An unusual complication of PEG feeding after pancreatico-gastrostomy.

CONTEXT: We describe a late complication of the pancreatico-gastrostomy (PG) anastomosis following pancreatico-duodenectomy (PD). CASE REPORT: A percutaneous endoscopic gastrostomy (PEG) feeding tube was inserted many months post-operatively. In this patient activated pancreatic enzymes eroded the gastrostomy tract, resulting in pain, recurrent infection and eventual removal of the gastrostomy tube. CONCLUSIONS: Where surgical insertion of a feeding jejunostomy is not viable or deemed too high risk after Whipple or PPPD, we recommend careful consideration of PEG tube insertion in patients with PG reconstruction. If a PEG is used the prophylactic use of Lanreotide is recommended.

A safe, effective, and cheap method of achieving pancreatic rest in patients with chronic pancreatitis with refractory symptoms and malnutrition.

OBJECTIVES: Chronic pancreatitis (CP) is common. It is associated with a substantial morbidity, including malnutrition, malabsorption, pseudocysts, metabolic disturbances, and intractable abdominal pain. Approximately 5% of patients with CP are refractory to nutritional support and opiate analgesia, making management challenging.Pancreatic rest can provide symptomatic relief. However, achieving simultaneous pancreatic rest and adequate nutritional support in these patients is difficult. We describe a technique for providing nutritional support and pancreatic rest in patients with intractable symptomatic CP. METHODS: Three patients with symptomatic CP refractory to standard treatment were included in the study. All 3 patients had masses associated with the pancreas. Symptom relief and adequate nutritional support were achieved by inserting a long-term nasojejunal (NJ) tube (Flocare Bengmark, Nutricia Clinical Care, United Kingdom) under ambulatory endoscopic guidance. Data were recorded prospectively. RESULTS: Long-term NJ tube feeding achieved pancreatic rest and significant symptomatic relief while delivering adequate nutritional support. Pseudocyst size decreased substantially in 2 patients. The third patient was found to have pancreatic carcinoma after pancreaticoduodenectomy. CONCLUSIONS: In patients with symptomatic CP refractory to standard nutritional support and opiate analgesia, long-term NJ tube feeding can be a cheap, well-tolerated, safe, and effective method of providing adequate nutritional support and substantially relieving intractable symptoms.

The effectiveness of behavioural interventions in the primary prevention of hepatitis C amongst injecting drug users: a randomised controlled trial and lessons learned.

AIM: To develop and evaluate the comparative effectiveness of behavioural interventions of enhanced prevention counselling (EPC) and simple educational counselling (SEC) in reducing hepatitis C viral (HCV) infection in sero-negative injecting drug users (IDU). DESIGN: Randomised controlled trial (RCT) of EPC intervention in comparison with simple educational counselling (SEC). SETTING SPECIALISED: Drug services in London and Surrey, United Kingdom. PARTICIPANTS AND MEASUREMENTS: Ninety five IDUs were recruited and randomised to receive EPC (n = 43) or SEC (n = 52). Subjects were assessed at baseline using the Addiction Severity Index (ASI), the Injecting Risk Questionnaire (IRQ), and Drug Injecting Confidence Questionnaire (DICQ). The primary outcome was measured by the rate of sero-conversion at 6 months and 12 months from baseline and by the ASI, IRQ and DICQ at 6 months from baseline. Hepatitis C testing was undertaken by the innovative test of the dried blood spot (DBS) test which increased the rate of testing by 4 fold compared to routine blood testing. FINDINGS SEVENTY: Eighty two subjects (82%) out of the 95 recruited were followed up at 6 months and 62 (65%) were followed up at 12 months. On the primary outcome measure of the rate of seroconversion, 8 out of 62 patients followed-up at twelve months seroconverted, three in the EPC group and five in the SEC group, indicating incidence rates of 9.1 per 100 person years for the EPC group, 17.2 per 100 person years for the SEC group, and 12.9 per 100 person years for the cohort as a whole. Analysis of the secondary outcome measures on alcohol use, risk behaviour, psychological measures, quality of life, showed no significant differences between the EPC and the SEC groups. However, there were significant changes on a number of measures from baseline values indicating positive change for both groups. CONCLUSION: We were not able to prove the efficacy of EPC in comparison with SEC in the prevention of hepatitis C in IDUs. This was related to low recruitment and retention rates of the participants. Moreover there was a low adherence rate to EPC. The study provided the benefits of developing and introducing behavioural interventions of the EPC and SEC and the DBS screening for Hepatitis C. Moreover the main lessons learnt were that piloting of a new intervention is a crucial first step before conducting pragmatic RCTs of psychological interventions in the field of addiction; that an infrastructure and culture for psychosocial interventions is needed to enable applied research in the service environment, and research funding is needed for enabling the recruitment of dedicated trained therapists for the delivery of these interventions.