Overtube for preventing abdominal-wall metastasis after PEG-tube placement

LETTERS TO THE EDITOR Overtube for preventing abdominal-wall metastasis after PEG-tube placement To the Editor: Cruz et al1 recently reaffirmed that there is a small (0.92%) but definite risk for tumor implantation in the gastrostomy site when using the pull technique in patients with untreated or residual head and neck cancer. To avoid tumor translocation, they proposed the use of other percutaneous techniques that do not involve traversing the hypopharynx with the catheter. Nevertheless, the pull technique is associated with the best risk:benefit ratio, and most of the centers have considerably more experience with the procedure than their counterparts. The risk of tumor translocation, therefore, is, in the appropriate context, almost negligible. Nevertheless, it exists. Curiously, in the same issue of Gastrointestinal Endoscopy, there is a debate about the use of an overtube during PEG placement to reduce the risk of abdominal-wall infection.2 The overtube, which appears not to prevent abdominal infection (certainly the cutaneous insertion explains most of it), might be useful in those patients with untreated or residual head and neck cancer to prevent tumor translocation, an issue that certainly deserves more consideration in forthcoming studies.

with ischemic cardiomyopathy supported by a nonpulsatile axial–flow Jarvik 2000 left ventricular assist device (LVAD) (Jarvik Heart Inc, New York, NY). The patient presented with melena and had undergone previous gastroscopy and colonoscopy without localization of a bleeding source. The detection of distal duodenal and proximal jejunal lesions at capsule endoscopy led to a therapeutic push enteroscopy. Endoscopic therapy (application of argon plasma coagulation) and pharmacologic treatment (subcutaneous octreotide 3 times a day and peroral sucralfate) resulted in the cessation of bleeding. No cardiac complications arose from the use of the capsule endoscopy system. GI bleeding because of arteriovenous malformations in patients supported by such devices was described by Letsou et al.1 They proposed that diminished pulsatility during support with the Jarvik 2000 may result in the same altered intestinal physiology seen in aortic stenosis. In this case series, 2 of the 3 patients required exploratory surgery to identify and treat small-intestinal sources of bleeding. The third patient underwent nuclear imaging, revealing small-intestinal arteriovenous malformations, and the patient was treated conservatively. We suggest that capsule endoscopy is safe and can be used in the diagnostic algorithm of obscure GI bleeding in such patients. It permits detection of lesions in the reach of a therapeutic enteroscope, negating the need for more invasive tests, including mesenteric angiography, exploratory laparotomy, and on-table enteroscopy.

Gilberto Couto, MD Gastroenterology Department Hospital de Egas Moniz Lisboa, Portugal

Cynthia H. Seow, MBBS Matthew J. Zimmerman, FRACP Department of Gastroenterology Royal Perth Hospital Perth, Western Australia, Australia

REFERENCES 1. Cruz I, Mamel JJ, Brady PG, CassGarcia M. Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head and neck cancer. Gastrointest Endosc 2005;62:708-11. 2. Mandot A, Gupta T, Abraham P, et al. An overtube is not required for reducing post-PEG peristomal infection. Gastrointest Endosc 2005;62: 821-2.

REFERENCE

doi:10.1016/j.gie.2006.01.007

doi:10.1016/j.gie.2006.01.018

Capsule endoscopy in the detection of small-intestinal bleeding in patients supported by a nonpulsatile axial-flow Jarvik 2000 left ventricular assist device

Self-administered alcohol (vodka) enema causing severe colitis: case report and review

To the Editor:

To the Editor:

We report the safe use of capsule endoscopy in the detection of obscure GI bleeding in a 59-year-old male patient

I read with great interest, and a bit of astonishment the Mian et al1 report on self-administered alcohol enema

www.giejournal.org

1. Letsou GV, Shah N, Gregoric ID, et al. Gastrointestinal bleeding from arteriovenous malformations in patients supported by the Jarvik 2000 axial-flow left ventricular assist device. J Heart Lung Transplant 2005; 24:105-9.

Volume 63, No. 7 : 2006 GASTROINTESTINAL ENDOSCOPY 1087