Exercise capacity following a percutaneous endoscopic gastrostomy in a young female with cystic fibrosis: a case report.

Cystic fibrosis (CF) is a genetic condition affecting the respiratory and gastrointestinal systems, with patients experiencing problems maintaining weight, especially during rapid growth periods such as puberty. The aim of this case report was to monitor the effect of gastrostomy insertion and implementation of overnight supplemental feeding upon clinical outcomes, including body mass index (BMI), lung function (FEV1), and exercise-related variables (maximal oxygen uptake [VO2max] and ventilatory efficiency [VE/VO2]) in an 11-year-old female with CF Combined incremental and supramaximal exercise testing to exhaustion was performed at four time points: 3 months prior to the procedure (T1), 2 days prior to (T2), 4 months (T3), and 1 year following the procedure (T4). Improvements following gastrostomy insertion were observed at the 1 year follow-up with regards to BMI (+20%); whereas absolute VO2max remained stable and lung function fluctuated throughout the period of observation. Declines in function with regards to body weight relative VO2max (-16.3%) and oxygen uptake efficiency (+7.5%) were observed during this period. This case report is the first to consider exercise-related clinical outcomes in assessing the effect of implementing gastrostomy feeding in CF The varied direction and magnitude of the associations between variables shows that further investigations are required.

Cirurgia plástica pós-gastroplastia: perfil das deficiências nutricionais com implicações na cicatrização / Plastic surgery after gastroplasty: nutritional deficiency profile with wound-healing implications

INTRODUÇÃO: Os cirurgiões plásticos têm recebido em seus consultórios e ambulatórios um número cada vez maior de pacientes com queixa de deformidade do contorno corporal após maciças perdas ponderais secundárias a cirurgias bariátricas. Todavia, em função das restrições alimentares e disabsorções cirúrgicas, são frequentes complicações metabólicas e distúrbios nutricionais no pós-operatório tardio das gastroplastias. O objetivo deste estudo é detectar a prevalência dos principais distúrbios nutricionais relacionados à cicatrização em pacientes de ambulatório especializado em cirurgia plástica do paciente pós-gastroplastia. MÉTODO: é um estudo observacional, transversal e descritivo, em que os pacientes foram avaliados clinicamente e através de protocolo laboratorial. RESULTADOS: foram avaliados 32 pacientes com gastroplastia há pelo menos dois anos e estabilidade ponderal há no mínimo seis meses. Os principais distúrbios detectados foram: anemia (56% dos pacientes), com carências na bioquímica do ferro (31,2%) e da vitamina B12 (25%), bem como deficiências dos íons zinco (18,7%) e cobre (3,1%). Houve carências discretas no perfil proteico e ausência de déficits na bioquímica básica e lipidograma. CONCLUSÃO: é dever do cirurgião plástico conhecer a fundo a prevalência dos principais distúrbios nutricionais relacionados à cicatrização na população de pacientes pós-gastroplastia no sentido de corrigir eventuais carências e prevenir complicações. Sabe-se, contudo, que ainda são necessários mais estudos para correlacionar qualquer deficiência alimentar às intercorrências observadas no pós-operatório deste grupo de pacientes.

INTRODUCTION: Plastic surgeons have received in their outpatient clinics an increasing number of patients complaining of body contour defects due to the massive weight loss after a bariatric surgery. However, owing to dietary restrictions and surgical desorption, metabolic complications and nutritional disorders are commonly observed in the late postoperative period after gastroplasty. The aim of this study was to determine the prevalence of major nutritional disorders related to healing in patients at a specialized outpatient plastic surgery clinic who underwent gastroplasty. METHOD: This is an observational, transversal, and descriptive study, in which a laboratory protocol was used to clinically evaluate and assess the patients. RESULTS: Thirty-two patients who underwent gastroplasty at least 2 years previously with weight stability for at least 6 months were evaluated. The major disorders identified included anemia (56% of patients) and deficiency in iron (31.2%), vitamin B12 (25%), zinc ions (18.7%), and copper (3.1%). Mild deficiencies in the protein profile were also observed; however, no deficiencies in basic and lipid biochemistry were noted. CONCLUSION: The plastic surgeon should have an in-depth knowledge about the prevalence of the major nutritional disorders related to healing in postbariatric patients, to allow correction of possible deficiencies and prevention of complications. However, more studies would be required to correlate any dietary deficiency to the complications observed in the postoperative period in this group of patients.

Growth and nutrition disorders in children with cerebral palsy.

Growth and nutrition disorders are common secondary health conditions in children with cerebral palsy (CP). Poor growth and malnutrition in CP merit study because of their impact on health, including psychological and physiological function, healthcare utilization, societal participation, motor function, and survival. Understanding the etiology of poor growth has led to a variety of interventions to improve growth. One of the major causes of poor growth, malnutrition, is the best-studied contributor to poor growth; scientific evidence regarding malnutrition has contributed to improvements in clinical management and, in turn, survival over the last 20 years. Increased recognition and understanding of neurological, endocrinological, and environmental factors have begun to shape care for children with CP, as well. The investigation of these factors relies on advances made in the assessment methods available to address the challenges inherent in measuring growth in children with CP. Descriptive growth charts and norms of body composition provide information that may help clinicians to interpret growth and intervene to improve growth and nutrition in children with CP. Linking growth to measures of health will be necessary to develop growth standards for children with CP in order to optimize health and well-being.

Metabolic bone disease in gastrointestinal illness.

Metabolic bone disease is often silent, often undiagnosed, and occurs frequently in patients with chronic gastrointestinal illnesses. Potentially modifiable risk factors, such as malnutrition, malabsorption, prolonged use of glucocorticoids, and a sedentary lifestyle, can lead to low bone mass, an increased rate of bone loss, and debilitating bone disease. This article explores common gastrointestinal illnesses that place patients at risk for developing metabolic bone disease. Concepts are presented to assist the practitioner in identifying patients at risk; clinical evaluation and diagnostic test selection are discussed, and therapeutic options for the prevention and treatment of metabolic bone disease in gastrointestinal illness are presented.

Risks and benefits of surgical management of gastroesophageal reflux in neurologically impaired children.

BACKGROUND: The aim of this study was to investigate the feasibility and results of laparoscopic antireflux procedure in neurologically impaired children. METHODS: Over a 5-yr period, 259 children affected by gastroesophageal reflux disease underwent laparoscopic antireflux procedure. Eighty of them (30.8%) were neurologically impaired. In 58 children we performed an anterior fundoplication according to Thal and in 22 patients a 360 degrees fundoplication according to Nissen. Forty-eight children underwent an associated gastrostomy placement at the same time as the laparoscopic antireflux procedure. RESULTS: We recorded 4/80 intraoperative complications; in all cases the complication was managed laparoscopically and no conversion was needed. Follow-up ranged from 6 months to 6 yrs (median 3 yrs). We recorded 24/80 postoperative complications, 5 of which required a redo procedure. We have a mortality rate of 17.5% but in only one case was the event related to the antireflux procedure. CONCLUSIONS: Laparoscopic fundoplication can be performed safely and with acceptable results in neurologically impaired children. The indication to add a gastrostomy should be tailored to the needs of the individual patient. Mortality rate in neurologically impaired children patients with gastroesophageal reflux disease is high but in most cases unrelated to the antireflux procedure.

Laparoscopic-assisted gastric button placement: a valuable alternative for a percutaneous endoscopic gastrostomy (PEG).

A percutaneous endoscopic gastrostomy remains the first choice when oral feeding is difficult. In some patients however an endoscopic placement of a gastrostomy tube is not possible. As an alternative, a laparoscopic-assisted insertion of a gastric button was performed to provide enteral feeding in seven patients. Enteral feeding could be resumed within one or two days after the procedure and no complications were encountered. This minimal invasive technique has certain advantages over a surgical gastrostomy by laparotomy. Therefore, a laparoscopically inserted gastric button should be considered a valuable alternative if percutaneous endoscopic gastrostomy is no longer possible.

[Percutaneous endoscopic gastrostomy in children with psychomotor retardation; less complaints and not as stressful]. / Percutane endoscopische gastrostomie bij psychomotorisch geretardeerde kinderen; minder klachten en weinig belastend.

OBJECTIVE: To evaluate the effects of percutaneous endoscopic gastrostomy (PEG) in children with psychomotor retardation. DESIGN: Prospective. METHOD: Data on symptoms, pros and cons and complications were collected by means of questionnaires from the parents of children with psychomotor retardation and severe nutritional problems in whom a PEG tube had been introduced between August 1995 and March 1998 in the department of Children's Gastroenterology and Nutrition of the Emma Children's Hospital/Academic Medical Centre in Amsterdam, the Netherlands, comparing the situations before the introduction and 6 and 18 months afterward. RESULTS: The patient group consisted of 17 boys and 23 girls with a mean age of 6 years and 3 months (range 8 months-10 years and 1 month). The frequency of vomiting and of airway infections decreased and the general nutritional condition improved. Restlessness and pain occurred less often in over half the children. The disadvantages most often reported were the logistics concerning the feeding (n = 11) and the reduced contact with the child (n = 10). Thirteen children displayed mild side effects such as skin irritation and proud flesh. Technical problems consisted of leakage (n = 11) and obstruction of the tube (n = 2). In one child, introduction of the tube was followed by a major complication. CONCLUSION: The PEG tube in this patient group reduced the frequency of complaints about nutrition and constituted a patient-friendly alternative to the nasal tube.

[Help to children and adolescents with malnutrition or eating disorders. Percutaneous endoscopic gastrostomy with button: simple, safe and cost-effective]. / Hjälp för barn och ungdomar med malnutrition eller ätstörning. Perkutan endoskopisk gastrostomi och knapp enkelt, säkert och billigt.

Percutaneous endoscopic gastrostomy (PEG) has gained great popularity for children with malnutrition and eating disorders secondary to chronic illness. However, the procedure is not without risks. We report on 62 infants and children, median age 4 years (1 month-20 years), who underwent PEG placement. Cerebral palsy with or without mental retardation was the most common diagnosis (50%). No complications related to the PEG procedure itself occurred, but postoperative pneumonia was seen in 10%. Late complications were few: intraperitoneal migration of the button in one child and prolapse of the stoma in another. At the time of button placement, after median 14 weeks, mean weight had increased from a standard deviation score of -2.7 to -2.2 (P < 0.001). We consider PEG to be a safe procedure for children with malnutrition requiring enteral feeding. Due to potential risks and complications related to this method, a multidisciplinary approach, as found in a "nutritional support team", is recommended.

Valoración del estado nutricional en pacientes quirúrgicos / Valoration of the nutritional state in surgical patients

La desnutrición es un problema frecuente y grave en pacientes quirúrgicos, de proporciones desconocidas en muchos hospitales de nuestro país, por lo que realizamos un trabajo prospéctivo entre febrero y septiembre de 1998, analizando 107 pacientes tratados en el Servicio de Cirugía General del Hospital Militar "Dr. Carlos Arvelo", se utilizó la evaluación por "Puntaje" de Feldtman, que consiste en asignar un valor a parámetros antropométricos (peso, pliegue del tripceps, circunferencia muscular del brazo) y a parámetros de laboratorio (albúmina, linfocitos absolutos, hierro sérico), sumando los mismos para catalogar a los pacientes en desnutrición leve, moderada, severa, o normales (sin desnutrición). Se obtuvo una desnutrición severa en el 37 por ciento, desnutrición leve en 6 por ciento desnutrición moderada en 12 por ciento y sin déficit nutricional en 45 por ciento de los pacientes al ingreso. Dicho método de evaluación es bastante objetivo pero tiene el inconveniente que no puede ser aplicado a todos los pacientes que consulten el Departamento de Cirugía General, por lo que no se usa como tamizaje para la detección de la desnutrición, alternativamente la Evaluación Global subjetiva si resulta práctica para la detección preoperatoria de este problema en vista que se basa en el interrogatorio y examen físico rápido, resultando muy eficiente para asignar a los sujetos como normales o con desnutrición severa, que son los grupos más numerosos en nuestro estudio

Desnutrición como factor de riesgo en infección de herida en pacientes operados por vólvulo del dolicomegasigmoides

En el Hospital Regional del Cusco, de setiembre de 1994 a diciembre de 1995 se estudiaron prospectivamente 60 pacientes intervenidos quirúrgicamente de emergencia por vólvulo del dolicomegasigmoides; con los objetivos de demostrar como factor de riesgo y factor atribuible a la desnutrición en la presentación de infección de herida operatoria y compararlos con el tipo de operación y otros factores condicionantes. Se utilizaron métodos antropométricos bioquímicos e inmunológicos para la valoración del estado nutricional. Esta patología se presentó preferentemente en varones (78.33 por ciento) y en mayores de 40 años (75 por ciento), provenientes de comunidades agrícolas de las provincias del Cusco. Se tuvo infección de herida en el 45 por ciento de pacientes operados. Se encontró desnutrición en el 97.67 por ciento de los pacientes; siendo alarmante el 81.67 por ciento encontrando para los grados moderados y severos; encontrando 5.84 por ciento veces más posibilidades de infectarse la herida en estos pacientes, en relación a los eutróficos y desnutridos leves (p<0.01); con un riesgo atribuible a la desnutrición del 83 por ciento. Existió 1.48 veces más posibilidades de infección en heridas de intervenciones sobre asas sigmooideas no viables. Se tuvo un promedio de intervención quirúrgica de 123 minutos, siendo de 137 y 111 minutos, en infección y no infección de herida respectivamente, estadísticamente significativo. La edad no constituye un factor de riesgo para el incremento en la presentación de esta complicación infecciosa. La mortalidad encontrada del 5 por ciento, es relativamente baja, en relación a lo reportado en la literatura, para esta enfermedad.

Ulcera péptica: complicaciones tardías del tratamineto quirúrgico / Peptic ulcer: late complications of surgical treatment

Aún cuando las intervenciones quirúrgicas para el tratamiento de la úlcera péptica se han reducido marcadamente en los últimos 20 años, debido fundamentalmente a los modernos tratamientos médicos, cerca de un 20 por ciento de los operados se quejan de algún disturbio; y entre el 1-2 por ciento de ellos tienen complicaciones tardías graves, como deficienciuas nutricionales, colelitiasis, esofagitis y gastritis de reflujo alcalino, síndrome de dumping, cáncer del muñón gástrico, los cuales se revisan en el presente artículo

Gastrostomía endoscópica percutánea: Una experiencia multicéntrica

El objetivo fue presentar la experiencia con dos variantes técnicas de la Gastrostomía Endoscópica Percutánea (GEP). Fueron practicadas 78 GEP, 63 por ciento por la técnica de deslizamiento y 37 por ciento por tracción, 44 mujeres (57 por ciento) y 34 hombres (43 por ciento) de 6 a 94 años, con enfermedades del sistema nervioso central en 89.6 por ciento de los casos. No fueron observadas diferencias estadísticas en los resultados dependientes de la institución ni el uso o no de antibióticos. Las complicaciones fueron más frecuentes durante las primeras 24 horas y después del séptimo día con la técnica por tracción, durante su estandarización. Los pacientes desnutridos tuvieron más complicaciones asociadas al procedimiento. Se concluye que la GEP es una técnica practicable en cualquier servicio de endoscopia, de bajo riesgo, con baja frecuencia de complicaciones y relacionadas con el estado nutricional del paciente y grado de pericia adquirido

Direct endoscopic percutaneous jejunostomy (EPJ). Clinical results.

Direct puncture of the small bowel under endoscopic guidance (direct EPJ) is possible in patients whose stomach has been removed or whose small bowel cannot be punctured by other methods. From January 1990 to June 1992 a total of 39 patients underwent successful direct EPJ at our institution. The indications were malnutrition after partial or total gastrectomy (n = 19), insufficient anastomosis or a stenosis after esophageal resection and esophagojejunostomy (n = 13), esophageal perforation (n = 3), fistulas (n = 2), or severe trauma (n = 2). The tubes were inserted at the bedside under local anesthesia using the string pull-through technique. The procedure was attempted in five other patients but it was technically impossible to insert the tubes in these patients. Postoperative enteral feeding was possible in all 39 patients whose direct EPJ was successful. Complications included tube dysfunction due to plugging and fracture in five patients, pressure-induced enteric ulcers in two, and local infections in three patients. The ulcers and infections were managed conservatively. We conclude that direct EPJ is a safe, effective alternative to surgical catheter-jejunostomy.

[The assessment of the nutritional status of patients in the terminal stage of liver disease who are candidates for orthotopic liver transplantation]. / Valoración del estado nutricional de los pacientes en estadio terminal de enfermedad hepática, candidatos a trasplante ortotópico de hígado.

Orthotopic liver transplant (OLT) is nowadays an accepted procedure for the treatment of patients with end-stage liver disease. Because of the significant state of malnutrition of such patients, we decided to evaluate the nutritional condition of patients accepted by the hospital's Transplants Committee as candidates for this type of therapy, with the eventual aim of discovering the types of malnutrition in the different pathologies, and which were the most frequent. The sample studied showed a significant prevalence of malnutrition. Patients with viral hepatitis showed only visceral type malnutrition, which affected 100% of them. The ethanolic cirrhosis group presented all types of malnutrition-energy-calorific (35%), protein (24%) and visceral (53%), while the group of other liver diseases presented 15% of energy-calorific malnutrition and 85% visceral. From these results, we conclude that the sample studied has a high prevalence of malnutrition and that the importance of its detection makes it possible to reduce pre- and post-surgical morbidity and mortality rates with an appropriate nutritional support.

Corrección quirúrgica y fijación segmentaria en cifosis vertebral por mal de pott o tuberculosis vertebral

La incidencia de espondilitis tuberculosa varía considerablemente a través del mundo y es usualmente proporcional a la calidad de Servicios de Salud Pública disponibles. Es extremadamente común en países en desarrollo, donde la malnutrición y la sobrepoblación son los mayores problemas. La patogénesis de los estadios tempranos de la tuberculosis vertebral es similar a la de las infecciones de la columna y puede resultar de una diseminación hematógena o por una extensión directa de la enfermedad. Se describen 3 tipos de lesión vertebral: peridiscal, central y anterior con déficits neurológicos que pueden ocurrir tanto en forma aguda como crónica. Los casos que a continuación relatamos, tuvieron un comienzo peridiscal y su cronicidad se provocó presión en la médula espinal por cifosis vertebral marcada.

Transgastrostomy jejunal intubation for enteric alimentation.

Malnourished patients who cannot maintain an adequate oral intake but have normal intestinal absorption and motility are candidates for enteric alimentation. When impaired gastric peristalsis or an increased risk for aspiration makes gastrostomy feeding unsafe, direct jejunal infusion is the preferred route of alimentation. Angiographic techniques were used to convert previously placed, simple gastrostomies to combined gastrostomy-jejunostomies in 14 patients. In 17 additional patients, a combined gastrostomy-jejunal tube was placed under local anesthesia; angiographic techniques assisted in the placement of 11 of these tubes.

Mortality risks of mentally retarded and mentally ill patients after a feeding gastrostomy.

Feeding gastrostomy procedures were performed on 9 mentally ill and 30 mentally retarded, institutionalized patients. The postoperative mortality was 0 percent (0/9) for the mentally ill and 13 percent (4/30) for the mentally retarded patients. Mortality within 1 year after the operation was 11 percent (1/9) for the mentally ill and 33 percent (10/30) for the retarded patients. This study revealed three important factors that affect mortality risks: the identification and elimination of a gastroesophageal reflux before surgery, the monitoring and improvement of the nutritional status both before and after surgery, and the evaluation and treatment of respiratory problems both before and after surgery. If care in these areas is improved, then the mortality risks for retarded patients will decrease.