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Abstract
Malignant bowel obstruction is a challenging clinical problem encountered in patients with advanced abdominal and pelvic malignancies. Although medical therapies form the foundation of management, some patients may be suitable candidates for surgical and procedural interventions. The literature is composed primarily of retrospective single-institution experiences and the results of prospective trials are pending. Given the high symptom burden and limited life expectancy of these patients, management may be best informed by multidisciplinary teams with relevant expertise.
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Affiliation(s)
- Caitlin T Yeo
- Division of Surgical Oncology, University of Calgary, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, Alberta T2N 4N2, Canada
| | - Shaila J Merchant
- Division of General Surgery and Surgical Oncology, Queen's University, Burr 2, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
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Abstract
Regardless of the anatomic site of malignant bowel obstruction leading to the need for palliative intervention, decisions must consider the natural history of the disease, the availability and success of nonsurgical treatments, the individual patient's symptom severity, goals, preferences, quality, and expectancy of life. Therapy for symptoms must remain flexible and individualized because the specific needs of the patient will change as disease progresses. Because strangulation is uncommon, malignant bowel obstruction is usually not a surgical emergency. There is usually time to proceed with deliberate and thoughtful decisions on how best to meet the needs and expectations of the individual patient and family. Providers must be well versed in both surgical and nonsurgical therapeutic options, the natural history of disease, and be active and compassionate providers to foster meaningful ongoing dialogue focused on excellent care even after cure is no longer possible. The palliative triangle not only allows patient, family, and surgeon to effectively utilize the full continuum of care that can be delivered, but also it supports end-of-life decisions when continuity in care matters most. Due to social distancing requirements, the dynamics of communication between patient, family, and surgeon have changed. Zoom, Skype, and FaceTime have become tools in our communication armamentarium.
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Affiliation(s)
- Eleanor A Fallon
- Division of Surgical Oncology, Department of Surgery, Warren Alpert Medical School of Brown University, USA
| | - Thomas J Miner
- Division of Surgical Oncology, Department of Surgery, Warren Alpert Medical School of Brown University, USA
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Kim DH, Kim B, Choi JH, Park SJ, Hong SP, Cheon JH, Kim WH, Kim TI. Tumor characteristics associated with malignant large bowel obstruction in stage IV colorectal cancer patients undergoing chemotherapy. Int J Colorectal Dis 2016; 31:1767-1774. [PMID: 27613728 DOI: 10.1007/s00384-016-2638-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Little is known about predictable clinical factors associated with the occurrence of malignant large bowel obstruction (MLBO) in incurable stage IV colorectal cancer (CRC) patients undergoing medical treatment. This study investigates the clinical characteristics associated with MLBO that occurred while patients with stage IV CRC were receiving chemotherapy. METHODS A total of 216 patients who were diagnosed with stage IV CRC without bowel obstruction and who received chemotherapy between May 2005 and June 2012 were retrospectively included in this study. Patients were divided into an "obstruction group" and a "non-obstruction group" based on whether they did or did not develop MLBO during chemotherapy or follow-up, respectively. The initial endoscopic findings and clinical information were retrospectively reviewed and compared between the two groups. RESULTS Forty-six patients (21.3 %) developed MLBO during the treatment or follow-up periods. The mean duration between diagnosis and MLBO was 9.8 ± 9.3 months. After adjusting for clinically relevant factors, MLBO development was independently associated with the following factors: higher initial tumor-occupying circumference (HR 1.030 [95 % CI, 1.012-1.049], P = 0.001), longer initial horizontal tumor width (HR 1.035 [95 % CI, 1.011-1.059], P = 0.004), primary tumor location at a turning point in the colon (HR 2.404 [95 % CI, 1.185-4.877], P = 0.015), and the presence of primary tumor ulceration at presentation (HR 3.767 [95 % CI, 1.882-7.538], P < 0.001). MLBO development was not associated with tumor response to chemotherapy. CONCLUSION In patients with stage IV CRC, MLBO development during chemotherapy treatment is associated with tumor ulceration, location, circumference, and width at diagnosis.
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Affiliation(s)
- Duk Hwan Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Bun Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Jae Hyuk Choi
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Sung Pil Hong
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
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Paul Olson TJ, Pinkerton C, Brasel KJ, Schwarze ML. Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review. JAMA Surg 2014; 149:383-92. [PMID: 24477929 DOI: 10.1001/jamasurg.2013.4059] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Care of patients with malignant bowel obstruction caused by peritoneal metastases may present an ethical dilemma for surgeons when nonoperative management fails. OBJECTIVE To characterize outcomes of palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis to guide decision making about surgery and postoperative interventions for patients with terminal illness. EVIDENCE REVIEW We searched PubMed, EMBASE, Cochrane Library, Web of Knowledge, Cumulative Index to Nursing and Allied Health Literature Plus, and Google Scholar and performed manual searches of selected journals from inception to August 30, 2012, with no filters, limits, or language restrictions. We used database-specific combinations of the terms intestinal obstruction, malignant, surgery or surgical, and palliat*. We included studies reporting outcomes after palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis from any primary malignant neoplasm and excluded case studies, curative surgery, isolated percutaneous procedures, stenting for intraluminal lesions, and studies in which benign and malignant obstructions could not be distinguished. We assessed quality with the Newcastle-Ottawa Scale. FINDINGS We screened 2347 unique articles, selected 108 articles for full-text review, and included 17 studies. Surgery was able to palliate obstructive symptoms for 32% to 100% of patients, enable resumption of a diet for 45% to 75% of patients, and facilitate discharge to home in 34% to 87% of patients. Mortality was high (6%-32%), and serious complications were common (7%-44%). Frequent reobstructions (6%-47%), readmissions (38%-74%), and reoperations (2%-15%) occurred. Survival was limited (median, 26-273 days), and hospitalization for surgery consumed a substantial portion of the patient's remaining life (11%-61%). CONCLUSIONS AND RELEVANCE Although palliative surgery can benefit patients, it comes at the cost of high mortality and substantial hospitalization relative to the patient's remaining survival time. Preoperatively, surgeons should present realistic goals and limitations of surgery. For patients choosing surgery, clarifying preferences for aggressive postoperative interventions preoperatively is critical given the high complication rate and limited survival after surgery for malignant bowel obstruction.
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Affiliation(s)
- Terrah J Paul Olson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Karen J Brasel
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Margaret L Schwarze
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
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Daines P, Stilos K, Moura S, Fitch M, McAndrew A, Gill A, Wright F. Nurses' experiences caring for patients and families dealing with malignant bowel obstruction. Int J Palliat Nurs 2013; 19:593-8. [DOI: 10.12968/ijpn.2013.19.12.593] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Shari Moura
- After Cancer Treatment Transition Clinic, Women's College Hospital, Toronto
| | | | | | - Ashlinder Gill
- Institute of Health Policy Management and Evaluation, University of Toronto
| | - Frances Wright
- Cancer Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada
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Isichei MW, Ismaila BO. The general surgeon in inter-disciplinary gynaecological cancer care. World J Obstet Gynecol 2013; 2:37-41. [DOI: 10.5317/wjog.v2.i3.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 03/01/2013] [Accepted: 04/10/2013] [Indexed: 02/05/2023] Open
Abstract
Gynaecological cancers pose a significant cancer burden globally. In 2008 cancers of the cervix, uterus and ovaries accounted for 529000 (4.2%), 287000 (2.3%) and 225000 (1.8%) cancers, respectively, and together were responsible for 486400 deaths. Inter-disciplinary gynaecological care is an emerging concept aimed at providing more effective care by integrating different disciplines into a team working together to perform the various aspects of management at one time. This model has both advantages and potential shortcomings. In advanced healthcare systems there appears to be little role for the general surgeon. However in developing world, the general surgeon has a valuable, but complementary role in inter-disciplinary gynaecological cancer care. This role depends on the available workforce and includes, but is not limited to, the establishment of a diagnosis and treatment, including the management of complications. There is however little evidence-based research to provide guidance on the general surgeon’s role in inter-disciplinary gynecologic cancer care and more research is needed.
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O'Connor B, Creedon B. Pharmacological treatment of bowel obstruction in cancer patients. Expert Opin Pharmacother 2011; 12:2205-14. [PMID: 21714777 DOI: 10.1517/14656566.2011.597382] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Brenda O'Connor
- Waterford Regional Hospital, Department of Palliative Medicine, Waterford, Ireland.
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Dalal KM, Gollub MJ, Miner TJ, Wong WD, Gerdes H, Schattner MA, Jaques DP, Temple LKF. Management of patients with malignant bowel obstruction and stage IV colorectal cancer. J Palliat Med 2011; 14:822-8. [PMID: 21595546 DOI: 10.1089/jpm.2010.0506] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Malignant bowel obstruction (MBO), a serious problem in stage IV colorectal cancer (CRC) patients, remains poorly understood. Optimal management requires realistic assessment of treatment goals. This study's purpose is to characterize outcomes following palliative intervention for MBO in the setting of metastatic CRC. STUDY DESIGN Retrospective review of a prospective palliative database identified 141 patients undergoing surgical (OR; n = 96) or endoscopic (GI; n = 45) procedures for symptoms of MBO. RESULTS Median patient age was 58 years, median follow-up 7 months. Most (63%) had multiple sites of metastases. Computed tomography (CT) scan findings of carcinomatosis (p = 0.002), ascites (p = 0.05), and multifocal obstruction with carcinomatosis and ascites (p = 0.03) significantly predicted the need for percutaneous or open gastrostomy tube, or stoma. Procedure-associated morbidity for 81 patients with small bowel obstruction (SBO) was 37%; 7% developed an enterocutaneous fistula/anastomotic leak. Thirty-day mortality was 6%. Most (84%) patients were palliated successfully; some received additional chemotherapy (38%) or surgery (12%). Procedure-associated morbidity for 60 patients with large bowel obstruction (LBO) was 25%; 11 patients (18%) required other procedures for stent failure, with one death at 30 days. Symptom resolution was >97%. Patients with LBO had improved symptom resolution, shorter length of stay (LOS), and longer median survival than patients with SBO. CONCLUSIONS Patients with MBO and stage IV CRC were successfully palliated with GI or OR procedures. Patients with CT-identified ascites, carcinomatosis, or multifocal obstruction were least likely to benefit from OR procedures. CT plays an important role in preoperative planning. Sound clinical judgment and improved understanding are required for optimal management of MBO.
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Affiliation(s)
- Kimberly Moore Dalal
- Department of Surgery, Memorial Sloan-Kettering Cancer Center , New York, NY 10065, USA
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Kucukmetin A, Naik R, Galaal K, Bryant A, Dickinson HO. Palliative surgery versus medical management for bowel obstruction in ovarian cancer. Cochrane Database Syst Rev 2010; 2010:CD007792. [PMID: 20614464 PMCID: PMC4170995 DOI: 10.1002/14651858.cd007792.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Ali Kucukmetin
- Northern Gynaecological Oncology CentreGynaecological OncologyQueen Elizabeth HospitalSheriff HillGatesheadTyne & WearUKNE9 6SX
| | - Raj Naik
- Northern Gynaecological Oncology CentreQueen Elizabeth HospitalGatesheadTyne and WearUKNE9 6SX
| | - Khadra Galaal
- Princess Alexandra Wing, Royal Cornwall HospitalGynaecological OncologyTruroUKTR1 3LJ
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Heather O Dickinson
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
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Abstract
The most common complaints among patients with cancer who present to the emergency department are related to the gastrointestinal system, and 40% of these patients complain of abdominal pain. These presentations can stem from the underlying malignancy itself, treatment directed toward the disease, or the full range of pathologies present in a healthy population. Immunosuppression may blunt many of the findings one expects in a healthy population of patients, thus rendering the clinical exam less reliable in many patients with cancer. Moreover, the degree of immunosuppression shapes both the types of pathologies the clinician should consider and the rate at which the disease may progress. Understanding the limitations of physical examination, pathophysiology of disease, and the methods by which these diagnoses are established is of critical importance in this population. This article focuses specifically on patients with cancer who present with an acute abdomen, and it discusses how a concurrent malignancy can shape the differential diagnosis in these cases.
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Affiliation(s)
- Jonathan S Ilgen
- Department of Emergency Medicine, Oregon Health & Science University, CDW-EM, Portland, OR 97239, USA.
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Holtmann M, Siepmann U, Mahlkow S, Domagk D, Pott G. Gastroenterologische Symptomenkontrolle in der Palliativmedizin (Teil 2). GASTROENTEROLOGE 2009. [DOI: 10.1007/s11377-008-0254-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Krouse RS. The international conference on malignant bowel obstruction: a meeting of the minds to advance palliative care research. J Pain Symptom Manage 2007; 34:S1-6. [PMID: 17544251 PMCID: PMC2834265 DOI: 10.1016/j.jpainsymman.2007.04.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 04/12/2007] [Indexed: 10/23/2022]
Abstract
There is a dearth of well-designed clinical research focusing on palliative care in cancer patients, especially those who are near the end of life. Reasons for this include ethical dilemmas in conducting such trials, communication barriers between specialties, and unclear standards for best care practices. To ensure that patients with incurable illnesses are offered the best available care, it is essential to develop and disseminate research methodologies well suited to this population. Given the multidimensional and culture-dependent nature of the end-of-life experience, it is necessary to adopt an interdisciplinary approach to developing research methods. As a means of initiating the process of palliative clinical research methodology development, malignant bowel obstruction (MBO) was used as a model to develop a research protocol. Although many treatment options for MBO have been proposed, existing literature offers little guidance with regard to algorithms for optimal management. To this end, an international leaders in quality-of-life research, ethnocultural variability, palliative medicine, surgical oncology, gastroenterology, major consortium research, medical ethics, and patient advocacy/cancer survivors was convened in Pasadena, California, on November 12-13, 2004. Participants also represented the broad ethnic and racial perspectives required to develop culturally sensitive research methods. Consensus on methodological approaches was attained through vigorous debate. Using the conference-developed MBO model to implement trials will advance palliative care research.
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Affiliation(s)
- Robert S Krouse
- Southern Arizona Veterans Affairs Health Care System, University of Arizona College of Medicine, Tucson, Arizona 85723, USA.
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Helyer LK, Law CHL, Butler M, Last LD, Smith AJ, Wright FC. Surgery as a bridge to palliative chemotherapy in patients with malignant bowel obstruction from colorectal cancer. Ann Surg Oncol 2007; 14:1264-71. [PMID: 17235711 DOI: 10.1245/s10434-006-9303-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Revised: 07/18/2006] [Accepted: 07/20/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Malignant bowel obstruction (MBO) is a feature of the clinical course of 10-28% of colorectal cancer (CRC) patients and is associated with a poor prognosis. Recent advancements in palliative chemotherapy regimens have prolonged survival in patients with stage IV CRC. Few reports exist that describe outcomes in patients who have had surgery for MBO and subsequent chemotherapy as part of their treatment. The objective of this study was to review surgical outcomes in patients with MBO for CRC and to evaluate the extent to which surgery can serve as a bridge to palliative chemotherapy. METHODS Patients who presented with MBO and had surgical treatment were identified from a prospectively kept database at a single tertiary care center between 09/99 and 08/04. Charts were retrospectively reviewed and clinical and outcomes data were abstracted. RESULTS Forty-seven patients were identified who had surgery as part of the treatment for MBO from CRC. Operations included resections, bypasses and stoma creation. Overall, 80% of patients were able to tolerate solid food post-operatively and return home. The median survival for the entire cohort was 3.5 months. Seven patients died within 30 days of surgery. Of the remainder, 24 patients were palliated with surgery alone and 16 patients ultimately received palliative chemotherapy. Survival in the final cohort was significantly prolonged (P < 0.001). CONCLUSION Surgery can adequately palliate a substantial proportion of patients with MBO from CRC with acceptable morbidity and mortality. In addition, in a subset of patients it can facilitate palliative chemotherapy that is associated with improved overall survival.
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Affiliation(s)
- Lucy K Helyer
- Department of Surgical Oncology, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room T2-063, Toronto, ON, M4N 3M5, Canada
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Dunn GP. Palliating Patients Who Have Unresectable Colorectal Cancer: Creating the Right Framework and Salient Symptom Management. Surg Clin North Am 2006; 86:1065-92. [PMID: 16905424 DOI: 10.1016/j.suc.2006.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The last phases of colorectal malignant illness may be the most challenging and saddening for all involved, but they offer opportunities to become the most rewarding. This transformation of hopelessness to fulfillment requires a willingness by surgeon, patient, and patient's family to trust one another to realistically set goals of care, stick together, and not let the treatment of the disease become a surrogate for treating the suffering that characterizes grave illness.
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Affiliation(s)
- Geoffrey P Dunn
- Department of Surgery and Palliative Care Consultation Service, Hamot Medical Center, 2050 South shore Drive, Erie, PA 16505, USA.
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Moloo H, Bédard ELR, Poulin EC, Mamazza J, Grégoire R, Schlachta CM. Palliative laparoscopic resections for Stage IV colorectal cancer. Dis Colon Rectum 2006; 49:213-8. [PMID: 16416080 DOI: 10.1007/s10350-005-0260-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Issues surrounding the safety and efficacy of palliative laparoscopic resections for patients with Stage IV colorectal cancer have not been explicitly examined in the literature. This article describes our experience with laparoscopic procedures for patients with Stage IV colorectal cancer and compares their perioperative outcomes to a contemporaneous group of patients with clinically curable (Stages I-III) disease. METHODS A prospective database of laparoscopic resections for colorectal cancer performed between 1991 and 2002 was reviewed. Data regarding patient demographics, perioperative morbidity and mortality, operative times, conversion rates, and length of stay were extracted. Statistical analysis included chi-squared and Student's t-tests as required and P<or=0.05 was considered significant. RESULTS A total of 375 cases were identified, of these 49 (13 percent) underwent laparoscopic palliative resections while 326 (87 percent) patients had resections for cure. When comparing palliative to curative procedures, there were no differences in intraoperative (4 percent vs. 9 percent) or postoperative complications (14 percent vs. 12 percent), perioperative mortality (8 percent vs. 4 percent), or length of hospital stay. Patients with Stage IV disease had larger tumors (5.4+/-2.3 cm vs. 4.6+/-2.6 cm, P=0.04) which contributed to an increased rate of conversion (22 percent vs. 11 percent, P=0.05) with most conversions secondary to tumor fixation or bulk (64 percent) preventing determination of resectability. CONCLUSIONS A palliative laparoscopic resection is a safe and feasible option and presents acceptable morbidity and mortality in patients with Stage IV colorectal cancer. Importantly, in this difficult group of patients, our results compare favorably with those from previously published series of open procedures.
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Affiliation(s)
- Husein Moloo
- St. Michael's Hospital, Toronto, Ontario, and Le Centre Hospitalier Universitaire de Québec, Université Laval, Canada
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Abstract
Surgery has always played a pivotal role in care of the patient with cancer, independent of treatment intent. Recent advances have expanded that role, not only in terms of modalities available, but more broadly in terms of the expectations of the surgeon as physician involved in the interdisciplinary care of the patient with symptomatic, incurable disease.
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Affiliation(s)
- Robert A Milch
- Center for Hospice and Palliative Care, Cheektowaga, NY 14227, USA
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Scarpa FJ, Tamerin NG, Franco MJ. Palliative care: a community surgeon's perspective. J Am Coll Surg 2004; 198:661-4. [PMID: 15051020 DOI: 10.1016/j.jamcollsurg.2003.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2003] [Accepted: 12/15/2003] [Indexed: 10/26/2022]
Affiliation(s)
- Frank J Scarpa
- Department of Surgery, Greenwich Hospital, 5 Perryridge Road, Greenwich, CT 06830, USA
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Krouse RS, Rosenfeld KE, Grant M, Aziz N, Byock I, Sloan J, Casarett D. Palliative Care Research: Issues and Opportunities. Cancer Epidemiol Biomarkers Prev 2004. [DOI: 10.1158/1055-9965.337.13.3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Robert S. Krouse
- 1Department of Surgery, Southern Arizona Veterans Affairs Health Care System and the University of Arizona, Tucson, AZ
| | - Kenneth E. Rosenfeld
- 2Department of Medicine, West Los Angeles Veterans Affairs Health Care System and the University of California at Los Angeles, Los Angeles, CA
| | - Marcia Grant
- 3Department of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA
| | - Noreen Aziz
- 4Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Ira Byock
- 5Section of Palliative Medicine, Dartmouth-Hitchcock Medical Center, Hanover, NH
| | | | - David Casarett
- 7Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center and Division of Geriatrics, University of Pennsylvania, Philadelphia, PA
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Easson AM, Lee KF, Brasel K, Krouse RS. Clinical research for surgeons in palliative care: challenges and opportunities. J Am Coll Surg 2003; 196:141-51. [PMID: 12517566 DOI: 10.1016/s1072-7515(02)01703-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Alexandra M Easson
- Division of Surgical Oncology, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
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