There was no doubt that gastroenterologist Dr. Nabil Toubia’s patient was in severe pain.
As Toubia stood bedside at Roger Williams Medical Center earlier this year, the 60-year-old Seekonk man curled into a fetal position in his hospital bed, racked by cramps caused by a blockage in a portion of his bowel and stomach.
“He wasn’t even able to look at me because he was in so much pain,” recalled Toubia, who specializes in endoscopic services at the Providence hospital. “This is what [the patient] was doing for months. And it was getting worse.”
Complicating the situation: the blockage was caused by the patient’s duodenal cancer, a rare form of cancer that attacks the upper section of the small intestine.
Pain medication may have reduced some of the cramps, Toubia said, but might have made the aching worse.
Because of the blockage, the patient could not undergo chemotherapy. And performing an invasive surgery to create a bypass to the area that was not draining would mean he wouldn’t be able to receive chemotherapy while he healed.
“He was miserable,” Dr. Abdul Saied Calvino, a surgical oncologist at Roger Williams, said of the patient. “And all we could think of is, what could we do to help him?”
The answer would lead Toubia, Calvino and Dr. Vince Armenio, a medical oncologist, to perform an innovative surgery in late May that had never been done in Rhode Island. It’s called an endoscopic gastrojejunostomy, a procedure that corrects blockages of the digestive system by using a special stent to keep the passageway open.
There were other options, such as sending the patient to a hospital out of state. But the patient, who wasn’t available to be interviewed, had already gone to a Boston hospital for a Whipple procedure in which doctors had removed a portion of his intestine and part of his pancreas.
The procedure was supposed to help treat his cancer but instead it returned, even more advanced.
It was decided that Toubia, Calvino and Armenio would perform the endoscopic gastrojejunostomy at Roger Williams Medical Center.
“We couldn’t just take [the blockage] out because it was now involving one of the main arteries and veins in that area,” Calvino explained. “The patient was in a lot of pain because [the bowel] was not draining and becoming very dilated.”
Using endoscopic ultrasound guidance in order to create a path between the blocked portion of the bowel and the stomach, the doctors placed a lumen apposing stent in the digestive tract, technology that has recently been made available in the United States, to open the blockage.
There were no complications during the procedure, and the patient’s bowel obstruction symptoms improved.
“This is a great example of the level of multidisciplinary care available at Roger Williams,” said Armenio.
The patient was soon able to resume chemotherapy. In the end, Calvino said the procedure shows that cancer patients living in the Greater Providence area don’t always have to go to renowned medical hubs such as Boston for state-of-the-art treatments or procedures.
“Patients with cancer here in Rhode Island want to stay here. They want to be near their families,” said Calvino, who works within the CharterCARE Digestive Disease Program at Roger Williams. “Either for chemotherapy, radiation therapy or even more-complex procedures, they want to stay in their own home state.”
Calvino said there’s a mentality among many cancer patients in Rhode Island that they have to travel to far-off health care facilities, to get access to these advanced procedures. Calvino says that’s just not the case.
“We want Rhode Islanders to know we can provide these procedures. This is just one of many examples,” he said.
The lumen apposing stent technology that was used for the endoscopic gastrojejunostomy was introduced to the U.S. in 2016, and was immediately used at Roger Williams in a procedure for patients who had large cysts that developed after inflammation of the pancreas led to severe pancreatitis or walled-off pancreatic necrosis, a painful condition, according to Toubia. In the past, large incisions would be made in a surgery, but an endoscopic ultrasound paired with the lumen apposing stent technology ensures that there’s no need for major surgery.
In the case involving the duodenal cancer patient, the procedure only required two days of recovery. With the blockage clear, the patient now can focus on cancer treatments. Calvino said that the innovative collaboration allowed Roger Williams to improve the quality of life in their patient and improve recovery.
Calvino and Toubia are already in discussions about performing this procedure on other patients. Since there’s no code to translate to private insurance companies for endoscopic gastrojejunostomy using the lumen apposing stent, it’s covered as an endoscopic ultrasound.
“We collaborated surgical oncology and gastroenterology,” said Calvino. “We’re just using this extra tool in our toolbox.”
Alexa Gagosz is a PBN staff writer. Contact her at Gagosz@PBN.com.
