Management of bowel obstruction in advanced cancer

Bowel obstruction is a common and distressing outcome in patients with abdominal or pelvic cancer. Patients may develop bowel obstruction at any time in their clinical history, with a prevalence ranging from 5.5% to 42% in those with ovarian cancer and from 10% to 28.4% in those with colorectal cancer. The causes of the obstruction may be benign postoperative adhesions, a focal malignant or benign deposit, or relapse or diffuse carcinomatosis. The symptoms, which are almost always present, are intestinal colic, continuous abdominal pain, nausea, and vomiting. Although surgery should be the primary treatment for malignant obstruction, it is now recognized that some patients with advanced disease or in generally poor condition are unfit for surgery and require alternative management to relieve distressing symptoms. A number of treatment options are now available for the patient with advanced cancer who develops intestinal obstruction. In this review, the indications for surgery are examined, the use of nasogastric tube and percutaneous gastrostomy evaluated, and the pharmacologic approach described.

Surgical management of pure pancreatic fistulas

This paper reports on 13 patients with pure pancreatic fistulas defined as persistent lesions originating directly from the gland tissue and not from a pancreatico-intestinal or pancreatico-gastric anastomosis. Six fistulas were external and seven internal. All external fistulas were postoperative whereas all the internal ones were due to chronic pancreatitis. Conservative treatment of 2 to 36 months duration was unsuccessful, so that all patients underwent surgery. To establish a proper surgical strategy, preoperative mapping of the fistula by endoscopic retrograde cholangiopancreaticography (ERCP), fistulography and/or computerized tomography proved of value. In eleven patients, pancreatic fistula flow was surgically redirected into the gastrointestinal tract, while the remaining two were submitted to a pancreatic left resection. There were no hospital deaths and the complication rate was low. During the follow-up time of 6 to 96 months no recurrent fistulas were seen.

Massive and recurrent gastrointestinal hemorrhage due to jejunal varices in an afferent loop--diagnosis and management

Bleeding from "ectopic" varices outside the gastroesophageal region is an uncommon complication of portal hypertension. Although the high mortality rate of bleeding duodenal varices has been emphasized (1-4), an awareness of the condition and its characteristic presentation may enable diagnostic and therapeutic procedures to be performed rapidly with an increased likelihood of a successful outcome. This report describes a patient with recurrent, frequent and massive hemorrhage from jejunal varices in the afferent loop after a Billroth II resection, chronic pancreatitis and portal hypertension; the diagnosis and management of this unusual case of recurrent gastrointestinal bleeding are discussed.

Temporomandibular joint contracture in spastic quadriplegia: effect on oral-motor skills

This study assessed the temporomandibular joint of 34 children with spastic quadriplegic cerebral palsy for contractures to determine whether joint abnormalities were related to oral-motor dysfunction. Subjects were found to have restrictions in mandibular range of motion, increased overjet and decreased overbite. Increased overjet corresponds to retrognathia and decreased overbite relates to fixed posterior rotation of the mandible. The severity of many of these abnormalities correlated with the severity of oral-motor dysfunction. Abnormalities in overbite were particularly significant. The authors conclude that temporomandibular joint contractures in this population are related to problems in oral-motor function. It is hoped that further research in this area will lead to new therapies for children with feeding and swallowing problems.

Oral Candida colonizes the stomach and gastrostomy feeding tubes

The lumen of gastrostomy tubes is frequently colonized with Candida. To investigate the source of this contamination, 20 consecutive malnourished patients undergoing placement of a percutaneous endoscopic gastrostomy tube and ten ambulatory controls having routine upper endoscopy performed had both their oral cavity and gastric antrum swabbed and cultured. Percutaneous endoscopic gastrostomy tube recipients who after several weeks were still under our care (9 of 20) had the lumen of their tubes cultured. Fungi were isolated from the stomach in 13 (65%) of 20 patients undergoing percutaneous endoscopic gastrostomy tube placement but in only 1 of 10 ambulatory patients (p < .01). The species isolated from the oral cavity, the stomach, and later the gastrostomy tube were identical in most cases. We conclude that gastrostomy tubes are probably colonized by oral organisms that have made their way into the stomach.

[The protection of gut mucosa with early enteral feeding in burned rabbits]

The mechanisms of the protection of gut mucosa with early enteral feeding in burns were investigated. A 25% TBSA burn rabbit model, in which a gastrostomy, and a blind segment of the jejunum were formed before the thermal injury. 39 rabbits were randomly divided into three groups: A. burn and feeding with the nutritional fluid within 30 minutes postburn through gastrostomy. B. same as A except feeding with cold water instead of nutritional fluid; and C. no burn and fed freely. The results showed that burn injury caused an increase in mucosal oxygen consumption, intestinal uric acid formation and MDA (malondialdehyde) production, and decrease in submucosal blood flow. However, these were significantly improved by early enteral feeding after burn injury. The changes in the mucosa of the jejunal blind segment were similar to that of the rest of jejunum. It indicated that the effect of enteral feeding might be a systemic as well as a local one. It is concluded that the early enteral feeding can maintain the mucosal function and structure of the gut, as evidenced by a decrease in the mucosal hypermetabolism, improvement in submucosal blood flow and reduction in gut injuries as a result of reperfusion.

[A gastric trichobezoar: a report of a clinical case with anomalous presentation]

The Authors describe a case of a voluminous trichobezoar in a girl 9 years old. The patient was referred for evaluation of abdominal pain that presented after a banal blunt abdominal trauma occurred some days earlier. On physical examination an epigastric mass was detected. For a few days the girl suffered of inappetence and postprandial vomit. She was noted to have thin and sparse hair, thin eyebrows and onychodysplasia: these findings were considered as features of cutaneous adnexa dystrophy. The blood test and other laboratory findings were within normal limits. Abdominal US and UGI series failed to detect the nature of the mass. Therefore the patient underwent gastroscopy that showed a voluminous trichobezoar, so big and hard that gastrotomy was required for removal. The weight of the mass was 700 g; it occupied the whole stomach from fundus to pylorus. Postoperative recovery was uneventful. After discharge the patient was referred to the Neuropsychiatric Service for treatment trichophagia and prevention of recurrence. The most common site of trichobezoar is stomach. Clinical findings are often aspecific. US and UGI series may not allow the correct diagnosis. A rational diagnostic suspicion can arise when alopecia circumscripta is present. Endoscopy remains the elective technique: this procedure can be contemporarily diagnostic and therapeutic. Surgical approach is required only in case of trichobezoar with peculiar size, shape and hardness. We feel that a neuropsychiatric support is necessary to avoid recurrence.

Some observations on acquired oesophageal obstruction in paediatric patients in Tanzania: a 5-year review

Thirteen consecutive paediatric patients with acquired oesophageal obstruction were managed at the Paediatric Surgical Unit (PSU) of Muhimbili Medical Centre (MMC), Dar es Salaam, Tanzania, between January 1988 and December, 1992 inclusive. There were seven males and six females. The ages of onset ranged from the neonatal period to 6 years, with seven (54%) of them being within 2 years of age. Ten (77%) of the patients had corrosive strictures, caused by the ingestion of caustic soda 4, hair-plaiting chemicals 5, and kerosene one. Two of the remaining patients had non-corrosive strictures following measles in one and candidiasis in the other, while in the last case (a newborn), the obstruction was due to post-traumatic retropharyngeal haematoma from attempted infanticide. All but one of the patients were managed with oesophageal dilation, with or without a preliminary feeding gastrostomy. Six (50%) of the stricture cases died, all of them having had corrosive strictures. The main cause of mortality was complications of oesophageal dilatation.

Management of bowel obstruction in advanced cancer patients

Bowel obstruction is a common and distressing outcome in patients with abdominal or pelvic cancer. While surgery must remain the primary treatment for malignant obstruction, it is now recognized that there is a group of patients with advanced disease or poor general condition who are unfit for surgery and require alternative management to relieve distressing symptoms. A number of treatment options are now available for the patient with advanced cancer who develops intestinal obstruction. This review examines the indications for surgery, the use of nasogastric tube and percutaneous gastrostomy, and the place of drugs for symptom control.

Experience with enteral nutrition in a hospital population of acutely ill patients

Enteral feeding has unique metabolic and immune advantages. This article describes the successful use of enteral nutrition, alone or in combination with parenteral feeding, in a tertiary-care hospital. Study participants were 89 patients who received enteral feeding during a 6-month period. These critically ill patients (ranging in age from 55 to 71 years) had severity of illness levels of 7 to 25 according to the Acute Physiologic and Chronic Health Evaluation (APACHE II) system and lengths of hospital stay from 27 to 73 days. Mortality was as high as 50% in patients with liver disease (nonmalignant), 35% in patients with cardiothoracic and vascular diseases, and 17% in patients with cancer and other diseases. Despite the severity of illness, patients met their energy and protein intake goals through enteral or combined feeding with total parenteral nutrition. Serial weights (ie, obtained weekly) and serum albumin concentrations did not improve during hospitalization. Complications related to enteral feeding were minimal (< 17% incidence). Differences were noted between survivors and nonsurvivors: nonsurvivors had lower serum albumin concentrations at the time of admission, had longer hospitalizations, and required total parenteral nutrition for more days than the survivors. Nonetheless, even with extremely sick patients, provision of enteral nutrition can be successful using the administration techniques we describe. Enteral nutrition could best be provided by beginning at a slow rate (10 c3/hour), inserting the feeding tube past the pylorus, and feeding according to sensible energy goals (25 kcal/kg of body weight), and using elemental then polymeric formulas.

Stroke-induced dysphagia in hospital: the nutritional perspective

Nursing staff play a key role in the multidisciplinary team responsible for treating patients with stroke-induced dysphagia. The following review describes a project set up in Bristol to develop an integrated and comprehensive service for the diagnosis, referral and management of elderly stroke patients with dysphagia.

Caustic esophageal burns in children

Images

Post-decompression gallbladder haemorrhage in obstructive jaundice. A report of 2 cases

Two cases of massive haemorrhage from the gallbladder in patients suffering from common bile duct obstruction are described. Sudden operative decompression of the massively distended gallbladder was the probable cause of the bleeding.

[Savariaud's maneuver in surgical procedures used for direct hemostasis in gastric hemorrhage]

The paper illustrates the manoeuvre proposed by Savariaud for the surgical exploration of the gastric cavity. The indications and results of the method are described and its considerable diagnostic and therapeutic value are underlined especially in the presence of severe gastric hemorrhage.

[Quality of life in the aged after surgery. IV. Pathology of the esophagus]

Following a careful examination of the literature on the subject, the authors examine the follow-up records of all patients operated over the past 10 years for non-neoplastic and neoplastic esophageal pathologies. From the results it emerged that all those operated for non-neoplastic pathologies were still living and their quality of life was good with a very high proportion of patients presenting a score of 100 for Karnofsky's index. With regard to neoplastic forms, on the other hand, many patients had died (approximately 50%), but the majority of those living, who had undergone gastro-esophageal resection and consequent esophago-gastrostomy with thoracization of the stomach, were well with a Karnofsky score of 100. The authors explain these results by taking into account the general conditions (biological age) of patients and conclude that surgery is advisable in both non-neoplastic and neoplastic forms, given that it is important to try to improve the quality of life even in the latter.

[Evaluation of anastomotic effect with esophagogastrostomy covered by tongue-like sero-muscular flap of gastric wall in 1515 cases]

Esophagogastrostomy covered by tongue-like sero-muscular flap of gastric wall has already been performed in 1515 cases with esophageal cancer of middle or lower third segment over the last three years. All cases were of squamous cell carcinoma. The same anastomotic procedure was done in all cases by authors in different hospitals. In this series the operative mortality was 0.07%, there were 5 anastomotic leaks (0.33%), and no anastomotic stricture and reflux esophagitis happened within 6 months to 3 years after surgery. The operative procedure is described again in detail. The authors believe that this new anastomotic procedure is satisfactory and prospectively beneficial for improving the therapeutic effect and patients' living quality after operation.

Gastroesophageal reflux complicating choanal atresia repair

Four infants with bilateral congenital choanal atresia (CCA) underwent transpalatal (3) or transnasal (1) repairs. Postoperatively all four infants experienced gastroesophageal reflux (GER) with intermittent nasal reflux. GER was documented by GER radionuclide scanning in one patient and by dual nasopharyngeal and esophageal pH probe studies in the remaining three patients. The infants with documented GER required prolonged stenting and dilations for choanal restenosis and granulations. The literature emphasizes the importance of the technical repair for prevention of these complications; GER can be a significant complicating factor.

Improvement of nutritional status and lung function after long-term nocturnal gastrostomy feedings in cystic fibrosis

We investigated weight gain and clinical course of 14 patients with cystic fibrosis (CF), aged 7 to 23 years, who received long-term nocturnal supplemental feedings by means of percutaneous endoscopic gastrostomies (PEGs). The patients (nine female, five male) were moderately malnourished; the weight-for-height value was 77.8% (SD 6.4%) of the predicted value. Lung function tests revealed severe airway obstruction; mean vital capacity was 46.1% (SD 14.4%), and mean forced expiratory volume in 1 second (FEV1) was 30.8% (SD 12.3%) of predicted value. A nonelemental formula providing 35% of total energy from fat was used for nocturnal feedings. The patients received 800 to 1500 kcal per night by slow intragastric infusions. Enteric-coated pancreatic microsphere preparations were taken orally just before bedtime. After 1 year of supplemental feedings, body weight had increased by 6.0 kg (SD 3.6 kg) and weight-for-height value by 9.0% (SD 6.1%) of predicted compared with baseline values. Lung function also improved significantly: vital capacity increased by 8.2% (SD6.3%) and FEV1 by 3.9% (SD 4.2%) of predicted values (p < 0.01). The total duration of nocturnal feedings was 364 months, or 26 months per patient. Nine of the fourteen patients continue to use the PEG, three patients had the PEG tube removed, and two patients have died 21 and 23 months after PEG insertion. We conclude that nocturnal PEG feedings of malnourished patients with CF improve nutritional status and lung function without major side effects.

Impact of nutritional rehabilitation on gastroesophageal reflux in neurologically impaired children

The impact of nutritional rehabilitation on gastroesophageal reflux (GER) in 10 malnourished neurologically impaired children (NIC) was studied (mean age, 9.1 +/- 3.1 years). None of the children had an antireflux procedure (ARP), and all were fed exclusively through a percutaneous endoscopic gastrostomy (PEG). Malnutrition was defined as triceps skin fold thickness (TSF) below the fifth percentile for age and sex. GER was established using standard criteria for a 24-hour pH probe study. All children were treated with an H2 antagonist and a prokinetic agent, along with aggressive nutritional rehabilitation. When TSF was > or = 50th percentile, medications were stopped, and the 24-hour pH probe study was repeated. The mean weight gain was 8.8 +/- 3.7 kg over 8.4 +/- 2.3 months. The 24-hour pH probe study showed marked improvement after nutritional rehabilitation in six of 10 children. These children remained asymptomatic throughout long-term follow-up, without the use of medications. Two children had abnormal pH probe results and worsening clinical symptoms when taken off medications after nutritional rehabilitation. They were reexamined after reinstituting the prokinetic drug; results of the pH probe study were normal, and there was no clinical symptomatology. The patients were then given long-term medication. Two children (one with erosive esophagitis and one with persistent symptoms) underwent ARP. We conclude that despite accompanying GER, successful nutritional rehabilitation can be achieved in malnourished NIC, using PEG feeding and antireflux medication. Although some NIC with GER may need an ARP or long-term medication, in most malnourished NIC nutritional rehabilitation is associated with resolution of GER.

Percutaneous endoscopic gastrostomy placement in children

Percutaneous endoscopic placement of gastrostomy tubes in children has become common since its introduction in 1980. Indications and technique for placement, as well as complications in children are discussed. A summary of the recent experience with percutaneous endoscopic jejunostomy is also provided.