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Introduction: Buried bumper syndrome (BBS) is a complication seen in 2.4% of percutaneous endoscopic gastrostomy (PEG) tubes. We present a case series of 30 patients with BBS managed at a regional referral centre over 13 years. Methods: The original pioneering service (2007-2013) involved sporadic management by various endoscopists or surgeons (group A). More recently (2014-2020), patients with endoscopic or clinically suspected BBS were referred to a specialist multidisciplinary team (MDT) clinic, facilitating a best interest approach to decision making (group B). The objective of this MDT clinic is to plan for an interventional endoscopic procedure under general anaesthesia (GA) with balloon assisted PEG manipulation±needle-knife excision aiming for successful endoscopic feeding tube (FT) replacement through the established tract. Results: Results are expressed as group B (n=19) vs group A (n=11). Statistical analysis used Fisher's exact and unpaired t-tests. In group B, less patients required surgery to replace their FT (1 (5.3 %) vs 4 (36.4 %), p<0.05), more FTs were replaced in the pre-existing tract (18 (94.7 %) vs 2 (18.2 %), p<0.001), mean length of stay (LOS) was shorter (4.2 vs 10.5 days, p<0.05) and there were fewer complications (2 (10.5 %) vs 4 (36.4 %), p=0.16). Overall, endoscopic versus surgical management was associated with a shorter LOS (5.3 vs 12 days, p<0.05). Conclusion: Nuanced decision making as part of a dedicated BBS service, employing MDT decision making and a structured management approach, is associated with improved patient outcomes.
RESUMO
BACKGROUND: There is a need for better management strategies to improve the survival and quality of life in patients with biliary tract cancer (BTC). AIM: To assess prognostic factors for survival in a large, non-selective cohort of patients with BTC. METHOD: We compared outcomes in 321 patients with a final diagnosis of BTC (cholangiocarcinoma n = 237, gallbladder cancer n = 84) seen in a tertiary referral cancer centre between 1998 and 2007. Survival according to disease stage and treatment category was compared using log-rank testing. Cox's regression analysis was used to determine independent prognostic factors. RESULTS: Eighty-nine (28%) patients underwent a surgical intervention with curative intent, of whom 38% had R0 resections. Among the 321 patients, 34% were given chemo- and/or radiotherapy, 14% were palliated with photodynamic therapy (PDT) and 37% with biliary drainage procedures alone. The overall median survival was 9 months (3-year survival, 14%). R0-resective surgery conferred the most favourable outcome (3-year survival, 57%). Although patients palliated with PDT had more advanced clinical T-stages, their survival was similar to those treated with attempted curative surgery but who had positive resection margins. On multivariable analysis, treatment modality, serum carbohydrate-associated antigen 19-9, distant metastases and vascular involvement were independent prognostic indicators of survival. CONCLUSION: In this large UK series of BTC, palliative PDT resulted in survival similar to those with curatively intended R1/R2 resections. Surgery conferred a survival advantage only in patients with R0 resection margins, emphasising the need for accurate pre-operative staging.