- Email: [email protected]
Prospective Multicenter Long Term Follow Up Results of New Introducer Percutaneous Endoscopic Gastrostomy Method with Gastropexy in 89 Patients
Abstracts
pattern score was allocated for each patients at the end of procedure as definitely present Z 1, partially present Z 2, definitely absent Z 3. Biopsies were taken from the most abnormal-looking mucosa or apparent normal when present using rocking biopsy forceps and mounted on filter paper and put into formalin for histological assessment. Three more samples were collected for in vitro challenge with gluten-derived toxic peptides . Frozen sections of the biopsies were then evaluated by immunohistochemistry. Results: 76.9 % of subject had a positive value of anti-tissue transglutaminase antibodies while 23.1 % had borderline value. The chromoendoscopic results showed normal villous pattern in 46.2%(6 pts), partially present 15.4%(2 pts), definitively absent 38.5% (5 pts). A significant positive correlation was found between a positive value of anti-tissue transglutaminase antibodies and the endoscopic score of villous pattern (Spearman, r Z 0,56, p ! 0.05). In vitro challenge was positive in 50% of normal villous pattern and in all patients with definitively absent villous pattern. Conclusions: This preliminary study suggest that chromoendoscopy with magnification may disclose with accuracy severe villous atrophy but it may have a great value in evaluating selected series of patients with doubtful diagnosis of celiac disease.
T1609 A New Technique for Direct Percutaneous Endoscopic Jejunostomy Using Double Balloon Endoscopy and Magnetic Anchors in a Porcine Model Tomonori Yano, Keijiro Sunada, Mitsuyo Yoshizawa, Masato Shigemori, Hirotsugu Sakamoto, Tomohisa Nakaya, Hiromi Fukushima, Daisuke Tsukui, Tetsuro Honda, Takashi Kitade, Yuuichi Iwashita, Takahito Takezawa, Norikatsu Numao, Aya Kitamura, Hozumi Tanaka, Eiji Kobayashi, Hironori Yamamoto, Kentaro Sugano Introduction: While direct percutaneous endoscopic jejunostomy (D-PEJ) is a stable and safe access to maintain enteral feeding, it is not yet carried out globally because of the technical difficulty in the procedure. The jejunal lumen is much smaller than that of the stomach. In addition, the location of the jejunal loop is not stable in relation to the abdominal wall. We developed a new technique for D-PEJ using double balloon endoscopy (DBE) and magnetic anchors to resolve these problems. Method: Two magnetic anchors are prepared. One is a small magnet 5 mm in diameter for the inside anchor. The other is a column 15 mm in diameter for the outside anchor. The inside anchor is tied to the double balloon endoscope at 3 cm from the tip. A miniature pig is fasted for 48 hours. Under general anesthesia, the DBE is inserted to the jejunum. The appropriate puncture point is searched out and confirmed by visualizing a clear and discrete finger indentation in the jejunum corresponding to the point of light transmission across the abdominal wall. After the outside anchor is put on the abdominal wall, the inside anchor stick to the wall of the jejunum directly under the outside anchor with magnetic force. For jejunal wall fixation, 18G needle and 18G Seldinger needle are punctured into the jejunum from the abdominal wall beside the outside anchor. Nylon thread with a loop is put through the 18G needle into the jejunum. The fixing thread is put through the 18G Seldinger needle and through the loop. The fixing thread is caught by tightening the loop and pulled out. The jejunal wall is fixed to the abdominal wall by suturing the fixing thread. After incision, the needle stylet with a plastic sheath is punctured into the jejunum. The thread is inserted through the plastic sheath, into the jejunum, grasped by the snare, and pulled out through the overtube with the endoscope. 14Fr pull-type PEG tube with an intraluminal bumper was placed through the overtube. Results: D-PEJ was successfully placed and used for feeding for over one week in all 8 pigs. There was no procedure related complications. The mean procedure time was 89 minutes. Discussion: DBE enabled easy access to the jejunum and exact maneuver in the jejunum. The magnetic anchors were useful to fix the jejunal wall and to confirm the actual puncture point without fluoroscopy. PEG tube placement through the overtube was useful to prevent contamination of the tube and trauma of the intestinal wall. Conclusion: D-PEJ using the DBE and the magnetic anchors was a useful and safe technique.
T1610 Prospective Multicenter Long Term Follow Up Results of New Introducer Percutaneous Endoscopic Gastrostomy Method with Gastropexy in 89 Patients Yogesh Shastri, Angelika Tessmer, Nicolas Hoepffner, Ju ¨Rgen Stein Background: Gauderer’s pull-PEG is the most commonly used method for achieving gastrostomy. But it may not be possible in certain patients with aero-digestive cancers, due to distortion or obstruction of the upper digestive passage. These fractions of patient have advanced malignancies and are severely malnourished so are not fit for the riskier radiological or surgical options of achieving the enteral access. Other drawbacks of pull type PEG are tumor seeding at the peristomal site and higher incidence of PEG site infections due to passage of the inner bumper of the PEG tube through oropharynx. To overcome these issues a new introducer technique has been in use, which avoids the sojourn of PEG catheter through the oropharynx. A prospective follow up study was performed to assess the indications, complications, technical difficulties and long term outcome of PEG-gastropexy. This is the largest
AB260 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
study of PEG-Gastropexy until now. Methods: From May ‘03-October ‘07 PEGgastropexy were placed in 89 selected patients using Freka (PexactÒ, Fresenius, Germany) under Propofol sedation. During this procedure, gastric wall was sutured non surgically to the anterior abdominal wall before catheter insertion using an endoscope. As against the standard PEG we could switch to button PEG much earlier (2-4 wks vs. 6 wks). These patients were followed up in nutrition outpatient clinic till death or end of treatment. Result: PEG placement was successful in all patients. There were 63 males and 26 females with an age range of 11-88 years (avg-62 yrs). The indications for the procedure were the following malignancies: Oral cavity-23, pharynx- 21, larynx-19, esophageal-18, and tumor metastasia-8. The time required to perform the procedure was 15-120 min (avg. 20 min). 5 patients developed peristomal infection during the follow up. In 3 patients there were technique related complications like breaking of the double needle puncture system in 1 and leakage of gastrostomy balloon in 2. 1 of the patients accidentally pulled out the gastrotube 14 days after gastropexy, which was replaced with a button PEG. In 12 patients, gastrotube or button PEG were removed as they were able to eat adequately 6-15 months after the procedure. The survival ranged from 1-23 months (avg-4.5 months). 47 patients died during follow up on PEG feeds. Conclusion: This new introducer PEG Gastropexy technique can be placed safely in almost all patients with obstructing oropharyngeal tumors. It would obviate the need for riskier and more expensive surgical or radiological options in patients in whom pull type PEG is not possible. Long term follow up of the patients revealed only minor complications.
T1611 Nasopharyngeal Selective Decolonization Is Not An Effective Measure to Prevent Percutaneous Endoscopic Gastrostomy Infection - A Randomized Controlled Trial Sandra Faias, Marı´Lia Cravo, Isabel Claro, Susana Ma˜O-De-Ferro, Carlos N. Leita˜O Background: The most comon complication of percutaneous endoscopic gastrostomy (PEG) placement is wound infection, particularly in head-and-neck cancer patients. It can be reduced, but not eliminated, using prophylactic broadspectrum antibiotics. Some studies sugested that selective nasapharyngeal decolonization can reduce stomal infection. Aim: To determine if nasopharyngeal selective decolonization is effective in reducing early PEG site infection in head-andneck cancer patients. Methods: Prospective, randomized trial, with 56 consecutive head-and-neck cancer patients undergoing PEG placement through the ‘‘pull’’ technique, that had oropharyngeal swabs performed prior to the procedure. The patients with negative swabs (group A), received broad-spectrum prophylactic antibiotic before the procedure. The patients with positive swabs were randomized into two goups, Group B that received only broad-spectrum prophylactic antibiotic and Group C that received selective decontamination of the isolated agents and broad-spectrum prophylactic antibiotic. 2- and 7-day PEG stoma evaluations were prospectively performed to search for early stomal infection, defined as purulent discharge with microbiologic isolate in PEG site since the procedure until day 7 after PEG inserton. The association between oropharyngeal decolonization and stomal infection was tested using Fisher’s exact test. Multiple logistic regression analysis tested factors associated with subsequent stomal infection. Results: 56 patients (50 males, mean age Z 58 years) were included. Oropharyngeal colonization was observed in 50% (28/56) of our patients. Early infections occurred in 20% (11/56) of the patients, of which 14% (4/28) in Group A, 33% (5/15) in Group B, and 15% (2/13) in Group C, (p Z ns). There was concordance between agents isolated in oropharynx and PEG site in 45% (5/11) of patients. None of the 11 patients required hospital admission or surgery and all were successfully treated with one course of antibiotics through the PEG tube. By logistic regression analysis, diabetes, steroids, chemoradiation therapy or previous hospitalization did not have a significant effect on early stomal infection. Conclusions: Head-and-neck cancer patients with oropharyngeal colonization (50% in our series) have a higher risk of early PEG site infection. Performing nasopharyngeal swabs and selective agent eradication prior to the procedure reduces the rate of early PEG site infection, but without statistical significance. Since early infections were all minor complications, isolation and selective decontamination of oropharyngeal agents has reduced beneficial clinical effect and may become a hazardous measure.
T1612 A New Device for the Introducer Percutaneous Endoscopic Gastrostomy Technique Jose´ H. Giordano-Nappi, Shinichi Ishioka, Fauze Maluf-Filho, Fabio Y. Hondo, Sergio E. Matuguma, Ivan Cecconello, Paulo Sakai Background: The popular PEG techniques are not adequate for patients with obstructive head and neck cancer due to a higher morbidity, including malignant implant at the abdominal wall. The introducer technique is then indicated and associated to gastropexy provides a safer situation for direct puncture of stomach. Aim: to evaluate the efficacy and safety of a new device for the introducer PEG technique for patients with obstructive head and neck cancer. Patients and Methods: from March to August 2007, 21 consecutive patients (mean age 55 y, range 35-81 y) were submitted to the introducer PEG technique
www.giejournal.org
pattern score was allocated for each patients at the end of procedure as definitely present Z 1, partially present Z 2, definitely absent Z 3. Biopsies were taken from the most abnormal-looking mucosa or apparent normal when present using rocking biopsy forceps and mounted on filter paper and put into formalin for histological assessment. Three more samples were collected for in vitro challenge with gluten-derived toxic peptides . Frozen sections of the biopsies were then evaluated by immunohistochemistry. Results: 76.9 % of subject had a positive value of anti-tissue transglutaminase antibodies while 23.1 % had borderline value. The chromoendoscopic results showed normal villous pattern in 46.2%(6 pts), partially present 15.4%(2 pts), definitively absent 38.5% (5 pts). A significant positive correlation was found between a positive value of anti-tissue transglutaminase antibodies and the endoscopic score of villous pattern (Spearman, r Z 0,56, p ! 0.05). In vitro challenge was positive in 50% of normal villous pattern and in all patients with definitively absent villous pattern. Conclusions: This preliminary study suggest that chromoendoscopy with magnification may disclose with accuracy severe villous atrophy but it may have a great value in evaluating selected series of patients with doubtful diagnosis of celiac disease.
T1609 A New Technique for Direct Percutaneous Endoscopic Jejunostomy Using Double Balloon Endoscopy and Magnetic Anchors in a Porcine Model Tomonori Yano, Keijiro Sunada, Mitsuyo Yoshizawa, Masato Shigemori, Hirotsugu Sakamoto, Tomohisa Nakaya, Hiromi Fukushima, Daisuke Tsukui, Tetsuro Honda, Takashi Kitade, Yuuichi Iwashita, Takahito Takezawa, Norikatsu Numao, Aya Kitamura, Hozumi Tanaka, Eiji Kobayashi, Hironori Yamamoto, Kentaro Sugano Introduction: While direct percutaneous endoscopic jejunostomy (D-PEJ) is a stable and safe access to maintain enteral feeding, it is not yet carried out globally because of the technical difficulty in the procedure. The jejunal lumen is much smaller than that of the stomach. In addition, the location of the jejunal loop is not stable in relation to the abdominal wall. We developed a new technique for D-PEJ using double balloon endoscopy (DBE) and magnetic anchors to resolve these problems. Method: Two magnetic anchors are prepared. One is a small magnet 5 mm in diameter for the inside anchor. The other is a column 15 mm in diameter for the outside anchor. The inside anchor is tied to the double balloon endoscope at 3 cm from the tip. A miniature pig is fasted for 48 hours. Under general anesthesia, the DBE is inserted to the jejunum. The appropriate puncture point is searched out and confirmed by visualizing a clear and discrete finger indentation in the jejunum corresponding to the point of light transmission across the abdominal wall. After the outside anchor is put on the abdominal wall, the inside anchor stick to the wall of the jejunum directly under the outside anchor with magnetic force. For jejunal wall fixation, 18G needle and 18G Seldinger needle are punctured into the jejunum from the abdominal wall beside the outside anchor. Nylon thread with a loop is put through the 18G needle into the jejunum. The fixing thread is put through the 18G Seldinger needle and through the loop. The fixing thread is caught by tightening the loop and pulled out. The jejunal wall is fixed to the abdominal wall by suturing the fixing thread. After incision, the needle stylet with a plastic sheath is punctured into the jejunum. The thread is inserted through the plastic sheath, into the jejunum, grasped by the snare, and pulled out through the overtube with the endoscope. 14Fr pull-type PEG tube with an intraluminal bumper was placed through the overtube. Results: D-PEJ was successfully placed and used for feeding for over one week in all 8 pigs. There was no procedure related complications. The mean procedure time was 89 minutes. Discussion: DBE enabled easy access to the jejunum and exact maneuver in the jejunum. The magnetic anchors were useful to fix the jejunal wall and to confirm the actual puncture point without fluoroscopy. PEG tube placement through the overtube was useful to prevent contamination of the tube and trauma of the intestinal wall. Conclusion: D-PEJ using the DBE and the magnetic anchors was a useful and safe technique.
T1610 Prospective Multicenter Long Term Follow Up Results of New Introducer Percutaneous Endoscopic Gastrostomy Method with Gastropexy in 89 Patients Yogesh Shastri, Angelika Tessmer, Nicolas Hoepffner, Ju ¨Rgen Stein Background: Gauderer’s pull-PEG is the most commonly used method for achieving gastrostomy. But it may not be possible in certain patients with aero-digestive cancers, due to distortion or obstruction of the upper digestive passage. These fractions of patient have advanced malignancies and are severely malnourished so are not fit for the riskier radiological or surgical options of achieving the enteral access. Other drawbacks of pull type PEG are tumor seeding at the peristomal site and higher incidence of PEG site infections due to passage of the inner bumper of the PEG tube through oropharynx. To overcome these issues a new introducer technique has been in use, which avoids the sojourn of PEG catheter through the oropharynx. A prospective follow up study was performed to assess the indications, complications, technical difficulties and long term outcome of PEG-gastropexy. This is the largest
AB260 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
study of PEG-Gastropexy until now. Methods: From May ‘03-October ‘07 PEGgastropexy were placed in 89 selected patients using Freka (PexactÒ, Fresenius, Germany) under Propofol sedation. During this procedure, gastric wall was sutured non surgically to the anterior abdominal wall before catheter insertion using an endoscope. As against the standard PEG we could switch to button PEG much earlier (2-4 wks vs. 6 wks). These patients were followed up in nutrition outpatient clinic till death or end of treatment. Result: PEG placement was successful in all patients. There were 63 males and 26 females with an age range of 11-88 years (avg-62 yrs). The indications for the procedure were the following malignancies: Oral cavity-23, pharynx- 21, larynx-19, esophageal-18, and tumor metastasia-8. The time required to perform the procedure was 15-120 min (avg. 20 min). 5 patients developed peristomal infection during the follow up. In 3 patients there were technique related complications like breaking of the double needle puncture system in 1 and leakage of gastrostomy balloon in 2. 1 of the patients accidentally pulled out the gastrotube 14 days after gastropexy, which was replaced with a button PEG. In 12 patients, gastrotube or button PEG were removed as they were able to eat adequately 6-15 months after the procedure. The survival ranged from 1-23 months (avg-4.5 months). 47 patients died during follow up on PEG feeds. Conclusion: This new introducer PEG Gastropexy technique can be placed safely in almost all patients with obstructing oropharyngeal tumors. It would obviate the need for riskier and more expensive surgical or radiological options in patients in whom pull type PEG is not possible. Long term follow up of the patients revealed only minor complications.
T1611 Nasopharyngeal Selective Decolonization Is Not An Effective Measure to Prevent Percutaneous Endoscopic Gastrostomy Infection - A Randomized Controlled Trial Sandra Faias, Marı´Lia Cravo, Isabel Claro, Susana Ma˜O-De-Ferro, Carlos N. Leita˜O Background: The most comon complication of percutaneous endoscopic gastrostomy (PEG) placement is wound infection, particularly in head-and-neck cancer patients. It can be reduced, but not eliminated, using prophylactic broadspectrum antibiotics. Some studies sugested that selective nasapharyngeal decolonization can reduce stomal infection. Aim: To determine if nasopharyngeal selective decolonization is effective in reducing early PEG site infection in head-andneck cancer patients. Methods: Prospective, randomized trial, with 56 consecutive head-and-neck cancer patients undergoing PEG placement through the ‘‘pull’’ technique, that had oropharyngeal swabs performed prior to the procedure. The patients with negative swabs (group A), received broad-spectrum prophylactic antibiotic before the procedure. The patients with positive swabs were randomized into two goups, Group B that received only broad-spectrum prophylactic antibiotic and Group C that received selective decontamination of the isolated agents and broad-spectrum prophylactic antibiotic. 2- and 7-day PEG stoma evaluations were prospectively performed to search for early stomal infection, defined as purulent discharge with microbiologic isolate in PEG site since the procedure until day 7 after PEG inserton. The association between oropharyngeal decolonization and stomal infection was tested using Fisher’s exact test. Multiple logistic regression analysis tested factors associated with subsequent stomal infection. Results: 56 patients (50 males, mean age Z 58 years) were included. Oropharyngeal colonization was observed in 50% (28/56) of our patients. Early infections occurred in 20% (11/56) of the patients, of which 14% (4/28) in Group A, 33% (5/15) in Group B, and 15% (2/13) in Group C, (p Z ns). There was concordance between agents isolated in oropharynx and PEG site in 45% (5/11) of patients. None of the 11 patients required hospital admission or surgery and all were successfully treated with one course of antibiotics through the PEG tube. By logistic regression analysis, diabetes, steroids, chemoradiation therapy or previous hospitalization did not have a significant effect on early stomal infection. Conclusions: Head-and-neck cancer patients with oropharyngeal colonization (50% in our series) have a higher risk of early PEG site infection. Performing nasopharyngeal swabs and selective agent eradication prior to the procedure reduces the rate of early PEG site infection, but without statistical significance. Since early infections were all minor complications, isolation and selective decontamination of oropharyngeal agents has reduced beneficial clinical effect and may become a hazardous measure.
T1612 A New Device for the Introducer Percutaneous Endoscopic Gastrostomy Technique Jose´ H. Giordano-Nappi, Shinichi Ishioka, Fauze Maluf-Filho, Fabio Y. Hondo, Sergio E. Matuguma, Ivan Cecconello, Paulo Sakai Background: The popular PEG techniques are not adequate for patients with obstructive head and neck cancer due to a higher morbidity, including malignant implant at the abdominal wall. The introducer technique is then indicated and associated to gastropexy provides a safer situation for direct puncture of stomach. Aim: to evaluate the efficacy and safety of a new device for the introducer PEG technique for patients with obstructive head and neck cancer. Patients and Methods: from March to August 2007, 21 consecutive patients (mean age 55 y, range 35-81 y) were submitted to the introducer PEG technique
www.giejournal.org