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Alwali A, Schafmayer C. Palliative Percutaneous Gastrostomy Decompression Methods for Small-Bowel Obstruction in Advanced Gastrointestinal Cancer. Cancers (Basel) 2025; 17:1287. [PMID: 40282463 PMCID: PMC12025771 DOI: 10.3390/cancers17081287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2025] [Revised: 04/01/2025] [Accepted: 04/09/2025] [Indexed: 04/29/2025] Open
Abstract
BACKGROUND Malignant bowel obstruction (MBO) is a common and distressing complication in advanced gastrointestinal cancers, significantly impacting patients' quality of life. When conservative management fails, palliative decompression is essential to relieve symptoms such as nausea, vomiting, and abdominal distension. Venting gastrostomy is the most established method; however, anatomical challenges may necessitate alternative percutaneous approaches. OBJECTIVE This narrative review aims to provide a comprehensive overview of percutaneous gastrostomy techniques for palliative gastrointestinal decompression, including percutaneous endoscopic gastrostomy (PEG), interdisciplinary imaging-guided percutaneous or transhepatic gastrostomy, and percutaneous transesophageal gastrostomy (PTEG). METHODS A literature review was conducted to evaluate the indications, techniques, efficacy, and complications associated with these procedures. The role of a multidisciplinary approach, incorporating radiologic, endoscopic, and palliative care expertise, was also explored. RESULTS PEG remains the gold standard for venting gastrostomy, achieving symptom relief in up to 92% of cases, with a low complication rate. However, interdisciplinary imaging-guided percutaneous or transhepatic gastrostomy offers a viable alternative for patients with surgically altered anatomy or difficult percutaneous access. PTEG, a newer technique, has demonstrated high technical success and symptom improvement, particularly in patients with extensive peritoneal carcinomatosis or massive ascites, where transabdominal approaches are not feasible. CONCLUSIONS Palliative percutaneous decompression provides effective symptom relief in advanced gastrointestinal cancer. The choice of technique should be individualized based on patient anatomy, clinical condition, and resource availability. A multidisciplinary approach remains crucial in tailoring decompression strategies to improve the quality of life in end-stage malignancies.
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Affiliation(s)
- Ahmed Alwali
- Department of General, Visceral, Vascular, Thoracic, and Transplantation Surgery, Rostock University Medical Center, 18057 Rostock, Germany
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Yildirim M, Kocabay A, Koca B, Saglam AI, Ozkan N. Factors Predicting Major Complications and Mortality in Percutaneous Endoscopic Gastrostomy: 8 Years of Experience of a Tertiary Surgery Center. Surg Laparosc Endosc Percutan Tech 2025; 35:e1342. [PMID: 39905856 DOI: 10.1097/sle.0000000000001342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Accepted: 10/22/2024] [Indexed: 02/06/2025]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is a safe method of choice for patients who need long-term nutritional support. However, complications and high mortality rates have been reported. Based on 8 years of experience in tertiary care hospitals, we aimed to identify risk factors associated with major complications and 30-day mortality after PEG. METHODS Patients who underwent PEG in the General Surgery clinic of Tokat Gaziosmanpaşa University, Faculty of Medicine between January 2014 and March 2022 were included in the study. Data regarding patient demographics, comorbidities, laboratory data, drugs used together, and indications for PEG tube placement were collected. RESULTS There were 429 patients. The mean age of the patients was 66.9±16.75 years, and 180 (44%) patients were female. The mean follow-up period was 8.84±6.75 months. Twenty patients (4.9%) had major complications. Female sex [Odds Ratio (OR) 0.33, 95% CI, CI=1.23-8.87, P =0.02] and diabetes mellitus (DM) (OR=0.23, 95% CI=1.93-6, P =0.002) were the independent variables associated with major complications. The all-cause 30-day mortality rate was 5.9% (n=24). Malignancy, DM, corticosteroid use, low albumin, and platelet values were associated with increased mortality in multivariate analysis as indications for PEG. CONCLUSIONS Female sex and patients with DM may potentially face major complications. The patients with cancer, diabetes, and corticosteroid use were associated with higher mortality. In addition, low serum albumin and platelet levels were an effective factor for survival in patients undergoing PEG, and this should be taken into account in decision-making.
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Affiliation(s)
- Murat Yildirim
- Department of General Surgery, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey
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3
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Roberson JL, Gasior JA, Ginzberg SP, Bakillah E, Passman J, Shreve L, Sharoky CE, Nadolski G, Courtright KR, Kaufman EJ. The Impact of Palliative Decompressive Gastrostomy Tube Placement on Patients and Their Caregivers: A Mixed Methods Analysis. Ann Surg Oncol 2024; 31:6931-6938. [PMID: 39085545 DOI: 10.1245/s10434-024-15943-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/16/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Palliative decompressive gastrostomy tubes are intended to relieve the severe physical symptoms of malignant small bowel obstruction (SBO) near the end of life. The objective of this study was to assess the impact of palliative decompressive gastrostomy tube on patient and caregiver well-being. PATIENTS AND METHODS We prospectively enrolled patients with a malignant SBO and their caregivers at the time of informed consent for decompressive gastrostomy tube placement. We collected the Edmonton Symptom Assessment Scale (ESAS) and the Functional Assessment of Chronic Illness Therapy-Palliative (FACIT-Pal-14) surveys from patients at baseline and at 2-week post-procedure follow-up. The Caregiver Burden Scale survey was administered to caregivers at baseline. Survey scores were compared using paired t-tests. We also conducted semistructured interviews with patients and their caregivers at two-week follow-up until thematic saturation was reached. Content analysis was used to identify themes with two independent coders. RESULTS We enrolled 15 patient-caregiver dyads. Preprocedure, the median caregiver burden scale score was 37.5 (significant burden ≥ 21). Eight patients (53%) survived to 2 weeks; among these patients, median ESAS scores (51 versus 43.5, p < 0.001) and median FACIT-Pal-14 scores (22 versus 32, p = 0.015) were significantly improved at 2-week follow-up. Interviews revealed three major themes: improved symptom management, new stressors, and opportunities for better education and resources. CONCLUSIONS Decompressive gastrostomy tubes effectively alleviated symptoms in patients with inoperable malignant SBOs. This palliative intervention may provide greater benefit if performed earlier, and caregivers and patients need improved resources and education for tube management to minimize added stressors.
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Affiliation(s)
- Jeffrey L Roberson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Julia A Gasior
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sara P Ginzberg
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA, USA
| | - Emna Bakillah
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse Passman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren Shreve
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine E Sharoky
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory Nadolski
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine R Courtright
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Skogar ML, Sundbom M. Time trends and outcomes of gastrostomy placement in a Swedish national cohort over two decades. World J Gastroenterol 2024; 30:1358-1367. [PMID: 38596497 PMCID: PMC11000080 DOI: 10.3748/wjg.v30.i10.1358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/27/2023] [Accepted: 01/31/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) and laparoscopically inserted gastrostomy have become the gold standard for adult patients and children, respectively, requiring long-term enteral nutrition support. Procedure-related mortality is a rare event, often reported to be zero in smaller studies. National data on 30-d mortality and long-term survival rates after gastrostomy placement are scarce in the literature. AIM To study the use of gastrostomies in Sweden from 1998-2019 and to analyze procedure-related mortality and short-term (< 30 d) and long-term survival. METHODS In this retrospective, population-based cohort study, individuals that had received a gastrostomy between 1998-2019 in Sweden were included. Individuals were identified in the Swedish National Patient Register, and survival analysis was possible by cross-referencing the Swedish Death Register. The cohort was divided into three age groups: Children (0-18 years); adults (19-64 years); and elderly (≥ 65 years). Kaplan-Meier with log-rank test and Cox regression were used for survival analysis. RESULTS In total 48682 individuals (52% males, average age 60.9 ± 25.3 years) were identified. The cohort consisted of 12.0% children, 29.5% adults, and 58.5% elderly. An increased use of gastrostomies was observed during the study period, from 13.7/100000 to 22.3/100000 individuals (P < 0.001). The use of PEG more than doubled (about 800 to 1800/year), with a corresponding decrease in open gastrostomy (about 700 to 340/year). Laparoscopic gastrostomy increased more than ten-fold (about 20 to 240/year). Overall, PEG, open gastrostomy, and laparoscopic gastrostomy constituted 70.0% (n = 34060), 23.3% (n = 11336), and 4.9% (n = 2404), respectively. Procedure-related mortality was 0.1% (n = 44) overall (PEG: 0.05%, open: 0.24%, laparoscopic: 0.04%). The overall 30-d mortality rate was 10.0% (PEG: 9.8%, open: 12.4%, laparoscopic: 1.7%) and decreased from 11.6% in 1998-2009 vs 8.5% in 2010-2019 (P < 0.001). One-year and ten-year survival rates for children, adults, and elderly were 93.7%, 67.5%, and 42.1% and 79.9%, 39.2%, and 6.8%, respectively. The most common causes of death were malignancies and cardiovascular and respiratory diseases. CONCLUSION The annual use of gastrostomies in Sweden increased during the study period, with a shift towards more minimally invasive procedures. Although procedure-related death was rare, the overall 30-d mortality rate was high (10%). To overcome this, we believe that patient selection should be improved.
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Affiliation(s)
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala 75185, Sweden
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Patterson M, Greenley S, Ma Y, Bullock A, Curry J, Smithson J, Lind M, Johnson MJ. Inoperable malignant bowel obstruction: palliative interventions outcomes - mixed-methods systematic review. BMJ Support Palliat Care 2024; 13:e515-e527. [PMID: 38557409 PMCID: PMC10850628 DOI: 10.1136/bmjspcare-2021-003492] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/27/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) and palliative venting gastrostomies (PVG) are two interventions used clinically to manage inoperable malignant bowel obstruction (MBO); however, little is known about their role in clinical and quality-of-life outcomes to inform clinical decision making. AIM To examine the impact of PN and PVG on clinical and quality-of-life outcomes in inoperable MBO. DESIGN A mixed-methods systematic review and narrative synthesis. DATA SOURCES The following databases were searched (from inception to 29 April 2021): MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Bielefeld Academic Search Engine, Health Technology Assessment and CareSearch for qualitative or quantitative studies of MBO, and PN or PVG. Titles, abstracts and papers were independently screened and quality appraised. RESULTS A total of 47 studies representing 3538 participants were included. Current evidence cannot tell us whether these interventions improve MBO survival, but this was a firm belief by patients and clinicians informing their decision. Both interventions appear to allow patients valuable time at home. PVG provides relief from nausea and vomiting. Both interventions improve quality of life but not without significant burdens. Nutritional and performance status may be maintained or improved with PN. CONCLUSION PN and PVG seem to allow valuable time at home. We found no conclusive evidence to show either intervention prolonged survival, due to the lack of randomised controlled trials that have to date not been performed due to concerns about equipoise. Well-designed studies regarding survival for both interventions are needed. PROSPERO REGISTRATION NUMBER CRD42020164170.
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Affiliation(s)
- Michael Patterson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Sarah Greenley
- Institute of Clinical and Applied Health Research, Hull York Medical School, Hull, UK
| | - Yangmyung Ma
- Department of Plastic Surgery, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Alex Bullock
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Jordan Curry
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Jacquelyn Smithson
- Gastrointestinal and Liver services, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Michael Lind
- Hull York Medical School, University of Hull, Hull, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Modi K, Lee D. Endoscopic Nutrition of Patients with Cancer. Gastrointest Endosc Clin N Am 2024; 34:167-177. [PMID: 37973227 DOI: 10.1016/j.giec.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The types of endoscopic interventions available for supporting the nutrition of patients with cancer have expanded in recent years to encompass a wide variety of different techniques and procedures. Many of these procedures reflect refinements of technique that have existed for some time, whereas others are implementations of novel technologies and instruments that have only become available in recent years. In this review, the authors seek to summarize the breadth of endoscopic techniques for maintaining nutrition in patients with cancer.
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Affiliation(s)
- Kinnari Modi
- Department of Internal Medicine, Methodist Dallas Medical Center, Dallas, TX, USA
| | - David Lee
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, TX, USA.
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Yu J, Sullivan BG, Nguyen NT, Hohmann SF, Harris AH, Micic D, Turaga KK, Senthil M, Eng OS. Readmission and Disposition in Patients With Malignant Bowel Obstructions Following Gastrostomy Tube. Am Surg 2023; 89:5915-5920. [PMID: 37257144 DOI: 10.1177/00031348231180915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Patients with peritoneal carcinomatosis (PC) can develop malignant bowel obstructions (MBOs) requiring inpatient admission and nasogastric tube decompression. Palliative decompressive gastrostomy tubes (G-tubes) may affect patient disposition, allowing for self-management and reduction in inpatient services. Therefore, we sought to assess disposition and inpatient readmission rates in patients admitted with PC and MBO following G-tube placement. METHODS The Vizient® Clinical Data Base was queried for inpatient admissions from October 2018 to May 2022 utilizing ICD-10 codes to identify patients admitted with PC and bowel obstruction, with or without G-tube placement. Demographics and hospital outcomes were recorded. Descriptive statistics and multivariate logistic regression analysis were performed. RESULTS From 750 patients, 59 (7.9%) had a G-tube placed. Compared to patients without G-tubes, those with G-tubes had lower rates of disposition to home (32.2% vs 70.0%, P < .001) and higher rates of disposition to hospice (home: 30.5% vs 7.8%, P < .001, facility: 10.2% vs 3.9%, P = .02). There was no significant difference in the rate (17.3% vs 22.3%, P = .40) or risk (OR = 1.44, 95% CI .69-3.01) of 30-day readmissions with G-tubes. However, palliative care consultation (OR 33.77, 95% CI 19.16-59.52) and G-tube placement (OR 5.82, 95% CI 2.56-13.25) were independent predictors for hospice. DISCUSSION Placement of G-tubes in patients with PC and MBO was associated with higher rates of disposition to hospice but there is no difference in 30-day readmission rates compared to those without G-tubes. Further prospective studies are needed to understand the role of G-tube placement in patients with MBO in relation to outcomes and disposition.
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Affiliation(s)
- Jingjing Yu
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
| | - Brittany G Sullivan
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
| | - Ninh T Nguyen
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
| | - Samuel F Hohmann
- Center for Advanced Analytics and Informatics, Vizient, Inc., Chicago, IL, USA
| | - Alyssa H Harris
- Center for Advanced Analytics and Informatics, Vizient, Inc., Chicago, IL, USA
| | - Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, IL, USA
| | - Kiran K Turaga
- Department of Surgery, Yale University, New Haven, CT, USA
| | - Maheswari Senthil
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
| | - Oliver S Eng
- Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA
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Cohen JT, Beard RE, Cioffi WG, Miner TJ. Was It Worth It? Critical Evaluation of a Novel Outcomes Measure in Oncologic Palliative Surgery. J Am Coll Surg 2023; 236:1156-1162. [PMID: 36786475 DOI: 10.1097/xcs.0000000000000649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Patient selection for palliative surgery is complex, and appropriate outcomes measures are incompletely defined. We explored the usefulness of a specific outcomes measure "was it worth it" in patients after palliative-intent operations for advanced malignancy. STUDY DESIGN A retrospective review of a comprehensive longitudinal palliative surgery database was performed at an academic tertiary care center. All patients who underwent palliative-intent operation for advanced cancer from 2003 to 2022 were included. Patient satisfaction ("was it worth it") was reported within 30 days of operation after palliative-intent surgery. RESULTS A total of 180 patients were identified, and 81.7% self-reported that their palliative surgery was "worth it." Patients who reported that their surgery was "not worth it" were significantly older and were more likely to have recurrent symptoms and to need reoperation. There was no significant difference in overall, recurrence-free, and reoperation-free survival for patients when comparing "worth it" with "not worth it." Initial symptom improvement was not significantly different between groups. Age older than 65 years (hazard ratio 0.25, 95% CI 0.07 to 0.80, p = 0.03), family engagement (hazard ratio 6.71, 95% CI 1.49 to 31.8, p = 0.01), and need for reoperation (hazard ratio 0.042, 95% CI 0.01 to 0.16, p < 0.0001) were all independently associated with patients reporting that their operation was "worth it." CONCLUSIONS Here we demonstrate that simply asking a patient "was it worth it" after a palliative-intent operation identifies a distinct cohort of patients that traditional outcomes measures fail to distinguish. Family engagement and durability of an intervention are critical factors in determining patient satisfaction after palliative intervention. These data highlight the need for highly individualized care with special attention paid to patients self-reporting that their operation was "not worth it."
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Affiliation(s)
- Joshua T Cohen
- From the Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
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Itou C, Arai Y, Sone M, Sugawara S, Kimura S, Onishi Y. Percutaneous Image-Guided Transesophageal Long Intestinal Tube Placement for Palliative Decompression in Advanced Cancer Patients with Unresectable Malignant Small Bowel Obstruction. Cardiovasc Intervent Radiol 2023:10.1007/s00270-023-03457-3. [PMID: 37188898 DOI: 10.1007/s00270-023-03457-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/26/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE To assess the safety and efficacy of long intestinal tube placement following percutaneous image-guided esophagostomy for palliative decompression of incurable malignant small bowel obstruction. MATERIALS AND METHODS Between January 2013 and June 2022, a single-institution retrospective study was conducted to examine patients undergoing percutaneous transesophageal intestinal intubation for an occluded intestinal segment. Patients' baseline characteristics, procedural details, and clinical courses were reviewed. Severe complications were defined as those with ≥ 4 grade according to the CIRSE classification. RESULTS This study included 73 patients (mean age, 57.7 years) who underwent 75 procedures. All bowel obstructions were caused by peritoneal carcinomatosis or similar disease, which precluded transgastric access in almost 50% of the patients due to massive cancerous ascites (n = 28), diffuse gastric involvement (n = 5), or omental dissemination in front of the stomach (n = 3). Technical success (appropriate tube positioning) was achieved in 98.7% (74/75) of procedures. The cumulative 1-month overall survival and sustained clinical success (adequate bowel decompression) rates were estimated at 86.8% and 88%, respectively, using Kaplan-Meier analysis. At the median survival of 70 days, the disease progression required other gastrointestinal interventions, including additional tube insertion, repositioning, or venting enterostomy in 16 patients (21.9%). The severe complication rate was 4% (3/75); one patient aspirated to death due to tube clogging and two encountered fatal perforation of isolated intestinal loops developing far beyond the tip of the indwelling tube. CONCLUSION Percutaneous image-guided transesophageal intestinal intubation achieves feasible bowel decompression as palliative care in advanced cancer patients. LEVEL OF EVIDENCE Level 4, Case Series.
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Affiliation(s)
- Chihiro Itou
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
| | - Yasuaki Arai
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Shunsuke Sugawara
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Shintaro Kimura
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Yasuyuki Onishi
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
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Roche KF, Bower KL, Collier B, Neel D, Esry L. When Should the Appropriateness of PEG be Questioned? Curr Gastroenterol Rep 2023; 25:13-19. [PMID: 36480136 DOI: 10.1007/s11894-022-00857-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This review aims to analyze the evidence regarding the appropriateness of PEG placement in the following clinical situations: short bowel syndrome, head and neck cancer, dementia and palliative use in malignant bowel obstruction. RECENT FINDINGS Percutaneous endoscopic gastrostomy (PEG) tubes are placed for a variety of clinical indications by numerous different specialties. First described in 1980, PEG tubes are now the dominant method of enteral access. Typically, PEG tubes are technically feasible procedures that can come with significant risk for both minor and major complications. Therefore, it is important to perform an in-depth, patient specific risk-benefit analysis when considering insertion. By analyzing the current evidence regarding benefits in these situations, superimposed by the lens of biomedical ethics, we make recommendations that are accessible to any provider who may be a consultant or proceduralist, helping to provide informed care that is in the patient's best interest.
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Affiliation(s)
- Keelin Flannery Roche
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), East Tennessee State University, Johnson City, TN, USA
| | - Katie L Bower
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Bryan Collier
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Dustin Neel
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), University of Missouri-Kansas City, Kansas City, MO, USA
| | - Laura Esry
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), University of Missouri-Kansas City, Kansas City, MO, USA
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11
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Bravington A, Obita G, Baddeley E, Johnson MJ, Murtagh FE, Currow DC, Boland EG, Nelson A, Seddon K, Oliver A, Noble SI, Boland JW. The range and suitability of outcome measures used in the assessment of palliative treatment for inoperable malignant bowel obstruction: A systematic review. Palliat Med 2022; 36:1336-1350. [PMID: 36131489 PMCID: PMC10150264 DOI: 10.1177/02692163221122352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Malignant bowel obstruction, a complication of certain advanced cancers, causes severe symptoms which profoundly affect quality of life. Clinical management remains complex, and outcome assessment is inconsistent. AIM To identify outcomes evaluating palliative treatment for inoperable malignant bowel obstruction, as part of a four-phase study developing a core outcome set. DESIGN The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA); PROSPERO (ID: CRD42019150648). Eligible studies included at least one subgroup with obstruction below the ligament of Treitz undergoing palliative treatment for inoperable malignant bowel obstruction. Study quality was not assessed because the review does not evaluate efficacy. DATA SOURCES Medline, Embase, the Cochrane Database, CINAHL, PSYCinfo Caresearch, Open Grey and BASE were searched for trials and observational studies in October 2021. RESULTS A total of 4769 studies were screened, 290 full texts retrieved and 80 (13,898 participants) included in a narrative synthesis; 343 outcomes were extracted verbatim and pooled into 90 unique terms across six domains: physiological, nutrition, life impact, resource use, mortality and survival. Prevalent outcomes included adverse events (78% of studies), survival (54%), symptom control (39%) and mortality (31%). Key individual symptoms assessed were vomiting (41% of studies), nausea (34%) and pain (33%); 19% of studies assessed quality of life. CONCLUSIONS Assessment focuses on survival, complications and overall symptom control. There is a need for definitions of treatment 'success' that are meaningful to patients, a more consistent approach to symptom assessment, and greater consideration of how to measure wellbeing in this population.
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Affiliation(s)
- Alison Bravington
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elin Baddeley
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elaine G Boland
- Queen's Centre for Oncology and Haematology, Cottingham, Hull, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Kathy Seddon
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Alfred Oliver
- National Cancer Research Institute, Consumer Liaison Group, Trans-Humber Consumer Research Panel, London, UK
| | - Simon Ir Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
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12
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Abdelfattah T, Kaspar M. Gastroenterologist's Guide to Gastrostomies. Dig Dis Sci 2022; 67:3488-3496. [PMID: 35579798 DOI: 10.1007/s10620-022-07538-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/22/2022] [Indexed: 12/09/2022]
Abstract
Gastroenterologists are frequently consulted for evaluation feeding tube placement, or for management of complications in an existing feeding tube. Though a frequent topic of consultation for GI Fellows, there are few comprehensive resources for feeding tube placement and troubleshooting available. In this review, we discuss different types of feeding tubes, when each should be considered, and various methods and techniques for placement. Considerations for when one type, method, technique, or specialty may be preferred over the other will be discussed. Additionally, we discuss management of the many complications of indwelling feeding tubes. Our goal is to create a comprehensive review for gastroenterologists to cover clinically relevant questions related to feeding tube placement and management.
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Affiliation(s)
- Thaer Abdelfattah
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, 1200 E Broad Street, West Hospital, 14th Floor, Box 980341, Richmond, VA, USA.
| | - Matthew Kaspar
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, 1200 E Broad Street, West Hospital, 14th Floor, Box 980341, Richmond, VA, USA
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13
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Stenberg K, Eriksson A, Odensten C, Darehed D. Mortality and complications after percutaneous endoscopic gastrostomy: a retrospective multicentre study. BMC Gastroenterol 2022; 22:361. [PMID: 35902805 PMCID: PMC9335963 DOI: 10.1186/s12876-022-02429-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Percutaneous endoscopic gastrostomy (PEG) is the method of choice for patients in need of long-term nutritional support or gastric decompression. Although it is considered safe, complications and relatively high mortality rates have been reported. We aimed to identify risk factors for complications and mortality after PEG in routine healthcare. Methods This retrospective study included all adult patients who received a PEG between 2013 and 2019 in Region Norrbotten, Sweden.
Results 389 patients were included. The median age was 72 years, 176 (45%) were women and 281 (72%) patients received their PEG due to neurological disease. All-cause mortality was 15% at 30 days and 28% at 90 days. Malignancy as the indication for PEG was associated with increased mortality at 90 days (OR 4.41, 95% CI 2.20–8.88). Other factors significantly associated with increased mortality were older age, female sex, diabetes mellitus, heart failure, lower body mass index and higher C-reactive protein levels. Minor and major complications within 30 days occurred in 11% and 15% of the patients, respectively. Diabetes increased the risk of minor complications (OR 2.61, 95% CI 1.04–6.55), while those aged 75 + years were at an increased risk of major complications, compared to those younger than 65 years (OR 2.23, 95% CI 1.02–4.85). Conclusions The increased risk of death among women and patients with malignancy indicate that these patients could benefit from earlier referral for PEG. Additionally, we found that age, diabetes, heart failure, C-reactive protein and body mass index all impact the risk of adverse outcomes.
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Affiliation(s)
- K Stenberg
- Department of Surgery, Sunderby Hospital, Kirurgkliniken, Sunderby sjukhus, Sjukhusvägen 10, 954 42, Södra Sunderbyn, Sweden.
| | - A Eriksson
- Department of Surgery, Sunderby Hospital, Kirurgkliniken, Sunderby sjukhus, Sjukhusvägen 10, 954 42, Södra Sunderbyn, Sweden
| | - C Odensten
- Department of Surgical and Preoperative Sciences, Surgery, Sunderby Research Unit, Umeå University, Umeå, Sweden
| | - D Darehed
- Department of Public Health and Clinical Medicine, Sunderby Research Unit, Umeå University, Umeå, Sweden
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14
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Rajan A, Wangrattanapranee P, Kessler J, Kidambi TD, Tabibian JH. Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices. World J Gastrointest Surg 2022; 14:286-303. [PMID: 35664365 PMCID: PMC9131834 DOI: 10.4240/wjgs.v14.i4.286] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/09/2022] [Accepted: 04/03/2022] [Indexed: 02/06/2023] Open
Abstract
Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.
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Affiliation(s)
- Anand Rajan
- Department ofGastroenterology, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
- Department ofGastroenterology, City of Hope Medical Center, Duarte, CA 91010, United States
| | | | - Jonathan Kessler
- Department ofInterventional Radiology, City of Hope Medical Center, Duarte, CA 91010, United States
| | - Trilokesh Dey Kidambi
- Department ofGastroenterology, City of Hope Medical Center, Duarte, CA 91010, United States
| | - James H Tabibian
- Department ofGastroenterology, UCLA-Olive View Medical Center, Sylmar, CA 91342, United States
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15
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Zhu C, Platoff R, Ghobrial G, Saddemi J, Evangelisti T, Bucher E, Saracco B, Adams A, Kripalani S, Atabek U, Spitz FR, Hong YK. What to do When Decompressive Gastrostomies and Jejunostomies are not Options? A Scoping Review of Transesophageal Gastrostomy Tubes for Advanced Malignancies. Ann Surg Oncol 2022; 29:262-271. [PMID: 34546480 DOI: 10.1245/s10434-021-10667-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/05/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND In advanced malignant bowel obstruction, decompressive gastrostomy tubes (GTs) may not be feasible due to ascites, peritoneal carcinomatosis, and altered gastric anatomy. Whereas nasogastric tubes (NGTs) allow temporary decompression, percutaneous transesophageal gastrostomy tubes (PTEGs) are an alternative method for long-term palliative decompression. This study performed a scoping review to determine outcomes with PTEG in advanced malignancies. METHODS A systematic literature search was performed to include all studies that reported the clinical results of PTEGs for malignancy. No language, national, or publication status restrictions were used. RESULTS The analysis included 14 relevant studies with a total of 340 patients. In 11 studies, standard PTEGs were inserted with a rupture-free balloon's placement into the mouth or nose and esophageal puncture under fluoroscopy or ultrasound, followed by a guidewire into the stomach with placement of a single-lumen tube. Of 340 patients, 65 (19.1%) had minor complications, and 5 (2.1%) had significant complications, including bleeding and severe aspiration pneumonia. Of 171 patients, 169 with PTEGs (98.8%) reported relief of nasal discomfort from NGT and alleviation of obstructive symptoms. The one randomized controlled trial reported a significantly higher quality of life with PTEGs than with NGTs. CONCLUSIONS When decompression for advanced malignancy is technically not feasible with a gastrostomy tube, the PTEG is a viable, safe option for palliation. The PTEG is associated with lower significant complication rates than the gastrostomy tube and significantly higher patient-derived outcomes than the NGT.
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Affiliation(s)
- Clara Zhu
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA
| | - Rebecca Platoff
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA
| | - Gaby Ghobrial
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA
| | - Jackson Saddemi
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA
| | - Taylor Evangelisti
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA
| | - Emily Bucher
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA
| | | | - Amanda Adams
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Umur Atabek
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA
| | - Francis R Spitz
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA
| | - Young K Hong
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
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16
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Shariff F, Bogach J, Guidolin K, Nadler A. Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review. Ann Surg Oncol 2021; 29:1995-2005. [PMID: 34664143 DOI: 10.1245/s10434-021-10922-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/30/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Malignant bowel obstruction from peritoneal carcinomatosis affects a significant proportion of luminal gastrointestinal and ovarian oncology patients, and portends poor long-term survival. The management approach for these patients includes a range of medical therapies and surgical options; however, how to select an optimal treatment strategy remains enigmatic. The goal of this narrative review was to summarize the latest evidence around multimodal malignant bowel obstruction treatment and to establish if and where progress has been made. METHODS A targeted literature search examining articles focused on the management of malignant bowel obstruction from peritoneal carcinomatosis was performed. Following data extraction, a narrative review approach was selected to describe evidence and guidelines for surgical prognostic factors, imaging, tube decompression, medical management, nutrition, and quality of life. RESULTS Outcomes in the literature to date are summarized for various malignant bowel obstruction treatment strategies, including surgical and non-surgical approaches, as well as a discussion of the role of total parenteral nutrition and chemotherapy in holistic malignant bowel obstruction management. CONCLUSION There has been little change in survival outcomes in malignant bowel obstruction in over more than a decade and there remains a paucity of high-level evidence to direct treatment decision making. Healthcare providers treating patients with malignant bowel obstruction should work to establish consensus guidelines, where feasible, to support medical providers in ensuring compassionate care during this often terminal event for this unique patient group.
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Affiliation(s)
- Farhana Shariff
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Jessica Bogach
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Keegan Guidolin
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ashlie Nadler
- Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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17
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Liu X, Yang Z, He S, Wang G. Percutaneous endoscopic gastrostomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021; 10:42-48. [DOI: 10.18528/ijgii210015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/09/2021] [Accepted: 03/09/2021] [Indexed: 11/25/2024] Open
Affiliation(s)
- Xudong Liu
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengqiang Yang
- Department of Radiology Intervention, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shun He
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guiqi Wang
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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18
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Banting SP, Waters PS, Peacock O, Narasimhan V, Lynch AC, McCormick JJ, Warrier SK, Heriot AG. Management of primary and metastatic malignant small bowel obstruction, operate or palliate. A systematic review. ANZ J Surg 2020; 91:282-290. [PMID: 32869479 DOI: 10.1111/ans.16188] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/07/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of patients presenting with malignant small bowel obstruction is a challenging paradigm. The aim of this systematic review was to examine different management strategies in these complex patients. The primary outcomes evaluated were the type of intervention, 30-day morbidity and mortality and overall survival rates. METHODS A systematic literature review of EMBase, Medline, PubMed and the Cochrane Library was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses for studies reporting on conservative and operative management of malignant small bowel obstruction. RESULTS Fifteen studies (n = 882 patients) reporting on outcomes for malignant small bowel obstruction were analysed. Outcomes measured were primarily survival and relief of obstructive symptoms. The median age ranged from 52 to 66 years. The most common cause of malignant small bowel obstruction was gynaecological in nature (56%), followed by colorectal (19%). Four hundred and eighty-six patients underwent primary surgical management and the remaining 396 patients were assigned to non-surgical intervention. Median overall survival in the operative studies ranged from 2.5 to 7.4 months compared with 0.9 to 1.9 months (P < 0.05). The 30-day mortality ranged from 13% to 28% in those who underwent surgical interventions versus 2% to 61% in the non-surgical group (P = 0.09). No significant difference in median survival in gastrointestinal (GI) and gynaecological malignancies was observed (4.3 versus 5.0 months, P = 0.12). Morbidity ranged from 21% to 85% in the surgical group and 12% to 29% in the percutaneous groups (P < 0.05). CONCLUSION Surgical intervention in malignant small bowel obstruction is associated with significant morbidity, although it may improve survival in selected patients with gynaecological and colorectal malignancy. It is imperative that realistic goals and expectations are discussed with patients preoperatively.
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Affiliation(s)
- Samuel P Banting
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Peadar S Waters
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Oliver Peacock
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Vignesh Narasimhan
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew C Lynch
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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19
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Noh JH, Na HK, Ahn JY, Hong SK, Kim J, Yang J, Jung HY. Clinical Outcomes of Enteral Feeding Protocol Via Percutaneous Endoscopic Gastrostomy: A Single-Center, Retrospective Study. Nutr Clin Pract 2020; 36:225-232. [PMID: 32710706 DOI: 10.1002/ncp.10561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The development of the endoscopic technique has resulted in an increasing number of patients undergoing percutaneous endoscopic gastrostomy (PEG) insertion; however, the protocols for increasing the volume of feeding formula after PEG insertion have not been established. Therefore, we compared the clinical outcomes of patients receiving low- and high-volume increase in enteral feeding formula. METHODS A total of 215 patients who underwent PEG insertion between January 2016 and March 2019 were included. They were divided into 2 groups according to the increase in volume of feeding formula: the low-volume group (n = 135) received ≤150 mL/d, and the high-volume group (n = 80) received ≥300 mL/d. Patient characteristics, procedure, and feeding-related clinical outcomes were retrospectively reviewed using medical records. RESULTS The adverse events of the feeding protocol did not significantly differ between the 2 groups. The number of days needed to attain the calorie targets was significantly lower in the high-volume group than in the low-volume group (5.4 ± 3.0 vs 2.4 ± 1.5; P < .001). The duration of supplemental parenteral nutrition and the length of hospitalization were also significantly lower in the high-volume group (3.9 ± 3.3 vs 1.2 ± 2.2; P < .001 and 5.8 ± 2.7 vs 4.6 ± 2.6; P = .007, respectively). CONCLUSION To rapidly attain the calorie targets in appropriately selected patients with PEG insertion, a high-volume increase in daily feeding can safely be recommended given the favorable outcomes.
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Affiliation(s)
- Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea.,Nutritional Support Team, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Suk-Kyung Hong
- Nutritional Support Team, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Jiyoun Kim
- Nutritional Support Team, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Jina Yang
- Nutritional Support Team, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
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20
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The Chicago Consensus on Peritoneal Surface Malignancies: Palliative Care Considerations. Ann Surg Oncol 2020; 27:1798-1804. [PMID: 32285272 DOI: 10.1245/s10434-020-08323-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Indexed: 01/22/2023]
Abstract
The Chicago Consensus Working Group provides multidisciplinary recommendations for palliative care specifically related to peritoneal surface malignancies. These guidelines are developed with input from leading experts including surgical oncologists, medical oncologists, gynecologic oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.
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21
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The Chicago Consensus on peritoneal surface malignancies: Palliative care considerations. Cancer 2020; 126:2571-2576. [PMID: 32282059 DOI: 10.1002/cncr.32826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/14/2019] [Indexed: 11/12/2022]
Abstract
The Chicago Consensus Working Group provides multidisciplinary recommendations for palliative care specifically related to peritoneal surface malignancies. These guidelines are developed with input from leading experts including surgical oncologists, medical oncologists, gynecologic oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.
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Affiliation(s)
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- Chicago Consensus Working Group, Chicago, Illinois
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22
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Singh Curry R, Evans E, Raftery AM, Hiscock J, Poolman M. Percutaneous venting gastrostomy/gastrojejunostomy for malignant bowel obstruction: a qualitative study. BMJ Support Palliat Care 2019; 9:381-388. [PMID: 31597626 DOI: 10.1136/bmjspcare-2019-001866] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/05/2019] [Accepted: 09/19/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Malignant bowel obstruction (MBO) is a complication of advanced malignancy and is associated with a short prognosis. MBO can infrequently be reversed by surgery or stenting. The focus of treatment is usually symptomatic management, of which percutaneous venting gastrostomy/gastrojejunostomy (PVG) is one consideration. There is little data considering the impact of PVG on quality of life; we therefore aimed to explore this. METHODS We identified patients with a PVG inserted for MBO and those who consented to participate were interviewed. The interviews were audio recorded, transcribed and analysed using Framework. Alongside patient interviews, a data collection tool was designed and used to record patient demographics and medical information, enabling us to contextualise individual patients' experiences. RESULTS 11 patients were interviewed and 10 patients' data were analysed (1 patient withdrew). No patients regretted having a PVG and many benefitted symptomatically and psychosocially. Challenges encountered included practical issues, pain and PVG tube complications. CONCLUSIONS The analysis provided a detailed insight into the impact of PVG insertion and demonstrated that each patient's experience is shaped by a complex interplay of individual factors, thereby highlighting the need to improve referral criteria and individualise patient selection. Other service improvements include enhancing information provision for patients and training for healthcare professionals, thus aiming to mitigate the challenges experienced. Our study is the first in-depth exploration of patients' experiences of PVG at a tertiary cancer centre. Ensuring that the insights from this study are fed back to guide future service provision is critical in enhancing future patient experiences.
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Affiliation(s)
| | - Elizabeth Evans
- Palliative Care Department, Betsi Cadwaladr University Health Board, Bangor, UK
| | - Anne-Marie Raftery
- The Supportive Care Team, The Christie NHS Foundation Trust, Manchester, UK
| | - Julia Hiscock
- Bangor Institute for Health & Medical Research, Bangor University, Bangor, UK
| | - Marlise Poolman
- Bangor Institute for Health & Medical Research, Bangor University, Bangor, UK
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23
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A randomized, controlled trial of the efficacy of percutaneous transesophageal gastro-tubing (PTEG) as palliative care for patients with malignant bowel obstruction: the JIVROSG0805 trial. Support Care Cancer 2019; 28:2563-2569. [PMID: 31494734 DOI: 10.1007/s00520-019-05066-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 08/28/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND A randomized, controlled trial to evaluate the superiority of percutaneous transesophageal gastro-tubing over nasogastric tubing as palliative care for bowel obstruction in patients with terminal malignancy was conducted. SUBJECTS AND METHODS The subjects were patients with malignant bowel obstruction with no prospect of improvement, for whom surgery was not indicated and with a Palliative Prognostic Index of < 6. They were randomly allocated in a 1:1 ratio to receive either percutaneous transesophageal gastro-tubing (PTEG group) or nasogastric tubing (NGT group). Their symptom scores (the worst 0 to no symptoms 10) were measured for a 2-week period after enrollment, and the areas under the curves for the two groups were compared. The EQ-5D and SF-8 were also used to assess overall quality of life. RESULTS Forty patients were enrolled between October 2009 and January 2015, with 21 allocated to the PTEG group and 19 to the NGT group. The mean areas under the curves (95% confidence intervals) for the PTEG group and the NGT groups were 149.6 (120.3-178.8) and 44.9 (16.4-73.5), respectively, significantly higher for the NGT group (p < 0.0001). The secondary endpoints of quality of life as assessed by the EQ-5D and SF-8 scores were also significantly higher for patients in the PTEG group (p = 0.0036, p = 0.0020). There was no difference in survival between the groups. No serious adverse events were observed. CONCLUSIONS In terms of quality of life, percutaneous transesophageal gastro-tubing was superior to nasogastric tubing as palliative care for patients with bowel obstruction due to terminal malignancy.
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24
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Thampy S, Najran P, Mullan D, Laasch HU. Safety and Efficacy of Venting Gastrostomy in Malignant Bowel Obstruction: A Systematic Review. J Palliat Care 2019; 35:93-102. [PMID: 31448682 DOI: 10.1177/0825859719864915] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Malignant bowel obstruction (MBO) is a common manifestation in patients with advanced intra-abdominal malignancy. It is especially common with bowel or gynecological cancers and produces distressing symptoms, including nausea, vomiting, and pain. Medical management options are less effective than decompressive strategies for symptom control. Surgery is the gold-standard treatment but is unsuitable for most patients with high complication rates. Consensus guidelines recommend nonsurgical management with a venting gastrostomy in those unsuitable for surgery or for whom medical management is ineffective. The aim of this systematic review is to establish the safety and efficacy of percutaneous venting gastrostomy in relieving symptoms of MBO. Twenty-five studies were included in this review comprising 1194 patients. Gastrostomy insertion was successful at first attempt in 91% of cases and reduction in symptoms of nausea and vomiting was reported in 92% of cases. Mean survival following the procedure ranged from 35 to 147 days. Major complications were rare, with most complications classed as minor wound infections or leakage of fluid around the tube. Studies suggest that the presence of ascites is not an absolute contraindication to the insertion of percutaneous venting gastrostomy in patients with MBO; however, these studies lack longitudinal outcomes and complication rates related to this. However, it is reasonable to suggest that ascitic drainage is performed to reduce potential complications. There is a relative lack of good quality robust data on the utilization of percutaneous venting gastrostomy in MBO, but overall, the combination of being a safe and efficacious procedure alongside the known complication profile suggests that it should be considered a suitable management option.
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Affiliation(s)
- Sreeharshan Thampy
- Department of Interventional Radiology, Christie NHS Foundation Trust, Manchester, UK
| | - Pavan Najran
- Department of Interventional Radiology, Christie NHS Foundation Trust, Manchester, UK
| | - Damian Mullan
- Department of Interventional Radiology, Christie NHS Foundation Trust, Manchester, UK
| | - Hans-Ulrich Laasch
- Department of Interventional Radiology, Christie NHS Foundation Trust, Manchester, UK
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25
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Hisanaga T, Shinjo T, Imai K, Katayama K, Kaneishi K, Honma H, Takagaki N, Osaka I, Matsuo N, Kohara H, Yamaguchi T, Nakajima N. Clinical Guidelines for Management of Gastrointestinal Symptoms in Cancer Patients: The Japanese Society of Palliative Medicine Recommendations. J Palliat Med 2019; 22:986-997. [DOI: 10.1089/jpm.2018.0595] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Takayuki Hisanaga
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Takuya Shinjo
- Department of Palliative Medicine, Shinjo Clinic, Kobe, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Kanji Katayama
- Cancer Care Promotion Center, University of Fukui, Fukui, Japan
| | - Keisuke Kaneishi
- Palliative Care Unit, JCHO Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Hideyuki Honma
- Department of Palliative Care, Niigata Cancer Center Hospital, Niigata, Japan
| | | | - Iwao Osaka
- Department of Palliative Care, HITO Medical Center, Ehime, Japan
| | - Naoki Matsuo
- Hospice, Medical Corporation Junkei-kai Sotosahikawa Hospital, Akita, Japan
| | - Hiroyuki Kohara
- Department of Palliative Care, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | | | - Nobuhisa Nakajima
- Department of Community-based Medicine and Primary Care, University of the Ryukyus, Okinawa, Japan
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Iwase R, Suzuki Y, Yamanouchi E, Suzuki N, Imakita T, Tsutsui N, Odaira H, Yanaga K. Double Percutaneous Transesophageal Gastrotubing for Gastric Cancer: A Pilot Study. J Surg Res 2018; 232:470-474. [PMID: 30463759 DOI: 10.1016/j.jss.2018.05.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 05/12/2018] [Accepted: 05/23/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND The management of gastric cancer causing gastric outlet obstruction and dilatation must include decompression of the stomach and intravenous nutrition. Percutaneous transesophageal gastrotubing (PTEG) is an effective technique for either gastric decompression or enteral nutrition. Here, we investigated the efficacy and safety of double PTEG (dPTEG), that is, using PTEG for both purposes simultaneously, in patients with gastric cancer. MATERIALS AND METHODS Eleven patients with gastric outlet obstruction due to gastric cancer were admitted to our hospital between January 2015 and March 2017 and enrolled in this study. Each patient underwent dPTEG as soon as possible. After dPTEG tubes were placed, gastric decompression was started immediately and enteral nutrition was started within 1 d. Feeding and decompression through the double tubes were continued until the day before operation. Using data from these patients, we investigated the efficacy and safety of dPTEG. RESULTS dPTEG was performed successfully in all patients and no critical adverse effects were observed. Eight of the 11 patients underwent radical or palliative resection. Decompression of the stomach was achieved and nutritional status was significantly improved after dPTEG in all patients. CONCLUSIONS We conclude that dPTEG is a safe and effective management technique for patients with gastric outlet obstruction and gastric dilatation due to gastric cancer.
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Affiliation(s)
- Ryota Iwase
- Department of Surgery, International University of Health and Welfare Hospital, Tochigi, Japan; Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Yutaka Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Eigoro Yamanouchi
- Department of Radiology, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Norihiko Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Tomonori Imakita
- Department of Surgery, International University of Health and Welfare Hospital, Tochigi, Japan; Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuhiro Tsutsui
- Department of Surgery, International University of Health and Welfare Hospital, Tochigi, Japan; Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hironori Odaira
- Department of Surgery, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Lilley EJ, Scott JW, Goldberg JE, Cauley CE, Temel JS, Epstein AS, Lipsitz SR, Smalls BL, Haider AH, Bader AM, Weissman JS, Cooper Z. Survival, Healthcare Utilization, and End-of-life Care Among Older Adults With Malignancy-associated Bowel Obstruction: Comparative Study of Surgery, Venting Gastrostomy, or Medical Management. Ann Surg 2018; 267:692-699. [PMID: 28151799 PMCID: PMC7509894 DOI: 10.1097/sla.0000000000002164] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO). BACKGROUND MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life. METHODS Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital. RESULTS Median survival after MBO admission was 76 days (interquartile range 26-319 days). Survival was shorter after VGT [38 days (interquartile range 23-69)] than medical management [72 days (23-312)] or surgery [128 days (42-483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29-0.58)], increased hospice enrollment [1.65 (1.42-1.91)], and less ICU care [0.69 (0.52-0.93)] and in-hospital death [0.47 (0.36-0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59-0.80)], decreased hospice enrollment [0.84 (0.76-0.92)], and higher likelihood of ICU care [1.38 (1.17-1.64)]. CONCLUSIONS VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients' priorities for end-of-life care.
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Affiliation(s)
- Elizabeth J. Lilley
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - John W. Scott
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - Christy E. Cauley
- Ariadne Labs, Boston, MA
- Department of Surgery, Massachusetts General Hospital, Boston
| | | | - Andrew S. Epstein
- Gastrointestinal Medical Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stuart R. Lipsitz
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Brittany L. Smalls
- Center for Health Services Research, University of Kentucky College of Medicine, Lexington, KY
| | - Adil H. Haider
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Angela M. Bader
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joel S. Weissman
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Zara Cooper
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
- Ariadne Labs, Boston, MA
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Miller ZA, Mohan P, Tartaglione R, Narayanan G. Bowel Obstruction: Decompressive Gastrostomies and Cecostomies. Semin Intervent Radiol 2017; 34:349-360. [PMID: 29249859 DOI: 10.1055/s-0037-1608706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Over the past 30 years, image-guided placement of gastrostomies and cecostomies for gastrointestinal decompression has developed into a safe and effective treatment for symptomatic bowel obstruction. Gastrostomies and cecostomies relieve patient symptoms, can prevent serious complications such as colonic perforation, and may bridge patients to more definitive treatment for the underlying cause of obstruction. This article will review the history of decompressive gastrostomies and cecostomies as well as the indications, contraindications, technique, complications, and outcomes of these procedures.
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Affiliation(s)
- Zoe A Miller
- Department of Interventional Radiology, University of Miami-Miller School of Medicine, Miami, Florida
| | - Prasoon Mohan
- Department of Interventional Radiology, University of Miami-Miller School of Medicine, Miami, Florida
| | - Robert Tartaglione
- Department of Interventional Radiology, University of Miami-Miller School of Medicine, Miami, Florida
| | - Govindarajan Narayanan
- Department of Interventional Radiology, University of Miami-Miller School of Medicine, Miami, Florida
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Ohkubo H, Fuyuki A, Arimoto J, Higurashi T, Nonaka T, Inoh Y, Iida H, Inamori M, Kaneda T, Nakajima A. Efficacy of percutaneous endoscopic gastro-jejunostomy (PEG-J) decompression therapy for patients with chronic intestinal pseudo-obstruction (CIPO). Neurogastroenterol Motil 2017. [PMID: 28631871 DOI: 10.1111/nmo.13127] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUNDS Chronic intestinal pseudo-obstruction (CIPO) is an intractable rare digestive disease manifesting persistent small bowel distension without any mechanical cause. Intestinal decompression is a key treatment, but conventional method including a trans-nasal small intestinal tube is invasive and painful. Therefore, a less invasive and tolerable new decompression method is urgently desired. We conducted a pilot study and assessed the efficacy and safety of percutaneous endoscopic gastro-jejunostomy (PEG-J) decompression therapy in CIPO patients. METHODS Seven definitive CIPO patients (2 males and 5 females) were enrolled. All patients received PEG-J decompression therapy. The number of days with any abdominal symptoms in a month (NODASIM), body mass index (BMI), serum albumin level (Alb), and small intestinal volume before and after PEG-J were compared in all patients. RESULTS Percutaneous endoscopic gastro-jejunostomy was well tolerated and oral intake improved in all patients. NODASIM has significantly decreased (24.3 vs 9.3 days/months) and BMI/Alb have significantly increased (14.9 vs 17.2 kg/m2 and 2.6 vs 3.8 g/dL, respectively), whereas total volume of the small intestine has not significantly reduced (4.05 vs 2.59 L, P=.18). Reflux esophagitis and chemical dermatitis were observed in one case but was successfully treated conservatively. CONCLUSIONS & INFERENCES Percutaneous endoscopic gastro-jejunostomy decompression therapy can contribute greatly to improvement of abdominal symptoms and nutritional status in CIPO patients. Although sufficient attention should be paid to acid reflux symptoms, PEG-J has the potential to be a non-invasive novel decompression therapy for CIPO available at home. However, accumulation of more CIPO patients and long-term observation are needed (UMIN000017574).
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Affiliation(s)
- H Ohkubo
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - A Fuyuki
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - J Arimoto
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - T Higurashi
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - T Nonaka
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan
| | - Y Inoh
- Department of Medical Education, Yokohama City University School of Medicine, Yokohama, Japan
| | - H Iida
- Department of Medical Education, Yokohama City University School of Medicine, Yokohama, Japan
| | - M Inamori
- Department of Medical Education, Yokohama City University School of Medicine, Yokohama, Japan
| | - T Kaneda
- Department of Radiology, Yokohama City University School of Medicine, Yokohama, Japan
| | - A Nakajima
- Hepatology and Gastroenterology Division, Yokohama City University School of Medicine, Yokohama, Japan
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Rami Reddy SR, Cappell MS. A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction. Curr Gastroenterol Rep 2017; 19:28. [PMID: 28439845 DOI: 10.1007/s11894-017-0566-9] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy. RECENT FINDINGS SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.
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Affiliation(s)
- Srinivas R Rami Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, 3535 West Thirteen Mile Road, Royal Oak, MI, 48073, USA
| | - Mitchell S Cappell
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, 3535 West Thirteen Mile Road, Royal Oak, MI, 48073, USA.
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, 48073, USA.
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Dittrich A, Schubert B, Kramer M, Lenz F, Kast K, Schuler U, Schuler MK. Benefits and risks of a percutaneous endoscopic gastrostomy (PEG) for decompression in patients with malignant gastrointestinal obstruction. Support Care Cancer 2017; 25:2849-2856. [DOI: 10.1007/s00520-017-3700-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 03/31/2017] [Indexed: 11/24/2022]
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Zucchi E, Fornasarig M, Martella L, Maiero S, Lucia E, Borsatti E, Balestreri L, Giorda G, Annunziata MA, Cannizzaro R. Decompressive percutaneous endoscopic gastrostomy in advanced cancer patients with small-bowel obstruction is feasible and effective: a large prospective study. Support Care Cancer 2016; 24:2877-82. [PMID: 26838026 DOI: 10.1007/s00520-016-3102-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/24/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study was to evaluate patient-centered outcomes of decompressive percutaneous endoscopic gastrostomy (dPEG) in patients with malignant bowel obstruction due to advanced gynecological and gastroenteric malignancies. METHODS This is a prospective analysis of 158 consecutive patients with small-bowel obstruction from advanced gynecological and gastroenteric cancer who underwent PEG or percutaneous endoscopic jejunostomy (PEJ) positioning for decompressive purposes from 2002 to 2012. All of them had previous abdominal surgery and were unfit for any other surgical procedures. Symptom relief, procedural complications, and post dPEG palliation were assessed. Global Quality of Life (QoL) was evaluated in the last 2 years (25 consecutive patients) before and 7 days after dPEG placement using the Symptom Distress Scale (SDS). RESULTS dPEG was successfully performed in 142 out of 158 patients (89.8 %). Failure of tube placement occurred in 16 patients (10.1 %). In 8/142 (5.6 %) patients, dPEG was guided by abdominal ultrasound. In 3/142 patients, dPEG was CT-guided. In 14 (9.8 %) patients, who had previously undergone total or subtotal gastrectomy, decompressive percutaneous endoscopic jejunostomy (dPEJ) was performed. In 1/14 patients, dPEJ was CT-guided. Out of 142 patients, 110 (77.4 %) experienced relief from nausea and vomiting 2 days after PEG. Out of 142 patients, 116 (81.6 %) were discharged. The median postoperative hospital stay was 9 days (range 3-60). Peristomal infection (14 %) and intermittent obstruction (8.4 %) were the most frequent complications associated with PEG. Median survival time was 57 days (range 4-472) after PEG placement. Twenty-five patients had QoL properly evaluated with SDS score before and 7 days after dPEG. Sixteen patients (64 %) out of 25 exhibited an improvement of QoL (p < 0.05), 7 (28 %) patients exhibited a non-significant worsening of QoL (p = 0.18), and in 2 (8 %) patients, it remained unmodified. CONCLUSIONS dPEG is feasible, effective, relieves nausea and vomiting in patients with unremitting small-bowel obstruction from advanced gynecological and gastroenteric cancer, and improves QoL.
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Affiliation(s)
- Elena Zucchi
- Department of Gastroenterology, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Via Franco Gallini, 2 33081, Aviano, PN, Italy
| | - Mara Fornasarig
- Department of Gastroenterology, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Via Franco Gallini, 2 33081, Aviano, PN, Italy
| | - Luca Martella
- Department of Surgery, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Aviano, PN, Italy
| | - Stefania Maiero
- Department of Gastroenterology, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Via Franco Gallini, 2 33081, Aviano, PN, Italy
| | - Emilio Lucia
- Division of Gynecologic Oncology, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Aviano, PN, Italy
| | - Eugenio Borsatti
- Department of Nuclear Medicine, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Aviano, PN, Italy
| | - Luca Balestreri
- Department of Radiology, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Aviano, PN, Italy
| | - Giorgio Giorda
- Division of Gynecologic Oncology, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Aviano, PN, Italy
| | - Maria Antonietta Annunziata
- Unit of Oncological Psychology, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Aviano, PN, Italy
| | - Renato Cannizzaro
- Department of Gastroenterology, National Cancer Institute, Centro di Riferimento Oncologico IRCCS, Via Franco Gallini, 2 33081, Aviano, PN, Italy.
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Daigle CR, Boules M, Corcelles R, McMichael J, Kroh M, El-Hayek K, Brethauer SA. Percutaneous Endoscopic Gastrostomy for Decompression of Nonmalignant Gastrointestinal Disease. J Laparoendosc Adv Surg Tech A 2015; 25:804-7. [PMID: 26394131 DOI: 10.1089/lap.2014.0619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The utility of percutaneous endoscopic gastrostomy (PEG) decompression for inoperable malignant bowel obstruction is well documented. However, there are limited data on decompressive PEG for prolonged ileus, gut dysmotility, and/or complicated nonmalignant bowel obstruction. The aim of this study was to assess the safety and short-term outcomes of decompressive PEG for nonmalignant indications. SUBJECTS AND METHODS After Institutional Review Board approval, we retrospectively reviewed and analyzed all PEG insertions completed at our institution between 2009 and 2014 for prolonged ileus, gut dysmotility, or nonmalignant obstruction. RESULTS We identified 72 patients (42 females, 30 males; mean age, 58.8 ± 15.2 years) who underwent decompressive PEG for nonmalignant indications. There were no procedural complications or mortalities. The mean pre- and postprocedural length of stays were 14.4 ± 10.7 and 7.6 ± 11.1 days, respectively (P = .0003). The 30-day re-admission rate was 12.5% (9 patients; the majority for unrelated issues). Fifty-two (72%) of the 72 patients were discharged with a PEG for decompression for a median of 69.5 (range, 17-316) days; the remaining 20 (28%) patients were lost to follow-up and were assumed to continue follow-up with their primary referring center. Of the 72 patients, 63 (87.5%) were discharged on total parenteral nutrition (TPN); 36 (50%) of those continued to receive TPN for a median of 51 (range, 4-316) days after discharge, and resolution of their mechanical obstruction was ultimately achieved, so that they subsequently resumed enteral nutrition. Twenty-four (33%) patients were lost to follow-up; because they were referred to our tertiary referral center, we assumed they continued follow-up at their referring institution. Three (4%) patients ultimately went on to use TPN indefinitely and thus were considered to be chronically TPN-dependent. CONCLUSIONS Decompressive PEG insertion is safe and effective at alleviating obstructive symptoms in patients with prolonged postoperative ileus, gut dysmotility, and/or complicated nonmalignant obstruction.
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Affiliation(s)
| | - Mena Boules
- 2 Digestive Disease Institute , Cleveland Clinic, Cleveland, Ohio
| | - Ricard Corcelles
- 1 Bariatric and Metabolic Institute , Cleveland Clinic, Cleveland, Ohio.,3 Foundation Clinic for Biomedical Research, Hospital Clinic of Barcelona, University of Barcelona , Barcelona, Spain
| | - John McMichael
- 2 Digestive Disease Institute , Cleveland Clinic, Cleveland, Ohio
| | - Matthew Kroh
- 1 Bariatric and Metabolic Institute , Cleveland Clinic, Cleveland, Ohio.,2 Digestive Disease Institute , Cleveland Clinic, Cleveland, Ohio
| | - Kevin El-Hayek
- 2 Digestive Disease Institute , Cleveland Clinic, Cleveland, Ohio.,4 Digestive Disease Institute , Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Stacy A Brethauer
- 1 Bariatric and Metabolic Institute , Cleveland Clinic, Cleveland, Ohio
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Management of intestinal obstruction in advanced malignancy. Ann Med Surg (Lond) 2015; 4:264-70. [PMID: 26288731 PMCID: PMC4539185 DOI: 10.1016/j.amsu.2015.07.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 02/07/2023] Open
Abstract
Patients with incurable, advanced abdominal or pelvic malignancy often present to acute surgical departments with symptoms and signs of intestinal obstruction. It is rare for bowel strangulation to occur in these presentations, and spontaneous resolution often occurs, so the luxury of time should be afforded while decisions are made regarding surgery. Cross-sectional imaging is valuable in determining the underlying mechanism and pathology. The majority of these patients will not be suitable for an operation, and will be best managed in conjunction with a palliative medicine team. Surgeons require a good working knowledge of the mechanisms of action of anti-emetics, anti-secretories and analgesics to tailor early management to individual patients, while decisions regarding potential surgery are made. Deciding if and when to perform operative intervention in this group is complex, and fraught with both technical and emotional challenges. Surgery in this group is highly morbid, with no current evidence available concerning quality of life following surgery. The limited evidence concerning operative strategy suggests that resection and primary anastomosis results in improved survival, over bypass or stoma formation. Realistic prognostication and involvement of the patient, care-givers and the multidisciplinary team in treatment decisions is mandatory if optimum outcomes are to be achieved.
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35
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Jeong EJ, Song HY, Park JH, Shin JH, Kim JH, Kim SH, Cho YC. Preliminary Results of Percutaneous Radiologic Gastrostomy in a Pediatric Population: A Modified Chiba-Needle Puncture Technique With Single Gastropexy. AJR Am J Roentgenol 2015; 205:W133-W137. [PMID: 26102411 DOI: 10.2214/ajr.14.12543] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2025]
Abstract
OBJECTIVE The purpose of this study was to evaluate the technical feasibility, safety, and clinical effectiveness of percutaneous radiologic gastrostomy using a modified Chiba-needle puncture technique with single gastropexy in pediatric patients. MATERIALS AND METHODS From July 2006 to December 2013, percutaneous radiologic gastrostomy was performed in 12 children (median age, 21 months; range, 6-46 months). Their stomachs were punctured using a 21-gauge Chiba needle. A single Cope gastrointestinal suture anchor was used for gastropexy, and a tube was inserted through the same tract as the anchor using a 12- or 14-French Dawson-Mueller pigtail drainage catheter. We then evaluated the technical success of the procedure, the number of puncture attempts using a 21-gauge Chiba needle, the procedure time, complications, and treatment of complications. RESULTS Percutaneous radiologic gastrostomy was technically successful in all patients. Only a single puncture attempt was required in 10 patients (83%); two attempts were needed in two patients (17%). The average procedure time was 10 minutes 25 seconds (range, 5 minutes 5 seconds to 25 minutes 24 seconds). Pneumoperitoneum requiring tube exchange occurred in two of the 12 patients (17%). Two patients experienced pain immediately after the procedure. Three patients who had esophagogastric reflux after percutaneous radiologic gastrostomy underwent conversion percutaneous radiologic gastrojejunostomy. CONCLUSION Percutaneous radiologic gastrostomy using a modified Chiba-needle technique with single gastropexy in pediatric patients is technically feasible and safe.
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Affiliation(s)
- Eun Ji Jeong
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Ho-Young Song
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Jung-Hoon Park
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Ji Hoon Shin
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Jin Hyoung Kim
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Soo Hwan Kim
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Young Chul Cho
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
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Mobily M, Patel JA. Palliative percutaneous endoscopic gastrostomy placement for gastrointestinal cancer: Roles, goals, and complications. World J Gastrointest Endosc 2015; 7:364-369. [PMID: 25901215 PMCID: PMC4400625 DOI: 10.4253/wjge.v7.i4.364] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 12/11/2014] [Accepted: 01/12/2015] [Indexed: 02/05/2023] Open
Abstract
Percutaneous endoscopic gastrostomy tube placement is an invaluable tool in clinical practice that has an important role in the palliative care of patients with gastrointestinal cancer. While there is no extensive data regarding the use of this procedure in patients with gastrointestinal malignancy, inferences can be made from the available information derived from studies of similar or mixed populations. Percutaneous endoscopic gastrostomy tubes can be used to provide enteral nutrition for terminal malignancies of the upper gastrointestinal tract as well as for decompression of malignant obstructions. The rates of successful placement for cancer patients with either of these indications are high, similar to those in mixed populations. There is no conclusive evidence that the procedure will help patients reach nutritional goals for those needing alimental supplementation. However, it is effective at relieving symptoms caused by malignant obstruction. A high American Society of Anesthesiologist physical status score and an advanced tumor stage have been shown to be independent predictors of poor outcomes following placement in cancer patients. This suggests the potential for similar outcomes in the palliative care of patients with advanced stage gastrointestinal cancer who may be in relatively poor physiologic condition. However, this potential should not preclude its use in patients with terminal gastrointestinal cancer considering the high rate of successful tube placement, the possible benefits and the ultimate goal of comfort in palliative care.
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Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World J Gastroenterol 2014; 20:7739-7751. [PMID: 24976711 PMCID: PMC4069302 DOI: 10.3748/wjg.v20.i24.7739] [Citation(s) in RCA: 325] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 02/26/2014] [Accepted: 04/08/2014] [Indexed: 02/06/2023] Open
Abstract
Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the "pull" technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.
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Baichoo E, Wong Kee Song LM. Palliative enteroscopic stent placement for malignant mid-gut obstruction. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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