Results of surgery for malignant bowel obstruction in advanced, unresectable, recurrent colorectal cancer. Symptom control in terminally ill patients with malignant bowel obstruction (MBO). Small bowel obstruction after colon resection for benign and malignant diseases. Surgical management of bowel obstruction in advanced ovarian carcinoma. Intestinal obstruction in patients with gynaecological malignancies. Palliative care for intestinal obstruction in recurrent ovarian cancer: a multivariate analysis. Palliative management of malignant rectosigmoidal obstruction. Colostomy vs. endoscopic stenting. A randomized prospective trial. Management of bowel obstruction in patients with advanced ovarian cancer. Treatment of bowel obstruction after operation for colorectal carcinoma.
When conservative treatment fails in the management of patients with malignant bowel obstruction secondary to advanced, recurrent colorectal cancer, the attitude toward surgery is often less than enthusiastic because of the limited life expectancy. We report a retrospective review of 30 patients with unresectable intra-abdominal disease who underwent laparotomy for the relief of bowel obstruction. Normal bowel function was restored in 19 patients (63 percent). The failures included five patients (17 percent) who died as a result of surgical complications and six patients (20 percent) who despite the surgery had continuing obstruction. Postoperative complications occurred in eight patients (27 percent). The median survival was significantly improved in those who benefited from the operation (192 days vs. 26 days; P = 0.0001). Whether the obstruction occurred at one site or more than one site appeared not to influence the outcome of surgery. Obstruction recurred after a mean symptom-free interval of 120 days in eight of those relieved by the initial operation. Half of these patients responded to conservative treatment, and surgery was again beneficial in three of the remaining four. Our results justify a more positive approach toward this problem, and, when conservatism fails, laparotomy should be undertaken in those who are not terminally ill. The inadequacy of prolonged conservative management with nasogastric suction and intravenous fluids for terminally ill patients with bowel obstruction has long been recognized. Using previous reports and our experience on the Palliative Care Unit at the Edmonton General Hospital, we have developed a basic approach to bowel obstruction management. In a review of 100 consecutive patients who died on our Palliative Care Unit, 15 required medical management for bowel obstruction. Evaluation of these cases suggests that intensive medical management can provide good symptom control without using intravenous lines and with minimal use of nasogastric tubes. To determine the etiology and outcome of patients with small bowel obstruction after a colon resection for benign and malignant diseases, the medical records of 118 patients who underwent 120 laparotomies for small bowel obstruction were reviewed. Contrary to previous reports, benign adhesions were responsible for the obstruction in all patients with a history of benign colon disease, 82.6 percent of patients with a history of adenocarcinoma of the colon without known recurrence, and 30.1 percent of patients with known recurrent malignancy. The morbidity and mortality was more related to the etiology of the obstruction rather than the preoperative delay or operative procedure performed. Considering the high likelihood of adhesive obstruction in patients with a history of, or known, metastatic colorectal carcinoma, it is suggested that these not deter surgeons from aggressive early surgical intervention in these patients who develop small bowel obstruction. The surgical management of 118 instances of bowel obstruction associated with advanced ovarian cancer in 98 patients is reviewed. In 12% of the treatment episodes, patients were found to have inoperable disease at laparotomy. Surgical correction of the intestinal obstruction was associated with an operative mortality of 12%. In 35% of the cases, patients did not benefit from surgical treatment, as they died within 8 weeks of the operation. Patients' age, nutritional status, tumor spread, presence of ascites, and the type and amount of prior chemotherapy and/or radiation therapy correlate well with the patients' prognosis. A simple prognostic index based upon these 6 criteria is suggested as a means of predicting the possible benefit from surgical intervention. Bowel obstruction developing in patients with gynaecological malignancies may present as a therapeutic dilemma. The causes, and results of surgical and conservative management of 92 patients are analysed. The causes of obstruction in the 64 patients who were treated surgically were: tumour recurrence in 42, adhesions in 12, radiation stricture in 9 and pelvic abscess in 1. Surgical palliation was effective in 45 patients in this group, with another 12 patients being palliated initially but subsequently developing further obstructive symptoms. Surgical palliation was ineffective in 7. Conservative management was effective only in 12 of the 41 patients, and even in this group 8 developed further obstructive episodes within the first month of discharge. The median survival in the surgically treated group for benign and malignant causes is 57 and 10 weeks respectively; while it is 4 weeks for those treated conservatively. Bowel obstruction is the most common complication in patients with ovarian cancer. Management of this situation is controversial. The aim of our retrospective study was to determine the best approach for managing bowel obstruction in recurrent ovarian cancer. A retrospective analysis of data on 47 patients with intestinal obstruction by ovarian cancer was performed. Twenty-seven patients were submitted to surgery, with 21 intestinal procedures performed, 2 gastrostomy tubes placed, and 4 patients deemed inoperable. Twenty patients were managed medically with Octreotide (mean dosage of 0.48 mg/day), of which 1 patient required a nasogastric tube. Age, performance status, diagnosis of tumor to occlusion time, obstruction site, previous chemotherapy or radiotherapy, presence of ascites, or palpable masses were the variables analyzed. Student's t-test and Pearson chi-square test were used to compare the two different groups of treatment (surgical vs medical therapy). Disease-free-survival curves were plotted according to the Kaplan-Meier method and analyzed by the log-rank test. Cox's proportional hazards model was used for multivariate analysis. Values less than or equal to 0.05 were considered significant. The mean age of the patients was 58.7 years. Perioperative mortality and morbidity were both 22%. All patients died with minimal distress. Performance status results were significantly different between the patients submitted to surgery and patients treated with Octreotide (P= 0.03). No significant differences were found in the other variables analyzed. In multivariate analysis, only type of treatment emerges as a strong predictor of poor outcome (P < 0.001). Both surgery and Octreotide therapy are able to control distressing symptoms in end-stage ovarian cancer. Survival was significantly longer in the surgical group, and surgical palliation should be considered first in patients with good performance status. Colostomy was the palliative treatment of choice in patients with malignant unresectable rectosigmoid obstruction. Palliative endoscopic treatment of malignant rectosigmoid obstruction by endoluminal self-expanding metallic stents is nowadays a well-established procedure.
                Twenty-two patients, referred for treatment with diagnosis of malignant obstruction of the rectosigmoid region presenting an advanced unresectable stage, were enrolled. Patients were randomly assigned into two treatment groups (endoscopic stenting vs colostomy) according to random-number tables. The length of procedure, morbidity and mortality rate, canalization of the gastrointestinal tract, restoration of oral intake and hospital stay were assessed.
                Endoscopic group: The median length of procedure was 36 minutes. No death was observed. None of the patients reported complications. All patients resumed bowel function within 24 hours. The restoration of oral intake was achieved one day after stent placement. The median hospital stay was 2.6 days. Colostomy group: The median length of the operation was 75.4 minutes. No mortality was reported. In 1 patient (9.1%) stoma prolapse was observed 3 days after the operation. Canalization of the gastrointestinal tract was restored when colostomy was opened (on postoperative day 3). All patients were able to resume oral feedings on postoperative day 3. The median hospital stay was 8.1 days.
                There were no statistically significant differences between the 2 groups concerning morbidity and mortality. Endoscopic stenting was significantly more effective concerning operative time, restoration of bowel function and oral intake and median hospitalization. Our results would suggest that endoscopically placed metal stents offer an effective alternative to surgical palliation in patients suffering from unresectable malignant rectosigmoid obstruction. In a retrospective study, 58 patients with bowel obstruction due to advanced ovarian cancer were analysed. In a forward stepwise proportional hazard regression analysis, we looked for factors influencing bowel obstruction-free survival. Patients who presented with bowel obstruction as the first sign of ovarian cancer and those with a longer interval between last cancer treatment and bowel obstruction did better. Patients with ascites did worse. No other independent factors were found. Based on these data, we classified patients into a favourable prognosis group (no previous treatment or interval since last treatment exceeding 6 months; no ascites) and a poor prognosis group (interval since last treatment shorter than 6 months; ascites). Patients from the favourable prognosis group had a median bowel obstruction-free survival of 8 months, compared to 1 month for the poor prognosis group (P < 0.001). Surgery had a marginally significant positive effect on bowel obstruction-free survival when compared to medical treatment in the favourable prognosis group (P = 0.052). Surgery had no effect at all in the poor prognosis patients. Operative therapy is beneficial in patients with bowel obstruction after operation for colorectal carcinoma. The cause of the bowel obstruction is more likely to be benign following colorectal carcinoma than following other malignancies. Also, the period of preoperative nasogastric suction can safely be extended to 3 to 4 days in these patients, since a resolution rate of 28 percent can be achieved with minimal risk of strangulation.
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 would 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. There needs to be a greater standardisation of management so that comparisons between different series can be made.