El. 7.No. GAggust1992
3oumeloJPain and @mptomManqpvnt
339
Arlene Chart, S, and Roger L&u& In&t& for CancerResearc?z-Austin HospiialMedkal OncologyUnit and Palliative Care &vice, AustinHospital, Heidelbeg Vitokz, Australia
?he clinical course of 2Spatimt.s u&h sqgically documented widespread in&abdominal malignancy who developed imkstinal obstruction was reviewed. Of26pah~nts, 13 responded to imiti conserva&e management, In the ten p&it%?&treated surgical~, Eherewas s@&kant morbidi in. 80% and a postoperative moltal@ PO%. Reobstruclion occurred in II pati&s, respondedpoor&to therapy, and was associati with a &on! l$e expectancy. These rerzlts support the use of consemative therapy in the management of intestinal obstrzction due to widkpread intraabdominal mal&mruy, with emphasis on thepalliation of symptomr and maintenance of qualip of 1fe.J Ipain Symptom Manage 1992;7:339-342.
of
Advanced intraabdominal mal&nancy, intestinal obstruction, consem&ive management, suqical manqement
Intestinal obstruction and reobstruction are common in patients with advanced intraabdominal malignancy,’ but the guidelines for conservative as against surgical management are conflicting.*-g We report the results of treatment of intestinal obstruction in a group of patients with surgically documented widespread intraabdominal disease with regard to symptom palliation, reobstruction, operative morbidity, and survival.
A retrospective analysis was made of all patients with surgically proven advanced inrep& requeststo: Roger K. Woodruff, FRACP, Suite 9,2 10 Burgundy Street, Heidelberg, Victoria 3084, Australia. Acceptrdfm@icatiorr March 27,1992. Address
0 U.S. Cancer Pain Relief Committee, 1992 Published by Elsevier, New York, New York
traabdominal malignancy who subsequently presented with intestinal obstruction. Advanced intraabdominal malignancy was defmed as tumor involving the mesentery, omentum, peritoneum, or serosa, soft tissue within the pelvis, or direct invasion of intraabdominal viscera. Patients who presented with obstruction at the time of initial diagnosis of malignancy, and those with liver metastases alone, were excluded. Intestinal obstruction was diagnosed clinically and confirmed on plain radiographs. Conservative therapy included no oral intake, intravenous fluid replacement, and antiemetics; nasogastric intubation was used when vomiting was a major symptom. Operative intervention included formation of colostomy or enteroenterostomy and, where possible, resection of the obstructed segment with reanastomosis. A complete response to treatment was defined as cessation of vomiting, abdominal colic, and/ or distension, relief of absolute constipation, and
0885-3924/92/$5.00
vol. 7Jvo. 6Au@
GUUZ@ldW&!
340
Table2
la4 I
Sites of Intraabd
site of Psrhary Malignancr Sites Colon Rectum
No. of patients 14 1 5
Pancreas lleal carcinoid Jejunal leiomyosarcoma Breast Non-Hodgkin’s lymphoma
Sites Mesentery/omentum/peritoneum/serosa Pelvic soft tissue Mesenteric/omental lymph nodes Anterior abdominal wall Small intestine Large intestine Diaphragm
1992
etastases No. of patients 24 6 4 3 3 1 1
Hodgkin’sdisease
to~mance of a normal oral intake. A partial response included a reduction in vomiting and
abdominal distension, together with tolerating fluids orally.
dts During the period between 1984 and 1989,
there were 28 patients eligiblefor inclusion in the study; 16 women and 12 men with a median age of 66 yr (range, 32-92 yr). The primary malig5 patientsand ovarian in nancy was colorectal cations for a previous 5 (Table 1). The laparotomy were attempted curative resection in 12, confirmation of the diagnosis in 8, and an acute abdomen resuhing from a complication of the primary in 8. The distributionof intraabdominal metastases is shown in Table 2. Intestinal obstruction developed a median of 10 mo (range, 0.25-86 mo) after the initial surgicaldemonstration of advanced intraabdominal disease. Obstruction was colonic in 2 patients and small bowel in 26. The clinical course of the patients is summarized in Figure 1. Two patients underwent laparotomy within 24 hr of admission at the discretion of the treating clinician. Conservative management was employed for 26 patients, with resolution of obstruction in 13 patients (11 complete response and 2 partial) after a median time of 4 days (range, 2- 14 days). Reobstruction occurred in 7 (54%) of these patients after a median of 27 days (range, 10-528 days). A total of 13 patients failed to respond to conservative measures; 5 patients, considered unsuitable for surgery because of their poor medical condition and extent of malignant disease, had continued intestinal obstruction and died 6-44 days later (median, 16 days).
A total of 10 patients underwent laparotomy as treatment for their initial obstruction (2 early and 8 after failed conservative treatment). No patients were found to have benign adhesions as the principal cause of intestinal obstruction. A malignant cause for obstruction was found in each case, with multiple levels of obstruction documented in 5. Division of malignant adhesions was performed in 1 patient, colostomy in 2, and an enterocolic bypass in 7. Surgical resolution of obstruction was achieved in 8 patients (6 complete response and 2 partial); surgery fded to relieve obstruction in 2 patients. Reobstruction occurred in 4 (40”/0)patients after a median of 148 days. Postoperative complications occurred in 8 of the 10 patients who underwent laparotomy. These included pneumonia (3 patients), urinary tract infection (2 patients), peritonitis (1 patient), pulmonary edema (3 patients), acute organic brain syndrome (2 patients), supraventricular tachycardia (1 patient), intestinal cutaneous fist& (2 patients), and small intestinal perforation necessitating reoperation in 1 patient. There were 4 postoperative deaths (death within 30 days), with 3 patients dying as a direct result of postoperative complications. Reobstruction occurred in 11 patients (Figure 1); 1 patient underwent immediate laparotomy because of the short interval (12 days) from previous obstruction and the presence of disease amenable to other therapy (Hodgkin’s disease); ten patients were treated conservatively-the obstruction resolvingin only 2. Of the remaining 8 patients, 5 were considered medically unfit for surgery and died with persistent obstruction after a median interval of 14 days (range, 12-60 days). The remaining 3 patients undement laparotomy, but none achieved relief of obstruction. The period of hospitalization for all episodes of intestinal obstruction in those treated conser-
m. 7J\r,. 6Algllst 1992
htestinal Obsttuchn and Intraabdominal Malignany
Conservative management
I
Resolution
341
26
13
ineligible for surgery 5
Laparol~my (including *) 10
Failed
Fig. 1. Clinical course of 28 patients with intestinal obstruction.
2
Reobslruction 7
Reobslruclion 4
(median time to
(median time to
reobstruction 27 days)
reobstruction 146 days)
vatively was 33% of the group’s total survival, compared with 30% for the patients managed surgically. The median survival of all patients was 46 days (range, 6-709 days). The median survival of the 13 patients responding to initial conservative management was 57 days (range, 14-709 days), compared with 62 days (range:e,$429 days) for the patients treated surgically.
The optimal management of intestinal obstruction in patients with advanced malignant disease remains controversial: surgery is claimed by some to give better palliation of symptoms,3h6-* while others have found significant response rates with conservative management and survival rates equivalent to those treated surgically.2~5~g Qne explanation for these confhcting results may be the inclusion of patients for whom the extent of malignant disease, particularly intraabdominal, is unknown or poorly documented. We have reviewed the clinical course of a specific subset of patients with surgically documented widespread intraabdominal malignancy. The primary malignancies seen were similar to
those in other studies,2~6~10 except for the absence of gastric carcinoma from the present series. A benign course for obstruction was not documented in any of our patients, compared with the go/o-38% incidence of benign abstruction reported in other series of patients with malignant disease, but whose disease was of variable extent.Z%sS&11 Conservative treatment was successful in 50% of our patients, which compares favorably with the 30% reported by others.**4*5J2 Advocates for conservative management report up to 93% control of abdominal colic,* and about 80% improvement in vomitingr~ts when symptoms are analyzed separately. The median survival (57 clays) of these responding patients approximated that for the entire group (46 days), indicating that survival was not shortened by conservative management. A comparison of response rate and survival cannot be made between the 2 treatment groups, as the majority of patients underwent laparotomy when conservative therapy failed. Similarly, a v&d interpretation cannot be made ofthe difference seen in the time to reobstruction (27 days and 148 days) in the group treated conservatively and surgically, respectively. Of the patients treated surgically, decompression was possible in all, although 20% fded to
342
QKUldWWd&-
derive clinical benefit, and the postoperative morbidity and mortality were considerable. Similar results are reported by others4*7B’oJ4 and where the results are significantly better, it is possible that this is a reflection of less extensive irmaabdominal disease than seen in our patients. The development of reobstxuction signified a uniformly grim outcome. There was no benefit fim surgery, with the exception of the single patient with Hodgkin’s disease for whom systemic therapy was available. In managing cancer patients with intestinal obstruction, distinction should be made between those with unproven intraabdominal malignancy and patients with documented advanced intraabdominal disease. In the former group, conventional surgical management should be undertaken as a significant number may have a benign cause for obstruction. Patients with advanced intraabdominal malignancy should be given a prolonged trial of conservative management as responses may require up to 14 days. Urgent operation is rarely necessary as intestinal strangulation is infrequent. I5 Treatment with antiemetics, antispasmodics, and analgesics, without nasogastric intubation and intravenous hydration, may allow the patient to remain outside hospital as well as avoiding the morbidity and mortality subsequent to surgery. Reobstruction may occur more frequently with conservative management, a fact that must be anticipated by both the patient and the treating clinician, but the overall survival is comparable to those treated surgically. Reobstruction should be treated conservatively. In conclusion, this study supports the use of conservative therapy for the management of intestinal obstruction due to widespread intraabdominal malignancy. rJ3
Refevenees 1. BainesM, Oliver DJ, Carter RL. Medical managementof intestinalobstructionin patientswith advanced malignantdisease.Lancet 1985;2:990-993.
h! ?JGo.GAugmt 1992
2. Gallick HL, Weaver DW, Sachs RJ, Bouman DL Intestinal obstruction in cancer patients. Am surg 1986;52:434-437. 3. Ketcham AS, Hoy RC, Pilch YH, Morton DL Delayed intestinal obstruction following treatment for cancer. Cancer 1970;25:406410. 4. Soo KC, Davidson T, Parker M, Paterson I, Paterson A, Intestinal obstruction in patients with gynaecological malignancies. Ann Acad Med 1988,17:72-75. 5. Glass RL, LeDuc RJ. Small intestinal obstruction from peritoneal carcinomatosis. Am J Surg 1973;125:316317. 6. Walsh HPJ, Schofield PF. Is laparotomy for small bowel obstruction justified in patients with previously treated malignancy? Br J Surg 1984;71:933-935. 7. Turnbull ADM, Guerra J, Stames HF. Results of surgery for obstructing carcinomatosis of gastrointestinal, pancreatic or biliary origin. J Clin Oncol 1989;7:381386. 8. Timca JC, Buchler DA, Mack EA, Ruzicka FF, Crowley JJ, Car WF. The management of ovariancancer-caused bowel obstruction. Gynecol Oncol 1989; 12:186-192. 9. Lund B, Hansen M, Lundvall F, Nielsen NC, Sorensen BL, Hansen HI-I. Intestinal obstruction in patients with advanced carcinoma of the ovaries treated with combination chemotherapy. Surg Gynecol Obstet 1989; 169:213-218. 10. Annest LS, Jolly PC. The results of surgical treatment of bowel obstruction caused by peritoneal carcinomatosis. Am Surg 1979;45:718-721. 11. Clarke-Pearson DL, Chin NO, DeIong ER, Rice R, Creasman WT. Surgical management of intestinal obstruction in ovarian cancer. Gynecol Oncol 1987; 26:11-18. 12. Osteen RT Guyton S, Steele G, Wilson RE. Malignant intestinal obstruction. Surgery 1980;87:61 l615. 13. Stellato TA, Shenk RR. Gastrointestinal emergencies in the oncology patient. Semin Oncol1989;16:521-531. 14. Ventaliidda V, Ripamonti Cl, Caraceni A, Spoldi E, Messina L, Conno FD. The management of inoperable gastrointestinal obstruction in terminal cancer patients. Tumori 1990;76:389-393. 15. Rubin SC, Hoskins WJ Benjamin I, IewisJL Jr. Palliative surgery for intestinal obstruction in advanced ovarian cancer. Gynecol Oncol1989,34:16-19.
3oumeloJPain and @mptomManqpvnt
339
Arlene Chart, S, and Roger L&u& In&t& for CancerResearc?z-Austin HospiialMedkal OncologyUnit and Palliative Care &vice, AustinHospital, Heidelbeg Vitokz, Australia
?he clinical course of 2Spatimt.s u&h sqgically documented widespread in&abdominal malignancy who developed imkstinal obstruction was reviewed. Of26pah~nts, 13 responded to imiti conserva&e management, In the ten p&it%?&treated surgical~, Eherewas s@&kant morbidi in. 80% and a postoperative moltal@ PO%. Reobstruclion occurred in II pati&s, respondedpoor&to therapy, and was associati with a &on! l$e expectancy. These rerzlts support the use of consemative therapy in the management of intestinal obstrzction due to widkpread intraabdominal mal&mruy, with emphasis on thepalliation of symptomr and maintenance of qualip of 1fe.J Ipain Symptom Manage 1992;7:339-342.
of
Advanced intraabdominal mal&nancy, intestinal obstruction, consem&ive management, suqical manqement
Intestinal obstruction and reobstruction are common in patients with advanced intraabdominal malignancy,’ but the guidelines for conservative as against surgical management are conflicting.*-g We report the results of treatment of intestinal obstruction in a group of patients with surgically documented widespread intraabdominal disease with regard to symptom palliation, reobstruction, operative morbidity, and survival.
A retrospective analysis was made of all patients with surgically proven advanced inrep& requeststo: Roger K. Woodruff, FRACP, Suite 9,2 10 Burgundy Street, Heidelberg, Victoria 3084, Australia. Acceptrdfm@icatiorr March 27,1992. Address
0 U.S. Cancer Pain Relief Committee, 1992 Published by Elsevier, New York, New York
traabdominal malignancy who subsequently presented with intestinal obstruction. Advanced intraabdominal malignancy was defmed as tumor involving the mesentery, omentum, peritoneum, or serosa, soft tissue within the pelvis, or direct invasion of intraabdominal viscera. Patients who presented with obstruction at the time of initial diagnosis of malignancy, and those with liver metastases alone, were excluded. Intestinal obstruction was diagnosed clinically and confirmed on plain radiographs. Conservative therapy included no oral intake, intravenous fluid replacement, and antiemetics; nasogastric intubation was used when vomiting was a major symptom. Operative intervention included formation of colostomy or enteroenterostomy and, where possible, resection of the obstructed segment with reanastomosis. A complete response to treatment was defined as cessation of vomiting, abdominal colic, and/ or distension, relief of absolute constipation, and
0885-3924/92/$5.00
vol. 7Jvo. 6Au@
GUUZ@ldW&!
340
Table2
la4 I
Sites of Intraabd
site of Psrhary Malignancr Sites Colon Rectum
No. of patients 14 1 5
Pancreas lleal carcinoid Jejunal leiomyosarcoma Breast Non-Hodgkin’s lymphoma
Sites Mesentery/omentum/peritoneum/serosa Pelvic soft tissue Mesenteric/omental lymph nodes Anterior abdominal wall Small intestine Large intestine Diaphragm
1992
etastases No. of patients 24 6 4 3 3 1 1
Hodgkin’sdisease
to~mance of a normal oral intake. A partial response included a reduction in vomiting and
abdominal distension, together with tolerating fluids orally.
dts During the period between 1984 and 1989,
there were 28 patients eligiblefor inclusion in the study; 16 women and 12 men with a median age of 66 yr (range, 32-92 yr). The primary malig5 patientsand ovarian in nancy was colorectal cations for a previous 5 (Table 1). The laparotomy were attempted curative resection in 12, confirmation of the diagnosis in 8, and an acute abdomen resuhing from a complication of the primary in 8. The distributionof intraabdominal metastases is shown in Table 2. Intestinal obstruction developed a median of 10 mo (range, 0.25-86 mo) after the initial surgicaldemonstration of advanced intraabdominal disease. Obstruction was colonic in 2 patients and small bowel in 26. The clinical course of the patients is summarized in Figure 1. Two patients underwent laparotomy within 24 hr of admission at the discretion of the treating clinician. Conservative management was employed for 26 patients, with resolution of obstruction in 13 patients (11 complete response and 2 partial) after a median time of 4 days (range, 2- 14 days). Reobstruction occurred in 7 (54%) of these patients after a median of 27 days (range, 10-528 days). A total of 13 patients failed to respond to conservative measures; 5 patients, considered unsuitable for surgery because of their poor medical condition and extent of malignant disease, had continued intestinal obstruction and died 6-44 days later (median, 16 days).
A total of 10 patients underwent laparotomy as treatment for their initial obstruction (2 early and 8 after failed conservative treatment). No patients were found to have benign adhesions as the principal cause of intestinal obstruction. A malignant cause for obstruction was found in each case, with multiple levels of obstruction documented in 5. Division of malignant adhesions was performed in 1 patient, colostomy in 2, and an enterocolic bypass in 7. Surgical resolution of obstruction was achieved in 8 patients (6 complete response and 2 partial); surgery fded to relieve obstruction in 2 patients. Reobstruction occurred in 4 (40”/0)patients after a median of 148 days. Postoperative complications occurred in 8 of the 10 patients who underwent laparotomy. These included pneumonia (3 patients), urinary tract infection (2 patients), peritonitis (1 patient), pulmonary edema (3 patients), acute organic brain syndrome (2 patients), supraventricular tachycardia (1 patient), intestinal cutaneous fist& (2 patients), and small intestinal perforation necessitating reoperation in 1 patient. There were 4 postoperative deaths (death within 30 days), with 3 patients dying as a direct result of postoperative complications. Reobstruction occurred in 11 patients (Figure 1); 1 patient underwent immediate laparotomy because of the short interval (12 days) from previous obstruction and the presence of disease amenable to other therapy (Hodgkin’s disease); ten patients were treated conservatively-the obstruction resolvingin only 2. Of the remaining 8 patients, 5 were considered medically unfit for surgery and died with persistent obstruction after a median interval of 14 days (range, 12-60 days). The remaining 3 patients undement laparotomy, but none achieved relief of obstruction. The period of hospitalization for all episodes of intestinal obstruction in those treated conser-
m. 7J\r,. 6Algllst 1992
htestinal Obsttuchn and Intraabdominal Malignany
Conservative management
I
Resolution
341
26
13
ineligible for surgery 5
Laparol~my (including *) 10
Failed
Fig. 1. Clinical course of 28 patients with intestinal obstruction.
2
Reobslruction 7
Reobslruclion 4
(median time to
(median time to
reobstruction 27 days)
reobstruction 146 days)
vatively was 33% of the group’s total survival, compared with 30% for the patients managed surgically. The median survival of all patients was 46 days (range, 6-709 days). The median survival of the 13 patients responding to initial conservative management was 57 days (range, 14-709 days), compared with 62 days (range:e,$429 days) for the patients treated surgically.
The optimal management of intestinal obstruction in patients with advanced malignant disease remains controversial: surgery is claimed by some to give better palliation of symptoms,3h6-* while others have found significant response rates with conservative management and survival rates equivalent to those treated surgically.2~5~g Qne explanation for these confhcting results may be the inclusion of patients for whom the extent of malignant disease, particularly intraabdominal, is unknown or poorly documented. We have reviewed the clinical course of a specific subset of patients with surgically documented widespread intraabdominal malignancy. The primary malignancies seen were similar to
those in other studies,2~6~10 except for the absence of gastric carcinoma from the present series. A benign course for obstruction was not documented in any of our patients, compared with the go/o-38% incidence of benign abstruction reported in other series of patients with malignant disease, but whose disease was of variable extent.Z%sS&11 Conservative treatment was successful in 50% of our patients, which compares favorably with the 30% reported by others.**4*5J2 Advocates for conservative management report up to 93% control of abdominal colic,* and about 80% improvement in vomitingr~ts when symptoms are analyzed separately. The median survival (57 clays) of these responding patients approximated that for the entire group (46 days), indicating that survival was not shortened by conservative management. A comparison of response rate and survival cannot be made between the 2 treatment groups, as the majority of patients underwent laparotomy when conservative therapy failed. Similarly, a v&d interpretation cannot be made ofthe difference seen in the time to reobstruction (27 days and 148 days) in the group treated conservatively and surgically, respectively. Of the patients treated surgically, decompression was possible in all, although 20% fded to
342
QKUldWWd&-
derive clinical benefit, and the postoperative morbidity and mortality were considerable. Similar results are reported by others4*7B’oJ4 and where the results are significantly better, it is possible that this is a reflection of less extensive irmaabdominal disease than seen in our patients. The development of reobstxuction signified a uniformly grim outcome. There was no benefit fim surgery, with the exception of the single patient with Hodgkin’s disease for whom systemic therapy was available. In managing cancer patients with intestinal obstruction, distinction should be made between those with unproven intraabdominal malignancy and patients with documented advanced intraabdominal disease. In the former group, conventional surgical management should be undertaken as a significant number may have a benign cause for obstruction. Patients with advanced intraabdominal malignancy should be given a prolonged trial of conservative management as responses may require up to 14 days. Urgent operation is rarely necessary as intestinal strangulation is infrequent. I5 Treatment with antiemetics, antispasmodics, and analgesics, without nasogastric intubation and intravenous hydration, may allow the patient to remain outside hospital as well as avoiding the morbidity and mortality subsequent to surgery. Reobstruction may occur more frequently with conservative management, a fact that must be anticipated by both the patient and the treating clinician, but the overall survival is comparable to those treated surgically. Reobstruction should be treated conservatively. In conclusion, this study supports the use of conservative therapy for the management of intestinal obstruction due to widespread intraabdominal malignancy. rJ3
Refevenees 1. BainesM, Oliver DJ, Carter RL. Medical managementof intestinalobstructionin patientswith advanced malignantdisease.Lancet 1985;2:990-993.
h! ?JGo.GAugmt 1992
2. Gallick HL, Weaver DW, Sachs RJ, Bouman DL Intestinal obstruction in cancer patients. Am surg 1986;52:434-437. 3. Ketcham AS, Hoy RC, Pilch YH, Morton DL Delayed intestinal obstruction following treatment for cancer. Cancer 1970;25:406410. 4. Soo KC, Davidson T, Parker M, Paterson I, Paterson A, Intestinal obstruction in patients with gynaecological malignancies. Ann Acad Med 1988,17:72-75. 5. Glass RL, LeDuc RJ. Small intestinal obstruction from peritoneal carcinomatosis. Am J Surg 1973;125:316317. 6. Walsh HPJ, Schofield PF. Is laparotomy for small bowel obstruction justified in patients with previously treated malignancy? Br J Surg 1984;71:933-935. 7. Turnbull ADM, Guerra J, Stames HF. Results of surgery for obstructing carcinomatosis of gastrointestinal, pancreatic or biliary origin. J Clin Oncol 1989;7:381386. 8. Timca JC, Buchler DA, Mack EA, Ruzicka FF, Crowley JJ, Car WF. The management of ovariancancer-caused bowel obstruction. Gynecol Oncol 1989; 12:186-192. 9. Lund B, Hansen M, Lundvall F, Nielsen NC, Sorensen BL, Hansen HI-I. Intestinal obstruction in patients with advanced carcinoma of the ovaries treated with combination chemotherapy. Surg Gynecol Obstet 1989; 169:213-218. 10. Annest LS, Jolly PC. The results of surgical treatment of bowel obstruction caused by peritoneal carcinomatosis. Am Surg 1979;45:718-721. 11. Clarke-Pearson DL, Chin NO, DeIong ER, Rice R, Creasman WT. Surgical management of intestinal obstruction in ovarian cancer. Gynecol Oncol 1987; 26:11-18. 12. Osteen RT Guyton S, Steele G, Wilson RE. Malignant intestinal obstruction. Surgery 1980;87:61 l615. 13. Stellato TA, Shenk RR. Gastrointestinal emergencies in the oncology patient. Semin Oncol1989;16:521-531. 14. Ventaliidda V, Ripamonti Cl, Caraceni A, Spoldi E, Messina L, Conno FD. The management of inoperable gastrointestinal obstruction in terminal cancer patients. Tumori 1990;76:389-393. 15. Rubin SC, Hoskins WJ Benjamin I, IewisJL Jr. Palliative surgery for intestinal obstruction in advanced ovarian cancer. Gynecol Oncol1989,34:16-19.
