH, Goldstein M, Robinson G, Levine GM. A prospective randomized study comparing surgical gastrostomy and percutaneous endoscopic gastrostomy (abstract). Gastrointest Endosc 1986;32:144.
Endoscopic management of postsphincterotomy hemorrhage To the Editor:
Figure 1. A, apposed stomach (small arrows) with tube tract and adherent omentum (large arrow). The parietal peritoneal surface is marked with an asterisk. B, PEG catheter in situ. Gastric mucosa, black arrow; skin, white arrow. C, strong adherence demonstrated by placing traction on the partially incised tube tract. Gastric lumen, small arrow; tube tract, large arrow.
Howard K. Gogel, MD Turner Osler, MD Gerald Demerest, MD Departments of Medicine and Surgery University of New Mexico School of Medicine Albuquerque, New Mexico
VOLUME 33, NO.4, 1987
Significant hemorrhage after endoscopic sphincterotomy is a well recognized complication. When hemorrhage does not spontaneously cease, treatment involves further invasive evaluation and intervention. This communication describes the successful endoscopic management of an elderly patient with a major postsphincterotomy hemorrhage. A 97-year-old woman was admitted to Bridgeport Hospital with cholangitis. A cholecystectomy and common bile duct exploration had been performed 10 years prior. Physical examination demonstrated fever, icterus, and right upper quadrant tenderness. Dilated ducts were seen ultrasonographically. ERCP demonstrated multiple common bile duct stones, and endoscopic sphincterotomy was performed. Four calculi were retrieved; however, a 2-cm calculus could not be recovered. Three days later, the patient was returned to the radiology suite and the sphincterotomy incision was extended. The stone was extracted, but bleeding from the ampulla was noted. After 72 hours of continued bleeding unresponsive to conservative treatment including H2 blockers, carafate, antacids, and 12 units of packed red blood cell replacement, surgical intervention was entertained. Preoperative gastroscopy using the Olympus T -10 duodenoscope demonstrated continued bleeding from the ampulla. After perfusion with a 1:10,000 solution of epinephrine, the BICAP@ probe was threaded into the distal end of the open ampulla. BICAP@ cauterization was applied to the distal region. After prolonged observation confirming that bleeding had ceased, the procedure was terminated. The patient was observed in the hospital during the next week without signs of bleeding. Postprocedure hemorrhage is a well described complication of endoscopic sphincterotomy occurring in 2% to 5% of cases. 1 ,2 The majority of patients with this complication have self-limited bleeding, which can be controlled with blood replacement and appropriate observation. Bleeding may be clinically identified immediately or after a lapse of up to several days.1,3 Risk factors have reportedly been associated with repeated procedures but not with age. 1 Therapy has largely focused on surgical intervention to ligate the retroduodenal artery or to oversew the sphincterotomy site. The ability to perform endoscopic hemostasis in this 337
Harry E. Rice, MD Hepatology and Pulmonary Units University of Southern California School of Medicine Rancho Los Amigos Medical Center Downey, California
REFERENCES 1. Greif JM, Ragland JJ, Ochsner MG, Riding R. Fatal necrotizing fasciitis complicating percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:292-4. 2. Majeski JA, Alexander JW. Early diagnosis, nutritional support and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg 1983;145:784-7.
Autopsy findings after PEG To the Editor:
Figure 1. A, chest x-ray showing subcutaneous emphysema (arrows). Note the infiltrate of pulmonary tuberculosis in right mid-zone. B, Gastrografin~ study through the gastrostomy tube showing contrast within the stomach and without extragastric leak.
all of which were sensitive to the antibiotics administered. His condition deteriorated and he died 10 days after PEG placement. Permission for autopsy was refused. Gastrografin@ study on the eighth postoperative day demonstrated a satisfactory location of the gastrostomy, (Fig. IB) without evidence of a leak or fistula. Surgical debridement was not an option because both he and his family were opposed to his undergoing any surgical procedure. A number of important points emerge from this case. Necrotizing fasciitis is now a recognized complication and must be included as a serious and potentially fatal complication in the informed consent, especially in high risk patients such as the elderly with arteriosclerosis and obesity.2 It is conceivable that hypochlorhydria and the presence of bacteria in the stomach may have contributed to this septic complication. More importantly, in our patient, the same organisms isolated from the gastrostomy site were cultured from the urine some days prior to PEG placement; this urinary tract infection was incompletely treated. Bacteremia probably contributed to the development of this necrotizing infection where ischemia and impaired defense mechanisms related to renal failure were concurrent factors. PEG is particularly advantageous in patients who are 336
Percutaneous endoscopic gastrostomy (PEG) is rapidly becoming a major technique for the placement of gastrostomy tubes. 1 . 2 A major anatomic difference between PEG and standard surgical gastrostomy (Stamm) is the method by which the stomach is apposed to the anterior abdominal wall. Apposition in PEG results from pressure created by cross pieces attached to the gastrostomy tube. In surgical gastrostomy, the stomach is attached with four quadrant sutures. Thus, a major potential difference in anatomic result between these two procedures is the short- and longterm nature and strength of the fibrous adhesions at the point of apposition. We describe a patient who had undergone PEG and had a careful dissection of his PEG site at autopsy. A 71-year-old man underwent PEG for feeding. He had longstanding, severe, progressive Parkinson's disease and dementia. PEG was performed under light intravenous sedation and local anesthesia. A modified Ponsky technique was used to place an 18 F Sachs-Vine tube (Microvasive, Milford, Mass.). The patient tolerated the procedure well. There were no complications and the tube functioned properly. The patient died 130 days later of pneumonia and underwent autopsy. Particular attention was paid to the gastrostomy site at autopsy (Fig. 1). In addition to finding significant fibrous adherence, strong traction on the tube tract demonstrated that it was extremely difficult to physically separate the stomach from the anterior abdominal wall. The size and strength of adherence was similar to that seen in patients with Stamm gastrostomy undergoing autopsy. The results in this case suggest that fibrous adhesions of adequate strength develop after performance of PEG. This concept is supported by reports of favorable results of clinical experience. 2.3 The nature and time course of fibrous adherence after PEG and its comparison with surgically placed gastrostomy tubes will require further study. GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without a laparotomy: a percutaneous endoscopic technique. J Ped Surg 1980;15:872-5. 2. Foutch PG, Haynes WC, Bellapravalu S, Sanowski RA. Percutaneous endoscopic gastrostomy (PEG). A new procedure comes of age. J Clin GastroenteroI1986;8:1O-5. 3. Tanker MS, Scheinfeldt BD, Steerman PH, Goldstein M, Robinson G, Levine GM. A prospective randomized study comparing surgical gastrostomy and percutaneous endoscopic gastrostomy (abstract). Gastrointest Endosc 1986;32:144.
Endoscopic management of postsphincterotomy hemorrhage To the Editor:
Figure 1. A, apposed stomach (small arrows) with tube tract and adherent omentum (large arrow). The parietal peritoneal surface is marked with an asterisk. B, PEG catheter in situ. Gastric mucosa, black arrow; skin, white arrow. C, strong adherence demonstrated by placing traction on the partially incised tube tract. Gastric lumen, small arrow; tube tract, large arrow.
Howard K. Gogel, MD Turner Osler, MD Gerald Demerest, MD Departments of Medicine and Surgery University of New Mexico School of Medicine Albuquerque, New Mexico
VOLUME 33, NO.4, 1987
Significant hemorrhage after endoscopic sphincterotomy is a well recognized complication. When hemorrhage does not spontaneously cease, treatment involves further invasive evaluation and intervention. This communication describes the successful endoscopic management of an elderly patient with a major postsphincterotomy hemorrhage. A 97-year-old woman was admitted to Bridgeport Hospital with cholangitis. A cholecystectomy and common bile duct exploration had been performed 10 years prior. Physical examination demonstrated fever, icterus, and right upper quadrant tenderness. Dilated ducts were seen ultrasonographically. ERCP demonstrated multiple common bile duct stones, and endoscopic sphincterotomy was performed. Four calculi were retrieved; however, a 2-cm calculus could not be recovered. Three days later, the patient was returned to the radiology suite and the sphincterotomy incision was extended. The stone was extracted, but bleeding from the ampulla was noted. After 72 hours of continued bleeding unresponsive to conservative treatment including H2 blockers, carafate, antacids, and 12 units of packed red blood cell replacement, surgical intervention was entertained. Preoperative gastroscopy using the Olympus T -10 duodenoscope demonstrated continued bleeding from the ampulla. After perfusion with a 1:10,000 solution of epinephrine, the BICAP@ probe was threaded into the distal end of the open ampulla. BICAP@ cauterization was applied to the distal region. After prolonged observation confirming that bleeding had ceased, the procedure was terminated. The patient was observed in the hospital during the next week without signs of bleeding. Postprocedure hemorrhage is a well described complication of endoscopic sphincterotomy occurring in 2% to 5% of cases. 1 ,2 The majority of patients with this complication have self-limited bleeding, which can be controlled with blood replacement and appropriate observation. Bleeding may be clinically identified immediately or after a lapse of up to several days.1,3 Risk factors have reportedly been associated with repeated procedures but not with age. 1 Therapy has largely focused on surgical intervention to ligate the retroduodenal artery or to oversew the sphincterotomy site. The ability to perform endoscopic hemostasis in this 337