Percutaneous endoscopic gastrostomy tube placement for end-stage palliation of malignant gastrointestinal obstructions

Inoperable malignant bowel obstruction: palliative interventions outcomes - mixed-methods systematic review

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.

Endoscopic Nutrition of Patients with Cancer

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.

When Should the Appropriateness of PEG be Questioned?

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.

MASCC multidisciplinary evidence-based recommendations for the management of malignant bowel obstruction in advanced cancer

PURPOSE

To provide evidence-based recommendations on the management of malignant bowel obstruction (MBO) for patients with advanced cancer.

METHODS

The Multinational Association for Supportive Care in Cancer (MASCC) MBO study group conducted a systematic review of databases (inception to March 2021) to identify studies about patients with advanced cancer and MBO that reported on the following outcomes: symptom management, bowel obstruction resolution, prognosis, overall survival, and quality of life. The review was restricted to studies published in English, but no restrictions were placed on publication year, country, and study type. As per the MASCC Guidelines Policy, the findings were synthesized to determine the levels of evidence to support each MBO intervention and, ultimately, the graded recommendations and suggestions.

RESULTS

The systematic review identified 17,656 published studies and 397 selected for the guidelines. The MASCC study group developed a total of 25 evidence-based suggestions and recommendations about the management of MBO-related nausea and vomiting, bowel movements, pain, inflammation, bowel decompression, and nutrition. Expert consensus-based guidance about advanced care planning and psychosocial support is also provided.

CONCLUSION

This MASCC Guideline provides comprehensive, evidence-based recommendations about MBO management for patients with advanced cancer.

Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices

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.

Safety and Efficacy of Venting Gastrostomy in Malignant Bowel Obstruction: A Systematic Review

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.

Surgical Management for Gastroparesis

Gastroparesis is a debilitating chronic condition of indeterminate cause. Although conservative management is the mainstay of treatment, a significant percentage of patients will need interventions. Interventions range from supportive measures, such as feeding tubes, to more radical surgeries, including endoscopic pyloromyotomy (per oral pyloromyotomy), laparoscopic pyloroplasty, laparoscopic gastric stimulator placement, and even subtotal or total gastrectomy. The authors present some current treatment algorithms focused on the treatment side of the spectrum along with outcomes data to support the various approaches.

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

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.

Drainage Percutaneous Endoscopic Gastrostomy for Malignant Bowel Obstruction in Gastrointestinal Cancers: Prognosis and Implications for Timing of Palliative Intervention

BACKGROUND

Malignant bowel obstruction (MBO) is a frequent complication in patients with advanced solid tumors. Palliative relief may be achieved by the use of a drainage percutaneous endoscopic gastrostomy (dPEG) tube, although optimal timing of placement remains unknown.

OBJECTIVES

To determine median survival after diagnosis of MBO and dPEG placement, factors associated with worse survival in MBO, factors associated with receipt of dPEG, and association of timing of dPEG placement on survival.

METHODS

This observational retrospective cohort study examined 439 patients with MBO on a gastrointestinal medical oncology inpatient service. Patients were characterized by age, gender, race, primary cancer type, length of stay, readmission, complications (aspiration pneumonia or bowel perforation), and receipt of dPEG. Select factors were analyzed to examine overall survival (OS) and dPEG placement.

RESULTS

Median survival from diagnosis of first MBO was 2.5 months. Median survival after dPEG placement was 37 days. In univariate analysis, dPEG placement, complications, longer length of stay, and readmissions were significantly associated with worse OS. Receipt of dPEG was significantly associated with younger age, longer length of stay at first admission, and shorter interval to readmission. In patients who received dPEG, longer interval from MBO diagnosis to dPEG placement did not affect OS.

CONCLUSION

We found that prognosis following diagnosis of MBO in patients with gastrointestinal malignancies remains poor. Our data suggest that timing of dPEG placement in MBO does not affect OS and, therefore, earlier intervention with this procedure may allow earlier and prolonged palliative relief.

Cervical Esophago-Gastric Tubes for Patients with Malignant Ascites

Patients with chronic small bowel obstruction and malignant ascites from diffuse peritoneal carcinomatosis have limited options for gastrointestinal decompression as part of end-of-life palliation. Insertion of a percutaneous gastrostomy tube is relatively contraindicated in patients with ascites. Alternatively, nasogastric tube placement often leads to significant discomfort to patients and necessitates hospitalization during their last days of life. Here, we demonstrate how placing a percutaneous cervical esophago-gastric tube can allow adequate gastrointestinal decompression for terminal patients with malignant small bowel obstruction. This palliative measure allows them to remain in the comfort of their own homes after the procedure.

Palliative percutaneous endoscopic gastrostomy placement for gastrointestinal cancer: Roles, goals, and complications

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.

Percutaneous endoscopic gastrostomy for decompression of malignant bowel obstruction

BACKGROUND

Previous reports on percutaneous endoscopic gastrostomy (PEG) for bowel decompression have included a relatively small number of patients and the details of post-procedural outcomes and complications are lacking. The aim of the present study was to evaluate the outcomes and safety of PEG for bowel decompression in a relatively large number of patients with malignant bowel obstruction.

PATIENTS AND METHODS

Over a 10-year period, 76 patients with malignant bowel obstruction were referred to the main referral cancer center in Shizuoka prefecture for PEG to obtain decompression. The method for gastrostomy was carried out by the pull-method, the modified introducer method and the percutaneous endoscopic gastrojejunostomy method. Patient demographics, procedural success, complications, elimination of nasal intubation, and survival were reviewed.

RESULTS

Successful placement was achieved in 93% of patients (71/76). Procedure-related complications occurred in 21% ofpatients (15/71), of which the majority involved stomal leakage (eight patients), and wound infection (six patients). There were no procedure-related deaths. Among the 55 patients who required nasal intubation before PEG, a trans-gastrostomy intestinal tube was inserted in 16 patients. The need for further nasal intubation was eliminated in 96% of the patients (53/55). The median survival time was 63 days (range, 8-444 days) after PEG placement.

CONCLUSIONS

PEG for bowel decompression in patients with malignant obstruction can be carried out with an acceptable risk of minor complications. In combination with a trans-gastrostomy intestinal tube insertion, the elimination of nasal intubation can be achieved in most patients.

Palliative venting percutaneous endoscopic gastrostomy tube is safe and effective in patients with malignant obstruction

BACKGROUND AND STUDY AIMS

Obstructive symptoms are common in advanced malignancies. Venting percutaneous endoscopic gastrostomy (VPEG) tubes can be placed for palliation. The aim of this study was to determine the outcomes of VPEG placement in patients with advanced malignancy.

METHODS

We retrospectively reviewed patients in whom a VPEG tube was attempted for a malignant indication from 1998 to 2010 at a tertiary care center. Clinical information, procedure details, and adverse events (AEs) were recorded.

RESULTS

Ninety-six patients meeting the inclusion criteria were identified. Colorectal (27 %), pancreas (18.8 %), and gynecologic (17.7 %) malignancies were most common. Overall, 46.9 % of patients had ascites, with 35.6 % undergoing drainage prior to VPEG placement. VPEG placement was successful in 89 patients (92.7 %), and relief of obstructive symptoms was observed in 91.0 % of patients. Seven patients had refractory symptoms despite functioning VPEG tube. Ten post-procedural AEs were noted in nine patients, with one death. Infectious complications were more common in patients with ascites (12.2 %) versus those without (0 %; p = 0.02). There was a trend towards decreased infectious AEs when ascites was drained prior to VPEG (14.8 vs. 7.1 %; p = 0.64) in our patient cohort. We observed a decreased survival when AEs occurred (73 ± 47.8 days) compared with when they did not occur (141 ± 367.8 days; p = 0.61).

CONCLUSIONS

VPEG tubes can be safely placed in patients with obstructive symptoms due to inoperable malignancy, with complete relief in the majority of patients. Ascites was a risk factor for post-procedural infectious AEs. Drainage of ascites prior to VPEG tube placement may decrease this risk, although this requires further study.

Safety and efficacy of radiological percutaneous jejunostomy for decompression of malignant small bowel obstruction. Eur Radiol. 2013;23:2747-2753. [PMID: 23657289 DOI: 10.1007/s00330-013-2883-1]

OBJECTIVES

This study aimed to evaluate the safety and efficacy of percutaneous radiological jejunostomy (PRJ) and stent placement in patients with malignant small bowel obstructions (MSBO).

METHODS

A total of 21 patients (mean age 60 years) with single (n = 4) or multiple (n = 17) MSBO underwent PRJ following jejunopexy. The medical records and imaging studies were retrospectively reviewed to evaluate the technical/clinical success and complications. Clinical success was determined by symptomatic relief and radiologic bowel decompression.

RESULTS

PRJ using a 12- or 14-F drainage catheter was technically successful in all patients. Eleven patients required placement of an 18-F nasogastric tube across one (n = 3), two (n = 6) and three (n = 2) obstructions to achieve clinical success. Subsequently, self-expandable stents were placed through the PRJ tracts to recanalise MSBO in four patients. Clinical success was achieved in 18 patients (85.7 %). The median food intake capacity score improved from 4.0 to 2.0 (P = 0.001). There were one major (peritonitis, 4.8 %) and six minor complications (28.6 %)

CONCLUSIONS

PRJ using a nasogastric tube across the obstructions is an effective palliative treatment for MSBO. The PRJ tract can be used as an approach route for stent placement to recanalise MSBO. However, dedicated devices should be developed to reduce frequent procedure-related complications.

KEY POINTS

• Bowel decompression provides palliative treatment in malignant small bowel obstruction • Percutaneous radiological jejunostomy (PRJ) is a safe and effective palliative treatment. • Long tube placement across obstructions facilitates adequate drainage of multiple bowel obstructions. • PRJ tract can be used for stent placement to approach MSBO recanalisation.