Dysphagia: An Unusual Presentation of Metastatic Uterine Cervical Carcinoma.

Worldwide, cervical cancer is the third most common cancer among women and the fourth leading cause of death from cancer. The most common sites of metastasis are the pelvic lymph nodes, vagina, and the pelvic sidewalls. Distant metastases are uncommon but can involve the bone, lung, and liver. Characteristics associated with increased rate of distant metastasis include bulky tumor, endometrial extension, lymph node involvement, and advanced disease. We report the case of a woman with stage II cervical carcinoma, who presented with dysphagia due to cervical cancer metastases to the mediastinum.

Natural language processing as an alternative to manual reporting of colonoscopy quality metrics.

BACKGROUND AND AIMS: The adenoma detection rate (ADR) is a quality metric tied to interval colon cancer occurrence. However, manual extraction of data to calculate and track the ADR in clinical practice is labor-intensive. To overcome this difficulty, we developed a natural language processing (NLP) method to identify adenomas and sessile serrated adenomas (SSAs) in patients undergoing their first screening colonoscopy. We compared the NLP-generated results with that of manual data extraction to test the accuracy of NLP and report on colonoscopy quality metrics using NLP. METHODS: Identification of screening colonoscopies using NLP was compared with that using the manual method for 12,748 patients who underwent colonoscopies from July 2010 to February 2013. Also, identification of adenomas and SSAs using NLP was compared with that using the manual method with 2259 matched patient records. Colonoscopy ADRs using these methods were generated for each physician. RESULTS: NLP correctly identified 91.3% of the screening examinations, whereas the manual method identified 87.8% of them. Both the manual method and NLP correctly identified examinations of patients with adenomas and SSAs in the matched records almost perfectly. Both NLP and the manual method produced comparable values for ADRs for each endoscopist and for the group as a whole. CONCLUSIONS: NLP can correctly identify screening colonoscopies, accurately identify adenomas and SSAs in a pathology database, and provide real-time quality metrics for colonoscopy.

Transnasal PEG tube placement in patients with head and neck cancer.

BACKGROUND: Head and neck cancer (H&NCa) patients have an increased risk of malnutrition and dysphagia because of their malignancy and the adverse events of therapy. Most of these patients require gastrostomies. Four percent to 7% of H&NCa patients are unable to undergo per oral percutaneous gastrostomies. Transnasal endoscopy is an option for gastrostomy placement in selected patients. OBJECTIVE: Clinical, epidemiologic characteristics and outcomes of transnasal PEG (t-PEG) placement. DESIGN: Retrospective analysis. SETTING: Tertiary care hospital, The University of Texas MD Anderson Cancer Center. PATIENTS: All patients who underwent t-PEG placement. MAIN OUTCOME MEASUREMENTS: Epidemiology, adverse events, and outcomes of t-PEG placement. RESULTS: Sixteen patients underwent t-PEG placement from January 2010 to May 2013. All patients had H&NCa and 56.3% had metastasis. Indications for the transnasal approach were airway compromise, malignant oropharyngeal obstruction, and trismus, among others. All procedures were successful using a 20F gastrostomy tube, push technique, anesthesiologist-guided propofol sedation, and/or nasotracheal intubation. Of all patients, 68.8% were white and 68.8% were men. Mean age was 54 years, and mean body mass index was 20.87. Two patients had a total of 2 adverse events: poor wound healing and wound site infection. Of all patients, 18.75% had leukopenia, 6.25% neutropenia, and 50% lymphopenia. Mean white blood cell count, absolute neutrophil count, and absolute lymphocyte count were 8.6 × 10(9)/L, 6.57 × 10(9)/L, and .93 × 10(9)/L, respectively. Eleven patients were alive, 2 were lost to follow-up, and 3 had died at the time of review. LIMITATIONS: Retrospective analysis, small cohort, patient selection bias. CONCLUSION: t-PEG placement is a viable and safe option for H&NCa patients when the standard endoscopic approach is not feasible.

Percutaneous endoscopic gastrostomy in cancer patients: predictors of 30-day complications, 30-day mortality, and overall mortality.

BACKGROUND: Cancer patients benefit from percutaneous endoscopic gastrostomy (PEG) in many ways including nutritional support and venting in cases of malignant obstruction. Lack of high-quality studies with adequate follow-up has led to limited information regarding risk stratification and predictors of morbidity and mortality. AIMS: Elucidate predictors of complications and mortality with long-term follow-up in cancer patients undergoing PEG. METHOD: Retrospective review of all patients undergoing PEG placement at MD Anderson Cancer Center from January 1, 2004 to December 31, 2006. Statistical analysis included descriptive statistics, Kaplan-Meier survival estimates, and Cox proportional hazards regression analyses. RESULTS: A total of 218 subjects underwent PEG. Those with American Society of Anesthesiology (ASA) scores of 4, 4E, or 5E were at significant risk of a major complication in the first 30 days. Multivariate analysis revealed ASA scores ≥4, elevated WBC count, and advanced tumor stage to be independent predictors of mortality in the first 30 days and INR >1.5 and diversion/venting as an indication for PEG placement to be independent predictors of overall mortality. CONCLUSIONS: Patients with high baseline illness severity are more likely to have complications and are at increased risk of mortality after PEG. Our study results suggest that particular attention be directed to ASA score, INR, WBC counts, transfusion requirements, presence of advanced malignancies, and the indication for PEG placement when determining risk of complications or death. Patients undergoing venting PEG are expected to have short post-PEG survival but improvement in quality of life likely justifies the risks associated with PEG placement.

Percutaneous transesophageal gastrostomy tube placement: an alternative to percutaneous endoscopic gastrostomy in patients with intra-abdominal metastasis.

BACKGROUND: PEG/jejunostomy (PEG/J) is often placed in patients with metastatic gastric cancer for palliating bowel obstruction or for feeding. However, PEG/J placement may not always be possible for many reasons. OBJECTIVE: We wish to bring attention to the percutaneous transesophageal gastrostomy/jejunostomy (PTEG/J) as a viable alternative to nasogastric decompression in patients who are not candidates for PEG/J. PTEG/J is a largely unknown technique in the United States that designed to gain access to the stomach and proximal small bowel in these patients. We describe the use of PTEG/J in 3 patients with metastatic gastric cancer by using resources and techniques readily available in a well-stocked interventional radiology suite. PATIENTS: In the first case, percutaneous transesophageal gastrostomy (PTEG) was placed for palliation of intractable nausea and vomiting in a 37-year-woman with diffuse gastric cancer and peritoneal carcinomatosis. In the second case, PTEG was extended into the jejunum for feeding a 60-year-old woman with metastatic gastric cancer. In the third case, PTEG extending into the jejunum was placed in a 69-year-old man for palliation of bowel obstruction caused by metastatic gastric cancer and peritoneal carcinomatosis. METHODS: After adequate sedation is administered, a 22 x 4-mm balloon catheter is passed into the esophagus over a guidewire just below the thoracic inlet. The balloon is ruptured with a needle passed through the neck under US guidance. A guidewire is then passed through the needle into the balloon and carried into the stomach or proximal small bowel by advancing the balloon catheter. The track is then dilated over the guidewire and a pigtail 45-cm-long 14F nephrostomy tube then passed into the stomach or into the proximal small bowel over the guidewire. The catheter is secured by suturing to the skin of the neck. RESULTS: PTEG/J was effective in achieving palliation or feeding in our patients. No complications occurred. CONCLUSIONS: PTEG/J is a safe and effective alternative to standard percutaneous gastrostomy/jejunostomy tube placement for decompression of bowel obstruction or feeding in appropriately selected patients.

Endoscopic treatment of colonic obstruction.

PURPOSE OF REVIEW: Over the past 15 years, great strides have been made in the nonsurgical management of malignant large bowel obstruction. Progress continues, particularly in the area of self-expanding metal stents. The purpose of this review is to assess the available endoscopic techniques for colonic decompression and document the inexorable trend toward supremacy of the self-expanding metal stent in this arena. RECENT FINDINGS: Stents are being designed with the structure and function of the colon in mind allowing better and longer-lasting palliation. Improvement in the design of the colonic decompression tube allows a low-tech approach to the palliation of colonic obstruction. Argon plasma coagulation is helpful in restoring continuity of the obstructed colonic lumen in certain circumstances. SUMMARY: As a consequence of technological innovation and growing expertise in the community, gastroenterology is becoming the go to specialty in the early management and palliation of malignant bowel obstruction.

Endoscopic biopsy diagnosis of acute gastrointestinal graft-versus-host disease: rectosigmoid biopsies are more sensitive than upper gastrointestinal biopsies.

OBJECTIVES: The diagnosis of gastrointestinal (GI) graft-versus-host disease (GVHD) is based upon histologic findings in endoscopic mucosal biopsy specimens. The portion of the GI tract with the highest diagnostic yield is a topic of debate. Our aim was to evaluate the sensitivity of simultaneous biopsy of the stomach, duodenum, and rectosigmoid in establishing the diagnosis of GI GVHD. METHODS: We identified 112 patients who had simultaneous endoscopic biopsies of the stomach, duodenum, and rectosigmoid within the first 100 days following allogeneic hematopoietic stem cell transplantation (HSCT). GVHD was defined histologically as the presence of gland apoptosis, not explained by other inflammatory or infectious etiologies. The patient was diagnosed with GI GVHD if at least one biopsy site was positive. RESULTS: Overall, 81% of the patients had GI GVHD. Of these, 66% had involvement at all three biopsy sites. Rectosigmoid biopsies had the highest sensitivity, specificity, positive predictive value, and negative predictive value for diagnosing GI GVHD, at 95.6%, 100%, 100%, and 84%, respectively. The sensitivities of gastric and duodenal biopsies were 72.5% (P < 0.0001 vs rectosigmoid) and 79.2% (P = 0.0018), respectively. The negative predictive values of gastric and duodenal biopsies were 45.6% (P = 0.0039 vs rectosigmoid) and 52.5% (P = 0.0205), respectively. Rectosigmoid biopsies had a higher sensitivity and negative predictive value than biopsies at other sites whether the patient presented with diarrhea or nausea/vomiting. No association between the degree of mucosal injury and the presence of GVHD was found at any site. CONCLUSIONS: Biopsy of the rectosigmoid is the single best test for diagnosing GI GVHD.