Effective Palliation of Nausea and Vomiting by Retrograde Enterogastric Decompression

Abstract

Purpose: Intractable nausea and vomiting are recognized complications of gastric cancer which is often unsuitable for decompression by gastrostomy when involvement is diffuse. Venting procedures also inherently require an invasive approach with additional access that entails risks and discomfort. We describe two cases wherein effective palliation was provided by retrograde enterogastric decompression via an existing jejunostomy with a second catheter introduced antegrade for feeding purposes. We are unaware that this approach has previously been described. Methods: Retrospective description of two cases. Results: CASE 1: A 68 year old male with locally advanced diffuse gastric cancer was seen in consultation for intractable nausea and vomiting that required intermittent NG suction. One month previous, he underwent surgery in his home country with CT scan negative for metastatic disease. Cancer was deemed unresectable and a feeding jejunostomy was performed. Subsequent endoscopy revealed diffuse neoplastic involvement of the stomach with no window for venting gastrostomy. Intractable nausea & vomiting were effectively palliated by retrograde enterogastric decompression via the existing jejunostomy. Decompression was maintained for the remaining 11 months of his life during which time he received enteral feedings via the same jejunostomy and intravenous chemotherapy with good performance status until his last month of life. CASE 2: A 60 year old female was diagnosed with poorly differentiated gastric cancer diffusely involving the antrum and distal body of the stomach. Staging laparoscopy prior to anticipated neoadjuvant therapy revealed peritoneal metastasis. Jejunostomy was performed. She was treated on protocol with systemic chemotherapy and maintained on enteral feedings. One month later, she developed intractable nausea and vomiting. Endoscopy revealed diffuse circumferential involvement of the stomach with the extent of malignancy unsuitable for stenting or endoscopic venting gastrostomy. Enterogastric decompression was accomplished with a 12 F pigtail catheter advanced retrograde with an 8 F catheter for feeding introduced antegrade. Effective palliation was accomplished until percutenous gastrostomy by interventional radiology was performed one month later for additional terminal palliation. Conclusion: These cases illustrate the potential for effective palliation of nausea and vomiting in patients with gastric cancer by retrograde enterogastric decompression via an existing jejunostomy. This previously undescribed technique provides a palliative option without supplemental risk to the patient and should be considered when gastric decompression cannot otherwise be accomplished and a jejunostomy is accessible.