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Ito Y, Fujitani K, Sakamaki K, Ando M, Kawabata R, Tanizawa Y, Yoshikawa T, Yamada T, Hirao M, Yamada M, Hihara J, Fukushima R, Choda Y, Kodera Y, Teshima S, Shinohara H, Kondo M. QOL assessment after palliative surgery for malignant bowel obstruction caused by peritoneal dissemination of gastric cancer: a prospective multicenter observational study. Gastric Cancer 2021; 24:1131-1139. [PMID: 33791885 DOI: 10.1007/s10120-021-01179-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with peritoneal dissemination of gastric cancer have poor oral intake caused by malignant bowel obstruction (MBO). Palliative surgery has often been undertaken to improve quality of life (QOL), but few prospective studies on palliative surgery in this patient population have been published. PATIENTS AND METHODS We prospectively investigated the significance of palliative surgery using patient-reported QOL measures. Patients underwent palliative surgery by small intestine/colon resection or small intestine/colon bypass or ileostomy/colostomy for MBO. The primary endpoint was change in QOL assessed at baseline, 14 days, 1 month, and 3 months following palliative surgery using the Euro QoL Five Dimensions (EQ-5D™) questionnaire and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire gastric cancer module (QLQ-STO22). Secondary endpoints were postoperative improvement in oral intake and surgical complications. RESULTS Between April 2013 and March 2018, 63 patients were enrolled from 14 institutions. The mean EQ-5D™ utility index baseline score of 0.6 remained consistent. Gastric-specific symptoms mostly showed statistically significant improvement from baseline. Forty-two patients (67%) were able to eat solid food 2 weeks after palliative surgery and 36 patients (57%) tolerated it for 3 months. The rate of overall morbidity of ≥ grade III according to the Clavien-Dindo classification was 16% (10 patients) and the 30-day postoperative mortality rate was 3.2% (2 patients). CONCLUSIONS In patients with MBO caused by peritoneal dissemination of gastric cancer, palliative surgery did not improve QOL while improving solid food intake, with an acceptable postoperative morbidity and mortality rate.
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Affiliation(s)
- Yuichi Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1, Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan.
| | - Kazumasa Fujitani
- Department of Surgery, Osaka Prefectural General Medical Center, Osaka, Japan
| | - Kentaro Sakamaki
- Center for Data Science, Yokohama City University, Yokohama, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | | | - Yutaka Tanizawa
- Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takaki Yoshikawa
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Takanobu Yamada
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Motohiro Hirao
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Makoto Yamada
- Department of Surgery, Gifu Municipal Hospital, Gifu, Japan
| | - Jun Hihara
- Department of Surgery, Hiroshima City Asa Hospital, Hiroshima, Japan
| | - Ryoji Fukushima
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Choda
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shin Teshima
- Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Hisashi Shinohara
- Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masato Kondo
- Department of Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
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Tan WJ, Lin W, Sultana R, Foo FJ, Tang CL, Chew MH. A prognostic score predicting survival following emergency surgery in patients with metastatic colorectal cancer. ANZ J Surg 2021; 91:2493-2498. [PMID: 34374482 DOI: 10.1111/ans.17065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/14/2021] [Accepted: 06/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Survival of patients with metastatic colorectal cancer (mCRC) varies. We aim to develop a prognostic score for mCRC after emergency surgery to guide treatment decisions. METHODS Newly diagnosed mCRC patients who presented with primary tumor-related complications and underwent emergency surgery between January 1999 and December 2013 were included. Univariate and multivariate Cox regression analyses were performed to identify covariates significantly associated with the time to death following surgery. A survival score was derived using the Cox regression equation. RESULTS The study cohort comprised 248 patients. Median patient age was 66 ± 13 years. Primary tumor was located in the left colon and rectum in 211 patients (85.1%) while 37 patients (14.9%) had primaries in the right colon. Liver, lung, and peritoneal metastases occurred in 161 patients (64.9%), 59 patients (23.8%), and 96 patients (38.7%), respectively. Majority of patients presented with either obstruction (174 patients, 70.1%) or perforation (52 patients, 21%). On multivariate analysis, age of 60 years or older (p = 0.007), carcinoembryonic antigen levels greater than 45 ng/ml (p = 0.022), presence of liver metastases (p = 0.024), and peritoneal carcinomatosis (p < 0.001) were found to be significantly associated with overall survival. A simplified score was derived with good survivors (score 0-2), moderate survivors (score 3-4), and poor survivors (score 5 and above) experiencing median survival of 7, 14, and 23 months, respectively (p < 0.001). CONCLUSION The management of mCRC presenting with an emergency is challenging. A prognostic score that estimates survival after emergency surgery may aid clinical decision-making.
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Affiliation(s)
- Winson Jianhong Tan
- Department of General Surgery, Colorectal Service, Sengkang General Hospital, Singapore.,Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Wenjie Lin
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Rehena Sultana
- Centre for Qualitative Medicine, DUKE NUS Graduate Medical School, Singapore
| | - Fung Joon Foo
- Department of General Surgery, Colorectal Service, Sengkang General Hospital, Singapore.,Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Choong Leong Tang
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Min Hoe Chew
- Department of General Surgery, Colorectal Service, Sengkang General Hospital, Singapore.,Department of Colorectal Surgery, Singapore General Hospital, Singapore
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Abstract
Malignant bowel obstruction is a challenging clinical problem encountered in patients with advanced abdominal and pelvic malignancies. Although medical therapies form the foundation of management, some patients may be suitable candidates for surgical and procedural interventions. The literature is composed primarily of retrospective single-institution experiences and the results of prospective trials are pending. Given the high symptom burden and limited life expectancy of these patients, management may be best informed by multidisciplinary teams with relevant expertise.
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Affiliation(s)
- Caitlin T Yeo
- Division of Surgical Oncology, University of Calgary, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, Alberta T2N 4N2, Canada
| | - Shaila J Merchant
- Division of General Surgery and Surgical Oncology, Queen's University, Burr 2, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
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Bleicher J, Lambert LA. A Palliative Approach to Management of Peritoneal Carcinomatosis and Malignant Ascites. Surg Oncol Clin N Am 2021; 30:475-490. [PMID: 34053663 DOI: 10.1016/j.soc.2021.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In addition to severe, life-limiting complications such as malignant bowel obstruction, fistulae, and malignant ascites, peritoneal carcinomatosis frequently causes life-impacting symptoms such as pain, nausea, anorexia, cachexia, and fatigue. A variety of medical, interventional, and surgical therapies are now available for management of both complications and symptoms. Although surgery in this population is often associated with a relatively high risk of morbidity and mortality, operative intervention can offer effective palliative treatment in appropriately selected patients. Early involvement of palliative care specialists as part of a multidisciplinary team is essential to providing optimal, holistic care of patients with peritoneal carcinomatosis.
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Affiliation(s)
- Josh Bleicher
- Division of General Surgery, Huntsman Cancer Institute, University of Utah, 1950 Circle of Hope, Suite 6405, Salt Lake City, UT 84112, USA.
| | - Laura A Lambert
- Division of General Surgery, Huntsman Cancer Institute, University of Utah, 1950 Circle of Hope, Suite 6405, Salt Lake City, UT 84112, USA
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Bleicher J, Lambert LA, Scaife CL, Colonna A. Current management of malignant bowel obstructions: a survey of acute care surgeons and surgical oncologists. Trauma Surg Acute Care Open 2021; 6:e000755. [PMID: 34222676 PMCID: PMC8211049 DOI: 10.1136/tsaco-2021-000755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background Malignant small bowel obstructions (MSBOs) are one of the most challenging problems surgeons encounter, and evidence-based treatment recommendations are lacking. We hypothesized that current opinions on MSBO management differ between acute care surgeons (ACSs) and surgical oncologists (SOs). Methods We developed three case scenarios describing patients with previously treated cancer who developed an MSBO. Each case had five to six alternate scenarios, intended to capture the heterogeneity of MSBO presentations. Members of the Society of Surgical Oncology, the American Society of Peritoneal Surface Malignancies, and the Eastern Association for the Surgery of Trauma were asked how likely they would be to offer surgical treatment in each scenario. Responses were analyzed for factors associated with the likelihood surgeons would offer surgical management. Results 316 surgeons completed the survey: 119 (37.7%) SOs and 197 (62.3%) ACSs. Overall, SOs were nearly twice as likely as ACSs to recommend surgical management. The largest differences between provider groups were seen in patients with an increased metastatic burden. In a patient with MSBO with metastatic colon cancer, both SOs (95.8%) and ACSs (94.4%) were likely or very likely to offer an operation (p=0.587); however, this fell to 91.6% and 77.7%, respectively, when this patient had multiple hepatic metastases (p=0.001). All surgeons were less likely to offer surgery to patients with multiple sites of obstruction, recurrent MSBO, and shorter disease-free intervals. Discussion Opinions on MSBO management differ based on surgeon training and experience. Multidisciplinary management of patients with MSBO should be offered when available and increased emphasis placed on determining optimal management guidelines across specialties. Level of evidence Level IV Epidemiologic.
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Affiliation(s)
- Josh Bleicher
- General Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Laura A Lambert
- General Surgery, University of Utah Health, Salt Lake City, Utah, USA.,Surgical Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, USA
| | - Courtney L Scaife
- General Surgery, University of Utah Health, Salt Lake City, Utah, USA.,Surgical Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, USA
| | - Alexander Colonna
- General Surgery, University of Utah Health, Salt Lake City, Utah, USA
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Bateni SB, Gingrich AA, Kirane AR, Sauder CAM, Gholami S, Bold RJ, Meyers FJ, Canter RJ. Chemotherapy After Diagnosis of Malignant Bowel Obstruction is Associated with Superior Survival for Medicare Patients with Advanced Malignancy. Ann Surg Oncol 2021; 28:7555-7563. [PMID: 33829359 PMCID: PMC8519893 DOI: 10.1245/s10434-021-09831-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/22/2021] [Indexed: 12/11/2022]
Abstract
Background Although malignant bowel obstruction (MBO) often is a terminal event, systemic therapies are advocated for select patients to extend survival. This study aimed to evaluate factors associated with receipt of chemotherapy after MBO and to determine whether chemotherapy after MBO is associated with survival. Methods This retrospective cohort study investigated patients 65 years of age or older with metastatic gastrointestinal, gynecologic, or genitourinary cancers who were hospitalized with MBO from 2008 to 2012 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Fine and Gray models were used to identify factors associated with receipt of chemotherapy accounting for the competing risk of death. Cox models identified factors associated with overall survival. Results Of the 2983 MBO patients, 39% (n = 1169) were treated with chemotherapy after MBO. No differences in receipt of chemotherapy between the surgical and medical patients were found in the univariable analysis (subdistribution hazard ratio [SHR], 0.96; 95% confidence interval [CI], 0.86–1.07; p = 0.47) or multivariable analysis (SHR, 1.12; 95% CI, 1.00–1.26; p = 0.06). Older age, African American race, medical comorbidities, non-colorectal and non-ovarian cancer diagnoses, sepsis, ascites, and intensive care unit stays were inversely associated with receipt of chemotherapy after MBO (p < 0.05). Chemotherapy with surgery was associated with longer survival than surgery (adjusted hazard ratio [aHR], 2.97; 95% CI, 2.65–3.34; p < 0.01) or medical management without chemotherapy (aHR, 4.56; 95% CI, 4.04–5.14; p < 0.01). Subgroup analyses of biologically diverse cancers (colorectal, pancreatic, and ovarian) showed similar results, with greater survival related to chemotherapy (p < 0.05). Conclusions Chemotherapy plays an integral role in maximizing oncologic outcome for select patients with MBO. The data from this study are critical to optimizing multimodality care for these complex patients. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-09831-0.
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Affiliation(s)
- Sarah B Bateni
- Division of Surgical Oncology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alicia A Gingrich
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Amanda R Kirane
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Candice A M Sauder
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Sepideh Gholami
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Frederick J Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Robert J Canter
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA.
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Bateni SB, Canter RJ. ASO Author Reflections: The Central Role of Chemotherapy in Patients with Advanced Cancer Recently Diagnosed with Malignant Bowel Obstruction. Ann Surg Oncol 2021; 28:7564-7565. [PMID: 33754226 DOI: 10.1245/s10434-021-09850-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/02/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Sarah B Bateni
- Division of Surgical Oncology, Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Robert J Canter
- Division of Surgical Oncology, Department of Surgery, Davis Medical Center, University of California, Sacramento, CA, USA
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Sakamoto S, Matsumura M, Tani K, Nemoto S, Tsuchida K, Koga F, Seyama Y. Jejunal limb obstruction by a tumor thrombus from pancreatic metastasis of renal cell carcinoma: a case report. Surg Case Rep 2021; 7:37. [PMID: 33534019 PMCID: PMC7859002 DOI: 10.1186/s40792-021-01122-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/27/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Renal cell carcinoma (RCC) is a primary tumor with the highest frequency of pancreatic metastasis. Although surgical resection can improve the prognosis of some patients with pancreatic metastasis of RCC (PM-RCC), the role of palliative surgery remains unclear. Herein, we described a case of jejunal limb occlusion caused by a tumor thrombus arising from a PM-RCC which was treated by surgical resection. CASE PRESENTATION A 75-year-old, male patient with metastatic RCC was admitted to our hospital with new-onset dysphagia and weight loss. Twenty years earlier he underwent a right nephrectomy with an adrenalectomy for the first surgical resection of RCC, and 12 years ago he underwent a left partial nephrectomy for metachronous primary RCC. Nine years later, multiple pancreatic metastases were detected. After discontinuing interferon therapy, he was followed up at his request without anticancer treatment. Multiple, pulmonary metastases developed 3 years ago, and resection of a brain metastasis was performed 6 months ago. He had also undergone a total gastrectomy with Roux-en Y reconstruction and splenectomy for gastric cancer 23 years ago. Computed tomography revealed a metastatic lesion in the pancreatic tail extending into the jejunal limb, which was obstructed by a tumor thrombus. Jejunal limb resection was performed concomitantly with a distal pancreatectomy as palliative surgery. The jejunal limb remnant was approximately 30 cm long and was re-anastomosed to the esophagus using a circular stapler. Blood perfusion at the anastomotic site was confirmed by indocyanine green fluorescence imaging. He was discharged on postoperative day 24 and was followed in the outpatient clinic. He achieved sufficient oral intake at 8 months postoperatively. CONCLUSIONS PM-RCC can invade the gastrointestinal tract and cause tumor thrombus formation resulting in bowel occlusion requiring surgical intervention.
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Affiliation(s)
- Shinya Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Masaru Matsumura
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Keigo Tani
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Satoshi Nemoto
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Kazuhito Tsuchida
- Department of Gastric Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Fumitaka Koga
- Department of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yasuji Seyama
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan.
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The effect of compound Da-Cheng-Qi Decoction on the treatment of malignant bowel obstruction with transnasal ileus tube. Complement Ther Clin Pract 2021; 43:101316. [PMID: 33545574 DOI: 10.1016/j.ctcp.2021.101316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/24/2020] [Accepted: 01/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To study the effect of compound Da-Cheng-Qi Decoction (CDCQD) on the treatment of malignant bowel obstruction (MBO) with transnasal ileus tube (TIT). METHODS We observed 30 cases of MBO from July 2018 to August 2019. The patients were divided into the control group (n = 15) and the CDCQD group (n = 15) according to a random number table. All patients were inserted the TIT after admission. Twenty-four hours later, the CDCQD group began to take 100 ml CDCQD twice a day for 7 days. The control group took the plain boiled water instead. Other treatment was the same in the two groups. The waistline reduction, the release time of abdominal pain and distention, recovery of exhaust and defecation time, drainage volume of TIT were observed and compared between the two groups. RESULTS Three days after insertion of TIT, the abdominal plain film was re-examined in the two groups. Most of the patients' gas-liquid level disappeared and there was no significant difference between the two groups (P > 0.05). The effective rate of CDCQD group (86.7%) was significantly higher than that of control group (53.3%). The recovery time of exhaust and defecation in the CDCQD group was earlier than that in the control group (P < 0.05). The daily drainage volume of TIT in the CDCQD group was less than that in the control group, especially from the fourth day to the sixth day after insertion of TIT, with a significant difference (P < 0.05). CONCLUSION TIT is an effective treatment for patients with MBO. With the basis of TIT treatment, CDCQD therapy can improve the curative effect of MBO. It can promote intestinal exhaust and defecation and improves the curative effect of palliative treatment of MBO. It is an effective method to assist Tit in the treatment for MBO patients.
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White B, Dahdaleh F, Naffouje SA, Kothari N, Berg J, Wiemann W, Salti GI. Impact of Enhanced Recovery After Surgery on Postoperative Outcomes for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2021; 28:5265-5272. [PMID: 33469794 DOI: 10.1245/s10434-020-09476-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/01/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been associated with significant morbidity and increased hospital length of stay (LOS). The authors report their experience after implementation of an enhanced recovery after surgery (ERAS) program for CRS-HIPEC. METHODS Outcomes were analyzed before and after ERAS implementation. The components of ERAS included preoperative carbohydrate loading, goal-directed fluid management, multimodal pain management, minimization of narcotic use, avoidance of nasogastric tubes, and early mobilization and feeding. RESULTS Of 168 procedures, 88 (52%) were in the pre-ERAS group and 80 (48%) were in the post-ERAS group. The two groups did not differ in terms of age, sex, comorbidities, peritoneal carcinomatosis index scores, completeness of cytoreduction, or operative time. The ERAS patients received fewer fluids intraoperatively (mean, 4.2 vs 6.4 L; p < 0.01). The mean LOS was 7.9 days post-ERAS compared with 10.0 days pre-ERAS (p = 0.015). Clavien-Dindo complications classified as grade ≥ 3 were lower after ERAS (23.7% vs 38.6%; p = 0.04). Moreover, the readmission rates remained the same (16.2% vs 13.6%; p = 0.635). CONCLUSIONS Implementation of an ERAS program for patients undergoing CRS-HIPEC is feasible and not associated with an increase in overall major complications or readmissions. These data support incorporation of ERAS protocols for CRS-HIPEC procedures.
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Affiliation(s)
- Bradley White
- Department of General Surgery, Division of Surgical Oncology, The University of Illinois at Chicago, 840 South Wood Street, M/C 820, Chicago, IL, 60612, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - Samer A Naffouje
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Neerav Kothari
- Department of Anesthesia, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Jessica Berg
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - Wendy Wiemann
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - George I Salti
- Department of General Surgery, Division of Surgical Oncology, The University of Illinois at Chicago, 840 South Wood Street, M/C 820, Chicago, IL, 60612, USA. .,Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA.
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Wey W, Mian M, Calabrese R, Hansen E, Walter M, Wang C, Miller A, Case AA. Palliative Medical Management of Inoperable Malignant Bowel Obstruction With "Triple Therapy": Dexamethasone, Octreotide, and Metoclopramide. Am J Hosp Palliat Care 2020; 38:340-345. [PMID: 33084354 DOI: 10.1177/1049909120968249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
CONTEXT Malignant bowel obstruction (MBO) is a complication of advanced malignancy. For inoperable patients, symptoms are often treated using analgesics, anticholinergics, and anti-emetics. There are, however, few published guidelines for the medical management of MBO. OBJECTIVE To measure the effect of the combination of dexamethasone, octreotide, and metoclopramide ("triple therapy") in patients with MBO, compared to patients who received none of the 3 medications ("no drug therapy"). METHODS A retrospective cohort study of patients with MBO admitted in a single-center comprehensive cancer center. Patients who received dexamethasone, octreotide, and metoclopramide during their hospitalization for treatment of inoperable MBO were selected for analysis. Patients were excluded if they received a venting gastric tube. Rate of de-obstruction as well as time to de-obstruction were measured. RESULTS There were 20 patients identified who received all 3 drugs of interest, and 29 patients identified who received none of the 3 medications. There was no statistically significant difference in rates of de-obstruction between the 2 groups, though there was a non-significant trend toward patients who received triple therapy were more likely to reach de-obstruction, compared to patients who had no drug therapy (95% vs. 83%, p = 0.379); there was no significant difference in adjusted analysis. CONCLUSION In patients with inoperable MBO, there was no statistically significant difference in rates of de-obstruction with triple drug therapy compared to patients who received none of the 3 drugs, though the study may not have been powered to detect a difference and further investigation is warranted.
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Affiliation(s)
- Winston Wey
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.,Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Moeena Mian
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.,Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Rebecca Calabrese
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Geriatrics and Palliative Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Eric Hansen
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Geriatrics and Palliative Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Michelle Walter
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Geriatrics and Palliative Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Chong Wang
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Austin Miller
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Amy A Case
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Geriatrics and Palliative Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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Jaruvongvanich V, Chesta FNU, Baruah A, Oberoi M, Adamo D, Singh PG, Meyer A, Law RJ, Buttar N. Palliative treatment for malignant gastrointestinal obstruction with peritoneal carcinomatosis: enteral stenting versus surgery. Endosc Int Open 2020; 8:E1487-E1494. [PMID: 33043118 PMCID: PMC7541184 DOI: 10.1055/a-1237-3956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Management of malignant gastrointestinal obstruction (MGIO) is more challenging in the presence of peritoneal carcinomatosis (PC). Outcomes data to guide the management of MGIO with PC are lacking. We aimed to compare the clinical outcomes and adverse events between endoscopic and surgical palliation and identify predictors of stent success in patients with MGIO with PC. Patients and methods Consecutive inpatients with MGIO with PC between 2000 and 2018 who underwent palliative surgery or enteral stenting were included. Clinical success was defined as relief of obstructive symptoms. Results Fifty-seven patients with enteral stenting and 40 with palliative surgery were compared. The two groups did not differ in rates of technical success, 30-day mortality, or recurrence. Clinical success from a single intervention (63.2 % versus 95 %), luminal patency duration (27 days vs. 145 days), and survival length (148 days vs. 336 days) favored palliative surgery (all P < 0.05) but the patients in the surgery group had a trend toward better Eastern Cooperative Oncology Group (ECOG) status. The rate of adverse events (AEs) (10.5 % vs. 50 %), the severity of AEs, and length of hospital stay (4.5 days vs. 9 days) favored enteral stenting ( P < 0.05). The need for more than one stent was associated with a higher likelihood of stent failure. Conclusions Our study suggests that enteral stenting is safer and associated with a shorter hospital stay than palliative surgery, although unlike other MGIOs, clinical success is lower in MGIO with PC. Identification of the right candidates and potential predictors of clinical success in ECOG-matched large-scale studies is needed to validate these results.
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Affiliation(s)
| | - FNU Chesta
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Anushka Baruah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Meher Oberoi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Daniel Adamo
- Division of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Prabh G. Singh
- Government Medical College and Hospital, Chandigarh, India
| | - Alyssa Meyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Ryan J. Law
- University of Michigan, Gastroenterology and Hepatology, Ann Arbor, Michigan, United States
| | - Navtej Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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64
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Yu K, Liu L, Zhang X, Zhang Z, Rao B, Chen Y, Li S, Shi H. Surgical and Conservative Management of Malignant Bowel Obstruction: Outcome and Prognostic Factors. Cancer Manag Res 2020; 12:7797-7803. [PMID: 32922079 PMCID: PMC7457748 DOI: 10.2147/cmar.s256219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/05/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Malignant bowel obstruction (MBO) is a common problem in late-stage cancer patients. Many factors are suggested to be associated with the prognosis of MBO. The current investigation was designed to explore the factors associated with the prognosis of conservative and surgery treatment in one single institution. Patients and Methods Sixty-four patients of MBO were recruited into the study. Demographic and clinical data including gender, age, primary cancer, radiological and laboratory examinations, and nutritional and pain index scaling were extracted for further analysis. Kaplan-Meier analysis and logistic regression analysis were used to compare the prognosis and detect significant factors. Results Of the 64 patients, there is no statistical difference in baseline features between conservative and surgical group. However, the length of stay, total medical costs, re-admission interval, and re-admission rate are statistically significant. There is no significance in Kaplan-Meier log rank test for median survival time, though the overall survival time in the conservative group is longer than that of the surgery group. Logistic regression analysis has found that prior chemotherapy is a significant predictor for final survival outcome. Conclusion The election of surgery might not improve the overall survival time. Non-surgical procedures, especially chemotherapy, might be preferable for MBO patients.
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Affiliation(s)
- Kaiying Yu
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Ninth School of Clinical Medicine, Peking University, Beijing 100038, People's Republic of China
| | - Lihui Liu
- Ninth School of Clinical Medicine, Peking University, Beijing 100038, People's Republic of China.,Department of Nursing, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China
| | - Xiaowei Zhang
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Ninth School of Clinical Medicine, Peking University, Beijing 100038, People's Republic of China
| | - Zhanzhi Zhang
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Ninth School of Clinical Medicine, Peking University, Beijing 100038, People's Republic of China
| | - Benqiang Rao
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Ninth School of Clinical Medicine, Peking University, Beijing 100038, People's Republic of China
| | - Yongbing Chen
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Ninth School of Clinical Medicine, Peking University, Beijing 100038, People's Republic of China
| | - Suyun Li
- Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Ninth School of Clinical Medicine, Peking University, Beijing 100038, People's Republic of China
| | - Hanping Shi
- Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, People's Republic of China.,Ninth School of Clinical Medicine, Peking University, Beijing 100038, People's Republic of China
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65
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Banting SP, Waters PS, Peacock O, Narasimhan V, Lynch AC, McCormick JJ, Warrier SK, Heriot AG. Management of primary and metastatic malignant small bowel obstruction, operate or palliate. A systematic review. ANZ J Surg 2020; 91:282-290. [PMID: 32869479 DOI: 10.1111/ans.16188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/07/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of patients presenting with malignant small bowel obstruction is a challenging paradigm. The aim of this systematic review was to examine different management strategies in these complex patients. The primary outcomes evaluated were the type of intervention, 30-day morbidity and mortality and overall survival rates. METHODS A systematic literature review of EMBase, Medline, PubMed and the Cochrane Library was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses for studies reporting on conservative and operative management of malignant small bowel obstruction. RESULTS Fifteen studies (n = 882 patients) reporting on outcomes for malignant small bowel obstruction were analysed. Outcomes measured were primarily survival and relief of obstructive symptoms. The median age ranged from 52 to 66 years. The most common cause of malignant small bowel obstruction was gynaecological in nature (56%), followed by colorectal (19%). Four hundred and eighty-six patients underwent primary surgical management and the remaining 396 patients were assigned to non-surgical intervention. Median overall survival in the operative studies ranged from 2.5 to 7.4 months compared with 0.9 to 1.9 months (P < 0.05). The 30-day mortality ranged from 13% to 28% in those who underwent surgical interventions versus 2% to 61% in the non-surgical group (P = 0.09). No significant difference in median survival in gastrointestinal (GI) and gynaecological malignancies was observed (4.3 versus 5.0 months, P = 0.12). Morbidity ranged from 21% to 85% in the surgical group and 12% to 29% in the percutaneous groups (P < 0.05). CONCLUSION Surgical intervention in malignant small bowel obstruction is associated with significant morbidity, although it may improve survival in selected patients with gynaecological and colorectal malignancy. It is imperative that realistic goals and expectations are discussed with patients preoperatively.
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Affiliation(s)
- Samuel P Banting
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Peadar S Waters
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Oliver Peacock
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Vignesh Narasimhan
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew C Lynch
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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66
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Goldberg JI, Goldman DA, McCaskey S, Koo DJ, Epstein AS. Illness Understanding, Prognostic Awareness, and End-of-Life Care in Patients With GI Cancer and Malignant Bowel Obstruction With Drainage Percutaneous Endoscopic Gastrostomy. JCO Oncol Pract 2020; 17:e186-e193. [PMID: 32758086 DOI: 10.1200/op.20.00035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Malignant bowel obstruction (MBO) is common in advanced GI cancer, and MBO management, including drainage percutaneous endoscopic gastrostomy (dPEG), is palliative. How patients understand the goals of dPEG and its impact on disease is inadequately understood in the literature. Therefore, we analyzed these issues in patients with GI cancer. METHODS Demographics, clinical variables, and patient outcomes were abstracted from the medical record. Illness understanding and future expectations were retrieved from palliative care notes. We described additional treatment and outcomes after dPEG and estimated overall survival (OS). RESULTS From January 2015 to June 2017, 125 admitted patients with metastatic GI cancer underwent dPEG for MBO. Cancers were most commonly colorectal (34%) and pancreatic/ampullary (25%). During the dPEG admission, 32% (40 of 125) of patients had a palliative care consultation, and 22% (28 of 125) were asked about illness understanding and future expectations. All (28 of 28) reported good understanding of the advanced nature of their disease, but few were accurate about prognosis given their stage IV disease (10 of 28). Of the 117 (94%) discharged, 13% (15 of 117) received additional chemotherapy, which rarely prevented progression; half (63 of 117) had a do-not-resuscitate order; and most (101 of 117) were enrolled in hospice at death. Median time to death was 37 days (95% CI, 29 to 45 days); 6-month OS was 3.7% (95% CI, 1.2% to 8.4%). CONCLUSION dPEGs are placed close to end of life in patients with advanced GI cancer. A minority of patients receive additional chemotherapy post-dPEG. Many have adequate disease understanding, but chemotherapy benefit is low, and future expectations vary. This may be an opportunity for improved communication regarding palliative procedures in advanced cancer.
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Affiliation(s)
- Jessica I Goldberg
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Debra A Goldman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sarah McCaskey
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Douglas J Koo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew S Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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Development and Validation of an Image-based Deep Learning Algorithm for Detection of Synchronous Peritoneal Carcinomatosis in Colorectal Cancer. Ann Surg 2020; 275:e645-e651. [PMID: 32694449 DOI: 10.1097/sla.0000000000004229] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to build a SVM classifier using ResNet-3D algorithm by artificial intelligence for prediction of synchronous PC. BACKGROUND Adequate detection and staging of PC from CRC remain difficult. METHODS The primary tumors in synchronous PC were delineated on preoperative contrast-enhanced computed tomography (CT) images. The features of adjacent peritoneum were extracted to build a ResNet3D + SVM classifier. The performance of ResNet3D + SVM classifier was evaluated in the test set and was compared to routine CT which was evaluated by radiologists. RESULTS The training set consisted of 19,814 images from 54 patients with PC and 76 patients without PC. The test set consisted of 7837 images from 40 test patients. The ResNet-3D spent only 34 seconds to analyze the test images. To increase the accuracy of PC detection, we have built a SVM classifier by integrating ResNet-3D features with twelve PC-specific features (P < 0.05). The ResNet3D + SVM classifier showed accuracy of 94.11% with AUC of 0.922 (0.912-0.944), sensitivity of 93.75%, specificity of 94.44%, PPV of 93.75%, and NPV of 94.44% in the test set. The performance was superior to routine contrast-enhanced CT (AUC: 0.791). CONCLUSIONS The ResNet3D + SVM classifier based on deep learning algorithm using ResNet-3D framework has shown great potential in prediction of synchronous PC in CRC.
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Chow FCL, Yip J, Foo DCC, Wei R, Choi HK, Ng KK, Lo OSH. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal and appendiceal peritoneal metastases - The Hong Kong experience and literature review. Asian J Surg 2020; 44:221-228. [PMID: 32605790 DOI: 10.1016/j.asjsur.2020.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/05/2020] [Accepted: 05/17/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly used to treat peritoneal metastases from appendiceal or colorectal origin. We evaluate our institution's experience and survival outcomes with this procedure, and its efficacy in symptom relief. METHODS This is a single-centre retrospective observational study on patients with peritoneal metastases (PM) from appendiceal neoplasm or colorectal cancer who underwent CRS/HIPEC in Queen Mary Hospital. Our primary endpoints were overall survival (OS) and morbidity and mortality of this procedure; secondary endpoints included disease-free survival (DFS) and symptom-free survival. RESULTS Between 2006 and 2018, thirty CRS/HIPEC procedures were performed for 28 patients - 17 (60.7%) had appendiceal PM while 11 (39.9%) had colorectal PM. The median peritoneal cancer index was 20; complete cytoreduction was achieved in 83.3% patients. High-grade morbidity occurred in 13.3% cases. There was no 30-day mortality. Two-year OS were 71.6% and 50% for low-grade appendiceal PM and colorectal PM patients (p = 0.20). Complete cytoreduction improved OS (2-year OS 75.4% vs 20%, p = 0.04). Median DFS was 11.8 months. Median symptom-free duration was 36.8 months; patients with complete cytoreduction were more likely to remain asymptomatic (82.9% at 1 year, vs 60% in incomplete cytoreduction group, p < 0.01). 91.7% low-grade appendiceal PM patients and 58.4% colorectal PM patients remained asymptomatic at post-operative one year (p = 0.31). CONCLUSION CRS/HIPEC is beneficial to appendiceal PM and selected colorectal PM patients - improving survival and offering prolonged symptom relief, with reasonable morbidity and mortality. Complete cytoreduction is key to realising this benefit.
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Affiliation(s)
- Felix Che-Lok Chow
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
| | - Jeremy Yip
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Dominic Chi-Chung Foo
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Rockson Wei
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Hok Kwok Choi
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ka Kin Ng
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Oswens Siu-Hung Lo
- Division of Colorectal Surgery, Department of Surgery, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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69
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Pletcher E, Gleeson E, Labow D. Peritoneal Cancers and Hyperthermic Intraperitoneal Chemotherapy. Surg Clin North Am 2020; 100:589-613. [PMID: 32402303 DOI: 10.1016/j.suc.2020.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy is an aggressive, potentially curative approach used to treat locoregional disease associated with primary and secondary malignancies of the peritoneum. It involves resection of all macroscopic disease larger than 2.5 mm, followed by instillation of hyperthermic chemotherapy directly into the peritoneum for higher drug exposure to microscopic disease. In select patients with primary peritoneal mesothelioma, pseudomyxoma peritonei, colorectal adenocarcinoma, appendiceal adenocarcinoma, or ovarian cancer, with no extra-abdominal metastasis and limited involvement of the peritoneum, the procedure can be performed to increase overall survival.
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Affiliation(s)
- Eric Pletcher
- Surgery Department, Mount Sinai West and Morningside, 425 West 59th Street, 7th Floor, New York, NY 10019, USA
| | - Elizabeth Gleeson
- Division of Surgical Oncology, Mount Sinai Hospital, 19 East 98th Street, Suite 7A, New York, NY 10029, USA
| | - Daniel Labow
- Surgery Department, Mount Sinai Hospital, Mount Sinai West and Morningside, 425 West 59th Street, 7th Floor, New York, NY 10019, USA.
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70
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Chen PJ, Wang L, Peng YF, Chen N, Wu AW. Surgical intervention for malignant bowel obstruction caused by gastrointestinal malignancies. World J Gastrointest Oncol 2020; 12:323-331. [PMID: 32206182 PMCID: PMC7081110 DOI: 10.4251/wjgo.v12.i3.323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/22/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Malignant bowel obstruction (MBO) is a common event for end-stage gastrointestinal cancer patients. Previous studies had demonstrated manifestations and clinical management of MBO with mixed malignancies. There still lack reports of the surgical treatment of MBO.
AIM To analyze the short-term outcomes and prognosis of palliative surgery for MBO caused by gastrointestinal cancer.
METHODS A retrospective chart review of 61 patients received palliative surgery between January 2016 to October 2018 was performed, of which 31 patients underwent massive debulking surgery (MDS) and 30 underwent ostomy/by-pass surgery (OBS). The 60-d symptom palliation rate, 30-d morbidity and mortality, and overall survival rates were compared between the two groups.
RESULTS The overall symptom palliation rate was 75.4% (46/61); patients in the MDS group had significantly higher symptom palliation rate than OBS group (90% vs 61.2%, P = 0.016). Patients with colorectal cancer who were in the MDS group showed significantly higher symptom improvement rates compared to the OBS group (overall, 76.4%; MDS, 61.5%; OBS, 92%; P = 0.019). However, patients with gastric cancer did not show a significant difference in symptom palliation rate between the MDS and OBS groups (OBS, 60%; MDS, 80%; P = 1.0). The median survival time in the MDS group was significantly longer than in the OBS group (10.9 mo vs 5.3 mo, P = 0.05).
CONCLUSION For patients with MBO caused by peritoneal metastatic colorectal cancer, MDS can improve symptom palliation rates and prolong survival, without increasing mortality and morbidity rates.
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Affiliation(s)
- Peng-Ju Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Lin Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Yi-Fan Peng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Nan Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Ai-Wen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Cancer Center, Unit III, Peking University Cancer Hospital and Institute, Beijing 100142, China
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Williams LA, Bruera E, Badgwell B. In Search of the Optimal Outcome Measure for Patients with Advanced Cancer and Gastrointestinal Obstruction: A Qualitative Research Study. Ann Surg Oncol 2020; 27:2646-2652. [PMID: 32152776 DOI: 10.1245/s10434-020-08328-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gastrointestinal obstruction (GIO) is the most common indication for palliative surgical consultation in patients with advanced cancer. The purpose of this study is to delineate the symptom burden and experience of these patients. PATIENTS AND METHODS Twenty patients with advanced cancer and GIO described symptoms at time of surgical consultation. We analyzed the content of interview transcripts and ranked symptoms by frequency and according to an assessment of relevance conducted by an expert panel (surgeons, palliative care physicians, nurses, and patients/caregivers). RESULTS Among the 20 study patients, malignancy types included colorectal (n = 9), gastric (n = 4), urothelial/renal (n = 3), and other (n = 4), whereas sites of obstruction were the small bowel (n = 11), gastric outlet (n = 3), and large bowel (n = 6). Thirteen patients (65%) had received chemotherapy within 6 weeks. Imaging evidence of a primary/recurrent tumor was documented in 13 patients (65%), carcinomatosis in 11 (55%), and ascites in 16 (80%). Thirty patient symptoms were identified on qualitative interviewing. Seven GIO-specific items were identified as relevant by the expert panel and will be added to the core symptom assessment inventory for further testing. CONCLUSIONS We identified symptoms of importance that can be used to assess outcome after treatment of patients with advanced cancer and GIO. Testing for validity and reliability will be required before formal survey development.
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Affiliation(s)
- Loretta A Williams
- Departments of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Departments of Palliative Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian Badgwell
- Departments of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Zattoni D, Christoforidis D. How best to palliate and treat emergency conditions in geriatric patients with colorectal cancer. Eur J Surg Oncol 2020; 46:369-378. [PMID: 31973923 DOI: 10.1016/j.ejso.2019.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 09/12/2019] [Accepted: 12/19/2019] [Indexed: 12/21/2022] Open
Abstract
Almost one third of colorectal cancer (CRC) cases are diagnosed in an emergency setting, mostly among geriatric patients. Clinical scenarios are often complex and decision making delicate. Besides the obvious need to consider the patient's and/or family and care givers' desires, the surgeon should be able to make the best educated guess on future outcomes in three areas: oncological prognosis, morbidity and mortality risk, and long-term functional loss. Using simple and brief tools for frailty screening reasonable treatment goals with curative or palliative intent can be planned. The most frequent clinical scenarios of CRC in emergency are bowel obstruction and perforation. We propose treatment algorithms based on assessment of the patient's overall reserve and discuss the indications, techniques and impact of a stoma in the geriatric patient. Bridge to surgery strategies may be best adapted to help the frail geriatric patient overcome the acute disease and maybe return to previous state of function. Post-operative morbidity and mortality rates are high in emergency surgery for CRC, but if the geriatric patient survives the post-operative period, oncological prognosis seems to be similar to younger patients. Because the occurrence of complications is the strongest predictor of functional decline and death, post-operative care plays a major role to optimize outcomes. Future studies should further investigate emergency surgery of CRC in the older adults focusing in particular on functional outcomes in order to help physicians counsel patients and families for a tailored treatment.
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Affiliation(s)
- Davide Zattoni
- Department of General Surgery, Ospedale per gli Infermi di Faenza, Viale Stradone 9, 48018, Faenza, Italy.
| | - Dimitri Christoforidis
- Department of General Surgery, Ospedale Civico di Lugano, Via Tesserete 46, 6900, Lugano, Switzerland; Department of Visceral Surgery, Lausanne University Hospital and Lausanne University, Rue du Bugnon 21, 1011, Lausanne, Switzerland.
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Abstract
Shared decision making requires the exchange of information from the patient and the surgeon (and ideally involves the expertise of the entire multidisciplinary team) to determine the medical and/or surgical treatment that best aligns with the patient's goals and values. Should the surgical patient wish to transition to end-of-life care, the transition to comfort-focused care is within the scope of practice for surgeons. Incorporating the expertise of other health care professionals is an important consideration for whole-patient care. Integrating primary palliative care into surgical practice can help mitigate unnecessary suffering and allow a smoother transition to comfort-focused care.
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Affiliation(s)
- Christine C Toevs
- Terre Haute Regional Hospital, 3901 South 7th Street, Terre Haute, IN 47802, USA; Indiana University School of Medicine, Terre Haute, IN, USA.
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Mir A, Parekh PJ, Shakhatreh M, Yeaton P. Endoscopic ultrasound-guided creation of an enterocolostomy to relieve malignant bowel obstruction. Endosc Int Open 2019; 7:E1034-E1037. [PMID: 31404448 PMCID: PMC6687478 DOI: 10.1055/a-0812-4328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/19/2018] [Indexed: 11/05/2022] Open
Abstract
Background and study aim Malignant bowel obstruction can cause significantly distressing symptoms in patients with end stage cancers, often requiring invasive surgical intervention. With such procedures, risks often outweigh the benefit. We report a novel application of the AXIOS stent and electrocautery-enhanced delivery system to create an enterocolostomy to bypass a small bowel obstruction in the setting of recurrent malignant bowel obstruction. A 72-year-old patient presented with recurrent malignant bowel obstruction and was deemed unfit for surgery. Endoscopic ultrasound was used to deploy an AXIOS stent, creating an enterocolostomy resolving the obstruction.
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Affiliation(s)
- Adil Mir
- Carilion Clinic – Internal Medicine, Roanoke, Virginia, United States
| | - Parth J. Parekh
- Carilion Clinic – Gastroenterology, Roanoke, Virginia, United States
| | | | - Paul Yeaton
- Virginia Tech Carilion School of Medicine, Gastroenterology, Roanoke, Virginia, United States
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Abstract
This article provides an overview of key palliative care considerations for management of patients with wounds and ostomies. Ostomy formation is indicated for a variety of intestinal conditions. Specifics of ostomy management, impact on quality of life, and patient perspectives can be complicated. Wound ostomy and continence nursing professionals play a central role in the successful management of this patient population.
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76
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Bozzetti F. The role of parenteral nutrition in patients with malignant bowel obstruction. Support Care Cancer 2019; 27:4393-4399. [DOI: 10.1007/s00520-019-04948-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/18/2019] [Indexed: 01/13/2023]
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Merchant SJ, Brogly SB, Booth CM, Goldie C, Peng Y, Nanji S, Patel SV, Lajkosz K, Baxter NN. Management of Cancer-Associated Intestinal Obstruction in the Final Year of Life. J Palliat Care 2019; 35:84-92. [PMID: 31307272 DOI: 10.1177/0825859719861935] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is variation in the clinical management of intestinal obstruction (IO) in patients with cancer. We describe the management of cancer-associated IO near the end of life in a population-based cohort with universal health coverage. METHODS Patients who died of gastric, colorectal, ovarian, and pancreatic cancers from 2002 to 2015 were identified from the Ontario Cancer Registry. Those with ≥1 hospital admission for IO in the final year of life were identified from administrative data. Management of IO at index admission was categorized as surgery, gastrostomy, stent, feeding jejunostomy, and medical management. Trends in management over the study period were assessed by the Cochran-Armitage test. RESULTS The cohort included 57 378 patients (gastric [n = 7448, 13%], colorectal [n = 30 577 53%], ovarian [n = 6273, 11%], and pancreatic [n = 13 080, 23%] cancers). Of those, 7618 (13%) patients had ≥1 admission for IO in the final year of life. Of these patients, 2657 (35%) patients were managed with a surgical/procedural intervention at index admission (surgery [86%], gastrostomy [8%], stent [6%], and jejunostomy [0.4%]); the remaining patients (n = 4961, 65%) received medical management. Over the study period, there was a small but statistically significant increase in the use of stents (0% in 2002 to 5% in 2015, P < .0001) and gastrostomy tubes (2% in 2002 to 4% in 2015, P = .002) and a large decrease in the use of surgery (41% in 2002 to 28% in 2015, P = .04). CONCLUSIONS Management of IO has changed over time with the increased use of stents and gastrostomy tubes and decreased use of surgery.
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Affiliation(s)
- Shaila J Merchant
- Department of Surgery, Queen's University, Kingston, Ontario, Canada.,ICES, Queen's University, Kingston, Ontario, Canada
| | - Susan B Brogly
- Department of Surgery, Queen's University, Kingston, Ontario, Canada.,ICES, Queen's University, Kingston, Ontario, Canada
| | - Christopher M Booth
- ICES, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Craig Goldie
- Division of Palliative Care, Queen's University, Kingston, Ontario, Canada
| | - Yingwei Peng
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | | | - Nancy N Baxter
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,ICES, University of Toronto, Toronto, Ontario, Canada
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78
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Outcomes following small bowel obstruction due to malignancy in the national audit of small bowel obstruction. Eur J Surg Oncol 2019; 45:2319-2324. [PMID: 31378418 DOI: 10.1016/j.ejso.2019.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Patients with cancer who develop small bowel obstruction are at high risk of malnutrition and morbidity following compromise of gastrointestinal tract continuity. This study aimed to characterise current management and outcomes following malignant small bowel obstruction. METHODS A prospective, multicentre cohort study of patients with small bowel obstruction who presented to UK hospitals between 16th January and 13th March 2017. Patients who presented with small bowel obstruction due to primary tumours of the intestine (excluding left-sided colonic tumours) or disseminated intra-abdominal malignancy were included. Outcomes included 30-day mortality and in-hospital complications. Cox-proportional hazards models were used to generate adjusted effects estimates, which are presented as hazard ratios (HR) alongside the corresponding 95% confidence interval (95% CI). The threshold for statistical significance was set at the level of P ≤ 0.05 a-priori. RESULTS 205 patients with malignant small bowel obstruction presented to emergency surgery services during the study period. Of these patients, 50 had obstruction due to right sided colon cancer, 143 due to disseminated intraabdominal malignancy, 10 had primary tumours of the small bowel and 2 patients had gastrointestinal stromal tumours. In total 100 out of 205 patients underwent a surgical intervention for obstruction. 30-day in-hospital mortality rate was 11.3% for those with primary tumours and 19.6% for those with disseminated malignancy. Severe risk of malnutrition was an independent predictor for poor mortality in this cohort (adjusted HR 16.18, 95% CI 1.86 to 140.84, p = 0.012). Patients with right-sided colon cancer had high rates of morbidity. CONCLUSIONS Mortality rates were high in patients with disseminated malignancy and in those with right sided colon cancer. Further research should identify optimal management strategy to reduce morbidity for these patient groups.
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79
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Baumgartner JM, Marmor R, Hsu A, Veerapong J, Kelly KJ, Lowy AM. Obstruction-Free Survival Following Operative Intervention for Malignant Bowel Obstruction in Appendiceal Cancer. Ann Surg Oncol 2019; 26:3611-3617. [PMID: 31190209 DOI: 10.1245/s10434-019-07507-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with peritoneal metastases from appendiceal cancer are at high risk of malignant bowel obstruction (MBO), which is associated with significant morbidity and mortality. There are no definitive treatment guidelines regarding operative intervention for MBO. We sought to evaluate the efficacy and safety of operative intervention in this population. METHODS We identified patients with peritoneal metastases from appendiceal cancer who underwent surgery for MBO at our institution between 2011 and 2018. Baseline characteristics, postoperative complications, and follow-up data were collected. The primary endpoint was obstruction-free survival (OFS). Other endpoints were postoperative recovery of bowel function, 60-day Clavien-Dindo (CD) morbidity, and overall survival (OS). RESULTS Twenty-six patients underwent operative treatment for MBO, of whom 14 had high-grade (HG) histology and 12 had low-grade (LG) histology. Seven (25.9%) patients had severe (CD grade 3 or higher) 60-day complications, including one (3.8%) postoperative death. All remaining patients had return of bowel function and resumed oral intake during hospitalization. Six (23.1%) patients had repeat admissions for MBO after surgery. Median OFS was 17.0 months (95% confidence interval [CI] 2.3-31.8), and median OS was 18.5 months (95% CI 3.6-33.3) following surgery. CONCLUSION In this carefully selected group of patients with peritoneal metastases from appendiceal cancer, surgery for MBO provided durable palliation with acceptable morbidity.
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Affiliation(s)
- Joel M Baumgartner
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA.
| | - Rebecca Marmor
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Athena Hsu
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Jula Veerapong
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Kaitlyn J Kelly
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Andrew M Lowy
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
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80
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Tian AP, Yin YK, Yu L, Yang BY, Li N, Li JY, Bian ZM, Hu SY, Weng CX, Feng L. Topical Delivery of Modified Da-Cheng-Qi Decoction (加味大承气汤) Using Low-Frequency Ultrasound Sonophoresis for Refractory Metastatic Malignant Bowel Obstruction: An Open-Label Single-Arm Clinical Trial. Chin J Integr Med 2019; 26:382-387. [DOI: 10.1007/s11655-019-3041-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2018] [Indexed: 10/26/2022]
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81
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Cohen JT, Miner TJ. Patient selection in palliative surgery: Defining value. J Surg Oncol 2019; 120:35-44. [DOI: 10.1002/jso.25512] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/25/2019] [Accepted: 04/22/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Joshua T. Cohen
- Department of Surgery, Rhode Island HospitalWarren Alpert Medical School of Brown UniversityProvidence Rhode Island
| | - Thomas J. Miner
- Department of Surgery, Rhode Island HospitalWarren Alpert Medical School of Brown UniversityProvidence Rhode Island
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82
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Deutsch GB, Deneve JL, Al-Kasspooles MF, Nfonsam VN, Gunderson CC, Secord AA, Rodgers P, Hendren S, Silberfein EJ, Grant M, Sloan J, Sun V, Arnold KB, Anderson GL, Krouse RS. Intellectual Equipoise and Challenges: Accruing Patients With Advanced Cancer to a Trial Randomizing to Surgical or Nonsurgical Management (SWOG S1316). Am J Hosp Palliat Care 2019; 37:12-18. [PMID: 31122027 DOI: 10.1177/1049909119851471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Prospective, randomized trials are needed to determine optimal treatment approaches for palliative care problems such as malignant bowel obstruction (MBO). Randomization poses unique issues for such studies, especially with divergent treatment approaches and varying levels of equipoise. We report our experience accruing randomized patients to the Prospective Comparative Effectiveness Trial for Malignant Bowel Obstruction (SWOG S1316) study, comparing surgical and nonsurgical management of MBO. METHODS Patients with MBO who were surgical candidates and had treatment equipoise were accrued and offered randomization to surgical or nonsurgical management. Patients choosing nonrandomization were offered prospective observation. Trial details are listed on www.clinicaltrials.gov (NCT #02270450). An accrual algorithm was developed to enhance enrollment. RESULTS Accrual is ongoing with 176 patients enrolled. Most (89%) patients chose nonrandomization, opting for nonsurgical management. Of 25 sites that have accrued to this study, 6 enrolled patients on the randomization arm. Approximately 59% (20/34) of the randomization accrual goal has been achieved. Patient-related factors and clinician bias have been the most prevalent reasons for lack of randomization. An algorithm was developed from clinician experience to aid randomization. Using principles in this tool, repeated physician conversations discussing treatment options and goals of care, and a supportive team-approach has helped increase accrual. CONCLUSIONS Experience gained from the S1316 study can aid future palliative care trials. Although difficult, it is possible to randomize patients to palliative studies by giving clinicians clear recommendations utilizing an algorithm of conversation, allotment of necessary time to discuss the trial, and encouragement to overcome internal bias.
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Affiliation(s)
- Gary B Deutsch
- Department of Surgery, Northwell Health, Lake Success, NY, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Camille C Gunderson
- Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke Cancer Institute, Durham, NC, USA
| | - Phillip Rodgers
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samantha Hendren
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Marcia Grant
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Jeff Sloan
- Mayo Clinic Rochester, Rochester, MN, USA
| | - Virginia Sun
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Kathryn B Arnold
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Garnet L Anderson
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Robert S Krouse
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Policy, Philadelphia, PA, USA
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83
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Bonanno AM, Kiraly LN, Siegel TR, Brasel KJ, Cook MR. Surgical palliative care training in general surgery residency: An educational needs assessment. Am J Surg 2019; 217:928-931. [DOI: 10.1016/j.amjsurg.2019.01.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/03/2019] [Accepted: 01/13/2019] [Indexed: 12/15/2022]
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84
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Catena F, De Simone B, Coccolini F, Di Saverio S, Sartelli M, Ansaloni L. Bowel obstruction: a narrative review for all physicians. World J Emerg Surg 2019; 14:20. [PMID: 31168315 PMCID: PMC6489175 DOI: 10.1186/s13017-019-0240-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/10/2019] [Indexed: 12/13/2022] Open
Abstract
Small and large bowel obstructions are responsible for approximately 15% of hospital admissions for acute abdominal pain in the USA and ~ 20% of cases needing acute surgical care. Starting from the analysis of a common clinical problem, we want to guide primary care physicians in the initial management of a patient presenting with acute abdominal pain associated with intestinal obstruction.
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Affiliation(s)
- Fausto Catena
- 1Emergency and Trauma Surgery Department, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Belinda De Simone
- 1Emergency and Trauma Surgery Department, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | | | | | | | - Luca Ansaloni
- Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
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85
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Abstract
Malignant bowel obstruction (MBO) is a common problem for patients with advanced malignancy, especially colorectal and ovarian cancers. Symptoms include pain, bloating, nausea and vomiting, and inability to eat. Treatment options consist of a wide range of surgical and nonsurgical interventions (medications, endoscopic, or interventional radiology approaches). Outcomes are variable no matter the strategy, and the optimal approach is often not clear. Greater research is needed to assist decision-making for clinicians treating patients with MBO.
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Affiliation(s)
- Robert S Krouse
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennylvania.,Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania.,Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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86
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Acute malignant obstruction in patients with peritoneal carcinomatosis: The role of palliative surgery. Eur J Surg Oncol 2019; 45:389-393. [DOI: 10.1016/j.ejso.2018.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/10/2018] [Accepted: 12/19/2018] [Indexed: 12/14/2022] Open
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87
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Bischoff K, Currow DC, Corvera C, Pantilat SZ. Unanswered Questions in Malignant Bowel Obstruction. J Palliat Care 2018. [DOI: 10.1177/082585971403000404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kara Bischoff
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, 521 Parnassus Avenue, Suite C-126, Box 0903, San Francisco, California, USA 94143–0903
| | - David C. Currow
- Department of Palliative and Supportive Services, Flinders University, Daw Park, Adelaide, Australia; C Corvera: Liver, Biliary, and Pancreatic Surgery Program, Department of Surgery, University of California, San Francisco, San Francisco, California, USA; SZ Pantilat: Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Carlos Corvera
- Department of Palliative and Supportive Services, Flinders University, Daw Park, Adelaide, Australia; C Corvera: Liver, Biliary, and Pancreatic Surgery Program, Department of Surgery, University of California, San Francisco, San Francisco, California, USA; SZ Pantilat: Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Steven Z. Pantilat
- Department of Palliative and Supportive Services, Flinders University, Daw Park, Adelaide, Australia; C Corvera: Liver, Biliary, and Pancreatic Surgery Program, Department of Surgery, University of California, San Francisco, San Francisco, California, USA; SZ Pantilat: Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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88
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Abstract
Despite advances in the management of peritoneal carcinomatosis, morbidity remains high with survival often measured in weeks to months. Patients are often subjected to symptoms and complications that impact quality of life. Much of the management revolves around palliation of symptoms and providing support and resources to address emotional and existential concerns. This article reviews surgical and nonsurgical palliative treatments for the symptoms and complications associated with advanced, incurable peritoneal carcinomatosis. It is important that providers caring for patients with peritoneal carcinomatosis be knowledgeable in the palliative management of this condition, including the usefulness of early palliative care referral.
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Affiliation(s)
- Laura A Lambert
- Surgical Oncology, Huntsman Cancer Institute, 2000 Circle of Hope Drive, Salt Lake City, UT 84112, USA.
| | - Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, 55 Lake Avenue N., Worcester, MA 01608, USA
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89
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Bateni SB, Gingrich AA, Stewart SL, Meyers FJ, Bold RJ, Canter RJ. Hospital utilization and disposition among patients with malignant bowel obstruction: a population-based comparison of surgical to medical management. BMC Cancer 2018; 18:1166. [PMID: 30477454 PMCID: PMC6258444 DOI: 10.1186/s12885-018-5108-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/19/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Malignant bowel obstruction (MBO) is often a terminal event in end-stage cancer patients. The decision to intervene surgically is complex, given the risk of harm in patients with a limited lifespan. Therefore, we sought to compare clinically meaningful outcomes in MBO patients treated with surgical versus medical management using population-based data. METHODS We performed a retrospective analysis of hospitalized patients with MBO from 2006 to 2010 using the California Office of Statewide Health Planning and Development dataset. Hospital-free days (HFDs) at 30-, 90-, and 180-days were calculated accounting for all hospitalization, emergency department visit, and skilled nursing facility lengths of stay. Adjusted regression models were used to compare HFDs, disposition, complications, in-hospital death, and survival for surgical versus medical MBO cohorts, using inverse probability of treatment weighting with propensity scores. RESULTS Of 4576 MBO patients, 3421 (74.8%) were treated medically and 1155 (25.2%) were treated surgically. Surgical patients had higher rates of complications (44.0% vs. 21.3%, p < 0.0001) and in-hospital death (9.5% vs. 3.9%, p < 0.0001) with lower rates of disposition to home (76.3% vs. 89.8%, p < 0.0001). Surgical patients had fewer 30- and 90-day HFDs compared to medical patients (p < 0.01). However, at 180-days, there were no differences in HFDs between treatment groups. There was no difference in overall survival between surgical and medical patients (median 6.5 vs. 6.4 months). CONCLUSION In this population-based analysis, medical management was associated with less hospital utilization at 30- and 90-days, fewer in-hospital deaths, and more frequent discharges to home. These data underscore the potential benefits of medical management for MBO patients at the end-of-life.
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Affiliation(s)
- Sarah B. Bateni
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
| | - Alicia A. Gingrich
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
| | - Susan L. Stewart
- Department of Public Health Sciences, Division of Biostatistics, UC Davis School of Medicine, 4800 2nd Ave, Suite 2209, Sacramento, CA 95817 USA
| | - Frederick J. Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, UC Davis Medical Center, 4610 X Street, Suite 3016, Sacramento, CA 95817 USA
| | - Richard J. Bold
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
| | - Robert J. Canter
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
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90
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Ozturk E, van Iersel M, Stommel MM, Schoon Y, Ten Broek RR, van Goor H. Small bowel obstruction in the elderly: a plea for comprehensive acute geriatric care. World J Emerg Surg 2018; 13:48. [PMID: 30377439 PMCID: PMC6196030 DOI: 10.1186/s13017-018-0208-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 09/24/2018] [Indexed: 12/16/2022] Open
Abstract
Small bowel obstruction is one of the most frequent emergencies in general surgery, commonly affecting elderly patients. Morbidity and mortality from small bowel obstruction in elderly is high. Significant progress has been made in the diagnosis and management of bowel obstruction in recent years. But little is known whether this progress has benefitted outcomes in elderly patients, particularly those who are frail or have a malignancy as cause of the obstruction, and when considering quality of life and functioning as outcomes. In this review, we discuss the specific challenges and needs of elderly in diagnosis and treatment of small bowel obstruction. We address quality of life aspects and explore how the concept of geriatric assessment can be utilized to improve decision-making and outcomes for elderly patients with a small bowel obstruction.
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Affiliation(s)
- Ekin Ozturk
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Marianne van Iersel
- 2Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn Mwj Stommel
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Yvonne Schoon
- 2Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands.,3Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard Rpg Ten Broek
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Harry van Goor
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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91
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Kuncewitch M, Levine EA, Shen P, Votanopoulos KI. The Role of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Appendiceal Tumors and Colorectal Adenocarcinomas. Clin Colon Rectal Surg 2018; 31:288-294. [PMID: 30186050 DOI: 10.1055/s-0038-1642052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Peritoneal surface disease (PSD) has historically been used interchangeably with the term peritoneal carcinomatosis (PC) and has a dismal natural history. A variety of malignant pathologies, including colorectal and appendiceal primary tumors, can disseminate throughout the peritoneal cavity, leading to bowel obstruction and death. In general, peritoneal spread from high-grade appendiceal and colorectal primaries has the potential of hepatic and distant spread and best classified as PC. Low-grade appendiceal tumors are better categorized as PSD, due to low cellularity, high mucin production, and lack of potential spread outside the peritoneal cavity. Growing international experience with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) over the past 30 years has presented a therapeutic option to patients with PSD from colorectal and appendiceal tumors that can provide significant disease control, as well as potential for previously unattainable long-term survival. The proliferation of HIPEC centers and ongoing prospective trials are helping to standardize HIPEC techniques and patient selection.
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Affiliation(s)
- Michael Kuncewitch
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Perry Shen
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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92
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Wang Z, Park JH, Kim KY, Choi J, Hu H, Bekheet N, Yoon SH, Song HY. Fluoroscopy-Guided Peroral Placement of a Self-Expandable Metallic Stent for Malignant Jejunal Obstruction in a Non-surgically Altered Stomach. Cardiovasc Intervent Radiol 2018; 42:145-149. [PMID: 30088059 DOI: 10.1007/s00270-018-2048-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/28/2018] [Indexed: 11/29/2022]
Abstract
Malignant small bowel obstruction is a common and distressing complication in advanced cancer patients. Recently, stent placement was reported to be a safe and effective alternative treatment. However, there are only a few case reports associated with stent placement in malignant jejunal obstruction. Furthermore, most patients had a history of gastrectomy before stent placement, which shortens the catheterization pathway. In our case series, we present five cases of malignant proximal jejunal obstruction in a non-surgically altered stomach in the management of fluoroscopy-guided self-expandable metallic stent placement and discuss the interventional management and clinical outcomes. LEVEL OF EVIDENCE: Level 4, Case Series.
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Affiliation(s)
- Zhe Wang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea.,Department of Radiology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, 300052, People's Republic of China
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Kun Yung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Joonmyeong Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hongtao Hu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea.,Department of Minimal-Invasive Intervention, The Affiliated Cancer Hospital of Zhengzhou University, 127 Dongming Road, Zhengzhou city, 450003, Henan Province, China
| | - Nader Bekheet
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea.,Gastrointestinal Endoscopy and Liver Unit, Kasr Al-Ainy, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sung Hwan Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea. .,Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olymic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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93
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Abstract
PURPOSE OF REVIEW Patients with gynecologic malignancies face many difficult issues in the course of their diseases, ranging from physical symptoms to advance care planning in light of a poor prognosis. This review examines the evidence supporting integration of palliative care early in the course of disease and symptom management, and provides a framework for difficult conversations. RECENT FINDINGS Palliative care has been demonstrated to improve quality of life and promote survival if integrated early in the course of disease. An evidence-based approach should guide symptom management, such as pain and nausea. Advance care planning and goals of care discussions are enhanced by a framework guiding discussion and the incorporation of empathetic responses. SUMMARY Palliative care is a diverse multidisciplinary field that can provide significant benefit for patients with gynecologic malignancies.
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94
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Malignant Bowel Obstruction in Advanced Gynecologic Cancers: An Updated Review from a Multidisciplinary Perspective. Obstet Gynecol Int 2018; 2018:1867238. [PMID: 29887891 PMCID: PMC5985138 DOI: 10.1155/2018/1867238] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/26/2018] [Indexed: 12/22/2022] Open
Abstract
Malignant bowel obstruction (MBO) is a major complication in women with advanced gynecologic cancers which imposes a significant burden on patients, caregivers, and healthcare systems. Symptoms of MBO are challenging to palliate and result in progressive decompensation of already vulnerable patients with limited therapeutic options and a short prognosis. However, there is a paucity of guidelines or innovative approaches to improve the care of women who develop MBO. MBO is a complex clinical situation that requires a multidisciplinary approach to ensure the appropriate treatment modality and interprofessional care to optimally manage these patients. This review summarizes the current literature on the different approaches targeting MBO management including surgical intervention, chemotherapy, total parenteral nutrition, and pharmacological treatment. In addition, the impact of MBO management on patients' quality of life (QOL) is examined. This article focuses on the challenges in developing evidence-based treatment guidelines for MBO and barriers in clinical trial design for MBO and proposes strategies to advance the MBO management. Collaboration is essential to design studies that may improve the overall care and quality of life for these patients. Prospective data are needed to inform clinical practice, establish a new benchmark for evidence-based MBO management, and better understand the biology of MBO.
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95
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Bateni SB, Canter RJ, Meyers FJ, Galante JM, Bold RJ. Palliative Care Training and Decision-Making for Patients with Advanced Cancer: A Comparison of Surgeons and Medical Physicians. Surgery 2018; 164:S0039-6060(18)30078-3. [PMID: 29709369 PMCID: PMC6204113 DOI: 10.1016/j.surg.2018.01.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/18/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgical decision-making in patients with advanced cancer requires careful thought and deliberation to balance the high risks with the potential palliative benefits. We sought to compare surgical decision-making and palliative care training among surgeons and medical physicians who commonly treat advanced cancer patients. We hypothesized that surgeons will report less palliative care training compared with medical physicians, and deficits in palliative care training will be associated with more aggressive treatment recommendations in clinical scenarios of advanced cancer patients with symptomatic surgical conditions. STUDY DESIGN Practicing surgeons, medical oncologists, intensivists, and palliative care physicians from a large urban city and its surrounding areas were surveyed with a 32-item questionnaire consisting of a survey addressing palliative care training and 4 clinical vignettes depicting patients with advanced cancer and symptomatic surgical conditions. RESULTS Of the 299 physicians surveyed, 102 responded (response rate 34.1%). Surgeons reported fewer hours of palliative care training during residency, fellowship, and continuing medical education combined (median 10, IQR 2-15) compared with medical oncologists (median 30, IQR 20-80) and medical intensivists (median 50 IQR 30-100), P < .05. Additionally, 20% of surgeons reported no history of any palliative care training. Analysis of physician recommendations for treatment of the 4 clinical vignettes showed minimal consensus regardless of physician specialty. Absence of palliative care training was associated with recommending major operative intervention more frequently compared with physicians with ≥40 hours of palliative care training (0.7 ± 0.7 vs 1.6 ± 0.8, P =.01). CONCLUSION Substantial deficiencies in palliative care training persist among surgeons and are associated with more aggressive recommendations for treatment for the selected scenarios presented in patients with advanced cancer. These findings highlight the need for greater efforts systemwide in palliative care education among surgeons, including incorporation of a structured palliative care training curriculum in graduate and continuing surgical education.
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Affiliation(s)
- Sarah B Bateni
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA
| | - Robert J Canter
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA
| | - Frederick J Meyers
- Hematology/Oncology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, CA
| | - Joseph M Galante
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of California, Davis Medical Center, Sacramento, CA
| | - Richard J Bold
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA.
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96
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Lilley EJ, Scott JW, Goldberg JE, Cauley CE, Temel JS, Epstein AS, Lipsitz SR, Smalls BL, Haider AH, Bader AM, Weissman JS, Cooper Z. Survival, Healthcare Utilization, and End-of-life Care Among Older Adults With Malignancy-associated Bowel Obstruction: Comparative Study of Surgery, Venting Gastrostomy, or Medical Management. Ann Surg 2018; 267:692-699. [PMID: 28151799 PMCID: PMC7509894 DOI: 10.1097/sla.0000000000002164] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO). BACKGROUND MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life. METHODS Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital. RESULTS Median survival after MBO admission was 76 days (interquartile range 26-319 days). Survival was shorter after VGT [38 days (interquartile range 23-69)] than medical management [72 days (23-312)] or surgery [128 days (42-483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29-0.58)], increased hospice enrollment [1.65 (1.42-1.91)], and less ICU care [0.69 (0.52-0.93)] and in-hospital death [0.47 (0.36-0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59-0.80)], decreased hospice enrollment [0.84 (0.76-0.92)], and higher likelihood of ICU care [1.38 (1.17-1.64)]. CONCLUSIONS VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients' priorities for end-of-life care.
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Affiliation(s)
- Elizabeth J. Lilley
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - John W. Scott
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - Christy E. Cauley
- Ariadne Labs, Boston, MA
- Department of Surgery, Massachusetts General Hospital, Boston
| | | | - Andrew S. Epstein
- Gastrointestinal Medical Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stuart R. Lipsitz
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Brittany L. Smalls
- Center for Health Services Research, University of Kentucky College of Medicine, Lexington, KY
| | - Adil H. Haider
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Angela M. Bader
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joel S. Weissman
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Zara Cooper
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
- Ariadne Labs, Boston, MA
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97
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Lambert LA, Wiseman J. Palliative Management of Peritoneal Metastases. Ann Surg Oncol 2018; 25:2165-2171. [PMID: 29383612 DOI: 10.1245/s10434-018-6335-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Indexed: 02/06/2023]
Abstract
Despite significant recent advances in the management of peritoneal carcinomatosis, this diagnosis still is accompanied frequently by a grim survival prognosis, often measured in weeks to months. The poor prognosis also is accompanied often by complications and symptoms that have a dramatic impact on quality of life and are challenging to the managing health care provider and devastating to loved ones caring for the person who is suffering. Consequently, management of carcinomatosis often revolves around palliation of symptoms such as bowel obstruction, nausea, pain, fatigue, and cachexia as well as emotional and existential concerns. This article reviews several palliative treatment options for some of the more common symptoms and complications associated with advanced, incurable peritoneal carcinomatosis. Although readers should recognize that carcinomatosis is no longer an imminent death sentence, providers caring for patients with peritoneal carcinomatosis also must be well-versed in the palliative management of this condition and recognize the utility of early palliative care referral in this setting.
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Affiliation(s)
- Laura A Lambert
- Surgical Oncology, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Salt Lake City, UT, USA.
| | - Jason Wiseman
- Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, MA, USA
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98
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Davidson BA, Moss HA, Kamal AH. Top 10 Tips Palliative Care Clinicians Should Know When Caring for Patients with Ovarian Cancer. J Palliat Med 2018; 21:250-254. [PMID: 29319389 DOI: 10.1089/jpm.2017.0679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The vast majority of women diagnosed with ovarian cancer present with advanced-stage disease with a five-year survival rate less than 50%. Studies have shown that in the past, gynecologic oncologists were not routinely collaborating with palliative care physicians resulting in goals of care planning often not occurring until the last 30 days before death. In recent years, professional societies have been increasingly more vocal about the importance of incorporating palliative care early in a patient's disease course. As these calls increase, palliative care clinicians will be likely to comanage patients with ovarian cancer and may benefit from additional targeted education on this unique population. We brought together a team of gynecologic oncology and palliative care experts to collate practical pearls for the care of women with epithelial ovarian cancer. In this article, we use a "Top 10" format to highlight issues that may help palliative care physicians understand a patient's prognosis, address common misconceptions about ovarian cancer, and improve the quality of shared decision making and goals-of-care discussions.
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Affiliation(s)
- Brittany A Davidson
- 1 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University , Durham, North Carolina
| | - Haley A Moss
- 1 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University , Durham, North Carolina
| | - Arif H Kamal
- 2 Division of Medical Oncology, Duke Cancer Institute, Duke Fuqua School of Business, Duke University , Durham, North Carolina
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99
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Santos DA, Alseidi A, Shannon VR, Messick C, Song G, Ledet CR, Lee H, Ngo-Huang A, Francis GJ, Asher A. Management of surgical challenges in actively treated cancer patients. Curr Probl Surg 2017; 54:612-654. [DOI: 10.1067/j.cpsurg.2017.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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100
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Bateni SB, Bold RJ, Meyers FJ, Canter DJ, Canter RJ. Comparison of common risk stratification indices to predict outcomes among stage IV cancer patients with bowel obstruction undergoing surgery. J Surg Oncol 2017; 117:479-487. [PMID: 29044598 DOI: 10.1002/jso.24866] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/01/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Among patients with disseminated malignancy (DMa), bowel obstruction is common with high operative morbidity. Since preoperative risk stratification is critical, we sought to compare three standard risk indices, the American Society of Anesthesiology (ASA) classification, Charlson comorbidity index (CCI), and modified frailty index (mFI). METHODS We identified 1928 DMa patients with bowel obstruction who underwent an abdominal operation from 2007 to 2012 American College of Surgeons National Surgical Quality Improvement Program. Multivariate analyses assessed predictors of prolonged length of stay (LOS), 30-day serious morbidity and mortality. Receiver operating characteristics' areas under the curves (AUCs) for risk indices scores and 30-day mortality were assessed. RESULTS Serious morbidity and mortality rates were 20.4% and 14.8%. ASA and CCI did not predict serious morbidity or prolonged LOS, but were predictors of mortality. The mFI did not predict prolonged LOS, but did predict serious morbidity and mortality. Subgroup analyses showed similar results. There were no significant differences between ASA, CCI, and mFI AUCs for mortality. CONCLUSIONS ASA, CCI, and mFI are limited in their ability to predict postoperative adverse events among DMa patients undergoing surgery for bowel obstruction. These data suggest that a more tailored preoperative risk stratification tool would improve treatment planning.
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Affiliation(s)
- Sarah B Bateni
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Richard J Bold
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Frederick J Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California
| | - Daniel J Canter
- Department of Urology, Ochsner Clinic, New Orleans, Louisiana
| | - Robert J Canter
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California
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