I Do It My Way: Alternative Approaches in Multidisciplinary Management of GI Diseases

Many medical conditions require multidisciplinary care to achieve successful outcomes for patients. There are certain conditions that require management that cross the boundaries of specialties. Several gastrointestinal disorders require complex care be it due to the nature of the condition or the advent of newer technologies in the respective field. A few such disease processes will be covered in this issue of Digestive Disease Interventions (DDI)— I Do It My Way – Alternative Approaches in Multidisciplinary Management of GI Diseases. These conditions include gastric varices, gallbladder drainage, enteral access, pancreatic necrosis, and liver biopsy and portal pressure measurements. These conditions either have the option of being managed using different interventional techniques or require multidisciplinary management through the collaboration of interventional radiology, gastroenterology, and surgery.

To illustrate the clinical conundrum of management choices, consider gastric varices as an example. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines from 2014 recommend obturation of gastric varices with a cyanoacrylate compound in the case of acute gastric variceal bleeding in centers familiar with this technique.[1] The American Association for the Study of Liver Disease (AASLD) guidelines from 2016 on the other hand recommend endoscopic variceal ligation (EVL) or cyanoacrylate injection for gastroesophageal varix type 1 (GOV1) while transjugular intrahepatic portosystemic shunt (TIPS) is the treatment recommended for control of bleeding from cardiofundal varices (GOV2 or isolated gastric varices type I).[2] The interventional radiology approach to management of gastric varices addresses the underlying hemodynamics and portal hypertension reduction along with the targeted obliteration of the varices which has proven improved long-term clinical outcomes and is the current standard of care. Therefore, ultimately in the case of gastric variceal management, multiple options exist for management such as EVL, cyanoacrylate injection, antegrade and retrograde obliteration techniques, TIPS, and splenic artery embolization. The risks and benefits of each approach are well studied, but higher quality data or head-to-head randomized trials with long-term outcomes are needed as well.

Regarding walled-off pancreatic necrosis, however, the management may require the input of both specialties simultaneously. When there is a pancreatic tail collection in close apposition to stomach wall, initial drainage can be achieved by placement of a lumen-apposing metal stent from the stomach into the collection, termed “cystgastrostomy” followed by direct endoscopic necrosectomy. However, if not technically accessible endoscopically, it requires placement of a percutaneous drain by interventional radiology and may even further require video-assisted retroperitoneal debridement by surgery. Given the inherent complexity of these conditions, they lend themselves to a multidisciplinary approach. Ultimately, an algorithmic approach can be created through collaboration that will allow for protocolization of clinical care to improve patient outcomes by improving efficiency and consistency in care.[3] Quencer et al describe their multidisciplinary algorithm in the issue.

Different techniques for gastrostomy tube placement in patients with aerodigestive cancers are important due to the risk of abdominal wall seeding albeit rare at 0.5 to 1%. In placing a gastrostomy tube endoscopically, typically done using the Gauderer-Ponsky pull method, the tube passing through the malignancy cannot be avoided; therefore, there is a risk of seeding the gastrostomy tract. The Russell technique on the other hand, which can be employed both endoscopically but more commonly by interventional radiology, involves percutaneous gastropexy followed by the use of the Seldinger technique to place a guidewire followed by a dilating catheter, peel-away sheath through which the feeding tube is advanced. This latter method obviates the need to pass the feeding tube through the malignancy. Though literature is scarce regarding the effectiveness of the Russell technique in avoiding abdominal wall seeding, Ellrichman et al completed a study of 50 patients with percutaneous endoscopic gastrostomy tube placement, 40 of who underwent pull technique and the other 10 who underwent Russell technique and found that abdominal wall metastasis was present in 9.4% of patients after 3 to 6 months of follow-up, while no patients who underwent the Russell push technique had malignant cells identified on brush cytology.[4] [5] Thus, in this controversial subset of patients, it may be safer to have interventional radiology preferentially perform gastrostomy tube placement. Anatomic considerations, risks, and benefits of different approaches are discussed in this issue.

Advances in endoscopic ultrasound have led to its use in performing liver biopsy in recent years. Although the mainstay of assessing hepatic parenchymal disease has been percutaneous liver biopsy, endoscopic ultrasound (EUS)-guided liver biopsy has gained attention due to its ability to be performed at the same time as endoscopy and ability to perform bilobar biopsies to decrease sampling error.[6] However, long-term clinical benefit and need for bilobar biopsies is yet to be proven. An adequate sample is a liver biopsy specimen that is 15–20 mm with >10 portal triads seen on microscopy. A recent meta-analysis demonstrated that percutaneous liver biopsy is superior in terms of producing the number of complete portal tracts and the length; however, in reviewing data from randomized controlled trials, there was no difference between EUS liver biopsy and percutaneous liver biopsy in terms of diagnostic accuracy. As the use of EUS-guided liver biopsy continues, future studies can evaluate whether these trends continue[7] and furthermore studies to compare cost-effectiveness and resource utilization for the different approaches will also need to be integrated into decision algorithms for institutions.

The advent of the EUS portal pressure device, with the addition of EUS liver biopsy and esophagogastroduodenoscopy for esophageal varices screening, has been termed the “one stop shop” for patients with liver disease. This can add convenience to the management of patients with liver disease if endoscopic evaluation is already underway for other clinical reasons such as screening for esophageal varices or abdominal pain. The technical differences between EUS portal pressure gradient (PPG) and hepatic venous pressure gradient (HVPG) are that the EUS device allows for direct portal vein measurements while HVPG done with interventional radiology technique utilizes a wedged hepatic vein pressure which serves as a surrogate for portal vein pressure. Small studies have demonstrated that the measurements are comparable; however, larger prospective comparative studies are ongoing to determine the accuracy of EUS-PPG compared with HVPG.[8] [9] However, benefit of direct portal measurements to long-term patient outcomes is yet to be proven. The “triple package” of liver biopsy, pressure measurements, and hepatic venography continues to be the stated standard of care as data for EUS approach evolves.

Percutaneous cholecystostomy has been the mainstay for gallbladder drainage in nonoperative candidates with the initial cases done in the late 1970s.[10] Recent advances in the use of choledochoscopes have been derived for percutaneous use and for gallstone lithotripsy which may be desired to prevent recurrent cholecystitis[11] and improve quality of life and getting nonsurgical candidates free of tubes. EUS gallbladder drainage was introduced later and first described in 2007 using double pigtail plastic stents but has become more refined with the use of lumen-apposing metal stents. The use of choledochoscopy in the setting of EUS-guided gallbladder drainage is not known and literature is scarce in describing its use in this setting, though it has been described in the use of Bouveret syndrome; however, its use may be useful if large stones were at risk of occluding the stent.[12]

Multidisciplinary care is the mainstay of management when it comes to oncology. The multidisciplinary approach in oncology began in the 1980s where its initial intent was simply to come up with a therapeutic plan; however, this approach resulted in improved survival. This eventually led to the integration of other specialists such as dieticians, pharmacists, and social workers leading also to improved patient compliance to treatment.[13] Organ transplantation is another clinical scenario where multidisciplinary management is imperative to ensure proper patient selection, adherence to treatment posttransplant, and management of chronic illness while on the transplant list. The BRIGHT study evaluating heart transplant centers showed that the institution of a multidisciplinary team was positively associated with higher levels of chronic illness management which has the potential to improve outcomes posttransplant.[14] Multidisciplinary care has also been well documented in the management of many other conditions such as diabetes and nonalcoholic fatty liver disease.[15] [16] Implementation of a multidisciplinary protocol for acute GI bleeding has shown improved outcomes[17] and given the significant overlap between IR and endoscopy specialties, adapting formal channels to multidisciplinary meetings at institutional and national level will be beneficial.

Communication across different specialties in managing these other conditions is often institution dependent and not considered common practice despite the education and collaboration that can be gleaned from all parties. Furthermore, the potential for cross-pollination through these platforms will enhance research and innovation for our individual specialties.

In this issue, these GI conditions are written through the perspective of both interventional gastroenterology and radiology to highlight the complexity and inherent multidisciplinary essence of these conditions. Adapting a multidisciplinary approach provides many opportunities including collaboration in the care of patients, creating an approachable rapport between specialties, development of research ideas, and learning from each other. We hope that you can walk a mile in the other's shoes as you explore this issue of DDI and will perhaps be inspired to create a multidisciplinary team of your own!

Publication History

Article published online:
02 November 2023

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