Hiroo Hatakeyama

Inhibition of Gastroesophageal Reflux by Semi-solid Nutrients in Patients With Percutaneous Endoscopic Gastrostomy

BACKGROUND Aspiration is one of the major complications after percutaneous endoscopic gastrostomy (PEG). The administration of semi-solid nutrients by means of gastrostomy tube has recently been reported to be effective in preventing aspiration pneumonia. The effects of semi-solid nutrients on gastroesophageal reflux, intragastric distribution, and gastric emptying were evaluated. METHODS Semi-solid nutrients were prepared by liquid nutrients mixed with agar at the concentration of 0.5%. The distribution of the administered radiolabeled liquid and semi-solid nutrients was monitored by a scintillation camera for 15 post-PEG patients. The percentage of esophageal reflux, the distribution of the proximal and distal stomach, and the gastric emptying time were evaluated. RESULTS The percentage of gastroesophageal reflux was significantly decreased in semi-solid nutrients (0.82 +/- 1.27%) compared with liquid nutrients (3.75 +/- 4.25%), whereas the gastric emptying time was not different. The distribution of semi-solid nutrients was not different from liquid nutrients in the early phase, whereas higher retention of liquid nutrients in the proximal stomach was observed in the late phase. CONCLUSIONS Gastroesophageal reflux was significantly inhibited by semi-solid nutrients. One of the mechanisms of the inhibition is considered to be an improvement in the transition from the proximal to distal stomach in semi-solid nutrients.

Predominant copper deficiency during prolonged enteral nutrition through a jejunostomy tube compared to that through a gastrostomy tube

BACKGROUND & AIMS Trace element deficiencies are known to occur during long-term enteral nutrition feeding. We compared the serum concentrations of trace elements between patients treated with gastrostomy and those treated with jejunostomy. METHODS Our subjects were 36 patients who underwent percutaneous endoscopic gastrostomy (PEG group) and 23 patients who underwent percutaneous endoscopic jejunostomy (PEJ group) and were maintained with enteral tube feeding for more than one year. The serum concentrations of copper, zinc, selenium, and iron were measured in the two groups. Clinical manifestations and the effectiveness of supplementation therapy against copper deficiency were also investigated. RESULTS From 6 months after the onset of enteral feeding, the copper concentration of the PEJ group was significantly decreased compared with that of the PEG group (p<0.001). There were no significant differences in the concentrations of zinc, selenium, or iron between the two groups. Severe copper deficiency was observed in 6 patients of the PEJ group and was accompanied with neutropenia and anemia. The copper deficiency was successfully treated in all of these patients by supplementation with 10-40 g of cocoa powder a day which was equivalent to a total daily dose of 1.36-2.56 mg of copper. CONCLUSIONS Prolonged PEJ tube nutrition tends to result in copper deficiency, and cocoa supplementation is effective for treating such copper deficiency.

Human papillomavirus type 16-positive esophageal papilloma at an endoscopic injection sclerotherapy site

Human papillomavirus infection is important for both the development of papilloma and the progression of the papilloma-carcinoma sequence in the cervix, larynx, lung, and colon. Esophageal squamous cell papilloma is rare but important as a possible precancerous lesion. Esophageal papilloma has previously been thought to develop mainly as a result of chemical irritation by chronic gastroesophageal reflux. However, a few recent studies suggested a role for papillomavirus infection in esophageal tumorigenesis, although the exact route of transmission and invasion of the virus has not been fully elucidated. A case of esophageal squamous papilloma at the site of endoscopic injection sclerotherapy (EIS) for varices is reported. Papilloma development was followed up clinically during a 2-year period, and the papilloma was removed by endoscopic mucosal resection. Histological examination of the tissue confirmed the diagnosis of squamous cell papilloma. DNA analysis of the tumor showed integration of papillomavirus type 16 but not types 18 and 33. The surrounding normal mucosa did not contain any of the three virus types. Injury such as ulceration resulting from EIS may have provided a locus susceptible to the viral infection. The clinical course after EIS should be monitored carefully to detect papilloma formation.

Retrospective analyses of complications associated with transcutaneous replacement of percutaneous gastrostomy and jejunostomy feeding devices

BACKGROUND Feeding device replacement is often required for long-term maintenance after initial percutaneous endoscopic gastrostomy or jejunostomy placement. Although there are several case reports on serious complications of gastrostomy device replacement, there are few reports of an overall analysis of the complications associated with feeding device replacement. OBJECTIVE To evaluate the frequency and variety of complications of transcutaneous replacement of feeding devices. DESIGN A retrospective study. SETTING Single center: Nishimino Kosei Hospital. PATIENTS This study involved 363 consecutive patients undergoing a total of 1265 percutaneous gastrostomy or jejunostomy device replacements from March 2000 to September 2010. INTERVENTION A new replacement device was inserted through the ostomy tract by using an obturator after traction removal of the previous device. Endoscopic treatments were performed in the cases of fistula disruption or hemorrhage. MAIN OUTCOME MEASUREMENTS Complications and their outcomes. RESULTS Gastrostomy and jejunostomy devices were replaced 1126 and 139 times, respectively. There were 16 complications (1.3% of total replacements) consisting of 10 cases of fistula disruption caused by misplacement of replacement devices into the peritoneal cavity, 4 cases of hemorrhage, and 1 case each of colocutaneous fistula and device breakage. Anticoagulation or antiplatelet medications were continued in all 4 hemorrhage cases but in only 27 of 347 (7.7%) complication-free cases (P < .0001). There were no replacement-related adverse events that required surgical repair. LIMITATIONS A single center, retrospective analysis. CONCLUSION Fistula disruption and hemorrhage were the most common complications associated with device replacement. In patients on anticoagulants, caution is necessary to avoid hemorrhage after replacement. It is also important to verify that the replaced device is located in the GI tract lumen before feeding.

Effects of Cytokines on the Binding of Leukocytes to Cultured Rat Hepatocytes and on the Expression of ICAM-1 by Hepatocytes

Adhesions of leukocytes to hepatocytes andsinusoidal endothelial cells mediates the induction andprogression of hepatic injury. However, in contrast toendothelial cells, information regarding the regulation of interactions between leukocytes andhepatocytes is limited. In the present study, weinvestigated the effect of inflammatory mediatorsincluding lipopolysaccharide (LPS), staphylococcalenterotoxin B (SEB), interferon-γ (IFN-γ), tumornecrosis factor-α (TNF-α), andinterleukin-1β (IL-1β) on the adhesion ofpolymorphonuclear leukocytes or lymphocytes to primarycultured rat hepatocytes, and on the expression of intercellular adhesionmolecule-1 (ICAM-1) gene in hepatocytes. Bothpolymorphonuclear leukocyte and lymphocyte adhesion tohepatocytes were enhanced after exposure of hepatocytes to IFN-γ and TNF-α, but not afterexposure to LPS, SEB or IL-1β. The adhesion inducedby either IFN-γ or TNF-α was inhibited bymonoclonal antibodies against ICAM-1 or lymphocytefunction-associated antigen-1 (LFA-1). Nonstimulated hepatocytesexpressed faintly ICAM-1 mRNA, which increased slightlyduring the culture period. ICAM-1 mRNA expression wasup-regulated to a greater extent by incubating hepatocytes with IFN-γ or TNF-α,and peaked after 12 hr of incubation with TNF-αand after 24 hr with IFN-γ. These results indicatethat IFN-γ and TNF-α induce the expressionof ICAM-1 on parenchymal hepatocytes and that theLFA-1-ICAM-1 pathway plays an important role in theinteraction between hepatocytes and neutrophils orlymphocytes.

Clinical investigation of upper gastrointestinal hemorrhage after percutaneous endoscopic gastrostomy.

Background:  Upper gastrointestinal (GI) hemorrhage after percutaneous endoscopic gastrostomy (PEG) is sometimes reported as one of the serious complications. Our purpose was to clarify the cause of upper GI hemorrhage after PEG.

Transcecostomal colonic stent placement after US-guided percutaneous cecostomy.

Colorectal stenting for the treatment of malignant largebowel obstruction is useful for palliation or as a bridge to surgery. 1 It is more difficult to position a stent in the rightsided colon by using a retrograde placement method via the rectum compared with the distal colon. Herein, we present a case involving the successful antegrade placement of a stent in the ascending colon after US-guided percutaneous cecostomy.

Transgastrostomal Observation and Management Using an Ultrathin Endoscope After Percutaneous Endoscopic Gastrostomy

Recent developments have made ultrathin endoscopes available for routine esophagogastroduodenoscopy and also for unsedated transnasal observation (Shaker, 1994). Transnasal endoscopy is known to be less of a burden for patients (more tolerable) than transoral endoscopy and has benefits including fewer effects on respiratory and cardiovascular status and reduced recovery time after the procedure (Campo et al., 1998; Dumortier et al., 1999; Mori et al., 2008). Transnasal ultrathin endoscopy has also been applied for biliary drainage, insertion of a nasoenteral feeding tube or a long intestinal tube, and percutaneous endoscopic gastrostomy (PEG) (Fang et al., 2005; Itoi et al., 2008; Sato et al., 2008; Vitale et al., 2005). PEG has become the primary access for long term enteral feeding since its introduction in 1980 (Gauderer et al., 1980; Ponsky & Gauderer, 1981), being a very easy and rapid method compared with the previous surgical technique to place a gastrostomy tube. The endoscopic approach from the gastrocutaneous tract was first described by Chaurasia , et al. for the insertion of a jejunal feeding tube through the PEG (PEG-J) tract (Chaurasia & Chang, 1995). Although they used a pediatric bronchoscope at that time, an ultrathin endoscope later took its place for this purpose (Adler et al., 2002). We have been employing an ultrathin endoscope through the gastrostomy tract for observation, diagnosis, and treatment of various digestive diseases from April 2003. We also investigated the usefulness of such transgastrostomal endoscopy (TGE) for management of patients who had undergone percutaneous endoscopic gastrostomy (PEG).

ENDOSCOPIC ULTRASONOGRAPHY-GUIDED GASTROSTOMY TUBE PLACEMENT FROM THE STOMACH

Dear Editor, A 92-year-old woman with severe dementia presented difficulty of oral intake after the treatments of a right femoral neck fracture and severe esophageal ulcer. Percutaneous endoscopic gastrostomy (PEG) was not available, because her stomach had largely ascended in the thoracic cavity. Subsequently, we attempted to place a gastrostomy tube (Ponsky PEG; Bard Access Systems, Inc., Salt Lake City, UT, USA) using the technique of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA), as shown in Fig. 1.The stomach was pushed downward to the abdominal wall from a subcostal location using an echoendoscope (GF-UCT240-AL5; Olympus Optical Co.,Tokyo, Japan) under fluoroscopic guidance. The interpositioning of the intestine, liver, spleen, and vessels was avoided using the echoendoscope, and we sought an appropriate puncture position using finger indentation from the abdominal wall (Fig. 2).A 19-gauge needle for FNA (Echo Tip Ultra; Cook Endoscopy, Winston-Salem, NC, USA) was used to puncture the abdominal wall, and the loop wire was inserted through the needle from the skin surface side. The needle was withdrawn into the endoscope and pulled out from the mouth with the endoscope. A 20-F gastrostomy tube was positioned by the pull-through technique. We compressed the gastric and abdominal walls between the internal and external bolster of the tube for 7 days until a gastrocutaneous fistula was successfully formed. Major reasons for failure of PEG include a lack of transillumination due to dislocation of the stomach, the anterior interposition of other organs, previous gastric resection, or the inability to carry out endoscopic insertion to the stomach. Chaves et al. reported five cases of EUS-guided PEG in patients lacking abdominal wall transillumination. Their method was to puncture a trocar from the abdominal wall over a 22-gauge needle inserted from EUS. In the present case, the use of a larger-bore puncture needle (19-gauge) Correspondence: Shinji Nishiwaki, Department of Internal Medicine, Nishimino Kosei Hospital, 986 Oshikoshi, Yoro-cho, Yoro-gun, Gifu 5031394, Japan. Email: wakky@nishimino.gfkosei.or.jp