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Tóth R, Tóth Z, Lőczi L, Török M, Ács N, Várbíró S, Keszthelyi M, Lintner B. Management of Malignant Bowel Obstruction in Patients with Gynaecological Cancer: A Systematic Review. J Clin Med 2024; 13:4213. [PMID: 39064252 PMCID: PMC11277705 DOI: 10.3390/jcm13144213] [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: 06/16/2024] [Revised: 07/06/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Objectives: This systematic review aimed to evaluate current surgical and non-surgical management strategies for malignant bowel obstruction (MBO) in patients with gynaecological cancer. Methods: Comprehensive literature searches were conducted across MEDLINE, Embase, CENTRAL, and Scopus, without restrictions on language or publication date. Following the removal of duplicates, 4866 articles were screened, with 34 meeting the inclusion criteria. Results: Surgical intervention remains the definitive treatment for MBO, offering longer symptom-free periods and improved survival, particularly when conservative methods fail. However, the selection of surgical candidates is crucial due to the high risk of morbidity and the potential for significant complications. Non-surgical treatments, such as the use of Gastrografin, Octreotide, and Dexamethasone, along with invasive procedures like nasogastric tubing, percutaneous gastrostomy, and stent placement, offer varying degrees of symptom relief and are often considered when surgery is not feasible. Conclusions: In this article we provide a potential therapeutic algorithm for the management of patients with MBO. This review underscores the urgent need for high-quality research to develop clear, evidence-based guidelines for MBO management in patients with gynaecologic cancer. Establishing standardised protocols will improve patient outcomes by aiding clinicians in making informed, individualised treatment decisions.
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Affiliation(s)
- Richárd Tóth
- Department of Obstetrics and Gynaecology, Semmelweis University, 1082 Budapest, Hungary; (R.T.); (Z.T.); (L.L.); (M.T.); (N.Á.); (S.V.); (B.L.)
| | - Zsófia Tóth
- Department of Obstetrics and Gynaecology, Semmelweis University, 1082 Budapest, Hungary; (R.T.); (Z.T.); (L.L.); (M.T.); (N.Á.); (S.V.); (B.L.)
| | - Lotti Lőczi
- Department of Obstetrics and Gynaecology, Semmelweis University, 1082 Budapest, Hungary; (R.T.); (Z.T.); (L.L.); (M.T.); (N.Á.); (S.V.); (B.L.)
- Workgroup of Research Management, Doctoral School, Semmelweis University, 1085 Budapest, Hungary
| | - Marianna Török
- Department of Obstetrics and Gynaecology, Semmelweis University, 1082 Budapest, Hungary; (R.T.); (Z.T.); (L.L.); (M.T.); (N.Á.); (S.V.); (B.L.)
- Workgroup of Research Management, Doctoral School, Semmelweis University, 1085 Budapest, Hungary
| | - Nándor Ács
- Department of Obstetrics and Gynaecology, Semmelweis University, 1082 Budapest, Hungary; (R.T.); (Z.T.); (L.L.); (M.T.); (N.Á.); (S.V.); (B.L.)
| | - Szabolcs Várbíró
- Department of Obstetrics and Gynaecology, Semmelweis University, 1082 Budapest, Hungary; (R.T.); (Z.T.); (L.L.); (M.T.); (N.Á.); (S.V.); (B.L.)
- Workgroup of Research Management, Doctoral School, Semmelweis University, 1085 Budapest, Hungary
- Department of Obstetrics and Gynaecology, University of Szeged, 6725 Szeged, Hungary
| | - Márton Keszthelyi
- Department of Obstetrics and Gynaecology, Semmelweis University, 1082 Budapest, Hungary; (R.T.); (Z.T.); (L.L.); (M.T.); (N.Á.); (S.V.); (B.L.)
| | - Balázs Lintner
- Department of Obstetrics and Gynaecology, Semmelweis University, 1082 Budapest, Hungary; (R.T.); (Z.T.); (L.L.); (M.T.); (N.Á.); (S.V.); (B.L.)
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Bravington A, Obita G, Baddeley E, Johnson MJ, Murtagh FE, Currow DC, Boland EG, Nelson A, Seddon K, Oliver A, Noble SI, Boland JW. The range and suitability of outcome measures used in the assessment of palliative treatment for inoperable malignant bowel obstruction: A systematic review. Palliat Med 2022; 36:1336-1350. [PMID: 36131489 PMCID: PMC10150264 DOI: 10.1177/02692163221122352] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Malignant bowel obstruction, a complication of certain advanced cancers, causes severe symptoms which profoundly affect quality of life. Clinical management remains complex, and outcome assessment is inconsistent. AIM To identify outcomes evaluating palliative treatment for inoperable malignant bowel obstruction, as part of a four-phase study developing a core outcome set. DESIGN The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA); PROSPERO (ID: CRD42019150648). Eligible studies included at least one subgroup with obstruction below the ligament of Treitz undergoing palliative treatment for inoperable malignant bowel obstruction. Study quality was not assessed because the review does not evaluate efficacy. DATA SOURCES Medline, Embase, the Cochrane Database, CINAHL, PSYCinfo Caresearch, Open Grey and BASE were searched for trials and observational studies in October 2021. RESULTS A total of 4769 studies were screened, 290 full texts retrieved and 80 (13,898 participants) included in a narrative synthesis; 343 outcomes were extracted verbatim and pooled into 90 unique terms across six domains: physiological, nutrition, life impact, resource use, mortality and survival. Prevalent outcomes included adverse events (78% of studies), survival (54%), symptom control (39%) and mortality (31%). Key individual symptoms assessed were vomiting (41% of studies), nausea (34%) and pain (33%); 19% of studies assessed quality of life. CONCLUSIONS Assessment focuses on survival, complications and overall symptom control. There is a need for definitions of treatment 'success' that are meaningful to patients, a more consistent approach to symptom assessment, and greater consideration of how to measure wellbeing in this population.
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Affiliation(s)
- Alison Bravington
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elin Baddeley
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elaine G Boland
- Queen's Centre for Oncology and Haematology, Cottingham, Hull, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Kathy Seddon
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Alfred Oliver
- National Cancer Research Institute, Consumer Liaison Group, Trans-Humber Consumer Research Panel, London, UK
| | - Simon Ir Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
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3
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Tigert M, Lau C, Mackay H, L'Heureux S, Gien LT. Factors impacting length of stay and survival in patients with advanced gynecologic malignancies and malignant bowel obstruction. Int J Gynecol Cancer 2021; 31:727-732. [PMID: 33509803 DOI: 10.1136/ijgc-2020-002133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES Malignant bowel obstruction in patients with gynecologic malignancies can impose a large symptomatic burden. The objectives of this study were to identify factors associated with shorter length of hospital stay and overall survival in gynecologic oncology patients with malignant bowel obstructions. METHODS A retrospective chart review was performed from December 2014 to March 2019 on patients admitted to a tertiary care center with a malignant bowel obstruction and advanced gynecologic malignancy. Data collection included patient and tumor characteristics, malignant bowel obstruction management (such as conservative management with bowel rest, nasogastric tube, pharmacotherapy or active intervention with surgery, chemotherapy, radiation, total parenteral nutrition or interventional stents), length of hospital stay, and survival outcomes. Statistical analysis included comparisons with Student's t-test and χ2 test, multivariable analysis, and survival analysis. RESULTS A total of 107 patients with gynecologic cancer with malignant bowel obstruction were included. The majority of patients (63%, n=67) had ovarian cancer. The median length of hospital stay was 12 days (range 1-23), with a median overall survival after malignant bowel obstruction diagnosis of 7 months (range 0.1-64.1). Patients with active interventions had a longer length of stay compared with those with conservative management (13 vs 6 days, p<0.001). However, patients who received multiple active interventions had increased overall survival (9.1 vs 2.9 months, p=0.049). CONCLUSION Patients who received multimodal treatment for malignant bowel obstruction had an increased length of stay and improvement in survival of over 6 months. This emphasizes the importance of a multidisciplinary approach to actively manage malignant bowel obstruction in advanced gynecologic cancer.
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Affiliation(s)
- Melissa Tigert
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christine Lau
- Palliative Care, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Helen Mackay
- University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.,Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Stephanie L'Heureux
- University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.,Division of Medical Oncology, Princess Margaret Hospital Department of Medical Oncology and Hematology, Toronto, Ontario, Canada
| | - Lilian T Gien
- University of Toronto Faculty of Medicine, Toronto, Ontario, Canada .,Gynecologic Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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4
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Banting SP, Waters PS, Peacock O, Narasimhan V, Lynch AC, McCormick JJ, Warrier SK, Heriot AG. Management of primary and metastatic malignant small bowel obstruction, operate or palliate. A systematic review. ANZ J Surg 2020; 91:282-290. [PMID: 32869479 DOI: 10.1111/ans.16188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/07/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of patients presenting with malignant small bowel obstruction is a challenging paradigm. The aim of this systematic review was to examine different management strategies in these complex patients. The primary outcomes evaluated were the type of intervention, 30-day morbidity and mortality and overall survival rates. METHODS A systematic literature review of EMBase, Medline, PubMed and the Cochrane Library was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses for studies reporting on conservative and operative management of malignant small bowel obstruction. RESULTS Fifteen studies (n = 882 patients) reporting on outcomes for malignant small bowel obstruction were analysed. Outcomes measured were primarily survival and relief of obstructive symptoms. The median age ranged from 52 to 66 years. The most common cause of malignant small bowel obstruction was gynaecological in nature (56%), followed by colorectal (19%). Four hundred and eighty-six patients underwent primary surgical management and the remaining 396 patients were assigned to non-surgical intervention. Median overall survival in the operative studies ranged from 2.5 to 7.4 months compared with 0.9 to 1.9 months (P < 0.05). The 30-day mortality ranged from 13% to 28% in those who underwent surgical interventions versus 2% to 61% in the non-surgical group (P = 0.09). No significant difference in median survival in gastrointestinal (GI) and gynaecological malignancies was observed (4.3 versus 5.0 months, P = 0.12). Morbidity ranged from 21% to 85% in the surgical group and 12% to 29% in the percutaneous groups (P < 0.05). CONCLUSION Surgical intervention in malignant small bowel obstruction is associated with significant morbidity, although it may improve survival in selected patients with gynaecological and colorectal malignancy. It is imperative that realistic goals and expectations are discussed with patients preoperatively.
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Affiliation(s)
- Samuel P Banting
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Peadar S Waters
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Oliver Peacock
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Vignesh Narasimhan
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew C Lynch
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Colorectal Surgical Unit, Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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5
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Thota RS, Ramanjulu R, Ahmed A, Jain P, Salins N, Bhatnagar S, Chatterjee A, Bhattacharya D. Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Pharmacological Management of Cancer Pain (Part II). Indian J Palliat Care 2020; 26:180-190. [PMID: 32874031 PMCID: PMC7444569 DOI: 10.4103/0973-1075.285693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group (SIG) guidelines on pharmacological management of cancer pain in adults provide a structured, stepwise approach, which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire, based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking, was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend that analgesics for cancer pain management should follow the World Health Organization 3-step analgesic ladder appropriate for the severity of pain. The use of paracetamol and nonsteroidal anti-inflammatory drugs alone or in combination with opioids for mild-to-moderate pain should be used. For mild-to-moderate pain, weak opioids such as tramadol, tapentadol, and codeine can be given in combination with nonopioid analgesics. We recommend morphine as the opioid of the first choice for moderate-to-severe cancer pain. Sustained-release formulations can be started 12 hourly, once the effective 24 h dose with immediate-release morphine is established. Opioid switch or rotation should be considered if there is inadequate analgesia or intolerable side effects. For opioid-induced respiratory depression, μ receptor antagonists (e.g. naloxone) must be used promptly. Antidepressants and/or anticonvulsants should be used to treat neuropathic cancer pain, and the dose should be titrated according to the clinical response and side effects. External beam radiotherapy should be offered to all patients with painful metastatic bone pain. There is evidence on use of ketamine in cancer neuropathic pain, but with no beneficial effect, thus, it is not recommended.
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Affiliation(s)
- Raghu S Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Raghavendra Ramanjulu
- Department of Pain and Palliative Care, Cytecare Hospital, Bengaluru, Karnataka, India
| | - Arif Ahmed
- Department of Anaesthesia, Critical Care and Pain Management, CK Birla Hospital for Women, Gurugram, Haryana, India
| | - Parmanand Jain
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Chatterjee
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dipasri Bhattacharya
- Department of Anaesthesiology, Critical Care and Pain, R. G. Kar Medical College, Kolkata, West Bengal, India
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Abstract
PURPOSE OF REVIEW Patients with gynecologic malignancies experience varied and often difficult-to-manage symptoms through their disease course, along with decisions surrounding preferences for advance care planning. This review focuses on evidence-based symptom management for these patients and offers a framework for conversations regarding goals of therapy. RECENT FINDINGS There is increasing literature on palliative care specifically in gynecologic oncology, including barriers and possible solutions for early palliative care use, along with updated guidelines on postoperative pain management and tools for communication. SUMMARY Integration of early palliative care and focus on symptom management is an important and multidisciplinary approach to help patients with gynecologic malignancies.
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7
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Abstract
PURPOSE OF REVIEW Patients with gynecologic malignancies face many difficult issues in the course of their diseases, ranging from physical symptoms to advance care planning in light of a poor prognosis. This review examines the evidence supporting integration of palliative care early in the course of disease and symptom management, and provides a framework for difficult conversations. RECENT FINDINGS Palliative care has been demonstrated to improve quality of life and promote survival if integrated early in the course of disease. An evidence-based approach should guide symptom management, such as pain and nausea. Advance care planning and goals of care discussions are enhanced by a framework guiding discussion and the incorporation of empathetic responses. SUMMARY Palliative care is a diverse multidisciplinary field that can provide significant benefit for patients with gynecologic malignancies.
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8
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Contributions of the Japanese Gynecologic Oncology Group (JGOG) in Improving the Quality of Life in Women With Gynecological Malignancies. Curr Oncol Rep 2017; 19:25. [PMID: 28303492 DOI: 10.1007/s11912-017-0580-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The Japanese Gynecologic Oncology Group (JGOG) is leading Japan in the treatment of gynecological malignancies. The JGOG consists of three treatment committees focusing on uterine cervical cancer, endometrial cancer, and ovarian cancer. Each committee makes efforts to improve treatment and diagnosis. In addition, the Supportive and Palliative Care Committee was established in 2015. Novel studies of supportive care and palliative care have been initiated by this committee. Furthermore, surveys about not only treatment results such as overall survival rates but also quality of life (QOL) and cost-effectiveness assessments are performed by the ovarian cancer committee. Improvements of patients' QOL in the treatment of gynecological malignancies were divided into three concepts as follows: QOL associated with cancer treatment, health care after cancer therapy, and progression of cancer. In this review, we report the contributions and future plans for the improvement of QOL in patients with gynecological malignancies.
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9
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Obita GP, Boland EG, Currow DC, Johnson MJ, Boland JW. Somatostatin Analogues Compared With Placebo and Other Pharmacologic Agents in the Management of Symptoms of Inoperable Malignant Bowel Obstruction: A Systematic Review. J Pain Symptom Manage 2016; 52:901-919.e1. [PMID: 27697568 DOI: 10.1016/j.jpainsymman.2016.05.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 05/02/2016] [Accepted: 05/24/2016] [Indexed: 12/01/2022]
Abstract
CONTEXT Somatostatin analogues are commonly used to relieve symptoms in malignant bowel obstruction (MBO) but are more expensive than other antisecretory agents. OBJECTIVES To evaluate the evidence of effectiveness of somatostatin analogues compared with placebo and/or other pharmacologic agents in relieving vomiting in patients with inoperable MBO. METHODS MEDLINE, EMBASE, CINAHL, and The Cochrane Controlled Trials Register databases were systematically searched; reference lists of relevant articles were hand searched. Cochrane risk of bias tool was used. RESULTS The search identified 420 unique studies. Seven randomized controlled trials (RCTs) met the inclusion criteria (six octreotide studies and one lanreotide); 220 people administered somatostatin analogues and 207 placebo or hyoscine butylbromide. Three RCTs compared a somatostatin analogue with placebo and four with hyoscine butylbromide. Two adequately powered multicenter RCTs with a low Cochrane risk of bias reported no significant difference between somatostatin analogues and placebo in their primary end points. Four RCTs with a high/unclear Cochrane risk of bias reported that somatostatin analogues were more effective than hyoscine butylbromide in reducing vomiting. CONCLUSION There is low-level evidence of benefit with somatostatin analogues in the symptomatic treatment of MBO. However, high-level evidence from trials with low risk of bias found no benefit of somatostatin analogues for their primary outcome. There is debate regarding the clinically relevant study end point for symptom control in MBO and when it should be measured. The role of somatostatin analogues in this clinical situation requires further adequately powered, well-designed trials with agreed clinically important end points and measures.
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Affiliation(s)
| | - Elaine G Boland
- Hull York Medical School, University of Hull, Hull, United Kingdom; Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom
| | - David C Currow
- Hull York Medical School, University of Hull, Hull, United Kingdom; Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia
| | - Miriam J Johnson
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Jason W Boland
- Hull York Medical School, University of Hull, Hull, United Kingdom
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10
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Walsh D, Davis M, Ripamonti C, Bruera E, Davies A, Molassiotis A. 2016 Updated MASCC/ESMO consensus recommendations: Management of nausea and vomiting in advanced cancer. Support Care Cancer 2016; 25:333-340. [DOI: 10.1007/s00520-016-3371-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/04/2016] [Indexed: 11/24/2022]
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11
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Romeo M, de Los LLanos Gil M, Cuadra Urteaga JL, Vilà L, Ahlal S, Indacochea A, Pardo N, Radua J, Font A, Tuca A. Outcome prognostic factors in inoperable malignant bowel obstruction. Support Care Cancer 2016; 24:4577-86. [PMID: 27286874 DOI: 10.1007/s00520-016-3299-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 05/31/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Inoperable malignant bowel obstruction (MBO), a severe complication of peritoneal carcinomatosis, has a low desobstruction rate (30-40 %) and end-of-life decision-making is hampered by the lack of known prognostic factors. This study aimed to explore prognostic factors for desobstruction in MBO. METHODS All patients with inoperable MBO admitted in our large oncology hospital between 2010 and 2013 were treated following a clinical protocol based on antiemetics, steroids and two antisecretories, octreotide, and hyoscine butylbromide. Two prognostic factor analyses using logistic regressions were performed, one based on data from day 1 of admission and the other on data from day 8. RESULTS Forty-five patients were included. Frequency of desobstruction was 48.9 %. In the analysis of prognostic factors on day 1, MBO episodes derived from functional physiopathologic mechanisms (vs. mechanic or mixed) were more prone to resolve (p < 0.001 corrected for multiple comparisons). Considering patients alive with persistent obstruction on day 8, a better clinical condition was the variable more associated with desobstruction, but without statistical significance after correction for multiple comparisons. CONCLUSIONS A functional physiopathologic mechanism of MBO development may be an early prognostic factor for desobstruction. A high proportion of desobstruction was observed, suggesting that the combination of antisecretories with different mechanism of action warrants further investigation.
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Affiliation(s)
- Margarita Romeo
- Medical Oncology Department, Institut Català d'Oncologia, Carretera del Canyet s/n, 08916, Badalona, Spain. .,Universitat Autónoma de Barcelona, Barcelona, Spain.
| | - Maria de Los LLanos Gil
- Medical Oncology Department, Institut Català d'Oncologia, Carretera del Canyet s/n, 08916, Badalona, Spain
| | - José Luís Cuadra Urteaga
- Medical Oncology Department, Institut Català d'Oncologia, Carretera del Canyet s/n, 08916, Badalona, Spain
| | - Laia Vilà
- Medical Oncology Department, Institut Català d'Oncologia, Carretera del Canyet s/n, 08916, Badalona, Spain
| | - Sara Ahlal
- Medical Oncology Department, Institut Català d'Oncologia, Carretera del Canyet s/n, 08916, Badalona, Spain
| | - Alberto Indacochea
- Medical Oncology Department, Institut Català d'Oncologia, Carretera del Canyet s/n, 08916, Badalona, Spain.,Center for Genomic Regulation (CRG), Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Núria Pardo
- Medical Oncology Department, Institut Català d'Oncologia, Carretera del Canyet s/n, 08916, Badalona, Spain.,Medical Oncology Department, Hospital Vall d'Hebron, Vall d'Hebron Institut of Oncology, Barcelona, Spain
| | - Joaquim Radua
- FIDMAG Germanes Hospitalàries- CIBERSAM, Sant Boi de Llobregat, Spain.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
| | - Albert Font
- Medical Oncology Department, Institut Català d'Oncologia, Carretera del Canyet s/n, 08916, Badalona, Spain
| | - Albert Tuca
- Supportive Care in Cancer Unit, Medical Oncology Department, Hospital Clínic de Barcelona, Barcelona, Spain
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12
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Management of intestinal obstruction in advanced malignancy. Ann Med Surg (Lond) 2015; 4:264-70. [PMID: 26288731 PMCID: PMC4539185 DOI: 10.1016/j.amsu.2015.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 02/07/2023] Open
Abstract
Patients with incurable, advanced abdominal or pelvic malignancy often present to acute surgical departments with symptoms and signs of intestinal obstruction. It is rare for bowel strangulation to occur in these presentations, and spontaneous resolution often occurs, so the luxury of time should be afforded while decisions are made regarding surgery. Cross-sectional imaging is valuable in determining the underlying mechanism and pathology. The majority of these patients will not be suitable for an operation, and will be best managed in conjunction with a palliative medicine team. Surgeons require a good working knowledge of the mechanisms of action of anti-emetics, anti-secretories and analgesics to tailor early management to individual patients, while decisions regarding potential surgery are made. Deciding if and when to perform operative intervention in this group is complex, and fraught with both technical and emotional challenges. Surgery in this group is highly morbid, with no current evidence available concerning quality of life following surgery. The limited evidence concerning operative strategy suggests that resection and primary anastomosis results in improved survival, over bypass or stoma formation. Realistic prognostication and involvement of the patient, care-givers and the multidisciplinary team in treatment decisions is mandatory if optimum outcomes are to be achieved.
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13
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Currow DC, Quinn S, Agar M, Fazekas B, Hardy J, McCaffrey N, Eckermann S, Abernethy AP, Clark K. Double-blind, placebo-controlled, randomized trial of octreotide in malignant bowel obstruction. J Pain Symptom Manage 2015; 49:814-21. [PMID: 25462210 DOI: 10.1016/j.jpainsymman.2014.09.013] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 09/15/2014] [Accepted: 09/22/2014] [Indexed: 12/16/2022]
Abstract
CONTEXT Does octreotide reduce vomiting in cancer-associated bowel obstruction? OBJECTIVES To evaluate the net effect of adding octreotide or placebo to standardized therapies on the number of days free of vomiting for populations presenting with vomiting and inoperable bowel obstruction secondary to cancer or its treatment. METHODS Twelve services enrolled people with advanced cancer presenting with vomiting secondary to bowel obstruction where surgery or anti-cancer therapies were not indicated immediately. In a double-blind study, participants were randomized to placebo or octreotide (600 μg/24 hours by infusion). Both arms received standardized supportive therapy (infusion of ranitidine [200 mg/24 hours], dexamethasone [8 mg/24 hours], and parenteral hydration [10-20 mL/kg/24 hours]). The primary outcome was patient-reported days free of vomiting at 72 hours. RESULTS In a study that recruited to the numbers identified in its power calculation, 87 participants provided data at 72 hours (45, octreotide arm). Seventeen people (octreotide) and 14 (placebo) were free of vomiting for 72 hours (P = 0.67). Mean days free of vomiting were 1.87 (SD 1.10; octreotide) and 1.69 (SD 1.15; placebo; P = 0.47). An adjusted multivariate regression of the incidence of vomiting over the study showed a reduced number of episodes of vomiting in the octreotide group (incidence rate ratio = 0.40; 95% CI: 0.19-0.86; P = 0.019); however, people in the octreotide arm were 2.02 times more likely to be administered hyoscine butylbromide (P = 0.004), potentially reflecting increased colicky pain. CONCLUSION Although there was no reduction in the number of days free of vomiting, the multivariate analysis suggests that further study of somatostatin analogues in this setting is warranted.
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia.
| | - Stephen Quinn
- Flinders Clinical Effectiveness, Flinders University, Adelaide, South Australia, Australia
| | - Meera Agar
- Sacred Heart Hospice, Braeside Hospital, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Janet Hardy
- Department of Palliative and Supportive Care, Mater Health Services, South Brisbane, Queensland, Australia
| | - Nikki McCaffrey
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; Flinders Clinical Effectiveness, Flinders University, Adelaide, South Australia, Australia
| | - Simon Eckermann
- Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Amy P Abernethy
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; Duke University Medical Center, Durham, North Carolina, USA
| | - Katherine Clark
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
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14
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Wu WG, Dong P, Wu XS, Li ML, Ding QC, Zhang L, Yang JH, Weng H, Ding Q, Tan ZJ, Lu JH, Gu J, Liu YB. Surgical management of patients with bowel obstructions secondary to gastric cancer. World J Gastroenterol 2013; 19:4559-4567. [PMID: 23901233 PMCID: PMC3725382 DOI: 10.3748/wjg.v19.i28.4559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 05/27/2013] [Accepted: 06/04/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess whole-body fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in the management of small bowel obstructions (SBOs) secondary to gastric cancer and its role in treatment strategies.
METHODS: The medical records of all of the patients who were admitted for an intestinal obstruction after curative resection for gastric cancer were retrospectively reviewed. PET/CT was performed before a clinical treatment strategy was established for each patient. The patients were divided into 2 groups: patients with no evidence of a tumor recurrence and patients with evidence of a tumor recurrence. Tumor recurrences included a local recurrence, peritoneal carcinomatosis or distant metastases. The primary endpoint was the 1-year survival rate, and other variables included patient demographics, the length of hospital stay, complications, and mortality.
RESULTS: The median time between a diagnosis of gastric cancer and the detection of a SBO was 1.4 years. Overall, 31 of 65 patients (47.7%) had evidence of a tumor recurrence on the PET/CT scan, which was the only factor that was associated with poor survival. Open and close surgery was the main type of surgical procedure reported for the patients with tumor recurrences. R0 resections were performed in 2 patients, including 1 who underwent combined adjacent organ resection. In the group with no evidence of a tumor recurrence on PET/CT, bowel resections were performed in 7 patients, adhesiolysis was performed in 7 patients, and a bypass was performed in 1 patient. The 1-year survival curves according to PET/CT evidence of a tumor recurrence vs no PET/CT evidence of a tumor recurrence were significantly different, and the 1-year survival rates were 8.8% vs 93.5%, respectively. There were no significant differences (P = 0.71) in the 1-year survival rates based on surgical vs nonsurgical management (0% with nonoperative treatment vs 20% after exploratory laparotomy).
CONCLUSION: 18F-FDG PET/CT can be used to identify the causes of bowel obstructions in patients with a history of gastric cancer, and this method is useful for planning the surgical management of these patients.
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15
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Bellavance EC, Alexander HR. Palliative Interventions in Patients With Peritoneal Metastases and Malignant Bowel Obstruction. J Clin Oncol 2012; 30:4290-1. [DOI: 10.1200/jco.2012.45.0536] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Emily C. Bellavance
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - H. Richard Alexander
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
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16
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Tuca A, Guell E, Martinez-Losada E, Codorniu N. Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors influencing spontaneous resolution. Cancer Manag Res 2012; 4:159-69. [PMID: 22904637 PMCID: PMC3421464 DOI: 10.2147/cmar.s29297] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Malignant bowel obstruction (MBO) is a frequent complication in advanced cancer patients, especially in those with abdominal tumors. Clinical management of MBO requires a specific and individualized approach that is based on disease prognosis and the objectives of care. The global prevalence of MBO is estimated to be 3% to 15% of cancer patients. Surgery should always be considered for patients in the initial stages of the disease with a preserved general status and a single level of occlusion. Less invasive approaches such as duodenal or colonic stenting should be considered when surgery is contraindicated in obstructions at the single level. The priority of care for inoperable and consolidated MBO is to control symptoms and promote the maximum level of comfort possible. The spontaneous resolution of an inoperable obstructive process is observed in more than one third of patients. The mean survival is of no longer than 4-5 weeks in patients with consolidated MBO. Polymodal medical treatment based on a combination of glucocorticoids, strong opioids, antiemetics, and antisecretory drugs achieves very high symptomatic control. This review focuses on the epidemiological aspects, diagnosis, surgical criteria, medical management, and factors influencing the spontaneous resolution of MBO in advanced cancer patients.
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Affiliation(s)
- Albert Tuca
- Cancer and Hematological Diseases Institute, Hospital Clínic de Barcelona, Barcelona, Spain
- Correspondence: Albert Tuca, Cancer and Hematological Diseases Institute, Hospital Clínic de Barcelona, C/Villarroel 170, 08036, Barcelona, Spain, Tel +34 932 275 400, Fax +34 93 227 98 11, Email
| | - Ernest Guell
- Palliative Care Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Nuria Codorniu
- Medical Oncology Department, Institut Català Oncologia L’Hospitalet, Barcelona, Spain
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