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ABSTRACT: BACKGROUND: Gastric electrical stimulator (GES) implantation is effective in certain patients with gastroparesis; however, laparotomy is often employed for placement. The aim of this study is to review outcomes of patients who underwent laparoscopic GES therapy for diabetic and idiopathic gastroparesis at a large referral center. METHODS: Patients who underwent GES (Enterra Therapy System; Medtronic, Minneapolis, MN) implantation with subsequent interrogation and programming between March 2001 and November 2011 were analyzed. RESULTS: A total of 113 patients underwent GES placement or revision during the study period. One hundred eleven patients underwent primary GES at our institution, while two patients underwent GES generator revision at our institution. Primary operations were completed laparoscopically in 110 of 111 cases, with one conversion to laparotomy due to severe adhesions. At a mean follow-up of 27 months (1-113), symptom improvement was achieved in 91 patients (80 %) and was similar for both the diabetic and idiopathic subgroups. Need for supplemental nutrition (enteral and/or parental) decreased in both groups. CONCLUSIONS: GES placement is feasible using a laparoscopic approach. Medical refractory gastroparesis in the diabetic and idiopathic groups had significant symptom improvement with no difference between the two groups. Need for supplemental nutrition is decreased following GES.
Journal of Gastrointestinal Surgery 01/2013; · 2.83 Impact Factor
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ABSTRACT: BACKGROUND: Despite technical refinements of percutaneous endoscopic gastrostomy (PEG) tube placement, complications such as early tube dislodgement remain relatively static. This study aimed to review the experience of a high-volume endoscopy center after the introduction of T-fastener placement in high-risk patients. METHODS: The authors retrospectively reviewed PEG placement from October 2010 to September 2011, when their group began to use T-fasteners selectively in high-risk patients. Patients deemed to have an increased risk for early tube dislodgement underwent T-fastener placement at the time of PEG placement. Patients with PEG alone were compared with patients who had PEG with T-fastener (PEG-T) placement. Statistical analysis was performed using SPSS version 18. RESULTS: During the study period, 195 patients underwent PEG placement. For 121 patients, PEG alone was performed, whereas PEG-T was performed for 74 patients. Six patients had tube dislodgement (five early, one late) in the PEG-T cohort versus none in the PEG-alone cohort (P = 0.003). The first patient underwent diagnostic laparoscopy with replacement gastrostomy 2 days after tube dislodgement and was noted to have no contamination, with direct apposition of the stomach to the abdominal wall from the T-fasteners. The subsequent four patients with early tube dislodgement underwent non-emergent PEG replacement in the endoscopy unit within 24 h after tube dislodgement. In the short-term follow-up period, no repeat dislodgements were noted. Early mortality in the entire cohort was experienced by 38 (19.5 %) of the 195 patients. CONCLUSION: Placement of T-fasteners in high-risk patients may decrease overall morbidity if early tube dislodgement occurs. The findings show the safety of non-emergent endoscopic replacement of PEGs in certain patients. Early tube dislodgement may be a marker of overall mortality.
Surgical Endoscopy 05/2012; · 4.01 Impact Factor
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ABSTRACT: Enteral feeding and gastric decompression devices are common in critical, terminal, and chronically ill patients. Percutaneous transesophageal gastrostomy (PTEG) is a nonsurgical technique that creates an esophagostomy and allows enteral access in patients with a hostile abdomen, altered gastric anatomy, massive ascites, and carcinomatosis. We review our indications, technical experience, complications, and short- and long-term quality of life (QOL) in patients that underwent the PTEG procedure.
Patients were terminally ill from advanced cancer requiring gastrointestinal decompression or had hostile abdomens needing long-term feeding access. The procedure is carried out by inserting a rupture-free balloon (RFB) into the cervical esophagus and utilizing transcutaneous ultrasound to puncture the balloon. A guide wire is passed through the needle into the balloon, followed by a dilator and sheath. The in-dwelling catheter is inserted through the sheath, which exits the esophagus, and resides in the stomach. Proper placement is confirmed by fluoroscopy.
From December 2003 to January 2006, 17 patients were treated with PTEG. Except for two patients, all of the patients had advanced metastatic cancer. Presenting symptoms were nausea, vomiting, and dysphagia. Average age was 62.8 years, with nine men. Placement was successful in 16 patients (94%). There were no major complications and three minor complications (17.6%). Minor complications included two esophageal leaks at the catheter site and one catheter dislodgement. Seven patients (41.2%) died within 1 month after the procedure from their preexisting medical conditions. All patients were capable of being discharged from the hospital with adequate enteral access and gastrointestinal decompression.
PTEG is a safe and effective method of enteral feeding and decompression in patients that have contraindications to standard enteral access. Appropriate patient selection and timing of PTEG placement is crucial for optimum benefit.
Surgical Endoscopy 08/2008; 22(10):2314-8. · 4.01 Impact Factor
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ABSTRACT: The optimal management of Barrett's esophagus, a precursor to esophageal adenocarcinoma, remains controversial. Current therapy includes surveillance and ablative or resection techniques of varying safety and efficacy. This study aimed to determine the feasibility of a new catheter-based, endoscopic water jet ablation technique.
A high-pressure flexible catheter that can be passed through the working port of a standard gastroscope was used. The catheter had micro-drilled holes on one side near the tip. A 1-cm water jet was delivered under foot pedal control and endoscopic view at pressures adjusted from 150 to 400 psi. After approval from the authors' Institutional Review Board, tissue segments from fresh esophagectomy specimens were ablated by the catheter without use of an endoscope. Using gross appearance and histologic analysis, variable ablation pressures and times were evaluated.
Using variable pressures and times, 11 ablation sessions were performed: 5 for normal esophagus, 4 for normal stomach, and 2 across the gastroesophageal junction in the setting of Barrett's esophagus. Ablation pressures of 150 to 300 psi for 30 to 60 s resulted in selective ablation of mucosa with preservation of the submucosa and muscularis propria. The depth of the ablation was determined by gross inspection at the time of ablation and confirmed by histologic evaluation. There was no embedding of epithelial cells in the muscularis propria. In a single normal esophagus specimen, a jet applied at 400 psi for 120 s in a confined area resulted in gross perforation.
Selective ablation of esophageal and gastric epithelium using a catheter-based water jet ablation technique is feasible. The preliminary data from this study investigating a nonendoscopic technique show that the mucosa can be removed with preservation of the underlying submucosa and muscular layers. Further studies are warranted that focus on defining more precisely the pressure and duration required for optimal results and the practical application of this technique endoscopically.
Surgical Endoscopy 04/2008; 22(11):2498-502. · 4.01 Impact Factor
