Gonçalo Nunes

Enteral feeding through endoscopic gastrostomy in amyotrophic lateral sclerosis patients

BACKGROUND Dysphagia is common in amyotrophic lateral sclerosis (ALS) and may result in malnutrition. Endoscopic gastrostomy (PEG) is recommended when oral feeding is unsafe. This work aims to assess the effectiveness and safety of PEG feeding on improving nutritional and prognostic parameters in ALS patients. METHODS Observational and retrospective study using records from ALS patients referred for gastrostomy. Age, gender and mortality data were collected. NRS 2002, body mass index (BMI), serum albumin, transferrin and total cholesterol were recorded at the time of PEG (T0) and repeated after 3 months (T3). The evolution of these parameters was analysed and compared to survival. RESULTS Data from 37 ALS patients (18 men/19 women) aged 43-88 years (mean: 69 years). All patients presented NRS 2002 ≥ 3 points. On average, patients underwent gastrostomy 11 months after diagnosis. No major procedural complications occurred. Mean survival after diagnosis was 22.2 months. Mortality rate at 3 months was 21.6% with a mean survival after PEG of 11.2 months. Albumin, transferrin and cholesterol levels increased from T0 to T3 without reaching statistical significance. Higher albumin (R = 0.3) and transferrin (R = 0.4) at admission tend to be positively correlated with survival. Mean BMI was similar at the two moments but higher initial values were associated with better outcome (R2 = 0.39, p < 0.05). CONCLUSIONS PEG is a safe and effective technique for enteral feeding and should be considered early in ALS patients with dysphagia. Higher BMI predicts longer survival. The association between higher serum proteins and survival must be confirmed in further studies.

Small bowel obstruction after endoscopic fragmentation of a gastric bezoar: An unexpected complication

We present the case of a 57-year-old man who was admitted for weight loss (>15% in 4 months) and recurrent vomiting. His medical history included type II diabetes mellitus and a gastroduodenal surgery 15 years before due to complicated peptic ulcer disease. On admission, he was malnourished and severely dehydrated. An abdominal computed tomography showed marked gastric distension due to partially occlusive heterogeneous luminal content in the antrum and proximal duodenum. On upper gastrointestinal endoscopy, a Billroth I partial gastrectomy was observed. A bulky bezoar extending from the distal body to the gastroduodenal anastomosis was identified and successfully broken up in fragments of <2 cm, using foreign body forceps and a polypectomy snare, after through-the-scope irrigation and needle injection with Coca-Cola® (Figure 1a, b). After the procedure, a solid diet was restarted. The patient became asymptomatic and was discharged the following day. He was advised to ingest large amounts of Coca-Cola® for a few weeks. After 3 days, he was readmitted because of recurrent vomiting, dehydration, and oral feeding intolerance. On endoscopy, his stomach was empty, but a striking distension of the duodenum and jejunum, filled by liquid and undigested material, prevented mucosal examination. Total parenteral nutrition was started to control malnutrition, and a magnetic resonance enterography performed 1 week later showed a 5.6×3.8-cm bezoar in the distal

Hypogammaglobulinemic sprue manifested as chronic intestinal failure: An uncommon but effective indication for home parenteral nutrition

Gonçalo Nunes1, Cláudio Martins2, Cristina Teixeira2, Miguel Fróis Borges3, Ana Paula Oliveira2, Jorge Fonseca1,4 1Department of Gastroenterology, GENE Artificial Feeding Team, Hospital Garcia de Orta, Almada, Portugal 2Department of Gastroenterology, Hospital de São Bernardo, Setúbal, Portugal 3Department of General Surgery, Hospital Garcia de Orta, Almada, Portugal 4Centro de investigação interdisciplinar Egas Moniz (CiiEM), Monte da Caparica, Portugal

Avoiding Stent-in-Stent Retrieval Strategy for Partially Covered Stents in Anastomotic Leakages: An Innovative Approach

Anastomotic leakage is still one of the most feared surgical complications with an incidence of 3–25% [1]. The endoscopic placement of self-expanded metallic esophageal stents has become the preferred primary treatment with an 85% clinical success [2]. Fully covered metal stents (FCMS) are prone to migration due to its reduced anchoring capacity and partially covered metal stents (PCMS) cause tissue ingrowth as early as 1 week after placement, impairing its removal with risk of bleeding and perforation [2]. The stent-in-stent technique requires placement of an FCMS inside the PCMS during 10–14 days to induce pressure necrosis of the overgrowing and ingrowing mucosa, allowing further safe removal [3]. An 82-year-old woman previously submitted to total gastrectomy due to gastric adenocarcinoma was newly diagnosed with a colorectal adenocarcinoma. A left hemicolectomy was performed but an incidental laceration of a proximal jejunal loop complicated the procedure and a new esophagojejunal anastomosis had to be accomplished. Few days after surgery, signs of sepsis developed and an esophagojejunal anastomosis leakage was confirmed. Gastroenterology consultation was requested for stent placement. In the upper gastrointestinal endoscopy, a 5-mm orifice with a milky draining fluid was detected 32 cm from the incisors. A PCMS 23 × 120 mm was placed and fixed with endoscopic clips after extensive cauterization of the tissue surrounding the fistula orifice (Fig. 1). Two weeks later, a follow-up outpatient endoscopy showed a 2-cm distal migration, albeit the orifice was still covered. Overgrowing tissue was present but the stent could be easily repositioned. The stent remained in place for two additional weeks and later was easily removed without complications. The orifice was completely sealed at this time and the patient remained asymptomatic (Fig. 2).

Giant esophageal diverticulum as a new clinical indication for endoscopic gastrostomy

Persistent mechanical or functional dysphagia is the most common clinical indication for endoscopic gastrostomy (PEG), however less common conditions may justify prolonged enteral feeding to avoid malnutrition and prevent aspiration. The authors report the case of a 76 year old man referred to the artificial feeding outpatient clinic presenting dysphagia, malnutrition and several episodes of aspiration pneumonia. Upper endoscopy showed a giant esophageal diverticulum, ineffective peristalsis and transient lumen narrowing. X-ray and CT scan confirmed a 9cm long diverticulum. Due to a high surgical risk and unsuitability of endoscopic therapy, the patient underwent PEG, which solved aspiration and improved nutritional status. Dysphagia and aspiration due to giant esophageal diverticula emerges as a new clinical indication for PEG in malnourished patients with respiratory aspiration, not previously reported in the literature.

Catheter traction and gastric outlet obstruction : a repeated complication of using a Foley catheter for gastrostomy tube replacement

BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is a safe procedure and major morbidity is unusual. However, the number of PEG fed patients is increasing all over the world and complications may become more and more frequent. CASE REPORT We describe a 73 years old woman with persistent vomit after replacement of the standard PEG tube with a Foley catheter. An upper GI endoscopy showed the catheter pulled into the duodenum causing gastric outlet obstruction. It was removed and replaced by a suitable standard PEG tube, allowing PEG feeding to be resumed. DISCUSSION Previous reports pointed the risk of this complication, almost always associated with insertion of a Foley-type catheter. Replacement of PEG tubes should be performed by experienced teams using standard PEG tubes and the use of Foley-type catheters for this purpose should be banned from routine practice.

Clinical use of metal and plastic calipers for nutritional assessment of patients under long-term enteral feeding through endoscopic gastrostomy

BACKGROUND Endoscopic gastrostomy (PEG) fed patients, including those with neurologic disorders (ND) or head and neck cancer (HNC) present high malnutrition risk and speech difficulties. Teams taking care of these patients need to rely on anthropometric data. Skinfold thickness (TSF) is used to assess nutritional status, but the use of heavy, large and expensive metal calipers may become a limitation. This study aimed to compare and correlate TSF measurements using a metal caliper and a plastic caliper in PEG fed patients. METHODS Prospective observational study on adult PEG fed patients. TSF was measured using plastic Ross and Lange metal calipers. Paired measurements were compared and correlated. RESULTS Fifty-one patients, 37 men (72.5%), 14 women (27.5%): 28 (54.9%) ND patients; 23 (45.1%) with HNC. In total, 94 TSF measurements were performed using both plastic and metal calipers. Significant association was found between TSF measurements with the two equipments (rs = 0.94; p < 0.001). High correlation was observed between TSF measurements using both calipers for both genders (men: rs = 0.93; p < 0.001; women: rs = 0.96; p < 0.001), age (< 65 years: rs = 0.98; p < 0.001; ≥ 65 years: rs = 0.88; p < 0.001), underlying condition (ND: rs = 0.91; p < 0.001; HNC: rs = 0.95; p < 0.001) and time of TSF evaluation (before PEG: rs = 0.95; p < 0,001; after PEG: rs = 0.92; p < 0.001). CONCLUSIONS TSF measurements obtained with small, light and cheap plastic Ross caliper were equivalent to those obtained with larger, heavier and more expensive metal caliper. For everyday clinical practice, plastic calipers may be suitable for teams taking care of PEG fed patients in hospital wards, outpatient clinic and home visits.

Adult Celiac Disease: The Importance of Extraintestinal Manifestations

Celiac disease (CD) is a chronic immune-mediated enteropathy driven by gluten and affecting individuals of all ages. The diagnosis of CD in adulthood is emerging and patients often present with nonclassical extraintestinal manifestations. We report the case of a 53-year-old man presenting with neuromuscular symptoms, skin rash, inconspicuous chronic diarrhea, marked weight loss, and biochemical markers of malabsorption. A strong clinical suspicion led to the diagnosis of CD with clinical recovery after the initiation of a gluten-free diet. Clinical presentation with atypical symptoms in adult CD patients is the rule and not the exception. Most of the extraintestinal manifestations depend on background autoimmune phenomena and micronutrient malabsorption. A gluten-free diet re-establishes homeostasis and prevents long-term complications.

GASTRIC SLEEVE SURGERY AS A NEW CLINICAL INDICATION FOR SURGICAL GASTROSTOMY AFTER FAILURE OF ENDOSCOPIC APPROACH IN PATIENTS WHO NEED LONG-TERM ENTERAL NUTRITION

Percutaneous endoscopic gastrostomy is currently the gold standard method for long-term enteral feeding in patients with persistent dysphagia owing to oncologic and neurologic disorders1. However, despite its safety and practical execution, some limitations persist, especially when obstructive lesions prevent endoscopic gastric access or abdominal wall transillumitation is hampered by obesity, ascites, previous abdominal surgery or visceral interposition1.