Digestive Endoscopy 2015; 27: 397–401
Letters, Techniques and Images 399
4 Gencosmanoglu R, Koc D, Tozun N. The buried bumper syndrome: Migration of internal bumper of percutaneous endoscopic gastrostomy tube into the abdominal wall. J. Gastroenterol. 2003; 38: 1077–80. 5 O’Dell KB, Gordon RS, Becker LB. Gastrostomy tube transmigration: A rare cause of small bowel obstruction. Ann. Emerg. Med. 1991; 20: 817–9.
A
B
C
Figure 2 Schema for the presumed process of migration of the gastrostomy site in the stomach. (A) Loosened stop tab. (B) Migration of the balloon from the gastric body into the bulbus. (C) Gastrostomy site moving to the pyloric ring by long-term excessive traction.
had initially been placed to the current position of the button in the bulbus, suggesting that the ulcer scar represented the path of migration of the gastrostomy site. The present case suggests that migration of the gastrostomy site can occur as a PEG-related late complication. This complication may be attributable to long-term excessive traction on the gastric wall as a result of inappropriate positioning, irregular exchange intervals, and loose fixation during the PEG procedure (Fig. 2). These considerations imply that regular exchanges of the gastrostomy tube using EGD are important. In addition, use of a non-balloon-type replacement such as a small bumper-type or button-type device may prevent migration of the gastrostomy site. More importantly, necessity for continuous use should be regularly evaluated, considering this type of long-term complication.
Overtubes and fluoroscopy for direct percutaneous endoscopic jejunostomy: Useful, although not always needful and sometimes harmful The authors read with great interest the article by Velázquez-Aviña et al. reporting a new technique for direct percutaneous endoscopic jejunostomy (DPEJ) using balloonassisted enteroscopy and fluoroscopy.1 The authors present some comments based on their experience with 14 DPEJ attempted in the last 4 years with single-balloon enteroscopy (SBE), applying a similar technique without fluoroscopy. SBE is advanced to the jejunum and the target loop is selected through transillumination and finger indentation. A 40-mm 21-G needle is used for lidocaine infiltration and jejunal loop puncture. This needle is grasped with a snare during skin incision, gastrostomy needle puncture and string advancement (Fig. 1). The 21-G needle is released and the string grasped with a forceps (Fig. 2), as this is easier than with a snare in the jejunum. After one complication caused by the overtube, it is left only for distal loops, as it enabled safer PEJ-bumper pulling through the jejunum. While being pulled, the PEJ-bumper
Authors declare no conflict of interests for this article. Takao Maekita,1 Kazuyuki Nakazawa2 and Jun Kato1 Department of Gastroenterology, School of Medicine, Wakayama Medical University and 2Department of Internal Medicine, Koyo Hospital, Wakayama City, Japan doi: 10.1111/den.12411 1
REFERENCES 1 Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987; 93: 48–52. 2 Loser C, Wolters S, Folsch UR. Enteral long-term nutrition via percutaneous endoscopic gastrostomy (PEG) in 210 patients: A four-year prospective study. Dig. Dis. Sci. 1998; 43: 2549–57. 3 Blomberg J, Lagergren J, Martin L, Mattsson F, Lagergren P. Complications after percutaneous endoscopic gastrostomy in a prospective study. Scand. J. Gastroenterol. 2012; 47: 737–42.
Figure 1 Endoscopic image showing the catheter of the gastrostomy kit penetrating the jejunal wall, while a snare grasping a 21-G needle is used to keep the jejunal loop in position.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
400
Letters, Techniques and Images
Digestive Endoscopy 2015; 27: 397–401
2 Maple JT, Petersen BT, Baron TH, Gostout CJ, Wong Kee Song LM, Buttar NS. Direct percutaneous endoscopic jejunostomy: Outcomes in 307 consecutive attempts. Am. J. Gastroenterol. 2005; 100: 2681–8. 3 Aktas H, Mensink PB, Kuipers EJ, van Buren H. Single-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy. Endoscopy 2012; 44: 210–12.
Endoscopic versus surgical cystogastrostomy for pancreatic pseudocysts
Figure 2 Endoscopic image showing the string of the gastrostomy kit grasped with a forceps.
(20 Fr; US Endoscopy, Mentor, OH, USA) became stuck at the overtube’s tip. Gentle traction to release the bumper resulted in sudden exteriorization from the overtube and through the jejunal wall, requiring surgical intervention. Fluoroscopy is not mandatory to locate the puncture site or to confirm final positioning of the bumper,2,3 as this is confirmed endoscopically. It can, however, be useful in difficult cases as in our only patient in which transillumination is not achieved – an obese woman with acute pancreatitis – although a similar case is also not successful in VelázquezAviña’s series.1 The remaining procedures were uneventful and successful. In conclusion, although leaving the overtube can be useful for distal jejunal loops, it can be safely removed in proximal loops to minimize complications. Moreover, although fluoroscopy is useful when available, particularly in challenging cases, DPEJ can be carried out relying only on transillumination and finger indentation. Authors declare no conflict of interests for this article. Rolando Taveira Pinho, Maria Adélia Resende Rodrigues and Maria Luísa Simões Proença Department of Gastroenterology, Centro Hospitalar de Vila Nova de Gaia, Vila Nova de Gaia, Portugal doi: 10.1111/den.12426
REFERENCES 1 Velázquez-Aviña J, Beyer R, Díaz-Tobar CP et al. New method of direct percutaneous endoscopic jejunostomy tube placement using balloon-assisted enteroscopy with fluoroscopy. Dig. Endosc. Published online 7 Nov 2014; doi: 10.1111/den.12352. [Epub ahead of print].
Dear Editor Pancreatic pseudocysts represent collections of fluid in the peri-pancreatic tissues.1 The incidence is relatively low, 0.5– 1.0/100 000 adults per year.2 Most pseudocysts develop after alcohol-related pancreatitis, with biliary tract disease ranking a close second.3 Invasive procedures for the management of pseudocysts include percutaneous or endoscopic drainage and surgery.4 Percutaneous drainage is rarely indicated because it is associated with high rates of mortality and complications.5 We carried out a systematic review in order to help physicians who hesitate at whether endoscopic or surgical cystogastrostomy is preferred for specific patients whose pseudocyst is located adjacent to the stomach. We searched PubMed and Cochrane Library for trials to 16 July 2014 and identified one randomized controlled trial (RCT) (Varadarajulu 2013) and two controlled clinical trials (CCT). (Varadarajulu 2008; Melman 200), including a total of 137 patients. According to the available data, we carried out a meta-analysis of treatment success rate and re-intervention rate of two CCT only. Results showed that surgical cystogastrostomy achieved treatment success in a higher proportion of patients compared to endoscopic cystogastrostomy when carrying out meta-analysis of two CCT (OR, 3.82; 95% CI, 1.20–12.09; P = 0.02). However, in the one RCT, the result showed no significant difference. We noticed that endoscopic cystogastrostomy was associated with lower cost and shorter hospital stay compared to surgical cystogastrostomy, which was proven in all three studies. The available evidence could not identify differences between endoscopic and surgical cystogastrostomy in terms of complications and re-intervention rate (meta-analysis of two CCT: OR, 0.63; 95% CI, 0.01–35.09; P = 0.82). In summary, this systematic review recommended that endoscopic cystogastrostomy could be the first-line treatment approach for patients with uncomplicated pancreatic pseudocyst. However, large-sample, multicenter RCT are necessary to demonstrate the findings above. Authors declare no conflict of interests for this article. Xin Zhao, Tao Feng and Wu Ji Jinling Hospital, Research Institute of General Surgery,
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
Copyright of Digestive Endoscopy is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Letters, Techniques and Images 399
4 Gencosmanoglu R, Koc D, Tozun N. The buried bumper syndrome: Migration of internal bumper of percutaneous endoscopic gastrostomy tube into the abdominal wall. J. Gastroenterol. 2003; 38: 1077–80. 5 O’Dell KB, Gordon RS, Becker LB. Gastrostomy tube transmigration: A rare cause of small bowel obstruction. Ann. Emerg. Med. 1991; 20: 817–9.
A
B
C
Figure 2 Schema for the presumed process of migration of the gastrostomy site in the stomach. (A) Loosened stop tab. (B) Migration of the balloon from the gastric body into the bulbus. (C) Gastrostomy site moving to the pyloric ring by long-term excessive traction.
had initially been placed to the current position of the button in the bulbus, suggesting that the ulcer scar represented the path of migration of the gastrostomy site. The present case suggests that migration of the gastrostomy site can occur as a PEG-related late complication. This complication may be attributable to long-term excessive traction on the gastric wall as a result of inappropriate positioning, irregular exchange intervals, and loose fixation during the PEG procedure (Fig. 2). These considerations imply that regular exchanges of the gastrostomy tube using EGD are important. In addition, use of a non-balloon-type replacement such as a small bumper-type or button-type device may prevent migration of the gastrostomy site. More importantly, necessity for continuous use should be regularly evaluated, considering this type of long-term complication.
Overtubes and fluoroscopy for direct percutaneous endoscopic jejunostomy: Useful, although not always needful and sometimes harmful The authors read with great interest the article by Velázquez-Aviña et al. reporting a new technique for direct percutaneous endoscopic jejunostomy (DPEJ) using balloonassisted enteroscopy and fluoroscopy.1 The authors present some comments based on their experience with 14 DPEJ attempted in the last 4 years with single-balloon enteroscopy (SBE), applying a similar technique without fluoroscopy. SBE is advanced to the jejunum and the target loop is selected through transillumination and finger indentation. A 40-mm 21-G needle is used for lidocaine infiltration and jejunal loop puncture. This needle is grasped with a snare during skin incision, gastrostomy needle puncture and string advancement (Fig. 1). The 21-G needle is released and the string grasped with a forceps (Fig. 2), as this is easier than with a snare in the jejunum. After one complication caused by the overtube, it is left only for distal loops, as it enabled safer PEJ-bumper pulling through the jejunum. While being pulled, the PEJ-bumper
Authors declare no conflict of interests for this article. Takao Maekita,1 Kazuyuki Nakazawa2 and Jun Kato1 Department of Gastroenterology, School of Medicine, Wakayama Medical University and 2Department of Internal Medicine, Koyo Hospital, Wakayama City, Japan doi: 10.1111/den.12411 1
REFERENCES 1 Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987; 93: 48–52. 2 Loser C, Wolters S, Folsch UR. Enteral long-term nutrition via percutaneous endoscopic gastrostomy (PEG) in 210 patients: A four-year prospective study. Dig. Dis. Sci. 1998; 43: 2549–57. 3 Blomberg J, Lagergren J, Martin L, Mattsson F, Lagergren P. Complications after percutaneous endoscopic gastrostomy in a prospective study. Scand. J. Gastroenterol. 2012; 47: 737–42.
Figure 1 Endoscopic image showing the catheter of the gastrostomy kit penetrating the jejunal wall, while a snare grasping a 21-G needle is used to keep the jejunal loop in position.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
400
Letters, Techniques and Images
Digestive Endoscopy 2015; 27: 397–401
2 Maple JT, Petersen BT, Baron TH, Gostout CJ, Wong Kee Song LM, Buttar NS. Direct percutaneous endoscopic jejunostomy: Outcomes in 307 consecutive attempts. Am. J. Gastroenterol. 2005; 100: 2681–8. 3 Aktas H, Mensink PB, Kuipers EJ, van Buren H. Single-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy. Endoscopy 2012; 44: 210–12.
Endoscopic versus surgical cystogastrostomy for pancreatic pseudocysts
Figure 2 Endoscopic image showing the string of the gastrostomy kit grasped with a forceps.
(20 Fr; US Endoscopy, Mentor, OH, USA) became stuck at the overtube’s tip. Gentle traction to release the bumper resulted in sudden exteriorization from the overtube and through the jejunal wall, requiring surgical intervention. Fluoroscopy is not mandatory to locate the puncture site or to confirm final positioning of the bumper,2,3 as this is confirmed endoscopically. It can, however, be useful in difficult cases as in our only patient in which transillumination is not achieved – an obese woman with acute pancreatitis – although a similar case is also not successful in VelázquezAviña’s series.1 The remaining procedures were uneventful and successful. In conclusion, although leaving the overtube can be useful for distal jejunal loops, it can be safely removed in proximal loops to minimize complications. Moreover, although fluoroscopy is useful when available, particularly in challenging cases, DPEJ can be carried out relying only on transillumination and finger indentation. Authors declare no conflict of interests for this article. Rolando Taveira Pinho, Maria Adélia Resende Rodrigues and Maria Luísa Simões Proença Department of Gastroenterology, Centro Hospitalar de Vila Nova de Gaia, Vila Nova de Gaia, Portugal doi: 10.1111/den.12426
REFERENCES 1 Velázquez-Aviña J, Beyer R, Díaz-Tobar CP et al. New method of direct percutaneous endoscopic jejunostomy tube placement using balloon-assisted enteroscopy with fluoroscopy. Dig. Endosc. Published online 7 Nov 2014; doi: 10.1111/den.12352. [Epub ahead of print].
Dear Editor Pancreatic pseudocysts represent collections of fluid in the peri-pancreatic tissues.1 The incidence is relatively low, 0.5– 1.0/100 000 adults per year.2 Most pseudocysts develop after alcohol-related pancreatitis, with biliary tract disease ranking a close second.3 Invasive procedures for the management of pseudocysts include percutaneous or endoscopic drainage and surgery.4 Percutaneous drainage is rarely indicated because it is associated with high rates of mortality and complications.5 We carried out a systematic review in order to help physicians who hesitate at whether endoscopic or surgical cystogastrostomy is preferred for specific patients whose pseudocyst is located adjacent to the stomach. We searched PubMed and Cochrane Library for trials to 16 July 2014 and identified one randomized controlled trial (RCT) (Varadarajulu 2013) and two controlled clinical trials (CCT). (Varadarajulu 2008; Melman 200), including a total of 137 patients. According to the available data, we carried out a meta-analysis of treatment success rate and re-intervention rate of two CCT only. Results showed that surgical cystogastrostomy achieved treatment success in a higher proportion of patients compared to endoscopic cystogastrostomy when carrying out meta-analysis of two CCT (OR, 3.82; 95% CI, 1.20–12.09; P = 0.02). However, in the one RCT, the result showed no significant difference. We noticed that endoscopic cystogastrostomy was associated with lower cost and shorter hospital stay compared to surgical cystogastrostomy, which was proven in all three studies. The available evidence could not identify differences between endoscopic and surgical cystogastrostomy in terms of complications and re-intervention rate (meta-analysis of two CCT: OR, 0.63; 95% CI, 0.01–35.09; P = 0.82). In summary, this systematic review recommended that endoscopic cystogastrostomy could be the first-line treatment approach for patients with uncomplicated pancreatic pseudocyst. However, large-sample, multicenter RCT are necessary to demonstrate the findings above. Authors declare no conflict of interests for this article. Xin Zhao, Tao Feng and Wu Ji Jinling Hospital, Research Institute of General Surgery,
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
Copyright of Digestive Endoscopy is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
