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Risk of Bowel Obstruction in Patients Undergoing Neoadjuvant Chemotherapy for High-risk Colon Cancer: A Nested Case-control-matched Analysis of an International, Multicenter, Randomized Controlled Trial (FOxTROT). Ann Surg 2024; 280:283-293. [PMID: 37947140 PMCID: PMC11224564 DOI: 10.1097/sla.0000000000006145] [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] [Indexed: 11/12/2023]
Abstract
OBJECTIVE This study aimed to identify risk criteria available before the point of treatment initiation that can be used to stratify the risk of obstruction in patients undergoing neoadjuvant chemotherapy (NAC) for high-risk colon cancer. BACKGROUND Global implementation of NAC for colon cancer, informed by the FOxTROT trial, may increase the risk of bowel obstruction. METHODS A case-control study, nested within an international randomized controlled trial (FOxTROT; ClinicalTrials.gov: NCT00647530). Patients with high-risk operable colon cancer (radiologically staged T3-4 N0-2 M0) that were randomized to NAC and developed large bowel obstruction were identified. First, clinical outcomes were compared between patients receiving NAC in FOxTROT who did and did not develop obstruction. Second, obstructed patients (cases) were age-matched and sex-matched with patients who did not develop obstruction (controls) in a 1:3 ratio using random sampling. Bayesian conditional mixed-effects logistic regression modeling was used to explore clinical, radiologic, and pathologic features associated with obstruction. The absolute risk of obstruction based on the presence or absence of risk criteria was estimated for all patients receiving NAC. RESULTS Of 1053 patients randomized in FOxTROT, 699 received NAC, of whom 30 (4.3%) developed obstruction. Patients underwent care in European hospitals including 88 UK, 7 Danish, and 3 Swedish centers. There was more open surgery (65.4% vs 38.0%, P =0.01) and a higher pR1 rate in obstructed patients (12.0% vs 3.8%, P =0.004), but otherwise comparable postoperative outcomes. In the case-control-matched Bayesian model, 2 independent risk criteria were identified: (1) obstructing disease on endoscopy and/or being unable to pass through the tumor [adjusted odds ratio: 9.09, 95% credible interval: 2.34-39.66] and stricturing disease on radiology or endoscopy (odds ratio: 7.18, 95% CI: 1.84-32.34). Three risk groups were defined according to the presence or absence of these criteria: 63.4% (443/698) of patients were at very low risk (<1%), 30.7% (214/698) at low risk (<10%), and 5.9% (41/698) at high risk (>10%). CONCLUSIONS Safe selection for NAC for colon cancer can be informed by using 2 features that are available before treatment initiation and identifying a small number of patients with a high risk of preoperative obstruction.
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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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Grigorean VT, Erchid A, Coman IS, Liţescu M. Colorectal Cancer-The "Parent" of Low Bowel Obstruction. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050875. [PMID: 37241107 DOI: 10.3390/medicina59050875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/29/2023] [Accepted: 04/30/2023] [Indexed: 05/28/2023]
Abstract
Introduction: Despite the improvement of early diagnosis methods for multiple pathological entities belonging to the digestive tract, bowel obstruction determined by multiple etiologies represents an important percentage of surgical emergencies. General data: Although sometimes obstructive episodes are possible in the early stages of colorectal cancer, the most commonly installed intestinal obstruction has the significance of an advanced evolutionary stage of neoplastic disease. Development of Obstructive Mechanism: The spontaneous evolution of colorectal cancer is always burdened by complications. The most common complication is low bowel obstruction, found in approximately 20% of the cases of colorectal cancer, and it can occur either relatively abruptly, or is preceded by initially discrete premonitory symptoms, non-specific (until advanced evolutionary stages) and generally neglected or incorrectly interpreted. Success in the complex treatment of a low neoplastic obstruction is conditioned by a complete diagnosis, adequate pre-operative preparation, a surgical act adapted to the case (in one, two or three successive stages), and dynamic postoperative care. The moment of surgery should be chosen with great care and is the result of the experience of the anesthetic-surgical team. The operative act must be adapted to the case and has as its main objective the resolution of intestinal obstruction and only in a secondary way the resolution of the generating disease. Conclusions: The therapeutic measures adopted (medical-surgical) must have a dynamic character in accordance with the particular situation of the patient. Except for certain or probably benign etiologies, the possibility of colorectal neoplasia should always be considered, in low obstructions, regardless of the patient's age.
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Affiliation(s)
- Valentin Titus Grigorean
- General Surgery Department, "Carol Davila" University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania
- General Surgery Department, "Bagdasar-Arseni" Clinical Emergency Hospital, 12 Berceni Road, 041915 Bucharest, Romania
| | - Anwar Erchid
- General Surgery Department, "Bagdasar-Arseni" Clinical Emergency Hospital, 12 Berceni Road, 041915 Bucharest, Romania
| | - Ionuţ Simion Coman
- General Surgery Department, "Carol Davila" University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania
- General Surgery Department, "Bagdasar-Arseni" Clinical Emergency Hospital, 12 Berceni Road, 041915 Bucharest, Romania
| | - Mircea Liţescu
- General Surgery Department, "Carol Davila" University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania
- General Surgery Department, "Sf. Ioan" Clinical Emergency Hospital, 13 Vitan-Bârzeşti Road, 042122 Bucharest, Romania
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Ma J, Wang G, Ding X, Wang F, Zhu C, Rong Y. Carbon-Based Nanomaterials as Drug Delivery Agents for Colorectal Cancer: Clinical Preface to Colorectal Cancer Citing Their Markers and Existing Theranostic Approaches. ACS OMEGA 2023; 8:10656-10668. [PMID: 37008124 PMCID: PMC10061522 DOI: 10.1021/acsomega.2c06242] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/23/2023] [Indexed: 06/19/2023]
Abstract
Colorectal cancer (CRC) is one of the universally established cancers with a higher incidence rate. Novel progression toward cancer prevention and cancer care among countries in transition should be considered seriously for controlling CRC. Hence, several cutting edge technologies are ongoing for high performance cancer therapeutics over the past few decades. Several drug-delivery systems of the nanoregime are relatively new in this arena compared to the previous treatment modes such as chemo- or radiotherapy to mitigate cancer. Based on this background, the epidemiology, pathophysiology, clinical presentation, treatment possibilities, and theragnostic markers for CRC were revealed. Since the use of carbon nanotubes (CNTs) for the management of CRC has been less studied, the present review analyzes the preclinical studies on the application of carbon nanotubes for drug delivery and CRC therapy owing to their inherent properties. It also investigates the toxicity of CNTs on normal cells for safety testing and the clinical use of carbon nanoparticles (CNPs) for tumor localization. To conclude, this review recommends the clinical application of carbon-based nanomaterials further for the management of CRC in diagnosis and as carriers or therapeutic adjuvants.
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Affiliation(s)
- Jiheng Ma
- Department
of Oncology, Danyang Hospital of Traditional
Chinese Medicine, Zhenjiang 212300, Jiangsu Province, China
| | - Guofang Wang
- Department
of Oncology, Danyang Hospital of Traditional
Chinese Medicine, Zhenjiang 212300, Jiangsu Province, China
| | - Xiaoyu Ding
- Department
of Oncology, Danyang Hospital of Traditional
Chinese Medicine, Zhenjiang 212300, Jiangsu Province, China
| | - Fulin Wang
- Department
of Oncology, Danyang Hospital of Traditional
Chinese Medicine, Zhenjiang 212300, Jiangsu Province, China
| | - Chunning Zhu
- Department
of Oncology, Danyang Hospital of Traditional
Chinese Medicine, Zhenjiang 212300, Jiangsu Province, China
| | - Yunxia Rong
- Department
of Oncology, Danyang Hospital of Traditional
Chinese Medicine, Zhenjiang 212300, Jiangsu Province, China
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Mesri M, Hitchman L, Yiaesemidou M, Quyn A, Jayne D, Chetter I. Protocol: The role of defunctioning stoma prior to neoadjuvant therapy for locally advanced colonic and rectal cancer-A systematic review. PLoS One 2022; 17:e0275025. [PMID: 36137109 PMCID: PMC9498940 DOI: 10.1371/journal.pone.0275025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/08/2022] [Indexed: 11/18/2022] Open
Abstract
Defunctioning stomas (ileostomy and colostomy) may be used prior to commencement of neoadjuvant therapy in patients with locally advanced colon or rectal cancer, in order to prevent clinical large bowel obstruction caused by radiotherapy associated oedema or progression of disease in patients who are not obstructed. However, the exact rate of clinical obstruction in patients undergoing neoadjuvant therapy who do not receive a defunctioning stoma is not known. Furthermore, it is not clear which factors predispose patients to developing clinical large bowel obstruction. Given that defunctioning stomas are associated with post operative and intra-operative risks, it is not currently possible to tailor defunctioning stomas to patients who have the greatest risk of developing obstruction. This systematic review which is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA), aims to define the role of defunctioning stomas in prevention of obstruction patients with locally advanced colon or rectal cancer while undergoing neoadjuvant therapy. Two researchers will perform the literature search which will include all published and "in process" articles published in the English language between 2002-2022 in the following databases: EMBASE (OVID), MEDLINE (EBSCO), CINHAL complete, Web of Science, Cochrane Central Registry of Controlled Trials, Clinical Trials Registry. The full text of the selected articles will be independently screened by two researchers against the inclusion criteria. Data will be extracted from each article regarding: study design, participants, type of intervention and outcomes. The effect size will be expressed in incidence rates and when appropriate in relative risk with 95% confidence intervals. If possible, we will perform a meta-analysis. Heterogeneity will be assessed using I2 statistics. We will pool the data extracted from the randomised controlled trials to perform a meta-analysis using the Review Manager 5 software (RevMan 5). The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system will be used to assess the certainty of the evidence.
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Affiliation(s)
- Mina Mesri
- University of Hull, Hull, United Kingdom
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Louise Hitchman
- University of Hull, Hull, United Kingdom
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Marina Yiaesemidou
- University of Hull, Hull, United Kingdom
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Aaron Quyn
- University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - David Jayne
- University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Ian Chetter
- University of Hull, Hull, United Kingdom
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
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Abstract
Malignant bowel obstruction is a challenging clinical problem encountered in patients with advanced abdominal and pelvic malignancies. Although medical therapies form the foundation of management, some patients may be suitable candidates for surgical and procedural interventions. The literature is composed primarily of retrospective single-institution experiences and the results of prospective trials are pending. Given the high symptom burden and limited life expectancy of these patients, management may be best informed by multidisciplinary teams with relevant expertise.
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Affiliation(s)
- Caitlin T Yeo
- Division of Surgical Oncology, University of Calgary, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, Alberta T2N 4N2, Canada
| | - Shaila J Merchant
- Division of General Surgery and Surgical Oncology, Queen's University, Burr 2, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.
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Bleicher J, Lambert LA, Scaife CL, Colonna A. Current management of malignant bowel obstructions: a survey of acute care surgeons and surgical oncologists. Trauma Surg Acute Care Open 2021; 6:e000755. [PMID: 34222676 PMCID: PMC8211049 DOI: 10.1136/tsaco-2021-000755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background Malignant small bowel obstructions (MSBOs) are one of the most challenging problems surgeons encounter, and evidence-based treatment recommendations are lacking. We hypothesized that current opinions on MSBO management differ between acute care surgeons (ACSs) and surgical oncologists (SOs). Methods We developed three case scenarios describing patients with previously treated cancer who developed an MSBO. Each case had five to six alternate scenarios, intended to capture the heterogeneity of MSBO presentations. Members of the Society of Surgical Oncology, the American Society of Peritoneal Surface Malignancies, and the Eastern Association for the Surgery of Trauma were asked how likely they would be to offer surgical treatment in each scenario. Responses were analyzed for factors associated with the likelihood surgeons would offer surgical management. Results 316 surgeons completed the survey: 119 (37.7%) SOs and 197 (62.3%) ACSs. Overall, SOs were nearly twice as likely as ACSs to recommend surgical management. The largest differences between provider groups were seen in patients with an increased metastatic burden. In a patient with MSBO with metastatic colon cancer, both SOs (95.8%) and ACSs (94.4%) were likely or very likely to offer an operation (p=0.587); however, this fell to 91.6% and 77.7%, respectively, when this patient had multiple hepatic metastases (p=0.001). All surgeons were less likely to offer surgery to patients with multiple sites of obstruction, recurrent MSBO, and shorter disease-free intervals. Discussion Opinions on MSBO management differ based on surgeon training and experience. Multidisciplinary management of patients with MSBO should be offered when available and increased emphasis placed on determining optimal management guidelines across specialties. Level of evidence Level IV Epidemiologic.
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Affiliation(s)
- Josh Bleicher
- General Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Laura A Lambert
- General Surgery, University of Utah Health, Salt Lake City, Utah, USA.,Surgical Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, USA
| | - Courtney L Scaife
- General Surgery, University of Utah Health, Salt Lake City, Utah, USA.,Surgical Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, USA
| | - Alexander Colonna
- General Surgery, University of Utah Health, Salt Lake City, Utah, USA
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Bateni SB, Gingrich AA, Kirane AR, Sauder CAM, Gholami S, Bold RJ, Meyers FJ, Canter RJ. Chemotherapy After Diagnosis of Malignant Bowel Obstruction is Associated with Superior Survival for Medicare Patients with Advanced Malignancy. Ann Surg Oncol 2021; 28:7555-7563. [PMID: 33829359 PMCID: PMC8519893 DOI: 10.1245/s10434-021-09831-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/22/2021] [Indexed: 12/11/2022]
Abstract
Background Although malignant bowel obstruction (MBO) often is a terminal event, systemic therapies are advocated for select patients to extend survival. This study aimed to evaluate factors associated with receipt of chemotherapy after MBO and to determine whether chemotherapy after MBO is associated with survival. Methods This retrospective cohort study investigated patients 65 years of age or older with metastatic gastrointestinal, gynecologic, or genitourinary cancers who were hospitalized with MBO from 2008 to 2012 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Fine and Gray models were used to identify factors associated with receipt of chemotherapy accounting for the competing risk of death. Cox models identified factors associated with overall survival. Results Of the 2983 MBO patients, 39% (n = 1169) were treated with chemotherapy after MBO. No differences in receipt of chemotherapy between the surgical and medical patients were found in the univariable analysis (subdistribution hazard ratio [SHR], 0.96; 95% confidence interval [CI], 0.86–1.07; p = 0.47) or multivariable analysis (SHR, 1.12; 95% CI, 1.00–1.26; p = 0.06). Older age, African American race, medical comorbidities, non-colorectal and non-ovarian cancer diagnoses, sepsis, ascites, and intensive care unit stays were inversely associated with receipt of chemotherapy after MBO (p < 0.05). Chemotherapy with surgery was associated with longer survival than surgery (adjusted hazard ratio [aHR], 2.97; 95% CI, 2.65–3.34; p < 0.01) or medical management without chemotherapy (aHR, 4.56; 95% CI, 4.04–5.14; p < 0.01). Subgroup analyses of biologically diverse cancers (colorectal, pancreatic, and ovarian) showed similar results, with greater survival related to chemotherapy (p < 0.05). Conclusions Chemotherapy plays an integral role in maximizing oncologic outcome for select patients with MBO. The data from this study are critical to optimizing multimodality care for these complex patients. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-09831-0.
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Affiliation(s)
- Sarah B Bateni
- Division of Surgical Oncology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alicia A Gingrich
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Amanda R Kirane
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Candice A M Sauder
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Sepideh Gholami
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Frederick J Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Robert J Canter
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA.
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Goldberg JI, Goldman DA, McCaskey S, Koo DJ, Epstein AS. Illness Understanding, Prognostic Awareness, and End-of-Life Care in Patients With GI Cancer and Malignant Bowel Obstruction With Drainage Percutaneous Endoscopic Gastrostomy. JCO Oncol Pract 2020; 17:e186-e193. [PMID: 32758086 DOI: 10.1200/op.20.00035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Malignant bowel obstruction (MBO) is common in advanced GI cancer, and MBO management, including drainage percutaneous endoscopic gastrostomy (dPEG), is palliative. How patients understand the goals of dPEG and its impact on disease is inadequately understood in the literature. Therefore, we analyzed these issues in patients with GI cancer. METHODS Demographics, clinical variables, and patient outcomes were abstracted from the medical record. Illness understanding and future expectations were retrieved from palliative care notes. We described additional treatment and outcomes after dPEG and estimated overall survival (OS). RESULTS From January 2015 to June 2017, 125 admitted patients with metastatic GI cancer underwent dPEG for MBO. Cancers were most commonly colorectal (34%) and pancreatic/ampullary (25%). During the dPEG admission, 32% (40 of 125) of patients had a palliative care consultation, and 22% (28 of 125) were asked about illness understanding and future expectations. All (28 of 28) reported good understanding of the advanced nature of their disease, but few were accurate about prognosis given their stage IV disease (10 of 28). Of the 117 (94%) discharged, 13% (15 of 117) received additional chemotherapy, which rarely prevented progression; half (63 of 117) had a do-not-resuscitate order; and most (101 of 117) were enrolled in hospice at death. Median time to death was 37 days (95% CI, 29 to 45 days); 6-month OS was 3.7% (95% CI, 1.2% to 8.4%). CONCLUSION dPEGs are placed close to end of life in patients with advanced GI cancer. A minority of patients receive additional chemotherapy post-dPEG. Many have adequate disease understanding, but chemotherapy benefit is low, and future expectations vary. This may be an opportunity for improved communication regarding palliative procedures in advanced cancer.
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Affiliation(s)
- Jessica I Goldberg
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Debra A Goldman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sarah McCaskey
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Douglas J Koo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew S Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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Tong JWV, Lingam P, Shelat VG. Adhesive small bowel obstruction - an update. Acute Med Surg 2020; 7:e587. [PMID: 33173587 PMCID: PMC7642618 DOI: 10.1002/ams2.587] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/05/2020] [Accepted: 09/18/2020] [Indexed: 12/13/2022] Open
Abstract
Small bowel obstruction (SBO) accounts for 12-16% of emergency surgical admissions and 20% of emergency surgical procedures. Even with the advent of laparoscopic surgery, intra-abdominal adhesions remain a significant cause of SBO, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Another critical aspect of evaluation includes establishing the underlying cause for obstruction and distinguishing between adhesive and non-adhesive etiologies as adhesive SBO (ASBO) can be managed non-operatively in 70-90% of patients. A patient with a history of abdominopelvic surgery along with one or more cardinal features of obstruction should be suspected to have ASBO until proven otherwise. Triad of severe pain, pain out of proportion to the clinical findings, and presence of an abdominal scar suggest possible closed-loop obstruction. Computed tomography has higher sensitivity and specificity compared to plain films and is recommended by the Bologna guidelines. Correcting fluid and electrolyte imbalance is an initial crucial step to mitigate severe hypovolemia. Patients should proceed with surgery if symptoms of bowel compromise are present, or if symptoms do not resolve or have worsened. Surgery is indicated in patients with ischemia, strangulation, perforation, peritonitis, or failure of non-operative treatment. With advances in minimal access technology and increasing experience, laparoscopic adhesiolysis is recommended. Mechanical adhesion barriers are an effective measure to prevent adhesion formation.
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Affiliation(s)
- Jia Wei Valerie Tong
- Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
| | - Pravin Lingam
- Department of General SurgeryTan Tock Seng HospitalSingaporeSingapore
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11
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Bozzetti F. The role of parenteral nutrition in patients with malignant bowel obstruction. Support Care Cancer 2019; 27:4393-4399. [DOI: 10.1007/s00520-019-04948-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/18/2019] [Indexed: 01/13/2023]
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12
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Bateni SB, Gingrich AA, Stewart SL, Meyers FJ, Bold RJ, Canter RJ. Hospital utilization and disposition among patients with malignant bowel obstruction: a population-based comparison of surgical to medical management. BMC Cancer 2018; 18:1166. [PMID: 30477454 PMCID: PMC6258444 DOI: 10.1186/s12885-018-5108-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/19/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Malignant bowel obstruction (MBO) is often a terminal event in end-stage cancer patients. The decision to intervene surgically is complex, given the risk of harm in patients with a limited lifespan. Therefore, we sought to compare clinically meaningful outcomes in MBO patients treated with surgical versus medical management using population-based data. METHODS We performed a retrospective analysis of hospitalized patients with MBO from 2006 to 2010 using the California Office of Statewide Health Planning and Development dataset. Hospital-free days (HFDs) at 30-, 90-, and 180-days were calculated accounting for all hospitalization, emergency department visit, and skilled nursing facility lengths of stay. Adjusted regression models were used to compare HFDs, disposition, complications, in-hospital death, and survival for surgical versus medical MBO cohorts, using inverse probability of treatment weighting with propensity scores. RESULTS Of 4576 MBO patients, 3421 (74.8%) were treated medically and 1155 (25.2%) were treated surgically. Surgical patients had higher rates of complications (44.0% vs. 21.3%, p < 0.0001) and in-hospital death (9.5% vs. 3.9%, p < 0.0001) with lower rates of disposition to home (76.3% vs. 89.8%, p < 0.0001). Surgical patients had fewer 30- and 90-day HFDs compared to medical patients (p < 0.01). However, at 180-days, there were no differences in HFDs between treatment groups. There was no difference in overall survival between surgical and medical patients (median 6.5 vs. 6.4 months). CONCLUSION In this population-based analysis, medical management was associated with less hospital utilization at 30- and 90-days, fewer in-hospital deaths, and more frequent discharges to home. These data underscore the potential benefits of medical management for MBO patients at the end-of-life.
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Affiliation(s)
- Sarah B. Bateni
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
| | - Alicia A. Gingrich
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
| | - Susan L. Stewart
- Department of Public Health Sciences, Division of Biostatistics, UC Davis School of Medicine, 4800 2nd Ave, Suite 2209, Sacramento, CA 95817 USA
| | - Frederick J. Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, UC Davis Medical Center, 4610 X Street, Suite 3016, Sacramento, CA 95817 USA
| | - Richard J. Bold
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
| | - Robert J. Canter
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
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13
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Bateni SB, Canter RJ, Meyers FJ, Galante JM, Bold RJ. Palliative Care Training and Decision-Making for Patients with Advanced Cancer: A Comparison of Surgeons and Medical Physicians. Surgery 2018; 164:S0039-6060(18)30078-3. [PMID: 29709369 PMCID: PMC6204113 DOI: 10.1016/j.surg.2018.01.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/18/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgical decision-making in patients with advanced cancer requires careful thought and deliberation to balance the high risks with the potential palliative benefits. We sought to compare surgical decision-making and palliative care training among surgeons and medical physicians who commonly treat advanced cancer patients. We hypothesized that surgeons will report less palliative care training compared with medical physicians, and deficits in palliative care training will be associated with more aggressive treatment recommendations in clinical scenarios of advanced cancer patients with symptomatic surgical conditions. STUDY DESIGN Practicing surgeons, medical oncologists, intensivists, and palliative care physicians from a large urban city and its surrounding areas were surveyed with a 32-item questionnaire consisting of a survey addressing palliative care training and 4 clinical vignettes depicting patients with advanced cancer and symptomatic surgical conditions. RESULTS Of the 299 physicians surveyed, 102 responded (response rate 34.1%). Surgeons reported fewer hours of palliative care training during residency, fellowship, and continuing medical education combined (median 10, IQR 2-15) compared with medical oncologists (median 30, IQR 20-80) and medical intensivists (median 50 IQR 30-100), P < .05. Additionally, 20% of surgeons reported no history of any palliative care training. Analysis of physician recommendations for treatment of the 4 clinical vignettes showed minimal consensus regardless of physician specialty. Absence of palliative care training was associated with recommending major operative intervention more frequently compared with physicians with ≥40 hours of palliative care training (0.7 ± 0.7 vs 1.6 ± 0.8, P =.01). CONCLUSION Substantial deficiencies in palliative care training persist among surgeons and are associated with more aggressive recommendations for treatment for the selected scenarios presented in patients with advanced cancer. These findings highlight the need for greater efforts systemwide in palliative care education among surgeons, including incorporation of a structured palliative care training curriculum in graduate and continuing surgical education.
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Affiliation(s)
- Sarah B Bateni
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA
| | - Robert J Canter
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA
| | - Frederick J Meyers
- Hematology/Oncology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, CA
| | - Joseph M Galante
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of California, Davis Medical Center, Sacramento, CA
| | - Richard J Bold
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA.
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14
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Lilley EJ, Scott JW, Goldberg JE, Cauley CE, Temel JS, Epstein AS, Lipsitz SR, Smalls BL, Haider AH, Bader AM, Weissman JS, Cooper Z. Survival, Healthcare Utilization, and End-of-life Care Among Older Adults With Malignancy-associated Bowel Obstruction: Comparative Study of Surgery, Venting Gastrostomy, or Medical Management. Ann Surg 2018; 267:692-699. [PMID: 28151799 PMCID: PMC7509894 DOI: 10.1097/sla.0000000000002164] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO). BACKGROUND MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life. METHODS Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital. RESULTS Median survival after MBO admission was 76 days (interquartile range 26-319 days). Survival was shorter after VGT [38 days (interquartile range 23-69)] than medical management [72 days (23-312)] or surgery [128 days (42-483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29-0.58)], increased hospice enrollment [1.65 (1.42-1.91)], and less ICU care [0.69 (0.52-0.93)] and in-hospital death [0.47 (0.36-0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59-0.80)], decreased hospice enrollment [0.84 (0.76-0.92)], and higher likelihood of ICU care [1.38 (1.17-1.64)]. CONCLUSIONS VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients' priorities for end-of-life care.
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Affiliation(s)
- Elizabeth J. Lilley
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - John W. Scott
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - Christy E. Cauley
- Ariadne Labs, Boston, MA
- Department of Surgery, Massachusetts General Hospital, Boston
| | | | - Andrew S. Epstein
- Gastrointestinal Medical Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stuart R. Lipsitz
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Brittany L. Smalls
- Center for Health Services Research, University of Kentucky College of Medicine, Lexington, KY
| | - Adil H. Haider
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Angela M. Bader
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joel S. Weissman
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Zara Cooper
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
- Ariadne Labs, Boston, MA
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15
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Merchant SJ, Lajkosz K, Brogly SB, Booth CM, Nanji S, Patel SV, Baxter NN. The Final 30 Days of Life. J Palliat Care 2017; 32:92-100. [DOI: 10.1177/0825859717738464] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Studies have reported overly aggressive end-of-life care (EOLC) in many cancers. We investigate trends in, and factors associated with, aggressive EOLC among patients who died of gastrointestinal (GI) cancers in Ontario, Canada. Methods: All patients with primary cause of death from esophageal, gastric, colon, and anorectal cancer from January 2003 to December 2013 were identified through the Ontario Cancer Registry, and information was collected from linked databases. Outcomes representing aggressive EOLC were assessed: administration of chemotherapy, any emergency department (ED) visits, hospital admissions, intensive care unit (ICU) admissions (all within 30 days of death), death in hospital and in ICU, and a composite outcome representing any aggressive EOLC. Temporal trends were analyzed using the Cochran-Armitage test. Results: There were 34 630 patients in the cohort: 43% colon, 26% anorectal, 19% gastric, and 12% esophageal cancers. Aggressive EOLC was delivered to 65%, with a significantly decreasing trend from 64.8% in 2003 to 62.5% in 2013 ( P = .001). Utilization of specific elements of aggressive EOLC included 8% chemotherapy, 46% ED visits, 49% hospital admissions, 6% ICU admissions, 45% death in hospital, and 5% death in ICU. Trends over the study period showed that ED visits (from 43% to 46.9%; P = .0001) and death in ICU (from 3.7% to 4.9%; P = .04) significantly increased; hospital admissions (from 48.9% to 47.8%; P = .02) and death in hospital (from 46.6% to 38.9%; P < .0001) significantly decreased. Conclusions: Two-thirds of patients with GI cancer had aggressive EOLC in the last 30 days of life.
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Affiliation(s)
| | - Katherine Lajkosz
- Institute for Clinical Evaluative Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Susan B. Brogly
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Christopher M. Booth
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Sunil V. Patel
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Nancy N. Baxter
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
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16
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Outcomes After Surgery for Benign and Malignant Small Bowel Obstruction. J Gastrointest Surg 2017; 21:363-371. [PMID: 27783343 PMCID: PMC5263174 DOI: 10.1007/s11605-016-3307-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common diagnosis; however, outcomes of and risk factors for SBO and malignant bowel obstruction (MBO) surgery are not well understood. We sought to characterize outcomes and risk factors for surgery for SBO and MBO. METHODS A retrospective cohort study was performed utilizing prospectively collected data from the Michigan Surgical Quality Collaborative (7/2012-3/2015). Cases included those with ICD9 diagnosis code of bowel obstruction and CPT codes for lysis of adhesions, intestinal bypass, and small bowel resection. Cases were stratified by disseminated malignancy (MBO). Factors associated with complications and 30-day mortality were evaluated. RESULTS Two thousand two hundred thirty-three patients underwent surgery for bowel obstruction, including 86 patients (3.9 %) with MBO. MBO patients had an adjusted mortality rate of 14.5 % (benign 5.0 %); the adjusted complication rate was 32.2 % (benign 27.0 %). Factors independently associated with mortality included disseminated cancer, older age, American Society of Anesthesiologists IV/V, cirrhosis, ascites, urinary tract infection, sepsis, albumin <3.5, hematocrit <30, and bowel resection. CONCLUSIONS Surgery for bowel obstruction carries a relatively high risk for morbidity and mortality, particularly in patients with malignant bowel obstruction. Considering the identified risk factors for mortality may help clinicians make recommendations regarding surgery in the setting of MBO.
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18
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Managing Malignant Colorectal Obstruction with Self-Expanding Stents. A Closer Look at Bowel Perforations and Failed Procedures. J Gastrointest Surg 2016; 20:1643-9. [PMID: 27342437 DOI: 10.1007/s11605-016-3186-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/07/2016] [Indexed: 01/31/2023]
Abstract
Stent treatment of large bowel obstruction is still controversial. There are concerns regarding complications, particularly bowel perforation, as well as long-term outcome in curable patients. Through a 10-year retrospective study, we have evaluated efficacy, complications, delay in surgical interventions and stent patency in cases of palliative treatment. We treated 183 patients, 85 as bridge to surgery and 98 as definitive, palliative treatment. At presentation, 58 % of patients had advanced local or metastatic disease. Seventeen patients required more than one stent insertion. The total number of procedures was 213. We recorded technical and clinical success or failure, complications, necessity of restenting or surgical intervention, mortality and stent patency in the palliation group. Stenting was clinically successful in 89 % of the bridge to surgery group and 86 % of the palliative group. Complications occurred in 7 %, including 12 perforations. Six patients suffered an early perforation, of which two died. Half of the six late perforations were silent. Procedure related mortality was 1 %. The clinical success rate was high in both the palliative and bridge to surgery setting. The complication rate was low, and the sum of early and late perforations was 5.6 %. Procedure related mortality was low.
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19
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Cousins SE, Tempest E, Feuer DJ. Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer. Cochrane Database Syst Rev 2016; 2016:CD002764. [PMID: 26727399 PMCID: PMC7101053 DOI: 10.1002/14651858.cd002764.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND This is an update of the original Cochrane review published in Issue 4, 2000. Intestinal obstruction commonly occurs in progressive advanced gynaecological and gastrointestinal cancers. Management of these patients is difficult due to the patients' deteriorating mobility and function (performance status), the lack of further chemotherapeutic options, and the high mortality and morbidity associated with palliative surgery. There are marked variations in clinical practice concerning surgery in these patients between different countries, gynaecological oncology units and general hospitals, as well as referral patterns from oncologists under whom these patients are often admitted. OBJECTIVES To assess the efficacy of surgery for intestinal obstruction due to advanced gynaecological and gastrointestinal cancer. SEARCH METHODS We searched the following databases for the original review in 2000 and again for this update in June 2015: CENTRAL (2015, Issue 6); MEDLINE (OVID June week 1 2015); and EMBASE (OVID week 24, 2015).We also searched relevant journals, bibliographic databases, conference proceedings, reference lists, grey literature and the world wide web for the original review in 2000; we also used personal contact. This searching of other resources yielded very few additional studies. The Cochrane Pain, Palliative and Supportive Care Review Group no longer routinely handsearch journals. For these reasons, we did not repeat the searching of other resources for the June 2015 update. SELECTION CRITERIA As the review concentrates on the 'best evidence' available for the role of surgery in malignant bowel obstruction in known advanced gynaecological and gastrointestinal cancer we kept the inclusion criteria broad (including both prospective and retrospective studies) so as to include all studies relevant to the question. We sought published trials reporting on the effects of surgery for resolving symptoms in malignant bowel obstruction for adult patients with known advanced gynaecological and gastrointestinal cancer. DATA COLLECTION AND ANALYSIS We used data extraction forms to collect data from the studies included in the review. Two review authors extracted the data independently to reduce error. Owing to concerns about the risk of bias we decided not to conduct a meta-analysis of data and we have presented a narrative description of the study results. We planned to resolve disagreements by discussion with the third review author. MAIN RESULTS In total we have identified 43 studies examining 4265 participants. The original review included 938 patients from 25 studies. The updated search identified an additional 18 studies with a combined total of 3327 participants between 1997 and June 2015. The results of these studies did not change the conclusions of the original review.No firm conclusions can be drawn from the many retrospective case series so the role of surgery in malignant bowel obstruction remains controversial. Clinical resolution varies from 26.7% to over 68%, though it is often unclear how this is defined. Despite being an inadequate proxy for symptom resolution or quality of life, the ability to feed orally was a popular outcome measure, with success rates ranging from 30% to 100%. Rates of re-obstruction varied, ranging from 0% to 63%, though time to re-obstruction was often not included. Postoperative morbidity and mortality also varied widely, although again the definition of both of these surgical outcomes differed between many of the papers. There were no data available for quality of life. The reporting of adverse effects was variable and this has been described where available. Where discussed, surgical procedures varied considerably and outcomes were not reported by specific intervention. Using the 'Risk of bias' assessment tool, most included studies were at high risk of bias for most domains. AUTHORS' CONCLUSIONS The role of surgery in malignant bowel obstruction needs careful evaluation, using validated outcome measures of symptom control and quality of life scores. Further information could include re-obstruction rates together with the morbidity associated with the various surgical procedures.Currently, bowel obstruction is managed empirically and there are marked variations in clinical practice by different units. In order to compare outcomes in malignant bowel obstruction, there needs to be a greater degree of standardisation of management.Since the last version of this review none of the new included studies have provided additional information to change the conclusions.
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Affiliation(s)
- Sarah E Cousins
- Barts Health NHS TrustMacmillan Palliative Care Team/Cancer Services1st Floor East WingWest SmithfieldLondonUKEC1A 7BE
| | - Emma Tempest
- Whipps Cross University HospitalWhipps Cross RoadLeytonstoneLondonUKE11 1NR
| | - David J Feuer
- Barts Health NHS TrustMacmillan Palliative Care Team/Cancer Services1st Floor East WingWest SmithfieldLondonUKEC1A 7BE
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20
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Abstract
PURPOSE OF REVIEW Surgical management of diseases of the colon and rectum continues to evolve. This review examines the recent publications that have led to or may lead to changes in practice in this field. RECENT FINDINGS We identified and reviewed the recent publications in the areas of colon, rectal, and anal cancers; inflammatory bowel disease; incontinence; diverticulitis; hemorrhoids; fistulas; and quality improvement initiatives. SUMMARY New technologies and novel questions have changed practice and will improve patient outcomes. Multiinstitutional studies, ideally randomized, continue to be essential to answer the questions that will lead to identification of best practices.
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21
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Winner M, Mooney SJ, Hershman DL, Feingold DL, Allendorf JD, Wright JD, Neugut AI. Incidence and predictors of bowel obstruction in elderly patients with stage IV colon cancer: a population-based cohort study. JAMA Surg 2013; 148:715-22. [PMID: 23740130 DOI: 10.1001/jamasurg.2013.1] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Research has been limited on the incidence, mechanisms, etiology, and treatment of symptoms that require palliation in patients with terminal cancer. Bowel obstruction (BO) is a common complication of advanced abdominal cancer, including colon cancer, for which small, single-institution studies have suggested an incidence rate of 15% to 29%. Large population-based studies examining the incidence or risk factors associated with BO in cancer are lacking. OBJECTIVE To investigate the incidence and risk factors associated with BO in patients with stage IV colon cancer. DESIGN AND SETTING Retrospective cohort, population-based study of patients in the Surveillance, Epidemiology, and End Results and Medicare claims linked databases who were diagnosed as having stage IV colon cancer from January 1, 1991, through December 31, 2005. PATIENTS Patients 65 years or older with stage IV colon cancer (n = 12 553). MAIN OUTCOMES AND MEASURES Time to BO, defined by inpatient hospitalization for BO. We used Cox proportional hazards regression models to determine associations between BO and patient, prior treatment, and tumor features. RESULTS We identified 1004 patients with stage IV colon cancer subsequently hospitalized with BO (8.0%). In multivariable analysis, proximal tumor site (hazard ratio, 1.22 [95% CI, 1.07-1.40]), high tumor grade (1.34 [1.16-1.55]), mucinous histological type (1.27 [1.08-1.50]), and nodal stage N2 (1.52 [1.26-1.84]) were associated with increased risk of BO, as was the presence of obstruction at cancer diagnosis (1.75 [1.47-2.04]). A more recent diagnosis was associated with decreased risk of subsequent obstruction (hazard ratio, 0.84 [95% CI, 0.72-0.98]). CONCLUSIONS AND RELEVANCE In this large population of patients with stage IV colon cancer, BO after diagnosis was less common (8.0%) than previously reported. Risk was associated with site and histological type of the primary tumor. Future studies will explore management and outcomes in this serious, common complication.
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Affiliation(s)
- Megan Winner
- Department of Surgery, Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York4Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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22
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Yoon YS, Kim CW, Lim SB, Yu CS, Kim SY, Kim TW, Kim MJ, Kim JC. Palliative surgery in patients with unresectable colorectal liver metastases: a propensity score matching analysis. J Surg Oncol 2013; 109:239-44. [DOI: 10.1002/jso.23480] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 10/07/2013] [Indexed: 12/24/2022]
Affiliation(s)
- Yong Sik Yoon
- Department of Surgery; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Chan Wook Kim
- Department of Surgery; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Seok-Byung Lim
- Department of Surgery; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Chang Sik Yu
- Department of Surgery; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - So Yeon Kim
- Department of Radiology; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Tae Won Kim
- Department of Internal Medicine; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Min-Ju Kim
- Departments of Clinical Epidemiology and Biostatistics; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
| | - Jin Cheon Kim
- Department of Surgery; University of Ulsan College of Medicine, Asan Medical Center; Seoul Korea
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