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Mushroom poisoning and auxiliary partial orthotopic liver transplantation
1272
Letters to the Editor
AJG – Vol. 97, No. 5, 2002
breath hydrogen profile obtained after ingesting a solid meal containing unabsorbable carbohydrate. Gut 1985;26:834 – 42. 6. Kondo T, Liu F, Toda Y. Milk is a useful test meal for measurement of oro-cecal transit time. J Gastroenterol 1994; 29:715–20.
Reprint requests and correspondence: Takaharu Kondo, M.D., Ph.D., Research Center of Health, Physical Fitness and Sports, Nagoya University, Chikusa-ku, Furo-cho, Nagoya 464-8601, Japan. Received Dec. 11, 2001; accepted Dec. 12, 2001.
Mushroom Poisoning and Auxiliary Partial Orthotopic Liver Transplantation Figure 1. Skin and breath hydrogen levels before and after lactulose loading (n ⫽ 6). Hydrogen levels of the hand were 1/1000 of breath levels. 0 min ⫽ before loading lactulose. *p ⬍ 0.05 compared with the prelactulose time 0 level per paired t test after analysis of variance.
lection of gases from the skin should be made readily available. Takaharu Kondo, M.D., Ph.D. Takao Tsuda, D. Eng. Kazutoshi Nose Hiroshi Ishiguro, M.D., Ph.D. Takahiro Mitsui, Ph.D. Kai-Ping Gao Kotoyo Fujiki Research Center of Health, Physical Fitness and Sports Nagoya University Nagoya Department of Applied Chemistry Nagoya Institute of Technology Nagoya, Japan
REFERENCES 1. Levitt MD, Donaldson RM. Use of respiratory hydrogen (H2) excretion to detect carbohydrate malabsorption. J Lab Clin Med 1970;75:937– 45. 2. Newcomer AD, Thomas PJ, McGill DB, et al. Lactase deficiency: A common genetic trait of the American Indian. Gastroenterology 1977;72:234 –7. 3. Stotzer PO, Kilander AF. Comparison of the 1-gram (14)C-Dxylose breath test and the 50-gram hydrogen glucose breath test for diagnosis of small intestinal bacterial overgrowth. Digestion 2000;61:165–71. 4. King CE, Toskes PP. Breath tests in the diagnosis of small intestine bacterial overgrowth. Crit Rev Clin Lab Sci 1984;21: 269 – 81. 5. Read NW, Al-Janabi MN, Bates TE, et al. Interpretation of the
TO THE EDITOR: I read with interest the article by Broussard et al. that appeared in the November issue (1). I have been involved in the management of several children with Amanita phalloides mushroom ingestion during my practice of pediatric hepatology and liver transplantation in California. Although the case report nicely summarized the spectrum of the disorder, the discussion failed to mention the option of auxiliary liver transplantation for toxic mushroom ingestion (2). Although orthotopic liver transplantation is clearly a lifesaving procedure for patients with fulminant hepatic failure secondary to mycetismus, it is associated with the need for lifelong immunosuppression to prevent rejection of the graft. Auxiliary partial orthotopic liver transplantation is a procedure whereby only a portion of the native liver is removed, and the remainder of the native liver is left in situ (3). Auxiliary partial orthotopic liver transplantation can provide temporary support until the native liver recovers and immunosuppression can be withdrawn. Long term follow-up (⬎4 yr) in my patient with mushroom poisoning in which this procedure was used reveals no evidence of hepatic dysfunction with normal liver function, and no need for immunosuppression. Mushroom poisoning is rare enough such that prognostic criteria are not well established. As the authors correctly indicate, there is a lack of controlled trials for therapy. The extent of hepatic injury might be expected to influence outcome because liver regeneration is required for ultimate recovery without transplantation. Surviving hepatocytes, even if few in number, have the potential for extensive regeneration with time and the potential for complete recovery of the native liver. From my experience, emergency auxiliary partial orthotopic liver transplantation is a therapeutic option for fulminant hepatic failure from poison mushroom ingestion. Philip Rosenthal, M.D., F.A.C.G. Pediatric Liver Transplant Program University of California, San Francisco San Francisco, California
AJG – May, 2002
REFERENCES 1. Broussard CN, Aggarwal A, Lacey SR, et al. Mushroom poisoning-from diarrhea to liver transplantation. Am J Gastroenterol 2001;96:3195– 8. 2. Rosenthal P, Roberts JP, Ascher NL, Emond JC. Auxiliary liver transplant in fulminant failure. Pediatrics 1997;100(2):E11. 3. Chenard-Neu MP, Boudjema K, Bernuau J, et al. Auxiliary liver transplantation: Regeneration of the native liver and outcome in 30 patients with fulminant hepatic failure—a multicenter European study. Hepatology 1996;23:1119 –27. Reprint requests and correspondence: Philip Rosenthal, M.D., F.A.C.G., Pediatric Liver Transplant Program, University of California, San Francisco, 500 Parnassus Avenue, Box 0136, MU 4-East, San Francisco, CA 94143– 0136. Received Dec. 14, 2001; accepted Dec. 26, 2001.
A Pilot Study of Transnasal Percutaneous Endoscopic Gastrostomy TO THE EDITOR: This is a follow-up letter to our previously published report of transnasal percutaneous endoscopic gastrostomy (T-PEG) using a pediatric endoscope in two cases of oropharyngeal obstruction (1). We subsequently performed a pilot study to determine the feasibility of T-PEG, particularly in patients with oropharyngeal obstruction due to head and neck cancer. Patients in whom consultation was requested for PEG placement because of potential oropharyngeal obstruction or dysphagia were considered. Patients were excluded if they could not fill out the postprocedure questionnaire or if they had any of the usual contraindications for PEG placement including ascites, obstructing hepatosplenomegaly, uncorrectable coagulopathy, and active systemic infection of cardiopulmonary instability. All eligible patients had the nature of the procedure, risks, and benefits explained before the procedure and signed a research consent form approved by the institutional review board. The study protocol was approved by the board in May, 2000. Patients were randomized by drawing a sealed envelope that contained a preassigned placement route, to either transoral or transnasal PEG placement. The primary study outcome was feasibility. Descriptive characteristics of the patients and endoscopists were recorded. Preprocedure information obtained included baseline demographic information and indication. Data obtained during endoscopy included time of procedure, amount of sedation given, and success of placement. Patients were monitored in the hospital for at least 23 h for immediate complications including bleeding, infection, or perforation. Patients and physicians filled out validated postprocedure questionnaires (2). The patient questionnaire inquired about discomfort on insertion, during the procedure, and overall. Patients were asked to score their responses on a scale from 0 to 10, with 0 being none and 10 equaling severe. The physician questionnaire asked about the optical
Letters to the Editor
1273
quality of the exam and comfort during performance of the procedure. Physicians were asked to score their responses on a scale from 10 to 0, with 10 equaling excellent and 0 meaning inability to perform the exam. At 4 wk all patients were followed up with a phone call to monitor for complications. A pediatric upper endoscope was used (GIF-XP20, Olympus, Lake Success, NY) for PEG placement with a standard push technique either through the mouth or via the nares. A 20F gastrostomy kit was used with a pediatric snare (Microvasive Gastrodome, Boston Scientific, Watertown, MA). Preprocedure antibiotics were given to all patients. Fifteen patients needing PEG placement were prospectively randomized to either a transnasal or a transoral technique. Thirteen patients were enrolled, and two declined to enter. Six patients were randomized to transnasal placement. Nine patients (69%) had head and neck cancer. PEG was placed successfully in three of six in the transnasal group and six of seven patients in the transoral group (p ⫽ 0.3). There were no immediate complications. Mean procedure time and sedation use were similar. Patients reporting any discomfort on insertion were two of six versus none of seven (p ⫽ 0.5), overall patient discomfort was two of six versus two of seven (p ⫽ 0.6), optical quality of the exam was 9.2 versus 9.3 (p ⫽ 0.9), and physician comfort was 8.2 versus 8.7 (p ⫽ 0.2) for transnasal and transoral placement, respectively. One transoral patient had self-limited bleeding at the PEG site in the follow-up period. In conclusion, we have conducted the first study of transnasal percutaneous endoscopic gastrostomy. This pilot study shows that T-PEG is feasible, particularly in patients with oropharyngeal obstruction. T-PEG did not have any long term complications. Recent concern over complications of PEG placement in patients concurrently receiving chemoradiotherapy was not seen (3). The main limitation of T-PEG was passage of scope beyond the nares. More experience and the use of a smaller diameter endoscope, which is now available, may improve scope passage in the future. Alexander M. Lustberg, M.D. Peter E. Darwin, M.D. University of Maryland Medical Center Baltimore, Maryland
REFERENCES 1. Lustberg A, Fleisher AS, Darwin PE. Transnasal placement of percutaneous endoscopic gastrostomy with a pediatric endoscope in oropharyngeal obstruction. Am J Gastroenterol 2001; 96:936 –7. 2. Zaman A, Hahn M, Hapke R, et al. A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin videoendoscope. Gastrointest Endosc 1999;49:279 – 84. 3. Ratnakar N, Brown RD, Venu RP. PEG placement for head and
Letters to the Editor
AJG – Vol. 97, No. 5, 2002
breath hydrogen profile obtained after ingesting a solid meal containing unabsorbable carbohydrate. Gut 1985;26:834 – 42. 6. Kondo T, Liu F, Toda Y. Milk is a useful test meal for measurement of oro-cecal transit time. J Gastroenterol 1994; 29:715–20.
Reprint requests and correspondence: Takaharu Kondo, M.D., Ph.D., Research Center of Health, Physical Fitness and Sports, Nagoya University, Chikusa-ku, Furo-cho, Nagoya 464-8601, Japan. Received Dec. 11, 2001; accepted Dec. 12, 2001.
Mushroom Poisoning and Auxiliary Partial Orthotopic Liver Transplantation Figure 1. Skin and breath hydrogen levels before and after lactulose loading (n ⫽ 6). Hydrogen levels of the hand were 1/1000 of breath levels. 0 min ⫽ before loading lactulose. *p ⬍ 0.05 compared with the prelactulose time 0 level per paired t test after analysis of variance.
lection of gases from the skin should be made readily available. Takaharu Kondo, M.D., Ph.D. Takao Tsuda, D. Eng. Kazutoshi Nose Hiroshi Ishiguro, M.D., Ph.D. Takahiro Mitsui, Ph.D. Kai-Ping Gao Kotoyo Fujiki Research Center of Health, Physical Fitness and Sports Nagoya University Nagoya Department of Applied Chemistry Nagoya Institute of Technology Nagoya, Japan
REFERENCES 1. Levitt MD, Donaldson RM. Use of respiratory hydrogen (H2) excretion to detect carbohydrate malabsorption. J Lab Clin Med 1970;75:937– 45. 2. Newcomer AD, Thomas PJ, McGill DB, et al. Lactase deficiency: A common genetic trait of the American Indian. Gastroenterology 1977;72:234 –7. 3. Stotzer PO, Kilander AF. Comparison of the 1-gram (14)C-Dxylose breath test and the 50-gram hydrogen glucose breath test for diagnosis of small intestinal bacterial overgrowth. Digestion 2000;61:165–71. 4. King CE, Toskes PP. Breath tests in the diagnosis of small intestine bacterial overgrowth. Crit Rev Clin Lab Sci 1984;21: 269 – 81. 5. Read NW, Al-Janabi MN, Bates TE, et al. Interpretation of the
TO THE EDITOR: I read with interest the article by Broussard et al. that appeared in the November issue (1). I have been involved in the management of several children with Amanita phalloides mushroom ingestion during my practice of pediatric hepatology and liver transplantation in California. Although the case report nicely summarized the spectrum of the disorder, the discussion failed to mention the option of auxiliary liver transplantation for toxic mushroom ingestion (2). Although orthotopic liver transplantation is clearly a lifesaving procedure for patients with fulminant hepatic failure secondary to mycetismus, it is associated with the need for lifelong immunosuppression to prevent rejection of the graft. Auxiliary partial orthotopic liver transplantation is a procedure whereby only a portion of the native liver is removed, and the remainder of the native liver is left in situ (3). Auxiliary partial orthotopic liver transplantation can provide temporary support until the native liver recovers and immunosuppression can be withdrawn. Long term follow-up (⬎4 yr) in my patient with mushroom poisoning in which this procedure was used reveals no evidence of hepatic dysfunction with normal liver function, and no need for immunosuppression. Mushroom poisoning is rare enough such that prognostic criteria are not well established. As the authors correctly indicate, there is a lack of controlled trials for therapy. The extent of hepatic injury might be expected to influence outcome because liver regeneration is required for ultimate recovery without transplantation. Surviving hepatocytes, even if few in number, have the potential for extensive regeneration with time and the potential for complete recovery of the native liver. From my experience, emergency auxiliary partial orthotopic liver transplantation is a therapeutic option for fulminant hepatic failure from poison mushroom ingestion. Philip Rosenthal, M.D., F.A.C.G. Pediatric Liver Transplant Program University of California, San Francisco San Francisco, California
AJG – May, 2002
REFERENCES 1. Broussard CN, Aggarwal A, Lacey SR, et al. Mushroom poisoning-from diarrhea to liver transplantation. Am J Gastroenterol 2001;96:3195– 8. 2. Rosenthal P, Roberts JP, Ascher NL, Emond JC. Auxiliary liver transplant in fulminant failure. Pediatrics 1997;100(2):E11. 3. Chenard-Neu MP, Boudjema K, Bernuau J, et al. Auxiliary liver transplantation: Regeneration of the native liver and outcome in 30 patients with fulminant hepatic failure—a multicenter European study. Hepatology 1996;23:1119 –27. Reprint requests and correspondence: Philip Rosenthal, M.D., F.A.C.G., Pediatric Liver Transplant Program, University of California, San Francisco, 500 Parnassus Avenue, Box 0136, MU 4-East, San Francisco, CA 94143– 0136. Received Dec. 14, 2001; accepted Dec. 26, 2001.
A Pilot Study of Transnasal Percutaneous Endoscopic Gastrostomy TO THE EDITOR: This is a follow-up letter to our previously published report of transnasal percutaneous endoscopic gastrostomy (T-PEG) using a pediatric endoscope in two cases of oropharyngeal obstruction (1). We subsequently performed a pilot study to determine the feasibility of T-PEG, particularly in patients with oropharyngeal obstruction due to head and neck cancer. Patients in whom consultation was requested for PEG placement because of potential oropharyngeal obstruction or dysphagia were considered. Patients were excluded if they could not fill out the postprocedure questionnaire or if they had any of the usual contraindications for PEG placement including ascites, obstructing hepatosplenomegaly, uncorrectable coagulopathy, and active systemic infection of cardiopulmonary instability. All eligible patients had the nature of the procedure, risks, and benefits explained before the procedure and signed a research consent form approved by the institutional review board. The study protocol was approved by the board in May, 2000. Patients were randomized by drawing a sealed envelope that contained a preassigned placement route, to either transoral or transnasal PEG placement. The primary study outcome was feasibility. Descriptive characteristics of the patients and endoscopists were recorded. Preprocedure information obtained included baseline demographic information and indication. Data obtained during endoscopy included time of procedure, amount of sedation given, and success of placement. Patients were monitored in the hospital for at least 23 h for immediate complications including bleeding, infection, or perforation. Patients and physicians filled out validated postprocedure questionnaires (2). The patient questionnaire inquired about discomfort on insertion, during the procedure, and overall. Patients were asked to score their responses on a scale from 0 to 10, with 0 being none and 10 equaling severe. The physician questionnaire asked about the optical
Letters to the Editor
1273
quality of the exam and comfort during performance of the procedure. Physicians were asked to score their responses on a scale from 10 to 0, with 10 equaling excellent and 0 meaning inability to perform the exam. At 4 wk all patients were followed up with a phone call to monitor for complications. A pediatric upper endoscope was used (GIF-XP20, Olympus, Lake Success, NY) for PEG placement with a standard push technique either through the mouth or via the nares. A 20F gastrostomy kit was used with a pediatric snare (Microvasive Gastrodome, Boston Scientific, Watertown, MA). Preprocedure antibiotics were given to all patients. Fifteen patients needing PEG placement were prospectively randomized to either a transnasal or a transoral technique. Thirteen patients were enrolled, and two declined to enter. Six patients were randomized to transnasal placement. Nine patients (69%) had head and neck cancer. PEG was placed successfully in three of six in the transnasal group and six of seven patients in the transoral group (p ⫽ 0.3). There were no immediate complications. Mean procedure time and sedation use were similar. Patients reporting any discomfort on insertion were two of six versus none of seven (p ⫽ 0.5), overall patient discomfort was two of six versus two of seven (p ⫽ 0.6), optical quality of the exam was 9.2 versus 9.3 (p ⫽ 0.9), and physician comfort was 8.2 versus 8.7 (p ⫽ 0.2) for transnasal and transoral placement, respectively. One transoral patient had self-limited bleeding at the PEG site in the follow-up period. In conclusion, we have conducted the first study of transnasal percutaneous endoscopic gastrostomy. This pilot study shows that T-PEG is feasible, particularly in patients with oropharyngeal obstruction. T-PEG did not have any long term complications. Recent concern over complications of PEG placement in patients concurrently receiving chemoradiotherapy was not seen (3). The main limitation of T-PEG was passage of scope beyond the nares. More experience and the use of a smaller diameter endoscope, which is now available, may improve scope passage in the future. Alexander M. Lustberg, M.D. Peter E. Darwin, M.D. University of Maryland Medical Center Baltimore, Maryland
REFERENCES 1. Lustberg A, Fleisher AS, Darwin PE. Transnasal placement of percutaneous endoscopic gastrostomy with a pediatric endoscope in oropharyngeal obstruction. Am J Gastroenterol 2001; 96:936 –7. 2. Zaman A, Hahn M, Hapke R, et al. A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin videoendoscope. Gastrointest Endosc 1999;49:279 – 84. 3. Ratnakar N, Brown RD, Venu RP. PEG placement for head and