The treatment of staghorn calculi

Between May 1989 and November 1991, 19 staghorn calculi were treated by extracorporeal shock-wave lithotripsy (ESWL) with a Dornier MFL 5000 or Northgate SD-3. The 19 calculi were evaluated. Treatment was with monotherapy by ESWL in 9, combination percutaneous nephrolithotomy (PNL)-ESWL in 9, and nephrostomy in 1. Of the patients, 14 had a cross stent catheter pre-ESWL treatment to improve fragment evacuation. Radiologic follow up in 19 kidneys revealed that 57.9% were stone free. We arbitrarily separated our cases into 3 groups: struvite renal calculi, calcium carbonate calculi and others. Result of stone-free rate was 100% for stones consisting of struvite, and 14. 3% for stones consisting of calcium carbonate. In our opinion, the best indication of monotherapy by ESWL is for staghorn calculi, which consists of struvite, without marked dilation of pelvis and calyces.     

Ultrasound-directed percutaneous endoscopic cyst-gastrostomy for the treatment of a pancreatic pseudocyst

The incidence of pseudocysts in patients with chronic pancreatitis ranges from 20-40%. Unlike pseudocysts associated with acute pancreatitis, these do not usually resolve spontaneously. Traditionally, these cysts were drained surgically. More recently, however, they have been successfully managed with endoscopic drainage. This report reviews the history and results of nonsurgical pseudocyst management and describes a case of drainage obtained using an alternative method of ultrasound-directed percutaneous endoscopic cyst-gastrostomy.     

Renal staghorn calculosis: our experience with the percutaneous treatment with or without extracorporeal shock wave lithotripsy

Signs of the left bronchus compression, caused by aneurysmatic dilatation of the aortic root with severe aortic regurgitation, occurred 5 months after repair of the truncus arteriosus with interrupted aortic arch in an 85-day-old infant. At reoperation the dilated ascending aorta was replaced with a 14-mm Dacron tube. The aortic valve was replaced with an 18-mm Carbomedics valve. Compression of the left bronchus and the right pulmonary artery were released. The right pulmonary artery was enlarged with a pericardial patch and the original homograft was replaced with a new one. The patient remains in good clinical condition 2 years later.     

Experiences with percutaneous endoscopic gastrostomy

Today the procedure of choice for long-term enteral tube feeding in patients with prolonged swallowing difficulties or inabilities is percutaneous endoscopic gastrostomy (PEG). The primary indications are head and neck cancers, neurologic dysphagia, cancer cachexia, and obstruction of the esophagus and pharynx with enough space for an endoscopic procedure. This technique requires no general anesthesia and is possible in patients with contraindications to surgical gastrostomy. Between September 1994 and April 1995 a total of 115 patients underwent PEG placement attempts. We employed the pull-technique with 15-Freka PEG tubes. The average procedure time, including esophagogastroduodenoscopy, was 17 minutes. In nine cases PEG insertion was impossible owing to severe obstruction of the esophagus. In 46 (40%) patients local abdominal pains started on the first or second postoperative day; 7 of these patients required surgical consultation, and no further intervention was needed. In only one patient was there a serious complication that required surgical intervention: a presumed perforation that turned out to have no correlate upon review. All patients received single-shot antibiotic prophylaxis; and only in those patients with abdominal symptoms do we recommend a prolonged antibiosis. The abdominal symptoms reported were due to a slight leak of gastric fluid causing a topical peritonitis, which required no further treatment. In our experience PEG is a useful alternative to surgical gastrostomy. The simplicity of this procedure leads to low complication rates, short hospitalization, and is possible on an outpatient basis. It is cost-efficient and has a much better psychological tolerance than nasogastric tubes.     

Lumbar percutaneous endoscopic interbody fusion

Since 1982, percutaneous endoscopic control has been found to be a fundamental help for selective posterior subligamentary decompression in lumbar contained disc herniations. After the first clinical experience in 1986 with percutaneous intervertebral bone grafting, the need for sufficient percutaneous preparation of the adjacent vertebral plates and postoperative immobilization of the operated on segment became evident. So in 1988, the original eccentrically abrasive end plate cutter for application under discoscopy was introduced. For a preoperative trial and postoperative stabilization, the complementary use of the external pedicle fixation device was standardized in 1988. The use of percutaneous autologous bone interposition was found essential for optimal bony interbody consolidation. The indications were limited strictly to monosegmental lumbar dysfunctions without a need for peridural decompression. In a series of 37 patients with standardized procedure and a mean followup of 33 months, bony interbody consolidation was achieved in 30 cases. The technique desists from any need for blood transfusion, and functional rehabilitation is facilitated because of the very limited percutaneous approach.     

Transnasally placed percutaneous endoscopic gastrostomy probe

HISTORY: A 78-year-old woman in an organic psychotic state with food refusal was referred for a percutaneous endoscopic gastrostomy (PEG), repeated fluid infusions at home having failed to deal with dehydration severe enough to cause coma. She was somnolent on admission; neither a history nor cooperation was obtainable. TREATMENT AND COURSE: Despite premedication with 20 mg diazepam and 100 mg pethidine endoscopy could not be performed through the mouth. A routine gastroscope (9 mm external diameter), however, could be passed transnasally into the stomach without difficulty and the PEG tube also placed transnasally. CONCLUSION: When endoscopic access to the stomach via the mouth fails, introduction via the nose is a possible alternative.     

Postoperative percutaneous endoscopic gastrostomy/jejunostomy

In order to cure complications appeared in the postoperative period two patients were treated with percutaneous endoscopic gastrostomy/jejunostomy (PEG, PEGJ) with the purpose of long-lasting enteral feeding and decompression. The indications of PEG/PEGJ were the following: external gastric fistula in one case and anastomotic leakage in one case. In the patients the PEG was located by intraoperative X-ray examination, this method was not published earlier. Regarding complications of the early postoperative period the PEG and the PEGJ are considered useful and expedient procedures with the aim of lasting enteral feeding and decompression.     

The "buried bumper" syndrome--a rare complication of percutaneous endoscopic gastrostomy

Since initially being described in 1980, percutaneous endoscopic gastrostomy (PEG) has had a dramatic impact on enteral access and alimentation techniques. Knowledge of the problems makes it possible to lower the complication rate of this method. We report a case of partial penetration of the gastric wall by the internal bolster of the tube. We focus on the prevention, recognition, and management of this PEG-related problem.     

Acetazolamide-induced nephrolithiasis: implications for treatment of neuromuscular disorders

Carbonic anhydrase inhibitors can cause nephrolithiasis. We studied 20 patients receiving long-term carbonic anhydrase inhibitor treatment for periodic paralysis and myotonia. Three patients on acetazolamide (15%) developed renal calculi. Extracorporeal lithotripsy successfully removed a renal calculus in one patient and surgery removed a staghorn calculus in another, permitting continued treatment. Renal function remained normal in all patients. Nephrolithiasis is a complication of acetazolamide but does not preclude its use.     

Complications of percutaneous endoscopic gastrostomy (PEG)

Percutaneous endoscopic gastrostomy (PEG) is a simple technique for the endoscopic placement of a permanent feeding access. The procedure is relatively safe and the technique well established. PEG can, however, be associated with serious complications and death. Following the rare PEG-related complication of an abdominal dislocation we review technique, indications and complications of this sixteen year old method.     

The immunological aspects of systemic enzyme therapy in the combined treatment of recurrent nephrolithiasis

BACKGROUND: Despite the popularity of complementary therapies with the public, knowledge and use of these therapies among doctors appear limited. However, studies show that physicians and medical students are positive toward complementary therapies and have a high level of interest in learning about them. METHODS: The attitudes of medical students toward complementary therapies were examined using a questionnaire distributed to 800 first-, third-, and fifth-year medical students at two universities in Melbourne, Australia. RESULTS: The survey revealed that whereas Australian medical students were positive toward complementary therapies, their self-reported knowledge was low, with 56% having no knowledge of the principles of complementary therapies. Attitudes toward different therapies were found to vary widely, with students having little knowledge of chiropractic and naturopathy, the two therapies most commonly used by Australians. Students consistently scored meditation, massage, and acupuncture the highest with regard to knowledge, perceived usefulness, intended patterns of referral after graduation, and desire for education in the undergraduate degree. CONCLUSIONS: When the medical course included some tuition on complementary therapies, students were more positive toward them. A single lecture on complementary therapies was found to have significant impact on medical students' views. Medical students have a high level of interest in complementary therapies that is not being satisfied by their undergraduate curricula.     

Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) tube placement is the preferred method for long-term enteral feeding of patients who are unable to take food by mouth. Despite the widespread acceptance of the procedure, no large-scale study of the long-term outcomes of patients receiving PEG tubes has been reported. The objective of this study was to determine the survival of patients in whom PEG tubes are placed. DESIGN: Retrospective cohort study using data obtained from two computerized databases. SETTING: Department of Veterans Affairs hospitals. PATIENTS: Seven thousand three hundred sixty-nine patients who received a PEG tube in fiscal years 1990 through 1992. RESULTS: For the 7,369 patients, the mean age was 68.1 years and 98.6% were men. PEG tubes were most commonly places in patients with cerebrovascular disease (18.9%), other organic neurologic disease (28.6%), or head and neck cancer (15.7%). Although the complication rate of the procedure itself was low (4%), because of the severity of their underlying disease, 1,732 patients (23.5%) died during the hospitalization in which the PEG tube was placed. The median survival of the full cohort was 7.5 months. CONCLUSIONS: This study documents the widespread placement of PEG tubes in severely ill patients, half of whom are in the terminal phase of their illness. Further study is needed to determine whether these patients benefit from PEG tube placement in terms of their quality of life and survival.     

Evaluation of percutaneous endoscopic gastrostomy in a university hospital

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) has become a commonly performed procedure to provide nutritional support for chronically ill patients. The aim of this study was to review the safety and results of PEG in a teaching hospital. METHODOLOGY: A retrospective review of 44 patients who underwent PEG procedure. The indication was long-term enteral feeding in patients who were unable to maintain adequate nutrition by mouth with an otherwise functioning gut. The most common primary diagnosis was cerebrovascular accident (17 patients). All patients were unable to swallow. RESULTS: There were six (13.6%) minor complications, and two mortalities from peritonitis (4.5%). The most common complication was gastrostomy site infection, which did not require exchange of the feeding tube. CONCLUSIONS: PEG is a useful means of providing nutrition in patients unable to swallow without the necessity for laparotomy and general anesthesia. This method provides an adequate avenue for enteral alimentation in selected patients and is relatively safe. Careful attention to the technique of insertion is important to prevent leakage or bowel perforation.     

Direct endoscopic percutaneous jejunostomy (EPJ). Clinical results

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