Facilitation of placement of jejunal feeding tubes utilizing the detachable snare

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Abstracts

AJG – Vol. 96, No. 9, Suppl., 2001

Methods: 120 patients were randomized to receive IL-10 (20 ␮g/kg IV) or placebo 15 minutes prior to ERCP. The 1° endpoint was incidence of clinical pancreatitis. The 2° endpoints were incidence of biochemical pancreatitis and severity of post-ERCP pancreatitis. Results: 119 of 120 patients were evaluable for clinical pancreatitis. 109 of 120 patients were evaluable for biochemical pancreatitis. Placebo

IL-10

Clinical pancreatitis 6.7% (n ⫽ 8) 8.8% (n ⫽ 6) 3.9% (n ⫽ 2) Biochemical pancreatitis 28% (n ⫽ 30) 29.8% (n ⫽ 20) 19.6% (n ⫽ 10) Severity 4 mild, 1 mod, 1 severe 1 mild, 1 mod Hosp Days (d) 6.7 d 3.5 d P Value P ⬎ .05 P ⬎ .05

Conclusions: IL-10 appears to reduce the incidence and severity of postERCP pancreatitis. A larger cohort of patients will be studied to ensure statistical significance. Supported in part by a research grant from Schering-Plough Research Institute. 193 Facilitation of placement of jejunal feeding tubes utilizing the detachable snare Manoj K. Mehta, M.D., Evanston Hospital, Evanston, IL. Gastroparesis, severe reflux, vomiting, and other situations with risk for aspiration may warrant the placement of a jejunal feeding tube in cases considered otherwise typically ideal for gastric tube feedings. Placement of a jejunal extension thru a PEG (PEG/J), or endoscopically assisted placement of a nasoenteral feeding tube may be appropriate in these settings. Avoiding gastric looping, or withdrawal of the device while removing the endoscope, appear to be major technical frustrations. A method is described which utilizes the Detachable Loop Ligation Device (Olympus®), or detachable snare. The technique for both the endoscopy-assisted nasoenteral tubes and the PEG/J’s are similar. After passage of the jejunal tube into the stomach thru either a PEG or transnasally, the endoscope is passed into the stomach and the tip of the enteric tube identified. The string at the tip is grasped using a detachable loop passed thru the scope. The scope, snare, and enteral tube, are then pushed down into the small bowel as far as possible. Looping is absent due to the traction effect. At this point the scope is exchanged for the snare and enteral tube by pulling the scope back into the stomach while feeding the snare forward. When the scope is out of the pylorus (for PEG cases) or out of the mouth (for nasoenteral cases), the detachable snare can be released. The snare catheter can generally be pulled out without dislodging the tube out of the small bowel. As most endoscopists are aware, the same cannot be said for an endoscope pulling thru the pylorus or the esophagus with a feeding tube alongside. Nine cases (7 PEG/J, 2 nasoenteral) have progressed uneventfully. Gastric looping was not encountered or easily remedied endoscopically. Six PEG/J-tubes were done without fluoroscopy; the 7th used fluoro as there was Billroth II anatomy. Fluoroscopy is recommended for nasoenteral tube placement due to the long length between the pylorus and mouth, where direct confirmation of placement of the tube into the pylorus without migration cannot be visually observed. Comparison of outcomes with this approach, such as procedure length and other benefits, is warranted via ongoing study. 194 Gastroparesis occuring post resection of a gastrointestinal stromal tumor arising from the interstitial cells of cajal (gastric pacemaker cells) Corey Saltin D.O2, Riad Azar MD1, Wahid Wassef MD1*, Barbara Banner MD3, Karen Strehlow MD3 and Savant Mehta MD1. 1Division of Gastroenterology, UMASS Medical Center, Worcester, MA, United States; 2 Medicine, UMASS Medical Center, Worcester, MA, United States; and 3 Pathology, UMASS Medical Center, Worcester, MA, United States.

Case Report: A 70 year old male presented with worsening heartburn and burping despite several months of treatment with an H2-blocker. Patient denied dysphagia, weight loss, alcohol abuse or chronic NSAID use. Physical exam was unremarkable except for a rectal exam which revealed guaiac positive stool. Laboratory data was significant for an initial hemoglobin level of 14.1 gm/dl which subsequently fell to 12.6 gm/dl. An UGI series revealed a polypoid mass in the proximal stomach along with a hiatal hernia with free reflux and no evidence of delayed gastric emptying. EGD findings were significant for grade I esophagitis, gastritis, duodenitis and a pedunculated smooth mass on the posterior wall of the proximal stomach. A mucosal pinch biopsy revealed non-neoplastic gastric mucosa on pathology. At this point, the patient was referred to us for further evaluation and underwent and EGD and an endoscopic ultrasound examination. This revealed a single pedunculated smooth mass visualized at the body of the stomach near the fundus. By EUS, it appeared as a hypoechoic, homogenous, well-defined intramural lesion originating from the muscularis propria and measuring 30 mm in diameter. These findings were consistent with a pedunculated leiomyoma. Patient subsequently underwent a laparoscopic gastrotomy with local resection of the mass. Results: Surgical pathology revealed a gastrointestinal stromal tumor. On further analysis of the immunophenotype it stained strongly for CD34, C-kit and Vimentin and was negative for S-100 protein, NSE, Smooth muscle actin, Desmin and low molecular keratin with a Ki-67 positivity of 4%. This was strongly suggestive of differentiation toward the interstitial cells of Cajal. Four months post resection, he underwent a push enteroscopy to evaluate persistent guaiac positive stools and worsening anemia (Hgb 13gm%). This revealed a large gastric bezoar suggestive of gastroparesis. There was no obstructive lesion found in the small bowel on push enteroscopy. Conclusions: The interstitial cells of Cajal are found in the deep gastrointestinal circular smooth muscle layer. They are believed to function as the pacemaker cells for the GI tract thereby regulating gastrointestinal motility. The resection of these gastric “pacemaker” cells in this patient probably led to gastroparesis.

195 Improvement of gastric atrophy after Helicobacter pylori eradication Hiroto Miwa, M.D., F.A.C.G., Toshio Yamada, M.D., Shu Hirai, M.D., Ryuichi Ohkura, M.D., Toshihumi Ohkusa, M.D., Nobuhiro Sato, M.D. Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan. Background and Aim: Whether gastric atrophy is reversible after H. pylori eradication remains controversial. To determine if gastric atrophy improves after H. pylori eradication we examined histological features in gastric biopsy specimens obtained from clinical patients before and after H. pylori eradication compared to those from control patients who did not receive H. pylori treatment. Methods: The treatment group included 87 patients cured of H. pylori infection (31 males and 56 females; age 52.6 ⫾ 1.2 yrs). The control group included 29 H. pylori-infected patients who had not received any H. pylori treatment (14 males and 15 females; age 57.1 ⫾ 2.1 yrs). Subjects in the treatment and control groups were followed for 12– 49 (mean 22 months) and 12–50 months (mean 22 months), respectively. Gastric biopsies of antrum and corpus were obtained at endoscopy from treatment and control groups at baseline and during the observation period. Histological features (activity, inflammation, atrophy, intestinal metaplasia) were scored according to the updated Sydney classification by a pathologist (S.H.) blinded to subject clinical status. Statistical analysis was done with student’ t test, Wilcoxon rank sum test. Results: There were no statistical differences in the histology scores between the two groups at the beginning of the study (pretreatment). As expected, scores for activity and inflammation were significantly improved in the H. pylori treatment group but not in the control group. The atrophy score was significantly improved in the corpus (mean score: 1.16 to 0.55,