La gastronómía endoscópica percutánea en pacientes con trastornos deglutorios de origen neurológico. Resultados de un estudio prospectivo multicéntrico internacional / Percutaneous endoscopic gastrostomy in patients with neurological diseases. Results of a prospective multicenter and international study

AIM: To determine prospectively the long-term evolution of patients with neurological diseases after insertion of percutaneous endoscopic gastrostomy (PEG). METHODS: 109 PEG were performed in 99 consecutive patients (49 females, 50 males), mean age 75 years (range: 20-97 years) as an alternative to a nasogastric tube. Patients were enterally fed because of chronic neurological swallowing difficulties: cerebrovascular disease 38, dementia 27, disordered swallowing mechanisms in elderly patients 10, motor neurona disease and multiple sclerosis 10, neuro-surgical disease 6, Parkinson's disease 3, brain tumor 3, neo-natal encephalopathy 1, HIV encephalopathy 1. The procedure took place in a dedicated endoscopy room. In all cases, prophylatic antibiotics were given and the PEG tube was inserted by the "pull" technique. RESULTS: PEG insertion was technically succesful in all cases. After PEG insertion, all patients were subsequently discharged to local nursing home facilities. 85/99 patients were long-term followed-up on an outpatient basis, 25% of them were followed for more than a year. The mean follow-up time was 3 months (range: 1-24 months). The most frequent complication were minor: local wound infection 6, ostomy leakage 8, silicon degradation 16, leading to the removal of the PEG and the placement of a new PEG tubes in 10 cases. Two major complications were observed : one gastric perforation and death 2 months after the PEG placement and one gastrocolic fistula. No aspiration pneumonia was reported. In one patient, PEG was removed after recuperation of a normal swallowing. All patients had a nutritional improvement. A total of 11 deaths occurred during the follow-up, related to the neurological disorder in 10/11 cases. Nursing home team, patient's physicians and patient's families found PEG manipulations easier than naso-gastric tube. CONCLUSION: Our study suggests that PEG is a method of choice for enteral feeding of patients with chronic neurological disorders. PEG is well-tolerated, leading to an improvement in nutritional status and offering good facilities for home nursing.

Low levels of gastric mucosal glutathione during upper gastric bleeding associated with the use of nonsteroidal anti-inflammatory drugs.

OBJECTIVES: To investigate the glutathione concentrations in gastric mucosa from patients with acute gastric bleeding related to nonsteroidal anti-inflammatory drugs (NSAIDs), and to test the influence of nutritional status on mucosal glutathione. Glutathione protects the gastrointestinal mucosa against reactive oxygen species, and glutathione content in various tissues may be depleted during malnutrition. METHODS: Endoscopic biopsies were obtained from 39 patients. Eighteen of these (9 well-nourished, 9 malnourished) presented with gastric bleeding ulcers related to NSAIDs. Twenty-one other patients (12 well-nourished, 9 malnourished) underwent normal routine diagnostic endoscopy and served as controls. Malnutrition was defined as a loss of over 10% of normal body weight and/or plasma albumin levels below 30 g/l. Gastric biopsies were taken from the fundus and antrum (controls) and from the region of the ulcer (patients with acute bleeding) and frozen quickly until glutathione analysis by high-performance liquid chromatography (HPLC) coulometric detection. Results were expressed as nmol/mg wet tissue. RESULTS: Gastric mucosal glutathione levels were significantly (P < 0.05) lower in both the antrum (0.81 +/- 0.34 v. 1.41 +/- 0.88 nmol/mg tissue) and the fundus (1.04 +/- 0.54 v. 1.43 +/- 0.92 nmol/mg tissue, P < 0.05) in malnourished than in well-nourished control patients. Glutathione mucosal concentrations were decreased significantly in patients with NSAID-induced gastric bleeding compared with control patients (0.38 +/- 0.36 v. 1.12 +/- 0.56 nmol/mg tissue, P < 0.001), and the lowest glutathione levels were observed in malnourished patients (0.28 +/- 0.20 v. 0.48 +/- 0.15 nmol/mg tissue in well-nourished patients, not significant). CONCLUSION: Malnutrition is associated with low levels of gastric glutathione. This may contribute to the severity and the onset of haemorrhage in NSAID-induced gastric ulcers.

Severe dysphagia after laparoscopic fundoplication: usefulness of barium meal examination to identify causes other than tight fundoplication--a prospective study.

Background. The aim of this study was to determine the results of a barium meal examination after laparoscopic wrap in symptomatic patients (SPs) with no upper endoscopic anomalies and no increase in inferior esophageal sphincter pressure (SPs). Radiologic results were compared with results from patients with no symptoms (ASPs) and were compared with the surgical findings in patients who underwent reoperation. Methods. Twenty SPs were included 27 +/- 6 months after a total wrap (n = 13 Nissen procedures) or a posterior wrap (n = 7 Toupet procedures) performed in several hospitals in Haute Normandie. All patients had severe symptomatic dysphagia with epigastric pain (n = 18 patients) and/or marked weight loss (n = 16 patients). Control subjects were 31 consecutive ASPs within our center who were prospectively included 4 +/- 1 months after a Nissen (n = 6 patients) or a Toupet (n = 25 patients) procedure. A barium meal examination was performed in all patients and interpreted by 3 independent observers who knew that the patients had undergone a wrap but who did not know whether the patients had symptoms. Fifteen of the 20 SPs underwent a second operation. Results. Barium meal examination was more often abnormal in SPs than in ASPs (17/20 vs 4/31 patients; P <.001), whichever the type of wrap. Two abnormal radiologic results were observed in both groups: an esophageal barium level and an esogastric plication. Only a high barium level in the esophagus was more frequently observed in SPs than in ASPs (P <.05). Three radiologic results were specifically observed in SPs: a long cardial narrowing beginning above the wrap, a mediogastric plication, and a gastric volvulus. A comparison of radiologic anomalies and surgical findings showed that (1) a radiologic long cardial narrowing was explained by fibrotic stenosis of the muscular esophageal hiatus (n = 6 patients), (2) a mediogastric plication (n = 4 patients) was due to gastric volvulus (n = 3 patient) or to gastric wrap (n = 1 patient), and (3) results of volvulus (n = 5 patients) indicated a gastric volvulus. Additional surgical procedures resulted in the disappearance of symptoms in 13 of 15 patients. Conclusions. After laparoscopic fundoplication when upper endoscopy and esophageal manometry are normal, results of a barium meal examination can explain the cause of dysphagia in almost all patients. Three radiologic results were specific for SPs and indicated major morphologic disturbances that could not be treated by endoscopic dilation but that could be treated by additional surgical procedures.

[Prospective evaluation of three kits for endoscopic percutaneous gastrostomy (PEG)]. / Evaluation prospective de trois kits de gastrostomie percutanée endoscopique (GPE).

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) is often used for long-term enteral feeding. Various PEG kits are currently available. A technical evaluation could be useful in providing a criteria of choice between the different kits. METHODS: Therefore, from January 1995 to January 1998, we prospectively performed a short- and a mid-term technical evaluation of 150 PEG kits: 106 Compat Sandoz, 37 Flocare Nutricia et 7 Sherwood. RESULTS: In 20% of the patients studied, technical problems during endoscopic insertion of the probe were observed. Only minor incidents were found for Compat Sandoz and Flocare Nutricia kits. However, major problems occurred with the Sherwood kits leading to a very difficult (4 cases) or impossible (2 cases) transcutaneous introduction of the catheter into the stomach. Mid-term outcome was evaluated in 86 of the 150 patients (57%) with a median follow-up duration of 5 months (range: 1-24). The main finding of the mid-term evaluation was a significant alteration of the Compat Sandoz tube. CONCLUSION: This prospective evaluation shows that technical improvement of the available PEG kits are needed, that the PEG polyurethane tube could be preferred for long-term enteral feeding.

Does percutaneous endoscopic gastrostomy prevent gastro-oesophageal reflux during the enteral feeding of elderly patients?

Percutaneous endoscopic gastrostomy (PEG) is reported to be a safe method for enteral feeding, although its ability to prevent gastro-oesophageal reflux (GOR) during enteral feeding remains controversial. In 12 elderly patients fed enterally to avoid the risk of tracheal aspiration, we have compared two 24-h oesophageal pH profiles, one recorded when enteral feeding was delivered at first via a nasogastric tube (NGT), and the other via a PEG. The second recording was always performed at least 8 days after gastrostomy placement. Enteral nutrition consisted of 500 ml of a polymeric diet delivered 3 times a day at 08:00, 13:00 and 18:00. After gastrostomy placement, enteral feeding was associated with a pathological acid reflux in 8 out of 12 patients. In all of these 8 patients, GOR was mostly related to a high number of reflux episodes. In 4 out of 8 patients, GOR occurred only during the 3 h following the administration of the nutritive diet. In 4 of the patients, GOR did not occur any more after removal of the NGT, whilst gastrostomy placement was followed by GOR in 5 patients. GOR during enteral feeding via PEG is common in elderly subjects. We have shown that a chronological relationship existed in some patients between the endoscopic procedure and the onset of a pathological GOR.

[Effect of lipid intake in meals on the duodenojejunal and sigmoid motor responses in healthy volunteers]. / Influence de la charge lipidique du repas sur les réponses motrices duodéno-jéjunale et sigmoïdienne chez le volontaire sain.

OBJECTIVES: In man, fat induces a fed motor pattern in the small bowel and stimulates colonic motility. With a pure lipid meal, these motor effects are dose-related. However, animal studies have suggested that the motor effects of fat are reduced when lipids are mixed with proteins and carbohydrates. Our aim was to study in healthy volunteers the duodeno-jejunal and sigmoid motor responses after two 750-kcal meals, one containing 28%, the other 58% lipids. METHODS: Combined duodeno-jejunal and sigmoid manometric sessions were performed in each volunteer during 3 hours after each test meal. Meal was always given 30 minutes after the occurrence of a phase III in the duodenum. The order of the two studies was randomly assigned with a minimal interval of 8 days between the two studies. The number of waves and the area under curve were calculated both on the overall and on each of the 6 successive half hours of the recording period. RESULTS: Phases III were interrupted at least for 3 hours by both types of meals in each volunteer. The overall duodeno-jejunal motor response was not different after the two meals and, in all cases, a progressive decrease of the motor parameters with time was demonstrated. A lower response in the duodeno-jejunum during the first postprandial hour and a delayed onset of the maximal motor activity were observed with the high fat meal. In the sigmoid, a motor response to food was observed in all volunteers without any quantitative difference between the low and high fat meals. CONCLUSION: A two-fold increase of the lipid fraction of a meal does not enhance the duodeno-jejunal and sigmoid motor responses to food. At variance, it reduces the first hour motor response and delays the peak of maximal activity in the duodeno-jejunum. Our data confirm that the specific motor effects of fat are modified by their combination with proteins and carbohydrates.

[Portal thrombosis disclosing antiphospholipid syndrome. 2 cases]. / Thrombose portale révélant un syndrome des antiphospholipides. Deux cas.

The presence of serum antiphospholipid antibodies is associated with arterial and venous thrombosis. We report two cases of portal vein thrombosis associated with serum antiphospholipid antibodies. In our two patients, systemic lupus erythematosus, chronic liver disease, hepatocellular carcinoma, myeloproliferative disorders and coagulation inhibitor deficiency were excluded after extensive tests were performed to diagnose portal vein thrombosis and after a follow-up period of 6 and 7 years, respectively. The test for serum antiphospholipid antibodies was positive on two occasions in both patients. Both patients were treated with endoscopic sclerotherapy for bleeding esophageal varices and with long term anticoagulant therapy for the prevention of recurrent thrombosis. These two cases suggest that serum antiphospholipid antibodies should be investigated in patients with portal vein thrombosis of unexplained etiology.

Endoscopic retrograde cholangiopancreatography: before and after laparoscopic cholecystectomy.

In 39 patients with indication of laparoscopic cholecystectomy (LC), an endoscopic cholangiopancreatography (ERCP) was performed before the procedure whenever intermittent cholestasis, acute pancreatitis or ultrasonografic biliary tract dilatation were detected. No abnormality was found in 24 of them. In 14, bile duct stones were removed by endoscopic sphincterotomy (EST). Later they were submitted to LC, and no complication was observed. Only 1 patient with cholangiografic diagnosis of Mirizzi's syndrome underwent open cholecystectomy. Twenty-four patients were referred to ERCP between 2 and 210 days following LC, after development of complications. The etiology of these complications could be established in all the cases. Sixteen patients had bile duct stones, 14 of them were treated successfully by EST and 2, with multiple stones, required open surgery extraction. Four patients had cystic bile leaks, of which 1 healed spontaneously, 1 closed his fistula after EST and removal of stones, 1 cured after a nasobiliary tube was inserted endoscopically and 1 required surgical treatment. Four patients with complete obstruction of common bile duct by misplaced clips received surgical treatment. We conclude that ERCP is indicated before LC in patients with clinical, humoral or ultrasound findings of extrahepatic cholestasis. The application of EST plus LC systematically in cases of biliary duct stones remains still controversial. We agree that ERCP is an excellent method in the diagnosis and treatment of LC complications.

Endoscopic retrograde cholangiopancreatography: before and after laparoscopic cholecystectomy

Em 39 pacientes con indicación de colecistectomía laparoscópica (LC), se realizó una colangiopancreatografía endoscópica (ERCP) antes de la cirugía por presentar colestasis intermitente, pancreatitis aguda o dilatación ecográfica de la vía biliar. No se encontró ninguna anormalidad en 24. En 14, con litiasis coledociana, se extrajeron los cálculos por esfinterotomia endoscópica (EST) y luego se realizó la LC sin observarse complicaciones. Un paciente con síndrome de Mirizzi requirió colecistectomía convencional. La ERCP se indicó por complicaciones de la LC en 24 pacientes entre el día 2 y 210 posteriores al procedimiento. La etiología de estas complicaciones se pudo establecer en todos los casos. Dieciseis tuvieron litiasis residual do colédoco, 14 pudieron tratarse endoscópicamente y 2 con múltiples cálculos requirieron cirugía. Cuatro pacientes presentaron fístulas del cístico remanente de los cuales 1 curó espontaneamente, 1 cerró despues de una EST y extracción de cálculos residuales, 1 curó con la colocación endocópicamente de un drenaje nasobiliar y el último requirió tratamiento. Cuatro pacientes con obstrucción completa del hepático comúm por clips metálicos recibieron tratamiento quirúrgico

Tratamiento con ondas de choque extracorporeas (ESWL) en la litiasis de la via biliar principal / Treatment with extracorporeal shockwave in lithiasis of the common bile duct

En el transcurso de 2 años (1988-1990) se estudiaron 373 pacientes por ERCP para determinar la etiología de una colestasis. En 190 se encontraron cálculos en la vía biliar principal. Treinta y nueve fueron tratados quirúrgicamente y en 151 se efectuó EPE y diferentes técnicas de extracción. En 12 pacientes de este grupo de utilizó como tratamiento adicional ESWL para fragmentar cálculos que ho habían podido ser extraídos con canastilla o litotripsia mecánica. De los 12, 9 eran mujeres y 3 varones con un promedio de edad de 71 años (rango 32-90). Nueve estaban colecistectomizados y 3 tenían vesícula. La litiasis coledociana fue única en 4, y 5 tenían 2 cálculos. En los restantes se comprobaron 3 o más litos. El diámetro de los cálculos superó los 2,5 cm. en 11 pacientes. Sólo en 1 fue de 1 cm. Se efectuaron entre 1200 y 5000 disparos en cada sesión, con un promedio de 1400. En 8 pacientes (66%) la fragmentación permitió la evaluación completa, espontánea o instrumental. Se fracasó en 4 casos que recibieron una sola sesión de ESWL. Se registró hematobilia leve en 1 paciente y equimosis de piel y dolor en 2. En los 8 pacientes en los que se consiguió la eliminación total de los cálculos no hubo complicaciones alejadas. El empleo de ESWL resultó ser un recursos terapéutico útil en el tratamiento de cálculos coledocianos que no pudieron ser extraídos por EPE y maniobras instrumentales con canastilla y litotripsia mecánica

[Treatment with extracorporeal shockwave (ESWL) in lithiasis of the common bile duct]. / Tratamiento con ondas de choque extracorporeas (ESWL) en la litiasis de la viá biliar principal.

During 2 years (1988-1990) 373 patients were studied by ERCP in order to establish the etiology of cholestasis. Biliary duct stones were found in 190. Thirty-nine were treated surgically and 151 by endoscopic sphincterotomy and different extraction techniques. In 12 patients of the last group (9 women, 3 men, mean age 71 years, 9 had undergone cholecystectomy and 3 has their gallbladders in situ), ESWL was used as additional treatment to fragment the stones that could not be removed with the Dormia basket or with mechanical lithotripsy. Four patients had only one stone in their biliary ducts, 5 had two, and 3 had more than two stones. The size of the stones was greater than 2.5 cm. in 11 patients, only 1 patient had a 1 cm. diameter stone. In each session between 1200 and 5000 shock waves were administered (mean 1400). In 8 patients (66%), the fragmentation was successful to achieve their spontaneous passage or their extraction with a basket. In 4 who received only one session of ESWL, the procedure failed to break the stones. Side effects were observed in 3 cases: mild haemobilia in 1, skin petechiae and pain in 2 patients. No complications were observed in the long term follow-up. We conclude that ESWL is useful in the treatment of biliary duct stones which cannot be extracted through sphincterotomy with a basket or mechanical lithotripsy.

Amiloidosis primaria: manifestaciones

La amiloidosis se caracteriza por el depósito tisular, localizado o sistémico, de una sustancia formada por tres fracciones: 1) proteica, 2) mucopolisacáridos, 3) lípidos e hierro, con ultraesctructura fibrilar. Son fibrillas finas, rígidas, con conformación cristalográfica beta, que le da sus propriedades especificas. Se individualizan cuatro tipos de amiloide derivados de la cadenas lovianas y otras inmunoglobulinas, aminoácidos o sustancias similares a la prealbúmina. Si todos los depósitos con acúmulos de fibrilas proteicas, una de sus causas sería la síntesisexcesiva de ellas. Esto no es suficiente y se requiere que estas proteínas precursosras sean captadas por los macrófagos, sometidas a proteolisis y por exocitosis depositadas extracelularmente. Se presenta una paciente de 55 años, en quien la participación hepática y renal hace sospechar uns amiloidosis que se confirma por hallarse una gamapatía monoclonal y por biopsia de tejidos

Amiloidosis primaria. Manifestaciones clínicas / [Primary amyloidosis. Clinical manifestations]

Amyloidosis is distinguished by store both localized or systemic, of a substance conformed for 3 fraction: 1) protein (90

), 2) Mucopolysaccharides, 3) fatty and iron, with filament ultrastructure. These filaments are thin and rigid, with beta crystallographic shape. Four pattern of amyloid are distinguished. They are derived of light chains or another immunoglobulins, aminoacids or prealbumin like substance. If all deposits are protein filaments storage, one of their trials would be increased synthesis of them. This is not sufficient and need that these precursor proteins be attrached by macrophages they are subjected to proteolysis and are enclosed extracellularly. We present a female, 55 years old. The hepatic and renal participation permit to suspect an amyloidosis who is confirmed by the presence of monoclonal gammopathy and by biopsy of tissues.

[Primary amyloidosis. Clinical manifestations]. / Amiloidosis primaria. Manifestaciones clínicas.

Amyloidosis is distinguished by store both localized or systemic, of a substance conformed for 3 fraction: 1) protein (90%), 2) Mucopolysaccharides, 3) fatty and iron, with filament ultrastructure. These filaments are thin and rigid, with beta crystallographic shape. Four pattern of amyloid are distinguished. They are derived of light chains or another immunoglobulins, aminoacids or prealbumin like substance. If all deposits are protein filaments storage, one of their trials would be increased synthesis of them. This is not sufficient and need that these precursor proteins be attrached by macrophages they are subjected to proteolysis and are enclosed extracellularly. We present a female, 55 years old. The hepatic and renal participation permit to suspect an amyloidosis who is confirmed by the presence of monoclonal gammopathy and by biopsy of tissues.