Advanced cystic fibrosis liver disease: Endovascular, endoscopic, radiologic, and surgical considerations.

Up to 90% of people with CF (pwCF) will have some form of hepatobiliary involvement. This manuscript aims to explore the different endovascular, endoscopic, radiological and surgical procedures available to diagnose and manage the most severe form of CF hepatobiliary involvement (CFHBI) known as advanced cystic fibrosis liver disease (aCFLD), seen in 10% of pwCF. These procedures and interventions include liver biopsy, hepatic venous pressure gradient measurement, gastrostomy tube placement to optimize nutrition, paracentesis, endoscopic variceal control of bleeding and portosystemic shunting before liver transplantation. By utilizing advanced diagnostic or surgical techniques, healthcare professionals of pwCF can more effectively manage patients with CFHBI and aCFLD and potentially improve patient outcomes.

Remimazolam As a Sole Sedative Agent for Gastrostomy Tubes Placed in the Interventional Radiology Suite: A Case Series.

Remimazolam is an ultrashort acting intravenous sedative-hypnotic approved for procedural sedation. We report a series of 8 cases of radiographically placed gastrostomy tubes using remimazolam as the sole anesthetic agent. Interventional radiology (IR) gastrostomy tube placement entails anesthetizing often complex patients in a nonoperating room environment. All 8 patients reported here underwent successful gastrostomy tube placement without the need for conversion to general anesthesia. Remimazolam is a feasible option to sedate patients for gastrostomy tube placement in the IR suite.

This is a successful removal of more than 450 pieces of metal objects from a patient's stomach: a case report.

BACKGROUND: Ingestion of foreign bodies may be seen unconsciously or intentionally in patients with mental health problems. Most cases pass through the esophagus slowly; however, in some cases, the tumor may be located in narrower areas of the digestive tract that require endoscopic or surgical intervention. This study describes a rare case of successful removal of more than 450 pieces of metal objects from the stomach of a 36-year-old man via ingestion of foreign bodies at Imam Khomeini Hospital in Ahvaz. CASE PRESENTATION: A 36-year-old male patient (Aryan race) presented with complaints of chronic abdominal pain, frequent vomiting, and intolerance to liquids and food. The patient's companions mentioned a history of gradual ingestion of small metal objects 3 months prior. The patient was conscious and had stable vital signs. In the patient's X-ray and endoscopy, multiple metal objects inside the patient's stomach were observed, causing gastric outlet obstruction. The patient underwent gastrostomy surgery, and 452 screws, nuts, keys, stones, and other metal parts weighing 2900 g were removed from the stomach. Five days after the operation, the patient was transferred to the psychiatric service in good general condition and was diagnosed with psychosis, and her condition returned to normal at follow-up. CONCLUSION: Successful removal of this foreign body is rare. In chronic abdominal pain, especially in the context of psychiatric disorders, attention should be given to the ingestion of foreign bodies. In swallowing large amounts of sharp and metallic foreign objects, surgical intervention is necessary, especially in cases of obstruction, and saves the patient's life.

Multiple ASM Administration via Percutaneous Feeding Tube as a Cause of Pseudo-Refractoriness Leading to Recurrent Seizure Clusters.

It is important to identify true refractoriness of seizures, before escalation of anti-seizure medications, to avoid side effects of medications. Bioavailability of medications changes with the formulations used and changes significantly with the route of administration. Both of these were significantly impacted in a lady who was being fed via percutaneous endoscopic gastrostomy (PEG) feeds and deemed refractory to medications. After altering the formulations and the method, she became seizure-free.

[New Swedish national guidelines - management of Percuteaneous Endoscopic Gastrostomy (PEG) and other enteral feeding tubes]. / Perkutan endoskopisk gastrostomi ­ nya nationella rekommendationer.

Numerous patients stand to gain significant health benefits from enteral nutrition support facilitated by percutaneous feeding tubes. Consequently it is crucial for endoscopists, general practitioners, surgeons and neurologists to be well-versed with indications, contraindications and potential complications of PEG and other enteral feeding tubes. In this context we present a concise overview of the new national guidelines by the Swedish Society of Gastroenterology regarding the management of PEG and other enteral feeding tubes. Indications for the use of enteral feeding tubes include conditions such as stroke and obstructive cancer. The care of patients with percutaneous feeding tubes necessitates the expertise of a specialized team. Complications related to PEG include, among others, buried bumper syndrome, local infection and dislocation of the feeding tube.

Pros and cons of partial reversal with gastro-gastrostomy in patients with refractory hypoalbuminemia following one-anastomosis gastric bypass.

PURPOSE: Hypoalbuminemia following One-Anastomosis Gastric Bypass (OAGB) surgery remains a major concern among bariatric surgeons. This study aims to assess the outcome of partial reversal to normal anatomy with gastro-gastrostomy alone in patients with refractory hypoalbuminemia following OAGB surgery. METHODS: A retrospective study was performed on patients who underwent partial reversal surgery with gastro-gastrostomy alone due to refractory hypoalbuminemia post-OAGB surgery, using data from the Iran National Obesity Surgery Database, from 2013 to 2022. RESULTS: Of 4640 individuals undergoing OAGB, 11 underwent gastro-gastrostomy due to refractory hypoalbuminemia. The median time from OAGB to partial reversal was 16.6 months and the BPL length ranged from 155 to 200 cm. The follow-up period ranged from 1 to 7 years. The mean BMI was 27.3 (7.5) kg/m² before partial reversal. The mean BMI post-reversal was 30.9 (4.2) kg/m² after 1 year and 33.3 (3.8) kg/m² after 2 years. Serum albumin levels significantly increased from 3.0 (0.4) g/dL to 4.0 (0.5) g/dL following gastro-gastrostomy (p-value < 0.001). Serum liver enzymes (SGOT, SGPT, ALP) significantly decreased post-gastro-gastrostomy (p-value < 0.05). Nine individuals (81.8%) achieved resolution of hypoalbuminemia after gastro-gastrostomy with maintenance of ≥ 20% TWL and ≥ 50% EWL. No cases of anastomotic stricture, leak, bleeding, or major complications were reported after gastro-gastrostomy. CONCLUSION: Gastro-gastrostomy appears to be a safe and efficacious technique for addressing refractory hypoalbuminemia following OAGB. The procedure preserves the weight loss achieved following OAGB without significant complications. However, further studies are required to validate these findings.

Anastomotic bleeding from invaginated pancreaticogastrostomy following pancreatoduodenectomy: incidence, risk factors, treatment and prevention.

BACKGROUND: Meta-analysis of 10 randomized prospective trials demonstrated a higher risk of postoperative bleeding from pancreaticogastrostomy (PG) compared with pancreatojejunostomy following pancreatoduodenectomy (PD). This study evaluated the incidence, risk factors, and treatment of anastomotic bleeding from invaginated PG. METHODS: We retrospectively evaluated all consecutive PDs performed between April 1, 2011 and December 31, 2022 using invaginated PG by the double purse-string technique. Multivariate analysis identified risk factors for anastomotic PG bleeding. RESULTS: During the study, 695 consecutive patients with a median age of 66 years underwent PD; the majority was performed for ductal pancreatic adenocarcinomas. Simultaneous vascular resections were performed in 328 patients. Postoperative mortality was 4.1%. Bleeding from PG occurred in 33(4.6%) patients at a median interval of 5 days (range, 1-14) from surgery, leading to reoperation in 21(63%). PG bleeding-related mortality was 9.0%. Multivariate analyses identified a soft pancreatic texture and Wirsung duct > 3 or ≤ 3 mm (Class C and D, respectively, of the ISGPS) (odds ratio [OR]: 2.17, 95% confidence interval [95% CI]: 1.38-3.44; P = 0.0009) and wrapping of the invaginated pancreas (OR: 0.37, 95% CI: 0.17-0.84; P = 0.01) as independent risk factors for PG bleeding. CONCLUSIONS: In a large volume setting, anastomotic bleeding from invaginated PG occurred in ~ 5% of patients and was associated with soft pancreatic parenchyma and small wirsung duct. The reduced rate of PG bleeding observed with wrapping of the invaginated pancreatic stump warrants further evaluation in a prospective randomized study.

Treatment of Leakage Following Sleeve Gastrectomy by Laparo-Endoscopic Gastrostomy (LEG).

Sleeve gastrectomy (SG) is widely recognized as the leading bariatric procedure worldwide. However, leakage, its major complication, remains a significant concern. This study focuses on the challenges of managing leakage, especially when conventional endoscopic treatments are ineffective. Although a novel one-step approach as reported by Pulimuttil James Zachariah from Wei-Jei Lee's team has demonstrated promise, further investigations and reports on its efficacy are currently insufficient. Between January 2021 and November 2023, we analyzed five patients treated at our center for SG leakage. Patient data include demographics, comorbidities, surgical details, and outcomes. The study details Laparo-Endoscopic Gastrostomy procedures performed post-SG leakage diagnosis, highlighting differences between acute and chronic instances. The study effectively implemented Zachariah's one-step approach, achieving favorable results in all five cases. Patient characteristics, presentation, postoperative progression, and additional treatments were documented. The outcome supports Zachariah's assertion that the one-step approach is a simple, safe, and cost-effective approach for SG leakage, avoiding digestive tract reconstruction. Despite potential limitations, including challenges in closing large defects and extended healing times, the procedure's effectiveness in decompression, drainage, and nutritional support significantly contributes to its elevated healing rate. The study emphasizes the importance of timely abdominal drain removal based on clinical conditions, challenging traditional practices for better clinical outcomes.

Administration of bicarbonates through percutaneous gastrostomy with continuous nocturnal infusion in a patient with Kearns-Sayre disease: a life changing therapeutical paradigm.

BACKGROUND: Mitochondrial diseases (MDs) are systemic disorders that can affect multiple organs. Renal manifestations, including renal tubular acidosis, are common because kidneys are particularly vulnerable to energy deprivation. Treatment of MDs is often complex and electrolyte replacement can be difficult especially in pediatric patients, because large and repeated amounts of oral supplements are needed but are not well tolerated. CASE PRESENTATION: We describe the case of a girl affected by Kearns-Sayre disease with severe renal tubular acidosis. The management of her metabolic acidosis was challenging because she showed persistent low levels of serum bicarbonates despite a progressive incrementation of oral bicarbonates. Furthermore, as a result to the ingestion of large amounts of alkali, the girl developed an aversion to oral supplementation. After positioning a percutaneous gastrostomy (PEG) and starting enteral administration of bicarbonates (with daily boluses and continuous nocturnal infusion), she finally obtained an adequate electrolyte control, with a significant increase in her quality of life. CONCLUSIONS: In MDs, the combination of nocturnal continuous enteral administration of alkali plus diurnal boluses may represent a valid solution to correct metabolic acidosis. It can also result in an improved patients' quality of life, particularly in pediatric settings, where compliance to oral therapy is often lacking due to the large and repeated amounts of unpalatable bicarbonates solutions required.

Obesity and Survival After Immune Checkpoint Inhibition for Head and Neck Squamous Cell Carcinoma.

Importance: For patients treated with immune checkpoint inhibitors (ICIs), recent data suggest that obesity has a beneficial effect on survival outcomes in various cancer types. Reports on this association in head and neck cancer are limited. Objectives: To compare overall survival (OS) to 5 years and functional outcomes in patients with head and neck squamous cell carcinoma (HNSCC) treated with ICIs based on pretreatment body mass index (BMI). Design, Setting, and Participants: This retrospective population-based cohort study used data obtained from the TriNetX Global Collaborative Network database to identify patients with HNSCC who received ICI treatment between January 1, 2012, and December 31, 2023, resulting in a total of 166 patients (83 with BMI of 20.0-24.9 [normal BMI] and 83 with BMI of ≥30.0 [obesity BMI]) after propensity score matching (PSM) for pretreatment medical comorbidities and oncologic staging. Exposure: Normal BMI vs obesity BMI. Main Outcomes and Measures: Overall survival and functional outcomes (dysphagia, tracheostomy dependence, and gastrostomy tube dependence) were measured to 5 years after ICI treatment and compared between patients with obesity BMI and normal BMI. Additional analyses compared OS and functional outcomes in the cohort with normal BMI and cohorts with overweight BMI (25.0-29.9) and underweight BMI (<20.0). Results: Among the 166 patients included in the PSM analysis (112 men [67.1%]; mean [SD] age, 62.9 [15.4] years), obesity BMI was associated with significantly improved OS at 6 months (hazard ratio [HR], 0.54 [95% CI, 0.31-0.96]), 3 years (HR, 0.56 [95% CI, 0.38-0.83]), and 5 years (HR, 0.62 [95% CI, 0.44-0.86]) after ICI treatment, compared with patients with normal BMI. Obesity BMI was also associated with decreased risk of gastrostomy tube dependence at 6 months (odds ratio [OR], 0.41 [95% CI, 0.21-0.80]), 1 year (OR, 0.41 [95% CI, 0.21-0.78]), 3 years (OR, 0.35 [95% CI, 0.18-0.65]), and 5 years (OR, 0.34 [95% CI, 0.18-0.65]). Obesity was also associated with decreased risk for tracheostomy dependence at 1 year (OR, 0.52 [95% CI, 0.28-0.90]), 3 years (OR, 0.45 [95% CI, 0.45-0.90]), and 5 years (OR, 0.45 [95% CI, 0.45-0.90]). There were no differences in rates of dysphagia or immune-related adverse events between cohorts at any points. Conclusions and Relevance: Using population-level data for patients with HNSCC treated with ICIs, these results suggest that having obesity was associated with improved 6-month, 3-year, and 5-year OS compared with having normal BMI. Additionally, obesity was associated with decreased gastrostomy and tracheostomy tube dependence compared with normal BMI. Further investigation is required to understand the mechanism of these findings.