Technique for the replacement of a feeding gastrostomy tube

The use of a urologic filiform catheter and followers is described for the replacement of feeding gastrostomy tubes that have been out of place for greater than 24 hours. The technique is simple, safe, and may be performed on an outpatient basis.     

Fatal intestinal perforation secondary to fragmentation of a Celestin tube

BACKGROUND/AIMS: Oesophageal intubation remains one of the principal methods of palliation for an obstructing oesophageal carcinoma. We present a case which illustrates a rare but fatal complication of this procedure. METHODS: A 60-year-old female with oesophageal cancer presented with total dysphagia 9 months following insertion of a Celestin tube for palliation. Oesophagoscopy revealed a bolus obstruction which was successfully cleared. Two days later she developed generalised peritonitis and subsequently died. RESULTS: A post-mortem examination demonstrated fragmentation and displacement of the distal part of the Celestin tube resulting in perforation of the small bowel. CONCLUSION: Celestin tube disintegration is a risk associated with long-term use, and routine replacement is indicated in patients with a prolonged survival to avoid this complication.     

Esophageal perforation

Sixty-nine patients with perforation of the esophagus were treated at the University of California, San Francisco, from 1977 to 1988. The perforation was iatrogenic in 33 (48%) of the patients, spontaneous in 8 (12%), and a result of external trauma in 23 (33%). Clinical findings included chest pain in 36 (52%) of 69 patients, subcutaneous emphysema in 22 (32%) of 59 patients, and pneumomediastinum in 21 (36%) of 59 patients. Esophagograms demonstrated the perforation in 40 (93%) of 43 patients. Treatment delays of more than 24 hours occurred in about half of spontaneous and iatrogenic perforations, but when the perforation was due to external trauma, treatment was delayed infrequently. Operative therapy in 59 (86%) of the patients included primary closure in 44 patients, drainage alone in 9 patients, and Celestin tube placement in 1 patient. Four patients with benign strictures had esophagectomy, and 4 patients with achalasia had Heller myotomy in addition to closure of the perforation. Eight (12%) of the patients were treated nonoperatively. For thoracic perforations, nonoperative treatment was reserved for patients who were diagnosed late but who had minimal evidence of sepsis. Seven (10%) of the patients died. Factors that influenced outcome included cause of perforation, anatomic location, and patient age. Our study shows that a high index of suspicion, aggressive use of esophagography, and individualized treatment are necessary for the best results when treating esophageal perforation.     

Laparoscopic tube gastrostomy.

A laparoscopic approach to fashioning a permanent mucosal gastrostomy is described for the first time. It has a place in patients in whom endoscopic or radiological placement is impractical.     

Colon perforation secondary to porphyria

Acute intermittent porphyria (AIP) is a rare, inherited metabolic disorder of the haem biosynthesis pathway. The diagnosis is well known to cause significant diagnostic challenge due to its broad range of symptoms that may mimic many other conditions. We report a case of AIP that presented with caecal perforation, a clinical scenario that has not previously been reported in the literature.     

Nonoperative conversion of tube gastrostomy to feeding jejunostomy

Although esophageal reflux of gastrostomy feeds is an uncommon problem, severe pulmonary complications can arise. If implementation in an upright position and use of continuous infusion does not prevent reflux, an alternative method of providing adequate nutrition must be used. This nonoperative technique of converting a tube gastrostomy to a feeding jejunostomy is simple to perform, atraumatic and extremely useful.     

Esophageal perforation during esophagogastroduodenoscopy

An esophageal perforation occurred during an esophagogastroduodenoscopy (EGD). The patient had an episode of retching and forceful vomiting just after an esophageal mucosal biopsy at the gastroesophageal junction. The only clinical feature demonstrated by the patient was neck crepitation after completion of the EGD. Initial evaluation of the referred patient by posterior and lateral chest x-rays revealed extensive pneumomediastinum with subcutaneous emphysema. A unique chest computed tomography scan demonstrated suspension of the esophageal mucosal surface and lumen in a “bull's eye” configuration. A water-soluble esophageal swallow followed by a thin liquid barium swallow demonstrated that the esophageal perforation had sealed. The patient completely recovered with conservative medical therapy of clear liquid diet and antibiotics.