The sky blue method as a screening test to detect misplacement of percutaneous endoscopic gastrostomy tube at exchange.

BACKGROUND: During tube exchange for percutaneous endoscopic gastrostomy (PEG), a misplaced tube can cause peritonitis and death. Thus, endoscopic or radiologic observation is required at tube exchange to make sure the tube is placed correctly. However, these procedures cost extensive time and money to perform in all patients at the time of tube exchange. Therefore, we developed the "sky blue method" as a screening test to detect misplacement of the PEG tube during tube exchange. METHODS: First, sky blue solution consisting of indigocarmine diluted with saline was injected into the gastric space via the old PEG tube just before the tube exchange. Next, the tube was exchanged using a standard method. Then, we checked whether the sky blue solution could be collected through the new tube or not. Finally, we confirmed correct placement of the tube by endoscopic or radiologic observation for all patients. RESULTS: A total of 961 patients were enrolled. Each tube exchange took 1 to 3 minutes, and there were no adverse effects. Four patients experienced a misplaced tube, all of which were detectable with the sky blue method. Diagnostic parameters of the sky blue method were as follows: sensitivity, 94% (95%CI: 92-95%); specificity, 100% (95%CI: 40-100%); positive predictive value, 100% (95%CI: 100-100%); negative predictive value, 6% (95%CI: 2-16%). CONCLUSION: These results suggest that the number of endoscopic or radiologic observations to confirm correct replacement of the PEG tube may be reduced to one fifteenth using the sky blue method.

Successful cystic fenestration for a macrocystic serous cystadenoma of the pancreas causing obstructive jaundice: report of a case.

A 72-year-old man was admitted to our hospital for investigation of jaundice. We made a preoperative diagnosis of macrocystic serous cystadenoma (SCA) of the pancreas, but did not perform palliative choledochojejunostomy because aspiration of the pancreatic cystic fluid caused the cysts to shrink and relieved the compressive stenosis of the common bile duct (CBD) during the operation. Frozen sections of the cyst wall taken by incision biopsy showed no signs of malignancy. Therefore, we performed fenestration of the cystic wall after fixing the inner epithelium of the cyst with 100% ethanol and aspirating the cystic fluid. Cholangiography after the cystic fenestration showed resolution of the CBD stenosis and abdominal computed tomography (CT) confirmed the disappearance of the pancreatic cysts. No recurrence of cystic swelling or obstructive jaundice has been detected by abdominal CT or laboratory data for more than 2 years since the cystic fenestration. Thus, cystic fenestration may be a better palliative option for treating benign compressive tumors such as macrocystic SCA of the pancreas causing obstructive jaundice.