Novel oesophago-gastro-duodenal stenting for gastric leaks after laparoscopic sleeve gastrectomy.

The management of gastric leak after laparoscopic sleeve gastrectomy (LSG) can be complex and challenging. Whilst operative interventions are mostly complicated and reserved for unstable or refractory cases, endoscopic self-expandable metal stenting (SEMS) is increasingly preferred as a safer treatment option. Yet, SEMS carries the problems of frequent stent migration and inconsistent healing as ordinary SEMS is designed mainly for stenotic disease. We hereby present two cases of early and chronic post-LSG leakage that were respectively failed to be treated by surgery and ordinary SEMS but were successfully managed by a dedicated extra-long oesophago-gastro-duodenal stent. In oesophago-gastro-duodenal stenting, the characteristics of extra-long stent length allow total gastric exclusion between the mid-oesophagus and the first part of duodenum to prevent stent migration and to equalise high pressure gradient within the gastric sleeve to promote fistula healing.

HeartMate-II left ventricular assist device infections resulting from gastrointestinal-tract fistulas.

BACKGROUND: In patients with a left ventricular assist device (LVAD), pump-related infection can cause adverse effects that may result in death. METHODS: We describe three patients who had infections related to a fistula between the gastrointestinal (GI) tract and the LVAD pocket and who subsequently underwent successful heart transplantation without developing sepsis. In no case did the LVAD-related infection adversely affect the outcome of transplantation. CONCLUSIONS: For detecting the fistulas, full upper-GI endoscopy and colonoscopy were superior to other types of diagnostic imaging studies.

The over-the-scope clip system--a novel technique for gastrocutaneous fistula closure: the first North American experience.

BACKGROUND: The mainstay of therapy for gastrocutaneous (GC) fistulas has been surgical intervention. However, endoclips are currently used for management of perforations and fistulas but are limited by their ability to entrap and hold the tissue. OBJECTIVE: To report the first North American experience with a commercially available over-the-scope clip (OTSC) device, a novel and new tool for the endoscopic entrapment of tissue for the closure of fistula and perforations. METHODS: The present single-centre study was conducted at a tertiary referral academic gastroenterology unit and centre for advanced therapeutic endoscopy and involved patients referred for endoscopic treatment for the closure of a GC fistula. The OTSC device was mounted on the tip of the endoscope and passed into the stomach to the level of the fistula. The targeted site of the fistula was grasped with the tissue anchoring tripod and pulled into the cap with concomitant scope channel suction. Once the tissue was trapped in the cap, a 'bear claw' clip was deployed. RESULTS: The patients recovered with fistula closure. No complication or recurrence was noted. Fistula sizes >1 cm, however, were difficult to close with the OTSC system. The length of stay of the bear claw clip at the fistula site is unpredictable, which may lead to incomplete closure of the fistula. CONCLUSION: Closure of a GC fistula using a novel 'bear claw' clip system is feasible and safe.

Bravo capsule system optimizes intragastric pH monitoring over prolonged time: effects of ghrelin on gastric acid and hormone secretion in the rat.

AIM: To evaluate measurements of intragastric pH with the Bravo capsule system over a prolonged time. METHODS: A Bravo capsule was placed inside the rat gastric body and pH was studied for periods up to five consecutive days. For comparison, a gastric fistula model was used. Effects of ghrelin and esomeprazole, with or without pentagastrin, on gastric pH were studied. In addition, effects of esomeprazole on plasma ghrelin, gastrin and somatostatin were analyzed. RESULTS: All rats recovered after surgery. The average 24-h pH during free feeding was 2.3 +/- 0.1 (n = 20) with a variation of 18% +/- 6% over 5 d. Ghrelin, 2400 pmol/kg, t.i.d. increased pH from 1.7 +/- 0.1 to 3.1 +/- 0.3 (P < 0.01) as recorded with the Bravo system. After esomeprazole (1 mg/kg, 3 mg/kg and 5 mg/kg) there was a dose-dependent pH increase of maximally 3.4 +/- 0.1, with day-to-day variation over the entire period of 8% +/- 3%. The fistula and pH studies generated similar results. Acid inhibition with esomeprazole increased plasma ghrelin from 10 +/- 2 pmol/L to 65 +/- 26 pmol/L (P < 0.001), and somatostatin from 10 +/- 2 pmol/L to 67 +/- 18 pmol/L (P < 0.001). CONCLUSION: pH measurements with the Bravo capsule are reliable, and comparable to those of the gastric fistula model. The Bravo system optimizes accurate intragastric pH monitoring over prolonged periods and allows both short- and long-term evaluation of effects of drugs and hormones.

Spontaneous resolution of pancreatic gastric fistula.

Pancreatic pseudocyst is one of the common complications of acute and chronic pancreatitis and has variable natural history. We present a case of spontaneous resolution of a pancreatic pseudocyst with gastric connection. This case presented a 46-year-old man with a pancreatic pseudocyst resulting from a complication of acute pancreatitis. This resolved spontaneously through the formation of a fistula between the pseudocyst and stomach. The fistula tract was also occluded spontaneously and the patient recovered without any complication or need for surgical treatment. The patient has been good progress at a two year follow up after spontaneous resolution of the fistula.

Analysis of factors affecting the spontaneous closure of a gastrocutaneous fistula.

BACKGROUND/PURPOSE: Few reports have documented the rate of persistence of a gastrocutaneous fistula (GCF) after gastrostomy removal or the reason for the persistence of a GCF. The purpose of this report was to analyze a large group of pediatric patients with a persistent GCF to determine the rate of persistence and any factors that correlate with the persistence of a GCF. METHODS: This was a retrospective review of 1,042 children from The Children's Hospital, Denver, Colorado who had a gastrostomy constructed between 1992 and 2002. The charts of all children with a persistent GCF after gastrostomy catheter removal were analyzed for correlation between 13 clinical parameters and the persistence of a GCF. RESULTS: There were 150 children with a persistent GCF for an incidence of 34%. Time elapsed between the creation of the GCF and removal of the gastrostomy appliance (< or =8 months versus >8 months) was the only parameter that showed any correlation with persistence of a GCF (P <.05). None of the other parameters studied showed any conclusive correlation with persistence of a GCF. CONCLUSIONS: Time was the only factor that determined whether a surgically created GCF would persist after removal of a gastrostomy appliance.

Gastric antisecretory and anti-ulcer effect of ME3407, a new benzimidazole derivative, in rats.

The effects of a new benzimidazole derivative, ME3407 (n-butyl-2-(thiazolo-[5,4-b]pyrid-2-yl) sulfinylacetate, CAS 133903-90-9), on gastric acid secretion and gastric and duodenal ulcers in rats were examined. ME3407, given orally, inhibited dose-dependently (0.3-30 mg/kg) the incidence of gastric lesions such as Shay ulcers, and water-immersion stress-, acetylsalicylic acid (ASA)- and histamine-induced erosions. In addition, ME3407 showed marked therapeutic effect on HCl- and ASA-induced lesions. In the lumen-perfused rats, oral administration of ME3407 inhibited dose-dependently (1-100 mg/kg) gastric acid secretion induced by histamine and tetragastrin with ED50 values of 3.02 and 3.37 mg/kg, respectively. Oral administration of ME3407 at a dose of 30 mg/kg also inhibited the elevation of serum gastrin level. The development of duodenal ulcers caused by mepirizole and systeamine was also potently inhibited by ME3407 at an oral dose of 0.1-30 mg/kg. However, when given at 30 mg/kg intraduodenally, subcutaneously or intravenously, ME3407 did not inhibit these acutely induced gastric elosion and acid output. ME3407 was not detected in the serum upon oral administration. These results indicated that ME3407 was active only by oral administration, and exerts direct action on the ulcers and acid secretion from the gastric membrane.

Mediators for fat-induced ileal brake are different between stomach and proximal small intestine in conscious dogs.

Our aim was to determine the mechanisms by which intraileal fat alters proximal gastrointestinal motility--the ileal brake. Five mongrel dogs with ileal Thiry-Vella fistulas were equipped with strain gauge force transducers on the upper gut to measure contractile activity. Ileal infusions of 115 mmol/L oleic acid and triglyceride were studied in dogs with extrinsically innervated and extrinsically denervated Thiry-Vella loops. Plasma concentrations of peptide YY and total glucagon-like immunoactivity were measured. Oleic acid but not triglyceride inhibited postprandial contractions in the gastric antrum in dogs with innervated and denervated Thiry-Vella loops. Postprandial duodenal and jejunal motility was inhibited by oleic acid regardless of extrinsic denervation to the loops (P <0.05), but triglyceride inhibited small intestinal motility only in dogs with innervated Thiry-Vella loops. Intraileal oleic acid but not triglyceride increased plasma concentrations of peptide YY and total glucagon-like immunoactivity in dogs with innervated and denervated Thiry-Vella loops. Intraileal oleic acid inhibits gastric and small intestinal motility possibly via increased plasma concentrations of peptide YY and enteroglucagon. Intact extrinsic innervation is necessary for intraileal triglyceride to inhibit small intestinal motility.

Artificial nutritional support in patients with gastrointestinal fistulas.

Gastrointestinal (GI) fistulas allow abnormal diversions of GI contents, digestive juices, water, electrolytes, and nutrients from one hollow viscus to another or to the skin, potentially precipitating a wide variety of pathophysiologic effects. Mortality rates have decreased significantly during the past few decades from as high as 40% to 65% to 5.3% to 21.3% largely as a result of advances in intensive care, nutritional support, antimicrobial therapy, wound care, and operative techniques. The primary causes of death secondary to enterocutaneous fistulas have been, and continue to be, malnutrition, electrolyte imbalances, and sepsis, especially in high-output fistulas, which continue to have a mortality rate of about 35%. Priorities in the management of GI fistulas include restoration of blood volume and correction of fluid, electrolyte, and acid-base imbalances; control of infection and sepsis with appropriate antibiotics and drainage of abscesses; initiation of GI tract rest including secretory inhibition and nasogastric suction; control and collection of fistula drainage with protection of the surrounding skin; and provision of optimal nutrition by total parenteral nutrition (TPN) or enteral nutrition (EN) (or both). The role of nutrition support in the management of enterocutaneous fistulas as either TPN or EN is primarily one of supportive care to prevent malnutrition, thereby obviating further deterioration of an already debilitated patient. It has been shown in several studies that TPN has substantially improved the prognosis of GI fistula patients by increasing the rate of spontaneous closure and improving the nutritional status of patients requiring repeat operations. Moreover, other studies have shown that nutritional support decreases or modifies the composition of the GI tract secretions and is thus considered to have a primary therapeutic role in the management of fistula patients. Finally, if a fistula has not closed within 30 to 40 days, or if it is unlikely to close because of a variety of collateral or compounding pathophysiologic conditions, consideration must be given to operative resection of the fistula while continuing to maintain the previous nutritional and metabolic support. The morbidity and mortality rates in such unfortunate patients remain high despite the many recent advances in surgical and metabolic technology.

Twenty-four-hour basal and repetitive pentagastrin-stimulated gastric acid secretion in normal and sham-operated rats and in rats after gonadectomy or treatment with estradiol or testosterone.

BACKGROUND: Studies in different species have suggested, but not established, that sex hormones influence gastric acid secretion. We studied how acid output is affected by the sex hormones estradiol or testosterone in vivo and in vitro. METHODS: In gastric fistula rats that were normal, sham-operated, neonatally gonadectomized, or treated with estradiol or testosterone, 24-h basal and pentagastrin-stimulated acid secretion was measured. The in vitro effects of estradiol and testosterone on histamine-induced aminopyrine accumulation in isolated parietal cells were also determined. RESULTS: Basal acid output was similar in the two sexes, but stimulated secretion was significantly higher (34%; P < 0.01) in males. Ovariectomy did not influence acid output, whereas orchidectomy reduced basal (18%; NS) and stimulated 24-h secretion (P < 0.01). Estradiol decreased (23%; NS) the 24-h basal output in females but not in males. Estradiol suppressed stimulated secretion in females (29%, P < 0.01) and males (42%, P < 0.01) during the day. At night the stimulated secretion increased in both females (17%, NS) and males (32%, P < 0.05). A similar pattern was found when rats were treated with testosterone. In vitro, estradiol and testosterone reduced histamine-stimulated aminopyrine accumulation in both female and male isolated parietal cells. CONCLUSIONS: Estradiol and testosterone both appear to influence gastric secretion in rats, and their action differs between day and night, between the sexes, and between basal and stimulated secretion.