Improvement In Oral Intake Research Articles

Treatment of Malignant Gastric Outlet Obstruction With Metallic Stents

ObjectivesGastric outlet obstruction (GOO) is a late complication of advanced gastric, pancreatic, and duodenal cancer. Palliative treatment of the obstruction is the main aim of therapy for these patients. Self-expandable...

Temporary gastric neuromodulation for intractable nausea and vomiting

Gastric neuromodulation (GNM) has been advocated for the treatment of drug refractory gastroparesis or persistent nausea and vomiting in the absence of a mechanical bowel obstruction. There is, however, little in the way of objective data to support its use, particularly with regards to its effects on gastric emptying. Six patients (male-to-female ratio: 4:2, mean age: 49 years, range: 44-57 years) underwent the GNM between April and August 2010. Three patients had confirmed slow gastrointestinal transit. Aetiology included previous gastric surgery in two, diabetes in one and idiopathic nausea and vomiting in three patients. GNM pacing wires were placed endoscopically and left in situ for seven days. Patients underwent gastric scintigraphy before and 24 hours after the commencement of GNM. Total gastroparesis symptom scores (TSS), weekly vomiting frequency scores (VFS), health-related quality of life (using the SF-12(®) questionnaire), gastric emptying, nutritional status and weight were compared before and after GNM. TSS improved after GNM in comparison with baseline data. VFS improved in three of four symptomatic patients. The SF-12(®) physical composite score improved in four patients (27.5 vs 34.3) and the mental composite score improved in five patients (34.9 vs 35.9). All patients reported an improvement in oral intake. A significant weight gain (mean: 1kg, range: 0.3-2.4kg) was observed over seven days. Gastric emptying half-time improved in four patients. GNM improved upper gastrointestinal symptoms, quality of life and nutritional status in patients with intractable nausea and vomiting. GNM merits further investigation.

Optimal indications of surgical palliation for incurable advanced gastric cancer presenting with malignant gastrointestinal obstruction

Decision-making for surgical palliation remains one of the most challenging clinical scenarios. We investigated the optimal indications for surgical palliation in advanced gastric cancer (AGC) patients presenting with gastrointestinal (GI) obstruction. A retrospective analysis was performed on 53 consecutive patients who underwent surgical palliation for GI obstruction caused by AGC between 2000 and 2007 at Osaka National Hospital. The clinical course of each patient was followed until death. Postoperative improvement of oral intake, achievement of hospital discharge, and implementation of chemotherapy in each patient were documented and used as a triad to assess the quality of life (QOL). Prognostic factors for overall survival were investigated by univariate and multivariate analyses. In addition, postoperative morbidity and mortality rates were recorded. Of the entire patient cohort, 64% demonstrated a QOL improvement by having achieved the triad. Performance status (PS) of 1 or less was the only significant predictive factor for QOL improvement. The median survival time (MST) of the whole patient cohort following surgical palliation was 161days, while the MSTs of patients fulfilling the triad and of those failing to achieve the triad were 253 and 60days, respectively, with a significant difference between them (P<0.0001). PS of 1 or less (hazard ratio 0.265, P=0.0008) and recurrent disease (hazard ratio 0.394, P=0.043) were identified as significant independent prognostic factors for longer survival on multivariate analysis. Overall morbidity and 30-day postoperative mortality rates were 24.5% (13 patients) and 7.5% (4 patients) respectively. In AGC patients presenting with GI obstruction, surgical palliation was beneficial in patients with PS of 0-1 and those with recurrent disease, in terms of improved QOL and prolonged survival, with acceptable operative morbidity and mortality rates.

Improvement of Oral Intake following Chemotherapy in Gastric Cancer Patients with an Inability to Eat

Background: Based on several phase III studies, oral S-1-based chemotherapy has become the standard for treatment of advanced gastric cancer in Japan. However, these studies included patients able to maintain sufficient oral intake, and the effectiveness of chemotherapy for patients unable to eat remained unclear. Methods: We retrospectively analyzed the effect of chemotherapy on patients with advanced gastric cancer who presented with inability to eat. We defined ‘inability to eat’ as requirement for daily intravenous fluids or hyperalimentation and ‘improvement of oral intake’ as no such requirement >1 week. Results: Among the 777 patients who received first-line chemotherapy, 100 patients (12.8%) were considered unable to eat and required daily intravenous fluids or hyperalimentation. Performance status was 0–1 in 26 patients and ≧2 in the other 74 patients. Seventy-eight patients (78%) had peritoneal metastasis and 62 patients (62%) had ascites. First-line chemotherapy with 5-fluorouracil-based regimens was used in 46 patients, taxane-based chemotherapy in 34 patients, oral fluoropyrimidine-based therapy in 19 patients, and irinotecan-cisplatin combination treatment in 2 patients. Median survival time was 5.0 months (95% confidence interval, CI, 3.9–6.6). Improvement in oral intake with duration for >1 week was achieved in 40 patients (40%) with the median duration of nutritional-support-free time of 3.1 months (95% CI 2.5–4.6). Conclusion: Chemotherapy is moderately effective in improving oral intake in patients with advanced gastric cancer with inability to eat. Further study is required to improve its prognosis.

The effect of polyvinylpyrrolidone-sodium hyaluronate gel (Gelclair) on oral microbial colonization and pain control compared with other rinsing solutions in patients with oral mucositis after allogeneic stem cells transplantation

SummaryBackgroundGelclair is an oral lubricating gel used in the management of oral mucositis (OM). We evaluated its efficacy, tolerance and impact on oral cavity microbial colonization in patients with OM after allogeneic hematopoietic stem cells transplantation.Material/MethodGelclair was administered in a group of 22 patients with active OM. A control group of 15 patients used other rinsing solutions (chlorhexidine, benzydamine, salvia). Tests with oral cavity swabs for microbiology analysis were performed once a week.ResultsThe characteristics of OM in both groups were comparable, and rinsing solutions had satisfactory tolerability. There was no difference in the median improvement of oral intake and OM-related pain relief, which was assessed mostly as “slight effect”. In the Gelclair group, the effect duration was longer (median 3 [0–5] vs. 1 [0–3] hours, p=0.001). There was significant increase of Enterococcus faecalis and Candida sp. colonization of the oral cavity over the course of the hospitalization and significantly reduced incidence of such colonization in patients with OM in the Gelclair group: 1/22 (5%) vs. 6/15 (40%), p=0.01. In vitro tests showed inhibited growth of Enterococcus faecalis and Candida sp. colonies within the area of the Gelclair application.ConclusionsGelclair may be individually helpful in the management of OM and pain in patients after allogeneic stem cells transplantation. Its use did not lead to worsened oral bacterial and yeast colonization and probably even helped to protect mucosa from Enterococcus and Candida sp. Further studies based on larger cohorts are needed.

Improved Oral Intake After Palliative Duodenal Stenting for Malignant Obstruction: A Prospective Multicenter Clinical Trial

We sought to test the hypothesis that placement of a new nitinol duodenal self-expandable metallic stent (SEMS) for palliation of malignant gastroduodenal obstruction is effective and safe in allowing patients to tolerate an oral diet. In a prospective multicenter study, SEMSs (Duodenal WallFlex, Boston Scientific) were placed to alleviate gastroduodenal obstruction in inoperable patients without the ability to tolerate solid food. The primary study end point was improvement in oral intake monitored according to the 4-point Gastric Outlet Obstruction Scoring System (GOOSS) up to 24 weeks after stent placement. Forty-three patients received SEMSs, which were successfully deployed on the first attempt in 41 cases (95%) and the second attempt in two (5%). Within 1 day and 7 days after SEMS placement, 52% and 75% of patients, respectively, benefited from a GOOSS increase > or =1. Resumption of solid food intake (GOOSS 2-3) was attained by 56% of patients within 7 days and 80% by 28 days. Of the patients attaining GOOSS 2-3, 48% remained on solid food until death or last follow-up. Device-related adverse events included stent occlusion/malfunction in 9% of patients and perforation in 5% of patients. Duodenal WallFlex stent placement promptly improves oral intake in a majority of inoperable patients with malignant gastroduodenal obstruction. In approximately half the patients achieving GOOSS 2-3, the capacity for solid food intake endures until death or last follow-up.

Efficacy of a Scheduled IV Cocktail of Antiemetics for the Palliation of Nausea and Vomiting in a Hospice Population

This is a retrospective analysis of 10 mg metoclopramide, 25 mg diphenhydramine, and 4 mg dexamethasone given intravenous piggyback every 6 hours for nausea or vomiting. Outcome measures were rapidity of symptom relief based on the self-report of the patient and nursing documentation of relief from symptoms of nausea or vomiting. Seven hundred and ninety seven patients were admitted to the inpatient hospice unit during a 2-year period. Sixty-three patients developed nausea or vomiting requiring the cocktail. Fifty-seven patients (90%) had objective response as reflected in nursing notes. Symptom relief was usually noted within 2 days with improvement in oral intake and enjoyment in activities, such as parties and family interactions. Partial relief was noted in patients with gastrointestinal malignancies and peritoneal carcinomatosis even with the addition of other antiemetics to the cocktail.

P0480 EOSINOPHILIC ESOPHAGITIS (EE) IN TODDLERS WITH FEEDING DISORDERS

Introduction: Dysphagia is a well documented symptom of eosinophilic esophagitis (EE) in children. There is no data regarding the clinical manifestations of this condition in infants and toddlers. Aim: The aim of this study was to evaluate the presentation of EE in younger children referred to the feeding disorders clinic of a tertiary referral center and to investigate the response of these children to therapy. Methods: Database matching was performed (January 2000-June 2003) to identify infants and toddlers diagnosed with EE and those attending the feeding disorders clinic. Children who had endoscopic evaluation both at the time of diagnosis and at follow up within 6 months of therapy were selected. Endoscopic features required for a diagnosis of EE included: esophageal mucosal furrowing, erythema, exudates, or decreased vascular markings. Histologic features of EE were: >24 eosinophils/HPF, thickening of basal layer, and rete peg elongation. Retrospective chart review was then performed to include demographic data, comorbidity, allergy profile, and clinical and histologic response to therapy. All study patients were treated with a combination of PPI and Fluticasone (swallowed). In addition, elemental diet was instituted in those found to have a food allergen. Treatment success was defined by an improved oral intake (per report), adequate weight gain, and improved endoscopic and histologic findings at 3–6 month follow up. Resolution of histologic changes included: fewer than 7 eosinophils/HPF, regression of both basal layer hyperplasia and rete pegs. Results: A total of 14 subjects, mean age of 26 months (range 13 to 60 moths) were identified who fulfilled the entry criteria during the study period. Ten subjects had neurodevelopmental delay, of whom 4 were supplemented by gastrostomy tube feeding in addition to oral intake. Eleven subjects were evaluated by an allergist and 7 were determined to be allergic to a food item (n=6) or environmental antigen (n=1). All 14 children had documented endoscopic and histologic improvement after therapy. Eight subjects demonstrated both increased oral intake and weight gain after therapy. Two children had either documented weight gain or improved oral intake. Conclusion: EE is a potential cause for dysphagia in infants and toddlers. Endoscopic evaluation, therefore, should be considered in this subset of children. In this study all children treated with a combination of PPI and swallowed fluticasone showed endoscopic and histologic resolution of EE. However, only 57% had improvement in oral intake and weight gain.

Defining Clinically Meaningful Outcomes in the Evaluation of New Treatments for Oral Mucositis: Oral Mucositis Patient Provider Advisory Board

Oral mucositis (OM)-related outcomes constituting a meaningful clinical advance in bone marrow transplant patients were considered by an interdisciplinary panel. Meaningful outcomes are essential in product development for OM, a condition without effective prevention or treatment. The most important outcomes to measure, the feasibility of measuring these in a clinical trial, and clinically meaningful differences in these outcomes were determined by the panel. Most important are reduction in oral pain and use of opioid analgesics, improvement in oral intake and quality of life, and reduction of hospitalization duration. Reduction in the severity of OM measured by an objective evaluation of oral mucosa could provide insight regarding the biologic activity of an intervention. Further data are required to define the precise relationship between reduction in visible OM and improvement in outcome. Minimally, clinical trials for OM should assess oral pain, opioid use, oral intake, and include objective assessment of OM.

Teaching Case: The Appearance of Pica in a 5 1/2‐Year‐Old Child With Short Bowel Syndrome

W.M., a 5 1/2‐year‐old male with short bowel syndrome (SBS) secondary to an in utero midgut volvulus, had been dependent on total parenteral nutrition (TPN) in addition to gastrostomy tube (GT) feeds to maintain his nutritional status since birth. Bowel lengthening procedures performed at 15 and 30 months of age left W.M. with 82 centimeters of small bowel. Despite these procedures and what was presumed to be adequate nutrition, W.M.'s weight/age and height/age remained below the 5th percentile. With an observed improvement in oral intake at 5 1/2 years of age (2000 kcal/d), his GT was removed. TPN, which was continued for several months thereafter, was subsequently discontinued after a septic episode that resulted in severe neutropenia. However, family members soon began to report significant alterations in his behavior. An evaluation performed by a behavioral psychologist demonstrated no familial or developmental contributions to this new behavior pattern, which is termed pica in the psychological literature. Although a nutritional deficiency was suspected, serum levels of trace metals were found to be normal. With a reported increase in listlessness and lethargy at school, TPN was promptly reinstituted (approximately 6 months after it had been discontinued). The observed pica disappeared 1 week following the reinitiation of TPN therapy.