[Placement of nasoenteral feeding tubes by nurses]. / Plaatsing van naso-enterale voedingssondes door verpleegkundigen.

Electromagnetic-guided placement of nasoenteral feeding tubes by nurses is an alternative to endoscopic placement by gastroenterologists. During placement, the electromagnetic signal that is emitted by the tip of the guidewire enables visualisation of the position of the tube on a portable monitor. The procedure can be performed by a trained endoscopy nurse at the bedside of the patient. This could have logistic advantages, as the patient transport is not necessary and confirmation of the position of the tube by an abdominal X-ray is not required. Other possible advantages of the new technique are no preprocedural fasting and no need for sedation. If the tube coils in the stomach, it can be repositioned without the need for a repeat procedure. A randomised multicentre trial found electromagnetic nasoenteral placement of feeding tubes to be non-inferior on comparison with endoscopic placement by gastroenterologists, and it can be considered as the preferred technique.

Incidence of refeeding syndrome in internal medicine patients.

BACKGROUND: Refeeding syndrome is a potentially fatal shift of fluids and electrolytes that may occur after reintroducing nutrition in a malnourished patient. Its incidence in internal medicine patients is not known. We aimed at determining the incidence in a heterogeneous group of patients acutely admitted to a department of internal medicine. METHODS: All patients acutely admitted to the department of internal medicine of a teaching community hospital in Amsterdam, the Netherlands, between 22 February 2011 and 29 April 2011, were included. We applied the National Institute for Health and Care Excellence (NICE) criteria for determining people at risk of refeeding syndrome and took hypophosphataemia as the main indicator for the presence of this syndrome. RESULTS: Of 178 patients included in the study, 97 (54%) were considered to be at risk of developing refeeding syndrome and 14 patients actually developed the syndrome (14% of patients at risk and 8% of study population). Patients with a malignancy or previous malignancy were at increased risk of developing refeeding syndrome (p < 0.05). Measurement of muscle strength over time was not associated with the occurrence of refeeding syndrome. The Short Nutritional Assessment Questionnaire score had a positive and negative predictive value of 13% and 95% respectively. CONCLUSION: The incidence of refeeding syndrome was relatively high in patients acutely admitted to the department of internal medicine. Oncology patients are at increased risk of developing refeeding syndrome. When taking the occurrence of hypophosphataemia as a hallmark, no other single clinical or composite parameter could be identified that accurately predicts the development of refeeding syndrome.

Endoscopic treatment: the past, the present and the future.

The obesity epidemic asks for an active involvement of gastroenterologists: many of the co-morbidities associated with obesity involve the gastrointestinal tract; a small proportion of obese patients will need bariatric surgery and may suffer from surgical complications that may be solved by minimally invasive endoscopic techniques; and finally, the majority will not be eligible for bariatric surgery and will need some other form of treatment. The first approach should consist of an energy-restricted diet, physical exercise and behaviour modification, followed by pharmacotherapy. For patients who do not respond to medical therapy but are not or not yet surgical candidates, an endoscopic treatment might look attractive. So, endoscopic bariatric therapy has a role to play either as an alternative or adjunct to medical treatment. The different endoscopic modalities may vary in mechanisms of action: by gastric distension and space occupation, delayed gastric emptying, gastric restriction and decreased distensibility, impaired gastric accommodation, stimulation of antroduodenal receptors, or by duodenal exclusion and malabsorption. These treatments will be discussed into detail.

The cooperation between endoscopists and surgeons in treating complications of bariatric surgery.

The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.

One-year adjustable intragastric balloons: results in 73 consecutive patients in the U.K.

BACKGROUND: Most intragastric balloons have 6-month approval. We report results with the Spatz Adjustable Balloon: approved for 12 months and adjustable. METHODS: Seventy-three patients (mean: age 45.5; weight 114.5 kg; BMI 36.6 kg/m2) scheduled for 1-year implantation with Spatz balloon (mean volume 417 ml saline). Adjustments performed for early intolerance and weight loss plateau. RESULTS: Three patients failed insertion. There were 21 early removals (4 intolerant refusing adjustment; 3 deflations; 14 satisfied patients) leaving 49 patients at 12 months. Results of 70 patients (49 patients at 12 months and 21 patients at <12 months) were a mean 21.6 kg weight loss; 19% weight loss; and 45.7% EWL (excess weight loss). Ten intolerant patients were adjusted and lost additional mean 13.2 kg. Fifty-one patients with weight loss plateau scheduled for adjustment: adjustments failed in 6 and non-response in 7. The adjusted 38 patients lost an additional mean 9.4 kg and at extraction had mean 40.9% EWL with 18.7% weight loss. Three catheter impactions required surgical extraction, and three deflated balloons didn't migrate beyond stomach. CONCLUSIONS: The Spatz balloon is an effective procedure without mortality; however, it carries a risk of catheter impaction necessitating surgical extraction (4.1%). The failure rate--4.1%; intolerance without ability to adjust balloon--5.5%; major complications occurred in 3 (4.1%); minor (balloon deflations) in 3 (4.1%), and 2 asymptomatic gastric ulcers at extraction (2.7%). The longer implantation period and adjustment option combine to produce greater weight loss, albeit <10% weight loss beyond the pre-adjustment weight loss.

Fasting and meal-suppressed ghrelin levels before and after intragastric balloons and balloon-induced weight loss.

BACKGROUND: Intragastric balloons may be an option for obese patients with weight loss failure. Its mode of action remains enigmatic. We hypothesised depressed fasting ghrelin concentrations and enhanced meal suppression of ghrelin secretion by the gastric fundus through balloon contact and balloon-induced delayed gastric emptying. METHODS: Patients were randomised to a 13-week period of sham or balloon treatment, followed by a 13-week period of balloon treatment in everyone. Blood samples for ghrelin measurement were taken in the fasting state and every 15 min for 1 h after a breakfast meal at the start, after 13 weeks and after 26 weeks. Patients filled out scales to assess satiety and kept a food diary. RESULTS: Forty obese patients (BMI 43.1 kg/m(2)) participated. At the start, fasting ghrelin values were low with a blunted ghrelin response to a test meal. The presence of a balloon had no influence on fasting or meal-suppressed ghrelin concentrations. Despite a weight loss of 10 % after 13 weeks and 15 % after 26 weeks, fasting ghrelin concentrations did not change; neither did the ghrelin response to a meal. No relation was found between ghrelin and insulin, satiety, intermeal interval, the number of meals or subsequent energy intake. Ghrelin concentrations were more suppressed with greater weight loss or with balloons located in the fundus. CONCLUSIONS: Ghrelin concentrations did not change by balloon treatment after 13 and 26 weeks and, unexpectedly, did not rise despite substantial weight loss and negative energy balance. This suppression might be of benefit in the maintenance of weight loss but could not be ascribed to the balloon treatment.

Safety, patient's tolerance, and efficacy of a 2-liter vitamin C-enriched macrogol bowel preparation: a randomized, endoscopist-blinded prospective comparison with a 4-liter macrogol solution.

BACKGROUND: Optimal bowel preparation is associated with lower polyp miss rates, but patients have difficulties in complying with the usual 4-L bowel preparation. OBJECTIVE: This study aimed to compare the safety, acceptance, and efficacy of 2-L polyethylene glycol electrolyte solution enriched in vitamin C with 4-L polyethylene glycol electrolyte solution. DESIGN: This study is an endoscopist-blinded randomized controlled trial. SETTINGS: The study was conducted at a tertiary referral hospital. PATIENTS: Consecutive outpatients were randomly assigned to receive 4-L polyethylene glycol electrolyte solution or 2-L polyethylene glycol electrolyte solution enriched in vitamin C with 2 L of clear fluids in a single-dose or a split-dose regime. MAIN OUTCOME MEASURES: Safety was assessed by blood sampling before and after the preparation and by a 30-day postcolonoscopy chart and complication database review. Acceptance was investigated by questionnaires, and the adequacy of bowel preparation was assessed by the Aronchick and Ottawa scales. RESULTS: One hundred eighty-eight patients, 98 in the polyethylene glycol electrolyte solution enriched in vitamin C group and 90 in the polyethylene glycol electrolyte solution group, participated. Although changes in bicarbonate blood concentrations with polyethylene glycol electrolyte solution enriched in vitamin C were seen to such an extent that the blinded investigator correctly guessed the preparation in 75.6%, no unsafe values were observed. A 30-day chart and complication database review revealed 1 severe adverse event of a myocardial infarction in the polyethylene glycol electrolyte solution enriched in vitamin C group. Patient acceptance and compliance were significantly higher with the polyethylene glycol electrolyte solution enriched in vitamin C group. The impact on sleep, daily activities, and physical complaints were similar in both groups. Polyethylene glycol electrolyte solution enriched in vitamin C was noninferior to polyethylene glycol electrolyte solution in cleansing efficacy, but the segmental rating of excellent and good preparation in right and transverse colon was significantly better for polyethylene glycol electrolyte solution, especially when taken as a split dose. LIMITATIONS: The results cannot be extrapolated to immobile inpatients with comorbidities. Another limitation of our study was the inability to determine plasma vitamin C concentrations and to assess the quality of colonoscopy performance. CONCLUSIONS: Two-liter polyethylene glycol electrolyte solution enriched in vitamin C is a safe and patient-friendly alternative to the 4-L polyethylene glycol electrolyte solution. Endoscopists slightly preferred the 4-L polyethylene glycol electrolyte solution.

Prospective enteroscopic evaluation of jejunal polyposis in patients with familial adenomatous polyposis and advanced duodenal polyposis.

Duodenal cancer originating from duodenal adenomas is an important cause of death in patients with familial adenomatous polyposis (FAP). Small intestinal adenomas also occur distal to the duodenum, and literature suggests that they mainly occur in the proximal jejunum in patients with severe duodenal polyp burden. We recently reported on 3 FAP-patients with a jejunal adenocarcinoma, all also harbouring advanced duodenal polyposis. Therefore we questioned whether FAP patients should also be submitted to endoscopic surveillance of the jejunum. The aim of this study was to determine the incidence and burden of jejunal adenomas in patients with FAP and advanced duodenal disease. All patients with FAP and advanced duodenal polyposis (Spigelman stage IV) at our academic centre were invited to undergo antegrade single balloon enteroscopy (Olympus SIF-Q180) with propofol-sedation. Patient characteristics, procedural characteristics (success, depth of insertion) and enteroscopic findings (number, size and pathology) are described. We identified 18 patients with FAP and duodenal polyposis Spigelman stage IV. Thirteen participated in the study with a mean age of 54 (30-64) years. SBE was successfully performed in 10 patients, with a mean depth of insertion of 72 cm beyond the ligament of Treitz. Adenomatous polyps were detected in 9 patients. Only one of them had extensive polyposis beyond Treitz, with large polyps covering up to one-third of the jejunal circumference. No cancers or adenomas with high-grade dysplasia were detected. Clinically significant jejunal polyposis in FAP is rare, even in high-risk patients with advanced duodenal disease. Routine jejunoscopy does not seem warranted in patients with FAP.

[Endobarrier: a unique but still premature concept]. / Endobarrier: een uniek maar onvoldoende uitgerijpt concept.

The EndoBarrier, an endoscopically delivered duodeno-jejunal bypass device, is a unique concept that starts to ameliorate the symptoms of diabetes mellitus type 2, soon after positioning. Weight-loss results are moderate, with 85% of patients showing a more than 10% excess weight loss in the 12 weeks preoperatively. Sufficient implant training is required, but problems can still occur, e.g., due to a short duodenal bulb length. The stability of the anchors and the tolerability of the device still leave much to be desired. In 25% of patients the EndoBarrier is explanted early, because of migration, physical symptoms, gastrointestinal haemorrhage, rotation and obstruction. Only seven studies on the EndoBarrier are available and these are mostly small in size, short-term and with limited follow-up, and many questions regarding the safety and long-term effects of the device remain. This calls for a large, long-term, randomised, placebo-controlled, double-blind trial. Lessons should have been learned from the disastrous results with intragastric balloon implantation before commercialising another such product.

Enteral nutrition and acute pancreatitis: a review.

Introduction. In patients with acute pancreatitis (AP), nutritional support is required if normal food cannot be tolerated within several days. Enteral nutrition is preferred over parenteral nutrition. We reviewed the literature about enteral nutrition in AP. Methods. A MEDLINE search of the English language literature between 1999-2009. Results. Nasogastric tube feeding appears to be safe and well tolerated in the majority of patients with severe AP, rendering the concept of pancreatic rest less probable. Enteral nutrition has a beneficial influence on the outcome of AP and should probably be initiated as early as possible (within 48 hours). Supplementation of enteral formulas with glutamine or prebiotics and probiotics cannot routinely be recommended. Conclusions. Nutrition therapy in patients with AP emerged from supportive adjunctive therapy to a proactive primary intervention. Large multicentre studies are needed to confirm the safety and effectiveness of nasogastric feeding and to investigate the role of early nutrition support.

Evaluation of management of desmoid tumours associated with familial adenomatous polyposis in Dutch patients.

BACKGROUND: The optimal treatment of desmoid tumours is controversial. We evaluated desmoid management in Dutch familial adenomatous polyposis (FAP) patients. METHODS: Seventy-eight FAP patients with desmoids were identified from the Dutch Polyposis Registry. Data on desmoid morphology, management, and outcome were analysed retrospectively. Progression-free survival (PFS) rates and final outcome were compared for surgical vs non-surgical treatment, for intra-abdominal and extra-abdominal desmoids separately. Also, pharmacological treatment was evaluated for all desmoids. RESULTS: Median follow-up was 8 years. For intra-abdominal desmoids (n=62), PFS rates at 10 years of follow-up were comparable after surgical and non-surgical treatment (33% and 49%, respectively, P=0.163). None of these desmoids could be removed entirely. Eventually, one fifth died from desmoid disease. Most extra-abdominal and abdominal wall desmoids were treated surgically with a PFS rate of 63% and no deaths from desmoid disease. Comparison between NSAID and anti-estrogen treatment showed comparable outcomes. Four of the 10 patients who received chemotherapy had stabilisation of tumour growth, all after doxorubicin combination therapy. CONCLUSION: For intra-abdominal desmoids, a conservative approach and surgery showed comparable outcomes. For extra-abdominal and abdominal wall desmoids, surgery seemed appropriate. Different pharmacological therapies showed comparable outcomes. If chemotherapy was given for progressively growing intra-abdominal desmoids, most favourable outcomes occurred after combinations including doxorubicin.

High cumulative risk of intussusception in patients with Peutz-Jeghers syndrome: time to update surveillance guidelines?

OBJECTIVES: Peutz-Jeghers syndrome (PJS) is characterized by gastrointestinal hamartomas. The hamartomas are located predominantly in the small intestine and may cause intussusceptions. We aimed to assess the characteristics, risk, and onset of intussusception in a large cohort of PJS patients to determine whether enteroscopy with polypectomy should be incorporated into surveillance recommendations. METHODS: All PJS patients from two academic hospitals were included in this cohort study (prospective follow-up between 1995 and July 2009). We obtained clinical data by interview and chart review. Deceased family members with PJS were included retrospectively. Cumulative intussusception risks were calculated by Kaplan­Meier analysis. RESULTS: We included 110 PJS patients (46% males) from 50 families. In all, 76 patients (69%) experienced at least one intussusception (range 1-6), at a median age of 16 (3-50) years at first occurrence. The intussusception risk was 50% at the age of 20 years (95% confidence interval 17-23 years) and the risk was independent of sex, family history, and mutation status. The intussusceptions occurred in the small intestine in 95% of events, and 80% of all intussusceptions (n=128) presented as an acute abdomen. Therapy was surgical in 92.5% of events. Based on 37 histology reports, the intussusceptions were caused by polyps with a median size of 35 mm (range 15-60 mm). CONCLUSIONS: PJS patients carry a high cumulative intussusception risk at young age. Intussusceptions are generally caused by polyps >15 mm and treatment is mostly surgical. These results support the approach of enteroscopic surveillance, with removal of small-intestinal polyps >10-15 mm to prevent intussusceptions. The effect of such an approach on the incidence of intussusception remains to be established in prospective trials.

Quality of life and psychological distress in patients with Peutz-Jeghers syndrome.

Little is known about psychological distress and quality of life (QoL) in patients with Peutz-Jeghers syndrome (PJS), a rare hereditary disorder. We aimed to assess QoL and psychological distress in PJS patients compared to the general population, and to evaluate determinants of QoL and psychological distress in a cross-sectional study. PJS patients completed a questionnaire on QoL, psychological distress, and illness perceptions. The questionnaire was returned by 52 patients (85% response rate, 56% females, median age 44.5 years). PJS patients reported similar anxiety (p = 0.57) and depression (p = 0.61) scores as the general population. They reported a lower general health perception (p = 0.003), more limitations due to emotional problems (p = 0.045) and a lower mental well-being (p = 0.036). Strong beliefs in negative consequences of PJS on daily life, a relapsing course of the disease, strong emotional reactions to PJS, and female gender were major determinants for a lower QoL. PJS patients experience a similar level of psychological distress as the general population, but a poorer general health perception, more limitations due to emotional problems, and a poorer mental QoL. Illness perceptions and female gender were major predictors for this lower QoL. These results may help to recognize PJS patients who might benefit from psychological support.

Increased colorectal cancer risk in first-degree relatives of patients with hyperplastic polyposis syndrome.

INTRODUCTION: Hyperplastic polyposis syndrome (HPS) is characterised by the presence of multiple colorectal hyperplastic polyps and is associated with an increased colorectal cancer (CRC) risk. For first-degree relatives of HPS patients (FDRs) this has not been adequately quantified. Reliable evidence concerning the magnitude of a possible excess risk is necessary to determine whether preventive measures, like screening colonoscopies, in FDRs are justified. AIMS AND METHODS: We analysed the incidence rate of CRC in FDRs and compared this with the general population through person-year analysis after adjustment for demographic characteristics. Population-based incidence data from the Eindhoven Cancer Registry during the period 1970-2006 were used to compare observed numbers of CRC cases in FDRs with expected numbers based on the incidence in the general population. RESULTS: A total of 347 FDRs (41% male) from 57 pedigrees were included, contributing 11 053 person-years of follow-up. During the study period, a total of 27 CRC cases occurred among FDRs compared to five expected CRC cases (p<0.001). The RR of CRC in FDRs compared to the general population was 5.4 (95% CI 3.7 to 7.8). Four FDRs satisfied the criteria for HPS. Based on the estimated HPS prevalence of 1:3000 in the general population the projected RR of HPS in FDRs was 39 (95% CI 13 to 121). CONCLUSIONS: FDRs of HPS patients have an increased risk for both CRC and HPS compared to the general population. Hence, as long as no genetic substrate has been identified, screening colonoscopies for FDRs seem justified but this needs to be prospectively evaluated.

High cancer risk in Peutz-Jeghers syndrome: a systematic review and surveillance recommendations.

OBJECTIVES: Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disorder associated with increased cancer risk. Surveillance and patient management are, however, hampered by a wide range in cancer risk estimates. We therefore performed a systematic review to assess cancer risks in PJS patients and used these data to develop a surveillance recommendation. METHODS: A systematic PubMed search was performed up to February 2009, and all original articles dealing with PJS patients with confirmed cancer diagnoses were included. Data involving cancer frequencies, mean ages at cancer diagnosis, relative risks (RRs), and cumulative risks were collected. RESULTS: Twenty-one original articles, 20 cohort studies, and one meta-analysis fulfilled the inclusion criteria. The cohort studies showed some overlap in the patient population and included a total of 1,644 patients; 349 of them developed 384 malignancies at an average age of 42 years. The most common malignancy was colorectal cancer, followed by breast, small bowel, gastric, and pancreatic cancers. The reported lifetime risk for any cancer varied between 37 and 93%, with RRs ranging from 9.9 to 18 in comparison with the general population. Age-related cumulative risks were given for any cancer and gastrointestinal, gynecological, colorectal, pancreatic, and lung cancers. CONCLUSIONS: PJS patients are markedly at risk for several malignancies, in particular gastrointestinal cancers and breast cancer. On the basis of these elevated risks, a surveillance recommendation is developed to detect malignancies in an early phase and to remove polyps that may be premalignant and may cause complications, so as to improve the outcome.

High resolution endoscopy and the additional value of chromoendoscopy in the evaluation of duodenal adenomatosis in patients with familial adenomatous polyposis.

BACKGROUND AND STUDY AIM: Duodenal polyposis occurs in approximately 90 % of patients with familial adenomatous polyposis (FAP) and 5 % - 10 % develop duodenal cancer. Novel imaging techniques may improve evaluation of duodenal polyposis using the Spigelman classification. We aimed to analyze the value of high resolution endoscopy (HRE) and the additional value of chromoendoscopy in the evaluation of duodenal polyposis in FAP. PATIENTS AND METHODS: 43 FAP patients scheduled for surveillance endoscopy in two academic centers underwent gastroduodenoscopy with HRE forward- and side-viewing devices. After number and size of adenomas had been scored, indigo carmine 0.5 % was sprayed onto the mucosa, polyps were scored again and biopsies taken from the larger lesions. Subsequently, Spigelman classifications were assessed for pre- and post-staining. RESULTS: Before staining, a median of 16 adenomas per patient were detected compared with 21 adenomas after staining ( P = 0.02). Staining led to upgrading of Spigelman stage in 5/43 patients (12 %). Using the side-viewing endoscope, ampullary enlargement was detected in 22 patients (51 %) of whom 18 (42 %) had histologically confirmed ampullary adenomas. CONCLUSION: HRE has raised the quality of endoscopic imaging considerably. Consequently, re-evaluation of the original Spigelman classification system seems advisable. Chromoendoscopy further increases detection of duodenal adenomas in FAP but without considerable change in Spigelman stage. Ampullary adenomas are commonly found in FAP and are best visualized using a side-viewing endoscope. Therefore, a combination of forward-viewing HRE and chromoendoscopy with side-viewing endoscopy for the periampullary region seems useful for surveillance of duodenal adenomatosis in FAP.

The role of endoscopy in bariatric surgery.

Morbid obesity is a chronic disease of excess fat storage, characterised by premature death and obesity-associated co-morbidities. The results of the current non-surgical treatment to treat obesity are disappointing, but surgical approaches may achieve a durable and longstanding weight loss with resolution and improvement of co-morbidities. Gastrointestinal complaints and digestive complications may, however, increase and may require an actively involved gastroenterologist.