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Wan Bahrum WFIB, Hardy J, Foster K, Good P. Oral water-soluble contrast for malignant bowel obstruction: open label pilot study. BMJ Support Palliat Care 2024; 13:e794-e797. [PMID: 35045980 DOI: 10.1136/bmjspcare-2021-003444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/27/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Malignant bowel obstruction (MBO) is a common, challenging condition in advanced cancer. Oral water-soluble contrast medium (Gastrografin) has been used in the management of MBO without quality studies of its effectiveness and safety. The purpose of this study was to evaluate the feasibility, effectiveness and adverse effects of Gastrografin in patients with MBO and to assess feasibility of the study protocol. METHODS A prospective, interventional, single-arm, open label study of Gastrografin across two centres. Patients with unresolved inoperable MBO after 24 hours of conservative medical management were given a single dose of 100 mL of oral Gastrografin. RESULTS Over 33 months, 69 individual patients were screened. Of the 20 recruited, 17 completed study assessments (85%). MBO resolved in 10 of 17 patients (59%). Gastrografin passed through to the rectum in 14 patients (78%). The most common adverse effects were diarrhoea, vomiting, nausea and abdominal pain. CONCLUSIONS Patient recruitment took longer than anticipated, but the study protocol is feasible. Gastrografin was found to be a relatively effective option for the treatment of MBO. An adeqautely powered randomised controlled trial is needed to formally assess the efficacy and safety of Gastrografin© in MBO.
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Affiliation(s)
- Wan Fadzrul Izuan Bin Wan Bahrum
- Palliative and Supportive Care, Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
- Department of Palliative Care, St Vincent's Private Hospital, Brisbane, Queensland, Australia
| | - Janet Hardy
- Palliative and Supportive Care, Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
- Mater Research - University of Queensland, South Brisbane, Queensland, Australia
| | - Karyn Foster
- Palliative and Supportive Care, Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
- Mater Research - University of Queensland, South Brisbane, Queensland, Australia
| | - Phillip Good
- Palliative and Supportive Care, Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
- Department of Palliative Care, St Vincent's Private Hospital, Brisbane, Queensland, Australia
- Mater Research - University of Queensland, South Brisbane, Queensland, Australia
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2
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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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3
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Walter M, Hansen E, Hamid S, Carozza D, Mann G, Roche C, George A, Attwood K, Case A. Palliative Management of Inoperable Malignant Bowel Obstruction: Prospective, Open Label, Phase 2 Study at an NCI Comprehensive Cancer Center. J Pain Symptom Manage 2024; 67:20-26. [PMID: 37769820 DOI: 10.1016/j.jpainsymman.2023.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/06/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023]
Abstract
CONTEXT Malignant bowel obstruction (MBO) is a common complication of intra-abdominal cancer, frequently seen in advanced gastrointestinal and gynecologic cancer. Management of MBO can be challenging, particularly if the patient is not a surgical candidate. No consensus exists on how best to manage these patients medically. Retrospective studies suggest that the combination of dexamethasone, octreotide and metoclopramide may lead to relief of obstruction and improvement in symptoms associated with the obstruction. OBJECTIVES This study seeks to prospectively evaluate the combination of drug "triple therapy" dexamethasone 4 mg BID, metoclopramide 10 mg Q6 and octreotide 300 mcg TID to assess tolerability, safety, and effect on symptoms and deobstruction. METHODS Adults admitted at Roswell Park Comprehensive Cancer Center with malignant bowel obstruction were eligible. Eligible patients who constented to the study were started on the triple therapy with close monitoring of symptoms and for adverse effects. RESULTS A total of 15 patients enrolled in the study. Two patients experienced bradycardia as adverse effect and there was no incidence of bowel perforation. All patients who completed the study had complete resolution of their nausea, and improvement in other symptoms including pain, constipation, tolerance of oral intake and resumption of bowel movements. Only two of the 15 patients were alive to complete the six-month post study follow up. CONCLUSION "Triple therapy" with dexamethasone, metoclopramide, and octreotide for management of nonsurgical MBO in this small sample size appears safe and well tolerated however a diagnosis of inoperable MBO remains associated with poor prognosis and death within months.
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Affiliation(s)
- Michelle Walter
- Department of Palliative and Supportive Care (M.W., E.H., D.C., A.C.), Rowell Park Comprehensive Cancer Center, Buffalo, NY, USA.
| | - Eric Hansen
- Department of Palliative and Supportive Care (M.W., E.H., D.C., A.C.), Rowell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Showkat Hamid
- Department of Medicine (S.H.), Rowell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Desi Carozza
- Department of Palliative and Supportive Care (M.W., E.H., D.C., A.C.), Rowell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Gary Mann
- Department of Surgical Oncology (G.M.), Rowell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Charles Roche
- Department of Diagnostic Radiology (C.R.), Rowell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Anthony George
- Department of Biostatistics and Bioinformatics (A.G., K.A.), Rowell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Kristopher Attwood
- Department of Biostatistics and Bioinformatics (A.G., K.A.), Rowell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Amy Case
- Department of Palliative and Supportive Care (M.W., E.H., D.C., A.C.), Rowell Park Comprehensive Cancer Center, Buffalo, NY, USA
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Krouse RS, Anderson GL, Arnold KB, Thomson CA, Nfonsam VN, Al-Kasspooles MF, Walker JL, Sun V, Alvarez Secord A, Han ES, Leon-Takahashi AM, Isla-Ortiz D, Rodgers P, Hendren S, Sanchez Salcedo M, Laryea JA, Graybill WS, Flaherty DC, Mogal H, Miner TJ, Pimiento JM, Kitano M, Badgwell B, Whalen G, Lamont JP, Guevara OA, Senthil MS, Dewdney SB, Silberfein E, Wright JD, Friday B, Fahy B, Anantha Sathyanarayana S, O'Rourke M, Bakitas M, Sloan J, Grant M, Deutsch GB, Deneve JL. Surgical versus non-surgical management for patients with malignant bowel obstruction (S1316): a pragmatic comparative effectiveness trial. Lancet Gastroenterol Hepatol 2023; 8:908-918. [PMID: 37541263 PMCID: PMC10530384 DOI: 10.1016/s2468-1253(23)00191-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Malignant small bowel obstruction has a poor prognosis and is associated with multiple related symptoms. The optimal treatment approach is often unclear. We aimed to compare surgical versus non-surgical management with the aim to determine the optimal approach for managing malignant bowel obstruction. METHODS S1316 was a pragmatic comparative effectiveness trial done within the National Cancer Trials Network at 30 hospital and cancer research centres in the USA, Mexico, Peru, and Colombia. Participants had an intra-abdominal or retroperitoneal primary cancer confirmed via pathological report and malignant bowel disease; were aged 18 years or older with a Zubrod performance status 0-2 within 1 week before admission; had a surgical indication; and treatment equipoise. Participants were randomly assigned (1:1) to surgical or non-surgical treatment using a dynamic balancing algorithm, balancing on primary tumour type. Patients who declined consent for random assignment were offered a prospective observational patient choice pathway. The primary outcome was the number of days alive and out of the hospital (good days) at 91 days. Analyses were based on intention-to-treat linear, logistic, and Cox regression models combining data from both pathways and adjusting for potential confounders. Treatment complications were assessed in all analysed patients in the study. This completed study is registered with ClinicalTrials.gov, NCT02270450. FINDINGS From May 11, 2015, to April 27, 2020, 221 patients were enrolled (143 [65%] were female and 78 [35%] were male). There were 199 evaluable participants: 49 in the randomised pathway (24 surgery and 25 non-surgery) and 150 in the patient choice pathway (58 surgery and 92 non-surgery). No difference was seen between surgery and non-surgery for the primary outcome of good days: mean 42·6 days (SD 32·2) in the randomised surgery group, 43·9 days (29·5) in the randomised non-surgery group, 54·8 days (27·0) in the patient choice surgery group, and 52·7 days (30·7) in the patient choice non-surgery group (adjusted mean difference 2·9 additional good days in surgical versus non-surgical treatment [95% CI -5·5 to 11·3]; p=0·50). During their initial hospital stay, six participants died, five due to cancer progression (four patients from the randomised pathway, two in each treatment group, and one from the patient choice pathway, in the surgery group) and one due to malignant bowel obstruction treatment complications (patient choice pathway, non-surgery). The most common grade 3-4 malignant bowel obstruction treatment complication was anaemia (three [6%] patients in the randomised pathway, all in the surgical group, and five [3%] patients in the patient choice pathway, four in the surgical group and one in the non-surgical group). INTERPRETATION In our study, whether patients received a surgical or non-surgical treatment approach did not influence good days during the first 91 days after registration. These findings should inform treatment decisions for patients hospitalised with malignant bowel obstruction. FUNDING Agency for Healthcare Research and Quality and the National Cancer Institute. TRANSLATION For the Spanish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Robert S Krouse
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
| | - Garnet L Anderson
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Kathryn B Arnold
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Cynthia A Thomson
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Valentine N Nfonsam
- Department of Surgery, University of Arizona, Tucson, AZ, USA; Department of Surgery, Louisiana State University, New Orleans, LA, USA
| | | | - Joan L Walker
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Virginia Sun
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Angeles Alvarez Secord
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Duke Cancer Institute, Durham, NC, USA
| | - Ernest S Han
- Division of Gynecologic Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | | | - David Isla-Ortiz
- Department of Surgical Oncology, National Cancer Institute, Tlalpan, Mexico City, Mexico
| | - Phillip Rodgers
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samantha Hendren
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Marco Sanchez Salcedo
- Department of Surgery, Instituto Nacional de Enfermedades Neoplásicas, Surquillo, Peru
| | - Jonathan A Laryea
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Whitney S Graybill
- Department of Gynecologic Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Devin C Flaherty
- Department of Surgical Oncology, Valley Health, Winchester, VA, USA
| | - Harveshp Mogal
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA; University of Washington, Seattle, WA, USA
| | - Thomas J Miner
- Department of Surgery, Rhode Island Hospital, Providence, RI, USA
| | - Jose M Pimiento
- Department of Gastrointestinal Oncology, H Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Mio Kitano
- Mays Cancer Center, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Brian Badgwell
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Giles Whalen
- Department of Surgical Oncology, Umass Memorial Medical Center, Worcester, MA, USA
| | - Jeffrey P Lamont
- Department of Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Oscar A Guevara
- Division of Gastrointestinal Surgery, Instituto Nacional de Cancerologia, Bogota, Colombia
| | - Maheswari S Senthil
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, USA; University of California-Irvine, Orange, CA, USA
| | - Summer B Dewdney
- Department of Obstetrics and Gynecology Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Eric Silberfein
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Columbia University Medical Center, New York, NY, USA
| | - Bret Friday
- Department of Hematology/Oncology Essentia Health Cancer Center, Duluth, MN, USA
| | - Bridget Fahy
- Department of Surgery, University of New Mexico, Albuquerque, NM, USA
| | | | - Mark O'Rourke
- Center for Integrative Oncology and Survivorship, Greenville Health System, Clemson, SC, USA
| | - Marie Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeff Sloan
- Mayo Clinic Rochester, Rochester, MN, USA
| | - Marcia Grant
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Gary B Deutsch
- Northwell Health Cancer Institute, Lake Success, NY, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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5
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Demarest K, Lavu H, Collins E, Batra V. Comprehensive Diagnosis and Management of Malignant Bowel Obstruction: A Review. J Pain Palliat Care Pharmacother 2023; 37:91-105. [PMID: 36377820 DOI: 10.1080/15360288.2022.2106012] [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: 11/16/2022]
Abstract
Malignant bowel obstruction is a common complication of advanced gastrointestinal, gynecologic, and genitourinary tumors. Patients present with nausea, vomiting, abdominal pain, and constipation. Cross-sectional imaging is essential to make a diagnosis of bowel obstruction. Initial management is conservative with fluid replacement, electrolyte replacement, bowel rest and sometimes nasogastric decompression. Numerous advanced options exist for definitive management, though none are overly promising but nevertheless may improve quality and quantity of life. Surgical bypass, endoscopic stenting, and endoscopic decompression are some of the options with variable efficacy and are employed in select patients. Chemotherapy may be utilized if the bowel obstruction resolves to reduce tumor burden in a limited number of patients. Parenteral nutrition is an option and should typically be used in surgical patients with good functional and nutritional status with limited tumor burden or curative intent. Palliative care and hospice should be discussed in patients with advanced malignancy who present with peritoneal carcinomatosis or multiple levels of obstruction. Overall prognosis of malignant bowel obstruction is poor, and median survival ranges from 26 to 192 days.
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Affiliation(s)
- Kaitlin Demarest
- Kaitlin Demarest, MD, is with, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Harish Lavu, MD, is with the Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Elizabeth Collins, MD, is with the Department of Family & Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Vivek Batra, MD, is with the Department of Medical Oncology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Harish Lavu
- Kaitlin Demarest, MD, is with, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Harish Lavu, MD, is with the Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Elizabeth Collins, MD, is with the Department of Family & Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Vivek Batra, MD, is with the Department of Medical Oncology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Elizabeth Collins
- Kaitlin Demarest, MD, is with, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Harish Lavu, MD, is with the Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Elizabeth Collins, MD, is with the Department of Family & Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Vivek Batra, MD, is with the Department of Medical Oncology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Vivek Batra
- Kaitlin Demarest, MD, is with, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Harish Lavu, MD, is with the Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Elizabeth Collins, MD, is with the Department of Family & Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Vivek Batra, MD, is with the Department of Medical Oncology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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6
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Blumenthaler AN, Bruera E, Badgwell BD. Palliative and Supportive Care Consultation for Patients With Malignant Gastrointestinal Obstruction is Associated With Broad Interdisciplinary Management. Ann Surg 2023; 277:284-290. [PMID: 36745760 PMCID: PMC9902762 DOI: 10.1097/sla.0000000000004974] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess rates of palliative care (PC) involvement in the care of patients with malignant gastrointestinal obstruction (GIO) and its influence on interdisciplinary team involvement. BACKGROUND Malignant GIO is an advanced oncologic diagnosis with associated poor prognosis. Data regarding PC and interdisciplinary team involvement in these patients is lacking. METHODS We identified consecutive surgical consultations for GIO in cancer patients at a single institution from August 2017 to July 2019. Clinical characteristics were collected. Rates of PC consultation, ACP discussion, code status change to do not resuscitate, and interdisciplinary service consultation were evaluated. RESULTS We identified 200 patients with consultations for GIO, of whom 114 (57%) had malignant GIO and were included in our study. Of these patients, 95 (83%) had stage IV disease; 68 (60%) had peritoneal metastasis, and 70 (61%) had other intra-abdominal recurrence or metastasis. PC consultation was obtained in 69 patients (61%). PC consultation was associated with higher rates of ACP discussion (64% vs 29%; P < 0.001), code status change to do not resuscitate (30% vs 2%; P < 0.001), nonsurgical procedure (46% vs 11%; P < 0.001), discharge to hospice (30% vs 7%; P < 0.001), and involvement of spiritual care (48% vs 22%; P = 0.01), social work (77% vs 42%, P < 0.001), psychology/psychiatry (42% vs 4%, P < 0.001), nutrition (86% vs 62%, P = 0.006), physical therapy (54% vs 31%, P = 0.02), and occupational therapy (42% vs 16%, P = 0.004). CONCLUSIONS PC consultation benefits patients with malignant GIO by facilitating comprehensive interdisciplinary care, ACP discussions, and transition to hospice care, where appropriate. Diagnosis of malignant GIO should be a trigger for PC consultation or, in facilities with limited PC resources, consideration of deliberately broad interdisciplinary consultation.
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Affiliation(s)
- Alisa N. Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston,
TX
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston,
TX
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7
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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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8
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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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9
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Xue Y, Mranda GM, Wei T, Wang Y, Zhou XG, Liu ZP, Gao ZX, Ding YL. The shadow in the darkness: Case report on adhesive intestinal obstruction secondary to ventriculoperitoneal shunt catheter in an elderly patient. Ann Med Surg (Lond) 2022; 77:103661. [PMID: 35638005 PMCID: PMC9142647 DOI: 10.1016/j.amsu.2022.103661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Shunt placement is an effective therapy for hydrocephalus. Ventriculoperitoneal shunt draining excess cerebrospinal fluid connects the cerebral ventricles to the abdominal cavity. However, intestinal obstruction may ensue as an infrequent complication of the shunt. Case presentation A 65 years old female patient presented with abdominal pain, abdominal bloating, and ceased passage of flatus and stool for six days. She had a history of undergoing a VP shunt procedure due to midbrain obstruction and supratentorial hydrocephalus. Conservative treatment at another local hospital couldn't relieve her symptoms. Laboratory investigations revealed elevated CRP and neutrophils. CT scan showed distended small bowel loops with aerated effusion. Thus, she was admitted to our hospital and underwent an emergent laparotomy following diagnostic modalities completion. Discussion Adhesive intestinal obstruction secondary to ventriculoperitoneal shunt is a rare but fatal shunt complication. The possible mechanisms involved include rubbing movements between the greater omentum and the catheter, cerebrospinal fluid reaction with abdominal organs, immunological rejection of the catheter, and deposition of brain tumor cells with the resultant abdominal metastatic lesions. Laparoscopic and laparotomy are warranted in the surgical management of the disease. Conclusion A high index of suspicion for adhesive intestinal obstruction is key to timely diagnosis and treatment. Ventriculoperitoneal (VP) shunt is the standard treatment for hydrocephalus. The common complications include bacterial infection and shunt malfunction. Adhesive intestinal obstruction is an infrequent VP catheter complication. Focused history, physical examination, and diagnostic modalities are of value. In emergencies, laparotomy is key in alleviating the disease's detrimental effects.
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Affiliation(s)
- Ying Xue
- Department of Gastrointestinal Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong Province, China
- Department of General Surgery, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong Province, China
| | - Geofrey Mahiki Mranda
- Department of Gastrointestinal Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong Province, China
| | - Tian Wei
- Department of Gastrointestinal Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong Province, China
| | - Yu Wang
- Department of Gastrointestinal Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong Province, China
| | - Xing-Guo Zhou
- Department of Gastrointestinal Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong Province, China
| | - Zi-Ping Liu
- Department of Gastrointestinal Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong Province, China
| | - Zhong-Xia Gao
- Department of Gastrointestinal Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong Province, China
| | - Yin-Lu Ding
- Department of Gastrointestinal Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong Province, China
- Corresponding author. Department of Gastrointestinal Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, No. 247 Beiyuan Street, Jinan, 250012, Shandong Province, China.
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10
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Li M, Bao Q, Guo J, Xie R, Shen C, Wei Q, Hu P, Qin H, Shi J. Low Colorectal Tumor Removal by E-Cadherin Destruction-Enabled Tumor Cell Dissociation. NANO LETTERS 2022; 22:2769-2779. [PMID: 35333538 DOI: 10.1021/acs.nanolett.1c04797] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Treatments for low colorectal cancer (CRC) remain a great challenge due to the heavy physical and psychological burdens of colostomy, strong drug toxicity in chemotherapy, and myelosuppression-/chemoradiation-related gastrointestinal symptoms. In this study, a highly biosafe and effective tumor cell dissociation-based low CRC treatment modality has been verified on both PDOs in vitro and colorectal tumor models in vivo. Notably, controllable EDTA release at the tumor sites was achieved by the LDH degradation in response to a slightly acidic microenvironment of low CRC tumors. Resultantly, the intratumoral E-cadherin for intercellular junctions of low CRC tumors was effectively destroyed via Ca2+ depletion by released EDTA from the interlayers, initiating remarkable tumor cell dissociation and resultant tumor disaggregation/removal via defecation. Dissociated tumor cells were prevailingly enveloped by LDH/EDTA, which prevented them from readhering to adjacent tissues, providing an unprecedented, efficient and safe therapeutic modality for low CRC, which will benefit patients suffering low CRC.
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Affiliation(s)
- Man Li
- Shanghai Tenth People's Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, 200072, P.R. China
- Department of Pathology, Shanghai Tenth People's Hospital, 301 Yan-chang Road, Shanghai 200072, P. R. China
| | - Qunqun Bao
- Shanghai Tenth People's Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, 200072, P.R. China
| | - Jing Guo
- Shanghai Tenth People's Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, 200072, P.R. China
- Department of Pathology, Shanghai Tenth People's Hospital, 301 Yan-chang Road, Shanghai 200072, P. R. China
| | - Ruting Xie
- Shanghai Tenth People's Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, 200072, P.R. China
- Department of Pathology, Shanghai Tenth People's Hospital, 301 Yan-chang Road, Shanghai 200072, P. R. China
| | - Chao Shen
- Shanghai Tenth People's Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, 200072, P.R. China
| | - Qing Wei
- Shanghai Tenth People's Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, 200072, P.R. China
- Department of Pathology, Shanghai Tenth People's Hospital, 301 Yan-chang Road, Shanghai 200072, P. R. China
| | - Ping Hu
- Shanghai Tenth People's Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, 200072, P.R. China
- State Key Laboratory of High Performance Ceramics and Superfine Microstructure, Shanghai Institute of Ceramics Chinese Academy of Sciences, Shanghai 200050, P.R. China
- Research Unit of Nanocatalytic Medicine in Specific Therapy for Serious Disease, Chinese Academy of Medical Sciences (2021RU012), Shanghai 200050, P.R. China
| | - Huanlong Qin
- Shanghai Tenth People's Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, 200072, P.R. China
- Department of GI Surgey, Shanghai Tenth People's Hospital, 301 Yan-chang Road, Shanghai 200072, P.R. China
| | - Jianlin Shi
- Shanghai Tenth People's Hospital, Shanghai Frontiers Science Center of Nanocatalytic Medicine, School of Medicine, Tongji University, Shanghai, 200072, P.R. China
- State Key Laboratory of High Performance Ceramics and Superfine Microstructure, Shanghai Institute of Ceramics Chinese Academy of Sciences, Shanghai 200050, P.R. China
- Research Unit of Nanocatalytic Medicine in Specific Therapy for Serious Disease, Chinese Academy of Medical Sciences (2021RU012), Shanghai 200050, P.R. China
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11
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Gjeorgjievski M, Abdelqader A, Sarkar A, Shahid H, Tyberg A, Kahaleh M. Endoscopic coloenterostomy for treatment of malignant small-bowel obstruction: troubleshooting and management of complications. Endoscopy 2022; 54:E176-E177. [PMID: 33910247 DOI: 10.1055/a-1463-2495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Mihajlo Gjeorgjievski
- Department of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Abdelhai Abdelqader
- Department of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Department of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Haroon Shahid
- Department of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Amy Tyberg
- Department of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Michel Kahaleh
- Department of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
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12
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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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13
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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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14
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Bateni SB, Gingrich AA, Kirane AR, Sauder CAM, Gholami S, Bold RJ, Meyers FJ, Canter RJ. Chemotherapy After Diagnosis of Malignant Bowel Obstruction is Associated with Superior Survival for Medicare Patients with Advanced Malignancy. Ann Surg Oncol 2021; 28:7555-7563. [PMID: 33829359 PMCID: PMC8519893 DOI: 10.1245/s10434-021-09831-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/22/2021] [Indexed: 12/11/2022]
Abstract
Background Although malignant bowel obstruction (MBO) often is a terminal event, systemic therapies are advocated for select patients to extend survival. This study aimed to evaluate factors associated with receipt of chemotherapy after MBO and to determine whether chemotherapy after MBO is associated with survival. Methods This retrospective cohort study investigated patients 65 years of age or older with metastatic gastrointestinal, gynecologic, or genitourinary cancers who were hospitalized with MBO from 2008 to 2012 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Fine and Gray models were used to identify factors associated with receipt of chemotherapy accounting for the competing risk of death. Cox models identified factors associated with overall survival. Results Of the 2983 MBO patients, 39% (n = 1169) were treated with chemotherapy after MBO. No differences in receipt of chemotherapy between the surgical and medical patients were found in the univariable analysis (subdistribution hazard ratio [SHR], 0.96; 95% confidence interval [CI], 0.86–1.07; p = 0.47) or multivariable analysis (SHR, 1.12; 95% CI, 1.00–1.26; p = 0.06). Older age, African American race, medical comorbidities, non-colorectal and non-ovarian cancer diagnoses, sepsis, ascites, and intensive care unit stays were inversely associated with receipt of chemotherapy after MBO (p < 0.05). Chemotherapy with surgery was associated with longer survival than surgery (adjusted hazard ratio [aHR], 2.97; 95% CI, 2.65–3.34; p < 0.01) or medical management without chemotherapy (aHR, 4.56; 95% CI, 4.04–5.14; p < 0.01). Subgroup analyses of biologically diverse cancers (colorectal, pancreatic, and ovarian) showed similar results, with greater survival related to chemotherapy (p < 0.05). Conclusions Chemotherapy plays an integral role in maximizing oncologic outcome for select patients with MBO. The data from this study are critical to optimizing multimodality care for these complex patients. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-09831-0.
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Affiliation(s)
- Sarah B Bateni
- Division of Surgical Oncology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alicia A Gingrich
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Amanda R Kirane
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Candice A M Sauder
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Sepideh Gholami
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Frederick J Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Robert J Canter
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA.
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15
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Caparica R, Amorim L, Amaral P, Uratani L, Muniz D, Hendlisz A, de Azambuja E, Glasberg J, Takahashi TK, Filho EA, Canellas R, Saragiotto D, Sabbaga J, Mak M. Malignant bowel obstruction: effectiveness and safety of systemic chemotherapy. BMJ Support Palliat Care 2020:bmjspcare-2020-002656. [PMID: 33334819 DOI: 10.1136/bmjspcare-2020-002656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/24/2020] [Accepted: 11/26/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Although systemic chemotherapy is often administered to patients with malignant bowel obstruction (MBO), its benefit remains unknown. This study assessed the outcomes of patients who received systemic chemotherapy as part of MBO treatment. METHODS For this retrospective cohort study, data were extracted from records of patients hospitalised due to MBO in a tertiary cancer centre from 2008 to 2020. Eligible patients were not candidates for surgery and received systemic chemotherapy targeting the underlying malignancy causing MBO. Primary objective was to assess patient outcomes after chemotherapy; secondary objectives were rates of intestinal function recovery, hospital discharge and grade ≥3 toxicities. The primary endpoint was overall survival (OS). RESULTS A total of 167 patients were included: median age was 55 (18-81) years, 91% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2, 75.5% had gastrointestinal tumours and 70% were treatment-naive. The median OS after chemotherapy was 4.4 weeks (95% CI 3.4 to 5.5) in the overall population. No OS difference was observed according to treatment line (p=0.24) or primary tumour (p=0.13). Intestinal function recovery occurred in 87 patients (52%), out of whom 21 (24.1%) had a reobstruction. Hospital discharge was possible in 74 patients (44.3%). Grade≥3 adverse events occurred in 26.9% of the patients, and a total of 12 deaths (7%) attributed to toxicities were observed after chemotherapy. CONCLUSIONS MBO was associated with a dismal prognosis in this mostly treatment-naive population. The administration of chemotherapy yielded a significant risk of toxicities, whereas it did not appear to provide any relevant survival benefit in this scenario.
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Affiliation(s)
- Rafael Caparica
- Department of Medical Oncology, Institut Jules Bordet, Brussels, Belgium
| | - Larissa Amorim
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Paulo Amaral
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Lucas Uratani
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - David Muniz
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alain Hendlisz
- Department of Medical Oncology, Institut Jules Bordet, Brussels, Belgium
| | | | - João Glasberg
- Department of Medical Oncology, Hospital Sao Luiz Anália Franco, Oncologia D'or, Sao Paulo, Brazil
| | | | - Elias Abdo Filho
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Canellas
- Department of Radiology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Daniel Saragiotto
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jorge Sabbaga
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Milena Mak
- Department of Medical Oncology, Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
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16
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Wey W, Mian M, Calabrese R, Hansen E, Walter M, Wang C, Miller A, Case AA. Palliative Medical Management of Inoperable Malignant Bowel Obstruction With "Triple Therapy": Dexamethasone, Octreotide, and Metoclopramide. Am J Hosp Palliat Care 2020; 38:340-345. [PMID: 33084354 DOI: 10.1177/1049909120968249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
CONTEXT Malignant bowel obstruction (MBO) is a complication of advanced malignancy. For inoperable patients, symptoms are often treated using analgesics, anticholinergics, and anti-emetics. There are, however, few published guidelines for the medical management of MBO. OBJECTIVE To measure the effect of the combination of dexamethasone, octreotide, and metoclopramide ("triple therapy") in patients with MBO, compared to patients who received none of the 3 medications ("no drug therapy"). METHODS A retrospective cohort study of patients with MBO admitted in a single-center comprehensive cancer center. Patients who received dexamethasone, octreotide, and metoclopramide during their hospitalization for treatment of inoperable MBO were selected for analysis. Patients were excluded if they received a venting gastric tube. Rate of de-obstruction as well as time to de-obstruction were measured. RESULTS There were 20 patients identified who received all 3 drugs of interest, and 29 patients identified who received none of the 3 medications. There was no statistically significant difference in rates of de-obstruction between the 2 groups, though there was a non-significant trend toward patients who received triple therapy were more likely to reach de-obstruction, compared to patients who had no drug therapy (95% vs. 83%, p = 0.379); there was no significant difference in adjusted analysis. CONCLUSION In patients with inoperable MBO, there was no statistically significant difference in rates of de-obstruction with triple drug therapy compared to patients who received none of the 3 drugs, though the study may not have been powered to detect a difference and further investigation is warranted.
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Affiliation(s)
- Winston Wey
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.,Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Moeena Mian
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.,Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Rebecca Calabrese
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Geriatrics and Palliative Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Eric Hansen
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Geriatrics and Palliative Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Michelle Walter
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Geriatrics and Palliative Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Chong Wang
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Austin Miller
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Amy A Case
- Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.,Department of Geriatrics and Palliative Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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17
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Blumenthaler AN, Ikoma N, Blum M, Das P, Minsky BD, Mansfield PF, Ajani JA, Badgwell BD. Relationship between initial management strategy and survival in patients with gastric outlet obstruction due to gastric cancer. J Surg Oncol 2020; 122:1373-1382. [PMID: 32810292 DOI: 10.1002/jso.26177] [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: 06/12/2020] [Accepted: 08/07/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The optimal management of gastric outlet obstruction (GOO) due to gastric cancer (GC) is unclear. We examined the relationships between clinical and management variables and outcomes in patients with GC having GOO. METHODS The GOO management and clinical course were reviewed in patients with GC and GOO. Cox regression and Kaplan-Meier analyses were used to identify variables predictive of overall survival (OS). RESULTS The study included 59 patients. Eleven had imaging evidence of metastasis and 35 had pathologically confirmed peritoneal disease. Initial management included resection in 23 patients, feeding jejunostomy ± decompressive gastrostomy (JT/GT) in 25, surgical gastrojejunostomy in five, and endoscopic intervention in six. Seven patients with initial JT/GT underwent resection after neoadjuvant therapy. Median OS (95% confidence interval [CI]) was 21.4 (0.0-45.1) months in the upfront resection group (median follow-up, 14.7 months) and not reached in those with initial JT/GT, neoadjuvant therapy, and later resection (median follow-up, 26.5 months) (P = .18). On multivariable analysis, clinically positive nodes (hazard ratio [HR]: 3.76; 95% CI, 1.17-12.12; P = .03), metastasis on CT (HR: 3.97; 95% CI: 1.53-10.26;P = .01), and resection (HR: 0.37; 95% CI: 0.17-0.79;P = .01) independently predicted OS. CONCLUSION In GOO due to GC, OS is similar after treatment with upfront resection compared with JT/GT, neoadjuvant therapy, and later resection. Upfront JT/GT may allow patients to tolerate chemotherapy and improve selection for gastrectomy.
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Affiliation(s)
- Alisa N Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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18
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Comparative Analysis of Efficacy of Intraoperative Decompression with Nasogastric and Nasojejunal Tubes in Patients with Malignant Small Bowel Obstruction. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02091-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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19
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Abstract
A common fallacy prevalent in surgical culture is for surgical intervention and palliation to be regarded as mutually exclusive or sequential strategies in the trajectory of surgical illness. Modern surgeons play a complex role as both providers and gatekeepers in meeting the palliative needs of their patients. Surgical palliative care is ideally delivered by surgical teams as a component of routine surgical care, and includes management of physical and psychosocial symptoms, basic communication about prognosis and treatment options, and identification of patient goals and values. Specialty palliative care services may be accessed through a through a variety of models.
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Affiliation(s)
- Ana Berlin
- Department of Surgery, Division of General Surgery, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 5-562, New York, NY 10032, USA; Department of Medicine, Division of Hematology/Oncology, Adult Palliative Medicine Service, Columbia University Medical Center, New York, NY, USA.
| | - Teresa Johelen Carleton
- Tucson Medical Center Palliative Care, Tucson Medical Center, 5301 E. Grant Road, Tucson, AZ 85712, USA; University of Arizona Phoenix, Phoenix, AZ, USA
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20
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Baumgartner JM, Marmor R, Hsu A, Veerapong J, Kelly KJ, Lowy AM. Obstruction-Free Survival Following Operative Intervention for Malignant Bowel Obstruction in Appendiceal Cancer. Ann Surg Oncol 2019; 26:3611-3617. [PMID: 31190209 DOI: 10.1245/s10434-019-07507-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with peritoneal metastases from appendiceal cancer are at high risk of malignant bowel obstruction (MBO), which is associated with significant morbidity and mortality. There are no definitive treatment guidelines regarding operative intervention for MBO. We sought to evaluate the efficacy and safety of operative intervention in this population. METHODS We identified patients with peritoneal metastases from appendiceal cancer who underwent surgery for MBO at our institution between 2011 and 2018. Baseline characteristics, postoperative complications, and follow-up data were collected. The primary endpoint was obstruction-free survival (OFS). Other endpoints were postoperative recovery of bowel function, 60-day Clavien-Dindo (CD) morbidity, and overall survival (OS). RESULTS Twenty-six patients underwent operative treatment for MBO, of whom 14 had high-grade (HG) histology and 12 had low-grade (LG) histology. Seven (25.9%) patients had severe (CD grade 3 or higher) 60-day complications, including one (3.8%) postoperative death. All remaining patients had return of bowel function and resumed oral intake during hospitalization. Six (23.1%) patients had repeat admissions for MBO after surgery. Median OFS was 17.0 months (95% confidence interval [CI] 2.3-31.8), and median OS was 18.5 months (95% CI 3.6-33.3) following surgery. CONCLUSION In this carefully selected group of patients with peritoneal metastases from appendiceal cancer, surgery for MBO provided durable palliation with acceptable morbidity.
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Affiliation(s)
- Joel M Baumgartner
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA.
| | - Rebecca Marmor
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Athena Hsu
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Jula Veerapong
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Kaitlyn J Kelly
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Andrew M Lowy
- Department of Surgery, University of California, San Diego Moores Cancer Center, La Jolla, CA, USA
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21
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Abstract
Malignant bowel obstruction (MBO) is a common problem for patients with advanced malignancy, especially colorectal and ovarian cancers. Symptoms include pain, bloating, nausea and vomiting, and inability to eat. Treatment options consist of a wide range of surgical and nonsurgical interventions (medications, endoscopic, or interventional radiology approaches). Outcomes are variable no matter the strategy, and the optimal approach is often not clear. Greater research is needed to assist decision-making for clinicians treating patients with MBO.
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Affiliation(s)
- Robert S Krouse
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennylvania.,Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania.,Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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22
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Bower KL, Lollar DI, Williams SL, Adkins FC, Luyimbazi DT, Bower CE. Small Bowel Obstruction. Surg Clin North Am 2018; 98:945-971. [PMID: 30243455 DOI: 10.1016/j.suc.2018.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.
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Affiliation(s)
- Katie Love Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA.
| | - Daniel I Lollar
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Sharon L Williams
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Farrell C Adkins
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - David T Luyimbazi
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Curtis E Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
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