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GI Grand Rounds

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Title: GI Grand Rounds


1
GI Grand Rounds
  • Johanna Chan
  • Gastroenterology Fellow
  • Baylor College of Medicine
  • 3/21/13

2
No conflicts of interest No financial disclosures
3
HPI
  • RFC hematemesis, melena
  • 67yo East Asian F p/w 4-5 days of burning
    epigastric pain, black emesis, melena
  • Presented to ER with dizziness, lightheadedness,
    fatigue
  • No prior similar episodes, no NSAIDs, no EtOH, no
    known H. pylori, no risk factors for chronic
    liver disease
  • No other associated symptoms, weight changes

4
Past Medical History
  • HTN
  • Previously on medication, now diet controlled

5
Medications
  • None
  • No OTC medications, including NSAIDs

6
Other history
  • Family history
  • Mother and father died of old age
  • Siblings alive and healthy
  • No GI malignancy
  • Social history
  • Denies all EtOH
  • Lifelong nonsmoker
  • No IV drug use or other illicits
  • Married, housewife

7
Exam
  • T 98.5, BP 121/62, HR 83, RR 12, O2 sat 99 RA
  • 411, 100 lbs
  • Gen NAD, AAOx4, conversational
  • HEENT PERRL, EOMI, MMM, OP clear
  • Neck supple, no LAD
  • CV RRR 2/6 SEM RUSB
  • Lungs CTAB
  • Abd S/NT, NABS, slightly distended
  • Ext WWP no c/c/e
  • Rectal no blood, no stool in rectal vault

8
Labs
136
23
101
7.9
368
6.9
131
25.9
0.6
4.1
26
69 PMNs
MCV 91
Total protein 7.3 Albumin 3.8 Total bili 0.4 ALT
26 AST 29 Alk phos 90
INR 1.2 PTT 28
9
Endoscopy
10
Endoscopy
11
Endoscopy
12
Pathology
  • Stomach antrum, biopsy
  • Adenocarcinoma, signet ring cell type
  • Focally invasive in muscular wall of stomach
  • HER-2 negative

13
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14
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15
Imaging
  • Pyloric/antral mass (2.7 x 2.9 x 1.8cm)
  • Distention of proximal stomach
  • Nonspecific lymph nodes (largest 7mm) adjacent to
    lesser curve of stomach
  • No significant pulmonary findings
  • ? nonspecific liver hypodensities
  • ? nodularity of omentum

16
Clinical course
  • No further hematemesis nor melena
  • Unable to tolerate even clear liquid diet
  • TPN initiated
  • Tumor board discussion
  • MRI liver to evaluate for metastases (negative)
  • Diagnostic laparoscopy to evaluate for peritoneal
    disease (pending)
  • Pending laparoscopy findings, further plans?

17
Management of malignant gastric outlet obstruction
18
Clinical questions
  • What are methods for palliation of malignant
    gastric outlet obstruction?
  • Open gastrojejunostomy
  • Laparoscopic gastrojejunostomy
  • Endoscopic stenting
  • What is the role for gastrojejunostomy versus
    stent for palliation of malignant gastric outlet
    obstruction?

19
Gastrojejunostomy
  • Historical/traditional treatment for malignant
    gastric outlet obstruction
  • 72 of patients with good functional outcome and
    relief of symptoms
  • 13-55 morbidity

20
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21
Open versus laparoscopic GJ
  • 3/1998 to 1/2000 78 GJ procedures (45 OGJ, 33
    LGJ)
  • 68 patients had advanced gastric cancer
    undergoing palliative GJ (38 OGJ, 30 LGJ)
  • 10 case matched controls (age, gender, ASA class,
    prior abdominal surgery)
  • Assessed operating time, time to PO intake, use
    of pain medication, morbidity, mortality, WBC,
    ESR, IL-6, TNF alpha
  • Laparoscopic GJ group had lower inflammatory
    markers, morbidity, earlier recovery of bowel
    function

Choi YB. Surg Endosc. 2002.16(11)1620-6.
22
Open versus laparoscopic GJ
  • 24 patients with inoperable neoplasm of distal
    stomach, duodenum, or biliary tract
  • Malignant metastatic or locally advanced
    unresectable
  • Randomized prospectively to undergo LGJ or OGJ,
    followed for 2 months
  • Age, gender, ASA class, primary tumor location,
    and mean duration of surgery not significantly
    different
  • LGJ significantly less blood loss and shorter
    time to PO intake compared with OGJ
  • Post-op stay shorter with LGJ (not statistically
    significant, 11 vs. 12 days)

Navarra G et al. Surg Endosc 2006 20(12)1831-4.
23
Stents
24
Stents for malignant GOO
  • 1st case report for self-expanding metallic stent
    for gastric outlet obstruction published in 1992
  • Common complications include recurrence of GOO
    symptoms due to stent obstruction (food, tumor
    in-/overgrowth), stent migration, perforation,
    biliary obstruction
  • Nitinol nickel-titanium shape-memory alloy,
    soft, flexible, smoother wire ends
  • Uncovered versus covered

Boskoski I et al. Adv Ther 2010
27(10)691-703. Dormann A et al. Endoscopy.
200436543-550. Mauro MA et al. Radiology 2000
215659-69.
25
Stents for malignant GOO
  • Systematic review in 2004 on gt600 cases shows
    reported technical success rate 97, with
    clinical success 87
  • Overall reported technical success rate 93-97,
    clinical success rate 84-93
  • Stents with gt20mm diameter should permit passage
    of solid food

Dormann A et al. Endoscopy. 200436543-550. Van
Hooft JE et al. Gastrointest Endosc. 2009
69(6)1059-66.
26
Stenting versus gastrojejunostomy
  • Systematic review (10 studies between 1/1990 to
    5/2008) includes 2 RCTs
  • 514 total patient outcomes (244 stents, 218 OGJ)
  • 30 day follow up
  • Endoscopic stenting more likely to result in
    earlier PO intake (7 days), shorter hospital stay
    (12 days)
  • Comparable periprocedural complication rate
    (15-16)
  • OGJ more major complications (AKI, MI, PNA)
  • ES usually technical complications requiring
    repeat intervention

Ly J et al. Surg Endosc 2010 24(2)290-7.
27
Stenting versus gastrojejunostomy
  • Systematic review, 44 publications between 1/1996
    and 12/2005
  • Includes same 2 RCTs (18 patients, 27 patients)
  • No difference in early and late major
    complications (though high variability)
  • More rapid food intake and relief of obstructive
    symptoms after stent
  • Recurrent obstructive symptoms more common after
    stent (food obstruction, tumor in-/overgrowth)
  • Stent may have more favorable short-term results
    GJ may be a better option in patients with longer
    survival

Jeurnink SM et al. BMC Gastroenterol. 2007 718.
28
Stenting versus gastrojejunostomy
  • SUSTENT multicenter randomized trial
  • 21 centers in the Netherlands, 1/2006-5/2008
  • 18 patients randomized to GJ, 21 patients to
    Enteral Wallflex stent
  • Compared GOO scoring system, early and late major
    complications, minor complications, persistent
    obstructive symptoms (gt4 weeks), HRQoL, and costs

Jeurnink SM et al. Gastrointest Endosc 2010.
71(3)490-9.
29
GOO Scoring System
  • 0 no oral intake
  • 1 liquids only
  • 2 soft solids
  • 3 almost complete diet
  • 4 full diet

Adler DG, Baron TH. Am J Gastroenterol.
20029772-78.
30
Jeurnink SM et al. Gastrointest Endosc 2010.
71(3)490-9.
31
Jeurnink SM et al. Gastrointest Endosc 2010.
71(3)490-9.
32
SUSTENT
  • Stent placement more rapid PO intake, shorter
    hospital stay, lower costs
  • GJ with longer follow-up (gt2 months) better food
    intake, fewer major complications, and fewer
    recurrent obstructive symptoms and
    re-interventions
  • Recommend GJ as primary treatment if expected
    survival gt 2 months
  • Recommend stent if expected survival lt 2 months

Jeurnink SM et al. Gastrointest Endosc 2010.
71(3)490-9.
33
Take home points
  • Several options for palliation of malignant
    gastric outlet obstruction
  • Treatment decisions often complicated by poor
    nutritional status, advanced underlying disease
  • Consider expected patient survival in management
    decisions

34
References
  • Boskoski I et al. Self-expandable metallic
    stents for malignant gastric outlet obstruction.
    Adv Ther 2010 27(10)691-703.
  • Brimhall B and Adler DG. Enteral stents for
    malignant gastric outlet obstruction.
    Gastrointest Endosc Clin N Am. 2011 21(3)
    389-403.
  • Canena JM et al. Oral intake throughout the
    patients lives after palliative metallic stent
    placement for malignant gastroduodenal
    obstruction a retrospective multicentre study.
    Eur J Gastroenterol Hepatol. 2012 24(7) 747-55.
  • Choi YB. Laparoscopic gastrojejunostomy for
    palliation of gastric outlet obstruction in
    unresectable gastric cancer. Surg Endosc. 2002
    16(11)1620-6.
  • Dormann A et al. Self-expanding metal stents for
    gastroduodenal malignancies systematic review
    of their clinical effectiveness. Endoscopy.
    200436543-550.
  • Jeurnink SM et al. Stent versus
    gastrojejunostomy for the palliation of gastric
    outlet obstruction a systematic review. BMC
    Gastroenterol. 2007 718.

35
References (cont)
  • Jeurnink SM et al. Surgical gastrojejunostomy or
    endoscopic stent placement for the palliation of
    malignant gastric outlet obstruction (SUSTENT
    study) a multicenter randomized trial.
    Gastrointest Endosc 2010. 71(3)490-9. 
  • Ly J et al. A systematic review of methods to
    palliate malignant gastric outlet obstruction.
    Surg Endosc 2010 24(2)290-7.
  • Mauro MA et al. Advances in gastrointestinal
    intervention the treatment of gastroduodenal and
    colorectal obstructions with metallic stents.
    Radiology 2000 215659-69.
  • Mehta S et al. Prospective randomized trial of
    laparoscopic gastrojejunostomy versus duodenal
    stenting for malignant gastric outlet
    obstruction. Surg Endosc. 2006 20(2)239-42.
  • Mendelsohn RB et al. Carcinomatosis is not a
    contraindication to enteral stenting in selected
    patients with malignant gastric outlet
    obstruction. Gastrointest Endosc. 2011
    73(6)1135-40.
  • Miller BH et al. An assessment of radiologically
    inserted transoral and transgastric
    gastroduodenal stents to treat malignant gastric
    outlet obstruction. Cardiovasc Intervent Radiol.
    2013 Mar 2 (epub ahead of print).

36
References (cont).
  • Navarra G et al. Palliative antecolic
    isoperistaltic gastrojejunostomy a randomized
    controlled trial comparing open and laparoscopic
    approaches. Surg Endosc 2006 20(12)1831-4.
  • Roy A et al. Stenting versus gastrojejunostomy
    for management of malignant gastric outlet
    obstruction comparison of clinical outcomes and
    costs. Surg Endosc 2012 26(11)3114-9.
  • Van Hooft JE, et al. Efficacy and safety of the
    new WallFlex enteral stent in palliative
    treatment of malignant gastric outlet obstruction
    (DUOFLEX study) a prospective multicenter study.
    Gastrointest Endosc. 2009 69(6)1059-66.

37
Questions?
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