Immunocytochemical studies using antibodies raised against a 62-kDa membrane protein isolated from developing soybean (Glycine max (L.) Merr.) cotyledons were performed on leaf tissue of spinach (Spinacia oleracea L.). This 62-kDa protein was labeled by 6'-deoxy-6'-(4-azido-2-hydroxy)-benzamidosucrose (HABS), a photoaffinity sucrose analogue (K. G. Ripp et al., 1988, Plant Physiol.88, 1435-1445). Western-blot analysis of spinach plasma-membrane proteins indicated a cross-reactive polypeptide identical in molecular mass to that found in soybean. Indirect immunogold labeling of resin-embedded sections of fully expanded leaf tissue resulted in specific localization of colloidal gold on the sieve-tube plasma membrane. The label was uniform and, except for a few non-specific gold particles over the cell wall, all other cellular organelles and membrane systems were free of label. With the exception of occasional gold particles associated with the companion-cell plasma membrane, all other cell types of the leaf contained little or no label. Control sections treated with non-immune rabbit immunoglobulin-G were also essentially free of label. Immunogold labeling of young leaves, in which the phloem contained no mature sieve-tube members, were free of label for the 62-kDa protein. However, young leaf tissue in which mature or nearly mature sieve tubes could be identified, contained immunolabel associated with the sieve-tube plasma membranes. Similar results were obtained with mature leaf tissue of sugar beet (Beta vulgaris L.). The results of the immunocytochemical studies are consistent with the suggestion that the concentrating step in the phloem-loading process in this species may occur across the sieve-tube plasma membrane.
Background. Mature cystic teratomas of the fallopian tube are extremely rare and only 54 cases have been reported in the literature. In this paper, we report a mature cystic teratoma of the fallopian tube in a postmenopausal woman and we report the review of literature of tubal cystic teratomas. Case. A 62-year-old, gravida 4 postmenopausal woman presented with pain in the right lower abdominal region for a long time. An 88 72 95 mm heterogeneous mass which contained calcifications and lipoid components was detected in the right adnexal region by transvaginal ultrasonogram (TV-USG). Serum tumour markers, namely, CA125, CA15-3, and CA19-9, were within normal range. A laparotomy revealed a 9 10 cm cystic mass within the fimbrial region in the right fallopian tube, and right salpingoopherectomy was performed consequently. Microscopic examination revealed squamous epithelium with sebaceous glands and hair follicles, and pseudostratified ciliated respiratory epithelium with cartilage and mucous glands. Because the frozen section resulted in a benign dermoid cyst, no further operative procedure was performed. The postoperative follow-up was uneventful and the patient was discharged on the second postoperative day. Conclusion. In cases of undetermined pelvic or abdominal masses, a teratoma of the fallopian tube should be considered.
A gastrostomy tube (G-tube) is indicated in patients that need long-term pre-pyloric feeding. Endoscopic gastrostomy tube placement is now the preferred modality over surgical gastrostomy owing to a less invasive nature and faster time to start feeding. If the tube is dislodged within 4 weeks of initial placement, patients are at significant risk of peritonitis and perforation due to peritoneal spillage of gastric contents through the immature track, and replacement should not be attempted without surgical consultation. This activity focuses on the methods of G-tube replacement, and possible complications of G-tube replacement. and highlights the role of the interprofessional team in the care of patients that require this procedure.
Objectives:Describe the anatomy of gastrostomy tube placement.Outline the indications and contraindications for bedside gastrostomy tube replacement.Review how to replace a displaced gastrostomy tube at the bedside.Summarize how the interprofessional team can work together to identify complications and how to manage them after gastrostomy tube replacement is performed to improve the care of patients that require this procedure.Access free multiple choice questions on this topic.
A gastrostomy tube (G-tube) is indicated for long-term enteral nutritional support in patients with dysphagia secondary to various disorders. Endoscopic gastrostomy tube placement is now the preferred modality over surgical gastrostomy owing to a less invasive nature and faster time to start feeding. During endoscopic gastrostomy tube placement, a small incision is made over the anterior abdominal wall through which the tube is placed via a push method (the tube inserted percutaneously through the incision) or a pull technique (the tube is pulled out from the stomach through the incision). Once the tube is placed, a fistulous gastrocutaneous tract is formed in about 2-4 weeks. However, in certain conditions such as severe malnutrition, immunocompromised patients, and large ascites, tract maturity is further delayed. If a percutaneous gastrostomy endoscopic (PEG) tube is dislodged within a month after placement, then endoscopic replacement is recommended. However, if the tube is dislodged after 4 to 6 weeks when tract maturity is expected, bedside replacement is usually sufficient. If the tube is dislodged within 4 weeks of initial placement, patients are at significant risk of peritonitis and perforation due to peritoneal spillage of gastric contents through the immature track, and replacement should not be attempted without surgical consultation. A blind attempt to re-insert the tube or even foley placement in an immature tract can lead to inadvertent placement of the tube into the peritoneal cavity. In this review article, we discuss the replacement of the Gastrostomy tube in adult patients with complete maturation of the gastrocutaneous tract.
During endoscopic placement of a G-tube, a gastroscope is inserted, and air insufflation inflates the stomach. About 2.5 cm below the costal margin and medial to the xiphoid process, an area of maximal transillumination is identified while shining an endoscope light through the anterior gastric wall. A good 1:1 contact is confirmed by firmly applying pressure on this point and visualizing the stomach wall sliding off by this pressure at the same time. Once the site is confirmed, this area is marked with a surgical pen for the incision site. After the tube placement with an endoscope, the mechanism of track maturation includes the anterior gastric wall adhering to the abdominal wall forming a gastrocutaneous fistula.
First, if the tube is still in place, it should be examined. There are cases of a malfunctioning tube. It is vital that the clinician take a careful history and review prior records when they are available, to know the type of tube that has been placed (with internal mushroom cap versus internal balloon). The dressing is removed, and the percutaneous incision site is examined for any signs of infection, track closure, or tube displacement in subcutaneous tissue. The area should be appropriately cleaned with sterilizing alcohol or povidone-iodine. The area is covered with either the sheath in the PEG replacement kit or surgical drapes to avoid contaminating the surroundings during PEG replacement.
If the PEG tube is not completely dislodged but has been clogged or malfunctioning, the old tube needs to be removed. If the old tube is an endoscopically placed tube with an internal mushroom tip, then gentle traction is applied to the external portion of the tube to remove the internal mushroom. This has to be done with very gentle traction, and excessive force should be avoided at all costs as it can lead to disruption of even a well-formed track. If unusual resistance is felt during the attempted removal of the tube by gentle traction, it is best to remove the tube after endoscopic cutting of the internal bumper/mushroom cap and removal of the rest of the tube through external puling. If the old G-tube has an internal balloon, the balloon is deflated by aspirating fluid through the balloon port which usually consists of 8 to 10 mL of fluid. After this step, once the tube is removed, a similar size PEG tube is prepared to be inserted.
For replacement G-tube, tubes with the balloon tip are usually preferred to minimize the risk of disruption of the old track. A similar diameter PEG tube as the prior tube should be used as a replacement tube. First, the balloon functioning is confirmed outside the body by injecting 8 to 10 mL of saline in the balloon port. Once confirmed, the balloon is then deflated again. The balloon tip G-tube is either inserted into the track blindly or via the use of a guidewire with or without fluoroscopy and is advanced within the track. Once fully inside, the balloon is inflated with 8 to 10 mL of saline or distilled water. The tube is slowly retracted till gentle resistance is encountered due to the internal balloon opposing the gastric wall. At this point, the external portion of the tube is secured with a dressing. Both ports of a traditional G-tube (feeding port and med port) are flushed and then capped. A dressing is then applied based on institutional policy. It is vital to apply a protective dressing to avoid accidental pulling or dislodgement in patients with altered mentation.
The final step in PEG tube replacement is to confirm the placement. There are certain ways gastric placement can be confirmed. The simplest method is the bedside method of flushing air through the tube and auscultating for gastric gurgle. However, this method is quite unreliable. The most accurate way of confirming internal balloon placement is with an endoscope. However, this might not be cost-effective. The most commonly used technique in most practices is to place water-soluble contrast through the replacement tube and obtain a post-contrast-enhanced abdominal x-ray to confirm placement in the stomach. 041b061a72