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Allan LL, Skene SS, Eastley KB, Herbertson R, Smith E, Michael A. Can we improve the management of inoperable malignant bowel obstruction? Results of a feasibility study of elemental diet as an alternative to parenteral nutrition in patients with advanced gynaecological cancer. Support Care Cancer 2024; 32:567. [PMID: 39093327 PMCID: PMC11297088 DOI: 10.1007/s00520-024-08709-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 07/01/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE Nutrition support in inoperable bowel obstruction (IBO) remains challenging. Parenteral nutrition (PN) is recommended if the prognosis is > 2 months. An elemental diet (ED) is licensed for strictures in Crohn's disease but has not been used in malignant bowel obstruction. The aim of this study was to evaluate the use of ED in patients with IBO and provide a proof of concept of ED as an acceptable feeding option. METHODS This was a mixed-methods single-arm feasibility study. The primary endpoint was to provide a 'proof of concept' of ED as an acceptable feeding option for patients with IBO. Secondary endpoints included taste acceptability, incidences of vomiting and pain, the proportion of women who tolerated ED, the number of cartons drunk, quality of life (QOL) and the number of women treated with chemotherapy. Patients (> 18 years) with CT-confirmed IBO who could tolerate 500 ml of liquid in 24 h remained on the trial for 2 weeks. RESULTS A total of 29 patients were recruited; of those, 19 contributed to the analysis for the primary endpoint; 13 (68.4%) participants tolerated the ED; 26 patients contributed to MSAS and EORTC QLQ questionnaires at baseline to allow for the assessment of symptoms. At the start of the study, 18 (69%) of patients experienced vomiting, reducing to 4 (25%) by the end of day 15 of the study; 24 (92%) of patients reported pain at consent, reducing to 12 (75%) by the end of day 15. QOL scores improved from 36.2 (95% CI 27.7-44.7) at baseline to 53.1 (95% CI 40.3-66) at the end of day 15; 16 (84%) participants commenced chemotherapy within the first week of starting ED. The number of cartons across all participants showed a median of 1.3 cartons per day (range 0.8 to 2.5). CONCLUSION ED is well tolerated by patients with IBO caused by gynaecological malignancies and may have a positive effect on symptom burden and QOL.
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Affiliation(s)
- Lindsey L Allan
- Royal Surrey NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, United Kingdom
| | - Simon S Skene
- Surrey Clinical Trials Unit, School of Biosciences, University of Surrey, Egerton Road, Guildford, GU2 7XP, United Kingdom
| | - Kate Bennett Eastley
- Surrey Clinical Trials Unit, School of Biosciences, University of Surrey, Egerton Road, Guildford, GU2 7XP, United Kingdom
| | - Rebecca Herbertson
- University Hospitals Sussex NHS Foundation Trust, Royal Sussex Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | - Eleanor Smith
- Royal Surrey NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, United Kingdom
| | - Agnieszka Michael
- Royal Surrey NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, United Kingdom.
- Surrey Clinical Trials Unit, School of Biosciences, University of Surrey, Egerton Road, Guildford, GU2 7XP, United Kingdom.
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Mitsuhashi S, Kamal F, Shinn BJ, Chalikonda D, Tyberg A, Shahid H, Sarkar A, Kahaleh M, Chiang A, Kumar A, Schlachterman A, Loren D, Kowalski T. Colonic-enteric lumen-apposing metal stents: a promising and safe alternative for endoscopic management of small-bowel obstruction. Gastrointest Endosc 2024; 99:606-613. [PMID: 37951278 DOI: 10.1016/j.gie.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND AND AIMS Lumen-apposing metal stents (LAMSs) have revolutionized the treatment of various gastroenterologic conditions that previously required surgery. The use of LAMSs for the management of small-bowel obstruction (SBO) involves EUS-guided coloenterostomy (EUS-CE) between the colon and a dilated loop of the small intestine proximal to the point of obstruction. This procedure is potentially beneficial for patients with malignant SBO who are poor surgical candidates. METHODS A retrospective cohort study was conducted at 2 tertiary care hospitals. Patients who underwent EUS-CE for SBO were identified, and data regarding patient demographics, indication for the procedure, location of the obstruction, procedural details, and adverse events were collected. The primary outcome was technical success of the procedure. Secondary outcomes were clinical success, resolution of symptoms, ability to tolerate enteral nutrition, and adverse events. RESULTS Twenty-six patients who underwent the EUS-CE procedure were included. Technical success was achieved in all 26 patients, clinical success (resolution of obstructive symptoms) was achieved in 92.3% of patients (24/26), and the ability to resume enteral nutrition in 84.6% (22/26). Adverse events occurred in 4 patients (15.4%) and included bleeding (1/26), diarrhea (2/26), and postprocedure sepsis (1/26). Patients were followed for a mean of 54.8 days (range, 2-190). CONCLUSIONS This study highlights that EUS-CE with LAMSs can be performed with high technical and clinical success for the management of SBO, particularly in patients with malignant obstructions who are not suitable candidates for surgical interventions. Further research with larger sample sizes will be essential to substantiate its efficacy and safety.
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Affiliation(s)
- Shuji Mitsuhashi
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Faisal Kamal
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brianna J Shinn
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Divya Chalikonda
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Amy Tyberg
- Department of Medicine, Division of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Haroon Shahid
- Department of Medicine, Division of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Department of Medicine, Division of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Michel Kahaleh
- Department of Medicine, Division of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Austin Chiang
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anand Kumar
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alex Schlachterman
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Loren
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thomas Kowalski
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Sotirianakou ME, Frountzas M, Sotirianakou A, Markogiannakis H, Theodoropoulos GE, Sotirianakos S, Toutouzas KG. Malignant Bowel Obstruction: A Retrospective Multicenter Cohort Study. J Clin Med 2024; 13:263. [PMID: 38202270 PMCID: PMC10779546 DOI: 10.3390/jcm13010263] [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: 11/28/2023] [Revised: 12/26/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Malignant bowel obstruction (MBO) is a serious clinical entity that requires surgical intervention in almost 50% of cases. However, overall survival remains low even for operable cases. The aim of the present study was to investigate the correlation between patients' characteristics, perioperative details, histopathological results and postoperative outcomes of patients who were operated on due to MBO. METHODS A retrospective search of patients who were operated on due to MBO in a university and a rural hospital was conducted. Patients' characteristics, perioperative details, histopathological results and postoperative outcomes were reported. Univariable and multivariable analysis was performed. RESULTS Seventy patients were included with a mean age of 76.1 ± 10.6 years. The 30-day mortality rate was 18.6%, the Intensive Care Unit (ICU) admission rate was 17.1% and the mean length of stay (LOS) was 12.4 ± 5.7 days. Postoperative 30-day mortality was associated with increased age, known malignant recurrence, microscopically visible metastatic foci and defunctioning stoma creation. Colorectal malignancy type, sigmoid obstruction and primary anastomosis were correlated with decreased 30-day mortality. In addition, operation at the university hospital led to increased LOS, while stoma creation led to decreased LOS. Finally, ICU admission rates were increased for operations at university hospitals, at least one comorbidity, known malignant recurrence and longer preoperative waiting interval, whereas they were decreased for colorectal primary malignancy type. CONCLUSIONS Surgery due to MBO leads to increased morbidity and mortality. Therefore, prospective studies are needed to highlight inter-patient differences regarding the best individualized therapeutic strategy.
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Affiliation(s)
- Maria-Evanthia Sotirianakou
- First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (M.-E.S.); (H.M.); (K.G.T.)
| | - Maximos Frountzas
- First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (M.-E.S.); (H.M.); (K.G.T.)
| | - Athina Sotirianakou
- Second Department of Surgery, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Haridimos Markogiannakis
- First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (M.-E.S.); (H.M.); (K.G.T.)
| | - George E. Theodoropoulos
- First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (M.-E.S.); (H.M.); (K.G.T.)
| | | | - Konstantinos G. Toutouzas
- First Propaedeutic Department of Surgery, Hippocration General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (M.-E.S.); (H.M.); (K.G.T.)
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Dhiman A, Kothary V, Witmer HDD, Bregio C, Sood D, Ong CT, Polite B, Eng OS, Shergill A, Turaga KK. Role of Tumor-informed Personalized Circulating Tumor DNA Assay in Informing Recurrence in Patients With Peritoneal Metastases From Colorectal and High-grade Appendix Cancer Undergoing Curative-intent Surgery. Ann Surg 2023; 278:925-931. [PMID: 36994703 DOI: 10.1097/sla.0000000000005856] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To investigate the role of a personalized, tumor-informed circulating tumor DNA (ctDNA) assay in informing recurrence in patients with peritoneal metastases (PM) from colorectal (CRC) and high-grade appendix (HGA) cancer after curative cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). BACKGROUND Over 50% of patients with CRC/HGA-PM recur after optimal CRS-HIPEC. The limited sensitivity of axial imaging and diagnostic biomarkers is a significant cause of delay in the detection of recurrence and initiation of further therapies. Plasma ctDNA has a promising role in monitoring response to treatment and/or recurrence after primary cancer resection. METHODS Patients with CRC/HGA-PM who underwent curative CRS-HIPEC and serial postresection ctDNA assessments were included. Patients with rising postoperative ctDNA levels were compared with those with stable, undetectable ctDNA levels. Primary outcomes were the percentage of patients with recurrence and disease-free survival (DFS). Secondary outcomes were overall survival, ctDNA sensitivity, lead time, and performance of ctDNA compared with carcinoembryonic antigen. RESULTS One hundred thirty serial postresection ctDNA assessments [median 4, interquartile range (IQR), 3 to 5] were performed in 33 patients (n = 13 CRC, n = 20 HGA) who underwent completeness of cytoreduction-0/1 CRS with a median follow-up of 13 months. Of the 19 patients with rising ctDNA levels, 90% recurred versus 21% in the stable ctDNA group (n = 14, < 0.001). Median DFS in the rising ctDNA cohort was 11 months (IQR, 6 to 12) and not reached in the stable ( P = 0.01). A rising ctDNA level was the most significant factor associated with DFS (hazard ratio: 3.67, 95% CI: 1.06-12.66, P = 0.03). The sensitivity and specificity of rising ctDNA levels in predicting recurrence were 85% and 84.6%, respectively. The median ctDNA lead time was 3 months (IQR, 1 to 4). Carcinoembryonic antigen was less sensitive (50%) than ctDNA. CONCLUSIONS This study supports the clinical validity of serial ctDNA assessment as a strong prognostic biomarker in informing recurrence in patients with CRC/HGA-PM undergoing curative resection. It also holds promises for informing future clinical trial designs and further research.
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Affiliation(s)
- Ankit Dhiman
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
| | - Vishesh Kothary
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
| | - Hunter D D Witmer
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
| | - Celyn Bregio
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Divya Sood
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
| | - Cecilia T Ong
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
| | - Blase Polite
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
| | - Oliver S Eng
- Division of Surgical Oncology, Department of Surgery, University of California, Irvine, Orange, CA
| | - Ardaman Shergill
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
| | - Kiran K Turaga
- Department of Surgery, Section of General Surgery and Surgical Oncology, University of Chicago Medical Center, Chicago, IL
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Shindo K, Ohuchida K, Nagasue T, Moriyama T, Goto F, Tamura K, Nagayoshi K, Mizuuchi Y, Ikenaga N, Nakata K, Nakamura M. Combined endoscopic stenting and laparoscopic stent fixation for benign gastric tube stricture after esophagectomy: a case report. Surg Case Rep 2023; 9:206. [PMID: 38030931 PMCID: PMC10686907 DOI: 10.1186/s40792-023-01787-5] [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: 09/25/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND There are several options for the treatment of gastrointestinal stricture, including endoscopic stent placement and bypass surgery. However, a benign stricture is difficult to manage in a reconstructed gastric tube in the thoracic cavity owing to the technical difficulty of bypass surgery, and the possibility of stent migration. CASE PRESENTATION A 78-year-old woman was admitted to our hospital for treatment for her inability to eat. She had undergone video-assisted subtotal esophagectomy with retromediastinal gastric tube reconstruction 7 years earlier. At the current admission, there was a severely dilated gastric tube in the thoracic cavity with a soft stricture immediately anterior to the spine. Conservative therapy was ineffective; therefore, endoscopic stenting was performed. However, the stent migrated to the upper side of the stricture because the stricture was mild, and the stent was not fixed in the gastric tube. Next, endoscopic stent placement followed by laparoscopic stent fixation was performed. The stent was patent and worked well, and the patient's body weight increased. However, the stent collapsed 2 years later, with recurrence of symptoms. Stent-in-stent placement with an over-the-scope clip was performed, and the second stent was also patent and worked well. CONCLUSIONS Laparoscopic stent fixation with endoscopic stent placement could be an effective option for patients with a benign stricture in the reconstructed gastric tube.
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Affiliation(s)
- Koji Shindo
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan.
| | - Kenoki Ohuchida
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Tomohiro Nagasue
- Department of Medicine and Clinical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Taiki Moriyama
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Fumika Goto
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Koji Tamura
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Kinuko Nagayoshi
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Yusuke Mizuuchi
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, 812-8582, Japan
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Itou C, Arai Y, Sone M, Sugawara S, Kimura S, Onishi Y. Percutaneous Image-Guided Transesophageal Long Intestinal Tube Placement for Palliative Decompression in Advanced Cancer Patients with Unresectable Malignant Small Bowel Obstruction. Cardiovasc Intervent Radiol 2023:10.1007/s00270-023-03457-3. [PMID: 37188898 DOI: 10.1007/s00270-023-03457-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/26/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE To assess the safety and efficacy of long intestinal tube placement following percutaneous image-guided esophagostomy for palliative decompression of incurable malignant small bowel obstruction. MATERIALS AND METHODS Between January 2013 and June 2022, a single-institution retrospective study was conducted to examine patients undergoing percutaneous transesophageal intestinal intubation for an occluded intestinal segment. Patients' baseline characteristics, procedural details, and clinical courses were reviewed. Severe complications were defined as those with ≥ 4 grade according to the CIRSE classification. RESULTS This study included 73 patients (mean age, 57.7 years) who underwent 75 procedures. All bowel obstructions were caused by peritoneal carcinomatosis or similar disease, which precluded transgastric access in almost 50% of the patients due to massive cancerous ascites (n = 28), diffuse gastric involvement (n = 5), or omental dissemination in front of the stomach (n = 3). Technical success (appropriate tube positioning) was achieved in 98.7% (74/75) of procedures. The cumulative 1-month overall survival and sustained clinical success (adequate bowel decompression) rates were estimated at 86.8% and 88%, respectively, using Kaplan-Meier analysis. At the median survival of 70 days, the disease progression required other gastrointestinal interventions, including additional tube insertion, repositioning, or venting enterostomy in 16 patients (21.9%). The severe complication rate was 4% (3/75); one patient aspirated to death due to tube clogging and two encountered fatal perforation of isolated intestinal loops developing far beyond the tip of the indwelling tube. CONCLUSION Percutaneous image-guided transesophageal intestinal intubation achieves feasible bowel decompression as palliative care in advanced cancer patients. LEVEL OF EVIDENCE Level 4, Case Series.
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Affiliation(s)
- Chihiro Itou
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
| | - Yasuaki Arai
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Shunsuke Sugawara
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Shintaro Kimura
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Yasuyuki Onishi
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
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Ornella MSC, Badrinath N, Kim KA, Kim JH, Cho E, Hwang TH, Kim JJ. Immunotherapy for Peritoneal Carcinomatosis: Challenges and Prospective Outcomes. Cancers (Basel) 2023; 15:cancers15082383. [PMID: 37190310 DOI: 10.3390/cancers15082383] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
Peritoneal metastasis, also known as peritoneal carcinomatosis (PC), is a refractory cancer that is typically resistant to conventional therapies. The typical treatment for PC is a combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Recently, research in this area has seen significant advances, particularly in immunotherapy as an alternative therapy for PC, which is very encouraging. Catumaxomab is a trifunctional antibody intraperitoneal (IP) immunotherapy authorized in Europe that can be used to diminish malignant ascites by targeting EpCAM. Intraperitoneal (IP) immunotherapy breaks immunological tolerance to treat peritoneal illness. Increasing T-cell responses and vaccination against tumor-associated antigens are two methods of treatment. CAR-T cells, vaccine-based therapeutics, dendritic cells (DCs) in combination with pro-inflammatory cytokines and NKs, adoptive cell transfer, and immune checkpoint inhibitors are promising treatments for PC. Carcinoembryonic antigen-expressing tumors are suppressed by IP administration of CAR-T cells. This reaction was strengthened by anti-PD-L1 or anti-Gr1. When paired with CD137 co-stimulatory signaling, CAR-T cells for folate receptor cancers made it easier for T-cell tumors to find their way to and stay alive in the body.
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Affiliation(s)
- Mefotse Saha Cyrelle Ornella
- Department of Pharmacology, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
- Bionoxx Inc., Parkview Tower #1905, 248 Jeongjail-ro, Bundang-gu, Seongnam 13554, Republic of Korea
| | - Narayanasamy Badrinath
- Bionoxx Inc., Parkview Tower #1905, 248 Jeongjail-ro, Bundang-gu, Seongnam 13554, Republic of Korea
| | - Kyeong-Ae Kim
- Bionoxx Inc., Parkview Tower #1905, 248 Jeongjail-ro, Bundang-gu, Seongnam 13554, Republic of Korea
| | - Jung Hee Kim
- Bionoxx Inc., Parkview Tower #1905, 248 Jeongjail-ro, Bundang-gu, Seongnam 13554, Republic of Korea
| | - Euna Cho
- Bionoxx Inc., Parkview Tower #1905, 248 Jeongjail-ro, Bundang-gu, Seongnam 13554, Republic of Korea
| | - Tae-Ho Hwang
- Department of Pharmacology, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
- Bionoxx Inc., Parkview Tower #1905, 248 Jeongjail-ro, Bundang-gu, Seongnam 13554, Republic of Korea
| | - Jae-Joon Kim
- Division of Hematology & Oncology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea
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Li Z, Qi J, Guo T, Li J. Research progress of Astragalus membranaceus in treating peritoneal metastatic cancer. JOURNAL OF ETHNOPHARMACOLOGY 2023; 305:116086. [PMID: 36587879 DOI: 10.1016/j.jep.2022.116086] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 06/17/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Peritoneal metastasis is a manifestation of advanced cancer often associated with a poor prognosis and poor response to treatment. Astragalus membranaceus (Fisch.) Bunge is a commonly used medicinal material in traditional Chinese medicine with various biological activities. In patients with cancer, Astragalus membranaceus has demonstrated anti-tumor effects, immune regulation, postoperative recurrence and metastasis prevention, and survival prolongation. AIM OF THE STUDY Peritoneal metastasis results from tumor cell and peritoneal microenvironment co-evolution. We aimed to introduce and discuss the specific mechanism of action of Astragalus membranaceus in peritoneal metastasis treatment to provide a new perspective for treatment and further research. MATERIALS AND METHODS We consulted reports on the anti-peritoneal metastases effects of Astragalus membranaceus from PubMed, Web of Science, China National Knowledge Infrastructure, and Wanfang databases, as well as Google Scholar. Meanwhile, we also obtained data from published medical works and doctoral and master's theses. Then, we focused on the research progress of Astragalus membranaceus in peritoneal metastatic cancer treatment. Plant names are provided in accordance with "The Plant List" (www.theplantlist.org). RESULTS To date, more than 200 compounds have been isolated from Astragalus membranaceus. Among them, Astragalus polysaccharides, saponins, and flavonoids are the main bioactive components, and their effects on cancer have been extensively studied. In this review, we systematically summarize the effects of Astragalus membranaceus on the peritoneal metastasis microenvironment and related mechanisms, including maintaining the integrity of peritoneal mesothelial cells, restoring the peritoneal immune microenvironment, and inhibiting the formation of tumor blood vessels, matrix metalloproteinase, and dense tumor spheroids. CONCLUSIONS Our analysis demonstrates that Astragalus membranaceus could be a potential therapeutic for preventing the occurrence of peritoneal metastasis. However, it might be too early to recommend its use owing to the paucity of reliable in vivo experiment, clinical data, and evidence of clinical efficacy. In addition, previous studies of Astragalus membranaceus report inconsistent and contradictory findings. Therefore, detailed in vitro, in vivo, and clinical studies on the mechanism of Astragalus membranaceus in peritoneal metastatic cancer treatment are warranted.
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Affiliation(s)
- Zhiyuan Li
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730030, China
| | - Jinfeng Qi
- The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730030, China
| | - Tiankang Guo
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, 730030, China
| | - Junliang Li
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, 730030, China; The First School of Clinical Medical, Gansu University of Chinese Medicine, Lanzhou, 730030, China; The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730030, China.
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Razak O A, Yang SY, Cho MS, Min BS, Han YD. Palliative surgery as a bridge to systemic treatment for malignant bowel obstruction due to peritoneal metastases: A retrospective, case-control study. Asian J Surg 2023; 46:160-165. [PMID: 35260331 DOI: 10.1016/j.asjsur.2022.02.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND High-quality data on palliative surgery in patients with malignant bowel obstruction (MBO) caused by peritoneal metastases (PM) are lacking. We aimed to determine the utility of palliative surgery for such patients. METHODS We retrospectively analyzed patients considered for surgery for MBO, caused by PM, in our department from January 2019 to October 2020. None of them could tolerate a diet, despite conservative treatment. We investigated the clinical characteristics and perioperative outcomes and calculated overall survival (OS). Kaplan-Meier survival analysis was performed, with the log-rank test to evaluate differences in OS rates. Multivariate Cox regression was performed to determine prognostic factors. RESULTS Sixty (67%) patients underwent surgery, whereas, 30 (33%) received the best supportive care (BSC) treatment. A better (p = 0.002) median OS was observed in patients undergoing surgery (3.9 months) than in those receiving BSC (2.6 months). Severe complications were observed in 12 (20%) patients, including 30-day mortality (7 patients). Forty-eight (80%) patients in the surgery group could tolerate a diet and the hospital stay (mean ± standard deviation) was 20.0 ± 23.1 days. Re-obstruction was observed in five (8.3%) patients after 78.6 ± 63.3 days. Patients in the postoperative chemotherapy group exhibited a better (p < 0.001) median OS (12.3 months) than did those in the no-postoperative chemotherapy group (3.5 months). Only postoperative chemotherapy (hazard ratio 0.264, 95% confidence interval 0.143-0.487, p < 0.001) was identified as an independent prognostic factor. CONCLUSIONS Compared with BSC, surgery is associated with a better OS in patients with MBO due to PM. Surgery should be considered as a bridge to systemic treatment for such patients.
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Affiliation(s)
| | - Seung Yoon Yang
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Soo Cho
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byung Soh Min
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yoon Dae Han
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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10
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Nagashima Y, Funahashi K, Kagami S, Ushigome M, Kaneko T, Miura Y, Yoshida K, Koda T, Kurihara A. Which preoperative immunonutritional index best predicts postoperative mortality after palliative surgery for malignant bowel obstruction in patients with late-stage cancer? A single-center study in Japan comparing the modified Glasgow prognostic score (mGPS), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT). Surg Today 2023; 53:22-30. [PMID: 35781553 DOI: 10.1007/s00595-022-02534-3] [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: 11/04/2021] [Accepted: 04/24/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To compare the utility of preoperative immunonutritional parameter measures for predicting postoperative mortality following palliative surgery (PS) for malignant bowel obstruction (MBO) in patients with late-stage cancer. METHODS The subjects of this retrospective study were 83 late-stage cancer patients with MBO who underwent PS between January, 2005 and December, 2018, at a single institution in Japan. We compared the modified Glasgow prognostic score (mGPS), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT) for predicting postoperative mortality following PS in these patients. RESULTS The most prevalent cancer in the patients who underwent PS was colorectal cancer (54.2%), followed by gastric cancer (24.1%). Postoperative complications of Clavien-Dindo classification grade ≥ 2 developed in 32 (38.6%) patients and stoma-related complications developed in 26 (31.3%) patients. There were 15 (18.1%) patients with 60-day mortality, 22 (26.5%) with 90-day mortality, and 4 (4.8%) with 30-day mortality. Multivariable analysis identified only mGPS as being associated with 60-day mortality (odds ratio, 9.387; 95% confidence interval, 0.001-4.478; p = 0.049). The overall survival of patients with a mGPS score of 2 was significantly worse than that of those with a mGPS score of < 2 (p = 0.013). CONCLUSIONS These results suggest that the mGPS is a good predictor not only of 60-day mortality, but also of the overall survival of patients with late-stage cancer and MBO.
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Affiliation(s)
- Yasuo Nagashima
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, 6-11-1 Omorinishi Otaku, Tokyo, 143-8541, Japan
| | - Kimihiko Funahashi
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, 6-11-1 Omorinishi Otaku, Tokyo, 143-8541, Japan.
| | - Satoru Kagami
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, 6-11-1 Omorinishi Otaku, Tokyo, 143-8541, Japan
| | - Mitsunori Ushigome
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, 6-11-1 Omorinishi Otaku, Tokyo, 143-8541, Japan
| | - Tomoaki Kaneko
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, 6-11-1 Omorinishi Otaku, Tokyo, 143-8541, Japan
| | - Yasuyuki Miura
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, 6-11-1 Omorinishi Otaku, Tokyo, 143-8541, Japan
| | - Kimihiko Yoshida
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, 6-11-1 Omorinishi Otaku, Tokyo, 143-8541, Japan
| | - Takamaru Koda
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, 6-11-1 Omorinishi Otaku, Tokyo, 143-8541, Japan
| | - Akiharu Kurihara
- Department of General and Gastroenterological Surgery, Toho University Omori Medical Center, 6-11-1 Omorinishi Otaku, Tokyo, 143-8541, Japan
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11
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Gonzalez-Ochoa E, Alqaisi HA, Bhat G, Jivraj N, Lheureux S. Inoperable Bowel Obstruction in Ovarian Cancer: Prevalence, Impact and Management Challenges. Int J Womens Health 2022; 14:1849-1862. [PMID: 36597479 PMCID: PMC9805709 DOI: 10.2147/ijwh.s366680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022] Open
Abstract
Malignant bowel obstruction (MBO) is one of the most severe complications in patients with advanced ovarian cancer, with an estimated incidence up to 50%. Its presence is related to poor prognosis and a life expectancy measured in weeks for inoperable cases. Symptoms are usually difficult to manage and often require hospitalization, which carries a high burden on patients, caregivers and the healthcare system. Management is complex and requires a multidisciplinary approach to improve clinical outcomes. Patients with inoperable MBO are treated medically with analgesics, antiemetics, steroids and antisecretory agents. Parenteral nutrition and gut decompression with nasogastric tube, venting gastrostomy or stenting may be used as supportive therapy. Treatment decision-making is challenging and often based on clinical expertise and local policies, with lack of high-quality evidence to optimally standardize management. The present review summarizes current literature on inoperable bowel obstruction in ovarian cancer, focusing on epidemiology, prognostic factors, clinical outcomes, medical management, multidisciplinary interventions and quality of life.
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Affiliation(s)
- Eduardo Gonzalez-Ochoa
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Husam A Alqaisi
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gita Bhat
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Nazlin Jivraj
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Stephanie Lheureux
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada,Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Correspondence: Stephanie Lheureux, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada, Tel +1 416-946-2818, Email
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12
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Read M, Powers BD, Pimiento JM, Laskowitz D, Mihelic E, Imanirad I, Dessureault S, Felder S, Dineen SP. Management of Malignant Small Bowel Obstruction: Is Intestinal Bypass Effective Palliation? Ann Surg Oncol 2022; 29:6980-6987. [PMID: 35864366 DOI: 10.1245/s10434-022-12204-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/25/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Malignant small bowel obstruction (mSBO) is a common consequence of advanced malignancies. Surgical consultation is common, however data on the outcomes following an operation are lacking. We investigated a specific operative approach-intestinal bypass-to determine the outcomes associated with this intervention. METHODS Patients with a preoperative diagnosis of mSBO who underwent intestinal bypass between 2015 and 2021 were included. Isolated colonic obstruction was excluded as was gastric outlet obstruction. Perioperative and postoperative outcomes were measured, including complications, overall survival, return to oral intake, and return to intended oncologic therapy. Patients were additionally grouped as to whether the operation was performed as elective or as inpatient. RESULTS Overall, 55 patients were identified, with a mean age of 61.2 ± 14 years. The most common primary malignancy was colorectal cancer (65.5%) and 80% of patients had a preoperative diagnosis of metastatic disease. Small bowel to colon was the most common bypass procedure (51%). Severe complications occurred in 25.5% of patients with three in-hospital mortalities (5.5%). Survival rates at 30, 90, and 180 days were 91%, 80%, and 62%, respectively. The majority of patients were discharged to home (85.5%) and were tolerating an oral diet (74.6%). Twenty-seven patients (49.1%) returned to some form of oncologic treatment. CONCLUSIONS Patients with mSBO face a potentially terminal condition. In this study, approximately 75% of patients who underwent intestinal bypass were able to regain the ability to eat, and 49% returned to oncologic therapy. Although retrospective, these data suggest the approach is efficacious for palliation of this difficult sequela of advanced cancer.
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Affiliation(s)
- Meagan Read
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Surgery, Morsani College of Medicine, Tampa, FL, USA
| | - Benjamin D Powers
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA.,Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Jose M Pimiento
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Danielle Laskowitz
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Erin Mihelic
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Iman Imanirad
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Sophie Dessureault
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Surgery, Morsani College of Medicine, Tampa, FL, USA.,Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Seth Felder
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA.,Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Sean P Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA. .,Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA.
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13
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Strong EA, Livingston A, Gracz M, Peltier W, Tsai S, Christians K, Gamblin TC, Kersting K, Clarke CN. Palliative Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis: Is It Safe and Effective? J Surg Res 2022; 278:31-38. [PMID: 35588572 DOI: 10.1016/j.jss.2022.04.012] [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: 07/22/2021] [Revised: 02/19/2022] [Accepted: 04/07/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Palliation is a controversial indication for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Patients with peritoneal carcinomatosis (PC) are living longer, and the roles of palliative CRS and HIPEC are increasingly challenged. The purpose of this study is to evaluate indications, morbidity, and symptom improvement from CRS/HIPEC in advanced PC. METHODS A retrospective review of patients undergoing CRS and/or HIPEC with a palliative intent at a single institution from February 2008 to February 2018 was performed. Main end points included symptom improvement, symptom-free interval, and overall survival. RESULTS Two hundred and seventy seven patients were referred for CRS/HIPEC during the study period and 17 underwent 20 palliative procedures. Appendiceal (n = 6) and colorectal cancers (n = 6) were the most common malignancies. Ascites (n = 8) and bowel obstruction (n = 8) were the most common indications for intervention. The postoperative complication rate was 50% and major complication rate was 20%. Partial symptom improvement or resolution of symptoms was achieved in 18 (90%) cases. A durable symptom control at 90 d was achieved in 13 (65%) cases. The median time to symptom recurrence was 5.1 mo (interquartile range: 2-11.4), and the median overall survival was 11.6 mo (interquartile range: 3.8-28.5). CONCLUSIONS Palliative CRS and/or HIPEC achieve symptom improvement in patients with advanced PC. Risk assessment and expected time to recovery from surgery remain paramount for patient selection.
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Affiliation(s)
- Erin A Strong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Palliative Care Center, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Austin Livingston
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Palliative Care Center, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Maciej Gracz
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Palliative Care Center, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wendy Peltier
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Palliative Care Center, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Susan Tsai
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Palliative Care Center, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathleen Christians
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Palliative Care Center, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - T Clark Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Palliative Care Center, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Karen Kersting
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Palliative Care Center, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Callisia N Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Palliative Care Center, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
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14
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Hsu PJ, Singh K, Dhiman A, Witmer HDD, He C, Eng OS, Catenacci DVT, Posner MC, Turaga KK. Utility of Perioperative Measurement of Cell-Free DNA and Circulating Tumor DNA in Informing the Prognosis of GI Cancers: A Systematic Review. JCO Precis Oncol 2022; 6:e2100337. [PMID: 35188804 PMCID: PMC8984241 DOI: 10.1200/po.21.00337] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Current surveillance imaging and tumor markers lack sensitivity for the early detection of recurrence in GI cancers. This study critically evaluates the current literature on the role of sequential measurement of circulating tumor DNA (ctDNA) before and after curative resection in informing recurrence. METHODS A systematic search using a predefined, registered protocol was conducted for studies published between January 2010 and May 2020. Included studies described patients with GI cancers treated with curative-intent surgical resection and measurement of ctDNA both before and after surgery. Patients were divided into three groups on the basis of the presence or absence of ctDNA at these time points. The primary outcome was recurrence-free survival (RFS). RESULTS The search yielded 3,873 articles; five met the inclusion criteria and collectively evaluated 57 patients. Pooled median RFS was 62 months (interquartile range 19 to not reached). Although median RFS was not reached in group 1 (- to -) or group 2 (+ to -), median RFS in group 3 (+ to +) was 15 months (interquartile range 9.6-60.4 months). Cox hazard ratio was 4.46 (95% CI, 1.17 to 16.99; P = .028) between group 1 and group 2, and 10.47 (95% CI, 2.91 to 37.74; P < .001) between group 2 and group 3. CONCLUSION Detectable ctDNA, either preoperatively or postoperatively, and its persistence after curative surgery are associated with a greater risk of recurrence and decreased RFS in GI cancers. Thus, perioperative measurement of ctDNA may be a useful postoperative risk stratification tool and guide additional therapies.
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Affiliation(s)
- Phillip J. Hsu
- Department of Surgery, University of Chicago, Chicago, IL,University of Chicago, Medical Scientist Training Program, Chicago, IL
| | - Khushboo Singh
- Department of Surgery, University of Chicago, Chicago, IL
| | - Ankit Dhiman
- Department of Surgery, University of Chicago, Chicago, IL
| | | | - Chuan He
- Department of Chemistry, University of Chicago, Chicago, IL
| | - Oliver S. Eng
- Department of Surgery, University of Chicago, Chicago, IL
| | | | | | - Kiran K. Turaga
- Department of Surgery, University of Chicago, Chicago, IL,Kiran K. Turaga, MD, MPH, 5841 S. Maryland Ave, MC 5094, Chicago, IL 60637; e-mail:
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15
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Song Y, Metzger DA, Bruce AN, Krouse RS, Roses RE, Fraker DL, Kelz RR, Karakousis GC. Surgical Outcomes in Patients With Malignant Small Bowel Obstruction: A National Cohort Study. Ann Surg 2022; 275:e198-e205. [PMID: 32209901 DOI: 10.1097/sla.0000000000003890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The study objectives were to characterize surgical outcomes for malignant small bowel obstruction (MaSBO) as compared to other small bowel obstructions (SBO) and to develop a prediction model for postoperative mortality for MaSBO. SUMMARY BACKGROUND DATA MaSBO is a morbid complication of advanced cancers for which the optimal management remains undefined. METHODS Patients who underwent surgery for MaSBO or SBO were identified from the National Surgical Quality Improvement Program (2005-2017). Outcomes [30-day morbidity, unplanned readmissions, mortality, postoperative length of stay (LOS)] were compared between propensity score-matched MaSBO and SBO patients. An internally validated prediction model for mortality in MaSBO patients was developed. RESULTS Of 46,706 patients, 1612 (3.5%) had MaSBO. Although MaSBO patients were younger than those with SBO (median 63 vs 65 years, P < 0.001), they were otherwise more clinically complex, including a higher proportion with recent weight loss (22.0% vs 4.0%, P < 0.001), severe hypoalbuminemia (18.6% vs 5.2%, P < 0.001), and cytopenias. After matching (N = 1609/group), MaSBO was associated with increased morbidity [odds ratio (OR) 1.2, P = 0.004], but not readmission (OR 1.1, P = 0.48) or LOS (incidence rate ratio 1.0, P = 0.14). The odds of mortality were significantly higher for MaSBO than SBO (OR 3.3, P < 0.001). A risk-score model predicted postoperative mortality for MaSBO with an optimism-adjusted Brier score of 0.114 and area under the curve of 0.735. Patients in the highest-risk category (11.5% of MaSBO population) had a predicted mortality rate of 39.4%. CONCLUSION Surgery for MaSBO is associated with substantial morbidity and mortality, necessitating careful patient evaluation before operative intervention.
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Affiliation(s)
- Yun Song
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel Aryeh Metzger
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adrienne N Bruce
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert S Krouse
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center of Philadelphia, Philadelphia, PA
| | - Robert E Roses
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Douglas L Fraker
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Giorgos C Karakousis
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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16
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Lodoli C, Covino M, Attalla El Halabieh M, Santullo F, Di Giorgio A, Abatini C, Rotolo S, Rodolfino E, Giovinazzo F, Fagotti A, Scambia G, Franceschi F, Pacelli F. Prognostic Factors for Surgical Failure in Malignant Bowel Obstruction and Peritoneal Carcinomatosis. Front Surg 2021; 8:769658. [PMID: 34901144 PMCID: PMC8660692 DOI: 10.3389/fsurg.2021.769658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Patients with peritoneal metastasis frequently develop malignant bowel obstruction (MBO). Medical palliative management is preferred but often fails. Conversely, the role of palliative surgery remains unclear and debated. This study aims to identify patients who could benefit from invasive surgical interventions and factors associated with successful surgical palliation. Materials and Methods: In this retrospective study, 98 consecutive patients who underwent palliative surgery for MBO over 5 years were reviewed. We evaluate as the primary outcome surgical failure to select patients who could benefit from palliative surgery, avoiding unnecessary surgery. A prognostic score was developed based on a logistic regression model to identify patients at risk of surgical failure. The score was evaluated for overall accuracy by receiver operating characteristic curve analysis. Results: Palliative surgery was achieved in 76 (77.5%) patients. The variables that were found to be significant factors for surgical failure are recurrent disease (P = 0.015), absence of bowel obstruction (P < 0.001), absence of bowel distension (P < 0.001), and mesenteric involvement (P = 0.001) and retraction (P < 0.001). The absence of bowel distension (P = 0.046) and bowel obstruction (P = 0.012) emerged as independent predictors of surgical failure. Carcinomatosis level assessment for peritoneum score, based on these factors, was built to evaluate the risk of surgical failure. Conclusion: Our proposed scoring system might help select patients most likely to benefit from palliative surgery.
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Affiliation(s)
- Claudio Lodoli
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Marcello Covino
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Miriam Attalla El Halabieh
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Santullo
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Andrea Di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carlo Abatini
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Rotolo
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Elena Rodolfino
- Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Radiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Francesco Giovinazzo
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Anna Fagotti
- Università Cattolica del Sacro Cuore, Rome, Italy.,Division of Gynecologic Oncology, Department of Women and Children's Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Giovanni Scambia
- Università Cattolica del Sacro Cuore, Rome, Italy.,Division of Gynecologic Oncology, Department of Women and Children's Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Francesco Franceschi
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabio Pacelli
- Surgical Unit of Peritoneum and Retroperitoneum Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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17
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Shariff F, Bogach J, Guidolin K, Nadler A. Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review. Ann Surg Oncol 2021; 29:1995-2005. [PMID: 34664143 DOI: 10.1245/s10434-021-10922-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/30/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Malignant bowel obstruction from peritoneal carcinomatosis affects a significant proportion of luminal gastrointestinal and ovarian oncology patients, and portends poor long-term survival. The management approach for these patients includes a range of medical therapies and surgical options; however, how to select an optimal treatment strategy remains enigmatic. The goal of this narrative review was to summarize the latest evidence around multimodal malignant bowel obstruction treatment and to establish if and where progress has been made. METHODS A targeted literature search examining articles focused on the management of malignant bowel obstruction from peritoneal carcinomatosis was performed. Following data extraction, a narrative review approach was selected to describe evidence and guidelines for surgical prognostic factors, imaging, tube decompression, medical management, nutrition, and quality of life. RESULTS Outcomes in the literature to date are summarized for various malignant bowel obstruction treatment strategies, including surgical and non-surgical approaches, as well as a discussion of the role of total parenteral nutrition and chemotherapy in holistic malignant bowel obstruction management. CONCLUSION There has been little change in survival outcomes in malignant bowel obstruction in over more than a decade and there remains a paucity of high-level evidence to direct treatment decision making. Healthcare providers treating patients with malignant bowel obstruction should work to establish consensus guidelines, where feasible, to support medical providers in ensuring compassionate care during this often terminal event for this unique patient group.
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Affiliation(s)
- Farhana Shariff
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Jessica Bogach
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Keegan Guidolin
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ashlie Nadler
- Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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19
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Aka AA, Wright JP, DeBeche-Adams T. Small Bowel Obstruction. Clin Colon Rectal Surg 2021; 34:219-226. [PMID: 34305470 DOI: 10.1055/s-0041-1725204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Small bowel obstruction (SBO) remains a common problem for surgeons and nonsurgeons alike. Management of SBO has shifted from primarily being surgical to a nonoperative approach, which can be attributed to a multitude of reasons, including better understanding of the pathophysiology of SBO, the advent of laparoscopy, and improvement in diagnostic imaging. But given the nature of SBO, the need for surgical consultation continues to remain a necessity. This article will review the etiology, diagnosis, and management of SBO.
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Affiliation(s)
- Allison A Aka
- Department of Colon and Rectal Surgery, AdventHealth Orlando, Orlando, Florida
| | - Jesse P Wright
- Department of Colon and Rectal Surgery, AdventHealth Orlando, Orlando, Florida
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20
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Faviana P, Boldrini L, Musco B, Ferrari M, Greco A, Fornaro L, Masi G, Forfori F, Ricci S, Brogi A, Basolo F, Falcone A, Gadducci A, Lippolis PV. Management of Peritoneal Carcinomatosis With Cytoreductive Surgery Combined With Intraperitoneal Chemohyperthermia at a Novel Italian Center. In Vivo 2021; 34:2061-2066. [PMID: 32606183 DOI: 10.21873/invivo.12008] [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: 03/25/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Peritoneal carcinomatosis (PC) is a common manifestation of many gastrointestinal (GI) malignancies and is an advanced stage that is often associated with disseminated disease. Considerable progress has been made to achieve safe elimination of macroscopic disease using cytoreductive surgery (CRS) and more recently in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of microscopic disease or disease with minimal volume. The aim of this study was to assess the effects of such procedures on the quality of life (QoL), the long-term benefit and the functional status of the treated patients. PATIENTS AND METHODS Data from patients who underwent CRS-HIPEC for peritoneal metastasis (PM) at our center from November 2016 to November 2018 were analyzed retrospectively. The drugs administered were mitomycin and cisplatin. Quality of life (QoL) was assessed using the Euroquol-5D-5L and National Comprehensive Cancer Network Functional Assessment of Cancer Therapy-Breast Cancer Symptom Index v2 questionnaires before CRS-HIPEC, and 1, 3 and 6 months after were administered. RESULTS In our series, the survival efficacy of CRS plus HIPEC was confirmed in the treatment of primary and secondary peritoneal pathologies, particularly in ovarian cancer, although larger studies are needed to investigate its role in the pathology of gastric, colonic and rectal cancer. The QoL data were promising, with essentially stable values between the preoperative and the 1-month follow-up, but with incremental benefits from the second to the third month.
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Affiliation(s)
- Pinuccia Faviana
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Laura Boldrini
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Barbara Musco
- Department of General Surgery, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Mauro Ferrari
- Department of General Surgery, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Alfonso Greco
- Department of General Surgery, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Lorenzo Fornaro
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gianluca Masi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesco Forfori
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Sergio Ricci
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Augusto Brogi
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Fulvio Basolo
- Department of Surgical, Medical, Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Alfredo Falcone
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Angelo Gadducci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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21
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Kou F, Gong J, Li Y, Li J, Zhang X, Li J, Shen L. Phase I study of intraperitoneal bevacizumab for treating refractory malignant ascites. J Int Med Res 2021; 49:300060520986664. [PMID: 33616416 PMCID: PMC7903826 DOI: 10.1177/0300060520986664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE This prospective, dose-escalation phase I study evaluated the safety and efficacy of intraperitoneal bevacizumab in managing refractory malignant ascites and explored the recommended dose of bevacizumab for further study. METHODS Patients with refractory malignant ascites were enrolled. Bevacizumab was intraperitoneal administered weekly at an initial dose of 2.5 mg/kg, with dose escalation to 5 and 7.5 mg/kg performed following the standard "3 + 3" rule. The total duration of treatment was 2 or 3 weeks. RESULTS Between December 2013 and September 2014, 13 patients (2.5 mg/kg, n = 4; 5 mg/kg, n = 3; 7.5 mg/kg, n = 6) with refractory malignant ascites were enrolled. Bevacizumab was well tolerated, and the most common treatment-related adverse events were abdominal pain (5/13), abdominal distension (2/13), and fatigue (2/13). The dose-limiting toxicity at 7.5 mg/kg was grade 3 bowel obstruction (1/13). The maximum tolerated dose (MTD) was not reached. The overall response and disease control rates were 7.7 and 61.5%, respectively. CONCLUSIONS Intraperitoneal bevacizumab safe and well tolerated for treating malignant ascites, and the MTD was not reached at doses of 2.5 to 7.5 mg/kg. Intraperitoneal bevacizumab at 7.5 mg/kg weekly is recommended for further study to verify its anti-tumor activity.Trial registration: Clinical Trials NCT01852409.
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Affiliation(s)
- Furong Kou
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Jifang Gong
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yan Li
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Jian Li
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Xiaotian Zhang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Jie Li
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Lin Shen
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing, China
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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Capona R, Hassab T, Sapci I, Aiello A, Liska D, Holubar S, Lightner AL, Steele SR, Valente MA. Surgical intervention for mechanical large bowel obstruction at a tertiary hospital: Which patients receive a stoma and how often are they reversed? Am J Surg 2020; 221:594-597. [PMID: 33288223 DOI: 10.1016/j.amjsurg.2020.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/05/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The surgical management of large bowel obstruction (LBO) is heterogeneous and influenced by multiple variables. The aim of this study was to analyze and compare the surgical interventions and outcomes of patients necessitating surgery for LBO. METHODS Patients with LBO between 2000 and 2017 were included. Main outcomes measures are intraoperative findings, operative management, post-operative outcomes and stoma closure rates. RESULTS 133 patients were included with predominately left-sided obstruction (82%). The most common etiology was colorectal cancer (44%) followed by extrinsic malignant compression (29%). The most common operation performed was fecal diversion without resection (46%). This group had significantly more stage 4 carcinoma, carcinomatosis and had the lowest stoma closure rate (16%). Eighty-six percent of the operated patients underwent fecal diversion, of these, 27% had stoma reversal at 6 months. Patients that had a resection and anastomosis with diverting loop ileostomy were most likely to undergo stoma reversal (p = 0.005) and had the lowest number of patients with stage-IV carcinoma. CONCLUSIONS In this single institution analysis, the management of LBO entails high operative and stoma rates, with less than 30% of patient undergoing stoma closure. Resection, anastomosis and DLI had the highest chance of stoma reversal.
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Affiliation(s)
- Rodrigo Capona
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarek Hassab
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexandra Aiello
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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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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Judge SJ, Ji J, Liu J, Kaur M, Kim E, Gong J, Tam KW, Kirane AR, Gholami S, Canter RJ, Bold RJ, Gangi A, Fakih M, Cho M. The Role of Palliative Surgery for Malignant Bowel Obstruction and Perforation in Advanced Microsatellite Instability-High Colorectal Carcinoma in the Era of Immunotherapy: Case Report. Front Oncol 2020; 10:581. [PMID: 32373540 PMCID: PMC7186327 DOI: 10.3389/fonc.2020.00581] [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: 01/18/2020] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
The role of palliative surgery in the management of acute complications in patients with disseminated malignancy remains controversial given the complexity of assessing acute surgical risk and long-term oncologic outcome. With the emergence of checkpoint blockade immunotherapy, there appears to be an increasing role for historically palliative procedures as a bridge to systemic immunotherapy. This is especially evident in advanced microsatellite instability-high (MSI-H) colorectal cancer where malignant obstruction and fistula formation are more common and where immunotherapy with checkpoint blockade (anti-PD-1/PD-L1, anti-CTLA-4) has a high response rate with potential for favorable oncologic outcomes. We present a series of three patients with MSI-H metastatic colorectal cancer complicated by malignant bowel obstruction and fistula formation, who having progressed on standard chemotherapy, underwent palliative intervention as a bridge to immune checkpoint blockade with durable and clinically meaningful anti-cancer responses. These cases highlight the need to re-evaluate the role of historically palliative operations in the setting of disease progression for immunotherapy-responsive tumors.
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Affiliation(s)
- Sean J Judge
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Jingran Ji
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
| | - James Liu
- Division of Hematology and Oncology, Department of Medicine, University of California, Davis, Sacramento, CA, United States
| | - Manmeet Kaur
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
| | - Edward Kim
- Division of Hematology and Oncology, Department of Medicine, University of California, Davis, Sacramento, CA, United States
| | - Jun Gong
- Division of Hematology and Oncology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Kit W Tam
- Division of Hematology and Oncology, Department of Medicine, University of California, Davis, Sacramento, CA, United States
| | - Amanda R Kirane
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Sepideh Gholami
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Robert J Canter
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, CA, United States
| | - Alexandra Gangi
- Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Marwan Fakih
- Division of Hematology and Oncology, Department of Medicine, City of Hope National Medical Center, Duarte, CA, United States
| | - May Cho
- Division of Hematology and Oncology, Department of Medicine, University of California, Davis, Sacramento, CA, United States
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26
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Koisser K. [Palliative surgery of malignant small bowel obstruction after colorectal cancer]. Wien Med Wochenschr 2019; 169:381-386. [PMID: 31713707 DOI: 10.1007/s10354-019-00715-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 10/21/2019] [Indexed: 12/28/2022]
Abstract
Although invasive surgical procedures in cancer patients can possibly cure malignancy, these strategies are potentially harmful by restricting quality of life and lifetime. Surgical therapies in palliative situations have to be carefully considered and well planned for every individual patient. The case report of the following patient suffering from malignant small bowel obstruction caused by local recurrence of colorectal cancer may make aware of difficulties and doubts in decision-making. After research oft the literature on this topic it is obvious that standards of therapy currently do not exist.
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Affiliation(s)
- Karin Koisser
- Abteilung für Allgemein, Viszeral- und Gefäßchirurgie, Landesklinikum Horn, Spitalgasse 10, 3580, Horn, Österreich.
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27
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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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Sarani B, Paspulati RM, Hambley J, Efron D, Martinez J, Perez A, Bowles-Cintron R, Yi F, Hill S, Meyer D, Maykel J, Attalla S, Kochman M, Steele S. A multidisciplinary approach to diagnosis and management of bowel obstruction. Curr Probl Surg 2018; 55:394-438. [PMID: 30526888 DOI: 10.1067/j.cpsurg.2018.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/11/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Babak Sarani
- Center for Trauma and Critical Care, George Washington University School of Medicine, Washington, DC.
| | | | - Jana Hambley
- Department of Trauma and Acute Care Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Efron
- Division of Acute Care Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jose Martinez
- Division of Minimally Invasive Surgery, Minimally Invasive Surgery/Flexible Endoscopy Fellowship Program, University of Miami Miller School of Medicine, Miami, FL
| | - Armando Perez
- University of Miami Miller School of Medicine, Miami, FL
| | | | - Fia Yi
- Brooke Army Medical Center, San Antonio, TX
| | - Susanna Hill
- University of Massachusetts Medical Center, Worcester, MA
| | - David Meyer
- Division of Colon and Rectal Surgery, University of Massachusetts Medical Center, Worcester, MA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts Medical Center, Worcester, MA
| | - Sara Attalla
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael Kochman
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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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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30
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Thadi A, Khalili M, Morano WF, Richard SD, Katz SC, Bowne WB. Early Investigations and Recent Advances in Intraperitoneal Immunotherapy for Peritoneal Metastasis. Vaccines (Basel) 2018; 6:E54. [PMID: 30103457 PMCID: PMC6160982 DOI: 10.3390/vaccines6030054] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/06/2018] [Accepted: 08/06/2018] [Indexed: 12/23/2022] Open
Abstract
Peritoneal metastasis (PM) is an advanced stage malignancy largely refractory to modern therapy. Intraperitoneal (IP) immunotherapy offers a novel approach for the control of regional disease of the peritoneal cavity by breaking immune tolerance. These strategies include heightening T-cell response and vaccine induction of anti-cancer memory against tumor-associated antigens. Early investigations with chimeric antigen receptor T cells (CAR-T cells), vaccine-based therapies, dendritic cells (DCs) in combination with pro-inflammatory cytokines and natural killer cells (NKs), adoptive cell transfer, and immune checkpoint inhibitors represent significant advances in the treatment of PM. IP delivery of CAR-T cells has shown demonstrable suppression of tumors expressing carcinoembryonic antigen. This response was enhanced when IP injected CAR-T cells were combined with anti-PD-L1 or anti-Gr1. Similarly, CAR-T cells against folate receptor α expressing tumors improved T-cell tumor localization and survival when combined with CD137 co-stimulatory signaling. Moreover, IP immunotherapy with catumaxomab, a trifunctional antibody approved in Europe, targets epithelial cell adhesion molecule (EpCAM) and has shown considerable promise with control of malignant ascites. Herein, we discuss immunologic approaches under investigation for treatment of PM.
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Affiliation(s)
- Anusha Thadi
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
| | - Marian Khalili
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
| | - William F Morano
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
| | - Scott D Richard
- Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
| | - Steven C Katz
- Department of Surgery, Boston University School of Medicine, Boston, MA 02118, USA.
| | - Wilbur B Bowne
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
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Malignant Bowel Obstruction in Relapsed Ovarian Cancer With Peritoneal Carcinomatosis: An Occlusive State. Int J Gynecol Cancer 2018; 27:1367-1372. [PMID: 28704322 DOI: 10.1097/igc.0000000000001049] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The aim of this study was to describe the clinical and oncological outcomes of women with malignant bowel obstruction (MBO) for relapsed ovarian cancer and peritoneal carcinomatosis. METHODS A retrospective cohort study was performed in all consecutive patients admitted at Instituto Valenciano de Oncología, Valencia, Spain, between July 2013 and July 2016 with MBO for relapsed ovarian cancer and peritoneal carcinomatosis. All patients underwent the same protocol of conservative management. Surgical treatment was indicated only in selected cases. RESULTS There were a total of 22 patients presenting 59 episodes of MBO; 17 (77.2%) of those patients presented more than 1 episode of MBO. All patients had serous epithelial ovarian cancer; 18 (81.8%) were high grade, and 4 (18.2%) low-grade tumors. The median (range) number of episodes per patient was 3 (range, 1-7) with a mean length of hospitalization of 13 (SD, 13.6) days. The median time interval between episodes of MBO (54 episodes in 17 patients) was 17 days (range, 1-727 days). Twenty of 22 patients died with a median overall survival time from the first episode of MBO of 95 days (95% confidence interval, 49-124 days). CONCLUSIONS Patients with MBO due to relapsed epithelial ovarian cancer in the peritoneal carcinomatosis setting have a short life expectancy, presenting a median of 3 episodes of MBO until death, with a short time interval between episodes. These findings show that bowel obstruction can represent a constant status over time until death.
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马 骏, 霍 介. 恶性肠梗阻的治疗现状与进展. Shijie Huaren Xiaohua Zazhi 2017; 25:1921-1927. [DOI: 10.11569/wcjd.v25.i21.1921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
恶性肠梗阻(malignant bowel obstruction, MBO)是晚期肿瘤常见并发症之一, 严重影响患者的生活质量. 恶性肿瘤本身的复杂性导致肠梗阻治疗的复杂性、难治性. 近年来, 随着腹腔镜、内镜技术及介入技术的发展以及对姑息手术适应证的把握, 肠梗阻患者的生存质量及治疗率得以提高, 但尚存在一定争议, 且在药物治疗方面暂无显著进展. 另外, 中医药在该领域亦有较多研究, 显示出一定的效果, 但尚缺乏前瞻性的随机对照研究. 临床处理要充分考虑治疗可能带来的益处及风险, 慎重选择个性化的治疗方案. 本文对国内外近年来MBO的中西医诊疗进展进行系统综述, 以期对临床诊疗具有一定的指导意义.
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Li KY, Mokdad AA, Minter RM, Mansour JC, Choti MA, Augustine MM, Polanco PM. Failure to rescue following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Surg Res 2017. [DOI: 10.1016/j.jss.2017.02.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Outcomes After Surgery for Benign and Malignant Small Bowel Obstruction. J Gastrointest Surg 2017; 21:363-371. [PMID: 27783343 PMCID: PMC5263174 DOI: 10.1007/s11605-016-3307-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common diagnosis; however, outcomes of and risk factors for SBO and malignant bowel obstruction (MBO) surgery are not well understood. We sought to characterize outcomes and risk factors for surgery for SBO and MBO. METHODS A retrospective cohort study was performed utilizing prospectively collected data from the Michigan Surgical Quality Collaborative (7/2012-3/2015). Cases included those with ICD9 diagnosis code of bowel obstruction and CPT codes for lysis of adhesions, intestinal bypass, and small bowel resection. Cases were stratified by disseminated malignancy (MBO). Factors associated with complications and 30-day mortality were evaluated. RESULTS Two thousand two hundred thirty-three patients underwent surgery for bowel obstruction, including 86 patients (3.9 %) with MBO. MBO patients had an adjusted mortality rate of 14.5 % (benign 5.0 %); the adjusted complication rate was 32.2 % (benign 27.0 %). Factors independently associated with mortality included disseminated cancer, older age, American Society of Anesthesiologists IV/V, cirrhosis, ascites, urinary tract infection, sepsis, albumin <3.5, hematocrit <30, and bowel resection. CONCLUSIONS Surgery for bowel obstruction carries a relatively high risk for morbidity and mortality, particularly in patients with malignant bowel obstruction. Considering the identified risk factors for mortality may help clinicians make recommendations regarding surgery in the setting of MBO.
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Santangelo ML, Grifasi C, Criscitiello C, Giuliano M, Calogero A, Dodaro C, Incollingo P, Rupealta N, Candida M, Chiacchio G, Riccio E, Pisani A, Tammaro V, Carlomagno N. Bowel obstruction and peritoneal carcinomatosis in the elderly. A systematic review. Aging Clin Exp Res 2017; 29:73-78. [PMID: 27837464 DOI: 10.1007/s40520-016-0656-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/12/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND There are not guidelines for surgical management of malignant bowel obstruction (MBO) caused by peritoneal carcinomatosis (PC), mainly when it involves elderly; so its treatment is still debated. AIM To outline indications and benefits of palliative surgery for obstructive carcinomatosis and determine what prognostic factors, including age, have independent and significant association with outcome. METHODS We conducted English-language MEDLINE and EMBASE searches of articles published between 1998 and 2016, which reported outcome data after palliative surgery for MBO due to PC. We excluded all articles lacking of surgical cohort and those with main interest in conservative treatment. Of 1275 articles identified, 12 satisfied selection criteria and were included in our analysis. RESULTS Overall, these studies involved 548 patients undergoing palliative surgery for MBO caused by PC. The median age was 58 (range 19-93). Relief of symptoms was achieved in 26.5-100% of cases. Postoperative morbidity ranged between 7 and 44%. Mortality was high (6-22%). The median survival was longer in surgical patients than in those receiving conservative therapy (8-34 vs 4-5 weeks). Factors associated with surgery failure were poor performance status, diffuse carcinomatosis, previous radiotherapy, and obstruction of small bowel. Old age was significantly associated with a poor prognosis upon univariate analysis, while this association vanished upon multivariate analysis. CONCLUSIONS Surgical palliation can provide relief of obstructive symptoms as well as improved survival in well-selected patients, even if elderly.
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Affiliation(s)
- Michele L Santangelo
- Abdominal Surgery and Transplantation, Department of Advanced Biomedical Sciences, University Federico II, via Pansini 5, 80131, Naples, Italy.
| | - Carlo Grifasi
- Abdominal Surgery, Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Carmen Criscitiello
- Division of Experimental Cancer Medicine, European Institute of Oncology, Milan, Italy
| | - Mario Giuliano
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
- Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Armando Calogero
- Abdominal Surgery, Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Concetta Dodaro
- Emergency Surgery, Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Paola Incollingo
- Abdominal Surgery and Transplantation, Department of Advanced Biomedical Sciences, University Federico II, via Pansini 5, 80131, Naples, Italy
| | - Niccolò Rupealta
- Abdominal Surgery and Transplantation, Department of Advanced Biomedical Sciences, University Federico II, via Pansini 5, 80131, Naples, Italy
| | - Maria Candida
- Abdominal Surgery, Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Gaetano Chiacchio
- Abdominal Surgery, Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Eleonora Riccio
- Department of Public Health, University Federico II, Naples, Italy
| | - Antonio Pisani
- Department of Public Health, University Federico II, Naples, Italy
| | - Vincenzo Tammaro
- Abdominal Surgery and Transplantation, Department of Advanced Biomedical Sciences, University Federico II, via Pansini 5, 80131, Naples, Italy
| | - Nicola Carlomagno
- Abdominal Surgery, Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
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Intraperitoneal immunotherapy: historical perspectives and modern therapy. Cancer Gene Ther 2016; 23:373-381. [PMID: 27834358 DOI: 10.1038/cgt.2016.49] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 09/12/2016] [Accepted: 09/19/2016] [Indexed: 12/18/2022]
Abstract
Intraperitoneal immunotherapy represents a novel strategy for the management of peritoneal metastases (PM). Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has remained the gold standard of treatment for patients with PM, yet despite optimal treatment, recurrence rates remain high and long-term survival poor. From Coley's toxins to immune checkpoint inhibitors, the wide variety of anticancer immunotherapeutic strategies are now garnering attention for control of regional disease of the peritoneal cavity. Early studies with vaccine-based therapies, adoptive cell transfer, immune checkpoint inhibitors, and chimeric T cells with tumor-specific antigen receptors (CAR-T cells) are being performed, showing promise for control of peritoneal spread and induction of lasting anticancer immunity. In addition, catumaxomab, a trifunctional antibody, has been approved for intraperitoneal immunotherapy in Europe for the control of malignant ascites in patients with epithelial cell adhesion molecule positive cancers. We review a brief history of immunotherapy and current modalities under investigation for intraperitoneal use in the treatment of PM.
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Rajeev R, Turaga KK. Hyperthermic Intraperitoneal Chemotherapy and Cytoreductive Surgery in the Management of Peritoneal Carcinomatosis. Cancer Control 2016; 23:36-46. [PMID: 27009455 DOI: 10.1177/107327481602300107] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Malignant peritoneal disease can lead to significant debility due to bowel obstructions, ascites, and cancer cachexia. Moreover, inadequate imaging techniques can lead to the suboptimal detection of disease, and the poor vascularity of tumors can lead to a poor response to systemic chemotherapy. However, combination cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising novel treatment for patients with this disease. METHODS The medical literature focusing on diagnostic updates and the management of peritoneal disease was reviewed. The application principles of HIPEC for use in peritoneal disease were also summarized. RESULTS Improvements in imaging and the application of laparoscopic techniques have significantly increased the rate of diagnosis of early peritoneal disease with consequently less morbid cytoreductive procedures. Appropriate patient selection based on prognostic scores along with complete cytoreduction can identify a cohort of patients likely to derive durable benefit from this combination treatment. CONCLUSIONS Advances in diagnostic and therapeutic techniques, including surgical cytoreductive techniques, have demonstrated significant survival gains in patients with peritoneal disease. Although HIPEC can be used for the management of various types of histologies, further development of high-level evidence is necessary to advance the field.
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Affiliation(s)
| | - Kiran K Turaga
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Management of intestinal obstruction in advanced malignancy. Ann Med Surg (Lond) 2015; 4:264-70. [PMID: 26288731 PMCID: PMC4539185 DOI: 10.1016/j.amsu.2015.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 02/07/2023] Open
Abstract
Patients with incurable, advanced abdominal or pelvic malignancy often present to acute surgical departments with symptoms and signs of intestinal obstruction. It is rare for bowel strangulation to occur in these presentations, and spontaneous resolution often occurs, so the luxury of time should be afforded while decisions are made regarding surgery. Cross-sectional imaging is valuable in determining the underlying mechanism and pathology. The majority of these patients will not be suitable for an operation, and will be best managed in conjunction with a palliative medicine team. Surgeons require a good working knowledge of the mechanisms of action of anti-emetics, anti-secretories and analgesics to tailor early management to individual patients, while decisions regarding potential surgery are made. Deciding if and when to perform operative intervention in this group is complex, and fraught with both technical and emotional challenges. Surgery in this group is highly morbid, with no current evidence available concerning quality of life following surgery. The limited evidence concerning operative strategy suggests that resection and primary anastomosis results in improved survival, over bypass or stoma formation. Realistic prognostication and involvement of the patient, care-givers and the multidisciplinary team in treatment decisions is mandatory if optimum outcomes are to be achieved.
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