Percutaneous endoscopic gastrostomy tube replacement: A simple procedure?

Replacement of gastrostomy tube in patients under-going percutaneous endoscopic gastrostomy (PEG) is generally considered as a safe and simple procedure. However, it could be associated with serious complications, such as gastrocutaneous tract disruption and intraperitoneal tube placement, which may lead to chemical peritonitis and even death. When PEG tube needs a replacement (e.g., occlusion or breakage of the tube), clinicians must realize that the gastrocutaneous tract of PEG is more friable than that of surgical gastrostomy because there is no suture fixation between gastric wall and abdominal wall in PEG. In general, the tract of PEG begins to mature in 1-2 wk after placement and it is well formed in 4-6 wk. However, this process could take a longer period of time in some patients. Accordingly, this article describes three major principles of a safe PEG tube replacement: (1) good control of the replacement tube along the well-formed gastrocutaneous tract; (2) minimal insertion force during the replacement, and, most importantly; and (3) reliable methods for the confirmation of intragastric tube insertion. In addition, the management of patients with suspected intraperitoneal tube placement (e.g., patients having abdominal pain or signs of peritonitis immediately after PEG tube replacement or shortly after tube feeding was resumed) is discussed. If prompt investigation confirms the intraperitoneal tube placement, surgical intervention is usually required. This article also highlights the fact that each institute should have an optimal protocol for PEG tube replacement to prevent, or to minimize, such serious complications. Meanwhile, clinicians should be aware of these potential complications, particularly if there are any difficulties during the gastrostomy tube replacement.     

Perforated Peptic Ulcer: Clinical Presentation,Surgical Outcomes,and the Accuracy of the Boey Scoring System in Predicting Postoperative Morbidity and Mortality

Background  The purposes of this study were to determine clinical presentations and surgical outcomes of perforated peptic ulcer (PPU), and to evaluate the accuracy of the Boey scoring system in predicting mortality and morbidity. Methods  We carried out a retrospective study of patients undergoing emergency surgery for PPU between 2001 and 2006 in a university hospital. Clinical presentations and surgical outcomes were analyzed. Adjusted odds ratio (OR) of each Boey score on morbidity and mortality rate was compared with zero risk score. Receiver-operating characteristic curve analysis was used to compare the predictive ability between Boey score, American Society of Anesthesiologists (ASA) classification, and Mannheim Peritonitis Index (MPI). Results  The study included 152 patients with average age of 52 years (range: 15–88 years), and 78% were male. The most common site of PPU was the prepyloric region (74%). Primary closure and omental graft was the most common procedure performed. Overall mortality rate was 9% and the complication rate was 30%. The mortality rate increased progressively with increasing numbers of the Boey score: 1%, 8% (OR = 2.4), 33% (OR = 3.5), and 38% (OR = 7.7) for 0, 1, 2, and 3 scores, respectively (p < 0.001). The morbidity rates for 0, 1, 2, and 3 Boey scores were 11%, 47% (OR = 2.9), 75% (OR = 4.3), and 77% (OR = 4.9), respectively (p < 0.001). Boey score and ASA classification appeared to be better than MPI for predicting the poor surgical outcomes. Conclusions  Perforated peptic ulcer is associated with high rates of mortality and morbidity. The Boey risk score serves as a simple and precise predictor for postoperative mortality and morbidity.     

Successful venous thrombectomy in complicated microsurgical head and neck reconstruction: report of two cases

Even with excellent results in microsurgical free flap surgery, the reported overall complication rates still range from 17.2% to 52.8%. Among these complications, venous thrombosis has been recognized as one of the most severe. This condition can be treated by various surgical and non-surgical methods. Two cases of a fibula osseofasciocutaneous free flap reconstruction for head and neck cancer complicated by venous thrombosis at anastomotic sites are reported. This was successfully salvaged by Fogarty venous catheter thrombectomy followed by re-anastomosis.     

Paget’s Disease as a Local Recurrence after Nipple-Sparing Mastectomy: Clinical Presentation, Treatment, Outcome, and Risk Factor Analysis

Background

Paget??s disease is a rare clinical and histological type of local recurrence (LR) after breast cancer treatment both in case of conservative surgery or nipple-sparing mastectomy (NSM) with or without intraoperative radiation.

Methods

We performed an analysis of 861 NSM with electron beam intraoperative radiotherapy (ELIOT) patients treated at the European Institute of Oncology from 2002 to 2008, focused on Paget??s disease local recurrence.

Results

In 861 patients (713 invasive carcinoma and 148 intraepithelial neoplasia), there were 36 local recurrences (4.18%), and among these were 7 Paget??s disease local recurrences (0.8%). Median follow-up was 50?months. Four cases presented with nipple areola complex (NAC) erosions, two crusted lesions, and one ulcerated NAC. The average latency period from the NSM to Paget??s disease local recurrence is 32 months (range, 12?C49). Complete NAC removal was performed in all seven recurrences. The average follow-up after NAC removal was 47.4 months (range, 20?C78). We found neither locoregional relapse nor metastatic event in this group. All patients were alive without disease.

Conclusions

Paget??s disease local recurrence can be found in a significant proportion after NSM. Any suspicious lesion on NAC requires prompt pathological confirmation. Primary carcinoma with ductal intraepithelial neoplasia or invasive ductal carcinoma with extensive in situ component, negative hormonal receptor, high pathological grade, overexpression of HER2/neu, and ??HER2 positive (nonluminal)?? subtype tend to be significantly associated with more Paget??s disease local recurrence and should be followed carefully.     

Surgical Outcomes of Lichtenstein Tension-Free Hernioplasty for Acutely Incarcerated Inguinal Hernia

Purpose The purpose of our study was to evaluate the short-term and long-term outcomes of emergency Lichtenstein tension-free hernioplasty for acutely incarcerated inguinal hernia. Methods We conducted a retrospective study of patients who underwent emergency Lichtenstein hernioplasty for acutely incarcerated inguinal hernia between September 2002 and January 2006 in a major city hospital in Thailand. We analyzed the early postoperative complications and surgical outcomes. Results All 24 patients were men, with a mean age of 53.8 ± 19.2 years (range 19–77). There was no perioperative mortality and only two postoperative complications (8.3%): a subcutaneous fluid collection, which resolved spontaneously within 2 weeks; and a superficial surgical site infection, which was treated successfully by intravenous antibiotics. The hospital stay was 3.8 ± 2.1 days (range 2–12). All patients attended regular follow-up visits (mean 20.2 ± 10.7 months, range 3–43). Clinical recurrence was found in one patient (4.2%), 7 months postoperatively. Conclusion Lichtenstein hernioplasty can be used effectively as an emergency operation for incarcerated inguinal hernia with a good outcome and an acceptably low rate of postoperative complications.     

Efficacy of perioperative parecoxib injection on postoperative pain relief after laparoscopic cholecystectomy： A prospective, randomized study

AIM： To determine the efficacy of perioperative parecoxib injection on postoperative pain relief after laparoscopic cholecystectomy. METHODS： A prospective, double-blind, randomized, placebo-controlled study was conducted on 70 patients who underwent elective laparoscopic cholecystectomy under general anesthesia at Siriraj Hospital, Bangkok, from January 2006 to December 2007. Patients were randomized to receive either 20 mg parecoxib infusion 30 min before induction of anesthesia and at 12 h after the first dose （treatment group）, or normal saline infusion, in the same schedule, as a placebo （control group）. The degree of the postoperative pain was assessed every 3 h in the first 24 h after surgery, and then every 12 h the following day, using a visual analog scale. The consumption of analgesics was also recorded. RESULTS： There were 40 patients in the treatment group, and 30 patients in the control group. The pain scores at each time point, and analgesic consumption did not differ between the two groups. However,there were fewer patients in the treatment group than placebo group who required opioid infusion within the first 24 h （60% vs 37%, P = 0.053）. CONCLUSION： Perioperative administration of parecoxib provided no significant effect on postoperative pain relief after laparoscopic cholecystectomy. However, preoperative infusion 20 mg parecoxib could significantly reduce the postoperative opioid consumption.     

Treatment of hemorrhoids: A coloproctologist’s view

Hemorrhoids is recognized as one of the most common medical conditions in general population. It is clinically characterized by painless rectal bleeding during defecation with or without prolapsing anal tissue. Generally, hemorrhoids can be divided into two types: internal hemorrhoid and external hemorrhoid. External hemorrhoid usually requires no specific treatment unless it becomes acutely thrombosed or causes patients discomfort. Meanwhile, low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures (such as rubber band ligation and injection sclerotherapy). Surgery is indicated for high-graded internal hemorrhoids, or when non-operative approaches have failed, or complications have occurred. Although excisional hemorrhoidectomy remains the mainstay operation for advanced hemorrhoids and complicated hemorrhoids, several minimally invasive operations (including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation and stapled hemorrhoidopexy) have been introduced into surgical practices in order to avoid post-hemorrhiodectomy pain. This article deals with some fundamental knowledge and current treatment of hemorrhoids in a view of a coloproctologist - which includes the management of hemorrhoids in complicated situations such as hemorrhoids in pregnancy, hemorrhoids in immunocompromised patients, hemorrhoids in patients with cirrhosis or portal hypertension, hemorrhoids in patients having antithrombotic agents, and acutely thrombosed or strangulated hemorrhoids. Future perspectives in the treatment of hemorrhoids are also discussed.