AIM To assess nutritional recovery,particularly regarding feeding jejunostomy tube(FJT)utilization,following upper gastrointestinal resection for malignancy. METHODS A retrospective review was performed of a prospecti...AIM To assess nutritional recovery,particularly regarding feeding jejunostomy tube(FJT)utilization,following upper gastrointestinal resection for malignancy. METHODS A retrospective review was performed of a prospectively-maintained database of adult patients who underwent esophagectomy or gastrectomy(subtotal or total)for cancer with curative intent,from January 2001 to June 2014. Patient demographics,the approach to esophagectomy,the extent of gastrectomy,FJT placement and utilization at discharge,administration of parenteral nutrition(PN),and complications were evaluated. All patients were followed for at least ninety days or until death.RESULTS The 287 patients underwent upper GI resection,comprised of 182 esophagectomy(n=107 transhiatal,58.7%; n=56 Ivor-Lewis,30.7%)and 105 gastrectomy [n=63 subtotal(SG),60.0%; n=42 total(TG),40.0%]. 181 of 182 esophagectomy patients underwent FJT,compared with 47 of 105 gastrectomy patients(99.5% vs 44.8%,P < 0.0001),of whom most had undergone TG(n=39,92.9% vs n=8 SG,12.9%,P < 0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups(14.7 d vs 17.1 d,P=0.076). Upon discharge,87 esophagectomy patients(48.1%)were taking enteral feeds,with 53(29.3%)fully and 34(18.8%)partially dependent. Meanwhile,20 of 39 TG patients(51.3%)were either fully(n=3,7.7%)or partially(n=17,43.6%)dependent on tube feeds,compared with 5 of 8 SG patients(10.6%),all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients(6.4% vs 29.3%,P=0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy(n=11,23.4% vs n=7,3.9%,P=0.0001). FJT-specific complications requiring reoperation within 30 d of resection occurred more commonly in the gastrectomy group(n=6),all after TG,compared to 1 esophagectomy patient(12.8% vs 0.6%,P=0.0003). Six of 7 patients(85.7%)who experienced tube-related complications required PN.CONCLUSION Nutritional recovery following esophagectomy and gastrectomy is distinct. Operations are associated with unique complication profiles. Nutritional supplementation alternative to jejunostomy should be considered in particular scenarios.展开更多
Malignant ascites indicates the presence of malignant cells in the peritoneal cavity and is a grave prognostic sign. While survival in this patient population is poor, averaging about 20 wk from time of diagnosis, qua...Malignant ascites indicates the presence of malignant cells in the peritoneal cavity and is a grave prognostic sign. While survival in this patient population is poor, averaging about 20 wk from time of diagnosis, quality of life can be improved through palliative procedures. Selecting the appropriate treatment modality remains a careful process, which should take into account potential risks and benefits and the life expectancy of the patient. Traditional therapies, including paracentesis, peritoneovenous shunt placement and diuretics, are successful and effective in varying degrees. After careful review of the patient’s primary tumor origin, tumor biology, tumor stage, patient performance status and comorbidities, surgical debulking and intraperitoneal chemotherapy should be considered if the benefit of therapy outweighs the risk of operation because survival curves can be extended and palliation of symptomatic malignant ascites can be achieved in select patients. In patients with peritoneal carcinomatosis who do not qualify for surgical cytoreduction but suffer from the effects of malignant ascites, intraperitoneal chemotherapy can be safely and effectively administered via laparoscopic techniques. Short operative times, short hospital stays, low complication rates and ultimately symptomatic relief are the advantages of laparoscopically administering heated intraperitoneal chemotherapy, making it not only a valuable treatment modality but also the most successful treatment modality for achieving palliative cure of malignant ascites.展开更多
Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure perform...Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of selfexpanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.展开更多
Gastric outlet obstruction(GOO) is a common problem associated with advanced malignancies of the upper gastrointestinal tract.Palliative treatment of patients' symptoms who present with GOO is an important aspect ...Gastric outlet obstruction(GOO) is a common problem associated with advanced malignancies of the upper gastrointestinal tract.Palliative treatment of patients' symptoms who present with GOO is an important aspect of their care.Surgical palliation of malignancy is defined as a procedure performed with the intention of relieving symptoms caused by an advanced malignancy or improving quality of life.Palliative treatment for GOO includes operative(open and laparoscopic gastrojejunostomy) and non-operative(endoscopic stenting) options.The performance status and medical condition of the patient,the extent of the cancer,the patients prognosis,the availability of a curative procedure,the natural history of symptoms of the disease(primary and secondary),the durability of the procedure,and the quality of life and life expectancy of the patient should always be considered when choosing treatment for any patient with advanced malignancy.Gastrojejunostomy appears to be associated with better long term symptom relief while stenting appears to be associated with lower immediate procedure related morbidity.展开更多
文摘AIM To assess nutritional recovery,particularly regarding feeding jejunostomy tube(FJT)utilization,following upper gastrointestinal resection for malignancy. METHODS A retrospective review was performed of a prospectively-maintained database of adult patients who underwent esophagectomy or gastrectomy(subtotal or total)for cancer with curative intent,from January 2001 to June 2014. Patient demographics,the approach to esophagectomy,the extent of gastrectomy,FJT placement and utilization at discharge,administration of parenteral nutrition(PN),and complications were evaluated. All patients were followed for at least ninety days or until death.RESULTS The 287 patients underwent upper GI resection,comprised of 182 esophagectomy(n=107 transhiatal,58.7%; n=56 Ivor-Lewis,30.7%)and 105 gastrectomy [n=63 subtotal(SG),60.0%; n=42 total(TG),40.0%]. 181 of 182 esophagectomy patients underwent FJT,compared with 47 of 105 gastrectomy patients(99.5% vs 44.8%,P < 0.0001),of whom most had undergone TG(n=39,92.9% vs n=8 SG,12.9%,P < 0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups(14.7 d vs 17.1 d,P=0.076). Upon discharge,87 esophagectomy patients(48.1%)were taking enteral feeds,with 53(29.3%)fully and 34(18.8%)partially dependent. Meanwhile,20 of 39 TG patients(51.3%)were either fully(n=3,7.7%)or partially(n=17,43.6%)dependent on tube feeds,compared with 5 of 8 SG patients(10.6%),all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients(6.4% vs 29.3%,P=0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy(n=11,23.4% vs n=7,3.9%,P=0.0001). FJT-specific complications requiring reoperation within 30 d of resection occurred more commonly in the gastrectomy group(n=6),all after TG,compared to 1 esophagectomy patient(12.8% vs 0.6%,P=0.0003). Six of 7 patients(85.7%)who experienced tube-related complications required PN.CONCLUSION Nutritional recovery following esophagectomy and gastrectomy is distinct. Operations are associated with unique complication profiles. Nutritional supplementation alternative to jejunostomy should be considered in particular scenarios.
文摘Malignant ascites indicates the presence of malignant cells in the peritoneal cavity and is a grave prognostic sign. While survival in this patient population is poor, averaging about 20 wk from time of diagnosis, quality of life can be improved through palliative procedures. Selecting the appropriate treatment modality remains a careful process, which should take into account potential risks and benefits and the life expectancy of the patient. Traditional therapies, including paracentesis, peritoneovenous shunt placement and diuretics, are successful and effective in varying degrees. After careful review of the patient’s primary tumor origin, tumor biology, tumor stage, patient performance status and comorbidities, surgical debulking and intraperitoneal chemotherapy should be considered if the benefit of therapy outweighs the risk of operation because survival curves can be extended and palliation of symptomatic malignant ascites can be achieved in select patients. In patients with peritoneal carcinomatosis who do not qualify for surgical cytoreduction but suffer from the effects of malignant ascites, intraperitoneal chemotherapy can be safely and effectively administered via laparoscopic techniques. Short operative times, short hospital stays, low complication rates and ultimately symptomatic relief are the advantages of laparoscopically administering heated intraperitoneal chemotherapy, making it not only a valuable treatment modality but also the most successful treatment modality for achieving palliative cure of malignant ascites.
文摘Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of selfexpanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.
文摘Gastric outlet obstruction(GOO) is a common problem associated with advanced malignancies of the upper gastrointestinal tract.Palliative treatment of patients' symptoms who present with GOO is an important aspect of their care.Surgical palliation of malignancy is defined as a procedure performed with the intention of relieving symptoms caused by an advanced malignancy or improving quality of life.Palliative treatment for GOO includes operative(open and laparoscopic gastrojejunostomy) and non-operative(endoscopic stenting) options.The performance status and medical condition of the patient,the extent of the cancer,the patients prognosis,the availability of a curative procedure,the natural history of symptoms of the disease(primary and secondary),the durability of the procedure,and the quality of life and life expectancy of the patient should always be considered when choosing treatment for any patient with advanced malignancy.Gastrojejunostomy appears to be associated with better long term symptom relief while stenting appears to be associated with lower immediate procedure related morbidity.
