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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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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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Baker J, Smith PJ, White SJ, Gifford AJ. Availability of palliative parenteral nutrition to patients with advanced cancer: A national survey of service provision. J Hum Nutr Diet 2023; 36:1225-1233. [PMID: 36992552 DOI: 10.1111/jhn.13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Patients with advanced malignancy who are unable to meet their nutritional requirements orally or enterally as a result of intestinal failure may be considered for parenteral nutrition support. Current UK guidance recommends that patients with a 3-month prognosis and good performance status (i.e., Karnofsky performance status >50) should be considered for this intervention at home (termed Home Parenteral Nutrition; HPN). However, HPN is a nationally commissioned service by National Health Service (NHS) England and Improvement that can only be initiated at specific NHS centres and so may not be easily accessed by patients outside of these centres. This survey aimed to identify current clinical practice across UK hospitals about how palliative parenteral nutrition is initiated. METHODS Clinical staff associated with Nutrition Support Teams at NHS Organisations within the UK were invited to complete an electronically administered survey of national clinical practice through advertisements posted on relevant professional interest groups. RESULTS Sixty clinicians responded to the survey administered between September and November 2020. The majority of respondents responded positively that decisions made to initiate palliative parenteral nutrition were conducted in alignment with current national guidance in relation to decision-making and formulation of parenteral nutrition. Variation was observed in relation to the provision of advance care planning in relation to nutrition support prior to discharge, as well as the consideration of venting gastrostomy placement in patients with malignant bowel obstruction unsuitable for surgical intervention. CONCLUSIONS Adherence to current national guidance in relation to the provision of palliative parenteral nutrition is variable for some aspects of care. Further work is required particularly in relation to maximising the opportunity for the provision of advance care planning prior to discharge in this patient cohort.
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Affiliation(s)
- James Baker
- Pharmacy Department, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
| | - Philip J Smith
- Department of Gastroenterology & Hepatology, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Simon J White
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
| | - Alison J Gifford
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
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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: 2.3] [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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Herb J, Rodriguez-Ormaza N, Cunningham C, Bartl N, Jadi J, Charles A, Reid T. Gastrostomy Tube Outcomes Among Surgical and Non-Surgical Services: A Retrospective Review. Am Surg 2021:31348211047173. [PMID: 34569313 DOI: 10.1177/00031348211047173] [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: 11/17/2022]
Abstract
BACKGROUND Our objective was to evaluate differences in baseline characteristics, complications, and mortality among patients receiving a gastrostomy tube (GT) by surgical or non-surgical services. METHODS We performed a retrospective analysis of adult patients who underwent GT placement from 2014 to 2017 at a single institution. Using bivariate and multivariable analyses, we compared baseline characteristics, complications, and overall 30-day mortality of patients undergoing GT placement with surgical or non-surgical services. RESULTS Of the 1339 adults who underwent GT placement, surgical and non-surgical services performed 45% (n = 609) and 55% (n = 730) procedures, respectively. Gastrostomy tube-related complications were similar (29.6% surgical vs 28.8% non-surgical, P = .76). Thirty-day mortality was higher among non-surgical services (23.7% vs 16.5%, P = .004). On multivariable analysis, this was not significant (OR 1.21, 95% CI 0.83; 1.77). CONCLUSION Surgical and non-surgical service placement of GTs had equivalent GT-related mortality and complication rates.
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Affiliation(s)
- Joshua Herb
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nidia Rodriguez-Ormaza
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Clark Cunningham
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Neal Bartl
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jihane Jadi
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Trista Reid
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Porter RJ, McKinlay AW, Metcalfe EL. Endoscopically placed venting gastrostomy can be a safe and effective palliative intervention in benign and malignant gastrointestinal obstruction. Frontline Gastroenterol 2021; 13:309-315. [PMID: 35722598 PMCID: PMC9186026 DOI: 10.1136/flgastro-2021-101930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/05/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Chronic gastrointestinal obstruction can precipitate a constellation of symptoms including nausea, vomiting, abdominal distension and pain that negatively impact on health-related quality of life. Decompression via venting gastrostomy can offer symptomatic relief but safety and efficacy data are sparse. This study characterises the diverse venting percutaneous endoscopic gastrostomy (vPEG) cohort at our tertiary referral centre and defines the safety and efficacy of this procedure. METHODS Patients undergoing vPEG between May 2012 and June 2020 were identified from a prospectively maintained database and demographic, procedure-related and mortality data were extracted. Retrospective analysis of case notes provided data on patient symptoms. Last follow-up was May 2021. RESULTS 27 patients (median age 63, range 18-90 years) underwent vPEG insertion. The majority of vPEGs were for patients with obstruction secondary to locally advanced or metastatic malignancy (n=21/27, 77.8%). Six procedures were performed for benign disease (n=6/27, 22.2%). No patients developed the recognised serious complications of bleeding, perforation or peritonitis from vPEG insertion. Symptoms of nausea (p=0.006), vomiting (p<0.001), abdominal distension (p<0.001) and abdominal pain (p=0.002) were improved following vPEG. Pain beyond the expected postprocedural discomfort was associated with a lower number of days survived postprocedure (p=0.026). CONCLUSION vPEG can be a safe and efficacious palliative intervention for benign and malignant chronic gastrointestinal obstruction. Severe postprocedural pain should be promptly investigated to exclude a potential complication. A defined clinical strategy for assessing and managing these patients would facilitate wider recognition of the benefits of vPEG and improve the safety profile in centres with more limited experience.
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Affiliation(s)
- Ross J Porter
- Department of Digestive Disorders, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK,Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK
| | - Alastair W McKinlay
- Department of Digestive Disorders, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Emma L Metcalfe
- Department of Digestive Disorders, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
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Williams LA, Bruera E, Badgwell B. In Search of the Optimal Outcome Measure for Patients with Advanced Cancer and Gastrointestinal Obstruction: A Qualitative Research Study. Ann Surg Oncol 2020; 27:2646-2652. [PMID: 32152776 DOI: 10.1245/s10434-020-08328-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gastrointestinal obstruction (GIO) is the most common indication for palliative surgical consultation in patients with advanced cancer. The purpose of this study is to delineate the symptom burden and experience of these patients. PATIENTS AND METHODS Twenty patients with advanced cancer and GIO described symptoms at time of surgical consultation. We analyzed the content of interview transcripts and ranked symptoms by frequency and according to an assessment of relevance conducted by an expert panel (surgeons, palliative care physicians, nurses, and patients/caregivers). RESULTS Among the 20 study patients, malignancy types included colorectal (n = 9), gastric (n = 4), urothelial/renal (n = 3), and other (n = 4), whereas sites of obstruction were the small bowel (n = 11), gastric outlet (n = 3), and large bowel (n = 6). Thirteen patients (65%) had received chemotherapy within 6 weeks. Imaging evidence of a primary/recurrent tumor was documented in 13 patients (65%), carcinomatosis in 11 (55%), and ascites in 16 (80%). Thirty patient symptoms were identified on qualitative interviewing. Seven GIO-specific items were identified as relevant by the expert panel and will be added to the core symptom assessment inventory for further testing. CONCLUSIONS We identified symptoms of importance that can be used to assess outcome after treatment of patients with advanced cancer and GIO. Testing for validity and reliability will be required before formal survey development.
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Affiliation(s)
- Loretta A Williams
- Departments of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Departments of Palliative Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian Badgwell
- Departments of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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