Faculty Bibliography

BACKGROUND:Direct percutaneous endoscopic jejunostomy (DPEJ) is a well-known approach to deliver postpyloric enteral nutrition support to individuals who cannot tolerate gastric feeding. DPEJ addresses many of the shortcomings of jejunal feeding tubes placed through percutaneous endoscopic gastrostomy tubes. The safety and efficacy of DPEJ in adults has been previously reported. There are no reports on the use of DPEJ in pediatric patients. OBJECTIVE:Our purpose was to report on 5 pediatric patients who underwent DPEJ placement between January 2000 and January 2003 over the available follow-up periods. DESIGN/METHODS:Retrospective case series. SETTING/METHODS:University of Utah Health Sciences Center and the Medical University of South Carolina. PATIENTS/METHODS:Five patients, age range 4 to 17 years. MAIN OUTCOME MEASUREMENTS/METHODS:Rate of successful tube placement, major and minor complications, and outcomes including weight gain and recurrent aspiration after DPEJ placement. RESULTS:All 5 attempted DPEJs were placed successfully with 2 minor complications of peristomal leakage and peristomal skin infection. One DPEJ was replaced 2 years after placement because of fungal degradation. The mean weight gain among all patients was 10.3 kg in a mean of 22.6 months. LIMITATIONS/CONCLUSIONS:Retrospective, small series. CONCLUSIONS:DPEJ placement appears to be a safe and effective approach to enteral nutritional support in pediatric patients requiring long-term access to the jejunum. No major complications occurred and all patients gained weight after tube placement.

BACKGROUND:Adequate lymph node evaluation is required for proper staging of colorectal cancer, and the number of lymph nodes examined is associated with survival. According to current guidelines, the recommended minimum number of lymph nodes examined to ensure adequate sampling is 12. We used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program to determine the proportion of colorectal cancer patients in the United States who receive adequate lymph node evaluation. METHODS:For 116,995 adults with colorectal adenocarcinoma, diagnosed from 1988 through 2001, who underwent radical surgery and did not receive neoadjuvant radiation, we evaluated the number of lymph nodes, the likelihood of receiving adequate lymph node evaluation (i.e., at least 12 lymph nodes examined), and the influence of tumor and patient factors on lymph node evaluation. All statistical tests were two-sided. RESULTS:Among all patients, the median number of lymph nodes examined was nine. Only 37% of all patients received adequate lymph node evaluation. The proportion of patients receiving adequate lymph node evaluation increased from 32% in 1988 to 44% in 2001 (P(trend)<.001, Cochran-Armitage test). Advanced tumor stage was statistically significantly associated with adequate lymph node evaluation (odds ratio [OR] of receiving adequate lymph node evaluation=2.27, 95% confidence interval [CI] = 2.18 to 2.35). Older patients (> or =71 years, OR = 0.45, 95% CI = 0.44 to 0.47) were less likely to receive adequate lymph node evaluation than younger patients, and those with left-sided (OR = 0.45, 95% CI = 0.44 to 0.47) or rectal (OR = 0.52, 95% CI = 0.50 to 0.54) cancers were less likely to receive adequate lymph node evaluation than patients with right-sided cancers. In all analyses, geographic location was an important predictor of adequate lymph node evaluation, which ranged from 33% to 53%, depending on geographic location. CONCLUSIONS:In 2001, the majority of patients with colorectal cancer still received inadequate lymph node evaluation. The association of demographic variables, particularly patient age and geographic location, with adequate lymph node evaluation indicates that local surgical and pathology practice patterns may affect adequacy of lymph node evaluation.