398
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Letters, Techniques and Images
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Digestive Endoscopy 2015; 27: 397–401
REFERENCES 1 Sakai H, Egi H, Hinoi T et al. Primary lung cancer presenting with metastasis to the colon. World J. Surg. Oncol. 2012; 10: 127. 2 Kim SY, Ha HK, Park SW et al. Gastrointestinal metastasis from primary lung cancer: CT findings and clinicopathologic features. Am. J. Roentgenol. 2009; 193: 197–201.
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Figure 1 (A) Histology of the lung revealed poorly differentiated squamous cell carcinoma (H&E, magnification ×20). (B) Histology of the stomach revealed poorly differentiated squamous cell carcinoma (H&E, mag. ×40). (C) Histology of the cecal lesion revealed poorly differentiated squamous cell carcinoma (H&E, mag. ×40). (D) Immunohistochemically, the carcinoma cells in the cecum were positive for p63 (mag. ×40).
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B
Migration of gastrostomy site: Rare complication of percutaneous endoscopic gastrostomy Although percutaneous endoscopic gastrostomy (PEG) is relatively safe and easy to carry out, complications can occur during and after the procedure.1–5 Here, we report a rare case with complications involving a gastrostomy tube. An 82-year-old woman with a history of cerebral hemorrhage underwent PEG using a Safety PEG kit (Boston Scientific Japan, Tokyo, Japan) with the pull technique at the anterior wall of the lower gastric body (Fig. 1A). Esophagogastroduodenoscopy (EGD) showed normal findings in the stomach and duodenum (Fig. 1B). Exchanges of the balloontype (Foley-type) gastrostomy tube had been carried out in an irregular manner with intervals of 1–6 months without using endoscopy. EGD 4 years after initial placement of the gastrostomy revealed a longitudinal ulcer scar extending from the anterior wall of the lower gastric body to the anterior wall of the pylorus ring, with shortening of the lesser curvature of the stomach (Fig. 1C). The internal balloon was placed in the bulbus (Fig. 1D). The ulcer scar of the stomach appeared to continue from the position where gastrostomy
Figure 2 (A) Esophagogastroduodenoscopy demonstrated multiple polypoid lesions with an irregular ulcer in the antrum. (B) Colonoscopy showed multiple polypoid lesions with an irregular ulcer in the cecum.
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colonic lesions revealed poorly differentiated squamous cell carcinoma (Fig. 1C). Immunohistochemically, the carcinoma cells in the stomach and cecum were positive for p63 (Fig. 1D). Recurrence of lung cancer presented with multiple metastasis to the gastrointestinal tract, forming volcano-like ulcerated lesions involving several segments of the gastrointestinal tract.
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Authors declare no conflict of interests for this article. Junichi Miyazaki, Seiichi Hirota and Takashi Abe Endoscopy Center, Takarazuka Municipal Hospital, Takarazuka, Japan doi: 10.1111/den.12412
Figure 1 Endoscopic views of the initial percutaneous endoscopic gastrostomy (PEG). (A) Lower gastric body. (B) Antrum. Endoscopic views 4 years after the initial PEG. (C) Longitudinal ulcer scar extends from the anterior wall of the lower gastric body to the anterior wall of the pyloric ring. (D) The balloon of the internal gastrostomy tube has migrated away from the current gastrostomy site into the duodenum.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2015; 27: 397–401
Letters, Techniques and Images 399
4 Gencosmanoglu R, Koc D, Tozun N. The buried bumper syndrome: Migration of internal bumper of percutaneous endoscopic gastrostomy tube into the abdominal wall. J. Gastroenterol. 2003; 38: 1077–80. 5 O’Dell KB, Gordon RS, Becker LB. Gastrostomy tube transmigration: A rare cause of small bowel obstruction. Ann. Emerg. Med. 1991; 20: 817–9.
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Figure 2 Schema for the presumed process of migration of the gastrostomy site in the stomach. (A) Loosened stop tab. (B) Migration of the balloon from the gastric body into the bulbus. (C) Gastrostomy site moving to the pyloric ring by long-term excessive traction.
had initially been placed to the current position of the button in the bulbus, suggesting that the ulcer scar represented the path of migration of the gastrostomy site. The present case suggests that migration of the gastrostomy site can occur as a PEG-related late complication. This complication may be attributable to long-term excessive traction on the gastric wall as a result of inappropriate positioning, irregular exchange intervals, and loose fixation during the PEG procedure (Fig. 2). These considerations imply that regular exchanges of the gastrostomy tube using EGD are important. In addition, use of a non-balloon-type replacement such as a small bumper-type or button-type device may prevent migration of the gastrostomy site. More importantly, necessity for continuous use should be regularly evaluated, considering this type of long-term complication.
Overtubes and fluoroscopy for direct percutaneous endoscopic jejunostomy: Useful, although not always needful and sometimes harmful The authors read with great interest the article by Velázquez-Aviña et al. reporting a new technique for direct percutaneous endoscopic jejunostomy (DPEJ) using balloonassisted enteroscopy and fluoroscopy.1 The authors present some comments based on their experience with 14 DPEJ attempted in the last 4 years with single-balloon enteroscopy (SBE), applying a similar technique without fluoroscopy. SBE is advanced to the jejunum and the target loop is selected through transillumination and finger indentation. A 40-mm 21-G needle is used for lidocaine infiltration and jejunal loop puncture. This needle is grasped with a snare during skin incision, gastrostomy needle puncture and string advancement (Fig. 1). The 21-G needle is released and the string grasped with a forceps (Fig. 2), as this is easier than with a snare in the jejunum. After one complication caused by the overtube, it is left only for distal loops, as it enabled safer PEJ-bumper pulling through the jejunum. While being pulled, the PEJ-bumper
Authors declare no conflict of interests for this article. Takao Maekita,1 Kazuyuki Nakazawa2 and Jun Kato1 Department of Gastroenterology, School of Medicine, Wakayama Medical University and 2Department of Internal Medicine, Koyo Hospital, Wakayama City, Japan doi: 10.1111/den.12411 1
REFERENCES 1 Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987; 93: 48–52. 2 Loser C, Wolters S, Folsch UR. Enteral long-term nutrition via percutaneous endoscopic gastrostomy (PEG) in 210 patients: A four-year prospective study. Dig. Dis. Sci. 1998; 43: 2549–57. 3 Blomberg J, Lagergren J, Martin L, Mattsson F, Lagergren P. Complications after percutaneous endoscopic gastrostomy in a prospective study. Scand. J. Gastroenterol. 2012; 47: 737–42.
Figure 1 Endoscopic image showing the catheter of the gastrostomy kit penetrating the jejunal wall, while a snare grasping a 21-G needle is used to keep the jejunal loop in position.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
Copyright of Digestive Endoscopy is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A
Letters, Techniques and Images
B
Digestive Endoscopy 2015; 27: 397–401
REFERENCES 1 Sakai H, Egi H, Hinoi T et al. Primary lung cancer presenting with metastasis to the colon. World J. Surg. Oncol. 2012; 10: 127. 2 Kim SY, Ha HK, Park SW et al. Gastrointestinal metastasis from primary lung cancer: CT findings and clinicopathologic features. Am. J. Roentgenol. 2009; 193: 197–201.
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D
Figure 1 (A) Histology of the lung revealed poorly differentiated squamous cell carcinoma (H&E, magnification ×20). (B) Histology of the stomach revealed poorly differentiated squamous cell carcinoma (H&E, mag. ×40). (C) Histology of the cecal lesion revealed poorly differentiated squamous cell carcinoma (H&E, mag. ×40). (D) Immunohistochemically, the carcinoma cells in the cecum were positive for p63 (mag. ×40).
A
B
Migration of gastrostomy site: Rare complication of percutaneous endoscopic gastrostomy Although percutaneous endoscopic gastrostomy (PEG) is relatively safe and easy to carry out, complications can occur during and after the procedure.1–5 Here, we report a rare case with complications involving a gastrostomy tube. An 82-year-old woman with a history of cerebral hemorrhage underwent PEG using a Safety PEG kit (Boston Scientific Japan, Tokyo, Japan) with the pull technique at the anterior wall of the lower gastric body (Fig. 1A). Esophagogastroduodenoscopy (EGD) showed normal findings in the stomach and duodenum (Fig. 1B). Exchanges of the balloontype (Foley-type) gastrostomy tube had been carried out in an irregular manner with intervals of 1–6 months without using endoscopy. EGD 4 years after initial placement of the gastrostomy revealed a longitudinal ulcer scar extending from the anterior wall of the lower gastric body to the anterior wall of the pylorus ring, with shortening of the lesser curvature of the stomach (Fig. 1C). The internal balloon was placed in the bulbus (Fig. 1D). The ulcer scar of the stomach appeared to continue from the position where gastrostomy
Figure 2 (A) Esophagogastroduodenoscopy demonstrated multiple polypoid lesions with an irregular ulcer in the antrum. (B) Colonoscopy showed multiple polypoid lesions with an irregular ulcer in the cecum.
A
B
colonic lesions revealed poorly differentiated squamous cell carcinoma (Fig. 1C). Immunohistochemically, the carcinoma cells in the stomach and cecum were positive for p63 (Fig. 1D). Recurrence of lung cancer presented with multiple metastasis to the gastrointestinal tract, forming volcano-like ulcerated lesions involving several segments of the gastrointestinal tract.
C
D
Authors declare no conflict of interests for this article. Junichi Miyazaki, Seiichi Hirota and Takashi Abe Endoscopy Center, Takarazuka Municipal Hospital, Takarazuka, Japan doi: 10.1111/den.12412
Figure 1 Endoscopic views of the initial percutaneous endoscopic gastrostomy (PEG). (A) Lower gastric body. (B) Antrum. Endoscopic views 4 years after the initial PEG. (C) Longitudinal ulcer scar extends from the anterior wall of the lower gastric body to the anterior wall of the pyloric ring. (D) The balloon of the internal gastrostomy tube has migrated away from the current gastrostomy site into the duodenum.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2015; 27: 397–401
Letters, Techniques and Images 399
4 Gencosmanoglu R, Koc D, Tozun N. The buried bumper syndrome: Migration of internal bumper of percutaneous endoscopic gastrostomy tube into the abdominal wall. J. Gastroenterol. 2003; 38: 1077–80. 5 O’Dell KB, Gordon RS, Becker LB. Gastrostomy tube transmigration: A rare cause of small bowel obstruction. Ann. Emerg. Med. 1991; 20: 817–9.
A
B
C
Figure 2 Schema for the presumed process of migration of the gastrostomy site in the stomach. (A) Loosened stop tab. (B) Migration of the balloon from the gastric body into the bulbus. (C) Gastrostomy site moving to the pyloric ring by long-term excessive traction.
had initially been placed to the current position of the button in the bulbus, suggesting that the ulcer scar represented the path of migration of the gastrostomy site. The present case suggests that migration of the gastrostomy site can occur as a PEG-related late complication. This complication may be attributable to long-term excessive traction on the gastric wall as a result of inappropriate positioning, irregular exchange intervals, and loose fixation during the PEG procedure (Fig. 2). These considerations imply that regular exchanges of the gastrostomy tube using EGD are important. In addition, use of a non-balloon-type replacement such as a small bumper-type or button-type device may prevent migration of the gastrostomy site. More importantly, necessity for continuous use should be regularly evaluated, considering this type of long-term complication.
Overtubes and fluoroscopy for direct percutaneous endoscopic jejunostomy: Useful, although not always needful and sometimes harmful The authors read with great interest the article by Velázquez-Aviña et al. reporting a new technique for direct percutaneous endoscopic jejunostomy (DPEJ) using balloonassisted enteroscopy and fluoroscopy.1 The authors present some comments based on their experience with 14 DPEJ attempted in the last 4 years with single-balloon enteroscopy (SBE), applying a similar technique without fluoroscopy. SBE is advanced to the jejunum and the target loop is selected through transillumination and finger indentation. A 40-mm 21-G needle is used for lidocaine infiltration and jejunal loop puncture. This needle is grasped with a snare during skin incision, gastrostomy needle puncture and string advancement (Fig. 1). The 21-G needle is released and the string grasped with a forceps (Fig. 2), as this is easier than with a snare in the jejunum. After one complication caused by the overtube, it is left only for distal loops, as it enabled safer PEJ-bumper pulling through the jejunum. While being pulled, the PEJ-bumper
Authors declare no conflict of interests for this article. Takao Maekita,1 Kazuyuki Nakazawa2 and Jun Kato1 Department of Gastroenterology, School of Medicine, Wakayama Medical University and 2Department of Internal Medicine, Koyo Hospital, Wakayama City, Japan doi: 10.1111/den.12411 1
REFERENCES 1 Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987; 93: 48–52. 2 Loser C, Wolters S, Folsch UR. Enteral long-term nutrition via percutaneous endoscopic gastrostomy (PEG) in 210 patients: A four-year prospective study. Dig. Dis. Sci. 1998; 43: 2549–57. 3 Blomberg J, Lagergren J, Martin L, Mattsson F, Lagergren P. Complications after percutaneous endoscopic gastrostomy in a prospective study. Scand. J. Gastroenterol. 2012; 47: 737–42.
Figure 1 Endoscopic image showing the catheter of the gastrostomy kit penetrating the jejunal wall, while a snare grasping a 21-G needle is used to keep the jejunal loop in position.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
Copyright of Digestive Endoscopy is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
