SALTO: a randomized, multicenter study assessing octreotide LAR in inoperable bowel obstruction. Bull Cancer. 2012;99:E1-E9. [PMID: 22265994 DOI: 10.1684/bdc.2011.1535]

Development of a Core Outcome Set for the research and assessment of inoperable malignant bowel obstruction

BACKGROUND

Malignant bowel obstruction is experienced by 15% of people with advanced cancer, preventing them from eating and drinking and causing pain, nausea and vomiting. Surgery is not always appropriate. Management options include tube or stent drainage of intestinal contents and symptom control using medication. Published literature describing palliative interventions uses a broad range of outcome measures, few of which are patient-relevant. This hinders evidence synthesis, and fails to consider the perspectives of people undergoing treatment.

AIMS

To develop a Core Outcome Set for the assessment of inoperable malignant bowel obstruction with clinician, patient and caregiver involvement, using COMET methodology (Core Outcome Measures in Effectiveness Trials).

METHODS

A systematic review of clinical trials and observational studies, a rapid review of the qualitative literature and in-depth patient and clinician interviews were conducted to identify a comprehensive list of outcomes. Outcomes were compared and consolidated by the study Steering Group and Patient and Public Involvement contributors, and presented to an international clinical Expert Panel for review. Outcomes from the finalised list were rated for importance in a three-round international Delphi process: results of two survey rounds were circulated to respondents, and two separate consensus meetings were conducted with clinicians and with patients and caregivers via virtual conferencing, using live polling to reach agreement on a Core Outcome Set.

RESULTS

130 unique outcomes were identified. Following the independent Expert Panel review, 82 outcomes were taken into round 1 of the Delphi survey; 24 outcomes reached criteria for critical importance across all stakeholder groups and none reached criteria for dropping. All outcomes rated critically important were taken forward for re-rating in round 2 and all other outcomes dropped. In round 2, all outcomes were voted critically important by at least one stakeholder group. Round 2 outcomes were presented again at online consensus meetings, categorised as high ranking (n = 9), middle ranking (n = 7) or low ranking (n = 8). Stakeholders reached agreement on 16 core outcomes across four key domains: Symptom control, Life impact, Treatment outcomes, and Communication and patient preferences.

CONCLUSION

Use of this Core Outcome Set can help to address current challenges in making sense of the evidence around treatment for inoperable malignant bowel obstruction to date, and underpin a more robust future approach. Clearer communication and an honest understanding between all stakeholders will help to provide a basis for responsible decision-making in this distressing situation in clinical practice.

Inoperable Bowel Obstruction in Ovarian Cancer: Prevalence, Impact and Management Challenges

Malignant bowel obstruction (MBO) is one of the most severe complications in patients with advanced ovarian cancer, with an estimated incidence up to 50%. Its presence is related to poor prognosis and a life expectancy measured in weeks for inoperable cases. Symptoms are usually difficult to manage and often require hospitalization, which carries a high burden on patients, caregivers and the healthcare system. Management is complex and requires a multidisciplinary approach to improve clinical outcomes. Patients with inoperable MBO are treated medically with analgesics, antiemetics, steroids and antisecretory agents. Parenteral nutrition and gut decompression with nasogastric tube, venting gastrostomy or stenting may be used as supportive therapy. Treatment decision-making is challenging and often based on clinical expertise and local policies, with lack of high-quality evidence to optimally standardize management. The present review summarizes current literature on inoperable bowel obstruction in ovarian cancer, focusing on epidemiology, prognostic factors, clinical outcomes, medical management, multidisciplinary interventions and quality of life.

The range and suitability of outcome measures used in the assessment of palliative treatment for inoperable malignant bowel obstruction: A systematic review

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.

MASCC multidisciplinary evidence-based recommendations for the management of malignant bowel obstruction in advanced cancer

PURPOSE

To provide evidence-based recommendations on the management of malignant bowel obstruction (MBO) for patients with advanced cancer.

METHODS

The Multinational Association for Supportive Care in Cancer (MASCC) MBO study group conducted a systematic review of databases (inception to March 2021) to identify studies about patients with advanced cancer and MBO that reported on the following outcomes: symptom management, bowel obstruction resolution, prognosis, overall survival, and quality of life. The review was restricted to studies published in English, but no restrictions were placed on publication year, country, and study type. As per the MASCC Guidelines Policy, the findings were synthesized to determine the levels of evidence to support each MBO intervention and, ultimately, the graded recommendations and suggestions.

RESULTS

The systematic review identified 17,656 published studies and 397 selected for the guidelines. The MASCC study group developed a total of 25 evidence-based suggestions and recommendations about the management of MBO-related nausea and vomiting, bowel movements, pain, inflammation, bowel decompression, and nutrition. Expert consensus-based guidance about advanced care planning and psychosocial support is also provided.

CONCLUSION

This MASCC Guideline provides comprehensive, evidence-based recommendations about MBO management for patients with advanced cancer.

Efficacy and Safety of Lanreotide Autogel in the Treatment of Clinical Symptoms Associated With Inoperable Malignant Intestinal Obstruction: A Prospective Phase II Study

PURPOSE

Inoperable malignant intestinal obstruction (IMIO) is a severe complication in patients with cancer, usually gastrointestinal or gynecologic in origin. For patients with IMIO, there is a need to relieve symptoms and limit nasogastric tube (NGT) use. Previous studies have suggested the efficacy of somatostatin analogues in relieving obstruction-related symptoms, such as nausea, vomiting, and pain. The purpose of this study was to assess the efficacy of lanreotide autogel 120 mg (LAN 120 mg) in the management of symptoms resulting from IMIO in patients with advanced cancer.

METHODS

This single-arm, multicenter study enrolled 52 patients mostly with advanced gastrointestinal or ovarian malignant tumors (35 patients with NGT and 17 patients without NGT). Patients received 1 deep subcutaneous injection of LAN 120 mg. Evaluations were performed on days 7, 14, and 28. The primary end point was the percentage of responding patients before or at day 7. Response was defined as ≤2 vomiting episodes per day (for patients without NGT at baseline) or no vomiting recurrence (after NGT removal) during at least 3 consecutive days at any time point between treatment and day 7. Responders at day 28 were offered a second LAN 120 mg injection and followed up until day 56.

FINDINGS

The proportion of responders in the intention-to-treat population was 24 of 52 (46.2%), which was significantly greater than the reference proportion of 30% (P = 0.0055). Patients without NGT had a higher response (88.2%) than patients with NGT (25.7%) and had a steady trend for clinical improvement that led to sustainable responses. Median time to response was 9 days for the overall population, 3 days for patients without NGT, and 14 days for patients with NGT (P < 0.0001).

IMPLICATIONS

Our study is the first to use long-acting LAN 120 mg in patients with IMIO and suggests an effect in controlling clinical symptoms in patients with and without NGT at baseline. The safety profile of LAN 120 mg was similar to that reported in other indications. ClinicalTrials.gov identifier: NCT02275338.

Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review

INTRODUCTION

Malignant bowel obstruction from peritoneal carcinomatosis affects a significant proportion of luminal gastrointestinal and ovarian oncology patients, and portends poor long-term survival. The management approach for these patients includes a range of medical therapies and surgical options; however, how to select an optimal treatment strategy remains enigmatic. The goal of this narrative review was to summarize the latest evidence around multimodal malignant bowel obstruction treatment and to establish if and where progress has been made.

METHODS

A targeted literature search examining articles focused on the management of malignant bowel obstruction from peritoneal carcinomatosis was performed. Following data extraction, a narrative review approach was selected to describe evidence and guidelines for surgical prognostic factors, imaging, tube decompression, medical management, nutrition, and quality of life.

RESULTS

Outcomes in the literature to date are summarized for various malignant bowel obstruction treatment strategies, including surgical and non-surgical approaches, as well as a discussion of the role of total parenteral nutrition and chemotherapy in holistic malignant bowel obstruction management.

CONCLUSION

There has been little change in survival outcomes in malignant bowel obstruction in over more than a decade and there remains a paucity of high-level evidence to direct treatment decision making. Healthcare providers treating patients with malignant bowel obstruction should work to establish consensus guidelines, where feasible, to support medical providers in ensuring compassionate care during this often terminal event for this unique patient group.

Medical Management of Inoperable Malignant Bowel Obstruction

OBJECTIVE

To review medical management of inoperable malignant bowel obstruction.

DATA SOURCES

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

STUDY SELECTION AND DATA EXTRACTION

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

DATA SYNTHESIS

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

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

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

CONCLUSIONS

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

Intellectual Equipoise and Challenges: Accruing Patients With Advanced Cancer to a Trial Randomizing to Surgical or Nonsurgical Management (SWOG S1316)

BACKGROUND

Prospective, randomized trials are needed to determine optimal treatment approaches for palliative care problems such as malignant bowel obstruction (MBO). Randomization poses unique issues for such studies, especially with divergent treatment approaches and varying levels of equipoise. We report our experience accruing randomized patients to the Prospective Comparative Effectiveness Trial for Malignant Bowel Obstruction (SWOG S1316) study, comparing surgical and nonsurgical management of MBO.

METHODS

Patients with MBO who were surgical candidates and had treatment equipoise were accrued and offered randomization to surgical or nonsurgical management. Patients choosing nonrandomization were offered prospective observation. Trial details are listed on www.clinicaltrials.gov (NCT #02270450). An accrual algorithm was developed to enhance enrollment.

RESULTS

Accrual is ongoing with 176 patients enrolled. Most (89%) patients chose nonrandomization, opting for nonsurgical management. Of 25 sites that have accrued to this study, 6 enrolled patients on the randomization arm. Approximately 59% (20/34) of the randomization accrual goal has been achieved. Patient-related factors and clinician bias have been the most prevalent reasons for lack of randomization. An algorithm was developed from clinician experience to aid randomization. Using principles in this tool, repeated physician conversations discussing treatment options and goals of care, and a supportive team-approach has helped increase accrual.

CONCLUSIONS

Experience gained from the S1316 study can aid future palliative care trials. Although difficult, it is possible to randomize patients to palliative studies by giving clinicians clear recommendations utilizing an algorithm of conversation, allotment of necessary time to discuss the trial, and encouragement to overcome internal bias.

Palliative Management of Advanced Peritoneal Carcinomatosis

Despite advances in the management of peritoneal carcinomatosis, morbidity remains high with survival often measured in weeks to months. Patients are often subjected to symptoms and complications that impact quality of life. Much of the management revolves around palliation of symptoms and providing support and resources to address emotional and existential concerns. This article reviews surgical and nonsurgical palliative treatments for the symptoms and complications associated with advanced, incurable peritoneal carcinomatosis. It is important that providers caring for patients with peritoneal carcinomatosis be knowledgeable in the palliative management of this condition, including the usefulness of early palliative care referral.

Management of Malignant Bowel Obstruction Associated With GI Cancers

For many patients with GI malignancies, the seeding of the abdominal cavity with tumor cells, called peritoneal carcinomatosis, is a common mode of metastases and disease progression. Prognosis for patients with this aspect of their disease remains poor, with high disease-related morbidity and complications. Uniform and proven practices that provide optimal palliative care and quality of life for these patients are needed. The objective of this review is to critically assess the current literature regarding palliative strategies in the management of peritoneal carcinomatosis and associated symptoms in patients with advanced GI cancers. Despite encouraging results in the select population where cytoreductive surgery and intraperitoneal chemotherapy are indicated, the majority of patients who develop peritoneal carcinomatosis in the setting of GI cancers have poor prognosis, with malignant bowel obstruction representing a common terminal phase of their disease process. For all patients with peritoneal carcinomatosis, aggressive symptom control and early multimodality palliative care as further outlined should be sought.

Practice Patterns of Medications for Patients With Malignant Bowel Obstruction Using a Nationwide Claims Database and the Association Between Treatment Outcomes and Concomitant Use of H2-Blockers/Proton Pump Inhibitors and Corticosteroids With Octreotide

CONTEXT

Malignant bowel obstruction impairs the quality of life in patients with advanced cancer. Octreotide, acid-suppressing medications such as H₂-receptor antagonists (H₂-blockers) and proton pump inhibitors (PPIs), and corticosteroids are often used in combination for symptom control.

OBJECTIVES

We evaluated the practice patterns of medications for patients hospitalized with malignant bowel obstruction using a large claims database in Japan. In addition, we explored the association of adding H₂-blockers/PPIs or corticosteroids to octreotide on treatment outcomes.

METHODS

We analyzed data from a nationwide medical claims database from April 2010 to March 2015 containing 975,000 patients. We included all adult inpatients with cancer who used octreotide 300 μg/day or more and summarized each patient's medication use. We also assessed whether concomitant use of H₂-blockers/PPIs or corticosteroids was associated with the number of days of nasogastric tube (NGT) insertion; logistic regression was used to adjust the patients' baseline factors.

RESULTS

We included 3090 patients; octreotide alone was used in 1649 (53%) cases. A combination of octreotide and H₂-blockers or PPIs was used in 419 and 337 cases (14% and 11%), respectively; a combination of octreotide and corticosteroids was used in 374 cases (12%). Of the 1595 patients who underwent NGT insertion, those using corticosteroids with octreotide had a higher odds ratio of NGT removal within four days of insertion (adjusted odds ratio = 1.16; 95% CI = 1.08-1.23).

CONCLUSION

Octreotide alone was used in the majority of patients, and the concomitant use of corticosteroids was more likely to be associated with early NGT removal.

Palliative Management of Peritoneal Metastases

Despite significant recent advances in the management of peritoneal carcinomatosis, this diagnosis still is accompanied frequently by a grim survival prognosis, often measured in weeks to months. The poor prognosis also is accompanied often by complications and symptoms that have a dramatic impact on quality of life and are challenging to the managing health care provider and devastating to loved ones caring for the person who is suffering. Consequently, management of carcinomatosis often revolves around palliation of symptoms such as bowel obstruction, nausea, pain, fatigue, and cachexia as well as emotional and existential concerns. This article reviews several palliative treatment options for some of the more common symptoms and complications associated with advanced, incurable peritoneal carcinomatosis. Although readers should recognize that carcinomatosis is no longer an imminent death sentence, providers caring for patients with peritoneal carcinomatosis also must be well-versed in the palliative management of this condition and recognize the utility of early palliative care referral in this setting.

Somatostatin Analogues Compared With Placebo and Other Pharmacologic Agents in the Management of Symptoms of Inoperable Malignant Bowel Obstruction: A Systematic Review

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.

A Formal Palliative Care Service Improves the Quality of Care in Patients with Stage IV Cancer and Bowel Obstruction

Background:

Patients with stage IV cancer and bowel obstruction present a complicated management problem. The aim of this study was to evaluate the role of the palliative care service (PC) in the management of this complex disease process.

Methods:

A retrospective analysis was conducted of all patients admitted to Roswell Park Cancer Institute with stage IV cancer and bowel obstruction from 2009 to 2012 after the institution of a formal PC. This cohort was matched to similar patients from 2005 to 2008 (no palliative care service or NPC). Patient characteristics and outcomes included baseline demographics, comorbid conditions, do-not-resuscitate (DNR) status, laboratory parameters, medical and surgical management, length of stay, symptom relief, and disposition status.

Results:

A total of 19 patients were identified in the PC group. Based on the PC group baseline characteristics, 19 patients were identified for the NPC group using matched values. Regarding outcomes, there were significant differences in the medication regimens (narcotics, octreotide, and Decadron) between the 2 groups. In the PC group, 14 of 19 patients showed improvement compared to 9 of 19 in the NPC group. Nearly 60% of patients in the PC group had a formal DNR order versus 10.5% in NPC ( P = .002). A significantly higher percentage of patients were discharged to hospice in the PC group (47.4% vs 0.0%, P = .006).

Conclusion:

Palliative care consultation improves the quality of care for patients with stage IV cancer and bowel obstruction, with particular benefits in symptom management, end-of-life discussion, and disposition to hospice.

[Constipation and cancer: Current strategies]

Digestive disorders, in particular constipation, are symptoms very often reported by cancer patients as having a major impact on their quality of life. An accurate diagnosis of bowel delayed transit and defecation disorders is required to best adapt therapeutic management. Constipation associated with cancer may be related to several causes, which can be placed in three nosological categories that sometimes overlap: chronic constipation prior to cancer and having its own evolution; constipation related to the cancer condition, in particular the occlusive syndrome, and constipation induced by cancer therapies. The stricter application of diet and lifestyle measures is often necessary and sometimes sufficient. Laxative drug treatments come under various galenic forms and administration routes and must be selected according to the clinical features of constipation. Surgical management can be indicated in case of ileus or pelvic static disorders. In the case of refractory constipation induced by opioids and within the framework of palliative care to treat an advanced pathology, a peripheral morphinic antagonist can offer fast symptom relief. A way forward to improve the patients' quality of life could be to identify the contributing factors (in particular, genetic factors) to determine which patients are the more at risk and anticipate their management.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Looking up: Recent advances in understanding and treating peritoneal carcinomatosis

Until recently, a diagnosis of peritoneal carcinomatosis was uniformly accompanied by a grim prognosis that was typically measured in weeks to months. Consequently, the management of carcinomatosis revolves largely around palliation of symptoms such as bowel obstruction, nausea, pain, fatigue, and cachexia. A prior lack of effective treatment options created the nihilistic view that currently exists and persists despite improvements in the efficacy of systemic therapy and the evolution of multimodality approaches including surgery and intraperitoneal chemotherapy. This article reviews the evolution and current state of treatment options for patients with peritoneal carcinomatosis. In addition, it highlights recent advances in understanding the molecular biology of carcinomatosis and the focus of current and future clinical trials. Finally, this article provides practical management options for the palliation of common complications of carcinomatosis. It is hoped that the reader will recognize that carcinomatosis is no longer an imminent death sentence and that through continued research and therapeutic innovation, clinicians can make an even greater impact on this form of metastatic cancer.

Double-blind, placebo-controlled, randomized trial of octreotide in malignant bowel obstruction

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.

Percutaneous needle decompression in treatment of malignant small bowel obstruction

AIM: To investigate the efficacy and safety of percutaneous needle decompression in the treatment of malignant small bowel obstruction (MSBO).

METHODS: A prospective analysis of the clinical data of 52 MSBO patients undergoing percutaneous needle decompression was performed.

RESULTS: Percutaneous needle decompression was successful in all 52 patients. Statistically significant differences were observed in symptoms such as vomiting, abdominal distension and abdominal pain before and after treatment (81.6% vs 26.5%, 100% vs 8.2%, and 85.7% vs 46.9%, respectively; all P < 0.05). The overall significantly improved rate was 19.2% (11/52) and the response rate was 94.2% (49/52) using decompression combined with nasal tube placement, local arterial infusion of chemotherapy and nutritional support. During the one-month follow-up period, puncture-related complications were acceptable.

CONCLUSION: Percutaneous needle intestinal decompression is a safe and effective palliative treatment for MSBO.

Recommendations for bowel obstruction with peritoneal carcinomatosis

This article reports on the clinical practice guidelines developed by a multidisciplinary group working on the indications and uses of the various available treatment options for relieving intestinal obstruction or its symptoms in patients with peritoneal carcinomatosis. These guidelines are based on a literature review and expert opinion. The recommended strategy involves a clinical and radiological evaluation, of which CT of the abdomen is a crucial component. The results, together with an analysis of the prognostic criteria, are used to determine whether surgery or stenting is the best option. In most patients, however, neither option is feasible, and the main emphasis, therefore, is on the role and administration of various symptomatic medications such as glucocorticoids, antiemetic agents, analgesics, and antisecretory agents (anticholinergic drugs, somatostatin analogues, and proton-pump inhibitors). Nasogastric tube feeding is no longer used routinely and should instead be discussed on a case-by-case basis. Recent studies have confirmed the efficacy of somatostatin analogues in relieving obstruction-related symptoms such as nausea, vomiting, and pain. However, the absence of a marketing license and the high cost of these drugs limit their use as the first-line treatment, except in highly selected patients (early recurrence). When these medications fail to alleviate the symptoms of obstruction, venting gastrostomy should be considered promptly. Rehydration is needed for virtually every patient. Parenteral nutrition and pain management should be adjusted according to the patient needs and guidelines.

The Use of Lanreotide Autogel® in the Treatment of Intestinal Obstruction in a Patient with Adenocarcinoma

Intestinal obstruction is a common complication in patients with advanced abdominal or pelvic cancer. The synthetic somatostatin analogue octreotide can help relieve nausea, vomiting and pain in patients with inoperable obstruction. Here, we report a case of recurrent intestinal obstruction in a patient with adenocarcinoma. Although the obstruction was resolved after 3 days of treatment with octreotide, new episodes of obstruction occurred, resulting in a delay of the chemotherapy treatment. After 3 episodes of obstruction, we initiated treatment with a longer-acting somatostatin analogue, lanreotide Autogel® 120 mg, administered once every 4 weeks. The treatment with lanreotide Autogel is being continued, allowing for continuation of the chemotherapy without further episodes of intestinal subocclusion or obstruction. Until November 2013, the patient received eighteen 4-weekly injections of lanreotide Autogel and did not report side effects. This case report demonstrates the successful treatment of intestinal obstruction with lanreotide Autogel in a patient with adenocarcinoma.

[Pharmacological treatment of malignant bowel obstruction in severely ill and dying patients : a systematic literature review]

BACKGROUND

Malignant bowel obstruction (MBO) occurs in 3-6% of patients suffering from advanced cancer. The incidence of MBO is highest in patients with gynaecological and colorectal malignancies. Typical symptoms include nausea, vomiting, abdominal pain and constipation. Initially, these symptoms may be isolated and sporadic, becoming more and more intense later on. The suggested treatment includes surgical, interventional and pharmacological strategies depending on the symptom pattern and the performance status of the patient. This study investigates the current evidence of pharmacological treatment for MBO during the last days of life.

MATERIALS AND METHODS

A systematic literature search of the electronic databases PubMed/Medline and Embase from 1966-2011 was conducted. All retrieved publications were screened for relevance with regard to content and methodology on the basis of title and abstract. The full text was obtained for all relevant articles and for those articles where classification was unsure.

RESULTS

The systematic literature search identified 5,431 papers. After screening, 90 publications were analyzed in detail. A total of 69 publications were excluded due to content or methodology. Finally, 21 manuscripts were considered for review. Only a few studies used high quality methodology and they all had rather small sample sizes. In summary, they show weak positive signs of efficacy for the use of somatostatin analogues or anticholinergics in the pharmacological treatment of MBO.

CONCLUSION

These results do not lead to a clear evidence base for the pharmacological treatment of MBO in the last days of life. As adverse events were infrequent and clinical studies suggest efficient symptom relief, the authors recommend the use of octreotide as the first line medication. Butylscopolamine may be an alternative, where octreotide is not available. Higher costs for octreotide compared with butylscopolamine have to be considered. Available data do not allow assessing the effect of corticosteroids on symptoms caused by MBO when given during the last days of life. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").

Octreotide prescribing patterns in the palliation of symptomatic inoperable malignant bowel obstruction patients at a single US academic hospital

BACKGROUND

Medical management is the cornerstone of malignant bowel obstruction (MBO) therapy and may include antisecretory agents such as octreotide. Currently, no data exist regarding octreotide prescribing patterns in US academic hospitals in the palliation of inoperable MBO. The aim of this study is to collect octreotide prescribing data to shape future prospective studies.

METHODS

This retrospective chart review evaluated inpatient inoperable MBO admissions at a single academic US hospital between 2008 and 2011. The prescribing primary service (medical vs. surgical), inpatient day initiated, average octreotide daily dose, cumulative octreotide dose, days receiving octreotide, length of stay (LOS), subject age, cancer stage, lines of chemotherapy, cancer type, and overall survival were analyzed utilizing a Wilcoxon rank sum test, Spearman rank correlation test, Kaplan-Meier curves, log rank test, and multiple linear regression analysis when appropriate.

RESULTS

A total of 767 patients received octreotide. A cancer diagnosis was documented in 134 patients and 37 of these (24 females and 13 males; mean age, 56.7 years) had a confirmed inoperable MBO. Statistical significance was not achieved for variables analyzed. However, octreotide prescribing trends were observed for several variables: the mean LOS was equivalent on both services (16.8 vs. 17 days), mean octreotide dose was higher on the medical service (201.2 μg vs. 119 μg surgical), cumulative octreotide dose was higher on the medical service (3,558 vs. 1,884 mcg), mean day of octreotide initiation was roughly equivalent (7.9 days medical vs. 8.8 days surgical), subjects on the medical service had a decreased overall survival, and earlier octreotide initiation (defined as <7 days) was associated with a decreased overall survival.

LIMITATION

The data were collected retrospectively, with a limited population distribution at a specific time.

CONCLUSIONS

These data possibly suggest that the MBO patients on the medical vs. surgical services are distinct patient populations. MBO patients on the medical service trended to receive higher cumulative doses and have a decreased overall survival compared with surgical patients. Consequently, future studies should possibly consider these distinct study groups.

Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors influencing spontaneous resolution

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.