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Background: American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommend gastrostomy for patients suspected to require enteral access device for 4-6 weeks. Our hypothesis was that traumatic brain injury (TBI) patients undergoing synchronous tracheostomy/gastrostomy (SYNC) compared to tracheostomy first (DELAY) have shorter length of stay (LOS) but higher rates of unnecessary gastrostomy., Methods: Retrospective review of TBI patients requiring tracheostomy in 2017-2022 ​at a Level 1 trauma center was conducted. SYNC and DELAY patients were compared, and CoxPH analysis was performed for LOS., Results: 394 patients were included [mean age: 42 (SD:18); mortality: 9 ​%]. The DELAY group had longer LOS (39 vs 32 days, p ​< ​0.001). There was no significant difference in unnecessary gastrostomy rate between groups (p ​= ​0.1331). In adjusted hazard analysis, SYNC predicted shorter LOS (HR:1.54; 95 ​% CI:1.20-1.98, p ​< ​0.001)., Conclusions: Synchronous gastrostomy was associated with shorter length of stay and similar rates of unnecessary gastrostomy in TBI patients., Competing Interests: Declaration of competing interest The authors declared no potential conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Low grade tumors located in the neck of the pancreas present a unique surgical challenge. Subtotal pancreatectomy results in significant loss of pancreatic gland and function, while pancreaticoduodenectomy may be too aggressive for these lesions. We present a case of a patient with a well differentiated neuroendocrine tumor in the neck of the pancreas who underwent a central pancreatectomy with pancreaticogastrostomy reconstruction. Patient selection and technical aspects of the procedure are described. The decision to perform a central pancreatectomy should not be made lightly as complications are frequent. Careful patient selection is imperative., Competing Interests: Declaration of competing interest The authors have no conflict of interest to report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Laparoscopic gastrostomy tube (GT) placement is a common procedure and frequent cause of morbidity. Some surgeons perform a Seldinger technique (ST), while others perform a modified open technique (MOT). We hypothesized that the modified open technique would result in more complications., Methods: A prospective study of primary GT placed 12/2016-06/2018, ensuring at least 6 months follow up. We assessed any episode of granulation tissue, troublesome leaking, tube dislodgment, and infection requiring antibiotic or drainage., Results: 92 GT were placed, with 56 were placed as modified open (60.9%). 34 children (37.0%) developed granulation tissue, 18 children (19.6%) experienced tube dislodgment, and 6 children (6.5%) developed a site infection, with no difference depending on technique (P = 0.56, 0.29, and 0.76, respectively). Following ST, 2 children developed leakage (5.6%), whereas 15 children (26.8%) had leakage following the MOT (P = 0.01)., Conclusion: MOT resulted in significantly more leaks. Other complications were similar between groups. Surgeons choosing MOT should be mindful of the size of gastrotomy at time of surgery, as this may result in increased complications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: A protocol for laparoscopic gastrostomy placement was implemented which specified perioperative antibiotics, feeding regimens, and discharge criteria. Our hypothesis was that hospital cost could be decreased, whereas at the same time improving or maintaining patient outcomes., Methods: Data were collected on consecutive patients beginning 6 months after implementation of our protocol. We recorded surgeon compliance, patient outcomes (as defined by 30-day NSQIP complication rates), and cost of initial hospitalization, which was then compare to a 6-month historical control period., Results: Our control group n = 26 and protocol group n = 39. Length of stay was shorter in the protocol group (P ≤ .05 by nonparametric analysis). The complication rate was similar in both groups (23% control vs 15% protocol, P = .43). Initial hospital costs were not different. Surgeon compliance to protocol was 82%., Conclusions: A standard protocol is achievable for gastrostomy tube management. After implementation of our protocol, we were able to show a significant decrease in length of stay, whereas maintaining quality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Despite the widespread use of percutaneous endoscopic gastrostomy (PEG) tubes, their placement may be associated with a variety of complications, including gastrocolic fistula., Methods: In total, 48 individuals underwent computed tomography-gastro-colonography (CT-GC)-guided PEG placement. Study end points included success of CT-GC, inability to thread the PEG tube, the eventual tube location, tube adjustments needed, adverse events, operating time, and PEG tube-related infection., Results: A successful CT-GC was achieved in all 48 patients (100%), and we successfully used a standard PEG technique to place the gastrostomy tube in 44 patients (92%). In 4 patients (8%), the laparoscopic-assisted PEG technique was used because the transverse colon became interposed between the abdominal wall and the anterior wall of the stomach. The overall procedure-related minor complication rate was 8%., Conclusion: CT-GC is an optional method for the estimation of intra-abdominal, anatomical orientations that may minimize the risk of complications before PEG placement., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Maintaining sufficient blood flow to the gastric tube is essential to avoid anastomotic leakage after esophageal reconstruction for esophageal cancer. We were able to obtain sufficient blood flow to the tip of the gastric tube by separating the inferior polar branches of the splenic vessels at their origin. By using this procedure, we were able to preserve the junction between the left gastroepiploic vessels and the inferior short gastric vessels without splenectomy. The entire greater omentum also was preserved to use the network between the right and left gastroepiploic vessels. Finally, the anastomotic site was wrapped with the omentum. By using these techniques, the anastomotic site of the gastric tube was well nourished in all patients who underwent esophageal reconstruction for esophageal cancer; anastomotic leakage did not occur., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: A technique combining upper endoscopy with percutaneous transgastric minilaparoscopic instrumentation for the formation of pancreatic cystgastrostomy is safe and effective for the internal drainage of pancreatic pseudocysts., Methods: At a tertiary-care academic medical center, 6 patients with pancreatic pseudocysts with a mean size of 19 cm (range, 16-23 cm) were selected for combined endoscopic and percutaneous transgastric minilaparoscopic (1.7-2 mm) pancreatic cystgastrostomy. All pseudocysts had been followed-up for a minimum of 5 weeks (range, 5-22 wk) and were noted to significantly displace the stomach anteriorly., Results: The mean surgical time was 98 minutes (range, 45-150 min). The mean amount of fluid removed from the pseudocysts was 2167 mL (range, 1600-2600 mL). All ports were removed from the stomach without the need to suture the gastric wall or skin except for 2 gastric serosal sites that were closed with a single intracorporeal stitch. The length of hospital stay averaged 2.2 days (range, 0-6 d). All patients were discharged in good condition, tolerating a regular diet. With a mean follow-up period of 13.4 months (range, 1-30 mo), all patients remain asymptomatic from their pancreatic pseudocysts., Conclusions: The technique of combining upper endoscopy with percutaneous transgastric minilaparoscopic instruments to create a pancreatic cystgastrostomy can be used to apply well-established surgical principals for internal drainage and has the potential to be used for the management of other gastric pathology.

Background: Standard methods of palliative gastrojejunostomy lead to delayed gastric emptying in up to 67% of patients. Partial stomach-partitioning gastrojejunostomy (PSPG) allows for the preferential passage of ingested material into the jejunum while maintaining endoscopic access to the diseased region and obviating the risk of leakage after antrectomy., Methods: A retrospective examination of all patients undergoing PSPG from February 1999 through November 2004 was undertaken. Successful palliative bypass was based on the patient's ability to tolerate a regular diet., Results: Thirty-nine patients underwent PSPG during the study period. All patients had locally advanced or metastatic gastrointestinal tract tumors. Sixteen patients presented with obstructive symptoms. The majority of patients (97%) were tolerating a regular diet at their last follow-up., Conclusions: PSPG is an alternative method of providing palliative bypass and allows for excellent palliation with delayed gastric emptying rates lower than that of standard gastrojejunostomy procedures.

Background: Percutaneous endoscopic gastrostomy is the standard for long-term enteral access. It can provide enteral nutrition or gastrointestinal decompression. Utilization of the gastrostomy for decompression has traditionally been reported in the setting of malignant obstruction. However, decompressive gastrostomy can play a role in the treatment of nonmalignant bowel dysfunction as well., Methods: Over a 2-year period, 20 of 121 percutaneous endoscopic gastrostomies attempted by this surgical endoscopist were for gastrointestinal decompression., Results: Eleven of 18 gastrostomies successfully placed for decompression were for benign conditions. In 5 patients with fistulous disease, the purpose of decompression was to divert the gastrointestinal tract until operative repair. Four of these patients have since undergone definitive surgery., Conclusions: This series presents the successful use of the percutaneous endoscopic gastrostomy for decompression of nonmalignant conditions. In such scenarios, the drainage gastrostomy can be employed as a bridge to future surgery, or as a means of long-term decompression for bowel dysfunction.

Background: Gastrostomies provide reliable long-term enteral access in patients with traumatic brain injuries. The impact of technique of gastrostomy on total hospital cost is not known., Methods: A retrospective analysis of patients who sustained head trauma and required gastrostomies for long-term enteral access between 1 July 1990 and 1 July 1996 was performed., Results: The patients who received percutaneous endoscopic gastrostomies (PEG) were similar to patients who received Stamm gastrostomies (OPEN) with respect to age, injury severity score, mechanism of injury, associated injuries, complication rates, and deaths. Total hospital costs ($ x 10(3)) were lower for patients who had PEGs placed in the intensive care unit (78.2 +/- 37.4) or endoscopy suite (71.9 +/- 37.7) compared with PEGs placed in the operating room (122.4 +/- 75.7) or OPEN gastrostomies (119.8 +/- 65.1)., Conclusions: In head-injured patients, PEGs are a reliable method of obtaining long-term enteral access with a complication rate equivalent to Stamm gastrostomies. If performed in either the intensive care unit or the endoscopy suite, PEGs are associated with significantly reduced total hospital costs.

Background: Management of the pancreatic stump after pancreaticoduodenectomy (PD) is still a matter of debate. Pancreaticojejunostomy (PJ) is used commonly but is associated with a significant incidence of pancreatic leaks. Pancreaticogastrostomy (PG) is an alternative that has been reported to be safer., Methods: The study is a retrospective analysis of all patients having PD for ampullary carcinoma in one surgical unit at All India Institute of Medical Sciences over 18 years, with PG being the only drainage procedure for the pancreatic stump., Results: Among 125 patients having PD for ampullary carcinoma, overall morbidity rate was 28%, mortality rate was 4.8%, with no cases of leakage from the pancreaticogastrostomy., Conclusions: In world literature (including the current series), the leakage rate of PG is 2.5% (14 of 553) with only 2 deaths (2 of 14) due to leakage from PG. Our large experience and these data conclusively prove the safety of pancreaticogastrostomy, which should be the drainage procedure of choice for the pancreatic stump following pancreaticoduodenectomy.

A technique for pancreaticogastrostomy is presented. The technique is a one-layer, invaginated anastomosis of the pancreatic remnant to the posterior gastric wall following a Whipple resection of the pancreatic head. Key steps to achieve a successful anastomosis are described. Using this technique, there have been no pancreatic anastomotic leaks in 29 consecutive patients.

Background: Laparoscopic gastrostomy (lap g-tube) and jejunostomy (lap j-tube) are relatively new procedures that do not require laparotomy. Our aim was to determine the role of laparoscopic feeding tube placement for enteral access and the safety of these techniques., Methods: We reviewed our experience with attempted laparoscopic placement of 93 enteral tubes in 81 patients over a 3-year period. Patients received either a lap g-tube (n = 64), lap j-tube (n = 5), or both lap g/j-tube (n = 12). When enteral access was needed for nutritional support, the choice of lap g-tube or lap j-tube was based on risk of gastroesophageal reflux., Results: The most common underlying conditions requiring tube placement were head and neck cancer (49%), neurologic disorders (19%), and trauma (11%). Mean operative times (minutes) were as follows (mean +/- SD): lap g-tube (39 +/- 7), lap j-tube (63 +/- 10), and lap g/j-tube (85 +/- 13). Lap g-tube placement was successful in 73 (96%) of 76 patients and lap j-tube in all 17 patients. The major complication rate for all tubes was 8% (7 of 93) and included gastrointestinal bleeding, wound infection, and failed placement. Five patients died in the 30-day period following surgery, but none of the deaths was procedure related., Conclusions: Laparoscopic tube placement should be considered for patients in whom endoscopy is not feasible or undesirable or who are undergoing other operative procedures. Lap g-tube and lap j-tube are safe procedures that avoid the potential risk of a laparotomy, and they can be done with a high success rate. This is a valuable approach for patients with head and neck cancer or neurologic disorders and for trauma patients with multiple disease processes.

Background: The Roux stasis syndrome, a syndrome of nausea, vomiting, abdominal pain, and postprandial fullness that follows Roux-en-Y gastrojejunostomy, is thought to result from the jejunal transection performed during the construction of a conventional Roux limb. The purpose of this study was to test a new type of "uncut" Roux limb construction, in which a neuromuscular bridge maintains neuromuscular continuity between the proximal jejunum and the Roux limb, while a jejunojejunostomy provides distal diversion of pancreaticobiliary secretions, Methods: After a distal hemigastrectomy, 5 dogs underwent the uncut Roux operation, while 5 others had a Billroth II reconstruction (controls). Three weeks later, recordings of jejunal myoelectrical activity and assessment of gastric emptying and bile reflux were performed in fully conscious dogs, Results: In the dogs with uncut Roux limbs, jejunal pacesetter potentials propagated aborally across the neuromuscular bridge, although their frequency was slightly slower distal to the bridge (proximal 19.5 +/- 0.7 cpm versus distal 18.8 +/- 1.1 cpm; P < 0.05). No frequency change occurred across the comparable area of jejunum of the controls. Both groups had similar rates of gastric emptying. Only small amounts of bile acids were found in gastric aspirates from dogs with uncut Roux limbs., Conclusions: A new uncut Roux operation eliminated the Roux stasis syndrome by preserving neuromuscular continuity between the proximal jejunum and the Roux limb, and yet provided near-total diversion of bile from the gastric remnant.

Background: The "Roux stasis syndrome" is characterized by symptoms of upper gut stasis following Roux-en-Y gastrojejunostomy (RG). Whether symptoms result from delayed gastric emptying, altered Roux-limb transit, or both has never been settled, partly because of the difficulty of measuring Roux-limb transit. The aim of this study was to develop a model to simultaneously quantitate Roux-limb transit and gastric emptying., Methods: Rats underwent vagotomy and antrectomy with RG or Billroth II reconstruction (B-II). Gastrointestinal transit of a solid meal (Technetium-99m sulfur colloid-labelled egg white) was assessed 0.5, 1, and 1.5 hours postprandial (pp). Transit of a liquid marker (Na51-CrO4 injected through an efferent-limb catheter) was measured at 25 minutes pp., Results: Solid gastric emptying was slower in RG than in B-II rats at 60 and 90 minutes pp. More of the solid meal and of the liquid marker was retained in the Roux limb than the efferent limb of the B-II at all time points (P < 0.05)., Conclusions: In a rodent model, Roux-en-Y gastrojejunostomy is associated with delayed gastric emptying and slowed efferent-limb transit of solids and liquids.

Surgical feeding gastrostomy is attended by a significant morbidity and mortality. The percutaneous endoscopic route is regarded as the best method, but it is not feasible in cases with pharyngoesophageal stenosis. We here describe a new method using laparoscopy. The technique is easy to perform. The patient retains continence, with the abdominal wall muscle acting as a sphincteric mechanism around the gastric tube.

Background: Percutaneous endoscopic gastrostomy (PEG) has been established as a faster and safer procedure than open surgical gastrostomy. It cannot be done, however, for many patients with partially obstructing pharyngeal or esophageal carcinoma, previous gastrectomy, upper abdominal surgery, or bowel distension from distal obstruction., Patients and Methods: We attempted percutaneous radiologic-assisted gastrostomy (RAG) in 231 patients referred for gastrostomy, 38 of whom had a relative contraindication for PEG. The procedure involves passing, under radiologic guidance, an orogastric inflation tube that contains a snare. We used a 5-inch long, 18-gauge needle to transabdominally insert a wire into the stomach, avoiding loops of bowel visualized by air contrast. Retrieving the transabdominal wire by snare allowed retrograde passage of the gastrostomy tube as done in standard PEG., Results: The procedure was successful in 230 of 231 cases, including 37 of the 38 patients with contraindications. We could not gain gastric access in 1 patient with a 75% gastrectomy. Overall, 6 patients developed complications and 1 died. There was no procedure-related morbidity or mortality in the patients with contraindications to PEG who underwent successful RAG. Subsequent laparotomy indicated tube passage through the liver in 2 of these cases and small bowel mesentery in 1 case without clinical problems. We performed a percutaneous jejunostomy in the efferent limb of the gastrojejunostomy in 1 patient with a previous gastrectomy., Conclusion: The snare technique is simpler and faster than the usual radiologic gastropexy technique, and safer than an endoscopic procedure. It has become our procedure of choice for gaining gastric access.

Percutaneous endoscopic gastrostomy (PEG) has become an effective alternative to surgical gastrostomy in patients who require enteral access or gastric decompression. Technical considerations, however, limit the application of PEG in selected patients and those who have contraindications to PEG. Laparoscopic gastrostomy tube placement has been introduced as an alternative to PEG. A technique for laparoscopic gastrostomy tube placement that emphasizes four-point fixation of the anterior gastric wall is presented.

A modified pancreaticogastrostomy without gastrotomy was performed in 46 patients undergoing pancreaticoduodenectomy for malignant or benign disease. Postoperative complications related to the modified pancreaticogastrostomy occurred in one patient (2%). Operative mortality was 4% and was unrelated to the pancreaticogastrostomy itself. During the first postoperative year, four patients died of causes unrelated to the original disease process, and nine patients died of recurrent carcinoma. The remaining 31 patients were alive and well at a mean follow-up of 20 months. Results of postoperative gastroscopy were normal in all patients studied. A modified pancreaticogastrostomy without gastrotomy is a safe and effective procedure for pancreatic reconstruction in pancreaticoduodenectomy.

Thirty-four children with familial dysautonomia (FD) underwent Nissen fundoplication and gastrostomy. The indications for operation were persistent cyclic vomiting that resulted in repeated aspiration pneumonia (94% of the patients), chronic dehydration (82%), failure to thrive (97%), and frequent hospitalizations (76%). There was no operative or early postoperative mortality. Long-term follow-up for up to 12 years was available. Eight patients died during this period from 7 months to 7.5 years postoperatively. In 5 patients (15% of the operated patients), the fundoplication ceased to function 16 months to 5 years postoperatively, which was attributed mainly to repeated severe dysautonomic crises with vigorous retching. Vomiting ceased in 85% of the symptomatic patients; pulmonary deterioration was halted, and the frequency of aspiration pneumonia was reduced in 68%; nutritional improvement was seen in 44%; the hydration status improved in 88%; and the frequency of hospital admissions decreased in 74%. These long-term findings resulted in a significant improvement in the quality of life for the majority of the patients. The absence of operative mortality and the low postoperative morbidity, together with the long-term beneficial results of this surgical procedure, should encourage early surgical intervention in selected FD patients.

Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) are well-accepted procedures for long-term enteral alimentation. PEG has replaced surgical gastrostomy at many institutions because of its safety and ease. This study was undertaken to evaluate the indications for PEG and PEJ, as well as their success rates, complications with special attention to aspiration, and long-term follow-up. We were specifically interested in reviewing the problem of aspiration in patients with PEG and PEJ. A retrospective review of 79 patients at Brooke Army Medical Center over a 3-year period was done. PEG or PEJ was successful in 79 of 81 patients (97%). The most common indications were neurologic disorders in 46 patients (58%) and cancer in 20 (25.3%). Complications other than aspiration occurred in 11 patients (14%). Aspiration occurred in nine patients after PEG or PEJ (11.4%); six patients had experienced aspiration prior to PEG or PEJ. Six patients had a jejunostomy tube placed through the PEG for prevention of aspiration, and three died of continued aspiration. We conclude that aspiration is not prevented by PEJ, continues to be a major problem after PEJ, and becomes manifest for the first time after PEG.

One hundred thirty-six percutaneous endoscopic gastrostomies (PEGs) were placed in 126 patients with head and neck malignancies. PEG was performed by the "push" technique described by Russell. There were 140 PEG attempts, with 136 successful placements (97%). Seven complications occurred related to tube placement (5% of placements). Complications encountered were prolonged ileus in one patient (1%), local skin wound infection in one patient (1%), and early tube dislodgment in five patients (4%). Three patients required laparotomy (2%). There were no episodes of aspiration and no deaths. Patients were followed up for an average of 11 months, with a mean duration of PEG tube placement of 6 1/2 months. Patients continued PEG feedings throughout the postoperative radiotherapy period and until oral intake was satisfactory. Acceptance of PEG feedings has been high. No patient required rehospitalization for nutritional support.

A modified Gauderer-Ponsky technique of percutaneous endoscopic gastrostomy has been described. The major advantage is elimination of a second insertion of the endoscope, as well as unnecessary traversing of the esophagus by snares and strings. The result achieved is equal to what has been achieved with the original technique, but the single-pass technique is more expeditious and less uncomfortable for the patient. In addition, it can easily be modified to insert both draining gastrostomy and feeding jejunostomy tubes at the same time, using only one pass of the endoscope.

A technique for gastrostomy has been described which includes circumferential, staggered interrupted sutures and an omental seal. The technique minimizes gastric necrosis and intraperitoneal leaks.

Percutaneous endoscopic gastrostomy has been shown by many investigators to be a safe, rapid means of gaining access to the gastrointestinal tract. Over a 3 1/2 year period, 155 percutaneous endoscopic gastrostomies were performed. All of the patients had an inability to nourish themselves orally. The technique described by Ponsky et al was used. Preoperative antibiotics were administered to 108 patients, and most of the procedures were performed under local anesthesia. Many of the procedures were performed in association with tracheostomies. There were 17 complications (11 percent), including 2 deaths (1 percent). Comparison of percutaneous endoscopic gastrostomy to operative gastrostomy revealed percutaneous endoscopic gastrostomy to be superior. We believe that percutaneous endoscopic gastrostomy should be considered the procedure of choice for tube gastrostomy.

Percutaneous endoscopic gastrostomy is rapidly becoming the preferred method of long-term enteral access with minimal complications obviating the need for prolonged nasogastric or orogastric intubation. Tracheostomy is the accepted technique for long-term airway control, especially for protection against upper airway secretions and respiratory failure. Over a 14 month period, 73 percutaneous gastrostomies were inserted in 71 patients. Nine patients (12.6 percent) had previously undergone tracheostomy, and 13 patients (18.3 percent) underwent a percutaneous endoscopic gastrostomy immediately after tracheostomy. All procedures were performed under local anesthesia. The concomitant percutaneous endoscopic gastrostomy added little time to the total procedure and was not associated with additional complications. Early experience with percutaneous gastrostomy indicates that a substantial number of patients (30.9 percent in the present study) also required tracheostomy. The tracheostomy and percutaneous endoscopic gastrostomy combination completely frees the nasopharynx of indwelling tubes. Concomitant percutaneous gastrostomy should be considered in patients undergoing tracheostomy.

Two-hundred seventy-seven morbidly obese patients were followed 6 to 48 months through three modifications of gastric partitioning. Technical failures caused poor results in 75 percent of patients in Groups I and II. Group III patients were operated on using a single TA-90 application with three midlateral staples removed. The proximal staple line was reinforced by a row of interrupted 2-0 silk sutures and a circumferential 1-0 silk suture supported with Teflon pledgets around the stoma. This technique effected good or excellent weight loss in 70 percent of the patients. Complications were minimal except for stomal dilatation through the gastroscope required in 22 percent of the patients and staple line disruption despite reinforcing maneuvers in 7 percent. Because of the dilatations and the 7 percent technical failure, I recently adopted the vertical gastroplasty as described by Eckhout and Prinzing [5]. Long-term follow-up by an experienced team consisting of a surgeon, gastroenterologist, dietition, and supportive staff is essential for the continued success of the surgical management of the morbidly obese patient.

In a consecutive, nonrandomized series of 92 patients, esophagogastric anastomosis was performed with a suture technique in 32 patients and with a stapler in 60 patients. Only one anastomotic leak occurred in each group. Stricture later formed in three sutured anastomoses and in eight of the stapled anastomoses. A review of published reports shows anastomotic leak in 3.5 percent of the patients with stapled anastomoses. In patients with sutured anastomoses, leak occurred in approximately 10 percent. The improved results with the stapler do not alter the necessity for meticulous attention to technical detail.

Feeding gastrostomy and jejunostomy provide effective access for long-term enteral nutrition. Traditional operative techniques for the performance of these procedures requires laparotomy and often, general anesthesia. This report describes our experience with two relatively new methods, percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy. Results of percutaneous gastrostomy and jejunostomy to date in 323 cases include a morbidity of 5.9 percent and a 0.3 percent operative mortality. Percutaneous endoscopic gastrostomy and jejunostomy should become the procedures of choice for the establishment of enteral access in patients requiring long-term enteral alimentation.

The use of autosuture staplers in intraabdominal surgery has become an accepted procedure for simplifying gastrointestinal surgery. Described in this report is a simple method of correcting unrelenting gastric obstruction that may occur after gastric partitioning for morbid obesity by utilizing the autosuture model EEA stapler to reestablish gastric continuity.

Repeated esophageal dilatation for chronic strictures secondary to corrosive burns or anastomotic scarring is commonly performed by the retrograde technic in children. This requires the presence of an indwelling string, tied in a circle, entering the nose, and exiting the gastrostomy site. Long-term presence of this string frequently leads to nasal and gastrostomy excoriations and resultant patient discomfort. We advocate and describe a technic using a piece of Silastic tubing as an alternative to the indwelling string. This has met with increased patient acceptance and comfort as compared with the previous "heavysilk" or other "string" materials.

Although esophageal reflux of gastrostomy feeds is an uncommon problem, severe pulmonary complications can arise. If implementation in an upright position and use of continuous infusion does not prevent reflux, an alternative method of providing adequate nutrition must be used. This nonoperative technique of converting a tube gastrostomy to a feeding jejunostomy is simple to perform, atraumatic and extremely useful.

We have reported our experience with pancreatoduodenectomy with preservation of the pylorus performed in 37 patients for the treatment of chronic pancreatitis and its complications. The remaining pancreatic tail duct was occluded in 12 patients without anastomosis. Eight complications were observed and reoperation was necessary in two patients. Three complications and one reoperation occurred in the 25 patients who underwent pancreatogastrostomy. There was no operative mortality in the 37 patients. Six to 30 months postoperatively, 23 patients were free of complaints, the average weight gain was 7.6 kg, and so far no marginal ulcers have developed. Technically, pancreatogastrostomy is easy and complications may be identified early. According to our results, this type of anastomosis is the most favorable so far and is particularly suitable for the significant reduction of complications and deaths related to partial pancreatoduodenectomy.

A refined endoscopically controlled percutaneous tube gastrostomy has been described in detail, and the experience gained in 28 patients has been reported herein. A majority of the patients had severe underlying neurologic disorders, malignancy of the oral pharynx or esophagus or chronic intestinal obstruction due to advanced malignancy. The three groups of patients were analyzed regarding mortality and morbidity. Three minor complications occurred in the entire group, and three in-hospital deaths occurred which were unrelated to the tube. In addition, four other patients died from their underlying disease several months after discharge from the hospital. Analysis of this technique has shown it to be safe, easy to perform, and acceptable to the patients and supporting personnel. A cost analysis showed significant savings when this technique was utilized instead of operative gastrostomy.

This technique of combined gastrojejunostomy and cholecystojejunostomy utilizing gastrointestinal staplers provides a quick, simple, safe, and effective means for palliation of biliary and duodenal obstruction occurring in patients with unresectable carcinoma of the head of the pancreas. Use of a common loop of jejunum for both biliary and gastric bypass avoids the complexities of other reported methods.

Standard tube feeding gastrostomy is associated with a myriad of problems among which leakage of gastric contents is the most serious. Over the years many methods of creating tubeless gastrostomy have been unsuccessful because of the extent of surgery required and the persistent leakage of gastric fluids. By using gastrointestinal staplers to create a gastric tube and by incorporating a reverse intussusception valve at its base, we created a continent tubeless feeding gastrostomy in 23 patients aged 10 to 81 years. Eight had head injuries, 12 had cerebrovascular strokes, and 3 had head and neck disorders leading to aphagopraxia. Twelve of the procedures were performed with local anesthesia and the remainder with general anesthesia. The GIA stapler was used to create a 5 cm gastric tube after which circumferential stitches were placed to intussuscept 2 cm of the tube into the stomach to create a valve. A 1 cm stoma was created at skin level. Operative time was 47 to 90 minutes and there were no operative deaths or complications. Stomal necrosis occurred in two patients so they were converted to a standard tube gastrostomy by leaving a Foley catheter in place. After 16 months of follow-up, one stricture developed at 4 months and two were electively closed under local anesthesia. None is incontinent. The tubeless continent feeding gastrostomy is convenient for both patients and nursing staff and should replace the standard feeding gastrostomy when long-term nutritional support is needed.

In this series, 90.6 percent of the patients who had revision of their original gastric bypass for failure to lose satisfactory weight had a significant additional weight loss. The postoperative complication rate was 21.4 percent, and there were no postoperative deaths. After proper evaluation of the patient, revision of a gastric bypass may be undertaken with expectation of a satisfactory result and an acceptable rate of complications.

Feeding gastrostomy can be troublesome, inconvenient and painful to the patient, especially if the catheter is redundant, thereby causing deformity of the opening ad leakage of gastric juice and food around the tube. A skin level permanent feeding gastrostomy was fashioned in four patients with neurologic disease. The mushroom catheter was introduced into the stomach, secured by a purse-string suture and fastened to the abdominal wall by a metal hub. The hub was fitted to a syringe by an adaptor for feeding purposes and was covered between meals. The device is simple to construct, safe, spill-proof and easily adopted by the patients.

In a 2 year period, 60 consecutive feeding enterostomies were placed in malnourished patients. The major complication rate was 1.6 percent. Total complications were 8 percent. Thirty day mortality was 13 percent. Nearly all patients were given isosmotic nonelemental diets. The incidence of diarrhea was 2 percent with this regimen. Four of five patients given elemental diets had diarrhea. Serum albumin levels increased significantly from a preoperative mean of 2.75 to 3.03 g/dl. Best overall results were achieved in patients undergoing upper gastrointestinal surgery or pancreatobilary procedures for nonmalignant lesions. More than $60,000 was saved in 2 years by substituting isosmotic formulas for elemental ones. It appears that many patients are given elemental formulas who do not actually require them. Since isosmotic solutions will not infuse through needle catheters, we advocate placing 12 F. catheters and have documented the safety of this change. By using these larger catheters, the surgeon will not lose the option of using isosmotic preparations. We have shown these preparations to be nutritionally effective with a marked lessening of diarrhea and a cost approximately a sixth of that of elemental products.

Percutaneous endoscopic gastrostomy in 23 patients was compared with operative gastrostomy in 25 patients in a prospective randomized fashion. Procedure-related morbidity occurred in five patients in each group. Tube feeding was initiated within 48 hours in 96 percent of the percutaneous endoscopic gastrostomy group and in 82 percent of the operative gastrostomy group (p less than 0.1). There were no deaths in the percutaneous endoscopic gastrostomy group, but two patients in the operative gastrostomy group died within 30 days of operation (p less than 0.1). Neither death appeared directly attributable to gastrostomy placement. The cost for a percutaneous endoscopic gastrostomy was less than that of an operative gastrostomy ($757 versus $1,446); however, if endoscopically placed tubes required replacement, as was seen in six patients, total percutaneous endoscopic gastrostomy cost increased to $1,198. Definitive conclusions regarding the superiority of one technique over the other cannot be drawn from this data. Trends favoring the use of percutaneous endoscopic gastrostomy merit continued study.

A technic of esophagogastrostomy is described for constructing an end-to-side, back-to-front anastomosis using stapling devices. Twelve consecutive cases are reported with no deaths and no anastomotic leaks.

Nasogastric suction is usually employed for gastric decompression because of its ease of application. However, it is associated with greater discomfort and more complications than temporary gastrostomy, especially in the young, the elderly, those who smoke, and those in whom prolonged decompression is necessary.

Seven hundred patients at a community hospital underwent gastric bypass for morbid obesity. Postoperative complications developed in 14.9 percent. The incidence of major complications was particularly low. Both weight loss and the percentage of excess weight lost in the postoperative period were very satisfactory. The criteria for selecting patients for gastric bypass are presented and preoperative evaluation is reviewed. Major technical points in the operation are stressed. Roux-Y reconstruction of gastrointestinal continuity is the preferred technique in our hands. This report reemphasizes the safety and efficacy of gastric bypass as a treatment for morbid obesity. When careful patient selection, preoperative evaluation and operative techniques are combined. excellent results can be expected in the community hospital.

We used an anchoring device to secure the stomach to the abdominal wall when performing percutaneous endoscopic gastrostomy. This method avoids many of the disadvantages of the technique currently used. The procedure is easy to perform, allows insertion of a proper size of gastrostomy tube, ensures fixation of the stomach to the abdominal wall, and facilitates changing of the feeding tube.