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Saigusa S, Aono Y, Fujikawa H, Uratani R, Watanabe S, Sakurai H, Ohi M, Tanaka K. Cerebral arterial air embolism after esophageal stenting for recurrence of gastroesophageal junction cancer: a case report. Int Cancer Conf J 2024; 13:460-467. [PMID: 39398936 PMCID: PMC11464815 DOI: 10.1007/s13691-024-00710-5] [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: 04/25/2024] [Accepted: 07/30/2024] [Indexed: 10/15/2024] Open
Abstract
Cerebral arterial air embolism (CAE) is a rare complication after esophageal stenting, but it can be life-threatening. It is especially a concern for those with a history of previous gastrointestinal cancer therapies. We report a case of CAE after esophageal stenting in a patient with recurrent gastroesophageal junction cancer and a history of multiple cancer treatments. A 71 year-old man with a history of a proximal gastrectomy, resection of the lower esophagus, chemotherapy, and radiation presented to our hospital 2 weeks after stenting with epigastric and back pain. Mediastinitis was suspected and conservative treatment was begun. The patient suddenly developed altered mental status, left hemiplegia, and anisocoria after drinking water. A brain computed tomography (CT) revealed right-sided predominance of multifocal CAE. Chest and abdominal CT showed a hematoma in the gastric and duodenal wall and an intraluminal hematoma from the esophagus, around the stent, to the upper ileum. CAE was thought to be due to rupture of the recurrent tumor. Unfortunately, despite intensive care, the patient died about 5 h after the onset of neurological symptoms. It has been reported that prior treatments, such as chemotherapy and radiotherapy, increase the risk of life-threatening adverse events, including CAE after esophageal stenting. Clinicians should keep in mind the possibility of CAE after esophageal stenting in patients with a history of multiple cancer treatments.
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Affiliation(s)
- Susumu Saigusa
- Department of Surgery, IGA City General Hospital, 831 Shijuku-cho, Iga, Mie 518-0823 Japan
| | - Yuki Aono
- Department of Gastroenterology and Hepatology, IGA City General Hospital, 831 Shijuku-cho, Iga, Mie 518-0823 Japan
| | - Hiroyuki Fujikawa
- Department of Surgery, IGA City General Hospital, 831 Shijuku-cho, Iga, Mie 518-0823 Japan
| | - Ryo Uratani
- Department of Gastrointestinal and Pediatric Surgery, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507 Japan
| | - Shuyo Watanabe
- Department of Surgery, IGA City General Hospital, 831 Shijuku-cho, Iga, Mie 518-0823 Japan
| | - Hiroyuki Sakurai
- Department of Surgery, IGA City General Hospital, 831 Shijuku-cho, Iga, Mie 518-0823 Japan
| | - Masaki Ohi
- Department of Gastrointestinal and Pediatric Surgery, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507 Japan
| | - Koji Tanaka
- Department of Surgery, IGA City General Hospital, 831 Shijuku-cho, Iga, Mie 518-0823 Japan
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Jaber F, Alsakarneh S, Alsharaeh T, Salahat AJ, Jaber M, Mohamed I, Gangwani MK, Aldiabat M, Kilani Y, Ahmed M, Madi M, Numan L, Bazarbashi AN. A Comprehensive Analysis of Reported Adverse Events and Device Failures Associated with Esophageal Self-Expandable Metal Stents: An FDA MAUDE Database Study. Dig Dis Sci 2024; 69:2765-2774. [PMID: 38811504 DOI: 10.1007/s10620-024-08483-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Esophageal Stents are used to maintain esophageal lumen patency in esophageal strictures caused by intrinsic and/or extrinsic malignancies and the occlusion of concomitant esophageal fistulas. While data on the efficacy and safety of esophageal stents exist, comprehensive evaluation of adverse events is limited. The aim of this study is to investigate the reported adverse events and device failures associated with esophageal self-expandable metal stents (SEMS) using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database. METHODS Post-marketing surveillance data for the esophageal SEMSs were analyzed using the FDA's MAUDE database from January 2014 to December 10, 2023. The outcomes of interest were patient-related adverse events and device failures. Statistical analysis was performed using Microsoft Excel 2010 and SPSS. Pooled numbers and percentages were calculated for each adverse event. Continuous variables underwent analysis using a two-tailed student t test, and significance was set to p ≤ 0.05. RESULTS During the study period, 548 MAUDE reports revealed 873 device failures and 186 patient-related adverse events. The most common device issues were stent activation, positioning, or separation problems (4 n = 403; 46.2%), followed by device detachment or migration (n = 109, 12.5%), and material problems (n = 93, 10.7%). Patient complications included dysphagia/odynophagia (10%), perforation, pain, and bleeding (each 7.6%). The most common device failures in over-the-wire (OTW) stents and through-the-scope (TTS) stents were activation, positioning, or separation problems (TTS: n = 183, 52.6% vs OTW: n = 220, 41.9%). Compared to OTW stents, TTS stents had higher migration and breakage (13.5% vs. 11.8%, p = 0.24), and (9.2% vs. 6.7%, p = 0.08) respectively, while OTW stents had more challenges with stent advancement or removal (5.1% vs. 0.3%, p < 0.001 and 4.6% vs 3.4%, p = 0.19, respectively) and material problems (14.7% vs. 4.6%, p < 0.001). Activation, positioning, and separation problems were the most frequent device failures in fully covered (FC) and partially covered (PC) stents (FC: n = 62, 32.8%, PC: n = 168, 43.5%). FC stents had higher migration rates (20.6% vs 9.8%, p < 0.001), while PC stents exhibited more material problems (17.4% vs. 5.8%, p < 0.001) and difficulties with advancing the stents (6.7% vs. 0%, p < 0.001). CONCLUSION Our examination showed a prevalence of reported device complications associated with stent activation, positioning, and separation problems. Dysphagia or odynophagia emerged as the most frequently reported patient complication. Furthermore, our analysis, provides insights into TTS vs. OTW and FC vs. PC esophageal SEMSs, enabling endoscopists and manufacturers to better understand adverse events and potentially optimize device design for future iterations.
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Affiliation(s)
- Fouad Jaber
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA.
| | - Saqr Alsakarneh
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | - Tala Alsharaeh
- Department of Medical Education, Faculty of Medicine, The University of Jordan, Amman, Jordan
| | - Ahmed-Jordan Salahat
- Department of Medical Education, Faculty of Medicine, The University of Jordan, Amman, Jordan
| | - Mohammad Jaber
- Department of Medical Education, Faculty of Medicine, Al-Azhar University, Gaza, Palestine
| | - Islam Mohamed
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, MO, USA
| | | | - Mohammad Aldiabat
- Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO, USA
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Yassine Kilani
- Department of Internal Medicine, NYC Health + Hospitals | Lincoln - Weill Cornell Medical College, Bronx, NY, USA
| | - Mohamed Ahmed
- Division of Gastroenterology and hepatology, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Mahmoud Madi
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Laith Numan
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO, USA
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Kim SH, Kang JM, Park Y, Jeong S, Na Y, Jung HD, An J, Kim HS, Lee SS, Park JH. Self-Expandable Electrode Based on Chemically Polished Nickel-Titanium Alloy Wire for Treating Endoluminal Tumors Using Bipolar Irreversible Electroporation. ACS APPLIED MATERIALS & INTERFACES 2023. [PMID: 37452740 DOI: 10.1021/acsami.3c04703] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
The application of irreversible electroporation (IRE) to endoluminal organs is being investigated; however, the current preclinical evidence and optimized electrodes are insufficient for clinical translation. Here, a novel self-expandable electrode (SE) made of chemically polished nickel-titanium (Ni-Ti) alloy wire for endoluminal IRE is developed in this study. Chemically polished heat-treated Ni-Ti alloy wires demonstrate increased electrical conductivity, reduced carbon and oxygen levels, and good mechanical and self-expanding properties. Bipolar IRE using chemically polished Ni-Ti wires successfully induces cancer cell death. IRE-treated potato tissue shows irreversibly and reversibly electroporated areas containing dead cells in an electrical strength-dependent manner. In vivo study using an optimized electric field strength demonstrates that endobiliary IRE using the SE evenly induces well-distributed mucosal injuries in the common bile duct (CBD) with the overexpression of the TUNEL, HSP70, and inflammatory cells without ductal perforation or stricture formation. This study demonstrates the basic concept of the endobiliary IRE procedure, which is technically feasible and safe in a porcine CBD as a novel therapeutic strategy for malignant biliary obstruction. The SE is a promising electrical energy delivery platform for effectively treating endoluminal organs.
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Affiliation(s)
- Song Hee Kim
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Jeon Min Kang
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Yubeen Park
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Seung Jeong
- Department of Biosystems & Biomaterials Science and Engineering, Seoul National University, Seoul 11 08826, Republic of Korea
| | - Yuhyun Na
- Department of Biomedical-Chemical Engineering, The Catholic University of Korea, Bucheon 14662, Republic of Korea
- Department of Biotechnology, The Catholic University of Korea, Bucheon 14662, Republic of Korea
| | - Hyun-Do Jung
- Department of Biomedical-Chemical Engineering, The Catholic University of Korea, Bucheon 14662, Republic of Korea
- Department of Biotechnology, The Catholic University of Korea, Bucheon 14662, Republic of Korea
| | - Jinsu An
- Department of Biomedical Engineering, School of ICT Convergence Engineering, College of Science & Technology, Konkuk University, Chungju-si 22478, Republic of Korea
| | - Hyung-Sik Kim
- Department of Mechatronics Engineering, School of ICT Convergence Engineering, College of Science & Technology, Konkuk University, Chungju-si 22478, Republic of Korea
| | - Sang Soo Lee
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Jung-Hoon Park
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
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Egeland C, Bazancir LA, Bui NH, Baeksgaard L, Gehl J, Gögenur I, Achiam M. Palliation of dysphagia in patients with non-curable esophageal cancer - a retrospective Danish study from a highly specialized center. Support Care Cancer 2022; 30:9029-9038. [PMID: 35947208 DOI: 10.1007/s00520-022-07316-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 08/02/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE A majority of the patients with esophageal cancer (EC) suffer from dysphagia. Several endoscopic treatment options are available such as stent placement, argon plasma coagulation, and esophageal dilatation. This study aimed to map the use of endoscopic dysphagia relieving interventions and secondly investigate possible impact on survival. METHODS Data was collected at the Dept. of Surgery & Transplantation, Rigshospitalet, Denmark. Patients with non-curable EC referred from 2016 to 2019 were included. Type of dysphagia treatment, complications and the need for repeated treatments, and survival were registered. RESULTS In the study, 601 patients were included. Forty-five percent were treated with an endoscopic procedure due to dysphagia (82% had a stent placed). The median time from diagnosis to intervention was 24 days. The overall complication rate was 35% (38% in the stent group and 20% in the non-stent group, p = 0.03) and 13% of the patients were readmitted due to a complication. After 26% of the procedures, a repeated treatment was required. Patients having an endoscopic intervention had a worsened survival prognosis compared with the patients in the non-intervention group (HR: 2.17, 95% CI: 1.80-2.61, p < 0.001). In the sub analysis where only patients who had an intervention was included, a survival difference in favor of the non-stent group was found (HR: 0.61, 95% CI: 0.43-0.86, p = 0.005). CONCLUSION In this cohort, the incidence of endoscopic procedures was high, complication rates were considerable, and many the patients required a second treatment. A survival difference was seen, where the patients who had a stent placed seemed to have the worst survival outcomes. However, the causal relationship is yet to be determined why the results must be interpreted carefully. New interventions and tailored approaches that may positively affect functional and long-term oncological outcomes are highly warranted and this should preferably be investigated in randomized clinical trials.
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Affiliation(s)
- Charlotte Egeland
- Department of Surgery and Transplantation, Rigshospitalet, Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark.
| | - Laser Arif Bazancir
- Department of Surgery and Transplantation, Rigshospitalet, Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
| | - Nam Hai Bui
- Department of Surgery, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lene Baeksgaard
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Julie Gehl
- Center for Experimental Drug and Gene Electrotransfer (C*EDGE), Department of Clinical Oncology and Palliative Care, Department of Clinical Medicine, Faculty of Health and Medical Sciences, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ismail Gögenur
- Department of Surgery, Center for Surgical Science, Department of Clinical Medicine, Faculty of Health and Medical Sciences, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Michael Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen, Denmark
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Jeene PM, Kuijper SC, van den Boorn HG, El Sharouni SY, Braam PM, Oppedijk V, Verhoeven RHA, Hulshof MCCM, van Laarhoven HWM. Improving survival prediction of oesophageal cancer patients treated with external beam radiotherapy for dysphagia. Acta Oncol 2022; 61:849-855. [PMID: 35651320 DOI: 10.1080/0284186x.2022.2079385] [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: 12/24/2022]
Abstract
INTRODUCTION The recent POLDER trial investigated the effects of external beam radiotherapy (EBRT) on dysphagia caused by incurable oesophageal cancer. An estimated life expectancy of minimally three months was required for inclusion. However, nearly one-third of the included patients died within three months. The aim of this study was to investigate if the use of prediction models could have improved the physician's estimation of the patient's survival. METHODS Data from the POLDER trial (N = 110) were linked to the Netherlands Cancer Registry to retrieve patient, tumour, and treatment characteristics. Two published prediction models (the SOURCE model and Steyerberg model) were used to predict three-month survival for all patients included in the POLDER trial. Predicted survival probabilities were dichotomised and the accuracy, sensitivity, specificity, and the area under the curve (AUC) were used to evaluate the predictive performance. RESULTS The SOURCE and Steyerberg model had an accuracy of 79% and 64%, and an AUC of 0.76 and 0.60 (p = .017), respectively. The SOURCE model had higher specificity across survival cut-off probabilities, the Steyerberg model had a higher sensitivity beyond the survival probability cut-off of 0.7. Using optimal cut-off probabilities, SOURCE would have wrongfully included 16/110 patients into the POLDER and Steyerberg 34/110. CONCLUSION The SOURCE model was found to be a more useful decision aid than the Steyerberg model. Results showed that the SOURCE model could be used for three-month survival predictions for patients that are considered for palliative treatment of dysphagia caused by oesophageal cancer in addition to clinicians' judgement.
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Affiliation(s)
- Paul M. Jeene
- Amsterdam UMC location University of Amsterdam, Radiotherapy, Amsterdam, the Netherlands
- Radiotherapiegroep, Deventer, The Netherlands
| | - Steven C. Kuijper
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Cancer Center Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Medical Oncology, Amsterdam, the Netherlands
| | - Héctor G. van den Boorn
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Cancer Center Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Medical Oncology, Amsterdam, the Netherlands
| | - Sherif Y. El Sharouni
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pètra M. Braam
- Department of Radiotherapy, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Vera Oppedijk
- Radiotherapeutisch Instituut Friesland, Leeuwarden, The Netherlands
| | - Rob H. A. Verhoeven
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Cancer Center Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Medical Oncology, Amsterdam, the Netherlands
- Department of Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | | | - Hanneke W. M. van Laarhoven
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Cancer Center Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Medical Oncology, Amsterdam, the Netherlands
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Spaander MCW, van der Bogt RD, Baron TH, Albers D, Blero D, de Ceglie A, Conio M, Czakó L, Everett S, Garcia-Pagán JC, Ginès A, Jovani M, Repici A, Rodrigues-Pinto E, Siersema PD, Fuccio L, van Hooft JE. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:751-762. [PMID: 33930932 DOI: 10.1055/a-1475-0063] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
MALIGNANT DISEASE 1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence. BENIGN DISEASE 5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.
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Affiliation(s)
- Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ruben D van der Bogt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Todd H Baron
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Academic Hospital, University of Duisburg-Essen, Essen, Germany
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Antonella de Ceglie
- Department of Gastroenterology, Ospedale Civile di Sanremo, Sanremo (IM), Italy
| | - Massimo Conio
- Department of Gastroenterology, Ospedale Santa Corona, Pietra Ligure (SV), Italy
| | - László Czakó
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Simon Everett
- Department of Gastroenterology and Hepatology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Juan-Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit - Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver) - Hospital Clinic, IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain
| | - Angels Ginès
- Gastroenterology Department, Hospital Clinic of Barcelona, IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain
| | - Manol Jovani
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alessandro Repici
- Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Federico JA, Martin JT. Surgeons' Role in Local Palliation of Esophageal Cancer. Surg Clin North Am 2021; 101:489-497. [PMID: 34048768 DOI: 10.1016/j.suc.2021.03.010] [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: 10/21/2022]
Abstract
Esophageal cancer commonly presents in advanced stage, and many patients will require palliative intervention. Endoscopic stenting remains an excellent first-line therapy; however, this should be discussed in a multidisciplinary setting, considering expectations for long-term survival.
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Affiliation(s)
- John A Federico
- Kalispell Regional Healthcare, 1333 Surgical Services Drive, Kalispell, MT 59901, USA.
| | - Jeremiah T Martin
- Southern Ohio Medical Center, 1711 27th Street, Braunlin Building, Suite 206, Portsmouth, OH 45662, USA
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Godin A, Liberman M. The modern approach to esophageal palliative and emergency surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:905. [PMID: 34164539 PMCID: PMC8184432 DOI: 10.21037/atm.2020.03.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Thoracic surgeons currently have multiple options and strategies to guide treatment in esophageal palliative and emergency conditions. To guide the selection of an individualized palliative approach, physicians, including thoracic surgeons, must take into consideration many factors including prognosis, performance status and comorbidities of patients. For dysphagia more specifically, esophageal stent placement is the most widely used intervention for rapidly relieving dysphagia in inoperable esophageal cancer patients. The combination of esophageal stent placement with other therapies has an impact on palliative care. Innovations including radioactive stents, drug-eluding stents and biodegradable stents will require further evaluation and validation studies. Currently, patients with inoperable esophageal cancer have access to oncological and biological therapies that are improving their prognosis. A shift toward restaging and potential curative intent is occurring in current clinical practice. In acute intrathoracic esophageal perforation cases, high index of suspicion, multidisciplinary team expertise, antibiotics and hybrid treatment strategies, have significantly improved outcomes of patients in recent years. Hybrid treatment strategies denote the combination of minimally invasive interventions for source control and endoluminal procedures to seal the esophageal perforation. Endoluminal procedures as treatment of acute intrathoracic esophageal perforation include stent placement, over-the-scope clip and endoluminal vacuum therapy. Future perspective in the management of esophageal perforation seems to be the combination of endoluminal therapies tailored to the specific clinical scenario. Thoracic surgeons benefit from mastering endoluminal therapies and advanced endoscopic techniques. An understanding of these rapidly evolving therapies, i.e., outcomes, limitations and innovations, is required to optimally manage esophageal palliative and emergency conditions.
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Affiliation(s)
- Anny Godin
- Division of Thoracic Surgery, CETOC-CHUM Endoscopic Tracheo-Bronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Moishe Liberman
- Division of Thoracic Surgery, CETOC-CHUM Endoscopic Tracheo-Bronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
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Mangiavillano B, Auriemma F, Bianchetti M, Mantovani N, Pilati S, Reggio D, Barletti C, Forcignanò E, Pentassuglia G, Arezzo A, Cavargini E, Fabbri C, Mezzanzanica M, De Luca L, Conigliaro R, Repici A. Through-the-scope esophageal stent for the relief of malignant dysphagia: Results of a multicentric study (with video). Dig Endosc 2021; 33:118-124. [PMID: 32333617 DOI: 10.1111/den.13704] [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: 01/15/2020] [Revised: 04/01/2020] [Accepted: 04/20/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM In presence of malignant dysphagia, in patients unfit for surgery, the placement of a self-expandable metal stent (SEMS) represents a safe and effective palliative treatment. Esophageal stents (ES) present an over-the-wire mechanism where the stent is deployed under X-ray control. Recently a through-the-scope (TTS) ES was launched. The aim of our retrospective study is to assess the technical and clinical success of the new TTS-ES. MATERIALS AND METHODS Patients with malignant dysphagia caused by esophageal cancer or ab-extrinsic compression, who underwent TTS esophageal stent in six Italian endoscopic referral centers, were retrospectively reviewed. RESULTS A total of 40 patients were enrolled. TTS stent placement was successful in 39/40 patients (97.5%). 31 patients had an Ogilvie score of 4, nine an Ogilvie 3. After 2 weeks from stent placement 29 reported Ogilvie score of 0, eight a score of 1. None of the patients developed retrosternal pain requiring drugs. No patient experienced perforation, bleeding or migration. A total of seven patients (18%) developed dysphagia as late adverse event (AE). CONCLUSION Through-the-scope ES presented less AEs, in terms of bleeding and perforation, if compared to the previous published data. An anti-migration system could be helpful, especially when the stent is placed for "ab-extrinseco" malignant dysphagia.
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Affiliation(s)
- Benedetto Mangiavillano
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy.,Humamitas University, Castellanza, Italy
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy
| | - Mario Bianchetti
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy
| | | | | | - Dario Reggio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Claudio Barletti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | | | | | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | | | - Carlo Fabbri
- Endoscopy Unit, Morgagni-Pietrantoni Hospital, Forlì, Italy
| | | | - Luca De Luca
- Gastroenterology and Digestive Endoscopy Unit, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Rita Conigliaro
- Gastrointestinal and Digestive Endoscopy Unit, Civile di Baggiovara Hospital, AOU Modena, Modena, Italy
| | - Alessandro Repici
- Humamitas University, Castellanza, Italy.,Digestive Endoscopy Unit, Istituto Clinico Humanitas Research Hospital, Milan, Italy
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10
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Nguyen MT, Feeney T, Kim C, Drake FT, Mitchell SE, Bednarczyk M, Sanchez SE. Patient-Level Factors Influencing Palliative Care Consultation at a Safety-Net Urban Hospital. Am J Hosp Palliat Care 2020; 38:1299-1307. [PMID: 33325245 DOI: 10.1177/1049909120981764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The influence of patient-level factors on palliative and hospice care is unclear. We conducted a retrospective review of 2321 patients aged ≥18 that died within 6 months of admission to our institution between 2012 and 2017. Patients were included for analysis if their chart was complete, their length of stay was ≥48 hours, and if based on their diagnoses, they would have benefited from palliative care consultation (PCC). Bayesian regression with a weakly informative prior was used to find the odds ratio (OR) and 99% credible interval (CrI) of receiving PCC based on race/ethnicity, education, language, insurance status, and income. 730 patients fit our inclusion criteria and 30% (n = 211) received PCC. The OR of receiving PCC was 1.26 (99% CrI, 0.73-2.12) for Blacks, 0.81 (99% CrI, 0.31-1.86) for Hispanics, and 0.69 (99% CrI, 0.19-2.46) for other minorities. Less than high school education was associated with greater odds of PCC (OR 2.28, 99% CrI, 1.09-4.93) compared to no schooling. Compared to English speakers, non-English speakers had higher odds of receiving PCC when cared for by medical services (OR 3.01 [99% CrI, 1.44-5.32]) but lower odds of PCC when cared for by surgical services (0.22 [99% CrI, <0.01-3.42]). Insurance status and income were not associated with differences in PCC. At our institution, we found no evidence of racial/ethnic, insurance, or income status affecting PCC while primary language spoken and educational status did. Further investigation is warranted to examine the system and provider-level factors influencing PCC's low utilization by medical and surgical specialties.
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Affiliation(s)
| | - Timothy Feeney
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - F Thurston Drake
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Suzanne E Mitchell
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - Sabrina E Sanchez
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
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11
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van Rossum PSN, Jeene PM, Rozema T, Braam PM, Lips IM, Muller K, van Kampen D, Vermeulen BD, Homs MYV, Oppedijk V, Berbée M, Hulshof MCCM, Siersema PD, El Sharouni SY. Patient-reported outcomes after external beam radiotherapy versus brachytherapy for palliation of dysphagia in esophageal cancer: A matched comparison of two prospective trials. Radiother Oncol 2020; 155:73-79. [PMID: 33065190 DOI: 10.1016/j.radonc.2020.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/25/2020] [Accepted: 10/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE A matched comparison of external beam radiotherapy (EBRT) versus brachytherapy recently demonstrated that EBRT appears at least as effective for palliating dysphagia in patients with incurable esophageal cancer. The aim of this analysis was to compare patient-reported outcomes (PROs) after EBRT versus brachytherapy. MATERIALS AND METHODS In a multicenter prospective cohort study, patients with incurable esophageal cancer requiring palliation of dysphagia were included to undergo EBRT (20 Gy in 5 fractions). This EBRT cohort was compared to the single-dose 12 Gy brachytherapy cohort of the previously reported SIREC-trial. Propensity score matching was applied to adjust for baseline imbalances. The primary endpoint of dysphagia improvement was reported previously. PROs were secondary outcomes and assessed at baseline and 3 months after treatment using EORTC QLQ-C30 and QLQ-OES18 questionnaires. RESULTS A total of 115 enrolled EBRT patients and 93 brachytherapy patients were eligible. After matching, 69 well-balanced pairs remained. At follow-up, significant deteriorations in functioning (i.e. physical, role, social), pain, appetite loss, and trouble with taste were observed after brachytherapy. In the EBRT group, such deterioration was observed only for role functioning, while significant improvements in trouble with eating and pain were found. Between-group comparison showed mostly comparable PRO changes, but significantly favored EBRT with regard to nausea, vomiting, pain, and appetite loss. CONCLUSION Short course EBRT results in similar or better PROs at 3 months after treatment compared to single-dose brachytherapy for the palliation of malignant dysphagia. These findings further support its use and inclusion in clinical practice guidelines.
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Affiliation(s)
- Peter S N van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands.
| | - Paul M Jeene
- Department of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Radiotherapiegroep, location Deventer, The Netherlands.
| | - Tom Rozema
- Instituut Verbeeten, Tilburg, The Netherlands
| | - Pètra M Braam
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Irene M Lips
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Karin Muller
- Radiotherapiegroep, location Deventer, The Netherlands
| | - Daphne van Kampen
- Zuidwest Radiotherapeutisch Instituut, Vlissingen and Roosendaal, The Netherlands
| | - Bram D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Vera Oppedijk
- Radiotherapeutisch Instituut Friesland, Leeuwarden, The Netherlands
| | - Maaike Berbée
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sherif Y El Sharouni
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
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12
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Jeene PM, Vermeulen BD, Rozema T, Braam PM, Lips I, Muller K, van Kampen D, Homs MY, Oppedijk V, Berbée M, van Rossum PS, el Sharouni S, Siersema PD, Hulshof MC. Short-Course External Beam Radiotherapy Versus Brachytherapy for Palliation of Dysphagia in Esophageal Cancer: A Matched Comparison of Two Prospective Trials. J Thorac Oncol 2020; 15:1361-1368. [DOI: 10.1016/j.jtho.2020.04.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 01/21/2023]
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13
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Vermeulen BD, Bruggeman L, Bac DJ, Schrauwen RWM, Epping LSM, Scheffer RCH, Tan ACITL, Groenen MJM, Verhoeven RHA, Siersema PD. Impact of multidisciplinary tumor board discussion on palliation of patients with esophageal or gastro-esophageal junction cancer: a population-based study. Acta Oncol 2020; 59:410-416. [PMID: 32067535 DOI: 10.1080/0284186x.2020.1725240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: The Dutch guidelines for esophageal and gastro-esophageal junction (GEJ) cancer recommend discussion of patients by a multidisciplinary tumor board (MDT). Despite this recommendation, one previous study in the Netherlands suggested that therapeutic guidance was missing for palliative care of patients with esophageal cancer. The aim of the current study was therefore to assess the impact of an MDT discussion on initial palliative treatment and outcome of patients with esophageal or GEJ cancer.Material and methods: The population-based Netherlands Cancer Registry was used to identify patients treated for esophageal or GEJ cancer with palliative intent between 2010 and 2017 in 7 hospitals. We compared patients discussed by the MDT with patients not discussed by the MDT in a multivariate analysis. Primary outcome was type of initial palliative treatment. Secondary outcome was overall survival.Results: A total of 389/948 (41%) patients with esophageal or GEJ cancer were discussed by the MDT before initial palliative treatment. MDT discussion compared to non-MDT discussion was associated with more patients treated with palliative intent external beam radiotherapy (38% vs. 21%, OR 2.7 [95% CI 1.8-3.9]) and systemic therapy (30% vs. 23%, OR 1.6 [95% CI 1.0-2.5]), and fewer patients treated with stent placement (4% vs. 12%, OR 0.3 [95% CI 0.1-0.6]) and best supportive care alone (12% vs. 33%, OR 0.2 [95% CI 0.1-0.3]). MDT discussion was also associated with improved survival (169 days vs. 107 days, HR 1.3 [95% CI 1.1-1.6]).Conclusion: Our study shows that MDT discussion of patients with esophageal or GEJ cancer resulted in more patients treated with initial palliative radiotherapy and chemotherapy compared with patients not discussed by the MDT. Moreover, MDT discussion may have a positive effect on survival, highlighting the importance of MDT meetings at all stages of treatment.
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Affiliation(s)
- Bram D. Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lukas Bruggeman
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dirk J. Bac
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Ruud W. M. Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven Hospital, Uden, The Netherlands
| | - Ludger S. M. Epping
- Department of Gastroenterology and Hepatology, Maasziekenhuis Pantein, Boxmeer, The Netherlands
| | - Robert C. H. Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands
| | - Adriaan C. I. T. L. Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marcel J. M. Groenen
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Rob H. A. Verhoeven
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - Peter D. Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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14
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15
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Vermeulen BD, Reijm AN, van der Bogt RD, van Hooft JE, Spaander MCW, Siersema PD. Through-the-scope placement of a fully covered metal stent for palliation of malignant dysphagia: a prospective cohort study (with video). Gastrointest Endosc 2019; 90:972-979. [PMID: 31265819 DOI: 10.1016/j.gie.2019.06.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS To further optimize endoscopic stent placement, an esophageal fully covered self-expandable metal stent with a through-the-scope (TTS) delivery system was designed, providing direct endoscopic control during stent placement. The aim of the study was to assess the feasibility and safety of a TTS stent approach for palliation of malignant dysphagia. METHODS This multicenter prospective feasibility study included patients with malignant dysphagia undergoing stent placement. The primary outcome was technical success of TTS stent placement. Secondary outcomes included functional outcome, adverse events, and survival. Patients were prospectively evaluated at days 14 and 28, and monthly thereafter, until death or stent removal. RESULTS In total, 33 stents were placed in 32 patients. TTS stent placement was feasible in 30 (91%) procedures. In the other 3 procedures (9%), no large-channel endoscope could be introduced because of patient discomfort. In 10 (33%) TTS procedures, technical success was achieved because no fluoroscopy and/or guidewire was used, whereas in 20 (67%) TTS procedures, placement was supported by a guidewire (n = 9), or fluoroscopy and a guidewire (n = 11). After 2 weeks, dysphagia scores had improved in 24 (86%) patients. Median dysphagia-free time was 32 days (interquartile range [IQR], 17-76 days). In 20 (63%) patients, 29 serious adverse events (SAEs) occurred. Recurrent dysphagia occurred in 13 (41%) patients due to migration (n = 5), tissue overgrowth (n = 4), and stent deformation (n = 4). Other SAEs included significant retrosternal pain (n = 4), hemorrhage (n = 2), and esophageal perforation (n = 1). No patient died from a stent-related cause. Median survival was 42 days (IQR, 28-91 days). CONCLUSION Placement of an esophageal TTS stent was feasible in most of the patients with malignant dysphagia. However, stent placement was associated with a relatively high adverse event rate, and in more than one-third of patients, stent placement still required fluoroscopy, which limited optimal benefit of the TTS approach. (Clinical trial registration number: NCT03269903.).
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Affiliation(s)
- Bram D Vermeulen
- Department of Gastroenterology & Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Agnes N Reijm
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ruben D van der Bogt
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology & Hepatology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology & Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
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16
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Nguyen MT, Feeney T, Kim C, Drake FT, Mitchell SE, Bednarczyk M, Sanchez SE. Differential Utilization of Palliative Care Consultation Between Medical and Surgical Services. Am J Hosp Palliat Care 2019; 37:250-257. [PMID: 31387366 DOI: 10.1177/1049909119867904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
There is a paucity of data regarding the utilization of palliative care consultation (PCC) in surgical specialties. We conducted a retrospective review of 2321 adult patients (age ≥18) who died within 6 months of admission to Boston Medical Center from 2012 to 2017. Patients were included for analysis if their length of stay was more than 48 hours and if, based on their diagnoses as determined by literature review and expert consensus, they would have benefited from PCC. Bayesian regression was used to estimate the odds ratio (OR) and 99% credible intervals (CrI) of receiving PCC adjusted for age, sex, race, insurance status, median income, and comorbidity status. Among the 739 patients who fit the inclusion criteria, only 30% (n = 222) received PCC even though 664 (90%) and 75 (10%) of these patients were identified as warranting PCC on medical and surgical services, respectively. Of the 222 patients who received PCC, 214 (96%) were cared for by medical services and 8 (4%) were cared for by surgical services. Patients cared for primarily by surgical were significantly less likely to receive PCC than primary patients of medical service providers (OR, 0.19, 99% CrI, 0.056-0.48). At our institution, many surgical patients appropriate for PCC are unable to benefit from this service due to low consultation numbers. Further investigation is warranted to examine if this phenomenon is observed at other institutions, elucidate the reasons for this disparity, and develop interventions to increase the appropriate use of PCC throughout all medical specialties.
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Affiliation(s)
| | - Timothy Feeney
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Chanmin Kim
- Boston University School of Public Health, Boston, MA, USA
| | - F Thurston Drake
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Suzanne E Mitchell
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - Sabrina E Sanchez
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
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