Cervical gastric decompression tube: safety and efficacy outcomes for inoperable malignant bowel obstruction

Introduction

Primary tumors, notably of the stomach, gallbladder, colon, uterus, and ovaries, can lead to malignant small bowel obstruction (MSBO) due to peritoneal carcinomatosis (1). Patients with advanced-stage malignancies exhibit MSBO that is often inoperable and terminal, presenting limited curative options. Thus, treatments should focus on symptomatic relief and palliative care. Although bypass surgery is a good surgical palliative treatment for these patients, it is not an option as many patients are unable to tolerate such a surgery (2). Alternative treatments for palliative decompression of MSBO are essential to relieve abdominal pain and help patients escape intractable vomiting.

Current non-surgical treatments for MSBO consist of a combination of systemic chemotherapy, parenteral nutrition, corticosteroids, antiemetics, antisecretory drugs, opioids, somatostatin, and dexamethasone (3). However, often these interventions do not effectively alleviate symptoms of gastrointestinal distension. Invasive treatment options include intestinal bypass (most common), stent placement, percutaneous needle decompression, and gastric tube placement (4). Of these options, gastric decompression tubes are some of the most effective methods for symptomatic relief in terminal patients with MSBO (1).

Due to drawbacks with percutaneous endoscopic gastrostomy (PEG) tubes and nasogastric (NG) tubes, cervical esophago-gastric (CEG) decompression tubes are emerging as a potential treatment alternative (5). CEG tubes can be placed into the esophagus and stomach through an incision in the neck, avoiding the nasal, sinus, and throat discomfort that many patients experience with NG tubes (6). In contrast, PEG tubes cannot often be placed in patients with MSBO due to surgical risks and the presence of a tumor altering the patient’s anatomy (7).

With the goal of establishing the safety and efficacy of CEG tubes, this report reveals important long-term outcomes of percutaneous CEG tube placement in 11 terminal patients with inoperable MSBO. We present this article in accordance with the STROBE reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-24-21/rc).

Methods

We retrospectively reviewed patients from 2016–2022 undergoing CEG decompression tube placement for malignant bowel obstruction requiring NG decompression not amenable to PEG tube placement or gastrointestinal bypass operation, as deemed by palliative care teams, gastroenterology, and general surgery services. Tubes were placed percutaneously and endoscopically through the left neck using the guidewire technique. Patients underwent rapid sequence intubation and sedation with propofol and fentanyl. Each patient was positioned in the supine position with neck extension. Esophagoscopy along with ultrasound was used to identify the insertion site 1–2 fingerbreadths above the clavicle anterior to the sternocleidomastoid muscle. The ultrasound was used to identify the internal jugular and carotid arteries as lateral landmarks and the trachea as the medial landmark. A light reflex is often visible in the neck using the flexible esophagoscope. A needle is inserted into the esophagus under esophagoscope visualization, followed by wire insertion into the esophagus into the stomach. A small incision is made at the level of the wire using an 11 blade. The tract is developed using a 22-Fr dilator with a sheath. The 18-Fr decompression tube is inserted through the sheath down into the stomach as confirmed by esophagoscopy. The decompression tube is then sutured to the skin.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Houston Methodist Research Institute (HMRI) institutional review board (approval number: PRO00031398) and individual consent for this retrospective analysis was waived.

Results

The demographics and indications of each patient who underwent CEG tube placement are outlined in Table 1. The average age of the patients at the time of the procedure was approximately 58 years, with an age range of 31 to 72 years. Most patients had either colorectal or ovarian cancer as shown in Figure 1.

Figure 1 Patient population by abdominal cancer type.

The patient outcomes following percutaneous CEG tube placement are summarized in Table 2, Figures 2,3. Table 2 highlights important metrics regarding the safety of the procedure.

Figure 2 Survival times after admission and procedure by cancer type.

Figure 3 Patients receiving chemotherapy and discharge home by cancer type.

The majority of patients who received CEG tubes had colorectal cancer (36.4%) or ovarian cancer (27.3%). Morbidities (rates) related to the CEG tubes were dislodgement (27%), infection (18%) and gastrointestinal bleeding (18%). Displaced tubes were able to be replaced at bedside. All infections were treated successfully with antibiotics. Gastrointestinal bleeding complications were minor and self-limiting. No one required further surgical intervention or reoperation due to CEG tube placement. None of the CEG tube placement procedures required conversion to open surgery. The 30-day mortality rate after the procedure was 9%. Importantly, no deaths were associated with CEG tube placement.

Data indicating the efficacy of CEG tubes were recorded for the same patients and are displayed in Figures 2,3.

Following the procedure, 82% of patients were able to return home, while 45% required readmission. None of the readmissions were linked to CEG tube placement, the tube itself, or any tube-related complications. On average, the patients survived for 180.7 days from their initial admission or diagnosis, with an average post-procedure survival time of approximately 137.6 days. Remarkably, 73% of the patients tolerated further chemotherapy after the procedure.

Interestingly, two patients had their CEG tubes permanently removed after sufficient abdominal decompression and treatment with chemotherapy. One of these patients remains alive without the need for decompression, and their insertion site healed without any issues. In the other patient, the CEG tube was removed after being used for feeding rather than decompression. One patient had their tube removed after their symptoms improved enough to advance to a regular diet; however, another tube was placed later due to recurrent small bowel obstruction and the second placement was technically more difficult.

Discussion

Malignant bowel obstruction is a difficult condition to manage, and many patients are dissatisfied. Palliative treatment with NG tube decompression can be an effective means; however, vomiting around the tube and persistent abdominal pain are major issues. CEG tubes are placed below the upper esophageal sphincter, which appears to limit vomiting around the tube; however, persistent abdominal pain that can be multifactorial will continue to be an issue for any decompressive measure. For patients who have had good palliation from NG tube decompression, CEG tube is an option for patients who are not candidates for surgical bypass or gastrostomy tubes and want symptomatic relief without the discomfort of a NG tube. At our institution, patients are carefully selected to undergo CEG tube placement on the basis of being palliated by NG tube decompression. Potential candidates are evaluated by general surgery, interventional radiology, and gastroenterology before referral to our service for CEG tube placement. Regarding who can place the CEG tube in patients, we believe that any medical professional with endoscopic skills can become qualified to perform the procedure if trained.

Most patients started chemotherapy 1–2 weeks after the procedure. It appears safe to start chemotherapy two weeks after the procedure. Infection at the tube site was noted in one patient after starting chemotherapy one week after the procedure, which required antibiotic treatment. Pain scores were collected for seven patients before and after CEG tube placement, with six of the seven patients reporting no pain within four days after placement. The average overall reduction in pain was 5.4 points on a scale of 0–10. These outcomes suggest that CEG tubes are effective at reducing pain associated with NG tubes and malignant bowel obstruction.

Although we do not have data on the number of patients with terminal malignant bowel obstruction, it is worth noting that none of the patients in this study regretted their decision to receive a CEG tube.

Conclusions

Based on our experience, CEG tubes appear safe and effective in decompressing malignant bowel obstruction patients requiring NG tubes who are not candidates for palliative gastrostomy tubes or bypass operations. Many patients tolerated additional chemotherapy, and most were discharged from the hospital.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-24-21/rc

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-21/dss

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-21/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-24-21/coif). M.P.K. is a consultant for Intuitive Surgical and Medtronic. E.Y.C. is a consultant for Intuitive Surgical, Olympus Corporation, and Noah Medical. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Houston Methodist Research Institute (HMRI) institutional review board (approval number: PRO00031398) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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