Surgical management of intestinal obstruction in ovarian cancer. I. Clinical features, postoperative complications, and survival

Management of Malignant Bowel Obstruction in Patients with Gynaecological Cancer: A Systematic Review

Objectives: This systematic review aimed to evaluate current surgical and non-surgical management strategies for malignant bowel obstruction (MBO) in patients with gynaecological cancer. Methods: Comprehensive literature searches were conducted across MEDLINE, Embase, CENTRAL, and Scopus, without restrictions on language or publication date. Following the removal of duplicates, 4866 articles were screened, with 34 meeting the inclusion criteria. Results: Surgical intervention remains the definitive treatment for MBO, offering longer symptom-free periods and improved survival, particularly when conservative methods fail. However, the selection of surgical candidates is crucial due to the high risk of morbidity and the potential for significant complications. Non-surgical treatments, such as the use of Gastrografin, Octreotide, and Dexamethasone, along with invasive procedures like nasogastric tubing, percutaneous gastrostomy, and stent placement, offer varying degrees of symptom relief and are often considered when surgery is not feasible. Conclusions: In this article we provide a potential therapeutic algorithm for the management of patients with MBO. This review underscores the urgent need for high-quality research to develop clear, evidence-based guidelines for MBO management in patients with gynaecologic cancer. Establishing standardised protocols will improve patient outcomes by aiding clinicians in making informed, individualised treatment decisions.

Non-Surgical Management of Malignant Bowel Obstruction in Advanced Ovarian Cancer patients: A Systematic Review and Meta-Analysis

Background:

Malignant bowel obstruction is a common cause of morbidity and mortality in patients with advanced ovarian cancer. Many patients aren’t suitable for, or decline, surgical decompression. The outcomes for this frail group of patients are not well characterized.

Aim:

To evaluate survival outcomes of ovarian cancer patients who undergo non-surgical management of malignant bowel obstruction.

Design:

Systematic review and meta-analysis.

Data Sources:

Online literature search of Pubmed, Embase and Medline libraries up until December 2020. Searching abstracts of scientific meetings, reference lists of included studies and contacting experts in the field.

Selection Criteria:

Studies that investigated non-surgical management of confirmed bowel obstruction in advanced ovarian cancer patients were included. All levels of evidence including RCTs, cohort studies and case-series if they included greater than 5 patients.

Data Collection and Analysis:

The studies were independently chosen by two reviewers who extracted and analyzed the data separately through OpenMeta Analyst software. Study quality was assessed using the JADAD score and the Newcastle Ottawa Score.

Results:

24 studies met the eligibility criteria for the systematic review and 9 for the meta-analysis. Median survival of patients managed non-surgically for bowel obstruction was 44 days (95% CI 38-49 days, I ² = 0%, P = 0.128).

Conclusion:

The quality of studies was relatively low, however the evidence shows that non-surgical management of bowel obstruction results in a short life expectancy but with controlled symptoms. Where quality of life is the main concern, this may be a feasible and effective strategy.

Medical Management of Inoperable Malignant Bowel Obstruction

OBJECTIVE

To review medical management of inoperable malignant bowel obstruction.

DATA SOURCES

A literature review using PubMed and MEDLINE databases searching malignant bowel obstruction, etiology, types, pathophysiology, medical, antisecretory, anti-inflammatory, antiemetic drugs, analgesics, promotion of emptying, prevention of infection, anticholinergics, somatostatin analogs, gastric antisecretory drugs, prokinetic agents, glucocorticoid, opioid analgesics, antibiotics, enema, and adverse effects.

STUDY SELECTION AND DATA EXTRACTION

Randomized or observational studies, cohorts, case reports, or reviews written in English between 1983 and November 2020 were evaluated.

DATA SYNTHESIS

Malignant bowel obstruction (MBO) commonly occurs in patients with advanced or recurrent malignancies and severely affects the quality of life and survival of patients. Its management remains complex and variable. Medical management is the cornerstone of MBO treatment, with the goal of reducing distressing symptoms and optimizing quality of life. Until now, there has been neither a standard clinical approach nor registered medications to treat patients with inoperable MBO.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

This review provides information on the etiology, type and pathophysiology, and medical treatment of MBO and related adverse reactions of the drugs commonly used, which can greatly assist clinicians in making clinical decisions when treating MBO.

CONCLUSIONS

Published research shows that medical management of MBO mainly consists of antisecretory, anti-inflammatory strategies, controlling vomiting and pain, promoting emptying, preventing infection, and combination therapy. Being knowledgeable about the most current treatment options, the related adverse effects, and the evidence supporting different practices is critical for clinicians to provide individualized medical therapy for MBO patients.

Intestinal occlusion by gynecological cancers treated by percutaneous endoscopic gastrostomy and lanreotide: an Aviano National Cancer Institute experience

The Commentary reports on our experience in Centro di Riferimento Oncologico IRCCS Aviano about the integrated and combined treatment with percutaneous endoscopic gastrostomy and lanreotide in patients with bowel obstructions by ovarian cancer and peritoneal carcinomatosis. We treated patients with gynecological cancers and bowel obstruction with percutaneous endoscopic gastrostomy and, when patients were partially responsive, with lanreotide. We registered a constant overall benefit for the quality of life and for the control of symptoms, which is very important especially during the home care follow-up of terminal patients.

Predictors of clinical outcome of colonic stents in patients with malignant large-bowel obstruction because of extracolonic malignancy

BACKGROUND AND AIMS

Colonic stent placement in patients with large-bowel obstruction (LBO) secondary to extracolonic malignancy (ECM) has been evaluated in small series with heterogeneous results. Our aim is to better characterize the technical and clinical success of colonic stent placement and to identify factors that affect this success in ECM patients.

METHODS

All patients at a single high-volume center who presented for colonic stent placement for LBO because of ECM between 2001 and 2012 were retrospectively identified. The outcomes of interest were technical success, clinical success, stent occlusion rate, and overall survival.

RESULTS

A total of 187 patients were identified. Mean age was 61.9 years (range, 23-89), and 150 (80.2%) were women. The most common malignancy type was urogynecologic (n = 104) and most common location sigmoid colon (n = 128). Overall, 142 patients (75.9%) achieved technical success and 102 patients (54.5%) clinical success. Radiographic presence of peritoneal carcinomatosis (P < .001) and multifocal disease (P < .001) were associated with both decreased technical and clinical success. Procedure-related adverse events were seen in 12 patients (6.4%). In patients with clinical success, the incidence of stent occlusion at 3 months was 14.7% (95% confidence interval, 7.8%-21.6%) and was higher in patients with prior radiation therapy (P = .011). The median overall survival for all patients from time of attempted stent placement was 3.3 months (95% confidence interval, 3.0-4.1).

CONCLUSIONS

This study represents the largest retrospective series of colonic stent placement for LBO in ECM patients in the literature. Our technical success rate of 75.9%, clinical success rate of 54.5%, and 3-month stent occlusion rate of 14.7% suggest that stent placement is a viable palliative option for patients with advanced disease because of ECM. Patients with peritoneal carcinomatosis and multifocal disease have reduced technical and clinical success. However, these factors should not dissuade an attempt at stent placement, if risk-to-benefit analysis is favorable.

The Management of Inoperable Gastrointestinal Obstruction in Terminal Cancer Patients

The aim of the study was to assess vomit and pain control in terminal cancer patients with inoperable gastrointestinal obstruction, using a pharmacologic symptomatic treatment which prevents recourse to nasogastric tube placement and intravenous hydration, in hospital and home care settings. Twenty-two symptomatic patients, who were judged as inoperable, were treated with a pharmacologic association of morphine hydrochloride and scopolamine butylbromide as analgesics and haloperidol as an antiemetic. The drugs were administered by continuous subcutaneous infusion via a syringe driver or intravenously only when a central venous catheter had been inserted previously. Daily recordings included assessment of pain, number of vomiting episodes, dry mouth, drowsiness, and thirst sensation. Data were examined before starting the treatment (T0), 2 days after (T2) and 2 days before death (T-2). They showed that there was a significant decrease in the pain score (p less than 0.001) on T2 and a further decrease on T-2 (p less than 0.05). Vomiting was controlled in all patients, with the exception of three patients with upper abdomen obstruction who required nasogastric tube placement. Dry mouth showed an upward trend throughout the observation period (p less than 0.05) but was successfully treated by administering liquids by mouth or ice-cubes to suck. Drowsiness too presented an upward trend from T0 to T-2 (p less than 0.001). Only one patient out of 16 who reported to be thirsty required intravenous hydration. We believe that in terminal cancer patients, vomit and pain resulting from inoperable intestinal obstruction, with the exception of obstruction of the upper abdomen, can be controlled through administration of analgesic and antiemetic drugs, in the hospital and at home, without recourse to nasogastric tube placement or intravenous hydration.

Decompressive percutaneous endoscopic gastrostomy in advanced cancer patients with small-bowel obstruction is feasible and effective: a large prospective study

PURPOSE

The purpose of this study was to evaluate patient-centered outcomes of decompressive percutaneous endoscopic gastrostomy (dPEG) in patients with malignant bowel obstruction due to advanced gynecological and gastroenteric malignancies.

METHODS

This is a prospective analysis of 158 consecutive patients with small-bowel obstruction from advanced gynecological and gastroenteric cancer who underwent PEG or percutaneous endoscopic jejunostomy (PEJ) positioning for decompressive purposes from 2002 to 2012. All of them had previous abdominal surgery and were unfit for any other surgical procedures. Symptom relief, procedural complications, and post dPEG palliation were assessed. Global Quality of Life (QoL) was evaluated in the last 2 years (25 consecutive patients) before and 7 days after dPEG placement using the Symptom Distress Scale (SDS).

RESULTS

dPEG was successfully performed in 142 out of 158 patients (89.8 %). Failure of tube placement occurred in 16 patients (10.1 %). In 8/142 (5.6 %) patients, dPEG was guided by abdominal ultrasound. In 3/142 patients, dPEG was CT-guided. In 14 (9.8 %) patients, who had previously undergone total or subtotal gastrectomy, decompressive percutaneous endoscopic jejunostomy (dPEJ) was performed. In 1/14 patients, dPEJ was CT-guided. Out of 142 patients, 110 (77.4 %) experienced relief from nausea and vomiting 2 days after PEG. Out of 142 patients, 116 (81.6 %) were discharged. The median postoperative hospital stay was 9 days (range 3-60). Peristomal infection (14 %) and intermittent obstruction (8.4 %) were the most frequent complications associated with PEG. Median survival time was 57 days (range 4-472) after PEG placement. Twenty-five patients had QoL properly evaluated with SDS score before and 7 days after dPEG. Sixteen patients (64 %) out of 25 exhibited an improvement of QoL (p < 0.05), 7 (28 %) patients exhibited a non-significant worsening of QoL (p = 0.18), and in 2 (8 %) patients, it remained unmodified.

CONCLUSIONS

dPEG is feasible, effective, relieves nausea and vomiting in patients with unremitting small-bowel obstruction from advanced gynecological and gastroenteric cancer, and improves QoL.

Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer

BACKGROUND

This is an update of the original Cochrane review published in Issue 4, 2000. Intestinal obstruction commonly occurs in progressive advanced gynaecological and gastrointestinal cancers. Management of these patients is difficult due to the patients' deteriorating mobility and function (performance status), the lack of further chemotherapeutic options, and the high mortality and morbidity associated with palliative surgery. There are marked variations in clinical practice concerning surgery in these patients between different countries, gynaecological oncology units and general hospitals, as well as referral patterns from oncologists under whom these patients are often admitted.

OBJECTIVES

To assess the efficacy of surgery for intestinal obstruction due to advanced gynaecological and gastrointestinal cancer.

SEARCH METHODS

We searched the following databases for the original review in 2000 and again for this update in June 2015: CENTRAL (2015, Issue 6); MEDLINE (OVID June week 1 2015); and EMBASE (OVID week 24, 2015).We also searched relevant journals, bibliographic databases, conference proceedings, reference lists, grey literature and the world wide web for the original review in 2000; we also used personal contact. This searching of other resources yielded very few additional studies. The Cochrane Pain, Palliative and Supportive Care Review Group no longer routinely handsearch journals. For these reasons, we did not repeat the searching of other resources for the June 2015 update.

SELECTION CRITERIA

As the review concentrates on the 'best evidence' available for the role of surgery in malignant bowel obstruction in known advanced gynaecological and gastrointestinal cancer we kept the inclusion criteria broad (including both prospective and retrospective studies) so as to include all studies relevant to the question. We sought published trials reporting on the effects of surgery for resolving symptoms in malignant bowel obstruction for adult patients with known advanced gynaecological and gastrointestinal cancer.

DATA COLLECTION AND ANALYSIS

We used data extraction forms to collect data from the studies included in the review. Two review authors extracted the data independently to reduce error. Owing to concerns about the risk of bias we decided not to conduct a meta-analysis of data and we have presented a narrative description of the study results. We planned to resolve disagreements by discussion with the third review author.

MAIN RESULTS

In total we have identified 43 studies examining 4265 participants. The original review included 938 patients from 25 studies. The updated search identified an additional 18 studies with a combined total of 3327 participants between 1997 and June 2015. The results of these studies did not change the conclusions of the original review.No firm conclusions can be drawn from the many retrospective case series so the role of surgery in malignant bowel obstruction remains controversial. Clinical resolution varies from 26.7% to over 68%, though it is often unclear how this is defined. Despite being an inadequate proxy for symptom resolution or quality of life, the ability to feed orally was a popular outcome measure, with success rates ranging from 30% to 100%. Rates of re-obstruction varied, ranging from 0% to 63%, though time to re-obstruction was often not included. Postoperative morbidity and mortality also varied widely, although again the definition of both of these surgical outcomes differed between many of the papers. There were no data available for quality of life. The reporting of adverse effects was variable and this has been described where available. Where discussed, surgical procedures varied considerably and outcomes were not reported by specific intervention. Using the 'Risk of bias' assessment tool, most included studies were at high risk of bias for most domains.

AUTHORS' CONCLUSIONS

The role of surgery in malignant bowel obstruction needs careful evaluation, using validated outcome measures of symptom control and quality of life scores. Further information could include re-obstruction rates together with the morbidity associated with the various surgical procedures.Currently, bowel obstruction is managed empirically and there are marked variations in clinical practice by different units. In order to compare outcomes in malignant bowel obstruction, there needs to be a greater degree of standardisation of management.Since the last version of this review none of the new included studies have provided additional information to change the conclusions.

Palliative care in patients with ovarian cancer and bowel obstruction

OBJECTIVE

Malignant bowel obstruction (MBO) is usually a pre-terminal event in patients with ovarian cancer. However, because of the lack of data in literature, decisions around surgical intervention, non-resectional procedures, or medical treatment of MBO in patients with ovarian cancer cannot be lightly undertaken. We analyzed medical and surgical procedures, performance status, nutritional status, cachexia, and their prognostic value in this group of patients.

METHODS

We retrospectively selected all consecutive patients with recurrent ovarian cancer who received medical or surgical treatment for MBO between October 2008 and January 2014 at the Academic Department of Gynecological Oncology of Mauriziano Hospital of Turin (Italy).

RESULTS

We found 40 patients: 18 of them underwent medical treatment and 22 of them were submitted to surgery. In the group of surgery, the hospitalization was shorter (p 0.02), the pain reduction was more effective (p 0.001), the number of chemotherapy lines was higher (p 0.03), and re-obstruction was more rare (p 0.02). Between the two groups, we did not find any differences in post-palliation episodes of vomit (p 0.83), type of diet (p 0.34), ability to return home (p 0.72), and death setting (p 0.28). Median survival after palliation was longer in the group of surgery (p 0.025). Cachexia, low performance status, and poor nutritional status were significant predictors of worse survival after MBO, independently by the treatment.

CONCLUSIONS

Surgery has to be considered in patients without serious contraindications; otherwise, a medical protocol, including antisecretory drugs, is the standard of care in frail patients.

Management and outcomes of bowel obstruction in patients with stage IV colon cancer: a population-based cohort study

BACKGROUND

Bowel obstruction is a common complication of late-stage abdominal cancer, especially colon cancer, which has been investigated predominantly in small, single-institution studies.

OBJECTIVE

We used a large, population-based data set to explore the surgical treatment of bowel obstruction and its outcomes after hospitalization for obstruction among patients with stage IV colon cancer.

DESIGN

This was a retrospective cohort study.

SETTING AND PATIENTS

We identified 1004 patients aged 65 years or older in the Surveillance, Epidemiology and End Results-Medicare database diagnosed with stage IV colon cancer January 1, 1991 to December 31, 2005, who were later hospitalized for bowel obstruction.

MAIN OUTCOME MEASURES

We describe outcomes after hospitalization and analyzed the associations between surgical treatment of obstruction and outcomes.

RESULTS

Hospitalization for bowel obstruction occurred a median of 7.4 months after colon cancer diagnosis, and median survival after obstruction was approximately 2.5 months. Median hospitalization for obstruction was about 1 week and in-hospital mortality was 12.7%. Between discharge and death, 25% of patients were readmitted to the hospital at least once for obstruction, and, on average, patients lived 5 days out of the hospital for every day in the hospital between obstruction diagnosis and death. Survival was 3 times longer in those whose obstruction claims suggested an adhesive obstruction origin. In multivariable models, surgical compared with nonsurgical management was not associated with prolonged survival (p = 0.134).

LIMITATIONS

Use of an administrative database did not allow determination of quality of life or relief of obstruction as an outcome, nor could nonsurgical interventions, eg, endoscopic stenting or octreotide, be assessed.

CONCLUSIONS

In this population-based study of patients with stage IV colon cancer who had bowel obstruction, overall survival following obstruction was poor irrespective of treatment. Universally poor outcomes suggest that a diagnosis of obstruction in the setting of advanced colon cancer should be considered a preterminal event.

The role of palliative surgery in gynecologic cancer cases

The decision to undergo major palliative surgery in end-stage gynecologic cancer is made when severe disease symptoms significantly hinder quality of life. Malignant bowel obstruction, unremitting pelvic pain, fistula formation, tumor necrosis, pelvic sepsis, and chronic hemorrhage are among the reasons patients undergo palliative surgeries. This review discusses and summarizes the literature on surgical management of malignant bowel obstruction and palliative pelvic exenteration in gynecologic oncology.

Bowel obstruction in elderly ovarian cancer patients: a population-based study

PURPOSE

Bowel obstruction is a common pre-terminal event in abdominal/pelvic cancer that has mainly been described in small single-institution studies. We used a large, population-based database to investigate the incidence, management, and outcomes of obstruction in ovarian cancer patients.

PATIENTS AND METHODS

We identified patients with stages IC-IV ovarian cancer, aged 65 years or older, in the Surveillance, Epidemiology and End Results (SEER)-Medicare database diagnosed between January 1, 1991 and December 31, 2005. We modeled predictors of inpatient hospitalization for bowel obstruction after cancer diagnosis, categorized management of obstruction, and analyzed the associations between treatment for obstruction and outcomes.

RESULTS

Of 8607 women with ovarian cancer, 1518 (17.6%) were hospitalized for obstruction subsequent to cancer diagnosis. Obstruction at cancer diagnosis (HR=2.17, 95%CI: 1.86-2.52) and mucinous tumor histology (HR=1.45, 95%CI: 1.15-1.83) were associated with increased risk of subsequent obstruction. Surgical management of obstruction was associated with lower 30-day mortality (13.4% in women managed surgically vs. 20.2% in women managed non-surgically), but equivalent survival after 30 days and equivalent rates of post-obstruction chemotherapy. Median post-obstruction survival was 382 days in women with obstructions of adhesive origin and 93 days in others.

CONCLUSION

In this large-scale, population-based assessment of patients with advanced ovarian cancer, nearly 20% of women developed bowel obstruction after cancer diagnosis. While obstruction due to adhesions did not signal the end of life, all other obstructions were pre-terminal events for the majority of patients regardless of treatment.

Outcomes of small bowel obstruction in patients with previous gynecologic malignancies

BACKGROUND

Features predictive of malignant small bowel obstructions among patients with previous gynecologic malignancies remain undetermined.

METHODS

Predictors of malignancy and mortality among patients with gynecologic malignancies and bowel obstructions were identified through a retrospective review of records.

RESULTS

Malignancy was noted among 69.8% of 189 patients included in the analysis. Advanced-stage cancer (P = .006, odds ratio [OR] = 6.62), ovarian malignancy (P = .001, OR = 25.64), and early-onset obstruction (P = .014) predicted malignant etiology, whereas chemotherapy (P < .001, OR = .02) or radiation therapy (P = .027, OR = .09) predicted benign obstruction. The average survival was 9 months versus 49 months for malignant and benign obstructions, respectively. Ovarian cancer (P = .009, hazard ratio [HR] = 4.45), anemia (P = .001, HR = 1.11), and renal dysfunction (P < .001, HR 1.81) impaired survival.

CONCLUSIONS

Palliative care should be considered for patients with advanced-stage cancer, ovarian malignancy, and a shorter time interval between cancer diagnosis and bowel obstruction, especially in the setting of anemia and renal dysfunction.

Outcomes of surgical management of bowel obstruction in relapsed epithelial ovarian cancer (EOC)

OBJECTIVE

To describe the outcomes of surgical management of bowel obstruction in relapsed epithelial ovarian cancer (EOC) so as to define the criteria for patient selection for palliative surgery.

METHODS

90 women with relapsed EOC underwent palliative surgery for bowel obstruction between 1992 and 2008.

RESULTS

Median age at time of surgery for bowel obstruction was 57 years (range, 26 to 85 years). All patients had received at least one line of platinum-based chemotherapy. Median time from diagnosis of primary disease to documented bowel obstruction requiring surgery was 19.5 months (range, 29 days-14 years). Median interval from date of completed course of chemotherapy preceding surgery for bowel obstruction was 3.8 months (range, 5 days-14 years). Ascites was present in 38/90(42%). 49/90(54%) underwent emergency surgery for bowel obstruction. The operative mortality and morbidity rates were 18% and 27%, respectively. Successful palliation, defined as adequate oral intake at least 60 days postoperative, was achieved in 59/90(66%). Only the absence of ascites was identified as a predictor for successful palliation (p=0.049). The median overall survival (OS) was 90.5 days (range, <1 day-6 years). Optimal debulking, treatment-free interval (TFI) and elective versus emergency surgery did not predict survival or successful palliation from surgery for bowel obstruction (p>0.05).

CONCLUSION

Surgery for bowel obstruction in relapsed EOC is associated with a high morbidity and mortality rate especially in emergency cases when compared to other gynaecological oncological procedures. Palliation can be achieved in almost two thirds of cases, is equally likely in elective and emergency cases but is less likely in those with ascites.

Pharmacological treatment of bowel obstruction in cancer patients

INTRODUCTION

Malignant bowel obstruction (MBO) is a common complication of advanced cancer, occurring most frequently in gynaecological and colorectal cancer. Its management remains complex and variable. This is in part due to the lack of evidence-based guidelines for the clinicians involved. Although surgery should be considered the primary treatment, this may not be feasible in patients with a poor performance status or advanced disease. Advances have been made in the medical management of MBO which can lead to a considerable improvement in symptom management and overall quality of life.

AREAS COVERED

This review emphasizes the importance of a prompt diagnosis of MBO with early introduction of pharmacological agents to optimize symptom control. The authors summarize the treatment options available for bowel obstruction in those patients for whom surgical intervention is not a feasible option. The authors also explore the complexities involved in the introduction of parenteral hydration and total parenteral nutrition in this group of patients.

EXPERT OPINION

It is not always easy to distinguish reversible from irreversible bowel obstruction. Early and aggressive management with the introduction of pharmacological agents including corticosteroids, octreotide and anti-cholinergic agents have the potential to maintain bowel patency, and allow for more rapid recovery of bowel transit. A combination of analgesics, anti-emetics and anti-cholinergics with or without anti-secretory agents can successfully improve symptom control in patients with irreversible bowel obstruction.

Surgical management of bowel obstruction in gynaecological malignancies

PURPOSE OF REVIEW

Bowel obstruction in gynaecological malignancies continues to present clinical challenges and a multidisciplinary approach to discuss management is crucial. Surgery, usually with palliative intent, is associated with significant morbidity and mortality. There is an absence of level 1 evidence and national guidelines, and only limited quality-of-life data.

RECENT FINDINGS

Acute bowel obstruction in gynaecological cancer patients is rare and surgery is associated with a higher morbidity and mortality rate. Less commonly, emergency bowel obstruction cases will have had radiotherapy or recent chemotherapy, which also increases surgical morbidity and mortality. However, most often, bowel obstruction in irradiated gynaecological cancer patients is not due to cancer. Ovarian cancer is the most common malignancy. Caution is needed in those EOC patients with ascites, short treatment-free interval, acute abdomen and chemoresistance. Comorbidities are frequent. The decision for surgery should be made on an individual basis. Palliative care input is important early in patient management as for most patients the surgical goal is palliation and not cure. There is still a paucity of published data on quality-of-life assessments.

SUMMARY

There is a need to identify those patients who may benefit from palliative surgical intervention and those who will not. Ideally, agreed national guidelines should be produced and regularly reviewed.

Review article: palliative care in gynecologic oncology

Patients with advanced gynecologic malignancies have a multitude of symptoms; pain, nausea, and vomiting, constipation, anorexia, diarrhea, dyspnea, as well as symptoms resulting from intestinal obstruction, hypercalcemia, ascites, and/or ureteral obstruction. Pain is best addressed through a multimodal approach. The optimum palliative management of end-stage malignant intestinal obstruction remains controversial, with no clear guidelines governing the choice of surgical versus medical management. Patient selection for palliative surgery, therefore, should be highly individualized because only carefully selected candidates may derive real benefit from such surgeries. There remains a real need for more emphasis on palliative care education in training programs.

Palliative surgery versus medical management for bowel obstruction in ovarian cancer

BACKGROUND

Ovarian cancer is the sixth most common cancer among women and is usually diagnosed at an advanced stage. Bowel obstruction is a common feature of advanced or recurrent ovarian cancer. Patients with bowel obstruction are generally in poor physical condition with a limited life expectancy. Therefore, maintaining their QoL with effective symptom control is the main purpose of the management of bowel obstruction.

OBJECTIVES

To compare the effectiveness and safety of palliative surgery (surgery performed to control the cancer, reduce symptoms and improve quality of life for those whose cancer is not able to be entirely removed) and medical management for bowel obstruction in women with ovarian cancer.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, The Cochrane Central Register of Controlled trials (CENTRAL), Issue 1 2009, MEDLINE and EMBASE up to February 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Studies that compared palliative surgery and medical interventions, in adult women diagnosed with ovarian cancer who had either full or partial obstruction of the bowel. Randomised controlled trials (RCTs) and non-RCTs that used multivariable statistical adjustment for baseline case mix were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria, abstracted data and assessed risk of bias. One non-randomised study was identified so no meta-analyses were performed.

MAIN RESULTS

The search strategy identified 183 unique references of which 22 were identified as being potentially eligible on the basis of title and abstract. Only one study met our inclusion criteria and was included in the review. It analysed retrospective data for 47 women who received either palliative surgery (n = 27) or medical management with Octreotide (n = 20) and reported overall survival and perioperative mortality and morbidity. Women with poor performance status were excluded from surgery. Although six (22%) women who received surgery had serious complications of the operation and three (11%) died of complications, multivariable analysis found that women who received surgery had significantly (p < 0.001) better survival than women who received Octreotide, after adjustment for important prognostic factors. However, the magnitude of this effect was not reported. Quality of life (QoL) was not reported and adverse events were incompletely documented.

AUTHORS' CONCLUSIONS

We found only low quality evidence comparing palliative surgery and medical management for bowel obstruction in ovarian cancer. Therefore we are unable to reach definite conclusions about the relative benefits and harms of the two forms of treatment, or to identify sub-groups of women who are likely to benefit from one treatment or the other. However, there is weak evidence in support of surgical management to prolong survival.

Role of computed tomography in the surgical management of patients with bowel obstruction secondary to recurrent ovarian carcinoma

BACKGROUND

The purpose of this study was to evaluate the potential role of preoperative computed tomography (CT) and clinical features for predicting the outcome of patients with bowel obstruction secondary to ovarian cancer.

MATERIALS AND METHODS

We identified a subpopulation of patients admitted to the Massachusetts General Hospital for bowel obstruction caused by recurrent ovarian cancer from January 1, 1995, to August 1, 2007. A retrospective review of 10 clinical features and 6 radiographic findings was performed. These findings were analyzed as variables with probable prognostic influence on survival and ability to predict successful palliation, defined as the ability to tolerate a regular or low-residue diet 60 days after discharge. Statistical significance was evaluated using the Fisher exact test. Univariate analysis was done by constructing probability curves according to the Kaplan-Meier method and comparing them by the log-rank test.

RESULTS

The study population consisted of 55 patients. Absence of carcinomatosis on CT scan and albumin > or = 3 g/dL were found to be able to predict successful palliation. Platinum resistance, albumin > or = 3 g/dL, and peritoneal carcinomatosis on CT scan were identified as variables with prognostic influence on survival in the univariate analysis. In the Cox regression analysis, only the absence of CT findings of carcinomatosis (P = .009) and albumin > or = 3 g/dL (P = .05) were independently associated with survival.

CONCLUSIONS

CT scan seems to be helpful in patients with a solitary site as the cause of bowel obstruction. All the patients in our study with this finding had a successful palliation. On the other hand, successful palliation is still feasible in the presence of peritoneal carcinomatosis on CT scan; therefore, this finding alone should not be the reason to avoid surgery in well-selected patients.

Efficacy of granisetron in the antiemetic control of nonsurgical intestinal obstruction in advanced cancer: a phase II clinical trial

The objective of this study was to assess antiemetic efficacy of granisetron in inoperable intestinal obstruction caused by advanced cancer. The study was open, prospective, and multi-centered. We assessed 24 patients (mean age: 61.3 years; 10 males, 14 females) with intestinal obstruction who were refractory to previous antiemetics. Obstruction involved the upper intestine in six patients, the lower intestine in three, and was at multiple levels in 15. Daily treatment included intravenous granisetron (3mg) and dexamethasone (8 mg); nasogastric drainage was not allowed. Subcutaneous haloperidol was available as rescue therapy. A numeric scale was used to evaluate nausea, pain, asthenia, and anorexia at baseline visit and every 24 hours up to the completion of four days of treatment (final visit). Treatment failure was defined as nausea >4 on the numeric scale, vomiting 2/day or more, and rescue therapy with haloperidol at 5mg/day or more. Of the 24 patients, 23 were evaluable for efficacy. Evaluation pre- vs. post-treatment indicated a significant decrease in the severity of nausea (score 6.9 vs. 0.8; P<0.001), number of episodes of vomiting (5.3 vs. 1.0; P<0.001), and abdominal pain (score 4.4 vs. 1.2; P<0.001). Nausea and vomiting control was achieved in 86.9% of patients. Although there was a trend toward greater efficacy in the lower and multiple levels of obstruction, the differences were not statistically significant owing, probably, to small sample size. We conclude that granisetron may be highly efficacious in the control of emesis resulting from intestinal obstruction caused by metastatic cancer, and can be used effectively in patients refractory to other antiemetics.

Laparoscopic colostomy in gynecologic cancer

STUDY OBJECTIVE

The purpose of our study was to report on our case series of 7 patients with gynecologic cancer who underwent laparoscopic colostomy for elective fecal diversion. Our aim was to retrospectively estimate feasibility, safety, and efficacy of the laparoscopic approach in the setting of gynecologic malignancy, given the high incidence of earlier abdominal surgery and pelvic radiation treatment in this select population.

DESIGN

Retrospective chart review (Canadian Task Force classification I).

SETTING

University of Texas, M.D. Anderson Cancer Center.

PATIENTS

All patients with a history of gynecologic cancers who underwent laparoscopic colostomy during the study period.

INTERVENTIONS

We retrospectively reviewed all patients who underwent elective laparoscopic diverting colostomy in our department of gynecologic oncology. Surgical indications, medical history, operative and stomal complications, estimated blood loss, return of bowel function, and length of hospital stay were collected.

MEASUREMENTS AND MAIN RESULTS

Seven patients underwent laparoscopic colostomy during the study period. Six of these patients underwent an end descending colostomy, and 1 patient underwent a loop colostomy. Indications included rectovaginal fistula (n = 5), colonic/pelvic fistula (n = 1), or large bowel obstruction (n = 1). No intraoperative or postoperative complications occurred, nor did any conversions to laparotomy. The median blood loss was 50 mL (range 10-75). Median operative time was 102 minutes (range 69-159). Six (86%) patients had a history of pelvic radiation. In addition, 3 (43%) patients had a history of laparotomy. The median patient weight was 59.8 kg (range 47.1-82.2). The median time to tolerance of a regular diet was 2 days (range 1-3) and the median length of hospital stay was 3 days (range 2-4). No immediate or delayed stomal complications were noted with a median follow-up of 6 months (range 1-15).

CONCLUSION

Laparoscopic colostomy in advanced gynecologic cancer may be a safe and feasible technique with minimal morbidity, rapid return of bowel function, and short hospital stay.

An analysis of surgical versus chemotherapeutic intervention for the management of intestinal obstruction in advanced ovarian cancer

The objective of this study was to compare the treatment outcomes of surgical versus chemotherapeutic interventions for the management of intestinal obstruction secondary to metastatic epithelial ovarian cancer. A retrospective analysis of 39 patients with epithelial ovarian cancer who had 98 events of intestinal obstruction was performed. A medical records review of patients treated for advanced ovarian cancer from 1973 to 2003 was conducted. Time from treatment to obstruction, complications, and predictors of outcome were analyzed. Mean time from diagnosis of cancer to first obstruction was 38 months (range, 7-234 months). Of 39 patients with obstruction, 5% were stage I, 2% stage II, 85% stage III, and 8% stage IV. Prior to first obstruction, the median number of prior surgeries was 2 and chemotherapy regimens 3. Sites of the 98 events of obstruction were small intestine, 79 (81%); large intestine, 8 (8%); and combined small and large intestines, 11 (11%). The mean time to re-obstruction was 6.4 months (0-24) for chemotherapy, 5.1 months (0-40) for surgery, and 1.9 months (0-15) for supportive care. The mean hospital stays were 7 days (2-10) for chemotherapy, 18 days (3-50) for surgery, and 7 days (0-20) for supportive care. There were 4 major complications in the chemotherapy patients, 11 in the surgical patients, and 2 in the supportive only patients. The only significant factor predictive of > or =6 month obstruction-free period was prior response to platinum-based chemotherapy. Of the 13 patients with a response to chemotherapeutic or surgical treatment, 46% had an initial response to platinum-based chemotherapy, while 27% of 22 patients who re-obstructed in <6 months were platinum sensitive. In this retrospective analysis of selected patients, surgery and chemotherapy were found to have similar outcomes. The surgical approach had higher morbidity. The best predictor of either treatment's effectiveness is tumor sensitivity to platinum-based chemotherapeutic agents (P= 0.168).

Palliative care for intestinal obstruction in recurrent ovarian cancer: a multivariate analysis

Bowel obstruction is the most common complication in patients with ovarian cancer. Management of this situation is controversial. The aim of our retrospective study was to determine the best approach for managing bowel obstruction in recurrent ovarian cancer. A retrospective analysis of data on 47 patients with intestinal obstruction by ovarian cancer was performed. Twenty-seven patients were submitted to surgery, with 21 intestinal procedures performed, 2 gastrostomy tubes placed, and 4 patients deemed inoperable. Twenty patients were managed medically with Octreotide (mean dosage of 0.48 mg/day), of which 1 patient required a nasogastric tube. Age, performance status, diagnosis of tumor to occlusion time, obstruction site, previous chemotherapy or radiotherapy, presence of ascites, or palpable masses were the variables analyzed. Student's t-test and Pearson chi-square test were used to compare the two different groups of treatment (surgical vs medical therapy). Disease-free-survival curves were plotted according to the Kaplan-Meier method and analyzed by the log-rank test. Cox's proportional hazards model was used for multivariate analysis. Values less than or equal to 0.05 were considered significant. The mean age of the patients was 58.7 years. Perioperative mortality and morbidity were both 22%. All patients died with minimal distress. Performance status results were significantly different between the patients submitted to surgery and patients treated with Octreotide (P= 0.03). No significant differences were found in the other variables analyzed. In multivariate analysis, only type of treatment emerges as a strong predictor of poor outcome (P < 0.001). Both surgery and Octreotide therapy are able to control distressing symptoms in end-stage ovarian cancer. Survival was significantly longer in the surgical group, and surgical palliation should be considered first in patients with good performance status.

Management of opioid-induced bowel dysfunction in cancer patients

The gastrointestinal (GI) effects of morphine and other opioids may result in opioid-induced bowel dysfunction (OBD) and the need for treatment. Although OBD is very common in morphine-treated patients, it is usually under-diagnosed. Opioids deliver their GI effect through central and peripheral mechanisms. Laxatives are the pharmaceuticals prescribed most in this area. Prokinetics as well as cholinergic agonists have been used satisfactorily. One-third of patients with OBD have to be treated rectally. The use of opioid antagonists has been favored, but the bioavailability of oral forms is poor. Opioid antagonists with a quaternary structure have a high affinity for peripheral opioid receptors and therefore do not interfere with the analgesia, nor do they generate alkaloid withdrawal syndrome. Opioid rotation is another strategy for maintaining or improving analgesic quality directed toward decreasing the effects of previous opiates on the GI tract.

Reoperation for palliation of recurrent malignant bowel obstruction in ovarian carcinoma

OBJECTIVE

While initial surgical treatment for palliation of malignant bowel obstruction is well described, data on reoperation for palliation of recurrent obstruction in ovarian carcinoma are limited. The purpose of this study was to analyze the outcome of patients undergoing reoperation for repeat bowel obstruction.

METHODS

We reviewed the records of all patients with ovarian cancer who underwent repeat surgery for recurrent, malignant bowel obstruction at our institution between 1994 and 2002.

RESULTS

Ten patients were identified. All patients had bowel obstruction caused by recurrent ovarian carcinoma and had a previous corrective surgical procedure for malignant bowel obstruction. The mean age at diagnosis of repeat obstruction was 54.1 years (range, 34-74 years). All patients had initial stage III or IV disease with moderately to poorly differentiated cancers. No patient received prior radiation therapy. The sites of obstruction in patients were as follows: small bowel, 3; large bowel, 3; both small and large bowel, 4. The mean number of prior laparotomies was 2.7 (range, 2-5). The mean interval from previous surgery for bowel obstruction to recurrent bowel obstruction was 8.3 months (range, 1-22 months). Surgical correction was possible in 5 (50%) of 10 patients, with 3 (60%) of these 5 patients obtaining successful palliation. Successful palliation is defined as the ability to tolerate a regular or low-residue diet at least 60 days postoperatively. Complications included enterocutaneous fistulas in three patients (two had enterotomies at time of surgery) and wound infection in one patient. There were no postoperative mortalities. The mean postoperative stay was 15.8 days (range, 8-29 days). Two of the three patients successfully palliated presented with a subsequent obstruction at 3 and 5 months postoperatively and were treated with gastrostomy tubes. The median length of survival for the entire cohort from the date of surgery for repeat obstruction was 4.5 months (range, 3-17 months).

CONCLUSIONS

Patients undergoing repeat surgery for recurrent bowel obstruction have a low likelihood of successful palliation (30%). The surgery is associated with significant complications after surgery, rapid development of subsequent bowel obstructions, and limited survival rates. Alternative management approaches such as percutaneous endoscopic gastrostomy (PEG) tube placement should be considered in this group of patients.

Spontaneous Enterocutaneous Fistula 27-years Following Radiotherapy in a Patient of Carcinoma Penis

Background

Radiotherapy in the radical doses can produce severe and often irreversible damage to the gut in the form of fibrosis, necrosis and fistulae formation. A previous pelvic surgery makes the gut extra-vulnerable. This is on account of adhesions to the pelvic wall, unless special care is taken during surgery to keep it out of the harms way, during adjuvant radiotherapy. These effects range from acute, to sub acute and delayed chronic manifestations like in the reported case.

Case report

A spontaneous low out put enterocutaneous fistula in a 68-year-old man following surgery and adjuvant radiotherapy given 27 years back for carcinoma penis is reported. Patient is making a satisfactory progress after three years of follow-up.

Conclusion

High dose external beam radiotherapy is known to produce deleterious side effects ranging from mild radiation enteritis to the development of internal and external fistulae. The effects may be acute, subacute or chronic. Presentation as spontaneous enterocutaneous fistula 27 years after radiotherapy is rare.

The utility of gastrojejunostomy in secondary cytoreduction and palliation of proximal intestinal obstruction in recurrent ovarian cancer

BACKGROUND

Gastrointestinal obstruction is a common complication of recurrent ovarian cancer. Proximal intestinal obstruction, at the level of the duodenum or proximal jejunum, can result from bulky intraperitoneal or retroperitoneal disease. Classic management has been palliation of symptoms with a gastrostomy or jejunostomy tube.

CASE

We describe a series of four patients with recurrent ovarian carcinoma and proximal intestinal obstructions treated with a bypass stapled side-to-side gastrojejunostomy at the time of secondary cytoreduction or surgical palliation. The clinical history, preoperative evaluation, surgical technique, and outcomes of each patient are reviewed.

CONCLUSIONS

Gastrojejunostomy may offer patients with ovarian cancer and a proximal intestinal obstruction symptomatic relief and an opportunity for resumption of enteral feedings.

Recent advances in malignant bowel obstruction: an interface of old and new

Malignant bowel obstruction continues to be a difficult problem for patients with abdominal and pelvic primary tumors and tumors originating in other sites. The main treatment options consist of surgery, stenting, and pharmacotherapy. Despite recent advances, the impact of available treatment modalities on symptom control, longevity, quality of life, and associated health care costs have not been evaluated rigorously. This article reviews the available data and suggests an approach to the management of this challenging patient population.

Palliative surgery for bowel obstruction in recurrent ovarian cancer:an updated series

OBJECTIVE

Intestinal obstruction is a frequent sequela of recurrent ovarian cancer. Previous series report median survivals of 3-6 months in patients undergoing surgery for obstruction due to recurrent disease. We analyze a contemporary series of patients to determine if outcomes have changed in patients undergoing palliative surgery.

METHODS

We retrospectively reviewed all patients undergoing surgery for intestinal obstruction due to recurrent ovarian cancer from 1994 to 1999.

RESULTS

During the study period, 68 operations were performed on 64 patients. Mean age at the time of obstruction was 57.3 years. Mean time from original diagnosis of ovarian cancer to obstruction was 2.8 years. Surgical correction (intestinal surgery performed for relief of obstruction) was attained in 57 of 68 (84%) cases. Successful palliation (the ability to tolerate a regular or low-residue diet at least 60 days postoperatively) was achieved in 71% of cases where surgical correction was possible. The rate of major surgical morbidity was 22%. There was one death from pulmonary embolus and one from peritonitis. Two other deaths occurred due to progression of disease, for an overall perioperative mortality rate of 6%. Postoperative chemotherapy was administered in 45 of 57 (79%) cases where surgical correction was possible. The median survival of the entire cohort was 8 months. If surgery resulted in successful palliation, median survival was 11.6 months, versus 3.9 months for all other patients (P <.01).

CONCLUSIONS

The majority of our patients undergoing surgery had successful palliation, and were able to receive further chemotherapy. They were discharged home, and could tolerate solid food.

Ovarian cancer in Western Australia (1982-1998): trends in surgical intervention and relative survival

OBJECTIVES

We aimed to review the utilisation and trends in surgical procedures for the primary management of ovarian cancer and the survival outcomes of patients surgically treated in Western Australia.

METHODS

The population-based Western Australia Data Linkage System was used to link hospital morbidity and mortality data for all women diagnosed with malignant primary ovarian cancer in the State Cancer Registry in the period 1982-1998. Poisson regression was used to analyse trends in surgical procedure rates. Logistic regression examined the likelihood of having a surgical procedure in the periods 1988-1993 and 1994-1998 compared with 1982-1987. Relative survival was used to adjust survival estimates for other causes of death occurring in the general female population.

RESULTS

There were 1,126 women who underwent a primary surgical procedure for ovarian cancer in Western Australia in the period 1982-1998. Women were more likely to undergo surgery in 1994-1998 (87.8%) compared with 1988-1993 (76.8%), but there was no difference when compared to 1982-1987 (89.2%) (P = 0.62). The likelihood of using specific surgical procedures to treat ovarian cancer increased for all but total abdominal hysterectomy. Bilateral salpingo-oophorectomy was 3.7 times more likely to be performed and omentectomy 5 times more likely to be performed in 1994-1998 compared with 1982-1987. The median length of hospital stay decreased from 15 to 12 days and emergency admissions decreased from 26.5 to 15.4% over the three time periods. Thirty-two percent of women were readmitted within 30 days of separation from their primary surgery, 23% of which were for the same-day treatment with either chemotherapy or radiotherapy. A 15% increase in relative survival was observed between the periods 1982-1997 (38.8%) and 1994-1998 (53.5%).Conclusion.

CONCLUSION

Surgery remains a cornerstone in the primary management of ovarian cancer. There have been dramatic shifts in surgical practice in Western Australia, with more women undergoing certain surgical procedures today than they were 20 years ago. Coupling the increasing surgical trends are improved outcomes. Fewer women are presenting as an emergency, the length of hospital stay has been reduced, and survival outcomes have shown a significant improvement.

Palliative management of malignant bowel obstruction

Bowel obstruction may be a mode of presentation of intra-abdominal and pelvic malignancy or a feature of recurrent disease following anticancer therapy. Malignant bowel obstruction is well-recognized in gynecologic patients with advanced cancer. Retrospective and autopsy studies found the frequency at approximately 5-51% of patients with gynecological malignancy(1-7). Malignant bowel obstruction (MBO) is particularly frequent in patients with ovarian cancer where it is the most frequent cause of death(7). Patients with stage III and IV ovarian cancer and those with high-grade lesions are at higher risk for MBO as compared to patients with lower stage or low-grade tumors(1,8). Ovarian carcinoma accounted for 50% of small bowel obstruction and 37% of large bowel obstruction treated in a large gynecological oncology service(8-11).

Survival and quality of life after palliative surgery for neoplastic gastrointestinal obstruction

OBJECTIVE

The aim was to identify the prognostic factors which relate to the results, in terms of survival and quality of life, of palliative surgery in cancer patients presenting with an occlusion.

METHODS

The files of 109 patients with a neoplasm who were operated on for occlusion between 1990 and 2000 have been re-examined. The prognostic factors studied were age, sex, the location of the primary tumour, the extension of the cancer at the time of the operation, and the surgical procedure carried out. The impact on the quality of life was assessed by the resumption of transit and the return home.

RESULTS

The median survival was 64 days and the peroperative mortality was 21%. The quality of life of patients has been improved in 65% of cases. The only factors clearly correlating to survival and the success of the operation are the aetiological diagnosis of the occlusion (local recurrence better than carcinomatosis) and the type of procedure it was possible to carry out (resection better than bypass).

CONCLUSION

Palliative surgery can, in a certain number of cases, improve the quality of life of patients, but it has not been possible for us to demonstrate prognostic factors which would allow the selection of patients who could benefit the most from such surgery.

[Intestinal obstruction in cancer patients: results of palliative surgery]

OBJECTIVE

The study aim was to investigate predictive factors related to the results, in terms of survival and quality of life, of palliative surgery in cancer patients presenting with intestinal obstruction.

METHODS

A total of 109 patients already treated for a neoplasm were operated on for intestinal obstruction between 1990 and 2000. The investigated prognostic factors were age, sex, location of the primary tumour, extension of the cancer at the time of the operation and the surgical procedure carried out. The impact on the quality of life was assessed by the resumption of intestinal transit and the return home.

RESULTS

The median survival rate was 64 days and the postoperative mortality rate 21%. The quality of life was improved in 65% of the patients. The only factors clearly correlated with survival and the success of the operation were the aetiological diagnosis of the intestinal obstruction and the type of procedure which was possible to carry out.

CONCLUSION

Palliative surgery may improve the quality of life of a certain number of patients, but it was not possible to demonstrate predictive factors for the selection of patients who could have the larger benefits of such surgery.

Recurrent ovarian carcinoma: is there a place for surgery?

The role of cytoreductive surgery is well established in patients with primary ovarian carcinoma. Minimal residual disease translates to improved response to adjuvant treatment and prolonged survival. For close clinical follow-up, different approaches may be helpful in detecting recurrent disease, including regular physical/pelvic examination, serial CA-125 levels, and imaging studies using computerized tomography, magnetic resonance imaging, or positron emission testing. At recurrence, those patients with a good performance status, a good response to primary therapy, and a macronodular tumor distribution pattern may be candidates for a secondary cytoreductive procedure. Data suggests that secondary cytoreduction is superior to chemotherapy alone in patients who have a significant disease-free interval (6 to 12 months). Survival after secondary cytoreduction is optimized with cytoreduction to microscopic disease, yet there is a recognized risk of surgical morbidity. Therefore, a strong relationship between the gynecologic oncology surgeon and the patient is key to obtaining appropriate informed consent and relaying appropriate outcome expectations.

Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer

BACKGROUND

Intestinal obstruction commonly occurs in progressive advanced gynaecological and gastrointestinal cancers. Management of these patients is difficult due to the patients deteriorating mobility and function (performance status), the lack of further chemotherapeutic options and the high mortality and morbidity associated with palliative surgery. There are marked variations in clinical practice concerning surgery in these patients between different countries, gynaecological oncology units, and general hospitals as well as referral patterns from oncologists under whom these patients are often admitted under. There is therefore a need for all the present information to be collated, analysed (with appropriate palliative care outcomes) to establish if surgery is of benefit and what further research is needed.

OBJECTIVES

The objective was to locate, appraise and summarise evidence from scientific studies on intestinal obstruction due to advanced gynaecological and gastrointestinal cancer, in order to assess the efficacy of surgery.

SEARCH STRATEGY

A comprehensive list of studies was provided by an extensive search of electronic databases, relevant journals, bibliographic databases, conference proceedings, reference lists, the grey literature, personal contact and the world wide web.

SELECTION CRITERIA

As the review concentrates on the 'best evidence' available of the role of surgery in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer the inclusion criteria were kept broad (included both prospective and retrospective studies) so as to include all studies relevant to the question.

DATA COLLECTION AND ANALYSIS

Data extraction forms were used to collect data from the studies included in the review. Two researchers extracted the data independently to reduce error. Due to the methodological quality of the studies, only a qualitative assessment was possible.

MAIN RESULTS

The role of surgery in malignant bowel obstruction remains controversial, and no firm conclusions from the many retrospective case series can be made. Control of symptoms varies from 42% to over 80%, though it is often unclear how symptoms were measured and whether the tools used to collect symptom scores are validated. There is a large range in the rates of re-obstruction, from 10-50%, though time to re-obstruction was often not included. There is a wide range of postoperative morbidity and mortality, although again the definition of both these surgical outcomes varied between many of the papers.

REVIEWER'S CONCLUSIONS

The role of surgery in malignant bowel obstruction needs careful evaluation, using validated outcome measures of symptom control and quality of life scores. Further information would include re-obstruction rates together with the morbidity associated with the various surgical procedures. Currently, bowel obstruction is managed empirically, and there are marked variations in clinical practice by different units. There needs to be a greater standardisation of management so that comparisons between different series can be made.

Gastrostomy tubes in patients with recurrent gynaecological cancer and intestinal obstruction

OBJECTIVE

Women with recurrent gynaecological cancers who are not suitable for exenterative surgery commonly present with gastrointestinal dysfunction. This paper is a retrospective review of the use of gastrostomy tubes in such women.

METHODS

We performed a chart review of women with recurrent gynaecological cancer who had a gastrostomy tube placed between January 1991 and April 1998.

RESULTS

Thirty-nine women (mean age 53.2 years, range 17-82) had a gastrostomy tube placed. Twenty-eight (72%) had ovarian cancer, eight (21%) had cervical cancer, two had endometrial cancer and one had vaginal cancer. In 14 women a gastrostomy tube was placed as the sole procedure for palliation (11 elective, 3 emergency). In the remaining 25 women, who underwent major surgery, a gastrostomy tube was placed in anticipation of, or in the presence of, significant intestinal distension and expected prolonged post-operative ileus. Eleven women (28%) died without leaving hospital after their operation (median 11 days, range 2-36). All but one of the 28 women who left hospital had satisfactory oral intake. Twenty-one women (54%) died with the gastrostomy tube in place (median 28 days, range 2-157) and 18 (46%) had the gastrostomy tube removed (median 14.5 days, range 9-180), 13 of whom (33%) have since died (median 167 days, range 77 days-7 years). Five women (13%) are alive (median 2.2 years, range 10 months-4.5 years). There were no problems which required the gastrostomy tube to be removed.

CONCLUSION

Gastrostomy tubes have an important role in the treatment of women with recurrent gynaecological cancer, allowing gastric drainage and decompression without the disadvantages of nasogastric tubes.

Salvage therapy for ovarian cancer

The majority of patients with ovarian cancer will relapse after initial chemotherapy and will be candidates for salvage treatment. Currently, five agents show clear activity in patients with platinum- and paclitaxel-resistant disease: topotecan, oral etoposide, liposomal doxorubicin, gemcitabine, and, possibly, docetaxel. In addition, other agents have activity in platinum-resistant patients: vinorelbine, tamoxifen, ifosfamide, altretamine, 5-fluorouracil with leucovorin, and, possibly, irinotecan. Furthermore, selected patients may benefit from other therapeutic approaches such as surgery or radiation therapy.

Integrating medical and surgical treatments in gastrointestinal, genitourinary, and biliary obstruction in patients with cancer

Although local expertise needs to be considered, the following general guidelines for the palliation of malignant biliary obstruction have been proposed: (1) patients in good general condition with small tumors should undergo laparotomy to assess resectability and undergo surgical bypass; (2) patients with advanced disease and poor general condition are suitable for endoscopic stenting to reduce jaundice, pruritus, and risk of cholangitis; (3) patients with poor cognition and limited life expectancy should be managed pharmacologically as appropriate; and (4) research is required to assess optimal management for patients between these extremes; however, clinicians can use the previously described guidelines to make these difficult management decisions.

Surgical management of ovarian cancer

Although several surgical approaches to the diagnosis and management of epithelial ovarian cancer are now standard, surprisingly few prospective data exist to support many of these procedures. However, retrospective data have accumulated over the past decade, much of it very recent, which allow clinicians to make informed decisions regarding most of the commonly performed procedures. This review is an attempt to critically evaluate the best available data regarding the following procedures: primary surgical staging, primary cytoreductive surgery, second look laparotomy and secondary cytoreductive surgery, and palliative surgery for relief of bowel obstruction. We conclude that there is evidence to support the continued use of primary surgical staging and primary cytoreductive surgery. However, data in support of second look laparotomy and secondary cytoreductive surgery are lacking, and we recommend that these procedures not be performed on a routine basis. Finally, we conclude that palliative surgery is hazardous at best and results in questionable benefits for most patients.

Management of bowel obstruction in advanced cancer patients

Bowel obstruction is a common and distressing outcome in patients with abdominal or pelvic cancer. While surgery must remain the primary treatment for malignant obstruction, it is now recognized that there is a group of patients with advanced disease or poor general condition who are unfit for surgery and require alternative management to relieve distressing symptoms. A number of treatment options are now available for the patient with advanced cancer who develops intestinal obstruction. This review examines the indications for surgery, the use of nasogastric tube and percutaneous gastrostomy, and the place of drugs for symptom control.

Management of bowel obstruction in patients with advanced ovarian cancer

In a retrospective study, 58 patients with bowel obstruction due to advanced ovarian cancer were analysed. In a forward stepwise proportional hazard regression analysis, we looked for factors influencing bowel obstruction-free survival. Patients who presented with bowel obstruction as the first sign of ovarian cancer and those with a longer interval between last cancer treatment and bowel obstruction did better. Patients with ascites did worse. No other independent factors were found. Based on these data, we classified patients into a favourable prognosis group (no previous treatment or interval since last treatment exceeding 6 months; no ascites) and a poor prognosis group (interval since last treatment shorter than 6 months; ascites). Patients from the favourable prognosis group had a median bowel obstruction-free survival of 8 months, compared to 1 month for the poor prognosis group (P < 0.001). Surgery had a marginally significant positive effect on bowel obstruction-free survival when compared to medical treatment in the favourable prognosis group (P = 0.052). Surgery had no effect at all in the poor prognosis patients.

Intestinal obstruction in patients with widespread intraabdominal malignancy

The clinical course of 28 patients with surgically documented widespread intraabdominal malignancy who developed intestinal obstruction was reviewed. Of 26 patients, 13 responded to initial conservative management. In the ten patients treated surgically, there was significant morbidity in 80% and a postoperative mortality of 40%. Reobstruction occurred in 11 patients, responded poorly to therapy, and was associated with a short life expectancy. These results support the use of conservative therapy in the management of intestinal obstruction due to widespread intraabdominal malignancy, with emphasis on the palliation of symptoms and maintenance of quality of life.

Percutaneous endoscopic gastrostomy for decompression of the stomach and small bowel

Percutaneous endoscopic gastrostomies are used most commonly for enteral feeding. We report the use of such gastrostomies for decompression of the obstructed gastrointestinal tract. Percutaneous endoscopic gastrostomies were performed on 53 patients over a 2-year period for gastrointestinal decompression because of gastric or small bowel obstruction. Forty-six patients had malignant obstruction from a primary abdominal or metastatic carcinoma and 7 patients had non-malignant obstruction or stasis. Gastrostomy for decompression was successful in 41 of 46 (89%) cases of malignant obstruction and in all 7 of the non-malignant cases. Tube utilization for decompression averaged 60 +/- 91 days. A 28 F tube with a 4-inch perforated intragastric portion was fashioned to maximize drainage. This efficient decompression tube allowed oral intake of liquids and soft foods in 88% of patients. Complications, which occurred in 4%, included one case of fatal peritonitis and one case of cellulitis.

Complications of colostomy performed on gynecologic cancer patients

From 1/1/80 to 5/31/90 111 patients underwent a colostomy on a gynecologic oncology service. Six patients developed 7 (6.3%) early colostomy-related complications, including sepsis (1), stomal retraction (1), ostomy wound infection (3), and partial stomal obstruction (2). The sepsis was felt to be related to spillage of stool upon maturing the colostomy, and this patient expired on Postoperative Day 63. There were no other mortalities attributed to the colostomies. Fourteen patients developed 17 (15.3%) delayed colostomy-related complications, including parastomal hernia (5), stomal retraction (1), stomal prolapse (3), tumor replacement (2), and site-choice problems (6). These results compare favorably with those in the literature and support the continued role of the gynecologic oncologist in gynecologic cancer-related gastrointestinal surgery.