Abstract : Percutaneous endoscopic gastrostomy (PEG) is a feasible and safe technique for patients who need long-term feeding and cannot eat orally. With the increasing maturity of PEG technique, a large number of patients receive PEG tube placement every year in the world. However, PEG tube placement is not necessary in some patients, and some other patients are not evaluated strictly, leading to serious complications. In a broad sense, the mainly two indications for PEG include long-term enteral nutrition and gastric decompression. On the other hand, the main contraindications of PEG are distal intestinal obstruction, severe coagulation abnormalities, and severe infection at the PEG site. In the first section of this review, the indications and contraindications of PEG are introduced. Although PEG tube placement is a relatively safe technique, it can still cause a number of complications, including minor and major complications. Through standard management and treatment, the outcome of most patients is very good. In the second section of this review, we describe a variety of minor and major tube-related complications, and the treatment and prevention of these complications. In addition, the preparation and post-insertion care are also very important for PEG, which can reduce the incidence of complications. In the last section of this review, we describe related issues about the preparation and post-insertion care of PEG. In conclusion, PEG tube placement is a widely accepted technique that can bring benefits to the right patients.
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Abstract : Percutaneous transesophageal gastrotubing (PTEG) procedure was developed in Japan as an alternative access route into the gastrointestinal tract, and it has been performed for patients in whom percutaneous endoscopic gastrostomy would be technically difficult to place or is contraindicated, such as in a prior gastrectomy and massive ascites. In the PTEG procedure, an indwelling tube is inserted through the cervical esophagus, which gives the patient a slight discomfort after the tube placement. Therefore, PTEG is performed not only for enteral feeding, but also for bowel decompression as a palliative care in patients with malignant gastrointestinal obstruction. Recently, several reports of PTEG from countries outside Japan indicated a high technical success rate without major complications. Furthermore, the usefulness of PTEG for bowel decompression as a palliative care was reported in prospective studies. In fact, PTEG is a technically feasible and safe procedure worldwide.
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Abstract : Although percutaneous radiologic jejunostomy has not been widely accepted as a primary insertion technique due to the technical difficulty for inexperienced operators, it may be a crucial procedure for patients with previous gastrectomy or an otherwise inaccessible stomach, particularly in patients who are not candidates for a surgical jejunostomy. Targeting the appropriate target jejunal loop and affixing the bowel with a t-fastener anchor are the most important and challenging technical steps. Technical success rate ranged from 92% to 100% based on 19 to 106 patients in several representative reports, with major complications ranging from 3.9% to 13.0%.
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Abstract : Division of Gastrointestinal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, KoreaNutritional support through feeding tubes for patients who are unable to take oral feed has many advantages over parenteral nutrition. The feeding tubes can also be used for decompression in patients with bowel obstruction or gastroparesis and those requiring peri-operative nutritional support when oral intake is contraindicated or limited. Therefore, insertion of the feeding tube is currently one of the most commonly performed procedures. With the advances in intervention, most of the feeding tubes are inserted under endoscopic or fluoroscopic guidance. However, in some cases only the insertion of a surgical feeding tube is possible. This paper introduces the indications for inserting a surgical feeding tube formation. It also describes the surgical management of dislodgement and clogging of the tube, and enterocutaneous fistula among the possible complications.
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Abstract : Surgical gastrojejunostomy (GJ) has traditionally been the mainstay of treatment for malignant gastric outlet obstruction (GOO). However, most patients preferentially choose to undergo self-expandable metal stent (SEMS) placement due to its minimally invasive nature, although it is wellrecognized that surgical GJ is associated with longer patency and less reinterventions than SEMS placement. Endoscopic ultrasound (EUS)-guided GJ has recently emerged as a novel procedure for the treatment of malignant GOO. This procedure offers a non-surgical means of performing GJ, but its widespread use is limited because it could only be performed by experienced endoscopists with expertise in EUS-guided procedures. The authors performed fluoroscopy-guided GJ in eight domestic pigs by puncturing the proximal jejunum from the stomach using a Rösch-Uchida transjugular liver access set followed by the placement of a lumen-apposing metal stent across the puncture tract. The results showed that fluoroscopy-guided GJ may be a technically feasible and simple procedure but, before clinical trials can be undertaken, further technical refinements are required to reduce the risk of inadvertent transgression of non-target organs.
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Abstract : Background: Radiographic guided percutaneous gastrostomy has become a safe and effective enteral nutrition method for patients who can not eat by mouth. Fluoroscopy, computed tomography (CT) and cone-beam CT have been routinely used clinically. The aim of this study was to compare the advantages and disadvantages of percutaneous gastrostomy using different radiographic guided methods. Methods: We retrospectively analyzed the clinical data of 538 patients undergoing percutaneous gastrostomy in our department. According to the image guidance method used in gastrostomy, the patients were divided into groups A by fluoroscopy guidance, group B by fluoroscopy combined with C-arm CT guidance, and group C with the whole process CT guidance. The gastrostomy success rate, complication rate, procedure time, and patient radiation dose were analyzed in the three groups. Results: Among 538 patients, 534 were successful and the success rates are 94.3%, 99.3%, and 100% in group A, B, and C, respectively (P > 0.05). There were 3 cases occurred postoperative bleeding as serious adverse events and transferred to surgical gastrostomy. The minor complications include local infection, hyperplasia of granulation tissue, tube obstruction or prolapse, and local pain of the ostomy. The minor complication rates were 10.5%, 10.4%, and 7.7% in group A, B, and C, respectively (P > 0.05). The average procedure time was 25.57 ± 5.99 minutes, 29.01 ± 6.63 minutes, and 45.47 ± 8.98 minutes, respectively (χ2 = 87.98, P < 0.001). The average radiation dosage was 27.30 ± 19.27 mGy, 145.07 ± 106.08 mGy, and 2,590.26 ± 1,088.22 mGy, respectively (χ2 = 204.44, P < 0.001). Conclusion: There were no significant differences in the success rates and complication rates of gastrostomy under the three guiding methods. For difficult cases, CT-guided gastrostomy may be a very useful supplemental method.
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Abstract : Background: Percutaneous radiologic gastrostomy (PRG) was considered as an alternative technique for long-term enteral nutrition, and the current study is aimed to evaluate the feasibility and safety of this technique in patients with amyotrophic lateral sclerosis (ALS) at a single medical center. Methods: From July 2017 to October 2020, a total of 14 patients underwent PRG with ALS were included in this retrospective study with a median age of 64.0 years, and 78.6% were male. The procedure comprised a dilation of the stomach via a nasogastric catheter, followed by puncture and gastrostomy tube placement under fluoroscopic guidance. The technical success rate and clinical outcomes were recorded over 3 months following the procedure. Results: The technical success rate was 100%. During the follow-up period, minor complications were reported in 2 of patients (14.3%) including superficial skin infection and early tube block. Neither major complications nor mortality were observed. Body mass index of the patients increased significantly from 16.4 ± 2.1 kg/m2 to 17.1 ± 2.0 kg/m2 (t = –13.77; P < 0.001), and the albumin level increased significantly from 37.5 ± 2.3 g/L to 41.8 ± 1.6 g/L (t = –8.82, P < 0.001). Conclusion: PRG is a relatively safe and effective method for ALS patients, and deserves widespread clinical acceptance.
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Abstract : Left-sided portal hypertension following pancreaticoduodenectomy (PD) with portal vein resection and splenic vein ligation may cause ectopic variceal formation, potentially resulting in life-threatening bleeding. We report of a 79-year-old male suffering from severe anemia and melena after PD. Emergency endoscopy and contrast-enhanced computed tomography (CECT) revealed ectopic varices at the anastomosis site of pancreaticojejunostomy. An interventional radiology approach was preferred over surgical and endoscopic treatment because of the poor general condition and altered anatomy. In the first procedure, percutaneous transhepatic retrograde obliteration was performed using the coaxial double balloon-occlusion technique. Although hemostasis was obtained, re-bleeding occurred two months later. CECT revealed the development of another collateral pathway and the recurrence of varices. Insufficient embolization of the afferent vein was considered the cause of recurrence. Therefore, a percutaneous transsplenic approach was used, and complete embolization of varices was achieved. When transhepatic retrograde obliteration is not effective, transsplenic antegrade obliteration can be a useful therapeutic option.
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Abstract : Esophageal cancer is one of the lethal malignant tumors because it is often diagnosed in the advanced stage with lymph node or distant metastasis. The recurrence rate of esophageal cancer is known to be about 40% to 50% even in the patients who underwent curative esophageal resection. Most frequent sites of metastases are known to be the liver. Furthermore, other distant metastases also could be developed in lung, bone, brain, kidney, adrenal, abdominal cavity, and skin. However, ampulla of Vater (AoV) metastasis rarely occurs from esophageal cancer. Therefore, we report herein a case of AoV metastasis from squamous cell carcinoma of the esophagus.
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Abstract : Foreign bodies in common bile duct (CBD) are rare. Obstructive jaundice in patients who have undergone cholecystectomy may be due to a variety of causes. Common causes of obstruction in these cases are residual stones, inflammatory or ischaemic strictures following CBD injury during cholecystectomy or malignant strictures. Foreign bodies in the bile duct in these post cholecystectomy patients are known but reported very rarely. Clinical features and biochemistry of these patients are no different than those due to other causes mentioned above. Imaging studies will show obstruction due to stones or sludge or narrowing but may not give conclusive diagnosis of a foreign body. Endoscopic ultrasound is helpful in these cases as it shows a hyperechoic foreign body within the stone if the substance is a metallic clip. In our current case series, we are presenting eight such cases with post cholecystectomy foreign bodies, in the form of materials used for ligating or clipping the cystic duct before transection during cholecystectomy, or a mistakenly left behind gauze piece, migrating into the bile duct and forming a nidus for stone formation and causing CBD obstruction. To conclude, if a patient presents with biliary obstruction with a history of cholecystectomy, the possibility of foreign body in the CBD must be considered as a possible differential diagnosis.
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