Relief Of Obstructive Symptoms Research Articles

SJLA_2024_A12: Clinical Outcomes of Endoscopic Stent in Curative and Palliative Management of Malignant Colonic Obstruction: A Retrospective Cohort Study

Background: Malignant colonic obstruction (MCO) occurs in 10%–18% of colorectal cancers. Conventionally, emergency surgery has been the standard treatment modality. However, it is associated with higher morbidity and mortality rates compared to patients undergoing elective surgery. With the advancement of endoscopic techniques, self-expandable metal stent has been advocated as an alternative management. It provides relief of obstructive symptoms, allowing the patient’s general condition to be restored and enabling elective surgery. Furthermore, the ability to complete staging allowed identification and avoidance of unnecessary surgery in patients with advanced disease who need palliative measures. However, various stent-related complications. have been reported in the literature, including perforation (4.5%), migration (11%), and obstruction (12%). Aim: This study aimed to evaluate the technical and clinical success rates and the complication rate of stent placement in patients with MCO. In addition, we compared the rates of laparoscopic surgery, stoma creation, and postoperative outcomes between different subgroups. Methods: We conducted a retrospective cohort study including all patients diagnosed with MCO between March 2015 and September 2021. Patients were divided into groups according to the initial treatment they received, stent versus surgery, and the intent of treatment, and curative versus palliative. Data were collected from medical records. Results: Among 112 patients, 24 had stenting as a bridge to surgery, and 16 underwent palliative stenting. The technical and clinical success rates were 95% and 94.7%, respectively. Stent placement failed in two patients in the curative group due to complete obstruction with the inability to pass the guidewire in one patient and perforation in the other. Clinical failure was encountered in two patients who had persistent symptomatic obstruction beyond 48 h from stenting. The early complication rate following stent insertion was 7.5%. Among curative patients, stenting did not affect surgical resection in terms of laparoscopic approach or need for stoma creation. However, it was associated with longer hospital stay. On long-term follow-up, half the patients who received stent in the palliative group required re-intervention due to re-obstruction with either re-stenting or surgery. The mean stent patency time was 7 months. Conclusion: Management of MCO varies based on the patients’ clinical presentation, tumor site, and surgeon’s preference. Stent placement is an effective and safe management option for selected patients with MCO with reasonable clinical and technical success rates. Complication rates are low, particularly when used as a bridge to surgery. However, long-term patency and the need for re-intervention are an area of concern among palliative patients.

Gall stone ileus: An uncommon cause of small bowel obstruction at an unusual age: A Case report

Gallstone ileus is a rare complication of cholelithiasis. It is an uncommon cause of a mechanical small bowel obstruction. Repeated episodes of cholecystitis results adhesion of the gallbladder to the small bowel (usually duodenum) with eventual formation of cholecystoenteric fistula via which gallbladder stone enters the small bowel. It is most commonly seen in elderly females hence linked with high morbidity & mortality. Computed tomography (CT) imaging have made it easier to diagnose gallstone ileus effectively. Surgical intervention results in prompt relief of obstructive symptoms by removing stone & repairing fistula. Here is a case of gall stone ileus in a 27-year-young gentleman who presented to us with history of acute abdomen & without any comorbidities or biliary manifestation.

Palliative treatment for malignant gastrointestinal obstruction with peritoneal carcinomatosis: enteral stenting versus surgery.

Background and study aims Management of malignant gastrointestinal obstruction (MGIO) is more challenging in the presence of peritoneal carcinomatosis (PC). Outcomes data to guide the management of MGIO with PC are lacking. We aimed to compare the clinical outcomes and adverse events between endoscopic and surgical palliation and identify predictors of stent success in patients with MGIO with PC. Patients and methods Consecutive inpatients with MGIO with PC between 2000 and 2018 who underwent palliative surgery or enteral stenting were included. Clinical success was defined as relief of obstructive symptoms. Results Fifty-seven patients with enteral stenting and 40 with palliative surgery were compared. The two groups did not differ in rates of technical success, 30-day mortality, or recurrence. Clinical success from a single intervention (63.2 % versus 95 %), luminal patency duration (27 days vs. 145 days), and survival length (148 days vs. 336 days) favored palliative surgery (all P < 0.05) but the patients in the surgery group had a trend toward better Eastern Cooperative Oncology Group (ECOG) status. The rate of adverse events (AEs) (10.5 % vs. 50 %), the severity of AEs, and length of hospital stay (4.5 days vs. 9 days) favored enteral stenting ( P < 0.05). The need for more than one stent was associated with a higher likelihood of stent failure. Conclusions Our study suggests that enteral stenting is safer and associated with a shorter hospital stay than palliative surgery, although unlike other MGIOs, clinical success is lower in MGIO with PC. Identification of the right candidates and potential predictors of clinical success in ECOG-matched large-scale studies is needed to validate these results.

Management of primary and metastatic malignant small bowel obstruction, operate or palliate. A systematic review.

The management of patients presenting with malignant small bowel obstruction is a challenging paradigm. The aim of this systematic review was to examine different management strategies in these complex patients. The primary outcomes evaluated were the type of intervention, 30-day morbidity and mortality and overall survival rates. A systematic literature review of EMBase, Medline, PubMed and the Cochrane Library was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses for studies reporting on conservative and operative management of malignant small bowel obstruction. Fifteen studies (n = 882 patients) reporting on outcomes for malignant small bowel obstruction were analysed. Outcomes measured were primarily survival and relief of obstructive symptoms. The median age ranged from 52 to 66 years. The most common cause of malignant small bowel obstruction was gynaecological in nature (56%), followed by colorectal (19%). Four hundred and eighty-six patients underwent primary surgical management and the remaining 396 patients were assigned to non-surgical intervention. Median overall survival in the operative studies ranged from 2.5 to 7.4 months compared with 0.9 to 1.9 months (P < 0.05). The 30-day mortality ranged from 13% to 28% in those who underwent surgical interventions versus 2% to 61% in the non-surgical group (P = 0.09). No significant difference in median survival in gastrointestinal (GI) and gynaecological malignancies was observed (4.3 versus 5.0 months, P = 0.12). Morbidity ranged from 21% to 85% in the surgical group and 12% to 29% in the percutaneous groups (P < 0.05). Surgical intervention in malignant small bowel obstruction is associated with significant morbidity, although it may improve survival in selected patients with gynaecological and colorectal malignancy. It is imperative that realistic goals and expectations are discussed with patients preoperatively.

Percutaneous transhepatic biliary stent placement in the palliative management of malignant obstructive jaundice: initial experience in a tertiary center in Ghana.

Introductionone of the mainstays of management of malignant biliary obstruction is the decompression of the biliary system and its associated obstructive symptoms. Non-surgical palliative treatment such as percutaneous transhepatic biliary stenting is desirable in many selected patients. However, this service is often not available in many resource-limited countries. We share our initial experience of percutaneous transhepatic biliary stenting for the management of malignant biliary obstruction in our first set of patients with surgically non resectable malignant biliary obstruction in Ghana.Methodspercutaneous transhepatic biliary stenting was performed on the first 23 consecutive patients at the Korle Bu Teaching Hospital. The procedure served as the first palliation for malignant obstruction through interventional radiology. Medical records as well as serum levels of total bilirubin (TBil), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were used to assess the efficiency of the intervention. Microsoft Excel 2010 was used to analysis the data.Resultsmost patients had resolution of jaundice with marked improvement in liver function and resolution of the itching associated with obstructive jaundice. During the follow-up of cases, one major complication of hemoperitoneum occurred requiring laparotomy. No other major complications such as bile leakage or death occurred. Four (4) patients had sepsis, which was managed.Conclusionthe introduction of the intervention in Ghana has proven to valuable for palliative drainage and relief of obstructive symptoms, hence contributing to better patient management. It is relatively safe with minor complications among Ghanaians with non-resectable obstructive symptoms.

Covered and uncovered biliary metal stents provide similar relief of biliary obstruction during neoadjuvant therapy in pancreatic cancer: a randomized trial

Preoperative biliary drainage with self-expanding metal stents (SEMSs) brings liver function within an acceptable range in preparation for neoadjuvant therapy (NATx) and provides relief of obstructive symptoms in patients with pancreatic cancer. We compared fully-covered SEMSs (FCSEMSs) and uncovered SEMSs (UCSEMSs) for sustained biliary drainage before and during NATx. Patients with pancreatic cancer and planned NATx who need treatment of jaundice and/or cholestasis before pancreaticoduodenectomy were randomized to FCSEMSs versus UCSEMSs. The primary endpoint was sustained biliary drainage, defined as the absence of reinterventions for biliary obstructive symptoms, and was assessed from SEMS placement until curative intent surgery or at 1 year. The intention-to-treat population included 119 patients (59 FCSEMSs, 60 UCSEMSs). Sustained biliary drainage was equally successful with FCSEMSs and UCSEMSs (72.2% vs 72.9%, noninferiority P= .01). Reasons for FCSEMS and UCSEMS failure differed significantly between the groups and included tumor ingrowth in 0% versus 16.7% (P< .01), and stent migration in 6.8% versus 0% (P= .03), respectively. Serious adverse event rates related to stent placement were not significantly different in both groups (23.7% [14/59] vs 20.0% [12/60], P= .66), as were acute cholecystitis rates when the gallbladder was in situ (9.3% [4/43] vs 4.8% [2/42], P= .68) for FCSEMSs and UCSEMSs, respectively. In our study, independent of stent type, predictors of reinterventions were 4-cm stent length and presence of the gallbladder. FCSEMSs and UCSEMSs provide similar preoperative management of biliary obstruction in patients with pancreatic cancer receiving NATx, but mechanisms of stent dysfunction depend on stent type, stent length, and presence of the gallbladder. (Clinical trial registration number: NCT02238847.).

Cavum Septum Pellucidum: Significance and Management

AbstractCavum septum pellucidum (CSP) is a cystic midline brain malformation; it is mostly congenital but can also be acquired. CSP is mostly asymptomatic. Symptomatic CSP is very rare. Clinical presentation is usually nonspecific which may be due to increased intracranial pressure as a result of obstructive hydrocephalus or due to direct compression of the nearby structures. Diagnosis of CSP is not very easy specially relating its contribution to the presenting symptoms is difficult. However, once diagnosis is established surgery remains the treatment of choice. Nowadays endoscopic fenestration of the cyst is the surgical modality of choice. The outcome after surgical intervention is very promising with relief of obstructive symptoms along with improvement of cognitive function and behavioral symptoms.

Superiority of Gastrojejunostomy Over Endoscopic Stenting for Palliation of Malignant Gastric Outlet Obstruction

Gastric outlet obstruction (GOO) in patients with malignancies causes nausea, vomiting, abdominal pain, malnutrition, and dehydration. Endoscopic placement of self-expandable metallic stent (SEMS) and gastrojejunostomy are the 2 main palliative options. We aimed to compare the outcomes of endoscopic SEMS placement with gastrojejunostomy in a propensity score matched study and identified factors associated with clinical success. We performed a retrospective analysis of patients with malignant GOO who underwent endoscopic SEMS placement (n= 183) or gastrojejunostomy (n= 127) from 2011 through 2017 at a tertiary academic medical center. Clinical success was defined as successful resumption of oral intake and relief of obstructive symptoms after either procedure. A propensity score matched analysis was conducted to compare clinical success rate, luminal patency duration, survival length, and adverse outcomes. We performed multivariable analyses to identify factors associated with clinical success. Proportions of patients with clinical success did not differ significantly between the SMES group (79.4%) and the gastrojejunostomy group (80.1%) (P= .83). The mean patency duration and survival lengths were significantly longer in the gastrojejunostomy group (169.2 and 193.4 days respectively), compared to the endoscopic stenting group (96.5 and 119.9 days respectively). Poor performance status, presence of ascites and low albumin were independent risk factors for failure of enteral stenting and gastrojejunostomy. In a retrospective analysis of patients with GOO, due to cancer, who underwent endoscopic SEMS placement or gastrojejunostomy, we found gastrojejunostomy to provide significant increases in patency duration and survival time. Gastrojejunostomy should therefore be considered the primary treatment option for patients with good performance status and reasonable survival expectancy. Nutritional status, the absence of ascites, and pre-procedure performance status are associated with clinical success.

Su1723 EFFICACY OF SELF EXPANDABLE METAL STENTS IN EXTRINSIC MALIGNANT COLONIC OBSTRUCTION. A 10-YEAR TERTIARY CARE CENTER EXPERIENCE

Uncovered Self Expandable Metal Stents (SEMS) are frequently used for the management or palliation of secondary extrinsic malignant colon obstruction. The efficacy of SEMS in this setting may be inferior compared to primary colonic obstruction. We retrospectively reviewed all patients who underwent SEMS for colonic obstruction due to extrinsic malignant compression at our institution from 1/1/2007 to 8/1/2017. The primary outcome measures were technical and clinical success. Technical success was defined as successful stent deployment across the stricture in the desired location. Clinical success was defined as relief of obstructive symptoms. Patient and procedural related data including complications were summarized and analyzed. Descriptive statistics were used to summarize patient and procedure characteristics. Fisher’s exact test was used to calculate statistical significance between categorical variables. Logistic regression models were used to look for predictors of clinical success. The Kaplan-Meier method was used to calculate survival. A total of 199 patients underwent colonic stent placement over a 10-year period. Thirty-eight (19.1%) patients had malignant extrinsic compression. Technical success was achieved in all cases. Clinical success was achieved in 24 (63.2%) cases. Clinical failure occurred in 36.8%. Median time to stent failure was 5 days (IQR 3-7). Endoscopic revision was performed in 4 (10.5%) patients. Surgery after stent placement was performed in 7 (18.4%) patients. Patient and procedural characteristics are listed in table 1 and table 2. The most common source of metastasis was gastroesophageal 21.1%. The most common location of stricture was the rectosigmoid colon 89.5%. The median stricture length was 38mm(IQR 30-50). The most common stent size placed was 25 x 120mm (57.9%). Eleven (28.9%) patients required two or more stents placed in overlapping tandem fashion. Nineteen (50%) stents were placed at an “angled” configuration > 45 degrees. After univariate analysis, stents placed in a straight configuration (angulation < 45 degrees) were more likely to be clinically successful even though this was not statistically significant OR 2.52 (95%CI 0.65-9.8) p=0.18. The median survival time in patients who had a clinical response was 2.6 months versus 1.4 months in patients who had clinical failure or a complication (p=0.63). Uncovered SEMS placement for extrinsic colonic obstruction is associated with a high rate of technical success but a high rate of clinical failure. This information can be used to better inform patients and referring providers as well as develop strategies to improve palliation in this patient population.Tabled 1Table 1 Patient characteristics, abbreviations: IQR: interquartile rangeAge (median) (IQR)57 (48-70)GenderFemale n (%)22 (57.9)Symptom duration (median) IQR7 (2-10)Primary Malignancy n(%)Gastroesophageal8 (21.1)Peritoneal7 (18.4)Pancreatic6 (15.8)Small Bowel Carcinoid4 (10.5)Ovary/Uterine4 (10.5)Breast2 (5.3)Prostate2 (5.3)Lung2 (5.3)Other3 (7.9) Open table in a new tab Tabled 1Table 2 Colonic stent procedural details, abbreviations: IQR: interquartile rangeTechnical Success, n (%)38 (100)Clinical Success, n (%)24 (63.2)Stricture Location n (%)Recto-sigmoid colon34 (89.5)Transverse colon2 (5.3)Ascending colon2 (5.3)Stricture length, median, (IQR)38 (30-50)Stent Configuration n (%)Straight19 (50)Angled19 (50)Multiple stents, n (%)Overlapping tandem n10Multifocal stricture n1Endoscopic revision post stent n (%)4 (10.5)Flexible Sigmoidoscopy2Flexible Sigmoidoscopy with repeat stent2Complications n (%)4 (10.5)Perforation n2Readmission for pain n2 Open table in a new tab

Rapid Access Palliative Radiation Workflow Using MRI-Guided Single-Session Simulation, Online Adaptation, and Treatment

In the palliative setting, priority is placed on streamlining the process of radiation delivery to avoid unnecessary treatment delay and expedite symptom relief. We hypothesized that using magnetic resonance imaging (MRI) guidance, adaptive planning software, and pre-existing diagnostic computed tomography (CT) imaging, we could deliver palliative radiation without the need for a separate CT simulation scan, thus decreasing the time and steps required to start palliative treatment. For patients necessitating urgent palliative radiotherapy, a simple “pre-plan” was created on diagnostic CT imaging prior to patient transport to the treatment machine. For dose calculation purposes, the electron density of the CT was deformed to MRI in the pre-plan or was overridden to water density. In the treatment vault, the patient was imaged in treatment position with volumetric MRI. The pre-plan was then rapidly adapted online to the MRI, updating the target definition, re-defining fields, and re-balancing beam weights. Once the online-adapted plan was finalized and approved, the patient was treated. Eighteen patients with metastatic cancer were treated from October 2015 to November 2016 with urgent palliative radiation for indications such as pain, obstruction, and bleeding. Dose/fractionation regimens included 8 Gy in 1 fraction (8 pts), 25 Gy in 5 fractions (4 pts), and 30 Gy in 10 fractions (6 pts). Median planning target volume (PTV) size was 187cc. Online adaptive MRI-guided radiotherapy enabled plan changes to be made rapidly. Conformal 3D adaptive plans were delivered as quickly as more conventional AP/PA beam arrangements with a median delivery time of 122s. MRI-guided adaptive radiotherapy was planned and delivered in one-hour appointments for each patient, compared with a mean time from CT simulation to delivery of first treatment of 30 hours (95% CI, 24-35) for a similar sample of urgent palliative cases planned and treated with more traditional radiotherapy workflow. Clinical outcomes were similar to historical and sampled controls, with improvement in pain in 11 of 14 patients, relief of obstructive symptoms in 3 of 3 patients, and hemostasis in 1 of 1 patient treated with MRI-guided adaptive radiotherapy. Integrated treatment planning using available MRI-guided online adaptive radiotherapy allows a rapid-access treatment workflow obviating the need for a separate CT simulation. Conformal pre-plans can be created without time pressure and, if necessary, adapted to anatomy at treatment. This streamlined palliative radiation workflow makes efficient use of both staff and patient time and expedites palliative treatment with similarly successful clinical results.

Abstract No. 227 - Percutaneous transesophageal gastrostomy (PTEG): indications, technique, and outcomes

PTEG technique is a rare palliative procedure performed in patients with a contraindication to percutaneous gastrostomy.We sought to evaluate our experience at a tertiary care center in 14 patients. This IRB approved, HIPAA-compliant study involved a search of the department’s electronic database to identify all PTEG procedures from 2014-2016.Electronic medical records were used to identify demographics, clinical history, cross-sectional imaging and outcomes for each patient.All available CT, US and procedural fluoroscopy images were reviewed to evaluate variations in technique.Procedures were performed under general anesthesia for airway protection;a 20 mm angioplasty balloon was used as a target for percutaneous access of the esophagus for placement of a 45cm,14F multipurpose drain. Between 2014-2016, PTEG was attempted in 14 patients (7M,7F) with an average age of 53(range 27-72) for gastric venting from malignant bowel obstruction.Average ECOG scores were 2 (range 1-4).Patients had metastatic disease originating from the ovary (28.7%), stomach (28.7%), pancreas (7.1%), liver (7.1%), colon (7.1%), appendix (7.1%), small bowel (7.1%), and lung (7.1%).The most common indication was peritoneal carcinomatosis (57.2%) followed by ascites (35.7%) and invasive gastric cancer (7.1%).Technical success of PTEG was 93% (n = 13).In 1 patient, fibrotic changes due to radiation therapy precluded access to the esophagus.Intraprocedural complication included aspiration during esophageal balloon inflation (n = 2; 15.4%).Immediate post-PTEG symptoms included throat pain (n = 5; 36%) which was resolved with oral viscous lidocaine.Long-term complications (n = 3; 21%)included occlusion of the PTEG (n = 1), aspiration (n = 1) and PTEG site cutaneous infection (n = 1).There was 1 death resulting from aspiration pneumonitis.No association between ECOG score and major/minor complications (p>0.05).Using the Edmonton Symptom Assessment Scale (ESAS)and the Karnofsky Performance Scale, patency rates and relief of obstructive symptoms were 100% at 7 and 14 days post-procedure (p<0.05). PTEG can provide dramatic symptomatic relief to palliative patients; ESAS and KPS scores were 100% up to 14 days post-placement.

Radiologic Placement of Uncovered Stents for the Treatment of Malignant Colonic Obstruction Proximal to the Descending Colon.

To evaluate the safety, feasibility, and patency rates of radiologic placement of uncovered stents for the treatment of malignant colonic obstruction proximal to the descending colon. This was a retrospective, single-center study. From May 2003 to March 2015, 53 image-guided placements of uncovered stents (44 initial placements, 9 secondary placements) were attempted in 44patients (male:female=23:21; mean age, 71.8years). The technical and clinical success, complication rates, and patency rates of the stents were also evaluated. Technical success was defined as the successful deployment of the stent under fluoroscopic guidance alone and clinical success was defined as the relief of obstructive symptoms or signs within 48h of stent deployment. In total, 12 (27.3%) patients underwent preoperative decompression, while 32 (72.7%) underwent decompression with palliative intent. The technical success rate was 93.2% (41/44) for initial placement and 88.9% (8/9) for secondary placement. Secondary stent placement in the palliative group was required in nine patients after successful initial stent placement due to stent obstruction from tumor ingrowth (n=7) and stent migration (n=2). The symptoms of obstruction were relieved in all successful cases (100%). In the palliative group, the patency rates were 94.4% at 1month, 84.0% at 3months, 64.8% at 6months, and 48.6% at 12months. The radiologic placement of uncovered stents for the treatment of malignant obstruction proximal to the descending colon is feasible and safe, and provides acceptable clinical results.

Primary malignant cardiac tumors: Surgical results

ObjectiveTo characterize primary malignant cardiac tumors operated on in our center and to analyze patient survival. MethodsBetween January 1994 and August 2014, 123 patients with cardiac tumors underwent surgery, of which 12 (9.8%) were primary malignant tumors – eight sarcomas (67%), three B-cell lymphomas (25%) and one epithelioid hemangioendothelioma (8.3%). The tumor affected the left atrium in five cases (42%), the right atrium in four (33%), the right ventricle in two (17%) and the pulmonary valve in one (8%). Patients’ mean age was 55.4±16.9 years, 67% were female and 75% presented in NYHA class III–IV. ResultsResection was complete (negative margins) in five cases and partial in seven (five sarcomas and two lymphomas), and 11 patients needed adjuvant therapy, surgery alone being curative in only one (epithelioid hemangioendothelioma). Mean follow-up was 41.7±61.3 months: 24.8±30.0 months (3.8–95.7) for sarcomas, 70.1±118.0 months (1–206.3) for lymphomas and 91.9 months for the epithelioid hemangioendothelioma. During follow-up, 10 patients died (83%) and two were alive (17%). Overall survival at 30 days, six months, one year and two years was 91.7%, 66.7%, 58.3% and 41.7%, respectively. In the sarcoma group, 1-year and 2-year survival were 62.5% and 37.5%, respectively. ConclusionsResection of primary malignant cardiac tumors, even partial, is safe, provides relief of obstructive symptoms and improves quality of life, but is rarely curative and has a low survival rate. Due to the rarity of such tumors, a multicenter database could improve knowledge and help clarify the indications for cardiac surgery as a treatment option.

Tumores cardíacos primários malignos: resultados cirúrgicos

ObjectiveTo characterize primary malignant cardiac tumors operated on in our center and to analyze patient survival. MethodsBetween January 1994 and August 2014, 123 patients with cardiac tumors underwent surgery, of which 12 (9.8%) were primary malignant tumors – eight sarcomas (67%), three B‐cell lymphomas (25%) and one epithelioid hemangioendothelioma (8.3%). The tumor affected the left atrium in five cases (42%), the right atrium in four (33%), the right ventricle in two (17%) and the pulmonary valve in one (8%). Patients’ mean age was 55.4±16.9 years, 67% were female and 75% presented in New York Heart Association class III–IV. ResultsResection was complete (negative margins) in five cases and partial in seven (five sarcomas and two lymphomas), and 11 patients needed adjuvant therapy, surgery alone being curative in only one (epithelioid hemangioendothelioma). Mean follow‐up was 41.7±61.3 months: 24.8±30.0 months (3.8–95.7) for sarcomas, 70.1±118.0 months (1–206.3) for lymphomas and 91.9 months for the epithelioid hemangioendothelioma. During follow‐up, 10 patients died (83%) and two were alive (17%). Overall survival at 30 days, six months, one year and two years was 91.7%, 66.7%, 58.3% and 41.7%, respectively. In the sarcoma group, 1‐year and 2‐year survival were 62.5% and 37.5%, respectively. ConclusionsResection of primary malignant cardiac tumors, even partial, is safe, provides relief of obstructive symptoms and improves quality of life, but is rarely curative and has a low survival rate. Due to the rarity of such tumors, a multicenter database could improve knowledge and help clarify the indications for cardiac surgery as a treatment option.

Placement of the Decompression Tube as a Bridge to Surgery for Acute Malignant Left-Sided Colonic Obstruction

PurposeThe aim of this study is to investigate the feasibility, safety, and effectiveness of placing the decompression tube as a bridge to surgery for acute malignant left-sided colonic obstruction. MethodsFrom January 2009 to August 2014, consecutive patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery in our center. The technical and clinical success of placing the decompression tube was evaluated. Clinical success was defined as relief of obstructive symptoms within 48 h after placing the decompression tube. Elective tumor resection was performed 7–9 days after colonic decompression. The types of surgery, primary anastomosis rate, and follow-up findings were analyzed. ResultsTwenty patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery. Placement of decompression tube was technically successful in all patients. No procedure-related complication occurred. Clinical success was achieved in 19 patients. Elective tumor resection and primary anastomosis were successfully performed in all 19 patients. The postoperative complications included wound infection (n = 2) and anastomotic stenosis (n = 1). ConclusionDecompression tube can serve as an easy, safe, and effective bridge to subsequent surgery for patients with acute malignant left-sided colonic obstruction.

Endoscopic bilio-duodenal bypass: outcomes of primary and revision efficacy of combined metallic stents in malignant duodenal and biliary obstructions.

Self-expandable metal stents (SEMSs) can be used for palliation of combined malignant biliary and duodenal obstructions. However, the results of the concomitant stent placement for the duration of the patients' lives, as well as the need for and efficacy of endoscopic revision, are unclear. This study evaluated the clinical effectiveness of SEMS placement for combined biliary and duodenal obstructions throughout the patients' lives and the need for endoscopic revision. This study is a retrospective multicenter study of 50 consecutive patients who underwent simultaneous or sequential SEMS placement for malignant biliary and duodenal obstructions. The data were collected to analyze the sustained relief of obstructive symptoms until the patients' death and the efficacy of endoscopic revision, as well as stent patency, adverse events, survival and prognostic factors for stent patency. Technical and immediate clinical success was achieved in all of the patients. Duodenal stricture occurred before the papilla in 35 patients (70%), involved the papilla in 11 patients (22%) and was observed distal to the papilla in four patients (8%). Initial biliary stenting was performed endoscopically in 42 patients (84%) and percutaneously in eight patients. After combined stenting, 30 patients (60%) required no additional intervention until the time of their death. The remaining 20 patients were successfully treated using endoscopic stent reinsertion: nine patients needed biliary revision, three patients needed duodenal restenting and eight patients needed both biliary and duodenal reinsertion. The median duodenal stent patency and median biliary stent patency were 34 and 27weeks, respectively. The median survival after combined stent placement was 18weeks. A Cox multivariate analysis showed that duodenal stent obstruction after combined stenting was a risk factor for biliary stent obstruction (hazard ratio 6.85; 95% confidence interval 1.43-198.98; P=0.025). Endoscopic bilio-duodenal bypass is clinically effective, and the majority of the patients need no additional intervention until their death. Endoscopic revision is feasible and has a high success rate.

Palliative venting percutaneous endoscopic gastrostomy tube is safe and effective in patients with malignant obstruction

Obstructive symptoms are common in advanced malignancies. Venting percutaneous endoscopic gastrostomy (VPEG) tubes can be placed for palliation. The aim of this study was to determine the outcomes of VPEG placement in patients with advanced malignancy. We retrospectively reviewed patients in whom a VPEG tube was attempted for a malignant indication from 1998 to 2010 at a tertiary care center. Clinical information, procedure details, and adverse events (AEs) were recorded. Ninety-six patients meeting the inclusion criteria were identified. Colorectal (27 %), pancreas (18.8 %), and gynecologic (17.7 %) malignancies were most common. Overall, 46.9 % of patients had ascites, with 35.6 % undergoing drainage prior to VPEG placement. VPEG placement was successful in 89 patients (92.7 %), and relief of obstructive symptoms was observed in 91.0 % of patients. Seven patients had refractory symptoms despite functioning VPEG tube. Ten post-procedural AEs were noted in nine patients, with one death. Infectious complications were more common in patients with ascites (12.2 %) versus those without (0 %; p = 0.02). There was a trend towards decreased infectious AEs when ascites was drained prior to VPEG (14.8 vs. 7.1 %; p = 0.64) in our patient cohort. We observed a decreased survival when AEs occurred (73 ± 47.8 days) compared with when they did not occur (141 ± 367.8 days; p = 0.61). VPEG tubes can be safely placed in patients with obstructive symptoms due to inoperable malignancy, with complete relief in the majority of patients. Ascites was a risk factor for post-procedural infectious AEs. Drainage of ascites prior to VPEG tube placement may decrease this risk, although this requires further study.

Newly designed coil tube for bowel decompression in patients with small bowel obstructions

The purpose of this study was to clinically evaluate a coil tube that we recently designed for bowel decompression in patients with a small bowel obstruction. The coil tube was composed of a stainless steel coil, a polyolefin tube, and a rubber adaptor. The tube was inserted under fluoroscopic guidance in 14 consecutive patients with small bowel obstructions. Technical success was defined as insertion of the distal end of the tube into at least the proximal jejunum, and clinical success was defined as intestinal decompression and relief of obstructive symptoms. The technical success rate was 100%. Clinical success was achieved in 12 patients (86%). The clinical failures were a patient with peritoneal carcinomatosis and an ileocolic fistula, and a patient with bezoars following intestinal hemorrhage. No coil-related complications occurred. Our newly designed coil tube was safe and effective in patients with bowel decompression associated with a small bowel obstruction. In addition, our tube has several advantages over other currently used tube types.

Efficacy and safety of venting percutaneous endoscopic gastrostomy (VPEG) tube placement in patients with malignant obstruction.

538 Background: Refractory nausea and vomiting are common in patients with advanced malignancy. A venting percutaneous endoscopic gastrostomy (VPEG) tube can be placed to eliminate the need for a nasogastric tube and palliate obstructive symptoms. The aim of this study was to determine the outcomes of VPEG placement in patients with advanced malignancy. Methods: We retrospectively reviewed all patients in whom a VPEG tube was attempted for a malignant indication over a 13-year period (1998-2010). Demographic and clinical information, procedure details, and immediate &amp; delayed complications were recorded. Results: Endoscopic VPEG placement was attempted in 96 patients (95% inpatient) with a median age of 57y. Colorectal (27%), pancreas (18.8%), and gynecologic (17.7%) malignancies were most common. Ascites was present in 46.9% of patients with drainage performed in a minority of patients (35.6%). VPEG was successfully placed by endoscopy in 89 patients (92.7%). Relief of obstructive symptoms was observed in 91.7% of patients. Eight patients had refractory obstructive symptoms despite functioning VPEG tube. Ten post-procedural complications were noted in 9 patients, with 1 death. Patients with ascites were more likely to have infectious complications (12.2%) than those without ascites (0%, p=0.02) with a trend towards decreased infectious complication when ascites was drained prior to VPEG placement (14.8% vs. 7.1%, p=NS). We observed decreased survival when complications occurred (73 days) compared to when they did not (141 days, p = NS). Conclusions: VPEG tubes can be safely placed in patients with inoperable malignancy and obstructive symptoms with complete relief of symptoms in the majority of patients. The presence of ascites was a risk factor for post-procedural infectious complications. Drainage of ascites prior to VPEG tube placement may minimize this risk, though this warrants further study.

A Novel Method of Punctured Miller-Abbott Tube Placement Using a Guidewire Under Fluoroscopic Guidance

The purpose of this article is to evaluate the usefulness of a new technique for placing Miller-Abbott tubes in patients with small-bowel obstruction. The Miller-Abbott tube was placed in 10 patients by use of the conventional method (group A) and in 11 patients with a punctured Miller-Abbott tube with the use of guidewire (group B). Technical success was defined as insertion of the tube into the duodenum beyond the pylorus of the stomach in group A and into the jejunum beyond the Treitz ligament in group B. Clinical success was defined as intestinal decompression and relief of obstructive symptoms. We evaluate the correlations between the cause of obstruction and the end results. The success rate of the tube placement was 40% (4/10) in group A and 100% (11/11) in group B. Clinical success of tube placement was achieved in five of 10 patients (50.0%) in group A and in nine of 11 patients (81.8%) in group B. Carcinomatosis was associated with significantly decreased clinical success rates in both groups (p = 0.038 in group A; p = 0.039 in group B). The mean (± SD) procedure time for placement of the Miller-Abbott tube was 35.8 ± 8.13 minutes in group A and 15.3 ± 5.93 minutes in group B, with a statistically significant difference (p < 0.001). The new technique of placing a punctured Miller-Abbott tube with the use of a guidewire enables the tube to pass through the pylorus and the Treitz ligament while significantly reducing the procedure time, with no clinical disadvantages caused by the puncture site.