Telebrix Gastro in the management of adhesive small bowel obstruction

BACKGROUND: This study aimed to determine whether an abdominal radiograph 8 hours after ingesting oral Telebrix Gastro is a reliable marker for non-operative management in patients with adhesive small bowel obstruction.METHODS: During a 5-year period (January 1, 1995, through December 31, 2000), 97 patients were admitted for small bowel occlusion due to adhesion with no indication for immediate surgery. All received 100 mL of Telebrix Gastro via gastric tube for small bowel obstruction due to adhesion. If the contrast reached the colon within 8 hours on plain abdominal radiograph, the test was considered to be negative. RESULTS: 126 cases of small bowel occlusions were analyzed due to recurring episodes for 11 patients. The test was negative in 113 cases (89.7%), and in this group, only two patients underwent surgery, the remaining being managed non-operatively. The 13 cases (10.3%) with a positive test for occlusion underwent surgery. The sensitivity, specificity and accuracy of the finding of contrast media reaching the colon as an indicator for conservative treatment were 98%, 100%, and 98%, respectively. CONCLUSIONS: A water-soluble contrast study can be of significant help in the clinical management of patients suspected of having small bowel obstruction.     

A prospective randomized trial of transnasal ileus tube vs nasogastric tube for adhesive small bowel obstruction

AIM:To study the therapeutic efficacy of a new transnasal ileus tube advanced endoscopically for adhesive small bowel obstruction.METHODS:A total of 186 patients with adhesive small bowel obstruction treated from September 2007 to February 2011 were enrolled into this prospective randomized controlled study.The endoscopically advanced new ileus tube was used for gastrointestinal decompression in 96 patients and ordinary nasogastric tube(NGT) was used in 90 patients.The therapeutic efficacy was compared between the two groups.RESULTS:Compared with the NGT group,the ileus tube group experienced significantly shorter time for relief of clinical symptoms and improvement in the findings of abdominal radiograph(4.1 ± 2.3 d vs 8.5 ± 5.0 d) and laboratory tests(P 0.01).The overall effectiveness rate was up to 89.6% in the ileus tube group and 46.7% in the NGT group(P 0.01).And 10.4% of the patients in the ileus tube group and 53.3% of the NGT group underwent surgery.For recurrent adhesive bowel obstruction,ileus tube was also significantly more effective than NGT(95.8% vs 31.6%).In the ileus tube group,the drainage output on the first day and the length of hospital stay were significantly different depending on the treatment success or failure(P 0.05).The abdominal radiographic improvement was correlated with whether or not the patient underwent surgery.CONCLUSION:Ileus tube can be used for adhesive small bowel obstruction.Endoscopic placement of the ileus tube is convenient and worthy to be promoted despite the potential risks.     

Percutaneous endoscopic gastrostomy for decompression of the stomach and small bowel.

Percutaneous endoscopic gastrostomies are used most commonly for enteral feeding. We report the use of such gastrostomies for decompression of the obstructed gastrointestinal tract. Percutaneous endoscopic gastrostomies were performed on 53 patients over a 2-year period for gastrointestinal decompression because of gastric or small bowel obstruction. Forty-six patients had malignant obstruction from a primary abdominal or metastatic carcinoma and 7 patients had non-malignant obstruction or stasis. Gastrostomy for decompression was successful in 41 of 46 (89%) cases of malignant obstruction and in all 7 of the non-malignant cases. Tube utilization for decompression averaged 60 +/- 91 days. A 28 F tube with a 4-inch perforated intragastric portion was fashioned to maximize drainage. This efficient decompression tube allowed oral intake of liquids and soft foods in 88% of patients. Complications, which occurred in 4%, included one case of fatal peritonitis and one case of cellulitis.     

Effects of percutaneous endoscopic gastrostomy tube placement on gastric antral motility and gastric emptying

Background Percutaneous endoscopic gastrostomy (PEG) is the preferred method for providing enteral nutritional support in patients with dysphagia. We examined gastric antral myoelectrical activity and gastric emptying before and after PEG tube placement to evaluate the effects of PEG on gastric motility.Methods PEG was performed in 41 patients; 21 fed by total parenteral nutrition (TPN) and 20 who received nasogastric tube feeding (NGF). Antral myoelectrical activity and gastric emptying were examined before and 4 weeks after PEG tube placement.Results The percentage of normal-range electrogastrograms (EGGs) was significantly lower in the TPN group than in the NGF group in both the pre- and postprandial periods before PEG tube placement. Enteral feeding after PEG tube placement improved gastric motility in the patients with TPN. The percentage of normal-range EGGs increased significantly after PEG tube placement in both the pre- and postprandial periods, and plasma concentrations of paracetamol increased significantly after PEG tube placement in patients with TPN. A total of 7.3% of the patients developed the complication of gastroesophageal reflux (GER) after PEG tube placement. Gastric myoelectrical activity and gastric emptying were improved in these patients with GER after PEG tube placement. In contrast, the prevalence of esophageal hiatus hernia was significantly higher in patients with GER after PEG tube placement than in patients without GER after PEG tube placement.Conclusions Prolonged TPN with bowel rest induces physiological dysfunction of gastric motility. Enteral nutrition is the preferable physiological nutritional route. GER after PEG tube placement is not related to gastric motility. Esophageal hiatus hernia seems to be a major risk factor for GER complications after PEG tube placement.     

Decompression of the small bowel by endoscopic long-tube placement

AIM: To investigate and compare the decompression effect on small bowel obstruction of a long tube inserted using either endoscopic or fluoroscopic placement.METHODS: Seventy-eight patients with small bowel obstruction requiring decompression were enrolled in the study and divided into two groups. Intubation of a long tube was guided by fluoroscopy in one group and by endoscopy in the other. The duration of the procedure and the success rate for each group were evaluated.RESULTS: A statistically significant difference in the mean duration of the procedure was found between the fluoroscopic group (32.6 ± 14.6 min) and the endoscopic group (16.5 ± 7.8 min) among the cases classified as successful (P < 0.05). The success rate was significantly different between the groups: 88.6% in the fluoroscopic group and 100% in the endoscopic group (P < 0.05).CONCLUSION: For patients with adhesive small bowel obstruction, long-tube decompression is recommended and long-tube insertion by endoscopy was superior to fluoroscopic placement.     

胃出口、十二指肠和近端小肠恶性梗阻的内镜治疗

目的 探讨经内镜金属支架置入术治疗胃出口、十二指肠和近端小肠恶性梗阻的临床价值.方法 对1999年3月至2005年3月经内镜放置金属支架治疗的21例胃出口、十二指肠和近端小肠恶性梗阻患者的临床资料进行回顾性分析.结果 21例中20例放置支架成功,成功率为95.2%,其中4例采取经内镜钳道（TTS）方式释放支架,16例为经导丝直接释放支架.19例支架放置后1-3d梗阻症状得到缓解或消除,临床有效率为90.5%,平均生存期4.5个月.1例术后出血,予保守治疗而愈.1例术后1个月支架移位,1例术后2个月肿瘤向支架内浸润生长,导致梗阻复发,均予放置第2根支架后缓解.结论 经内镜放置金属支架治疗胃出口、十二指肠和近端小肠恶性梗阻是一种简单可行、安全有效的方法.     

A novel technique for treatment of intrahepatic biliary obstruction using an endobronchial ultrasound system

Biliary obstruction (BO) is one of the complications after hepatobiliary surgery decreasing patients?? quality of life. Existing interventional methods, such as endoscopic retrograde biliary drainage, occasionally fail to treat this condition. This is the first report of treatment of BO using an endobronchial ultrasound (EBUS) system. A 65-year-old woman developed BO at the confluence of the bile duct of segment 3 of the liver (B3) and segment 2 (B2) after extended right hepatectomy for hepatocellular carcinoma. Percutaneous transhepatic biliary drainage (PTBD) was performed through B3, and its fistula was dilated up to the size of an 18-Fr PTBD silicone catheter. An EBUS endoscope was inserted through the dilated PTBD route. B2 was punctured through the EBUS endoscope inserted to B3 just before the obstruction with a needle for fine-needle aspiration biopsy. A guidewire was inserted to the common bile duct through the needle, and a 7.2-Fr PTBD catheter was placed over the guidewire. The inserted PTBD catheter was clamped, and internal biliary drainage was established. The catheter was patent for 24?months, and the patient had no episodes of jaundice or cholangitis. This technique using the EBUS system can be a treatment option for BO.     

Clinical impact of a newly developed capsule endoscope: usefulness of a real-time image viewer for gastric transit abnormality

Background A new capsule endoscope has been developed by Olympus Medical Systems. The visualization and usefulness of its real-time image viewer for gastric transit abnormality were evaluated by using this new device. Methods Thirty-seven consecutive patients were enrolled. In cases of gastric transit abnormality (gastric transit > 60 min, detected by the real-time viewer), intramuscular metoclopramide (10 mg) was administered. Diagnostic yield and gastric and small bowel transit times in ten patients receiving (group A) and 27 not receiving (group B) metoclopramide were analyzed. Results Median gastric transit time was longer in group A than in group B (110 vs. 24 min; P < 0.0001). Conversely, median small bowel transit time was shorter in group A than in group B (270 vs. 347 min; P < 0.05). Further, small bowel transit was complete in 9/10 patients (90%) in group A, and in 23/27 patients (85%) in group B, but the difference was not significant. Overall diagnostic yield was 78% (29/37 patients), and there was no significant difference in the ratio of abnormal findings documented between group A (8/10, 80%) and group B (21/27, 78%) patients. Conclusions This new technology allowed clear image interpretation, and the real-time viewer was useful for detecting gastric transit abnormalities and determining a need for metoclopramide administration in patients undergoing capsule endoscopy.     

Preliminary study of enteroscopy-guided, self-expandable metal stent placement for malignant small bowel obstruction

Background and Aims: Technical limitations of conventional endoscopes and delivery systems frequently hamper palliative endoscopic placement of self‐expandable metal stents for malignant small bowel obstruction. This study examined feasibility of the double balloon enteroscope‐guided withdrawal‐reinsertion method as a rescue procedure in patients with failed palliative stent placement for malignant small bowel obstruction. Methods: We enrolled 19 consecutive patients with small bowel obstruction due to metastatic gastric (n = 15) or colorectal cancer (n = 2), or primary small bowel carcinoma (n = 2), in whom previous attempts to place self‐expandable metal stents using conventional endoscopy had failed. Ten patients had undergone previous gastric surgery. After passing a guide‐wire using an enteroscope with or without the double‐balloon method, the enteroscope was withdrawn. A conventional endoscope was re‐inserted along the guide‐wire, and through‐the‐scope self‐expandable metal stent placement was performed. Results: Obstruction sites were efferent jejunal loop, proximal jejunum, and third duodenal portion. Technical success was achieved with 94.7% (18/19) of stents, and clinical success occurred with 84.2% (16/19) of patients. The gastric outlet obstruction score (pre‐procedure: 0.68 ± 0.58) increased by one week (2.05 ± 0.52, P < 0.001). Stent migration and restenosis occurred in two (10.5%) and four (21.1%) of 19 stents, respectively. Median stent patency duration was 67 days and median survival was 93 days; these did not differ significantly by palliative chemotherapy (P = 0.76 and 0.67, respectively). Conclusions: The double‐balloon enteroscopy‐guided method followed by conventional endoscopic self‐expandable metal stent delivery was effective for rescue palliation of malignant small bowel obstruction.     

Pancreatic carcinoma-induced changes in gastric myoelectric activity and emptying

BACKGROUND/AIMS: Twenty patients with histologically confirmed pancreatic carcinoma without any endoscopic evidence of gastroduodenal obstruction were included in the study. The aim was to determine changes in gastric myoelectric activity and liquid/solid gastric emptying induced by pancreatic tumor. METHODOLOGY: According to TNM/UICC classification patients were divided into two groups A (T2) and B (T3) due to extent of tumor invasion (mainly to retroperitoneum space). In all patients electrogastrography, solid and liquid gastric emptying tests were performed. RESULTS: In the majority of patients of groups A and B the most commonly reported complaints included upper abdominal pain (60% vs. 80%) and icterus (80% vs. 60%). Dyspeptic symptoms were observed in 40% patients of group A and 90% in group B. In group electrogastrography recordings showed dysrhythmia patterns, mostly bradygastria, in 50% of group A patients and in 80% of group B. Liquid/solid gastric emptying were delayed in 20/40% of group A patients and 50/80% of group B. Disorders of gastric myoelectric activity and emptying correlated with tumor stage and location across analyzed groups but not with histology and hyperbilirubinemia levels. CONCLUSIONS: It was observed that solid gastric emptying is affected earlier compared to liquid gastric emptying. Delayed gastric emptying may be attributed to gastric dysrhythmia and/or abdominal pain but not mechanical effects of tumor growth that occur during the course of disease.     

Nutritional support through percutaneous transhepatic internal drainage route in common bile duct cancer

Abstract A 69 year old female with a duodenal bulb obstruction due to direct invasion of common bile duct cancer who received total enteral nutrition through the route of percutaneous transhepatic internal drainage (PTID) was presented. The tip of PTID tube was placed over the duodeno-jejunal flexure. Jejunal infusion of all nutrients and the bile juice through this route kept her in good nutritional condition until the terminal stage of primary disease. This procedure did not cause the infection of the biliary system. Major problems, tube obstruction and diarrhoea, were easily resolved with the selection of an appropriate infusion schedule and nutrient concentration. We conclude that nutritional support through the PTID route is a beneficial means for compromised patients without laparotomy or hospitalization.     

Cecostomy

PURPOSE: The role and effectiveness of catheter tube cecostomy as a means of colonic decompression are not clearly defined. Our aim was to clarify the clinical indications, functional performance, and concomitant morbidity associated with tube cecostomy. METHOD: This was a retrospective chart review of patients receiving catheter tube cecostomy at the Mayo Clinic over an 11-year period. RESULTS: Sixty-seven patients (median age, 69 years) had catheter tube cecostomy placement. Clinical indications for tube cecostomy were colonic pseudo-obstruction, distal colonic obstruction, cecal perforation, cecal volvulus, preanastomotic decompression, and miscellaneous usage. Operation was emergent in 43 (64 percent) patients and elective in 24 (36 percent) patients. Tube cecostomy was the primary procedure in 47 (70 percent) patients and complimentary in 20 (30 percent) patients. Minor complications were seen in 30 patients (45 percent), including pericatheter leak, superficial wound infection, tube occlusion, skin excoriation, premature tube dislodgment, colocutaneous fistula, and ventral hernia. No patient required reoperation for tube-related morbidity. CONCLUSIONS: Catheter tube cecostomy is of therapeutic value in select clinical situations including refractory colonic pseudo-obstruction, cecal volvulus, cecal perforation, or distal colonic obstruction. Proper patient selection, careful tube placement, and vigilant postoperative tube care should provide adequate function with minimal morbidity.     

Small Bowel Obstruction: Conservative vs. Surgical Management

PURPOSE The aim of this study was to assess incidence, risk factors, and recurrence rates for conservative and surgical management of small bowel obstruction.METHODS Retrospective chart review was conducted of 329 patients accounting for 487 admissions with small bowel obstruction. Data were obtained from the institutional database and patient charts. Patients with early recurrent small bowel obstruction had prior operations or hospitalization with conservative therapy for small bowel obstruction, then had a hospital stay >10 days following abdominal surgery because of obstruction or required readmission for small bowel obstruction within 30 days. Patients treated for prior small bowel obstruction and then readmitted after 30 days for a recurrent small bowel obstruction were classified as having late recurrent small bowel obstruction.RESULTS A total of 329 patients with a diagnosis of small bowel obstruction were identified. At index admission, 43 percent (142) were successfully treated conservatively, whereas 57 percent (187) failed conservative treatment and underwent surgery. Overall, there were eight early deaths, four in each group (2.8 percent conservative vs. 2.1 percent surgical; no significant difference). The frequency of recurrence for those treated nonoperatively was 40.5 percent compared with 26.8 percent for patients treated operatively (P < 0.009). Patients treated without operation had a significantly shorter time to recurrence (mean, 153 vs. 411 days; P < 0.004) and had fewer hospital days for their index small bowel obstruction (4.9 vs. 12.0 days; P < 0.0001). Two hundred one (63 percent) patients had abdominal surgery and 119 (37 percent) patients had no prior abdominal surgery before developing a small bowel obstruction. Previous abdominal operations by procedure type were colorectal surgery (34 percent), gynecologic surgery (28 percent), exploratory laparotomy (20 percent), appendectomy (14 percent), cholecystectomy (12 percent), herniorraphy (8 percent), and gastric bypass (5 percent). The mean time interval between initial procedure and index small bowel obstruction was 1.3 years for gastric bypass, 6.1 years for herniorraphy, 7.8 years for exploratory laparotomy, 8 years for cholecystectomy, 8.4 years for colorectal surgery, 11.8 years for gynecologic surgery, and 22.5 years for appendectomy. There was no significant difference between early and late recurrent small bowel obstruction in patients treated nonoperatively or operatively, regardless of prior history of abdominal surgery. Logistic regression analysis failed to identify any specific risk factors that were predictors of the success of conservative or surgical management.CONCLUSIONS Operatively treated patients had a lower frequency of recurrence and a longer time interval to recurrence; however, they also had a longer hospital stay than that of patients treated nonoperatively. There was no significant difference in treatment type or in incidence or type of prior surgery among patients with early and late small bowel obstruction. None of the variables analyzed in this study were significant predictors of the success of a particular treatment.Reprints are not available.S. B. Williams funded by the 2002 W. T. Gill Jr. Research Fellowship.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, June 21 to 26, 2003, New Orleans, Louisiana.     

A new operative technique for the resection of gastric tube cancer by means of lifting the anterior chest wall and videoscope-assisted surgery

SUMMARY.  The prolonged survival of patients receiving surgery for esophageal cancer has led to an increased incidence of adenocarcinoma arising in the gastric tube used for reconstruction (gastric tube cancer). In patients with advanced gastric tube cancer, resection of the gastric tube should be considered, but currently available procedures are very invasive. In patients undergoing curative surgery for gastric tube cancer that has developed after reconstruction through the retrosternal route, the gastric tube is usually resected through a median sternotomy, followed by reconstruction with the colon. However, postoperative complications often occur and treatment outcomes remain poor. We developed a new surgical technique for gastric tube resection without performing a sternotomy in patients with gastric tube cancer who had previously undergone reconstruction through the retrosternal route. Our technique was used to treat two patients. Two Kirschner wires were passed subcutaneously through the anterior chest; the chest was lifted to extend the retrosternal space and secure an adequate surgical field. The stomach was separated from the surrounding tissue under videoscopic guidance. Total resection of the gastric tube was done. The retrosternal space was used to lift the jejunum. Roux-en-Y reconstruction was performed. Neither patient had suture line failure or surgical site infection. Their recovery was uneventful. Our surgical technique has several potential advantages including (i) reduced surgical stress; (ii) the ability to use the retrosternal space for reconstruction after gastric tube resection; and (iii) a reduced risk of serious infections such as osteomyelitis in patients with suture line failure. Our findings require confirmation by additional studies.     

胃镜引导下经鼻肠梗阻减压管置入在小肠梗阻中的应用

目的探讨胃镜辅助下鼻肠减压管置人技术在小肠梗阻治疗中的作用。方法回顾分析我院2007年4月～2009年1月收治的13例小肠梗阻患者,在使用常规鼻胃减压管治疗无效后在胃镜辅助下放入鼻肠减压管,并进行胃肠减压治疗,观察置管效果并对疗效进行分析。结果胃镜辅助下鼻肠减压管置入平均时间19．4min,成功率100％,导管头端到达梗阻上方的平均时间4．3d,经造影观察均能明确病变部位并对病变性质作出初步判断;置管后病人腹痛、腹胀均有显著缓解,引流量增加,腹围减少;7例患者经减压治疗后小肠梗阻完全缓解,6例需手术治疗患者在手术治疗时均能依据导管头端位置准确定位。结论鼻肠减压管治疗小肠梗阻安全有效,应作为治疗小肠梗阻的首选方法;胃镜辅助置人鼻肠减压管操作简单,成功率高。     

The endoscopic transilluminator: an endoscopic device for identification of the proximal jejunum for transgastric endoscopic gastrojejunostomy

BACKGROUND: Localization of the proximal jejunum is important for creation of gastrojejunal anastomosis to palliate gastric outlet obstruction or for treatment of obesity with gastric bypass. OBJECTIVE: To facilitate identification of the proximal jejunum during transgastric endoscopic gastrojejunostomy with the use of an endoscopic transilluminator (ET). DESIGN AND SETTING: Acute experiments in a live porcine model. INTERVENTIONS: The ET is a 3500-mm long, 6F radio-opaque tube with a fiberoptic core that lights up at its distal end. When situated in the intestinal lumen, it transilluminates the bowel wall. With the animal under general anesthesia with endotracheal intubation, a colonoscope was advanced to the proximal jejunum. A plastic tube (3500-mm long, 3.5 mm in diameter) was passed through the biopsy channel and placed into the small bowel. The colonoscope was withdrawn, leaving the tube in place. The ET was introduced into the jejunum through the tube. A gastric wall incision was made and the endoscope was advanced to the peritoneal cavity. The transilluminated loop of the proximal jejunum was identified and gastrojejunal anastomosis was made by use of a previously reported endoscopic technique. MAIN OUTCOME MEASUREMENTS: Identification of the proximal jejunum. RESULTS: Eleven pigs (average weight 55 kg) had ET placement. In all of the pigs, placement of the ET was performed easily to the proximal small bowel, and the proximal jejunum was successfully localized by either direct visualization of the transilluminated loop only or with the aid of fluoroscopy. The tip of the ET was usually located about 50 to 70 cm distal to the ligament of Treitz. There were no complications related to the use of ET. LIMITATIONS: The device has not yet been evaluated in humans. CONCLUSIONS: The ET is a safe instrument and can be used to identify the proximal jejunum to facilitate endoscopic gastrojejunostomy.     

内镜下射频热疗联合局部化疗治疗晚期大肠癌的随机对照研究

目的：探讨射频加局部化疗治疗晚期大肠癌的疗效,并与单纯射频治疗比较。方法选择晚期大肠癌失去手术切除时机患者55例行射频加局部化疗或单纯射频治疗,随机分为射频加局部化疗组（A组）27例、射频组（B组）28例,观察两组患者5年内肠梗阻缓解率、再转移率、生存率。结果 A组与B两组1～5年肠梗阻缓解率分别为88.9%vs 70.8%、95.8 vs 70%、89.5%vs 52.9%、100%vs 33.3%、100%vs 0,具有统计学差异（P＜0.05）;5年内再转移情况,A组27例无一例出现再转移,再转移率为0（0/27）,B组11例出现了新的转移病灶,再转移率为39.3%（11/28）,有统计学差异（P＜0.05）;A组5年生存率为44.4%（19/27）,B组为无一例生存,有统计学差异（P＜0.05）。结论内镜下射频热疗联合局部化疗能显著提高晚期大肠癌患者5年内肠梗阻缓解率和5年生存率,显著降低再转移率。     

Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series

BACKGROUND: Self-expandable metal stents (SEMS) are being increasingly used to palliate malignant stenoses of the gastric outlet and proximal small bowel. Accordingly, we reviewed our experience in this setting. METHODS: Patients with gastric outlet or proximal small bowel stents were identified by reviewing hospital charts. Outcome criteria included survival data, need for reintervention, and clinical improvement. RESULTS: A total of 52 SEMS were placed in 36 patients with nonesophageal upper GI stenosis. Initial stent placement was successful in 92% and clinical improvement documented in 75%. Mean survival of patients who eventually died was 3.5 months. Seven patients are alive (mean follow-up, 5.0 months). Stent dysfunction occurred in 36% and required subsequent interventions. Biliary obstruction was documented in 50% of patients, 12 of whom had previously undergone biliary stenting and 5 who needed subsequent biliary decompression. CONCLUSIONS: Enteral stent placement has been reported to be an effective alternative for palliation of high-risk surgical patients with malignant gastric outlet and small bowel obstruction. Considering the short life expectancy of these patients and significant complications including stent migration, perforation, biliary obstruction, and need for subsequent endoscopic, radiologic and surgical interventions, the authors suggest that this procedure be performed in experienced centers on selected patients only and that biliary decompression be ensured early.     

Intestinal Obstruction Due to Bezoars

A patient with acute intestinal obstruction due to unrecognized gastric phytobezoars is presented. There was no history of prior gastric or other abdominal surgery. At laparotomy several fragments of rubbery material were discovered obstructing the ileocecal valve. Exploration of the upper gastrointestinal tract revealed two partially fragmented bezoars in the stomach which were removed through a gastrotomy. After surgery the patient recounted the ingestion of persimmons a few weeks before the onset of her symptoms. A review of the literature reveals bezoars to be an infrequent, although not an altogether rare, cause of small bowel obstruction in patients without antecedent gastric surgery. A careful dietary history should accompany all patients presenting with acute intestinal obstruction.     

Randomized Prospective Trial of Early Versus Delayed Feeding After Percutaneous Endoscopic Gastrostomy Placement

Objective : By convention, most clinicians delay feeding through the gastrostomy tube until 24 h after placement. However, evidence is lacking to support the rationale for such a delay in PEG use. This randomized, prospective study was designed to assess the safety of early feeding after PEG placement. Methods : One hundred-twelve patients referred for PEG were randomized to begin tube feedings at 4 h (group A) or at 24 h (group B) after placement. All patients received prophylactic antibiotics. Full-strength Isocal was administered with the following schedule: day 1,100 ml every 4 h for six feedings; day 2, 200 ml every 4 h for six feedings. Immediately before each scheduled feeding, gastric residual volume was recorded and the next feeding was withheld if the residual volume was > 50 percent (gastric retention). Patients were evaluated on day 1, day 2, day 7, and day 30 for major and minor complications. Results : The two groups were similar with regard to age, gender, baseline nutritional status, and indications for PEG placement. On the first day of feeding, 14 of 57 patients (25%) in group A, but only five of 55 patients (9%) in group B, had evidence of gastric retention,   p × 0.029  . The proportion of patients with high gastric residual volumes was not significantly different on day two. In group B, one death occurred because of aspiration of gastric contents on day 2. All other complications were minor and did not differ significantly between the two groups. Conclusions : Early initiation of PEG feedings is safe, well tolerated, and reduces cost by decreasing hospital stay.