Guidelines for gastrostomy tube placement and enteral nutrition in patients with severe,refractory hypoglycemia after gastric bypass

BackgroundPostbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients.ObjectivesTo provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management.SettingStanford University Hospital and Clinics.MethodsBased on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners.ResultsA team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia.ConclusionsG-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.     

Colon perforation caused by transanal decompression tube after laparoscopic low anterior resection: A case report

IntroductionThe effectiveness of transanal decompression tube (TDT) to prevent anastomotic leakage after rectal surgery has been widely accepted in recent years. However, a rare complication of intestinal perforation due to TDT has been also reported.Presentation of caseA 88-year-old woman underwent laparoscopic low anterior resection for rectal cancer. An abdominal drainage tube adjacent to the colorectal anastomosis and a TDT were placed. The patient experienced abdominal pain, nausea and elevated inflammatory markers on postoperative day 6. Enema and computed tomography demonstrated colonic perforation due to the TDT, and emergency laparotomy was performed. Perforation of the anterior sigmoid colon located at the proximal side of the colorectal anastomosis was seen, and the TDT was exposed to the abdominal cavity. Therefore, primary closure of the perforation site, peritoneal lavage, drainage tube placement and transverse colostomy was performed.DiscussionIn our case, TDT seemed to compress the anterior wall of the colon and lead to perforation. The looseness of the remaining oral intestinal tract depressed in the pelvis was compressed by the TDT.ConclusionTDTs should be very carefully placed to avoid complication. The length and looseness of the oral intestine and the relationship between the TDT to be inserted might be important.     

Pulse wave reflection at the collapsed segment of an artery in Riva-Rocci's method

Summary The contours of pressure and flow of a pulse wave arriving at the entrance of a collapsed segment of an elastic tube can be described by application of the basic laws of reflection. The collapsed segment acts like a valve. It is opened by the pressure of the pulse wave when the pressure within the tube becomes higher than the collapse pressure, i.e. the pressure exerted on the segment from outside. This opening of the collapsed segment suddenly changes the sign of the pulse wave reflection from positive to negative; thus a typical contour change of the pulse proximal to the segment is observed. The most obvious effect is a reduction of the pulse pressure. The extent of this reduction is a function of the collapse pressure.A typical example of this phenomenon can be observed in an artery proximal to the segment which is collapsed due to the pressure exerted by an inflated Riva-Rocci cuff. The effect is explained by the assumption that the sign of reflection changes when the pressure of the pulse wave crosses the level of the cuff pressure. This explanation is supported by the results of model experiments.     

数字X射线成像中的摄像机技术比较

数字化已成为现代医学成像的主流，摄像机则是数字Ｘ射线成像设备中的核心技术，本文就上前在数字Ｘ射线成像系统中使用的两种摄像机技术－－摄像管及ＣＣＤ摄像机进行了讨论和比较，结果在未来主分辩力成像研究中ＣＣＤ优于摄像管。     

孕妇血清标记物在中孕筛查中的应用

目的 :通过对孕妇血清标记物甲胎蛋白 (AFP)和人绒毛膜促性腺激素 ( β -HCG )测定来筛选缺陷儿。 方法 :用放射免疫法对 6 2例孕 14～ 2 3周妊娠妇女上述标记物连测 3次 ,每次隔 12～ 14d ,以两次异常为高危个体。每例筛查者跟踪至胎儿出生后。结果 :在筛查中发现了 1例先天愚型和 1例无脑儿。结论 :上述两种血清标记物可以作为神经管缺陷和先天愚型筛查的一项常规方法     

不孕症的腹腔镜检查及手术治疗

目的 :为探讨腹腔镜在不孕症诊治中的价值。方法 :对 6 3例女性不孕症进行了腹腔镜检查 ,并对其中的 5 5例施行了腹腔镜手术。结果 :6 0 .3 % (38 6 3)为输卵管因素 ,而输卵管因素中因盆腔炎引起的输卵管病变高达 94.7% (36 38)。其他因素为子宫内膜异位症、多囊卵巢综合征、卵巢囊肿等。HSG与输卵管腹腔镜检比较的总符合率为 71.2 1% (47 6 6 ) ,手术后输卵管通畅率比术前提高 99.6 7% (6 1.1 30 .6 % )。结论 :腹腔镜检查及手术是当前诊治女性不孕症最有效的方法 ,但手术难度大 ,手术费用较高。HSG操作简便 ,价格便宜 ,可做为腹腔镜检前的筛查。     

2158 例神经管缺陷儿的产前B型超声波诊断分析

回顾性分析1990～1993年全国28省、市、自治区233所医院,住院分娩的孕满28周的2158例神经管缺陷儿的产前诊断情况,了解我国神经管缺陷儿产前B型超声波诊断情况.结果显示:我国神经管缺陷产前诊断的比例为61.8%,产前B型超声波诊断的比例为56.5%,其中无脑畸形、脑膜脑膨出、脊髓外翻的产前B型超声波诊断比例分别为66.7% 、62.5%、52.5%.胸段(46.4%)、腰段(43.4%)的脊柱裂产前B型超声波诊断的病例较颈段 (35.5%)、骶段(31.7%)高(P<0.05).省级、市级、县级及部队工矿医院神经管缺陷的产前B型超声波诊断比例分别为55.7%、59.4%、49.0%、57.2%.1991～1993年神经管缺陷产前B型超声波诊断比例分别为53.5%、55.8%、60.7%、54.7%.无脑畸形、脑膜脑膨出、脊髓外翻产前B型超声波诊断的比例较高.     

Monitoring normal and aberrant electrocardiographic activity from an endotracheal tube: Comparison of the surface,esophageal, and tracheal electrocardiograms

Introduction. We designed an endotracheal (ET) tube with orthogonally spaced ECG cuff electrodes. This ET tube was evaluated in dogs and sheep to determine (1) whether ECGs recorded from our tube were sufficient to make accurate clinical decisions concerning heart rate and rhythm; and (2) whether metallic cuff electrodes in direct contact with the trachea could induce mucosal burn injury during episodes of defibrillation.Methods. Using experimental animals, we obtained ECGs from their tracheae and compared our findings with ECGs obtained from surface and esophageal electrodes. The electrical activity of the heart was modified by increasing the depth of anesthesia, occluding the left coronary artery, and administering beta-adrenergic drugs. Before the dogs were euthanized, they were subjected to episodes of transthoracic and intrathoracic defibrillation at energy levels of 200 to 400 J. A postmortem pathological examination of the trachea was performed to determine the incidence of mucosal burn injury.Results. Tracheal electrocardiography provided valid information on heart-rate monitoring and certain morphology profiles. The R-R, PR, QRS, and QT intervals measured from the trachea had a correlation of 1.0, 0.96, 0.83, and 0.98, respectively, when compared with the same intervals obtained from surface electrodes. Two tracheae subjected to intrathoracic defibrillation at >300 J revealed evidence of minor burn injury. Some localized epithelium loss was displayed in all tracheae; we attributed this to tracheal intubation.Conclusion. Tracheal electrocardiography may be useful in trauma patients who require intubation where injury precludes placement of chest ECG electrodes.