ANALYSIS OF BURIED BUMPER SYNDROME AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY DUE TO USE OF A BUTTON‐TYPE KIT

Background: Buried bumper syndrome (BBS) is a rare complication of percutaneous endoscopic gastrostomy (PEG). Along with the widespread use of the button‐type kit, BBS is encountered frequently. Methods: In the present study, we examined causes and treatments for BBS among 1400 patients who had undergone PEG. Results: The causes of BBS after PEG were classified into two categories: early causes consisted of wound infection, inappropriate size of kit and severe lordosis, while late causes were inappropriate exchange of kit, rough management or weight gain. The treatments for BBS could be determined by the degree of wound infection, fistula and burial of the bumper. Conclusion: We prepared a flowchart for replacement, by which BBS can be managed safely and quickly without surgical or endoscopic intervention.     

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY AND VENTRICULOPERITONEAL SHUNTS: A DANGEROUS COMBINATION?

Background: We report the largest European series of patients in whom both ventriculoperitoneal shunts (VPS) and percutaneous endoscopic gastrostomies (PEG) have been inserted with the aim of determining if this combination is safe or if there is an increased risk of VPS infection. Patients and Methods: The paper and electronic records of 302 patients who had a ventriculoperitoneal (VP) shunt inserted in the regional Neurosciences unit at Salford Royal NHS Foundation Trust between 2002 and 2007 were reviewed. Results: A total of 24 patients with VP shunts had 26 PEG inserted. Thirteen PEG were inserted in 11 patients with a pre‐existing VP shunt. The median age was 58 years (21–77 Yrs) with seven male and 17 female patients. In total, five patients developed a shunt infection (20.8%) compared to the overall rate of VP shunt infection for Salford Royal NHS Foundation Trust of 7% (P = 0.017). The increase in number of VP shunt infections when the procedures were done more than 10 days apart (2/14) was not significant (P = 0.25). Conclusion: In patients who need long‐term enteral feeding following a VP shunt insertion it may be prudent to delay insertion of a PEG for at least 10 days to reduce VPS infection. In stable patients who have had a VP shunt inserted on previous hospital admissions PEG insertion need not be avoided because of concern regarding cerebrospinal fluid or shunt infection.     

Buried Bumper Syndrome as a Rare Complication of Percutaneous Endoscopic Gastrostomy

Abstract: Percutaneous Endoscopic Gastrostomy (PEG), which can be performed under local anesthesia and does not require laparotomy, has become an accepted means of providing long-term nutritional support for patients who cannot swallow. PEG can be successfully performed in 10–20 minutes with minimal invasion. Although the incidences are low, some complications with PEG have been reported. We describe herein a patient who developed an early complication of PEG in which the internal bumper became buried in the gastric wall. The buried bumper was immediately removed under local anesthesia, and a new PEG tube was successfully placed. There have also been reports of tube migration into the appears to result from excessive traction on the tube with subsequent ischemic necrosis of the gastric mucosa and pressure necrosis. Careful management of the tube is needed prevent this complication.     

CLINICAL TRIAL: A RANDOMIZED STUDY COMPARING THE DURABILITY OF SILICONE AND LATEX PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBES

Background: The use of percutaneous endoscopic gastrostomy (PEG) for nutrition support is increasing worldwide, but few studies have evaluated the durability of and complications related to the different materials used to manufacture gastrostomy tubes. Latex PEG tubes are widely used in our clinical setting, but no studies have compared their durability with silicone PEG tubes. The aim of the present study was to compare the durability of latex tubes with the durability of silicone tubes. Patients and Methods: A randomized clinical trial was conducted in patients with head and neck cancer with indications for PEG. Sixty patients were randomized to receive either latex or silicone PEG tubes and followed up for 90 days. The analyzed outcomes were duration, peristomal infection, granulated tissue formation, and leakage around the tube. Results: The durability of silicone PEG tubes was significantly greater than the durability of latex PEG tubes. The survival curves showed that silicone PEG tubes lasted twice as long (hazard ratio = 2.0, 95% confidence interval = 1.1–3.7, P = 0.01). No differences were found with regard to rate of peristomal infection, granulated tissue formation, or leakage. Conclusion: Silicone PEG tubes are associated with a reduced need for replacement (attributable to higher durability) compared with latex PEG tubes.     

IMPORTANCE OF THE FISTULA TRACT ANGLE IN FISTULA TRACT DISRUPTION IN PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

Background : The fistula tract angle formed by percutaneous endoscopic gastrostomy (PEG) was examined. Also, the previous literature on fistula tract disruption is reviewed and the possible influence of the fistula tract angle on fistula tract disruption by non‐endoscopic catheter change is discussed. Methods : A total of 15 patients aged 24–80 years were examined.The fistula tract angle was measured as the angle of elevation between the tangent line at the orifice of the PEG stoma and the longitudinal axis of the catheter. Results : Values of the angle ranged from 56 to 90° (mean 77.6°), with four cases (27%) having angles below 70°.With one case of pan‐peritonitis after catheter insertion at 90°, laparotomy revealed that the angle of the fistula tract was low at 62° and that the catheter had broken through the tract just below the abdominal wall. Conclusion : This study suggests that the fistula tract angle might be a potential risk factor for fistula tract disruption by non‐endoscopic catheter change.     

REDUCING THE RISK OF PERISTOMAL INFECTION AFTER PEG PLACEMENT

Percutaneous endoscopic gastrostomy (PEG) was first described in 1980 as an effective means of enteral nutrition where oral intake is not possible. PEG placement is safe and has now replaced the nasogastric tube in patients who need long‐term feeding. Although it is relatively safe with a very low associated mortality, minor complications, especially local and systemic infection, remain a problem. Of these, peristomal wound infections are the most common complication of PEG. In patients indicated for this procedure who are aged and/or frail, this complication may pose a critical problem. In the commonly used pull or push methods for PEG placement, the PEG tube is readily colonized by oropharyngeal bacteria. Infection of the PEG site is considered to be associated with contamination of the PEG catheter. There are important measures that should be taken to prevent peristomal infection. A number of rigorous studies have shown that prophylactic antibiotics are effective in reducing the risk of peristomal infection. As methicillin‐resistant Staphylococcus aureus (MRSA) or other resistant organisms are emerging as a major pathogen in peristomal infection, however, currently recommended antibiotic prophylaxis regimens might be inappropriate. Alternative regimens and other approaches to prevent contamination of the PEG tube during the procedure are required.     

FACTORS RELATED TO LATERAL MARGIN POSITIVITY FOR CANCER IN GASTRIC SPECIMENS OF ENDOSCOPIC SUBMUCOSAL DISSECTION

Background: With the widespread use of endoscopic submucosal dissection (ESD), more large early gastric cancers (EGC) have become candidates for endoscopic resection. A precise diagnosis of the extent of cancer is indispensable to obtain R0 resection. The aim of the present study was to clarify the factors related to lateral margin positivity for cancer in specimens resected by ESD for EGC. Methods: Among 1549 EGC treated by ESD during September 2002 to December 2008, lesions that were resected in an en‐bloc fashion and resulted in a pathological diagnosis of lateral margin positive (LM+) for cancer, were extracted. The reason for LM+ and pathological characteristics of the lesions were studied and compared to lesions successfully resected with margins negative for cancer. Results: There were three types of lesion that resulted in LM+ resection: lesions with a flat spreading area, lesions with an unexpected nearby lesion, and lesions with lateral extension beneath a non‐cancerous mucosa. Compared to lesions resected with margins negative for cancer, diameter of the tumor, recurrent‐type cancer, submucosal cancer, and undifferentiated‐type cancer were factors significantly related to LM+ resection. Conclusion: Other than misdiagnosing a small portion of cancer extension, lateral margin positivity for cancer by ESD could result from a neighboring lesion and an unexpected lateral submucosal cancer extension. To avoid LM+ resection of EGC by ESD, one should be careful of unexpected lateral extension and simultaneous multi‐lesions.     

INTRADUCTAL ULTRASONOGRAPHY OF THE GALLBLADDER IN APPLICATION OF THE ENDOSCOPIC NASO‐GALLBLADDER DRAINAGE

Background: Although endoscopic naso‐gallbladder drainage (ENGBD) for gallbladder disease is useful, the procedure is difficult and investigations involving many cases are lacking. Furthermore, reports on transpapillary intraductal ultrasonography (IDUS) of the gallbladder using a miniature probe are rare. Methods: A total of 150 patients (119 suspected of having gallbladder carcinoma, 24 with acute cholecystitis (AC), and seven with Mirizzi’s syndrome (MS)) were the subject. (i) ENGBD: We attempted to put ENGBD tube into the GB. (ii) IDUS of the gallbladder: Using the previous ENGBD tube, we attempted to insert the miniature probe into the gallbladder and perform transpapillary IDUS of the gallbladder. In five patients, we attempted three‐dimensional intraductal ultrasonography (3D‐IDUS). Results: (i) ENGBD: Overall success rate was 74.7% (112/150); the rate for the patients suspected of having gallbladder carcinoma was 75.6% (90/119), and was 71.0% (22/31) for the AC and MS patients. Inflammation and jaundice improved in 20/22 successful patients with AC and MS. Success rate was higher when cystic duct branching was from the lower and middle parts of the common bile duct than from the upper part, and was higher when branching was upwards than downwards. (ii) IDUS of the gallbladder: Success rate for miniature probe insertion into the gallbladder was 96.4% (54/56). Lesions could be visualized in 50/54 patients (92.6%). Of these, detailed evaluation of the locus could be performed in 41. In five patients attempted 3D‐IDUS, the relationship between the lesion and its location was readily grasped. Conclusion: IDUS of the gallbladder is superior for diagnosing minute images. Improvement on the device will further increase its usefulness.     

USEFUL ENDOSCOPIC ULTRASONOGRAPHY TO ASSESS THE EFFICACY OF NEOADJUVANT THERAPY FOR ADVANCED ESOPHAGEAL CARCINOMA: BASED ON THE RESPONSE EVALUATION CRITERIA IN SOLID TUMORS

Objective: The aim of the present study was to assess the usefulness of endoscopic ultrasonography (EUS) for evaluating the efficacy of neoadjuvant therapy for advanced esophageal carcinoma based on the Response Evaluation Criteria in Solid Tumors (RECIST). Patients and Methods: Sixty‐two patients with advanced esophageal carcinoma underwent surgical resection after neoadjuvant therapy. The maximal tumor thickness was measured by EUS before and after neoadjuvant therapy, and the percent reduction was compared with the pathological response. Based on the RECIST, PD‐SD (progressive disease‐stable disease) was defined as < 30% reduction of tumor thickness on EUS, PR (partial response) as ≥ 30% reduction of tumor thickness, and CR (complete response) as no detectable tumor (100%). Results: The percent reduction of the thickness of Grade 0–1, Grade 2 and Grade 3 tumor was 11.5 ± 21.0%, 48.2 ± 17.0% and 74.9 ± 21.1%, respectively. There were significant differences in the extent of reduction among the three groups. Based on the RECIST, 80% of Grade 0–1 cases, 91% of Grade 2 cases and 22% of Grade 3 cases were PD‐SD, PR, and CR according to EUS, respectively. EUS correctly identified 80% of non‐responders and 94% of responders. Conclusions: The percentage reduction of tumor thickness on EUS closely reflected the pathological evaluation. EUS evaluation based on the RECIST seems to be useful for monitoring neoadjuvant therapy in patients with esophageal carcinoma.     

LONG‐TERM FOLLOW UP OF PATIENTS WITH SMALL GASTROINTESTINAL STROMAL TUMORS IN THE STOMACH USING ENDOSCOPIC ULTRASONOGRAPHY‐GUIDED FINE‐NEEDLE ASPIRATION BIOPSY

Background: Gastrointestinal stromal tumors (GIST) are one of the most common mesenchymal tumors of the gastrointestinal tract. GIST are defined by positive immunohistochemical staining for KIT or CD34 and thus are generally diagnosed after surgery. Because small GIST are rarely diagnosed before surgery, the clinical course of these small tumors is not clear. The aim of the present study was to follow changes in size and configuration of small GIST that were pathologically confirmed using endoscopic ultrasonography‐guided fine‐needle aspiration biopsy (EUS‐FNAB). Methods: Between July 1997 and December 2003, 16 tumors in 16 patients (10 men and 6 women) with an immunohistochemical diagnosis of GIST were regularly followed in our hospital. The median patient age when EUS‐FNAB was performed was 62 years (range 26–82 years) and the median follow‐up period was 4.9 years (range 0.5–9.6 years). Results: Fourteen tumors showed no remarkable changes in size and shape during follow up compared with the initial diagnosis. Two tumors enlarged: one tumor approximately doubled its diameter in 8 years and the other tumor increased from 1.8 cm at diagnosis to up to 10 cm after only 2 years. Doubling time of the latter tumor was calculated as 3.1 months. Conclusions: We conclude that EUS‐FNAB might be a good modality for final diagnosis of GIST without surgery, and that GIST without rapid growth on follow up can be endoscopically followed.     

EVALUATION OF THE RISK FACTORS OF LYMPH NODE METASTASIS IN PT1 STAGE COLORECTAL CARCINOMA: INDICATION FOR AN ENDOSCOPIC MUCOSAL RESECTION

Aim: In the present study, we aimed to clarify the parameters that can be used for clinically relevant treatment decisions. Patients and methods: During the period from July 1985 to April 2005, 283 pT1 cancers were selected for this study. Risk factors for lymph node (LN) metastasis were evaluated as follows: endoscopic appearance, tumor size, location, lymphatic permeation, venous invasion, patterns of cancer invasion into the submucosal layer, and depth of vertical invasion in the submucosal layer. Results: Results of the logistic regression analysis from these significant parameters were as follows: infiltrating growth pattern (odds ratio: 12.63); lymphatic permeation positive (odds ratio: 5.726); sigmoid colon (odds ratio: 4.585); tumor size (odds ratio: 1.718). However, the leading edge of only one cancer with LN metastasis in the expanding growth group was also cribriform pattern. Conclusion: The invasive growth patterns of infiltrating growth, lymphatic permeation, tumor location of the sigmoid colon, and maximum tumor size were independent and significant risk factors for LN metastasis in our logistic regression analysis. In particular, the former three factors (infiltrating growth, lymphatic permeation and sigmoid colon) revealed high odds ratio and covered all cases of LN metastasis. From the results of our study, the indication for operative intervention after EMR in pT1 cancer is those lesions which possess at least one factor among the three (infiltrating growth, lymphatic permeation and sigmoid colon). Also, assessment of the leading edge with a cribriform pattern should be dealt with carefully.     

MID‐TERM PROGNOSIS AFTER ENDOSCOPIC RESECTION FOR SUBMUCOSAL COLORECTAL CARCINOMA: SUMMARY OF A MULTICENTER QUESTIONNAIRE SURVEY CONDUCTED BY THE COLORECTAL ENDOSCOPIC RESECTION STANDARDIZATION IMPLEMENTATION WORKING GROUP IN JAPANESE SOCIETY FOR CANCER OF THE COLON AND RECTUM

We carried out a retrospective questionnaire survey of 792 submucosal colorectal carcinoma (CRC) cases from 15 institutions affiliated with the Colorectal Endoscopic Resection Standardization Implementation Working Group in Japanese Society for Cancer of the Colon and Rectum. In these cases, endoscopic resection (ER) and surveillance was carried out without additional surgical resection. Local recurrence or metastasis was observed in 18 cases. Local submucosal recurrence was observed in 11 cases, and metastatic recurrence was observed in 13 cases. Among the 15 cases in which the depth of submucosal invasion was measured, two cases showed depth less than 1000 µm, which has other risk factors for metastasis. Metastatic recurrence was observed in the lung, liver, lymph node, bone, adrenal glands, and the brain; in some cases, metastatic recurrence was observed in multiple organs. Death due to primary disease was observed in six cases. The average interval between ER and recurrence was 19.7 ± 9.2 months. In 16 cases, recurrence was observed within 3 years after ER. Thus, validity of ER without additional surgical resection for cases with the conditions that the depth of submucosal invasion is less than 1000 µm and the histological grade is well or moderately differentiated adenocarcinoma with no lymphatic and venous involvement was proven.     

ARGON PLASMA COAGULATION: IN VIVO TISSUE DAMAGE TO THE ESOPHAGUS AND STOMACH AND CLINICAL EFFICACY FOR EARLY ESOPHAGEAL AND GASTRIC CANCER

Background: Argon plasma coagulation (APC) has been proven to be safe in vitro, and has been widely introduced to therapeutic endoscopy. We evaluated the thermal effects on esophageal or gastric wall in vivo, and its effectiveness as an adjunct to incomplete resection of early esophageal and gastric cancer after endoscopic mucosal resection (EMR). Methods: Thermal injuries were made using endoscopic APC irradiation in porcine esophagus and stomach under various conditions during general anesthesia, and depth of tissue damage was determined histopathologically. Patients with early gastric cancer (n = 24) and early esophageal cancer (n = 5) were treated with additional APC following microscopically incomplete EMR. APC was applied to coagulate the entire edge of EMR‐induced ulcer 1 week after resection at power/gas settings of 50 W and 1.5 L/min in the stomach, and 40 W and 1.5 L/min in the esophagus for less than 5 s at each point. Results: Depth of tissue damage was related to pulse duration and power output. At power/gas settings of 60 W and 2.0 L/min, thermal damage extended across the submucosal layer with 5‐s pulse duration in the stomach. Thermal damage with 5‐s pulse duration at power/gas settings of 40 W and 2.0 L/min extended to the muscularis propria in the esophagus. In the clinical study of additional APC therapy, the recurrence rate was 6.9% (two of 29 cases). Conclusion: To avoid perforation, we recommend an APC power setting of 40–60 W for less than 5 s in the stomach and a lower power setting with shorter duration in the esophagus. APC seems to reduce recurrence of esophageal or gastric cancer after incomplete EMR.     

重组组织型纤溶酶原激活剂治疗急性心肌梗塞42例临床分析

本文报道应用重组组织型纤溶酶原激活剂（ｒｔ－ＰＡ）治疗４２例急性心肌梗塞，对其临床效果进行分析，证实ｒｔ－ＰＡ有缩小梗塞范围，改善心功能，提高患者生活质量和降低病死率的作用。在用药过程中。本组病例未见到严重出血及其他严重副作用。作者对ｒｔ－ＰＡ的给药时机、应用指征及禁忌证作了探讨。     

SELF‐EXPANDABLE METALLIC STENT FOR PATIENTS WITH NON‐RESECTABLE MALIGNANT COLORECTAL STRICTURE: REVIEW OF 102 CASES IN THE JAPANESE LITERATURE

Alternative procedures using endoscopy have been developed, one of which is treatment with self‐expandable metallic stents (SEMS). In Japan, as SEMS for colorectal stricture has not been approved by the public insurance system, esophageal stent is used for colon and rectum exceptionally as a colonic SEMS after obtaining informed consent from the patient. This situation is very different to other countries. In the present study, we review the Japanese medical literature to determine the current status, feasibility, and challenges remaining for SEMS to show the current status of SEMS usage for colonic strictures in Japan. We investigated SEMS for patients with non‐resectable malignant colorectal stricture in 102 Japanese case reports. Primary colorectal cancer comprised half of the cases. The insertion success rate was 100% and the clinical effectiveness rate was 93%. Restricture occurred in 12 cases (12%), and half of those cases were treated by stent in stent. Stent migration occurred in eight cases (8%) and perforation in two cases (2%). The range of SEMS insertion duration was 1 to 576 days (mean: 132 days, median 142 days). There were no deaths related to the procedure. This procedure allows patients to forgo colostomy and is cheap, safe and effective, with a short treatment time. This procedure is a viable palliative alternative to colostomy for patients with inoperative malignant colorectal stricture. Widespread application of the procedure has been hampered.