Malignant small bowel obstruction (MSBO) is a common diagnosis in patients with advanced stage malignancies.
1 Bypass surgery is the standard surgical palliative treatment for these patients; however, palliative surgery in these terminal patients is often not well-tolerated.
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2 In these patients, palliative decompression of MSBO to avoid intractable vomiting is necessary. While these patients are admitted, nasogastric tubes (NGTs) are often placed for immediate decompression of the stomach. However, NGTs are poorly tolerated as they cause significant discomfort to patients and may even cause sinusitis and pressure ulcers of the nasal septum.
3 In addition, NGTs commit most patients to spend their last few days of life in the hospital since discharging them home risks dislodgement of the tube. Therefore, percutaneous endoscopic gastrostomy (PEG) tube has been advocated for gastrointestinal decompression to allow end-of-life care and palliation at home.
2 However, often times in patients with MSBO and diffuse peritoneal carcinomatosis, the presence of ascites makes PEG placement technically difficult, as ascites fluid limits the degree of transillumination through the stomach, impairs maturation of the fibrous tract along the PEG tube,
4 and sets the patient up for intraperitoneal contamination as well as persistent ascites leakage from the PEG tube site.
4 Although large-volume paracentesis prior to PEG tube insertion and at intervals thereafter may reduce the likelihood of peristomal ascitic fluid leakage,
2 ascites have been viewed as a relative contraindication to PEG placement.
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In an effort to allow end-of-life care at home for patients with ascites associated with MSBO, over the last 2 years we have successfully placed three percutaneous palliative cervical esophago-gastric tubes in terminal patients to decompress their gastrointestinal tract.