Biomedical subjects
Publications and source records attributed to J L Ponsky.
Feeding gastrostomy is a useful means of providing nutrition in patients unable to swallow. Percutaneous endoscopic gastrostomy provides a means for creating a feeding gastrostomy without the necessity for laparotomy. It adds a new tool to the armamentarium of the therapeutic endoscopist.
A technique has been developed to establish a tube feeding gastrostomy without the need for laparotomy or general anesthesia. To date, it has been used in 53 patients with excellent results. This technique should prove to be the preferred method in the performance of tube feeding gastrostomy.
Sixteen Broviac catheters were inserted in 15 patients ranging from 15 to 61 years of age for purposes other than parenteral nutrition. These patients required long-term intravenous (IV) antibiotic therapy for cystic fibrosis or chemotherapy for malignant neoplasm. There were no major complications. The Broviac catheter provides excellent long-term IV access for total parenteral nutrition. In addition, it may be used very effectively in patients requiring extended IV antibiotic therapy and/or chemotherapy.
Displacement of the gastric remnant in patients with left diaphragmatic eventration may lead to gastric remnant volvulus requiring surgical correction. This results from the strong negative intrathoracic pulling force created by the potential subphrenic space an paradoxical movement of th diaphragm. Unless this strong negative force is first eliminated, gastropexy alone is likely to result in recurrence. Obliteration of the subphrenic space by colonic displacement is an effective and simple way of abolishing this negative subdiaphragmatic pulling force. Once this is achieved, any form of gastropexy will suffice to permanently prevent gastric remnant translocation and volvulus.
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A new technique has been developed to establish a tube feeding gastrostomy without a laparotomy. The procedure is particularly useful in high risk patients because general anesthesia is not usually required. The procedure is simple, safe, and rapid. It has been employed in 12 children (and 19 adults) with minimal morbidity and no mortality.
Lymphangiosarcoma is a fatal complication of postmastectomy lymphedema. The pathogenesis of lymphangiosarcoma in chronic lymphedema is a combination of two factors. First, the edematous region responds in a manner similar to "immunologically privileged sites." Second, because of its anatomic and physiologic properties, it is a favorable site for the development of mutant cell populations for reasons that are not fully understood. As a result, these mutant cells, with their genetically nonidentical antigens, escape recognition by the host's impaired immune surveillance mechanism. The failure to promote a sufficient immune response allows unrestricted tumor growth to take place, resulting in the ultimate death of the patient. Available therapeutic measures are equally unsatisfactory. Emphasis is placed on periodic examination of the lymphedematous extremity, aggressive treatment of established lymphedema and infections, and surgical preservation of lymphatic channels during breast cancer surgery.
A case of portal hypertension secondary to an arteriovenous fistula in a pancreatic tumor is presented. Recurrent gastrointestinal hemorrhage prompted endoscopy which revealed esophageal varices and an abnormal papilla of Vater. Ultrasonography and arteriography were instrumental in demonstrating the nature of the pathological process. In this situation portal hypertension resulted from increased portal venous flow rather than portal obstruction. Correction must include obliteration of systemic arterial to portal venous communication.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Percutaneous endoscopic gastrostomy was introduced in 1980 as an alternative to traditional operative methods for the creation of a feeding gastrostomy. The indications for the procedure are essentially the same as those for traditional gastrostomy and include the inability to swallow secondary to neurological impairment, oropharyngeal neoplasms, and facial trauma. The method is contraindicated in the presence of massive ascites, total esophageal obstruction, coagulation disorders, and sepsis. Several variations on the original technique have been developed, and results with each are comparable. The morbidity and mortality with percutaneous methods has been at least as good as those reported for operative techniques while the cost has been lower and patient acceptance high. In spite of the ease with which gastrostomy may be performed by the percutaneous method, patient selection must be appropriate and details of technique closely followed if results are to remain acceptable.
Endoscopic sphincterotomy has become the undisputed method of choice for removing common bile duct calculi following previous cholecystectomy. This approach has also been applied to selected patients with intact gallbladders deemed unfit for surgery. More recently, endoscopic clearance of the bile duct has been used in concert with laparoscopic cholecystectomy to avoid laparotomy. Modalities available for stone therapy via the endoscope include baskets and balloons, mechanical lithotripters, electrohydraulic lithotripsy probes, and laser energy. In difficult cases stents may be placed to provide drainage in lieu of stone extraction.
Percutaneous endoscopic gastrostomy (PEG) is the preferred method of establishing long-term enteral access for feeding. Many patients requiring PEG are elderly and at risk for complications. Expeditious placement of the gastrostomy tube will minimize complications, but distorted esophageal anatomy can significantly lengthen the procedure. Some endoscopists abandon conventional repeat gastroscopy in difficult cases to accelerate the procedure. The authors describe a reliable method for quick reinsertion of the endoscope which shortens time required for PEG, and may reduce complications.