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One-step button PEG
Letters to the Editor
John J. Garvie, MD Department of Gastroenterology University of California Medical Center Daniel S. Anderson, MD Department of Gastroenterology Kaiser Permanente Medical Care Program San Diego, California, USA
Chips and rips: ‘‘chew your food well’’ To the Editor: Only 8 cases of esophageal trauma from normally ingested food are reported.1-7 We would like to share with your readers 4 additional patients that we have cared for. A 60-year-old man had substernal/epigastric pain, dysphagia, melena, hematemesis, and presyncope minutes after eating corn chips. Endoscopy showed a 4-cm, deep, distal esophageal tear, and his hemoglobin decreased to 9.7 g/dL. He recovered with routine care. A 38-year-old man developed substernal pain, dysphagia, and fever hours after eating taquitos. He had mild leukocytosis, bibasilar infiltrates, a small right pleural effusion, and normal results on Gastrografin (Bracco Diagnostics Inc, Princeton, NJ) esophagraphy. Endoscopy revealed a 6-cm midesophageal laceration and multiple, small distal lacerations. Blood cultures revealed Streptococcus pneumoniae, and he recovered with antibiotic therapy. A 53-year-old man developed epigastric pain immediately after forcefully swallowing an unchewed bite of taquito because it was so hot. Melena and hematemesis followed. A chest radiograph showed normal results. Endoscopy showed a 9-cm middle and distal esophageal tear with an adherent clot, and his hemoglobin decreased to 10.5 g/dL. He recovered with routine care. A 38-year-old woman presented with 7 days of progressive substernal pain, dysphagia, and odynophagia that started immediately after she ate a toasted pita bread chip. A chest radiograph showed normal results. Her hemoglobin was 10.0 g/dL, and chest CTshowed a 34 mm 26 mm subcarinal mass with a hypodense area. Endoscopy revealed a midesophageal bulge without tear, but her symptoms and mass implied prior esophageal perforation. EUS needle aspiration and culture of the mass yielded Streptococcus (viridans and mitus) and Veillonella. Antibiotic therapy intravenously for several days and orally for 6 months cured her. Corn or wheat foods (toasted or fried) caused our patients’ esophageal injuries. None had previous esophageal symptoms, used dentures, or developed underlying esophageal disease in 2 to 7 1⁄2 years of follow-up. Our cases underscore the importance of chewing such foods well to prevent serious esophageal trauma.
REFERENCES 1. Hunter TB, Protell RL, Horsley WW. Food laceration of the esophagus: the taco tear. AJR Am J Roentgenol 1983;140:503-4. 2. Meislin H, Kobernick M. Corn chip laceration of the esophagus and evaluation of suspected esophageal perforation. Ann Emerg Med 1983;12:455-7. 3. Longstreth GF. Esophageal tear caused by a tortilla chip [erratum in: N Eng J Med 1990;323:70]. N Engl J Med 1990;322:1399-400. 4. Carrougher JG, Kadakia SC, Peluso F. Tortilla corn chip-associated esophageal perforation: an unusual presentation of achalasia. Am J Gastroenterol 1992;87:128-31. 5. Klygis LM. Esophageal hematoma and tear from a taco shell impaction. Gastrointest Endosc 1992;38:100. 6. Reino AJ, Jahn AF, Parsons J, et al. Traumatic pneumomediastinum in a child secondary to corn chip perforation of the esophagus. Ped Emerg Care 1993;9:211-5. 7. Alameddine AK, Girard MJ. Esophageal laceration caused by a bagel. N Eng J Med 1999;340:241. doi:10.1016/j.gie.2006.11.008
One-step button PEG To the Editor:
George F. Longstreth, MD Department of Gastroenterology Kaiser Permanente Medical Care Program Jeffrey C. Buehler, MD Department of Gastroenterology University of California Medical Center Gordon C. Hunt, MD Department of Gastroenterology Kaiser Permanente Medical Care Program
Evans et al1 are to be commended for their insightful report regarding the use of one-step (single-stage) button (OSB) PEG devices in the pediatric population. The investigators state that the use of such devices has not been widespread in the pediatric community. I would suggest that for unclear reasons, this statement would also apply to the adult population. Since 1994, our group has preferentially placed OSB devices in patients requiring gastrostomy placement.2 The only patients in whom we place tube-style devices are those who are estimated to have a gastrocutaneous fistula tract that is too long to properly accommodate an OSB device. Since 1994, we placed more than 700 OSB devices. We have preferentially chosen this type of PEG device for multiple reasons. This low-profile, skin-level device is clearly more aesthetically pleasing (especially for the ambulatory patient), and the design makes it intrinsically difficult for mentally challenged or neurologically impaired patients to remove inadvertently. Also, this device is available with a 24F shaft diameter, which makes it less prone to clogging. Reticence to use OSB PEGs may relate to a lack of familiarity with the device and/or a high rate of previously reported complications.3,4 My use of OSB-PEG devices for more than 12 years has taught me a great deal, and some aspects of this experience
556 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 3 : 2007
www.giejournal.org
Letters to the Editor
merit comment. Earlier in our experience (from 1996 through 2002) severe peri-PEG cellulitis and button migration/extrusion, which required hospitalization or prolongation of a hospital stay for longer than 24 hours were documented to occur in a prospective fashion at the hospital where our group places all PEGs at a frequency of w2.0% and 1.0 %, respectively. It became apparent to me that cellulitis in these patients was sometimes a prelude to subsequent button migration/extrusion.5 As time has passed, it has become abundantly clear that making a generous (w15 mm) skin incision and appropriate sizing of the OSB are critically important considerations when placing these devices. Specifically, I now use the OSB measuring device to guide me, but I am always vigilant in choosing a button shaft of adequate length to ensure that the fit is not tight. I now frequently use a button with a shaft ‘‘the next size up,’’ especially in ambulatory patients. My bias is that buttons may be more snuggly fitting when an ambulatory patient is upright, and performing physical activity. Importantly, if I have any reticence in relation to the gastrocutaneous fistula tract being too long to accommodate a OSB device, I err on the side of placing a tube-style PEG. I always attempt to ensure that the button device is a bit lax at the skin level and is easily able to be rotated. With these considerations in mind, over the last 3 years, no severe peri-PEG cellulitic infections (requiring or prolonging a hospitalization) and no button extrusions have been documented to occur. Over the past 3 years (20032005), compared with the 3 years before (2000-2002), there were no changes in the indications for which PEG was performed, the mode of antibiotic prophylaxis, or postprocedure peri-PEG care. It is worth reiterating, however, that over this most recent time period, we had a few patients in whom we preemptively changed the OSB to either another button of longer shaft length or a tube-style gastrostomy device, if any swelling, discomfort, or other peri-PEG change is detected, and if a physical examination suggests that the button device is too tight. Interestingly, as one might expect, from 2003 to 2005, 22% of PEGs placed were tube style, whereas in marked contrast, from 2000 to 2002, only 2.5% were the tube-style variety. Of particular note is that, despite our current practice of erring on the side of placing ‘‘less tight’’ button devices, no recent case of peritonitis or intraperitoneal leakage of feeding has been documented. I would conclude that, in the adult population, the placement of OSB PEGs has many advantages and the rare case of button extrusion/migration can be avoided by placing OSB devices of adequate shaft length, being certain to ‘‘err on the generous side.’’ Making the abdominal incision of adequate length is also anecdotally important, and it may help to decrease the frequency of severe post-PEG cellulitis. Joseph C. Yarze, MD, FACP, FACG, FASGE Gastroenterology Associates of Northern New York Glens Falls, New York, USA www.giejournal.org
REFERENCES 1. Evans JS, Thorne M, Taufiq S, et al. Should single-stage PEG buttons become the procedure of choice for PEG placement in children? Gastrointest Endosc 2006;64:320-4. 2. Yarze JC, Herlihy KJ, Fritz HP, et al. Prospective trial evaluating early initiation of feeding in patients with newly placed one-step button gastrostomy devices. Dig Dis Sci 2001;46:854-8. 3. Treem WR, Etienne NL, Hyams JS. Percutaneous endoscopic placement of the ‘‘button’’ gastrostomy tube as the initial procedure in infants and children. J Pediatr Gastroenterol Nutr 1993;17:382-6. 4. Kozarek RA, Payne M, Barkin J, et al. Prospective multicenter evaluation of an initially placed button gastrostomy. Gastrointest Endosc 1995;41: 105-8. 5. Yarze JC. Peri-PEG cellulitis as a prelude to button extrusion [letter]. Am J Gastroenterol 2000;95:313. doi:10.1016/j.gie.2006.09.013
EUS-guided FNA diagnosis of pancreatic tuberculosis To the Editor: Cheng et al1 report a patient with pancreatic tuberculosis diagnosed with EUS-guided FNA (EUS-FNA). The investigators claim that EUS-FNA diagnosis of pancreatic tuberculosis has not been previously reported. However, before the publication of their report, we described a patient with pancreatic tuberculosis who was accurately diagnosed when using EUS-FNA.2 We agree that the exact success rate of EUS-FNA diagnosis of pancreatic tuberculosis is not known. Image-guided transcutaneous biopsy is successful in accurate diagnosis of pancreatic tuberculosis in less than 50% of patients.3 As pointed out by the investigators, in a recent report4 of pancreatic tuberculosis EUS-FNA failed to yield the correct diagnosis, despite 2 attempts on separate occasions. In our report, the first attempt of EUS-FNA did not provide the correct diagnosis, but the second attempt succeeded when the specimen was also submitted for polymerase chain reaction (PCR), in addition to the acid-fast bacilli (AFB) culture. Direct AFB smears were negative in all 3 reports.1,2,4 Based on these reports,1,2,4 only 2 attempts succeeded of a total of 5; a success rate similar to that of percutaneous approach. However, patient numbers are too small to draw any definite conclusion on the exact success rate of EUS-FNA. A possible explanation of failure, at least in 1 of the reports,4 could be related to an inability to submit EUS-FNA specimen for PCR or AFB culture. Cheng et al1 and our report2 highlight the importance of submitting an EUS-FNA specimen for AFB culture and PCR. An AFB culture takes a longer time for mycobacterium to grow; however, a rapid diagnosis is possible by using PCR. The major limitation of PCR is inability to perform drug susceptibility. However, one should not wait for the culture results to come back before initiating antituberculosis therapy if the clinical suspicion for tuberculosis is high.2 Volume 65, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 557
John J. Garvie, MD Department of Gastroenterology University of California Medical Center Daniel S. Anderson, MD Department of Gastroenterology Kaiser Permanente Medical Care Program San Diego, California, USA
Chips and rips: ‘‘chew your food well’’ To the Editor: Only 8 cases of esophageal trauma from normally ingested food are reported.1-7 We would like to share with your readers 4 additional patients that we have cared for. A 60-year-old man had substernal/epigastric pain, dysphagia, melena, hematemesis, and presyncope minutes after eating corn chips. Endoscopy showed a 4-cm, deep, distal esophageal tear, and his hemoglobin decreased to 9.7 g/dL. He recovered with routine care. A 38-year-old man developed substernal pain, dysphagia, and fever hours after eating taquitos. He had mild leukocytosis, bibasilar infiltrates, a small right pleural effusion, and normal results on Gastrografin (Bracco Diagnostics Inc, Princeton, NJ) esophagraphy. Endoscopy revealed a 6-cm midesophageal laceration and multiple, small distal lacerations. Blood cultures revealed Streptococcus pneumoniae, and he recovered with antibiotic therapy. A 53-year-old man developed epigastric pain immediately after forcefully swallowing an unchewed bite of taquito because it was so hot. Melena and hematemesis followed. A chest radiograph showed normal results. Endoscopy showed a 9-cm middle and distal esophageal tear with an adherent clot, and his hemoglobin decreased to 10.5 g/dL. He recovered with routine care. A 38-year-old woman presented with 7 days of progressive substernal pain, dysphagia, and odynophagia that started immediately after she ate a toasted pita bread chip. A chest radiograph showed normal results. Her hemoglobin was 10.0 g/dL, and chest CTshowed a 34 mm 26 mm subcarinal mass with a hypodense area. Endoscopy revealed a midesophageal bulge without tear, but her symptoms and mass implied prior esophageal perforation. EUS needle aspiration and culture of the mass yielded Streptococcus (viridans and mitus) and Veillonella. Antibiotic therapy intravenously for several days and orally for 6 months cured her. Corn or wheat foods (toasted or fried) caused our patients’ esophageal injuries. None had previous esophageal symptoms, used dentures, or developed underlying esophageal disease in 2 to 7 1⁄2 years of follow-up. Our cases underscore the importance of chewing such foods well to prevent serious esophageal trauma.
REFERENCES 1. Hunter TB, Protell RL, Horsley WW. Food laceration of the esophagus: the taco tear. AJR Am J Roentgenol 1983;140:503-4. 2. Meislin H, Kobernick M. Corn chip laceration of the esophagus and evaluation of suspected esophageal perforation. Ann Emerg Med 1983;12:455-7. 3. Longstreth GF. Esophageal tear caused by a tortilla chip [erratum in: N Eng J Med 1990;323:70]. N Engl J Med 1990;322:1399-400. 4. Carrougher JG, Kadakia SC, Peluso F. Tortilla corn chip-associated esophageal perforation: an unusual presentation of achalasia. Am J Gastroenterol 1992;87:128-31. 5. Klygis LM. Esophageal hematoma and tear from a taco shell impaction. Gastrointest Endosc 1992;38:100. 6. Reino AJ, Jahn AF, Parsons J, et al. Traumatic pneumomediastinum in a child secondary to corn chip perforation of the esophagus. Ped Emerg Care 1993;9:211-5. 7. Alameddine AK, Girard MJ. Esophageal laceration caused by a bagel. N Eng J Med 1999;340:241. doi:10.1016/j.gie.2006.11.008
One-step button PEG To the Editor:
George F. Longstreth, MD Department of Gastroenterology Kaiser Permanente Medical Care Program Jeffrey C. Buehler, MD Department of Gastroenterology University of California Medical Center Gordon C. Hunt, MD Department of Gastroenterology Kaiser Permanente Medical Care Program
Evans et al1 are to be commended for their insightful report regarding the use of one-step (single-stage) button (OSB) PEG devices in the pediatric population. The investigators state that the use of such devices has not been widespread in the pediatric community. I would suggest that for unclear reasons, this statement would also apply to the adult population. Since 1994, our group has preferentially placed OSB devices in patients requiring gastrostomy placement.2 The only patients in whom we place tube-style devices are those who are estimated to have a gastrocutaneous fistula tract that is too long to properly accommodate an OSB device. Since 1994, we placed more than 700 OSB devices. We have preferentially chosen this type of PEG device for multiple reasons. This low-profile, skin-level device is clearly more aesthetically pleasing (especially for the ambulatory patient), and the design makes it intrinsically difficult for mentally challenged or neurologically impaired patients to remove inadvertently. Also, this device is available with a 24F shaft diameter, which makes it less prone to clogging. Reticence to use OSB PEGs may relate to a lack of familiarity with the device and/or a high rate of previously reported complications.3,4 My use of OSB-PEG devices for more than 12 years has taught me a great deal, and some aspects of this experience
556 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 3 : 2007
www.giejournal.org
Letters to the Editor
merit comment. Earlier in our experience (from 1996 through 2002) severe peri-PEG cellulitis and button migration/extrusion, which required hospitalization or prolongation of a hospital stay for longer than 24 hours were documented to occur in a prospective fashion at the hospital where our group places all PEGs at a frequency of w2.0% and 1.0 %, respectively. It became apparent to me that cellulitis in these patients was sometimes a prelude to subsequent button migration/extrusion.5 As time has passed, it has become abundantly clear that making a generous (w15 mm) skin incision and appropriate sizing of the OSB are critically important considerations when placing these devices. Specifically, I now use the OSB measuring device to guide me, but I am always vigilant in choosing a button shaft of adequate length to ensure that the fit is not tight. I now frequently use a button with a shaft ‘‘the next size up,’’ especially in ambulatory patients. My bias is that buttons may be more snuggly fitting when an ambulatory patient is upright, and performing physical activity. Importantly, if I have any reticence in relation to the gastrocutaneous fistula tract being too long to accommodate a OSB device, I err on the side of placing a tube-style PEG. I always attempt to ensure that the button device is a bit lax at the skin level and is easily able to be rotated. With these considerations in mind, over the last 3 years, no severe peri-PEG cellulitic infections (requiring or prolonging a hospitalization) and no button extrusions have been documented to occur. Over the past 3 years (20032005), compared with the 3 years before (2000-2002), there were no changes in the indications for which PEG was performed, the mode of antibiotic prophylaxis, or postprocedure peri-PEG care. It is worth reiterating, however, that over this most recent time period, we had a few patients in whom we preemptively changed the OSB to either another button of longer shaft length or a tube-style gastrostomy device, if any swelling, discomfort, or other peri-PEG change is detected, and if a physical examination suggests that the button device is too tight. Interestingly, as one might expect, from 2003 to 2005, 22% of PEGs placed were tube style, whereas in marked contrast, from 2000 to 2002, only 2.5% were the tube-style variety. Of particular note is that, despite our current practice of erring on the side of placing ‘‘less tight’’ button devices, no recent case of peritonitis or intraperitoneal leakage of feeding has been documented. I would conclude that, in the adult population, the placement of OSB PEGs has many advantages and the rare case of button extrusion/migration can be avoided by placing OSB devices of adequate shaft length, being certain to ‘‘err on the generous side.’’ Making the abdominal incision of adequate length is also anecdotally important, and it may help to decrease the frequency of severe post-PEG cellulitis. Joseph C. Yarze, MD, FACP, FACG, FASGE Gastroenterology Associates of Northern New York Glens Falls, New York, USA www.giejournal.org
REFERENCES 1. Evans JS, Thorne M, Taufiq S, et al. Should single-stage PEG buttons become the procedure of choice for PEG placement in children? Gastrointest Endosc 2006;64:320-4. 2. Yarze JC, Herlihy KJ, Fritz HP, et al. Prospective trial evaluating early initiation of feeding in patients with newly placed one-step button gastrostomy devices. Dig Dis Sci 2001;46:854-8. 3. Treem WR, Etienne NL, Hyams JS. Percutaneous endoscopic placement of the ‘‘button’’ gastrostomy tube as the initial procedure in infants and children. J Pediatr Gastroenterol Nutr 1993;17:382-6. 4. Kozarek RA, Payne M, Barkin J, et al. Prospective multicenter evaluation of an initially placed button gastrostomy. Gastrointest Endosc 1995;41: 105-8. 5. Yarze JC. Peri-PEG cellulitis as a prelude to button extrusion [letter]. Am J Gastroenterol 2000;95:313. doi:10.1016/j.gie.2006.09.013
EUS-guided FNA diagnosis of pancreatic tuberculosis To the Editor: Cheng et al1 report a patient with pancreatic tuberculosis diagnosed with EUS-guided FNA (EUS-FNA). The investigators claim that EUS-FNA diagnosis of pancreatic tuberculosis has not been previously reported. However, before the publication of their report, we described a patient with pancreatic tuberculosis who was accurately diagnosed when using EUS-FNA.2 We agree that the exact success rate of EUS-FNA diagnosis of pancreatic tuberculosis is not known. Image-guided transcutaneous biopsy is successful in accurate diagnosis of pancreatic tuberculosis in less than 50% of patients.3 As pointed out by the investigators, in a recent report4 of pancreatic tuberculosis EUS-FNA failed to yield the correct diagnosis, despite 2 attempts on separate occasions. In our report, the first attempt of EUS-FNA did not provide the correct diagnosis, but the second attempt succeeded when the specimen was also submitted for polymerase chain reaction (PCR), in addition to the acid-fast bacilli (AFB) culture. Direct AFB smears were negative in all 3 reports.1,2,4 Based on these reports,1,2,4 only 2 attempts succeeded of a total of 5; a success rate similar to that of percutaneous approach. However, patient numbers are too small to draw any definite conclusion on the exact success rate of EUS-FNA. A possible explanation of failure, at least in 1 of the reports,4 could be related to an inability to submit EUS-FNA specimen for PCR or AFB culture. Cheng et al1 and our report2 highlight the importance of submitting an EUS-FNA specimen for AFB culture and PCR. An AFB culture takes a longer time for mycobacterium to grow; however, a rapid diagnosis is possible by using PCR. The major limitation of PCR is inability to perform drug susceptibility. However, one should not wait for the culture results to come back before initiating antituberculosis therapy if the clinical suspicion for tuberculosis is high.2 Volume 65, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 557