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Percutaneous transgastrostomy placement of jejunal feeding tubes using an ultrathin endoscope
*3436 EUS APPLICATIONS IN PORTAL HYPERTENSION: INTRAMURAL FINDINGS BUT NOT PARAMURAL COLLATERALS (PC) NOR PERFORATOR VEINS (PV) CAN PREDICT VARICEAL RECURRENCE (VR) IN PATIENTS (PTS) WITH ENDOSCOPIC ERADICATION OF OESOPHAGEAL VARICES (EV). Claudio De Angelis, Valeria Maglione, Patrizia Carucci, Maurizio Fadda, Francesca Curri, Alessandro Repici, Nicola Leone, Claudio Barletti, Stefania Caronna, Anna Isabello, Giorgio Saraeco, Mario Rizzetto, Dept of Gastroenterology, Turin Italy BACKGROUND AND AIM: VR and rebleending remain a major problem after endoscopic eradication of EV by means of sclerotherapy(EST) or rubber band ligation (RBL). Some studies suggested that in pts with endoscopic signs of EV obliteration EUS may demonstrate still patent himina in the esophageal wall and mainly the presence of PC or PV that seem to correlate with VR and rebleeding. Our study aimed to asses if EUS findings can be helpful in predicting VR. MATERIAL AND h~ETHODS: 115 pts ( 81 men, mean age 56±12 yrs) bleeding from EV underwent endoscopic treatment by means of EST or RBL until obtaining endoscopic eradication in 108 of them. Then they underwent EUS with a rotating sector scanner ( Olympus GF-UM3/UMQ130) within 1 month from the treatment. 92 of the 108 eradicated pts had an endoscopic follow-up (7.6±7.5 months) to evaluate VR. RESULTS: 59 of the endoscopically eradicated pts with follow-up (64%) were not judged completely eradicated by EUS, owing to the presence of still patent variceal lumina or just partially thrombosed vessels or small anechoic structures in the wall. 44 of them (74.6%) developed VR in the follow-up (FU), while just 10 out of the remaining 33 pts(30%) judged eradicated by both Endoscopy and EUS, showed VR in the FU ( Chisquare P< 0.001). Periesophageal, perjunctional, perifundal collateral vessels and esophageal, junctional PV were evaluated: PC were classified as none, small (<5mm), medium (5-10 mm),large (>10mm) and PV as none or present in 21/92 pts or none, small (<1 mm), medium (2-3 mm), large (>3mm) in 71/92 pts. We found presence of PC in 48/54 (89%) pts with VR and in 33/38 (87%} pts with no VR(P=NS}. Also large PC were found in similar proportion (10/54=18.5% vs 7/38= 18.4%) in both groups. Esophageal PV were found in 36/54 (67%} pts with VR and in 25/38 (66%) in the other group (P=NS). Large PV were found in 7/40 (17.5%)pts with VR vs 5/31 (16%)pts without VR (P= NS). CONCLUSIONS: EUS has a higher sensitivity than endoscopy in identifying a complete varices eradication after EST or RBL, because it can detect patent residual vessels in the esophageal wall that endoscopy can not see. These EUS findings may have a precise clinical impact: predicting VR, they can indicate the need for further medical or endoscopic treatment and/or closer endoscopic follow-up. Unlike previously reported data, in our series, PC and PV don't correlate with VR in the FU.
*3437 PERCUTANEOUS TRANSGASTROSTOMY PLACEMENT OF JEJUNAL FEEDING TUBES USING AN ULTRATHIN ENDOSCOPE Douglas G. Adler, Todd H. Baron, Christopher J. Gostout, Mayo Clin, Rochester, MN Introduction Patients with PEG tubes may require jejunal feeding, usually after placement of a jejunal extension tube through the PEG. This may be technically difficult and allow relatively small jejunal tubes to be placed. We describe a method for simple, easy, and rapid placement of wider jejunal feeding tubes via a transgastrostomy (TG) route using an ultrathin endoscope. Methods 13 patients requiring jejunal feeding who failed PEG tube feeding underwent TG placement of jejunal feeding tubes. After removing the PEG tube, the 6mm diameter GIF-N230 endoscope was inserted through the gastrostomy tract into the stomach and small bowel beyond the ligament of Treitz. A 0.035 guidewire was then advanced through the working channel into the jejunum. The endoscope was withdrawn leaving the guidewire in place. A jejunal feeding tube was then advanced over the wire under fluoroscopic guidance into the jejunum beyond the ligament of Treitz. Since all patients had mature (>2 weeks old) gastrotomy tracts, feeding was recommended to commence immediately. Results 13 patients (5 F, 8 M) underwent a total of 16 procedures.
ABII8
GASTROINTESTINAL ENDOSCOPY
Indications: gastric atony (2), aspiration (3}, vomiting (1), proximal migration or gastric coiling of J extension (2), replacement (2), PEG stoma leak (3), pyloric ulcer (1), severe GERD (1), and blunt head trauma (1). All procedures were successful. One patient required the procedure 3 times over 6 months due to recurrent feeding tube balloon rupture (six months after placement and two hours after placement, respectively) ; another patient underwent a second placement 7 days later after the initial jejunal feeding tube coiled in the stomach. Sedation was required in only 6 out of 16 procedures; five times due to patient preference and 1 pt underwent EGD prior to tube placement and received sedation for that procedure. Mean procedure time was 10 minutes. There were no complications. In all patients, jejunal feeding commenced the same day the tubes were placed. Tubes remained in proper position b/w 16 and 186 days. Conclusions Transgastric placement of jejunal feeding tubes using an ultrathin endoscope is simple, easy to perform, rapid, and safe in patients who have failed or are not candidates for PEG tube feedings. Sedation can be avoided in most cases and the feeding tubes can be used immediately after placement. This technique allows placement of larger-bore jejunal feeding tubes than nmst jejunal extension tubes on the market, whose size is limited by the restrictions imposed by the PEG tube lumen.
*3438 THERAPEUTIC ERCP IN PATIENTS WITH LONG-LIMB SURGICAL BYPASS USING A NEW OBLIQUE-VIEWING ENTEROSCOPE. Douglas A. Howell, Raj J. Shah, Phyllidia M. Ku-Ruth, David J. Desilets, Maine Medical Ctr, Portland, ME Background: Therapeutic ERCP in the setting of long-limb surgical bypass including Roux-en-Y, post-Whipple's resection, and long-limb Billroth II requires instruments longer than standard duodenoscopes. Successful intubation using the pediatric eolonoscope or enteroscope with eventual advancement into the right upper quadrant is possible in more than 80%. We have noted improved intubation using an extra-slim prototype pediatric colonoscope. The front view and lack of an elevator make subsequent cannulation and therapy very difficult. We report our recent experience with a specifically designed instrument. Methods: The JF-QK140 (Olympus America, Melville, NY} therapeutic enteroscope was patterned after an ultra-slim pediatric colonoscope with a length of 170 cms, a 10mm diameter, and a 2.8 channel that includes an elevator. The tip of the instrument is angled to view at 30-degrees from the forward axis to facilitate visualization of the papilla from the afferent limb. Standard length ERCP accessories can be utilized. 4 patients with hepaticojejunostomy (N=2) and long-limb Billroth II (N=2) were initially studied. Results: The enteroscope produces a good forward view to permit intubation and advancement of the instrument when compared to side-viewing duodenoscopy. The length was long enough to permit access to the ampullary area in 3 of the 4 cases. In one patient with complex anatomy, including several surgical blind-limbs, the anatomy could be defined but final advancement into the right upper quadrant was not possible and subsequently not possible using the 240cm Olympus SIF-100 enteroscope. The 3 remaining patients underwent successful therapeutic ERCP for CBD stone disease. One was performed with a needle-knife over an inserted stent and the other could be performed using the needle-knife alone. The final patient underwent extensive stone extraction through a hepaticojejunostomy with final placement of two 7Fr stents. There were no complications. Conclusions: This is the initial report on the use of a new specialized endoscopy designed for better access to the periampullary duodenum in post-surgical patients. Intubation and advancement was facilitated by a partial forward view. The technical aspect of cannulation and therapeutic ERCP are greatly simplified by an oblique view of the papilla and by the addition of an elevator. Additional experience and refinement of the equipment will define its role compared to continued use of conventional non-specialized endoscopes.
VOLUME 53, NO. 5, 2001
*3437 PERCUTANEOUS TRANSGASTROSTOMY PLACEMENT OF JEJUNAL FEEDING TUBES USING AN ULTRATHIN ENDOSCOPE Douglas G. Adler, Todd H. Baron, Christopher J. Gostout, Mayo Clin, Rochester, MN Introduction Patients with PEG tubes may require jejunal feeding, usually after placement of a jejunal extension tube through the PEG. This may be technically difficult and allow relatively small jejunal tubes to be placed. We describe a method for simple, easy, and rapid placement of wider jejunal feeding tubes via a transgastrostomy (TG) route using an ultrathin endoscope. Methods 13 patients requiring jejunal feeding who failed PEG tube feeding underwent TG placement of jejunal feeding tubes. After removing the PEG tube, the 6mm diameter GIF-N230 endoscope was inserted through the gastrostomy tract into the stomach and small bowel beyond the ligament of Treitz. A 0.035 guidewire was then advanced through the working channel into the jejunum. The endoscope was withdrawn leaving the guidewire in place. A jejunal feeding tube was then advanced over the wire under fluoroscopic guidance into the jejunum beyond the ligament of Treitz. Since all patients had mature (>2 weeks old) gastrotomy tracts, feeding was recommended to commence immediately. Results 13 patients (5 F, 8 M) underwent a total of 16 procedures.
ABII8
GASTROINTESTINAL ENDOSCOPY
Indications: gastric atony (2), aspiration (3}, vomiting (1), proximal migration or gastric coiling of J extension (2), replacement (2), PEG stoma leak (3), pyloric ulcer (1), severe GERD (1), and blunt head trauma (1). All procedures were successful. One patient required the procedure 3 times over 6 months due to recurrent feeding tube balloon rupture (six months after placement and two hours after placement, respectively) ; another patient underwent a second placement 7 days later after the initial jejunal feeding tube coiled in the stomach. Sedation was required in only 6 out of 16 procedures; five times due to patient preference and 1 pt underwent EGD prior to tube placement and received sedation for that procedure. Mean procedure time was 10 minutes. There were no complications. In all patients, jejunal feeding commenced the same day the tubes were placed. Tubes remained in proper position b/w 16 and 186 days. Conclusions Transgastric placement of jejunal feeding tubes using an ultrathin endoscope is simple, easy to perform, rapid, and safe in patients who have failed or are not candidates for PEG tube feedings. Sedation can be avoided in most cases and the feeding tubes can be used immediately after placement. This technique allows placement of larger-bore jejunal feeding tubes than nmst jejunal extension tubes on the market, whose size is limited by the restrictions imposed by the PEG tube lumen.
*3438 THERAPEUTIC ERCP IN PATIENTS WITH LONG-LIMB SURGICAL BYPASS USING A NEW OBLIQUE-VIEWING ENTEROSCOPE. Douglas A. Howell, Raj J. Shah, Phyllidia M. Ku-Ruth, David J. Desilets, Maine Medical Ctr, Portland, ME Background: Therapeutic ERCP in the setting of long-limb surgical bypass including Roux-en-Y, post-Whipple's resection, and long-limb Billroth II requires instruments longer than standard duodenoscopes. Successful intubation using the pediatric eolonoscope or enteroscope with eventual advancement into the right upper quadrant is possible in more than 80%. We have noted improved intubation using an extra-slim prototype pediatric colonoscope. The front view and lack of an elevator make subsequent cannulation and therapy very difficult. We report our recent experience with a specifically designed instrument. Methods: The JF-QK140 (Olympus America, Melville, NY} therapeutic enteroscope was patterned after an ultra-slim pediatric colonoscope with a length of 170 cms, a 10mm diameter, and a 2.8 channel that includes an elevator. The tip of the instrument is angled to view at 30-degrees from the forward axis to facilitate visualization of the papilla from the afferent limb. Standard length ERCP accessories can be utilized. 4 patients with hepaticojejunostomy (N=2) and long-limb Billroth II (N=2) were initially studied. Results: The enteroscope produces a good forward view to permit intubation and advancement of the instrument when compared to side-viewing duodenoscopy. The length was long enough to permit access to the ampullary area in 3 of the 4 cases. In one patient with complex anatomy, including several surgical blind-limbs, the anatomy could be defined but final advancement into the right upper quadrant was not possible and subsequently not possible using the 240cm Olympus SIF-100 enteroscope. The 3 remaining patients underwent successful therapeutic ERCP for CBD stone disease. One was performed with a needle-knife over an inserted stent and the other could be performed using the needle-knife alone. The final patient underwent extensive stone extraction through a hepaticojejunostomy with final placement of two 7Fr stents. There were no complications. Conclusions: This is the initial report on the use of a new specialized endoscopy designed for better access to the periampullary duodenum in post-surgical patients. Intubation and advancement was facilitated by a partial forward view. The technical aspect of cannulation and therapeutic ERCP are greatly simplified by an oblique view of the papilla and by the addition of an elevator. Additional experience and refinement of the equipment will define its role compared to continued use of conventional non-specialized endoscopes.
VOLUME 53, NO. 5, 2001