Percutaneous endoscopıc gastrostomy: results of 50 cases

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY:

RESULTS OF 50 CASES

Rasim Gençosm anoğlu, M .D .* / O rhan Şad, M .D .* / Erol A vşar, M .D .**

Hülya Ö v e r H am zao ğ lu , M .D .** / Osman Ö zd o ğ an , M .D .**

Cem K alaycı, M .D .** / N urdan Tözün, M .D .**

* S u r g ic a l U n it, I n s t i t u t e o f G a s tr o e n te r o lo g y , M a r m a r a U n iv e r s ity , I s t a n b u l, T u r k e y . * * S u b - d e p a r t m e n t o f G a s tr o e n te r o lo g y , D e p a r t m e n t o f I n t e r n a l M e d ic in e , S c h o o l o f

M e d ic in e , M a r m a r a U n iv e r s ity , I s t a n b u l, T u rk e y .

ABSTRACT

Objective:

To

present

the

results

of

percutaneous endoscopic gastrostomy (PEG),

which has been an alternative method to

conventional surgical gastrostomy for the last 20

years. PEG is one of the gastrostomy methods

used for patients unable to take food orally.

Patients and Methods: Between January 1996

and July 2000, 50 consecutive patients in need of

enteral feeding for more than four weeks and

undergoing PEG with 20 Fr tube by pull

technique were retrospectively evaluated in

terms of indication, complications, durability of

tube, and mortality. The assessment of wound

infection was conducted according to the criteria

developed by Jain and Shapiro.

Results: A PEG was successfully positioned in

50 of the 52 referred patients (96%). Of the 50

cases 26 (52%) were men and 24 (48%) women

with the median age of 63 years (range 2 to 88

years). Indications for PEG placement were

cerebrovascular accident in 20, brain tumors in

11, subarachnoidal hemorrhage in 9, several

neurologic disorders in 5 (2 infections, 2

Parkinson’s disease, 1 Alzheimer’s disease),

head injury in 3, iatrogenic in 1 (esophago-

cutaneous fistula), and hypoxic encephalopathy

in 1. The durability of the tube was a median of

217.5 days (range 9 to 1669 days). In 9 patients

the tube was removed with a median of 158.5

days (range 35 to 427 days) and then oral

feeding was started. The tube was changed

in 7 patients who had tube dysfunction

because of clogging, porosity or fracture with a

median interval of 122 days (range 35 to 1252

days). Of these patients, 2 needed replacement

tube insertion twice and 3 three times. Two (4%)

cases had minor complications (wound infection)

during the the first 30 days. During total follow­

up, two wound infections, one buried bumper

syndrome, and one aspiration pneumonia

developed. The last patient underwent JETPEG

which was performed by introducing a 10 Fr

jejunal tube through the 20 Fr PEG opening.

Total follow-up was 41.8 patient-years with a

procedure-related mortality

of 0%,

30-day

mortality of 8% (4/50), and overall mortality of

32% (16/50). The mortality rate was 63.6% (7/11)

for patients who had brain tumor and 23% (9/39)

for the rest.

Conclusion: PEG is a minimally invasive

gastrostomy method with low morbidity and

mortality rates, easy to follow-up, easy to replace

when clogged.

K ey

W o rd s :

Percutaneous endoscopic

gastrostomy, Enteral feeding.

( A c c e p t e d 2 1 A u g u s t, 2 0 0 0 ) M a r m a r a M e d ic a l J o u r n a l 2 0 0 0 ; 1 3 ( 4 ) : 2 1 2 - 2 1 8

Percutaneous endoscopic gastrostomy: Results of 50 cases

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) is

an alternative to traditional surgical methods for

creating a feeding gastrostomy. Since its first

description by Gauderer and Ponsky (1) in 1980,

PEG has become a widely accepted means of

providing enteral alimentation. The most

common indication for PEG tube placement is to

provide access to a functioning gastrointestinal

tract for long-term enteral nutrition (2). This term

is usually accepted as a minimum of 4 weeks (3).

Patients in this group often have neurologic

disorders and neoplasms of the head, neck, and

esophagus. Other applications of PEG include

decompression in patients with malignant

carcinomatosis and intestinal obstruction,

treatment of gastric volvulus, recirculation of bile,

accessing the stomach for endoscopic or surgical

instrumentation, administration of unpalatable

medications to pediatric patients, and provision

of nutrition to patients in various hypercatabolic

states (such as those with Crohn's disease and

severe burns) (2,4,5). Absolute contraindications

to PEG tube placement include a limited life

expectancy, inability to pass the endoscope

through the esophagus, and peritonitis (6,7).

Relative contraindications include massive

ascites, coagulopathy, portal hypertension,

peritoneal dialysis, hepatomegaly, large hiatal

hernia, prior subtotal gastrectomy, morbid

obesity, anorexia nervosa, and infiltrative or

malignant disorders of the stomach (2,7-9).

PEG can be performed by the pull method, the

introducer method, or the push method (2).

However, the “pull method” has changed little

since its original description and remains the

most popular method of PEG tube placement

(1,2,10). Major complications of PEG include

peritonitis, hemorrhage, aspiration, peristomal

wound infection, buried bumper syndrome, and

gastrocolic fistula (2,11,12). The morbidity rate is

given as approximately 3% in large series

(13,14). These complications are uncommon, but

when they occur they result in death in 25% of

the patients. One of the most common

complications of PEG is aspiration especially in

patients who have preexisting gastro-esophageal

reflux disease. JETPEG (introducing a thinner

jejunal tube distally to Treitz’s ligament through

the PEG) has recently become more popularized

to avoid this complication (3,4,15).

PATIENTS AND METHODS

Patients:

Between January 1996 and July 2000, 52

patients were referred from Marmara University

Institute of Neurologic Sciences to our

endoscopy unit for the placement of a PEG tube.

Of the 52 patients, a PEG was successfully

positioned in 50. Patients, or in the case of

complete incapacitation, their legally responsible

relatives, were informed about the possibilities

and risks associated with PEG and written

informed consent was obtained from each of

them.

The PEG Technique:

All patients received antibiotic prophylaxis, 1 g

ceftriaxone (Rocephin®, Roche) intravenously,

30 minutes before PEG placement and weight-

and age-adapted premedication (up to 100 mg

pethidine, or 5 mg midazolam). Local disinfection

of the oropharyngeal cavity was not done. The

patients’ abdomen was thoroughly disinfected

from the costal margin to the navel.

PEG placement was applied using the “pull

method” (16). After preparation of the abdomen,

a complete upper gastrointestinal endoscopy

was performed. The stomach was then

insufflated, resulting in close opposition of the

stomach to the abdominal wall. A local anesthetic

(Jetocaine®, Adeka) was infiltrated into the skin

in the midepigastrium where there was maximum

transillumination and indentation of the gastric

lumen by an examining finger. After performing

a 5 mm skin incision, a 16-gauge angiocath was

inserted into the gastric lumen under direct

endoscopic observation. A guidewire was

threaded through the angiocath and grasped

with a snare. After the endoscope and the

snare grasping the guidewire were withdrawn

from the mouth at the same time, the tapered end

of the gastrostomy tube was secured to the

guidewire and the PEG tube guidewire unit was

placed in the stomach by pulling the end of

the guidewire exiting the skin incision. The

internal bumper remained in the gastric lumen.

The external bumper was subsequently used

to secure the PEG tube in place. A control

endoscopy was done to be sure of the success of

the procedure and to check for any

complications.

Rasim Gençosmanoglu, et al

After PEG tube placement, both the patient and

the family members as well were instructed by

nurses concerning the system of nutrition and the

use of the feeding pump. Patients were allowed

to return home once they had mastered the

implementation of the system. Nutrition was

initiated 4-24 hours after complication-free PEG

placement, and the level was increased

continuously over several days up to individually

adequate feeding rate, in order to minimize the

side effects of tube-based nutrition.

Table III. Indications for PEG tube placement.

Cerebrovascular accident 20

Brain tumor 11

Subarachnoidal hemorrhage 9

Miscallaneous neurologic disorders 5

Infectious 2

Parkinson’s disease 2

Alzheimer's disease 1

Head injury 3

Iatrogenic (esophago-cutaneous fistula) 1

Hypoxic encephalopathy 1

Follow-up and Evaluation of Peristomal

Wound Infection:

All the patients were followed-up daily for the first

week, then weekly for the first month, and

monthly thereafter. Discharged patients were

also followed-up monthly by telephone inquiries.

For the first 7 days after PEG tube placement,

the wound dressing at the site of puncture was

renewed daily by the same team and checked for

possible infection. The assessment of wound

infection was conducted on a daily basis

according to the criteria developed by Jain et al.

(17) and Shapiro et al. (18), as shown in Table I.

Patients were defined as having minor or major

complications according to their daily score

(Table II).

RESULTS

In 2 of 52 patients (4%), PEG placement was not

possible due to failure to achieve transillumination

0 1 2 3 4

Erythema no <5 mm 6-10 mm 11-15 mm >15 mm Induration no <10 mm 11-15 mm >15 mm

Exudate no serous sero-sanguineous sanguineous purulent

Table II. Classification of Infectious complications according to the patients' dally score.

Dally score Grade I less then 2 Grade II between 3 and 8

Grade III over 8 or manifest purulent exudate Grade IV Peritonitis or had to have PEG removed Grade l-ll-lll minor complication

Grade IV major complication

or “safe tract” technique explained below. Of the

50 cases, 26 (52%) were men, 24 (48%) women

with the median age of 63 years (range 2 to 88

years). The indications for PEG tube placement

are shown in Table III. The durability of the tube

was a median of 217.5 days (range 9 to 1669

days). In 9 (18%) patients the tube was removed

with a median of 158.5 days (range 35 to 427

days) because they were able to return to oral

feeding. The tubes were changed in 7 (14%)

patients who had tube dysfunction due to

clogging, porosity or fracture with a median

interval of 122 days (range 35 to 1252 days). Of

those patients, 2 needed replacement tube

insertion

twice,

3

three

times.

Minor

complications (wound infection) developed in 2

(4%) patients during first 30 days. Neither

hemorrhage nor major complication was seen in

all patients. During total follow-up 4 (8%)

complications (2 wound infections, 1 buried

bumper syndrome, and 1 aspiration pneumonia)

developed. The patients who had grade ll-lll

wound infection were successfully treated by

close wound care and antibiotics. Buried bumper

syndrome was recognized incidentally when the

patient underwent tube replacement because of

porosity and clogging. Endoscopic finding was

mucosal dimpling to non-visualization of the

internal bolster. The problem was solved by

dissecting the buried appliance from the

abdominal wall under local anesthesia and a 15

Fr replacement tube inserted into the stomach

from the same site. The patient who had

aspiration pneumonia underwent JETPEG for the

solution of the problem. JETPEG was performed

by introducing a 10 Fr jejunal tube through the 20

Fr PEG tube, and placing it distally to the Treitz’s

ligament. Total follow-up was 41.8 patient-years.

Procedure related mortality was 0%, 30-day

mortality 8% (4/50), and overall mortality 32%

Percutaneous endoscopic gastrostomy: Results of 50 cases

(16/50). The mortality rate was 63.6% (7/11) for

patients who had brain tumors and 23% (9/39)

for the rest.

D IS C U S S IO N

Nutritional support can be quite challenging. The

advantages of enteral nutrition over parenteral

nutrition are well known and include lower cost,

increased safety, better patient tolerance,

maintenance of structural gastrointestinal

integrity, and increased resistance against

infection (19,20). Several advantages of the

percutaneous approach compared to operative

gastrostomy are the use of local anesthesia,

decreased procedure time, ability to perform the

procedure in the endoscopy suite, decreased

cost and earlier feeding after placement (3,21).

PEG for enteral nutrition has become widespread

and offers distinct advantages with regard to cost

and a low level of complications compared with

parenteral nutrition (22,23). PEG proved to be a

very safe and reliable method in the scope of

literature. On the other hand, short- and long­

term prospective studies have demonstrated the

superiority of a PEG over nasogastric feeding

tubes in patients with dysphagia due to chronic

neurologic disease (3,24-27).

The performance of a full diagnostic upper

endoscopy is imperative before PEG tube

placement (2). Patients scheduled for PEG tube

placement may have endoscopic findings, such

as peptic ulcer disease and gastric outlet

obstruction that ultimately lead to major

modifications in management or abandonment of

the procedure. Wolfsen et al. (28) gave this rate

as high as 36%. However, we did not find such

endoscopic

findings

before

starting

the

procedure in our patients. Although it has been

suggested that if a point of resistance is felt

between the 3rd and 6th cm marking on the PEG

tube or if the internal bumper can be appreciated

by finger palpation of the abdominal wall, repeat

endoscopy is not necessary; we preferred to

perform it in order to avoid any suspicion in the

endoscopist's mind (29,30). Several of the early

papers describe transillumination of the stomach

prior to gastric puncture as being integral to the

procedure (21,31). Larson et al. (32) describe a

failure to transilluminate the stomach as being an

absolute contraindication to PEG tube insertion.

However, it became a relative contraindication

with pioneering the “safe tract technique” by

Foutch et al. (33) and verifying in a retrospective

series by Stewart and Hagan (34). When

transillumination fails, we try the safe tract

technique with gastric mucosal indentation which

can be achieved by simple palpation, and then

introduce 16-gauge angiocath into the stomach.

This gives the safe way to gastric puncture.

However, in our series, a PEG tube could not be

positioned in two patients, even though both

transillumination and the safe tract technique

were used. In such circumstances, the other

gastrostomy methods should be chosen instead

of insisting on completion of the procedure.

The time interval between the PEG tube

placement and feeding initiation is controversial.

Some authors recommend 12-24 hours before

initiating the PEG feeding, whereas others prefer

4 hours of rest after PEG tube placement (2,22).

In a randomized prospective trial of early versus

delayed feeding after PEG, it has been

suggested that early initiation of PEG feeding is

safe, well tolerated, and reduces cost by

decreasing hospital stay (35). We allowed to

feeding 4-24 hours after PEG placement.

Antibiotic prophylaxis is recommended as a

general measure in PEG (22). It has been shown

that antibiotic prophylaxis significantly reduces

the risk of peristomal wound infection associated

with PEG insertion (22). Dormann et al. (36) have

shown that a single dose of ceftriaxone

administered

30

minutes

before

PEG

significantly reduces local and systemic infective

complications. We preferred ceftriaxone as a

prophylactic antibiotic to avoid infectious

complications. The wound infection rate of the

present study was as low as 4% when compared

to 5-30% of the studies in the literature (2,36).

Buried bumper syndrome occurs when excessive

traction is applied to the PEG tube for an

extended period. This results in ischemic

necrosis of the gastric mucosa and migration of

the internal bolster into the gastric or abdominal

wall. It usually becomes apparent after 4 months

of use (2). This complication developed in one

case in our series, almost one year after the PEG

tube placement. Treatment requires dissection of

the buried appliance from the abdominal wall,

and the same site can be used for placement of

Rasim Genposmanoglu, et at

a second PEG or replacement tube. To prevent

buried bumper syndrome, it is advisable to allow

for an additional 1.5 cm between the external

bumper of the PEG tube and the skin to minimize

the risk of pressure necrosis (2).

Patients with gastroparesis and gastric atony, for

instance neurosurgical trauma or with gastric

outlet obstructions, are at risk of aspiration.

Consistently, factors such as a history of

aspiration (pneumonia), reflux esophagitis, age

older than 70 years, absent swallowing, gag and

cough reflexes and cerebrovascular accident

emerge from published data as factors

predisposing to aspiration (37,38). Despite many

improvements in tube design and size, a

tremendous controversy exists as to the use of a

JETPEG (39). Opponents argue that the

associated mortality and morbidity of a JETPEG

tube together with the inability to protect against

pulmonary complications and the high incidence

of jejunal tube failure make its use unjustifiable

(40,41). Those who advocated intestinal feeding

have observed a substantial reduction in

aspiration pneumonia and have accepted a high

catheter failure (42). However, it has been shown

in a recent study that JETPEG may reduce the

aspiration risk in the compliant high-risk patients

and

those

with

ongoing

or

previously

documented aspiration (3). In the same study,

the catheter failure rate was 26.8% during

extended follow-up, which was significantly lower

than the reported 53% (3,40). In our series, we

performed a JETPEG in one patient who had

developed aspiration pneumonia during follow­

up.

To summarize, during the 20 years since its

introduction, PEG has remained the benchmark

for long-term enteral alimentation against which

all other such innovative methods must be

measured. JETPEG should be reserved for well-

selected patients at risk of aspiration.

REFERENCES

3. M a th u s -V lie g e n LMH, H o n in g H. P e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y a n d g a s tro je ju n o s to m y : a c r itic a l re a p p ra is a l o f p a tie n t s e le c tio n , tu b e fu n c tio n a n d th e fe a s ib ility o f n u tr itio n a l s u p p o r t d u r in g e x te n d e d fo llo w -u p . G a s tro in te s t E n d o s c 19 9 9 :5 0 :7 4 6 -7 5 4 . 4. S c h e id b a c h H, P lo rb a c h T, G r o it l fl, H o h e n b e rg e r W. P e rc u ta n e o u s e n d o s c o p ic g a s tr o s to m y / je ju n o s t o m y (PEG /PEJ) f o r d e c o m p re s s io n in th e u p p e r g a s tr o in te s tin a l tra c t. I n it ia l e x p e r ie n c e w ith p a llia tiv e tr e a tm e n t o f g a s tr o in te s tin a l o b s tr u c tio n in t e r m in a lly i l l p a tie n ts w ith a d v a n c e d c a rc in o m a s . S u rq E n d o s c 1 9 9 9 :1 3 : 1 1 0 3 - 11 0 5 . 5. S h e rid a n R, S c h u lz J, Ryan C, A c k ro y d E, B a s h a G, T o m p k in s R. P e rc u ta n e o u s e n d o s c o p ic g a s tr o s to m y in b u rn p a tie n ts . S u rg E n d o s c 1 9 9 9 ;1 3 :4 0 1 -4 0 2 . 6. G u tt Cn, H e ld S, P a o lu c c i V. e t al. E x p e rie n c e s w ith p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y . W o rld J S urg 19 9 6 ;2 0 : 1 0 0 6 -1 0 0 9 . 7. M a rk s JM , P o n s k y JL. A c c e s s ro u te s f o r e n te r a l n u t r it io n . G a s tro e n te ro lo g is t. 1 9 9 5 :3 :1 3 0 -1 3 9 .

8. S te lla to TA. E x p a n d e d a p p lic a tio n s o f p e r c u ta n e o u s e n d o s c o p ic g a s tr o s to m y . G a s tro in te s t C lin N A m 1 9 9 2 ;2 :2 4 9 -2 5 7 . 9. S a w y e r AM, G h o s h S, E a s tw o o d MA.

S a tis fa c to ry o u tc o m e o f p e r c u ta n e o u s e n d o s c o p ic g a s tro s to m y in tw o p a tie n ts w ith c ir r h o s is a n d p o r t a l h y p e r te n s io n . A m J G a s tro e n te ro l 1 9 9 5 ;9 0 :8 2 6 -8 2 8 .

10. A k k e rs d ijk WL, van B e rg e ijk JD , van E g m o n d T, e t a l. P e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y (PEG): c o m p a ris o n o f p u s h a n d p u ll m e th o d s a n d e v a lu a tio n o f a n tib io tic p ro p h y la x is . E n d o s c o p y 19 9 5 ;2 7 : 3 1 3 - 3 16. 11. Y a m a z a k i T, S a k a i Y, H a ta k e y a m a R, H o s h iy a m a Y. C o lo c u ta n e o u s fis tu la a fte r p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y in a re m n a n t s to m a c h . S u rg E n d o s c 19 9 9 ; 13 :2 8 0 - 2 8 2 .

12. S c h a p iro GD, E d m u n d o w ic z SA. C o m p lic a tio n s o f p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y . G a s tro in te s t E n d o s c C lin H A m 1 9 9 6 ;6 :4 0 9 - 4 2 2 . 13. K o h li H, B lo c h R. P e rc u ta n e o u s e n d o s c o p ic g a s tr o s to m y : a c o m m u n it y h o s p ita l e x p e rie n c e . A m J S u rg 1 9 9 5 ;6 1 :1 9 1 -1 9 4 . 14. M ille r RE, C a s tle m a n B, L a c q u a EJ, e t al.

P e rc u ta n e o u s e n d o s c o p ic g a s tr o s to m y : re s u lts in 3 1 6 p a tie n ts a n d r e v ie w o f lite ra tu re . S u rg E n d o s c 1 9 8 9 ;3 :1 8 6 -1 9 0 .

Percutaneous endoscopic gastrostomy: Results of 50 cases

1 7. J a in HR, L a rs o n DE, S c h ro e d e r li, e t al. A n t ib io t ic p r o p h y la x is f o r p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y . A n n In te rn M ed

1 9 8 7 ;1 0 7 :8 2 4 -8 2 8 .

18. S h a p iro M, M u n o z 7,A, T ager ID, e t al. Risk fa c to rs f o r in fe c tio n a t th e o p e ra tiv e s ite a fte r a b d o m in a l o r v a g in a l h y s te re c to m y . Pi E ngl J M e d 1 9 8 2 ;3 0 7 :1 6 6 1 -1 6 6 6 .

19. L ig h t VL, S le za k FA, P o rte r JA, G erson LW, M c C o rd G. P re d ic tiv e fa c to rs f o r e a rly m o r t a lit y a f t e r p e r c u ta n e o u s e n d o s c o p ic g a s tr o s to m y . G a s tro in te s t E n d o s c 1 9 9 5 ;4 2 :3 3 0 -3 3 5 . 2 0 . M c A rd le AH, P a lm a so n C, M o re n c y l, D row n RA. A ra tio n a le f o r e n te ra l fe e d in g as th e p r e f e r a b le r o u t e f o r h y p e r a lim e n ta tio n . S u rg e ry 1 9 8 1 ;9 0 :6 1 6 -6 2 3 . 2 1 . R u sse l TR, D ro tm a n M, H o rn s F. P e rc u ta n e o u s g a s tro s to m y . A n e w s im p lifie d a n d c o st- e ff e c tiv e te c h n iq u e . A m J S u rg 1 9 8 4 ; 1 4 8 :1 3 2 -1 3 7 .

2 2 . G o s s n e r L, K e y m lin g J, H ahn EG, E ll C. A n t ib io t ic p r o p h y la x is in p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y (PEG): A p ro s p e c tiv e ra n d o m iz e d c lin ic a l tr ia l. E n d o s c o p y

1 9 9 9 ,3 1 :1 1 9 -1 2 4 .

2 3 . H e y m s fie ld SB, B e th e l RA, A n s le y JD. E n te ra l h y p e ra lim e n ta tio n : an a lte rn a tiv e to c e n tra l v e n o u s h y p e ra lim e n ta tio n . A n n In te rn M ed

1 9 7 9 ;9 0 :6 3 -7 1 .

2 4 . P a rk R11R, A llis o n MC, L a ry J, e t al. R a n d o m is e d c o m p a r is o n o f p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y a n d n a s o g a s tric tu b e fe e d in g in p a tie n ts w ith p e rs is tin g n e u ro lo g ic a l d ysp h a g ia . BM J 19 9 2 ; 3 0 4 : 14 0 6 -

1 4 09.

2 5 . W icks C, G im b s o n A, V lavianas P, e t al. A s s e s s m e n t o f th e p e rc u ta n e o u s e n d o s c o p ic g a s tr o s to m y fe e d in g tu b e as p a r t o f an in te g ra te d a p p ro a c h to e n te ra l fe e d in g . G ut

1 9 9 2 ;3 3 :6 1 3 -6 1 6 .

2 6 . P anas MZ, R e illy H, M o ra n A, e t al. P e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y in a g e n e ra l h o s p ita l: p ro s p e c tiv e e v a lu a tio n o f in d ic a tio n s , o u tc o m e , a n d ra n d o m iz e d c o m p a r is o n o f th e tu b e d e s ig n s . G u t

1 9 9 4 ;3 5 :1 5 5 1 -1 5 5 6 .

2 7 . H o rto n B, H o m e r-W a rd M, D o n n e lly MT, L ong RG, H o lm e s GET. A ra n d o m iz e d p ro s p e c tiv e c o m p a r is o n o f p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y a n d n a s o g a s tric tu b e fe e d in g a ft e r a c u te d y s p h a g ic s tro k e . BM J

1 9 9 6 ;3 1 2 :1 3 -1 6 .

2 8 . W olfsen HC, R o z a re k RA, B a ll TJ. Value o f u p p e r e n d o s c o p y p re c e d in g p e rc u ta n e o u s g a s tro s to m y . A m J G a s tro e n te ro l 1 9 9 0 ;8 5 :2 4 9 -2 5 1 . 2 9 . A rs e n b e rg J, C o h e n L, Lew is BL. M a rke d e n d o s c o p ic g a s tro s to m y tu b e s p e rm it one- p a ss P o n sky te c h n iq u e . G a s tro in te s t E n d o sc 1 9 9 1 ;3 7 :5 5 2 -5 5 3 . 3 0 . S a rto rl S, T re v is a n i L, H ie lse n I. P e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y p la c e m e n t u sin g th e p u ll-th ro u g h o r p u s h -th ro u g h te c h n iq u e s : is th e s e c o n d p a ss o f th e e n d o s c o p e n e ce ssa ry? E n d o s c o p y 1 9 9 6 :2 8 :6 8 6 -6 8 8 .

3 1. S tro d e I WE, L e m m e r J, E c k h a u s e r F. E arly e x p e rie n c e w ith e n d o s c o p ic p e rc u ta n e o u s g a s tro s to m y . A rc h S urg 1 9 8 3 ; 1 1 8 :4 4 9 -4 5 1 . 3 2 . L a rso n DE, B u rto n DD, S c h ro e d e r RW, e t al.

P e rc u ta n e o u s e n d o s c o p ic g a s tro e n te ro s to m y . In d ic a tio n s , s u c c e s s , c o m p lic a tio n s a n d m o r ta lit y in 3 1 4 c o n s e c u tiv e p a tie n ts . G a s tro e n te ro lo g y 1 9 8 7 ,-9 3 :4 8 -5 2 .

3 3 . F o u tc h PG, T a lb e rt GA, W aring JP, et al. P e rc u ta n e o u s e n d o s c o p ic g a s tr o s to m y in p a tie n ts w ith p r io r a b d o m in a l su rg e ry: v irtu e s o f th e s a fe tra c t. A m J G a s tro e n te ro l 1 9 8 8 ; 8 3 :1 4 7 -1 5 0 .

3 4 . S te w a rt JA D , H agan P. F a ilu re to tr a n s illu m in a t e th e s to m a c h is n o t an a b s o lu te c o n tra in d ic a tio n to PEG in s e rtio n . E n d o s c o p y 1 9 9 8 :3 0 :6 2 1 -622.

3 5 . M c C a rte r TL, C o n d o n SC, A g u ila r RC, G ib so n DJ, C hen YR. R a n d o m iz e d p ro s p e c tiv e tr ia l o f e a rly v e rs u s d e la y e d fe e d in g a fte r p e rc u ta n e o u s e n d o s c o p ic g a s tr o s to m y p la c e m e n t. A m J G a s tro e n te ro l 1 9 9 8 :9 3 :4 1 9 - 4 2 1 .

3 6 . D o rm a n n AJ, W igginghaus B, R isius H. e t al. A s in g le d o s e o f c e ftria x o n e a d m in is te re d 3 0 m in u te s b e fo r e p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y s ig n ific a n tly re d u c e s lo c a l a n d s y s te m ic in fe c tiv e c o m p lic a tio n s . A m J G a s tro e n te ro l 1 9 9 9 :9 4 :3 2 2 0 -3 2 2 4 .

3 7 . P a te l PH, T h o m a s E. R isk fa c to rs fo r p n e u m o n ia a fte r p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y . J C lin G a s tro e n te ro l

1 9 9 0 ,1 2 :3 8 9 -3 9 2 .

3 8 . E lp e re n EH. P u lm o n a ry a s p ir a tio n in h o s p ita liz e d a d u lts . H u tr C lin P ra ct 1 9 9 7 ; 12:5

Rasim Gençosmanoglu, et al

40. W olfsen HC, R o z a re k RA, B a ll TJ, P a tte rso n DJ, B o to m a n VA. T u b e d y s fu n c tio n fo llo w in g p e rc u ta n e o u s g a s tro s to m y a n d je ju n o s to m y . G a s tro in te s t E n d o s c 1 9 9 0 :3 6 :2 6 1 -2 6 3 . 4 1 . D iS a rio JA , P o u tc h PG, S a n o w s k i RA. P o o r re s u lts w ith p e r c u ta n e o u s e n d o s c o p ic je ju n o s t o m y . G a s tr o in te s t E n d o s c 1 9 9 0 ;3 6 :2 5 7 -2 6 0 .

4 2 . H e n d e rs o n JM , S tro d e l WE, G ilin s k y HH. L im it a tio n s o f p e r c u ta n e o u s e n d o s c o p ic je ju n o s to m y . JPEH 1 9 9 3 ; 1 7 :5 4 6 -5 5 0 .

l ' O U / f t h ü Ñ < v V* v ' l ‘* I J ■ . I^ A V r tŞ O N ’İ K f y ı d ^ K » ^ “ fû

1

v.ıj^iuJj cQi ul<l.ırri.ı_ vf-rııc

; V í d i t y n / W j m . i ^ m * k.nydNÎ'.ırı ijç hVÎık rlı fu o / r d . ı jı l if 5 r ı ! n jA ( Î I

ve *y.it.ırke7ı*

II Râff İLAÇ $AN A.Ş.

G

A

V

I

S

C

O

N

A ljin ik a s r t

M i d e Y a n m a s ı \ f e R e f l ü d e

İ l k

-Mí.» Jd4 m İ lil<(c¿y#*y<nrmr.l yjıflfrrıırı i(< rır f ı N IÍÍFJI.-T A l 'f l f V . jII-, y - . ü U t e ı 7 A , 7 l u . / i : lü rriırm ım ^ ıy t^ o iflc fF 4 Im jl ii u rf?*T r t11 >Im.1 k u/m m* r j.n f ııU y .* fl^ fS fiir; r ^ iŞ iıık n f l f * ‘tí*- fie in l)*-^ l)*-^ n jk i r ttflk .n y o r ıll)*-^ fi M i l i í l)*-^ k o fi I Aj rı d l k .í$y¿/n1^ .yVjkiı.V f l o / . i j i I m>I<

W' y.ıK ırh çİrf iPy.i Ö .ı ? t . ı b l ? > r Ş ^ L t Ç tffJOO K r ^ ( / lı ¿ 0 A y u n tıfı Ijıla ı ir m lu tlo » fiir> n .ırtı> § i K it 0 *'

»

t *

y

•

. 4

.

'

V

/

^ O í i w m , x P y n A . r . i r h o f n ^ ^ f f c l j J .«’^¡16 / < n lriu m ı .u h o n .ifj? iiM< rn â ri^ y ıl ^ lın ^ r rı/<*r«- o a ı l flif j/n f JjínInr (j.ttlrtK r«*flú il«- h e i.^ b ‘ j o l.n i

jd n u j^ r b ir l<»i i r f r r ^ U d y . i j i # l r r . h n /c^ I /

I fJ V A # ^ í . kV^íy^al^lMv q eul^tard .i y e m e k te n -.nnr.i /« /.'ilrir k» 11 *. I U .m l

f'átjlH Í A k K A ií« r ik . Xlm}*T» s^ id l l f f lf lf ir t iij . k o d lu m h^f drTjorı.ıl« W i ip m q l ' h f u i J'» m«j ^ n d lk .ııy r ın h ır ı tje b ^ lfk ittik r«*fl& H í j e I i f t i l i i * . | ı e m ı \ ı ve n l l u o / o f .ij t t

y o k lifk ö u / ı l ı : I M \k»n vé 1 i ve 1 /J y.i> U M u <oc u khm d.i, y e m e k te n \ o n i . i ve y.i> ü \ t u c t)t u k k ird .i. y e m e k te n \ o n i . i ve 4 Í 1 H 0 0 0 TI iq ijffJ J /')/ 0 0 0 I I

É

yeni çözümlerle bilimden yaşama...

ö n c ü

b i l i m s e l a r a ş t ı r m a l a r l a

21.yü^ılın

s a ğ lık lı d ü n y a s ı iç in

yeni

kim geliştiriyor?

ilaçları

t h

N O V A R T I S

Yaşam B ilim le rin d e dünya lideri. Ciba ve Sandoz'u birleştiren kuruluş.

yaşam bilimi

O

#

O E M e d i c a l S y s t e m s - M a r m a r a Ü n i v e r s i t e s i İ ş b ir liğ iy le

Ü l k e m i z i n e n k a p s a m lı v e m o d e r n

erkezı

(Türkiye ve çevre ülkelerde ilk ve tek)

:::İİî::::::::;.Beyin Patolojilerinde cerahi

I: I

müdahaleye gerek kalmaksızın

• • • S • • • • • • %• • «u»• ♦ • • • • • • • • • • • • ■

**•#*•••••

*tedavı olanağı

Radyasyon Onkolojisi

Satürn

42

Lineer Akselerator

» • • • • • » t i P f « • t •--« • t •-* t t t *

r

t

Target Doz Planlama Uniti

Nuclital Simulator

Nükleer T i t t ü S İ ^

Camstar X-CT

•Camstar X-RT

OptimalîıHmt

Genie Work Station:

Radyodiagnostik

Magnetic Rezonans

Helical Bilgisayar!

Tomografi

DSA Angiography

Pereferic Angiography

Mammografi

Fioroscopj:::::::::::::::::

Konvansiyonel X-Ray

Mobile X- Ray

Ultrasonografi

Doppler Ultrasonografi

Advantage Windows

(Görüntü Değerlendirme Sistemler

K

PD

5

ya da aynı türden İngilizce sınavlara

İnternet üzerinden beraber hazırlanalım

Powered by

_{& S ü Y l}

T o m c a t