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1.  Anæsthesia in Chest Surgery, with Special Reference to Controlled Respiration and Cyclopropane 
Problems in chest surgery: Cases with prolonged toxæmia or amyloid disease require an anæsthetic agent of low toxicity. When sputum or blood are present in the tracheobronchial tree the anæsthesia should abolish reflex distrubances and excessive sputum be removed by suction. The technique should permit the use of a high oxygen atmosphere; controlled respiration with cyclopropane or ether fulfil these requirements. Open pneumothorax is present when a wound of the chest wall allows air to pass in and out of the pleural cavity. The lung on the affected side collapses and the mediastinum moves over and partly compresses the other lung.
The dangers of an open pneumothorax: (1) Paradoxical respiration—the lung on the affected side partially inflates on expiration and collapses on inspiration. Part of the air entering the good lung has been shuttled back from the lung on the affected side and is therefore vitiated. Full expansion of the sound lung is handicapped by the initial displacement of the mediastinum which increases on inspiration. The circulation becomes embarrassed.
(2) Vicious circle coughing. During a paroxysm of coughing dyspnœa will occur. This accentuates paradoxical respiration and starts a vicious circle. Death from asphyxia may result.
Special duties of the anæsthetist: (1) To carry out or supervise continuous circulatory resuscitation. During a thoracotomy a drip blood transfusion maintains normal blood-pressure and pulse-rate.
(2) To maintain effcient respiration.
Positive pressure anæsthesia: Risk of impacting secretions in smaller bronchi with subsequent atelectasis; eventual risk of CO2 poisoning without premonitory signs.
Controlled respiration: (1) How it is produced. (2) Its uses in chest surgery.
Controlled respiration means that the anæsthetist, having abolished the active respiratory efforts of the patient, maintains an efficient tidal exchange by rhythmic squeezing of the breathing bag. This may be done mechanically by Crafoord's modification of Frenkner's spiropulsator or by hand.
Active respiration will cease (i) if the patient's CO2 is lowered sufficiently by hyperventilation, (ii) if the patient's respiratory centre is depressed sufficiently by sedative and anæsthetic drugs, and (iii) by a combination of (i) and (ii) of less degree.
The author uses the second method, depressing the respiratory centre with omnoponscopolamine, pentothal sodium, and then cycloprȯpane. The CO2 absorption method is essential for this technique, and this and controlled respiration should be mastered by the anæsthetist with a familiar agent and used at first only in uncomplicated cases.
The significance of cardiac arrhythmias occuring with cyclopropane is discussed.
The place of the other available anæsthetic agents is discussed particularly on the advisability of using local anæsthesia for the drainage of empyema or lung abscess.
Pharyngeal airway or endotracheal tube? Anæsthesia may be maintained with a pharyngeal airway in many cases but intubation must be used when tracheobronchial suction may be necessary and when there may be difficulty in maintaining an unobstructed airway.
A one-lung anæsthesia is ideal for pneumonectomy. This may be obtained by endotracheal anæsthesia after bronchial tamponage of the affected side (Crafoord, v. fig. 6b) or by an endobronchial intubation of the sound side (v. figs. 9b and 9c). Endobronchial placing of the breathing tube may be performed “blind”. Before deciding on blind bronchial intubation, the anæsthetist must examine X-ray films for any abnormality deviating the trachea or bronchi. Though the right bronchus may be easily intubated blindly as a rule, there is the risk of occluding the orifice of the upper lobe bronchus (fig. 9d) when the patient will become cyanosed. If the tube bevel is facing its orifice the risk of occlusion will be decreased (fig. 9c).
Greater accuracy in placing the tube can be effected by inserting it under direct vision. Instruments for performing this manœuvre are described.
In lobectomy for bronchiectasis the anæsthetist must try to prevent the spread of infection to other parts. Ideally, the bronchus of the affected lobe should be plugged with ribbon gauze (Crafoord, v. fig. 6c) or a suction catheter with a baby balloon on it placed in the affected bronchus. In the presence of a large bronchopleural fistula controlled respiration cannot be established during operation. As the surgeon is rarely able to plug the fistula, if pneumonectomy is to be performed intubation for a one-lung anæsthesia is the best method. During other procedures it is essential to maintain quiet respiration.
In war casualties it is almost always possible, with the technique described, to leave the lung on the affected side fully expanded and thus frequently to restore normal respiratory physiology. Co-operation between surgeon and anæsthetist is essential.
PMCID: PMC1998132  PMID: 19992357
2.  All the Wrong Places: An Unusual Case of Foreign Body Ingestion and Inhalation 
Case Reports in Gastroenterology  2012;6(3):778-783.
Intentional ingestion of foreign bodies is common in psychiatric patients and prison inmates. Timing of endoscopy for ingested foreign bodies varies and depends on the type and location of the foreign body in the gastrointestinal tract. We present the case of a 26-year-old man who was brought from a correctional facility after confessing to have swallowed a few shower curtain hooks. Abdominal X-ray done in the emergency room revealed multiple foreign bodies in the stomach. An upper endoscopy was done in the emergency room with the use of an overtube. The first metal piece was caught by a snare and removed with the endoscope. All other foreign bodies which were present on the abdominal X-ray could not be visualized initially as there was retained food in the stomach. After multiple attempts, four other foreign bodies were found and each one was caught by the forceps and then the scope was removed with the forceps holding the foreign body. There was an additional foreign body in the right mainstem bronchus. The patient had coughed up the foreign body and swallowed it into the gastrointestinal tract. A computed tomography scan of chest and abdomen was done for evaluation, which showed the foreign body in the cecum. To our knowledge, this is the first case report of a patient intentionally transferring a foreign body from one organ system to another. Colonoscopy was done and the foreign body was removed rectally with a snare without any complications.
doi:10.1159/000346287
PMCID: PMC3551388  PMID: 23341801
Foreign bodies in the stomach; Bronchus; Colon
3.  Effectiveness of Chest Physiotherapy in Infants Hospitalized with Acute Bronchiolitis: A Multicenter, Randomized, Controlled Trial 
PLoS Medicine  2010;7(9):e1000345.
Vincent Gajdos and colleagues report results of a randomized trial conducted among hospitalized infants with bronchiolitis. They show that a physiotherapy technique (increased exhalation and assisted cough) commonly used in France does not reduce time to recovery in this population.
Background
Acute bronchiolitis treatment in children and infants is largely supportive, but chest physiotherapy is routinely performed in some countries. In France, national guidelines recommend a specific type of physiotherapy combining the increased exhalation technique (IET) and assisted cough (AC). Our objective was to evaluate the efficacy of chest physiotherapy (IET + AC) in previously healthy infants hospitalized for a first episode of acute bronchiolitis.
Methods and Findings
We conducted a multicenter, randomized, outcome assessor-blind and parent-blind trial in seven French pediatric departments. We recruited 496 infants hospitalized for first-episode acute bronchiolitis between October 2004 and January 2008. Patients were randomly allocated to receive from physiotherapists three times a day, either IET + AC (intervention group, n = 246) or nasal suction (NS, control group, n = 250). Only physiotherapists were aware of the allocation group of the infant. The primary outcome was time to recovery, defined as 8 hours without oxygen supplementation associated with minimal or no chest recession, and ingesting more than two-thirds of daily food requirements. Secondary outcomes were intensive care unit admissions, artificial ventilation, antibiotic treatment, description of side effects during procedures, and parental perception of comfort. Statistical analysis was performed on an intent-to-treat basis. Median time to recovery was 2.31 days, (95% confidence interval [CI] 1.97–2.73) for the control group and 2.02 days (95% CI 1.96–2.34) for the intervention group, indicating no significant effect of physiotherapy (hazard ratio [HR]  = 1.09, 95% CI 0.91–1.31, p = 0.33). No treatment by age interaction was found (p = 0.97). Frequency of vomiting and transient respiratory destabilization was higher in the IET + AC group during the procedure (relative risk [RR]  = 10.2, 95% CI 1.3–78.8, p = 0.005 and RR  = 5.4, 95% CI 1.6–18.4, p = 0.002, respectively). No difference between groups in bradycardia with or without desaturation (RR  = 1.0, 95% CI 0.2–5.0, p = 1.00 and RR  = 3.6, 95% CI 0.7–16.9, p = 0.10, respectively) was found during the procedure. Parents reported that the procedure was more arduous in the group treated with IET (mean difference  = 0.88, 95% CI 0.33–1.44, p = 0.002), whereas there was no difference regarding the assessment of the child's comfort between both groups (mean difference  = −0.07, 95% CI −0.53 to 0.38, p = 0.40). No evidence of differences between groups in intensive care admission (RR  = 0.7, 95% CI 0.3–1.8, p = 0.62), ventilatory support (RR  = 2.5, 95% CI 0.5–13.0, p = 0.29), and antibiotic treatment (RR  = 1.0, 95% CI 0.7–1.3, p = 1.00) was observed.
Conclusions
IET + AC had no significant effect on time to recovery in this group of hospitalized infants with bronchiolitis. Additional studies are required to explore the effect of chest physiotherapy on ambulatory populations and for infants without a history of atopy.
Trial registration
ClinicalTrials.gov NCT00125450
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Bronchiolitis, which is usually caused by the respiratory syncytial virus (RSV), is the commonest infection of the lower respiratory tract (the lungs and the passages through which air enters the lungs) in infants. A third of all children have bronchiolitis during their first year of life. The illness begins with stuffiness, a runny nose, a mild cough, and mild fever. Then, as the smallest airways in the lung (the bronchioles) become inflamed (swell) and blocked with mucus, the cough worsens, and the infant may develop a wheeze, shallow breathing, and a rapid heartbeat. Most cases of bronchiolitis are mild and clear up within two weeks without any treatment but some infants develop severe disease. Such infants struggle to get enough air into their lungs, drawing in their chest with each breath (chest recession). They have trouble eating and drinking, and the oxygen level in their blood can drop dangerously low. About 1% of previously healthy infants need hospitalization because of severe bronchiolitis. These severely affected infants are not normally given any medications but, where necessary, they are given oxygen therapy, fed through a tube into their stomach, and given fluids through a vein.
Why Was This Study Done?
In some countries, chest physiotherapy is routinely given to infants with bronchiolitis even though this is not a recommended treatment internationally. In France, for example, virtually all outpatients with bronchiolitis receive a form of chest physiotherapy known as increased exhalation technique with assisted cough (IET + AC). IET—manual chest compression—is designed to clear mucus from the bronchioles whereas AC—coughing triggered by applying pressure to the top of the breastbone—facilitates clearance of the large airways. But is IET + AC an effective treatment for bronchiolitis? In this study, the researchers undertook a multicenter, randomized, controlled trial to answer this question. A randomized trial is a study in which patients are randomly allocated to receive either the treatment under study or a control treatment. Usually in such trials, noone is aware of the treatment allocations until the trial has been completed. This is called blinding and avoids unconscious biases being introduced into the results. In this trial, although the parents, caregivers, and outcome assessors were blinded, the physiotherapists and the infants were aware of treatment allocations. The physiotherapists were not involved in patient assessment, however, and the infants were sufficiently young that their knowledge of their treatment was unlikely to bias the results.
What Did the Researchers Do and Find?
The researchers enrolled nearly 500 children aged 15 days to 2 years who were admitted to seven French hospitals for a first episode of acute bronchiolitis. They randomly allocated the patients to receive IET + AC (intervention group) or nasal suction (control group) three times a day from a physiotherapist working alone in a room with blacked-out windows. The primary outcome of the trial was the patients' time to recovery. Infants were judged to have recovered if they had not had oxygen therapy or showed signs of chest recession for 8 hours and had ingested more than two-thirds of their daily food requirement. Infants in the control group took an average of 2.31 days to recover whereas those in the intervention group took 2.02 days. However, this difference in recovery time was not statistically significant. That is, it could have happened by chance. The researchers also recorded several secondary outcomes such as admission to an intensive care unit, help with breathing, antibiotic treatment, and parental perceptions of their child's comfort. There were no significant differences between the two treatment groups for any of these secondary outcomes, although the parents did report that the IET + AC treatment was harder on their children than nasal suction while not reducing their overall comfort.
What Do These Findings Mean?
These findings show that IET + AC had no significant effect on the time to recovery of a large population of French infants admitted to hospital with severe bronchiolitis. These results cannot be extrapolated, however, to infants with mild or moderate bronchiolitis, and further studies are needed to assess whether chest physiotherapy is of any benefit in an outpatient setting. Three small trials of a different form of chest physiotherapy have also previously failed to find any effect of chest physiotherapy on recovery time. Thus, none of the currently available results support the routine use of chest physiotherapy in infants admitted to a hospital for severe bronchiolitis.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000345
The UK National Health Service Choices Web site provides detailed information on all aspects of bronchiolitis
Kidshealth, a resource maintained by the Nemours Foundation (a not-for-profit organization for children's health) provides information for parents on bronchiolitis schizophrenia and on respiratory syncytial virus (in English and Spanish)
The British Lung Foundation also provides information on bronchiolitis schizophrenia and on respiratory syncytial virus
The MedlinePlus encyclopedia has a page on bronchiolitis schizophrenia (in English and Spanish)
The US Centers for Disease Control and Prevention has detailed information on respiratory syncytial virus
doi:10.1371/journal.pmed.1000345
PMCID: PMC2946956  PMID: 20927359
4.  Percutaneous Needle Decompression during Laparoscopic Gastric Surgery: A Simple Alternative to Nasogastric Decompression 
Yonsei Medical Journal  2005;46(5):648-651.
Laparoscopic gastric surgeries are routinely performed with use of a nasogastric tube to decompress the upper gastrointestinal tract. A distended upper gastrointestinal tract can complicate successful laparoscopic gastric surgery as the distention compromises not only the visual field but also the laparoscopic manipulation of the stomach. Since nasogastric intubation is not without risks, we have attempted laparoscopic-assisted gastric cancer surgeries without nasogastric tubes. In this article we describe a simple method of aspirating gastric contents using a 9 cm long 19-gauge needle inserted percutaneously during laparoscopic-assisted gastrectomy. First, a 9 cm long 19-gauge disposable needle was introduced through the abdominal wall. This needle was then introduced to the stomach through the anterior wall and the stomach gases and fluids were aspirated by connecting the needle to suction. Thus, a collapsed upper gastrointestinal tract was easily obtained. We performed this procedure instead of nasogastric decompression on twenty-two patients with gastric cancer who underwent laparoscopic-assisted distal subtotal gastrectomy with lymph node dissection. The results were good with only one patient experiencing wound infection (4.5%) and one patient with postoperative acalculus cholecystitis (4.5%). There were no patients with either intraabdominal infection or anastomotic leakage and none of the patients needed postoperative nasogastric decompression, except the patient who experienced acaculus cholecystitis. Percutaneous needle aspiration is a very simple and efficient technique with little risk of postoperative complications. It can be used as an alternative to nasogastric tube decompression of the gastrointestinal tract for laparoscopic-assisted gastrectomy.
doi:10.3349/ymj.2005.46.5.648
PMCID: PMC2810570  PMID: 16259062
Laparoscopy; nasogastric intubations; gastric surgery; percutaneous aspiration
5.  The effect of expiratory rib cage compression before endotracheal suctioning on the vital signs in patients under mechanical ventilation 
Background:
In patients undergoing mechanical ventilation, mucus production and secretion is high as a result of the endotracheal tube. Because endotracheal suction in these patients is essential, chest physiotherapy techniques such as expiratory rib cage compression before endotracheal suctioning can be used as a means to facilitate mobilizing and removing airway secretion and improving alveolar ventilation. As one of the complications of mechanical ventilation and endotracheal suctioning is decrease of cardiac output, this study was carried out to determine the effect of expiratory rib cage compression before endotracheal suctioning on the vital signs in patients under mechanical ventilation.
Materials and Methods:
This study was a randomized clinical trial with a crossover design. The study subjects included 50 mechanically ventilated patients, hospitalized in intensive care wards of Valiasr and Mousavi hospitals in Zanjan, Iran. Subjects were selected by consecutive sampling and randomly allocated to groups 1 and 2. The patients received endotracheal suctioning with or without rib cage compression, with a minimum of 3 h interval between the two interventions. Expiratory rib cage compression was performed for 5 min before endotracheal suctioning. Vital signs were measured 5 min before and 15 and 25 min after endotracheal suctioning. Data were recorded on a data recording sheet. Data were analyzed using paired t-tests.
Results:
There were statistically significant differences in the means of vital signs measured 5 min before with 15 and 25 min after endotracheal suctioning with rib cage compression (P < 0. 01). There was no significant difference in the means of diastolic pressure measured 25 min after with baseline in this stage). But on the reverse mode, there was a significant difference between the means of pulse and respiratory rate 15 min after endotracheal suctioning and the baseline values (P < 0.002). This effect continued up to 25 min after endotracheal suctioning just for respiratory rate (P = 0.016). Moreover, there were statistically significant differences in the means of vital signs measured 5 min before and 15 min after endotracheal suctioning between the two methods (P ≤ 0001).
Conclusions:
Findings showed that expiratory rib cage compression before endotracheal suctioning improves the vital signs to normal range in patients under mechanical ventilation. More studies are suggested on performing expiratory rib cage compression before endotracheal suctioning in patients undergoing mechanical ventilation.
PMCID: PMC4061630  PMID: 24949068
Endotracheal suctioning; expiratory rib cage compression; mechanical ventilation; vital signs
6.  Repeated open endotracheal suctioning causes gradual desaturation but does not exacerbate lung injury compared to closed endotracheal suctioning in a rabbit model of ARDS 
BMC Anesthesiology  2013;13:47.
Background
Although endotracheal suctioning induces alveolar derecruitment during mechanical ventilation, it is not clear whether repeated endotracheal suctioning exacerbates lung injuries. The present study aimed to determine whether repeated open endotracheal suctioning (OS) exacerbates lung injury compared to closed endotracheal suctioning (CS) during mechanical ventilation in an animal model of acute respiratory distress syndrome (ARDS).
Methods
Briefly, thirty six Japanese white rabbits were initially ventilated in pressure-controlled mode with a constant tidal volume (6 mL/kg). Then, lung injury was induced by repeated saline lavage. The rabbits were divided into four groups, namely: a) OS; b) CS; c) control with ARDS only; d) and healthy control (HC) without ARDS. Animals in all the groups were then ventilated with positive end expiratory pressure (PEEP) at 10 cm H2O. CS was performed using 6 French-closed suctioning catheters connected to endotracheal tube under the following conditions: a) a suctioning time and pressure of 10 sec and 140 mm Hg, respectively; and b) a suction depth of 2 cm (length of adapter) plus tracheal tube. OS was performed using the same conditions described for CS, except the ventilator was disconnected from the animals. Each endotracheal suctioning was performed at an interval of 30 min.
Results
PaO2/FIO2 (P/F) ratio for CS, control and HC groups remained at >400 for 6 hours, whereas that of the OS group progressively declined to 300 (p < 0.05), with each suctioning. However, no difference was observed either in lung injury score (histology) or in the expression pattern of inflammatory cytokines (tumor necrosis factor-α and interleukin-6) after 6 hours between the OS and CS groups in the circulatory as well as the pulmonary tissues.
Conclusions
Progressive arterial desaturation under conditions of repeated endotracheal suctioning is greater in OS than in CS time-dependently. However, OS does not exacerbate lung injury during mechanical ventilation when observed over a longer time span (6 hours) of repeated endotracheal suctioning, based on morphological and molecular analysis.
doi:10.1186/1471-2253-13-47
PMCID: PMC3878988  PMID: 24308643
Acute respiratory distress syndrome; Lung injury; Repeated endotracheal suctioning; Repeated derecruitments; Mechanical ventilation
7.  Effect of tracheal suctioning on aspiration past the tracheal tube cuff in mechanically ventilated patients 
Background
This clinical study evaluated the effect of a suctioning maneuver on aspiration past the cuff during mechanical ventilation.
Methods
Patients intubated for less than 48 hours with a PVC-cuffed tracheal tube, under mechanical ventilation with a PEEP ≥5 cm H2O and under continuous sedation, were included in the study. At baseline the cuff pressure was set at 30 cm H2O. Then 0.5ml of blue dye diluted with 3 ml of saline was instilled into the subglottic space just above the cuff. Tracheal suctioning was performed using a 16-French suction catheter with a suction pressure of – 400 mbar. A fiberoptic bronchoscopy was performed before and after the suctioning maneuver, looking for the presence of blue dye in the folds within the cuff wall or in the trachea under the cuff. The sealing of the cuff was defined by the absence of leakage of blue dye either in the cuff wall or in the trachea under the cuff.
Results
Twenty-five patients were included. The size of the tracheal tube was 7-mm ID for 5 patients, 7.5-mm ID for 16 patients, and 8-mm ID for four patients. Blue dye was never seen in the trachea under the cuff before suctioning and only in one patient (4%) after the suctioning maneuver. Blue dye was observed in the folds within the cuff wall in 6 of 25 patients before suctioning and 11 of 25 after (p = 0.063). Overall, the incidence of sealing of the cuff was 76% before suctioning and 56% after (p = 0.073).
Conclusions
In patients intubated with a PVC-cuffed tracheal tube and under mechanical ventilation with PEEP ≥5 cm H2O and a cuff pressure set at 30 cm H2O, a single tracheal suctioning maneuver did not increase the risk of aspiration in the trachea under the cuff.
Trial registration
ClinicalTrials.gov, number NCT01170156
doi:10.1186/2110-5820-2-45
PMCID: PMC3520779  PMID: 23134813
Tube cuff; Aspiration; Suctioning maneuver
8.  Prevention of meconium aspiration syndrome: an update and the Baylor experience 
The approach to preventing meconium aspiration syndrome (MAS) in the newborn has changed markedly over the last 30 years. In the late 1970s, all infants born through meconium-stained amniotic fluid (MSAf) had upper-airway suctioning before delivery of the shoulders and then had tracheal intubation and suctioning in the delivery room. Now suctioning of the upper airway is no longer recommended, and only “depressed” infants are intubated for tracheal suctioning. The incidence of MAS and the associated high mortality rate have both declined significantly over time. This is due to improved antepartum and intrapartum obstetrical management as well as the postdelivery resuscitation of the neonate born through MSAf. MAS is no longer considered to be solely a postnatal disorder that is preventable with routine delivery room suctioning of the trachea; rather, it is considered a complex and multifactorial disorder with antenatal as well as intrapartum factors. The incidence and severity of MAS have been positively affected by a combined obstetrical and neonatal approach to the infant born through MSAf. In this article, we detail our experience at Baylor University Medical Center with MAS and its prevention and review the current literature.
PMCID: PMC2666857  PMID: 19381312
9.  The effect of open and closed endotracheal tube suctioning system on respiratory parameters of infants undergoing mechanical ventilation 
Aims:
Mechanical ventilation is used for some infants in neonatal intensive care units (NICU) due to many physiological and clinical causes. Since these patients have endotracheal tubes, cleaning and keeping the airways open through suctioning should be done to increase oxygenation. This study aimed to evaluate effect of open and closed suctioning methods on respiratory parameters of infants undergoing mechanical ventilation.
Materials and Methods:
In this crossover clinical trial, 44 infants were selected among those undergone mechanical ventilation in NICU of Isfahan's Al-Zahra Hospital using convenience sampling method. The subjects were randomly divided into two groups. In the first group, open suctioning was carried out and after three hours of cleaning, closed suctioning was done. In the second group, closed suctioning was firstly done and following three hours of cleaning, open suctioning was implemented. Respiratory rate (RR) and percentage of arterial blood oxygen saturation was measured before, during and after each type of suctioning. Data were analyzed using repeated measures ANOVA and independent student's t-test.
Findings:
There was a significant difference between mean respiratory rate and arterial blood oxygen saturation in infants before, during and after the closed and open suctioning. The percentage of arterial blood oxygen saturation had a significant reduction in open method compared to closed method during suctioning and immediately after it. RR three minutes after suctioning showed a significant reduction in both steps in open method compared to closed method.
Conclusions:
Close method caused fewer changes in hemodynamic status of infants. Therefore, in order to prevent respiratory complications in infants, nurses are recommended to perform the endotracheal tube suctioning by closed method.
PMCID: PMC3590691  PMID: 23493041
Respiratory rate; ventilation; neonate; suction
10.  Generation of Gastroesophageal Reflux Disease Symptoms During Esophageal Acid Infusion With Concomitant Esophageal pH Monitoring in Healthy Adults 
Background/Aims
The sensitivity of the upper and lower esophageal mucosa to acid is considered to differ. We investigated the relationship between pH changes in different sites of the esophagus and generation of gastroesophageal reflux symptoms during an acid infusion test.
Methods
An acid infusion catheter was placed at 5 or 15 cm above the lower esophageal sphincter (LES) in 18 healthy volunteers, while a 2-channel pH sensor catheter was also placed in each with the sensors set at 5 and 15 cm above the LES. Solutions containing water and hydrochloric acid at different concentrations were infused through the infusion catheter.
Results
Acid infusion in the upper esophagus caused a pH drop in both upper and lower esophageal sites, whereas that in the lower esophagus resulted in a significant pH drop only in the lower without a corresponding pH decline in the upper esophagus. Stronger heartburn, chest pain, and chest oppression symptoms were noted when acid was infused in the upper as compared to the lower esophagus, while increased intra-esophageal acidity strengthened each symptom. Regurgitations caused by upper and lower esophageal acid infusions were similar, and not worsened by a larger drop in intra-esophageal pH. Chest pain was caused only by lowered intra-esophageal pH, while heartburn, chest oppression, and regurgitation were induced by a less acidic solution.
Conclusions
Higher intra-esophageal acidity caused stronger heartburn, chest pain, and chest oppression symptoms. However, regurgitation was not significantly influenced by intra-esophageal acidity. The upper esophagus showed higher acid sensitivity than the lower esophagus.
doi:10.5056/jnm.2013.19.4.503
PMCID: PMC3816185  PMID: 24199011
Heartburn; Esophagus; Gastroesophageal reflux
11.  Novel treatment options for perforations of the upper gastrointestinal tract: Endoscopic vacuum therapy and over-the-scope clips 
Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention. In the past years, covered self-expanding metal stents were the mainstay of endoscopic therapy. However, two new techniques are now available that enlarge the possibilities of defect closure: endoscopic vacuum therapy (EVT), and over-the-scope clip (OTSC). EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage. Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing, comparable to the application of vacuum therapy in cutaneous wounds. The system is changed every 3-5 d. The overall success rate of EVT in the literature ranges from 84% to 100%, with a mean of 90%; only few complications have been reported. OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope. By bringing the edges of the perforation into the cap, by suction or by dedicated devices, such as anchor or twin grasper, the OTSC can be placed to close the perforation. For acute endoscopy associated perforations, the mean success rate is 90% (range: 70%-100%). For other types of perforations (postoperative, other chronic leaks and fistulas) success rates are somewhat lower (68%, and 59%, respectively). Only few complications have been reported. Although first reports are promising, further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.
doi:10.3748/wjg.v20.i24.7767
PMCID: PMC4069305  PMID: 24976714
Upper gastrointestinal; Perforation; Fistula; Endoscopy; Over-the-scope clip; Endoscopic vacuum therapy
12.  Successful treatment of cervical esophageal leakage by endoscopic-vacuum assisted closure therapy 
AIM: To evaluate the efficacy and safety of endoscopic-vacuum assisted closure (E-VAC) therapy in the treatment of cervical esophageal leakage.
METHODS: Between May and November 2012, three male patients who developed post-operative cervical esophageal leakage were treated with E-VAC therapy. One patient had undergone surgical excision of a pharyngo-cervical liposarcoma with partial esophageal resection, and the other two patients had received surgical treatment for symptomatic Zenker’s diverticulum. Following endoscopic verification of the leakage, a trimmed polyurethane sponge was fixed to the distal end of a nasogastric silicone tube and endoscopically positioned into the wound cavity, and with decreasing cavity size the sponge was positioned intraluminally to cover the leak. Continuous suction was applied, and the vacuum drainage system was changed twice a week.
RESULTS: The initial E-VAC placement was technically successful for all three patients, and complete closure of the esophageal leak was achieved without any procedure-related complications. In all three patients, the insufficiencies were located either above or slightly below the upper esophageal sphincter. The median duration of the E-VAC drainage was 29 d (range: 19-49 d), with a median of seven sponge exchanges (range: 5-12 sponge exchanges). In addition, the E-VAC therapy reduced inflammatory markers to within normal range for all three patients. Two of the patients were immediately fitted with a percutaneous enteral gastric feeding tube with jejunal extension, and the third patient received parenteral feeding. All three patients showed normal swallow function and no evidence of stricture after completion of the E-VAC therapy.
CONCLUSION: E-VAC therapy for cervical esophageal leakage was well tolerated by patients. This safe and effective procedure may significantly reduce morbidity and mortality following cervical esophageal leakage.
doi:10.4253/wjge.v5.i7.340
PMCID: PMC3711065  PMID: 23858378
Endoscopic-vacuum assisted closure therapy; Vacuum therapy; Negative pressure wound therapy; Cervical esophageal leakage; Anastomotic leakage
13.  Neonatal infection due to Salmonella worthington transmitted by a delivery-room suction apparatus. 
The Journal of Hygiene  1976;77(3):307-314.
An outbreak of diarrhoea due to Salmonella worthington in five newborn babies, 5 weeks after a similar outbreak in 13 babies for which no cause had been found, occurred in the nursery of a maternity ward. The source of infection was traced to the contaminated rubber tubing of a mechanical suction apparatus. S. worthington was isolated from the rubber tubing and the Y connexion of the suction apparatus from which all the five infected babies had received suction. Reflux of contaminated amniotic fluid into the sterile catheter connected to the apparatus some time before use could have been the means of introducing the infected material to the oropharynx of the newborn babies, and amniotic fluid, acting as a good medium to support the growth of S. worthington, might be responsible for the long-lasting contamination.
PMCID: PMC2129816  PMID: 1069811
14.  Otorrhagia bleeding due to leech bite 
Leeches are blood-sucking hermaphroditic parasites that attach to vertebrate hosts, bite through the skin, and suck out blood. When leeches feed, they secrete an anticoagulant (hirudin), which helps them get a full meal of blood. This is the first report of leech removal from external auditory canal. Previous leech involvement cases were explained in nasopharynx, larynx, pharynx, eye, and gastrointestinal tract. Prominent sign of all cases was active bleeding from the leech attachment site; that stopped with leech removal. A 24-year-old man was presented to Al-Zahra hospital with left otorrhagia and otalgia from 2 days ago. After suction of ear a small soft foreign body was seen in the external ear near the tympanic membrane, then the ear filled with glycerine phenice, the patient explained decreased movement of foreign body. Four hours later the bloody discharge stopped and otalgia decreased. After suction of clots, a leech was extruded from external auditory canal by alligator. Leech infestation is a rare cause of otorrhagia and should be suspected in the endemic region in all of unusual bleeding; it can be diagnosed and treated by exact inspection and removal.
doi:10.4103/2277-9175.96041
PMCID: PMC3507012  PMID: 23210074
Ear; external; leeches
15.  Placement of percutaneous transhepatic biliary stent using a silicone drain with channels 
This report describes a method for percutaneous transhepatic biliary stenting with a BLAKE Silicone Drain, and discusses the usefulness of placement of the drain connected to a J-VAC Suction Reservoir for the treatment of stenotic hepaticojejunostomy. Percutaneous transhepatic biliary drainage was performed under ultrasonographic guidance in a patient with stenotic hepaticojejunostomy after hepatectomy for hepatic hilum malignancy. The technique used was as follows. After dilatation of the drainage root, an 11-Fr tube with several side holes was passed through the stenosis of the hepaticojejunostomy. A 10-Fr BLAKE Silicone Drain is flexible, which precludes one-step insertion. One week after insertion of the 11-Fr tube, a 0.035-inch guidewire was inserted into the tube. After removal of the 11-Fr tube, the guidewire was put into the channel of a 10-Fr BLAKE Silicone Drain. The drain was inserted into the jejunal limb through the intrahepatic bile duct and was connected to a J-VAC Suction Reservoir. Low-pressure continued suction was applied. Patients can be discharged after insertion of the 10-Fr BLAKE Silicone Drain connected to the J-VAC Suction Reservoir. Placement of a percutaneous transhepatic biliary stent using a 10-Fr BLAKE Silicone Drain connected to a J-VAC Suction Reservoir is useful for the treatment of stenotic hepaticojejunostomy.
doi:10.3748/wjg.15.4201
PMCID: PMC2738821  PMID: 19725159
Biliary tract; Drainage; Hepaticojejunostomy; Stenosis; Stents
16.  Oesophageal atresia 
Oesophageal atresia (OA) encompasses a group of congenital anomalies comprising of an interruption of the continuity of the oesophagus with or without a persistent communication with the trachea. In 86% of cases there is a distal tracheooesophageal fistula, in 7% there is no fistulous connection, while in 4% there is a tracheooesophageal fistula without atresia. OA occurs in 1 in 2500 live births. Infants with OA are unable to swallow saliva and are noted to have excessive salivation requiring repeated suctioning. Associated anomalies occur in 50% of cases, the majority involving one or more of the VACTERL association (vertebral, anorectal, cardiac, tracheooesophageal, renal and limb defects). The aetiology is largely unknown and is likely to be multifactorial, however, various clues have been uncovered in animal experiments particularly defects in the expression of the gene Sonic hedgehog (Shh). The vast majority of cases are sporadic and the recurrence risk for siblings is 1%. The diagnosis may be suspected prenatally by a small or absent stomach bubble on antenatal ultrasound scan at around 18 weeks gestation. The likelihood of an atresia is increased by the presence of polyhydramnios. A nasogastric tube should be passed at birth in all infants born to a mother with polyhydramnios as well as to infants who are excessively mucusy soon after delivery to establish or refute the diagnosis. In OA the tube will not progress beyond 10 cm from the mouth (confirmation is by plain X-ray of the chest and abdomen). Definitive management comprises disconnection of the tracheooesophageal fistula, closure of the tracheal defect and primary anastomosis of the oesophagus. Where there is a "long gap" between the ends of the oesophagus, delayed primary repair should be attempted. Only very rarely will an oesophageal replacement be required. Survival is directly related to birth weight and to the presence of a major cardiac defect. Infants weighing over 1500 g and having no major cardiac problem should have a near 100% survival, while the presence of one of the risk factors reduces survival to 80% and further to 30–50% in the presence of both risk factors.
doi:10.1186/1750-1172-2-24
PMCID: PMC1884133  PMID: 17498283
17.  X-ray diagnosis with a bloating agent for foreign object ingestion 
The location of an ingested foreign object is often difficult to determine by X-ray if gastric air bubbles are not clear in the image. Methods that provide negative contrast can facilitate precise object localization, which is important for object retrieval and treatment of the patient. This case report describes a male child, 2 years and 2 mo of age, who accidentally swallowed a lithium battery while playing at home. A plain X-ray showed that the battery was in the abdomen, but it was unclear whether the object was still inside the stomach. A second X-ray examination performed after oral administration of a bloating agent to produce expansion of the stomach and provide negative contrast confirmed that the ingested battery was still in the stomach. The battery was then carefully removed using magnetic and balloon catheters under fluoroscopic guidance. This case report describes the successful use of an orally administered bloating agent without pain to the child in order to determine the precise location of a foreign object in the abdomen.
doi:10.12998/wjcc.v2.i5.157
PMCID: PMC4023311  PMID: 24868517
Accidental ingestion; Bloating agent; X-ray; Minimal invasion; Foreign object
18.  Dislodgement of port-A catheters in pediatric oncology patients: 11 years of experience 
Background
Port-A catheters are frequently used in pediatric cancer patients. Their dislodgement is potentially seriously risky although the incidence is not high. We analyzed our 11 years of data to address this important problem.
Methods
From January 2001 to December 2011, 330 port-A catheters of different brands were implanted in pediatric cancer patients. In total, eight children suffered a dislodgement of their catheter. Their ages ranged from four to thirteen years, with a median age of ten. Five patients presented with catheter dysfunction, two presented with a cough and one was identified incidentally during surgery to remove his port.
Results
The downstream ends of the dislodged catheters were located in the right atrium (three patients), left pulmonary artery (three) and inferior vena cava (two). Six of the eight catheters were broken at the site of anastomosis to the port and the other two were broken halfway in between. All episodes of dislodgement happened after the chemotherapy regimen was completed. The dislodged catheters were successfully retrieved without complications by transcatheter retrieval using a gooseneck snare.
Conclusions
The dislodgment rate of port-A catheter in our series was 2.4%. Chest X-rays can rapidly detect the problem. Most of the catheters were broken at the site of anastomosis. Earlier explantation of port-A catheters after completing chemotherapy may be considered to avoid the dislodgement of catheters, but this needs to be weighed against the possibility of underlying disease recurrence. However, we should re-examine how long port-A catheters need to be retained after chemotherapy considering the improved cure rate of pediatric cancer.
doi:10.1186/1477-7819-11-191
PMCID: PMC3765137  PMID: 23941644
Children; Dislodgement; Port-A catheter; Transcatheter retrieval
19.  Rare presentation of a gastrointestinal stromal tumor with spontaneous esophageal perforation: A case report 
INTRODUCTION
Gastrointestinal stromal tumors (GISTs) of the alimentary canal are malignant tumors with <1% of cases diagnosed in esophagus. These cases require special consideration given their close proximity to vital structures and propensity to be highly aggressive. Management of patients with GISTs has been transformed since the introduction of tyrosine kinase inhibitors. In this report, we present an unusual case of GIST with spontaneous esophageal perforation.
PRESENTATION OF CASE
A 39-year-old Caucasian male presented to our hospital with complaints of severe chest and abdominal pain. A diagnostic chest radiograph revealed a moderate right-sided pleural effusion. Subsequently, an esophagram demonstrated a perforation proximal to an elongated stricture in the distal esophagus. A left thoracotomy was performed whereby a large mediastinal mass firmly attached to the esophagus and gastroesophageal junction was encountered. The neoplasm involved proximal one-third of the stomach and perforated into the right hemithorax. Histopathological evaluation of the tumor led to a diagnosis of GIST.
DISCUSSION
GISTs of the gastroesophageal junction are uncommon and may rarely present with esophageal perforation. The standard of care for treating GIST at present includes tyrosine kinase inhibitors. This pharmacologic agent, along with improved surgical techniques and understanding of molecular markers for accurate diagnosis, will assuredly continue to improve overall survival of patients with GISTs.
CONCLUSION
When stricture or achalasia is detected on imaging, GIST should be considered in the differential diagnosis for individual patients. Additionally, chest and abdomen CT scans of may be performed to confirm presence of a tumor mass, thereby ruling out achalasia.
doi:10.1016/j.ijscr.2013.02.029
PMCID: PMC3679434  PMID: 23702440
GIST; Gastroesophageal junction; KIT; Esophageal perforation; Imatinib
20.  Chemical Carcinogenesis of the Gastrointestinal Tract in Rodents: An Overview with Emphasis on NTP Carcinogenesis Bioassays 
Toxicologic pathology  2009;38(1):188-197.
Cancers of the stomach and large intestine (LI) are the second and fourth leading causes of human cancer mortality. A review of the National Toxicology Program (NTP) database and the Carcinogenic Potency Database (CPDB) reveals that chemically induced neoplasms of the gastrointestinal tract (GIT) are relatively common. Within the GIT, epithelial tumors of the forestomach in mice and rats and LI of the rat are most common. Generally, there is a high species concordance for forestomach with at least 26 chemicals inducing tumors in both species. Glandular stomach tumors are rare, and the few reported are usually neuroendocrine tumors (carcinoids) originating from the enterochromaffin-like (ECL) cells. Of 290 carcinogenic agents identified by the NTP, 19 (7%) caused intestinal neoplasia, 14 in the rat and 5 in the mouse. Neoplasms occurred in both males and females, exclusively in the small intestine (SI) of the mouse and in the LI or both SI and LI in the rat. Enteric carcinogens (NTP) frequently induced neoplasms at other alimentary sites (oral cavity, esophagus, and stomach). In conclusion, the most common induced GIT tumors are squamous neoplasms of the forestomach, glandular neoplasms of the stomach are rare, and rats appear more prone to developing LI (colorectal) cancer compared to mice.
doi:10.1177/0192623309356452
PMCID: PMC3166531  PMID: 20019352
cancer; gastrointestinal tract; forestomach; stomach; intestine; rat; mouse; rodent; carcinoid; papilloma; carcinoma; adenoma; adenocarcinoma; neuroendocrine tumor; colon; colorectal; carcinogens; genotoxic; non-genotoxic; molecular biology; review; p53; animal model; NTP
21.  Managing urine leakage following laparoscopic radical prostatectomy with active suction of the prevesical space 
Introduction
Urine leakage following laparoscopic radical prostatectomy (LRP) is a possible complication that may herald chronic urine incontinence. Intraoperative measures aiming to prevent this is not standardised.
Aim
Presentation of experience with active suction of the prevesical space in managing postoperative urine leakage.
Material and methods
At the Department of Urology, where laparoscopy of the upper abdomen and open RP were performed, a protocol for extraperitoneal LRP was established in 8/2008. Until 5/2011, 154 LRPs have been performed. Urine leakage from a suction drain appeared in 9 cases (5.8%). Permanent active suction (with a machine for Büllae thoracic drainage) of the prevesical space with negative pressure of 7-12 cm of H2O was started immediately.
Results
Urine leakage started after a mean of 0.9 (0-2) days postoperatively and stopped after a mean of 8.1 (15-42) days. Leakage stopped with only suctioning in 7 cases. In one case, open re-anastomosis was performed on the 7th postoperative day (POD). In another case, ineffective active suction was replaced on the 10th POD by needle vented suction without effect and the leakage stopped following gradual shortening of the drain up to the 15th POD.
Conclusions
Active suction of the prevesical space seems to be an effective intervention to stop postoperative urine leakage after laparoscopic radical prostatectomy.
doi:10.5114/wiitm.2011.31533
PMCID: PMC3627153  PMID: 23630554
prostate cancer; radical prostatectomy; laparoscopy; complications; urinary leakage
22.  Long-term nephrostomy in an adult male spinal cord injury patient who had normal upper urinary tracts but developed bilateral hydronephrosis following penile sheath drainage: pyeloplasty and balloon dilatation of ureteropelvic junction proved futile: a case report 
Cases Journal  2009;2:9335.
Introduction
The consequences of spinal cord injury upon urinary bladder are readily recognised by patients and health care professionals, since neuropathic bladder manifests itself as urinary incontinence, or retention of urine. But health care professionals and persons with spinal cord injury may not be conversant with neuropathic dysmotility affecting the ureter and renal pelvis. We report an adult male patient with spinal cord injury, who developed bilateral hydronephrosis after he started managing neuropathic bladder by penile sheath drainage.
Case presentation
A male patient, born in 1971, sustained spinal cord injury following a motorbike accident in September 1988. In November 1988, intravenous urography showed normal upper tracts. He was advised spontaneous voiding with 2-3 catheterisations a day. In February 1995, this patient developed fever, chills and vomiting. Blood urea: 23.7 mmol/L; creatinine: 334 umol/L. Ultrasound revealed marked hydronephrosis of right kidney and mild hydronephrosis of left kidney. Bilateral nephrostomy was performed in March 1995. Right pyeloplasty was performed in May 1998. In July 2005, this patient developed urine infection and was admitted to a local hospital with fever and rigors. He developed septicaemia and required ventilation. Ultrasound examination of abdomen revealed bilateral hydronephrosis and multiple stones in left kidney. Percutaneous nephrostomy was performed on both sides. Subsequently, extracorporeal shock wave lithotripsy of left renal calculi was carried out. Right nephrostomy tube slipped out in January 2006; percutaneous nephrostomy was performed again. In June 2006, left ureteric antegrade stenting was performed and nephrostomy tube was removed. Currently, right kidney is drained by percutaneous nephrostomy and left kidney is drained by ureteric stent. This patient has indwelling urethral catheter.
Conclusion
It is possible that regular intermittent catheterisations along with anticholinergic medication right from the time of rehabilitation after this patient sustained paraplegia might have prevented the series of urological complications. Key components to successful management of external drainage of kidney in this patient are: [1] use of size 14 French pigtail catheter for long-term nephrostomy, [2] anchoring the catheter to skin to with Percufix catheter cuff to prevent accidental tug [3], replacing the nephrostomy dressing once a week by the same team in order to provide continuity of care, and [4] changing nephrostomy catheter every six months by a senior radiologist.
doi:10.1186/1757-1626-2-9335
PMCID: PMC2803994  PMID: 20062594
23.  Aerodigestive Foreign Bodies in Adult Ethiopian Patients: A Prospective Study at Tikur Anbessa Hospital, Ethiopia 
Introduction. Foreign bodies (FBs) in the aerodigestive tract are important causes of morbidity and mortality and pose diagnostic and therapeutic challenges. The best method of removal of an esophageal and tracheobronchial FB is endoscopic guided extraction. Objective. To present our experience of the removal of aerodigestive FBs in adult Ethiopian patients using rigid endoscopes. Methods. A hospital-based prospective study, at Tikur Anbessa Referral and Teaching Hospital, from January 2011 to December 2012 (over two years). Results. A total of 32 patients (18 males and 14 females) with a mean age of 28.0 ± 12.74 years were treated for FB ingestion and aspiration at Tikur Anbessa Hospital. The FBs were impacted at the esophagus in 18 (56.2%) patients, at the pharynx in 7 (21.8%), and at the air way in 7 (21.8%) patients. Pieces of bones were the commonest objects found in the esophagus (17/18 of the cases) and the pharynx (4/7), while fractured tracheostomy tubes and needles were frequently seen in the air way (3/7 cases each). The foreign bodies were visible in plain radiographs of 26 (81.2%) patients. Successful extraction of FBs was achieved by using Mc gill forceps in 11 cases, rigid esophagoscopes in 9 patients, and bronchoscopes in 4 cases. Four cases required open surgery to remove the foreign bodies. Two complications (one pneumothorax and one esophageal perforation) occurred. All patients were discharged cured. Discussion and Recommendations. Aerodigestive FBs are not so rare in the hospital and timely diagnosis and removal of accidentally ingested and aspirated foreign body should be performed so as to avoid the potentially lethal complications associated. Rigid esophagoscopy requires general anesthesia and is associated with its own complications, but our experience and outcome of its use are encouraging.
doi:10.1155/2014/293603
PMCID: PMC4009294  PMID: 24834074
24.  The Relationship Between Somatic Growth and In Vivo Esophageal Segmental and Sphincteric Growth in Human Neonates 
Background
Measurement of aerodigestive tract length is an important determinant for accurate placement of esophageal probes and gavage tubes at the desired location. The relationship of esophageal body, upper esophageal sphincter (UES) and lower esophageal sphincter (LES) lengths with somatic growth in neonates is not well understood.
Objectives
Our objectives were to (1) evaluate a relationship between segmental esophageal lengths and somatic growth parameters and (2) ascertain the relationship between segmental esophageal lengths and gestational age (GA) and postmenstrual age (PMA) in preterm and full-term born human neonates.
Design/Methods
One hundred esophageal manometry studies were performed in 75 infants (30–60 weeks PMA) and the high-pressure zones of LES and UES identified. The distance from nares to LES and from nares to UES, esophageal body length, length of UES and LES derived from the manometry studies were correlated with somatic growth parameters. Growth rate of different esophageal segments was also determined in 26 subjects that underwent longitudinal studies. Analysis of variance and linear regression analysis were performed.
Results
Seventy-five neonates of 23.0–40.6 weeks gestational age (0.6–4.4 kg) were studied at 29.1–58.6 weeks PMA (1.0–6.4 kg). Significant correlation (P < 0.001) of PMA and physical growth parameters with the growth of nares-LES (R2 = 0.8), esophageal body length (R2 = 0.6) and nares-UES (R2 = 0.4) were noted. Nares-to-LES length increased at a rate of 0.25 cm/wk PMA during 33.0–36.0 weeks of age.
Conclusions
In vivo esophageal segmental lengths correlated strongly with somatic growth parameters and PMA in neonates. We speculate that this approach has many practical applications with the use of esophageal probes and catheters.
doi:10.1097/01.mpg.0000226368.24332.50
PMCID: PMC4028631  PMID: 16819375
Esophagus; Neonate; Growth; Upper esophageal; sphincter; Lower esophageal sphincter
25.  New Approaches to Percutaneous Gastrostomy 
ABSTRACT
Novel approaches to percutaneous gastrostomy have evolved because of catheter clogging and displacement, which is commonly seen with currently available gastrostomy catheters. Low-profile button gastrostomy catheters, designed to be inserted into mature tracts, have recently been inserted into fresh gastrostomy tracts. Catheter clogging rarely occurs with these low-profile devices. Catheter displacement remains a problem but new buttons can be inserted at the patient's bedside without the need for a return visit to the radiology department. A 90 to 100% success rate has been shown for placement of gastrostomy buttons. Pull-type endoscopic gastrostomy catheters can be placed radiologically using a standard puncture of the stomach and cannulation of the gastroesophageal junction. A guide wire is manipulated up the esophagus and out the mouth. The pull-type gastrostomy catheter is then attached and pulled down through the esophagus and out through the anterior abdominal wall. These catheters have very good retention devices and rarely become dislodged. Catheter clogging is also rarely seen, provided larger devices are used. Radiological placement of percutaneous endoscopic gastrostomy tubes has been termed the “hybrid method” and has been shown to be cheaper than endoscopic and other fluoroscopic methods of gastrostomy.
doi:10.1055/s-2004-860877
PMCID: PMC3036222  PMID: 21331128
Percutaneous gastrostomy; button gastrostomy

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