585
Ausr. N . Z . J . Surg. 1990, 60, 585-588
SMALL BOWEL OBSTRUCTION AS A LATE COMPLICATION OF THE TREATMENT OF HODGKIN'S DISEASE IAN
N.
OLVER,' PAULA PEARL,2 PETER
H. W I E R N I K AND ~ JOSEPH AlSNER4
University qf Maryland Cancer Center, University qf Maryland School of Medicine, Baltitnore, Maryland. USA Small bowel obstruction (SBO) as a late complication of the treatment of Hodgkin's disease was found in 32 of 398 ( 8 % ) patients followed over a 20 year period. The vast majority of these patients had an initial staging laparotomy as part of staging protocols. O f 5 I obstructive episodes, 13 were diagnosed clinically, 12 of the 13 had prior radiological or surgical documentation. Thirty-one episodes were shown radiologically; four were demonstrated at laparotomy and three recurrent episodes were identified in an unspecified manner. The mcdian duration of each episode was 3 days and the median time between commencement from treatment for Hodgkin's disease and the development of a SBO was 21 months. Thirty-one of the 32 patients had had a staging laparotomy or prior abdominal surgery. Two patients had SBO because of non-Hodgkin's lymphoma and one had SBO secondary to short bowel syndrome. These are thus not true complications of disease treatment. Twenty-nine of the 32 or 7.2"/0 of patients thus had possible treatment-related SBO. The cause of SBO was recorded as adhesions from previous surgery in 27 of the 51 episodes. This was confirmed at laparotoniy in 16 patients. Twenty-five of the 32 patients had received abdominal irradiation but only three obstructive episodes were attributed to radiation enteritis and fibrosis. In one of 22 patients who received chemotherapy, Vinblastine was implicated as a cause for SBO. Eighteen patients required laparotomy to lyse adhesions while the others were treated conservatively with tube drainage. The aetiologies for these obstructive episodes can be attributed to staging laparotomy and its combination with other treatment modalities, and their incidence is likely to be lower in more recent series where more conservative staging procedures are used.
Key words: Hodgkin's disease, laparotomy, non-Hodgkin's lymphoma, radiation enteritis and fibrosis, short bowel syndrome, small bowel obstruction, Vinblastine. Vincristine.
Introduction Small bowel obstruction (SBO) is a possible late complication associated with the treatment of Hodgkin's disease. I Since a significant proportion of patients with Hodgkin's disease are cured, future treatment strategies should aim to improve survival and reduce the long-term morbidity of therapy.' Treatment related to toxicities should be reviewed so that risks can be identified and balanced against benefit in planning future treatment policy. Staging laparotomy,' abdominal i r r a d i a t i ~ n ,and ~ chemotherapy' could all contribute to the development of
' MB, BS, FRACP. 'NP. 'MD. MD, FACP Present addrcsscs: ' Pctcr MacCallum Canccr
Institutc. Mclbourne. Victoria. Australia. 2.4 Univcrsity of Maryland Canccr Ccntcr, Baltimorc. Maryland, USA. Montcfiore Medical Ccnter. I I I E. 210 Strcct, Bronx. Ncw York, USA.
'
Corrcspondcncc: Ian Olvcr, Pctcr MacCallurn Canccr Institutc. 4x1 Little Lonsdalc Strcct. Melbourne, Vic. 3000. Australia. Acccptcd for publication 28 Fcbruary 1990
small bowel obstruction. We previously reported on the occurrence of SBO in a cohort of 210 patients with Hodgkin's disease. This report extends this analysis to a larger cohort and reviews a group of patients who developed signs or symptoms of partial or complete SBO following a completed treatment for Hodgkin's disease.
Patients and methods The records of patients treated at the University of Maryland Cancer Center (UMCC - formerly the Baltimore Cancer Research Center) between 1966 and 1985 were reviewed to identify those who developed any signs or symptoms of complete or partial SBO. All clinical events were considered including those documented only clinically as well as those documented radiologically or by laparotomy so that an accurate estimate of the incidence of SBO could be obtained. The assessment of the treating physician was used for the evaluation of the cause ot SBO.
OLVER ET A L .
586
Most patients had previously undergone a staging laparotomy which consisted of two needle biopsies of each lobe of the liver and wedge biopsy of the right, removal of the spleen and splenic hilar nodes as well as coeliac, duodenal, para-aortic and bilateral iliac nodes, a right iliac crest marrow biopsy and oophoropexy in the females.
'
Results Fifty-one episodes of SBO were recorded in 32 of the 398 patients treated (8%). If the two patients with second neoplasms are excluded, the incidence is 29 of 398 or 7.2%. Ten patients had multiple obstructive episodes. Three patients had complete and 29 had partial small bowel obstructions. The characteristics of this group of patients who subsequently developed SBO were unremarkable at the time of their presentation with Hodgkin's disease. They were young (median age 26) and their disease had little impact on their ability to carry out normal activities of daily living (often expressed as performance status and scored on a scale such as that devised by Karnofsky of 0-100 where 100 is normal while below 40 indicates inability to care for oneself.6 The predominant histology was nodular sclerosis and most were Stage I1 or 111. Half of the patients had abdominal disease at presentation (Table I ) . Their Hodgkin's disease responded well to treatment with 30 complete responses, one partial response and one patient with progressive disease. At the time of the obstructive episodes the Hodgkin's Table 1. Patient characteristics at initial presentation Number of patients Median age
32 26 (14-61)
Sex: Male Female
Performance status: 80- 100 Histology: Lymphocyte predominant Nodular sclerosis Mixed cellularity Lymphocyte depleted Unknown Stage of diagnosis: IA 11 A 11 B
14 18 32 1
23
5 2 I 3 12
Table 2. Small bowel obstruction
Number of episodes Method of diagnosis: Clinical" Clinical + X-ray Clinical, X-ray and laparotoniy Unknown? Cause: Adhesions Radiation
Other
111 A
Unknown
111 B IV A IV B Unknown Abdominal disease at presentation
Response to Hodgkin's disease to therapy: Complete response Partial response Progressive disease
disease was in remission in 20 patients. Of ten patients who had relapsed, eight relapsed in the abdomen. At the time of the analysis 21 patients were alive and 1 1 dead. The median survival has therefore not been reached at I8 1 months. Thirteen of the 51 episodes were diagnosed on clinical examination only. Twelve of the 13 had documentation of a prior or subsequent episode by radiographic means, or by laprotomy. Thirty-one episodes had radiological confirmation. Four were found at laparotomy and in three with repeated episodes, the method of diagnosis was unspecified (Table 2). The cause of the SBO was recorded by the treating physicians as adhesions from previous surgery in 27 episodes. This diagnosis was confirmed with laparotomy in 16 of the 27 patients including one with a short bowel syndrome after two previous laparotomies. At laparotoniy, the adhesions were lysed and variously described as multiple fibrous adhesions causing obstruction at several levels of the small bowel. In three episodes of obstruction, the cause was thought to be radiation enteritis and fibrosis. This was demonstrated at laparotomy in one of the patients, where deep ulceration of the colon with both acute and chronic inflammation and granulomatous change was described. In two patients the SBO was due to progressive lymphoma. Another patient's first documented obstruction developed while on second-line (salvage) chemotherapy. Vinblastine was implicated as a causal factor. She subsequently had six further episodes of symptomatic partial SBO of uncertain aetiology but refused investigative efforts or laparotomy. Each episode settled with conservative treatment (tube drainage). In 19 cases, the cause of obstruction was not specified by the treating physician. The median duration of each obstructive episode was 3 days (range: 1 day to 3 months intermittent).
Treatment for SBO Laparotomy Conservative (tube drainage) Spontaneous resolution 30 I I
51 13
31 4
3 27 3 3 I8 18 22 II
iMost of these, 12/13, were prior or subsequent events in patients previously documented by other means In thrcc patients tube drainape was needed for relief: diagnosis i \ presumptive. .i-Diagnosis (recurrent) established by the treating physician. or method of assessment otherwise not speciricd.
587
SMALL BOWEL OBSTRUCTION IN HODGKINS DISEASE
The median time between commencement of treatment of Hodgkin's disease and the development of SBO was 21 months with the longest interval being 140 months. Four patients developed SBO after laparotomy but before definitive treatment. Eighteen cases were treated surgically, attempting mainly to treat the obstruction by lysing adhesions. The other episodes were treated conservatively; seven with a Cantor tube and the remainder with nasogastric tubes, fluids and analgesia. Eleven episodes resolved spontaneously (Table 2). The obstructive episodes resolved in all but two cases. In both of these the obstruction was due to malignant disease, as they had developed a diffuse histiocytic lymphoma (DHL). One of these patients died as a complication of gastric outlet obstruction; the other was treated with a Cantor tube, but died of progressive DHL. Thirty-one of the 32 patients had had prior abdominal surgery, the exception being one of the patients whose obstruction was due to DHL. Twenty-nine patients had an initial staging laparotomy. Two of these patients had also had previous abdominal surgery. Of four patients who had a 'restaging' laparotomy, two had had no prior surgery. The treatment of Hodgkin's disease among these 32 patients was radiation therapy plus chemotherapy in 17 patients, radiation therapy alone in 12 patients and chemotherapy alone in three patients. Of the 29 patients who received irradiation, 25 had abdominal fields. Thirteen had a mantle port with extension to the para-aortic nodes, 1 1 received total nodal irradiation and one had fields including pelvis and lumbar spine. In the 20 patients where the irradiation dose was known, it ranged between 40 and 45 Gy using anterior and posterior fields in conventional fractions. Of the 22 patients who received chemotherapy, 15 had nitrogen mustard, Vincristine, Procarbazine and Prednisone (MOPP). The acute gastrointestinal effects of radiation and chemotherapy were no more severe in this group of patients than expected, but one patient receiving irradiation and two receiving chemotherapy developed acute symptoms of partial bowel obstruction.
Discussion The diagnosis of small bowel obstruction as a late complication in the treatment of Hodgkin's disease at 7 . 2 % in our series is higher than in most other series reporting this complication in adults. We have included, however, all patients with clinical or radiological evidence of partial or complete SBO, not only those requiring surgical correction. Most symptomatic episodes resolved with conservative treatment. Given the frequency of this late complication and the long-term survival expected in Hodgkin's disease, we should evaluate our treatment approach and its relationship to the development of bowel obstructions.
It seems that the predominant cause of obstruction was multiple adhesions from the previous laparotomy, but the additive effect of the other treatment modalities must not be overlooked. In the group of patients studied, staging laparotomy was performed on nearly all patients, as part of early staging and investigative protocols. The laparotomy for staging of Hodgkin's disease was used to assess the extent of Hodgkin's disease in the abdomen, particularly splenic and upper abdominal nodal involvement.9 Surgical staging helped to ensure adequate initial treatment fields when involved or involved-plus-adjacent-field irradiation was used. It also allowed a reduction of fields among patients with pathologically staged I and I1 Hodgkin's disease. The staging laparotomy , however, is not uniformly accepted and lesser procedures can be as effective in assessing stage, particularly in earlier stage disease.*.' ' - I 3 In addition, removing the spleen may not offer any advantage. I' Staging laparotomy could still be important if it causes a change in the treatment plan. One of the explanations for the high incidence of SBO, as a late complication in our series might be surgical technique such as incision placement, tissue handling, gauze, talc, etc. The majority of the staging laparotomies in our 398 patients, however, were performed by two surgeons and were thus felt to be generally representative of surgical expertise. The reason that our obstructive episodes occurred late rather than in the first 12 months as reported in most series is unclear? Since most patients treated at the UMCC were on a protocol which included a staging laparotomy, there was no large group treated without laparotomy, for comparison of the incidence of bowel obstruction. At the Peter MacCallum Cancer Institute (Melbourne), however, 74 patients of 197 on a Hodgkin's disease database had not had a laparotomy. All had received chemotherapy and 39 had received abdominal radiotherapy. Only one episode of small bowel obstruction was seen, which pathologically was attributed to radiation, where there was narrowing of the ileum with granuloinatous change and vascular adhesions. Radiation then can also be a contributing factor to SBO. Irradiation damage is usually related to the total dose and volume of small bowel irradiated. Although the para-aortic and pelvic irradiation fields for Hodgkin's disease include considerable portions of small bowel, there is a very low incidence (1-5%) of acute or subacute bowel damage with doses less than 45Gy as is usual in treating Hodgkin's disease.','s The symptoms of late bowel damage may include colicky pain and diarrhoea, or may present as obstruction, often developing within 6-8 months but sometimes occurring 20 years later. The irradiation can cause damage to fine vessels and fibroconnective tissue. Arterial damage with bowel ischaemia is thought to cause strictures. ''.I7
'"
588
Potish analysed risk factors for the development of enteric irradiation damage in 92 women receiving abdominal and pelvic irradiation for ovarian tumours. IXMore than half of the enteric complications could be attributed to the predisposing factors of prior surgery, thin physique and pre-existing vascular damage. The mechanism of the effect of prior surgery is unclear, but certainly more irradiation damage would be anticipated if loops of bowel were fixed by adhesions from the surgery. Of our 33 episodes where aetiology was defined, only three ( 10%) were attributed predominantly to abdominal irradiation; however, this does not reflect the contribution of the combination of surgery plus radiotherapy to this complication. Despite the acute gastrointestinal toxicity of chemotherapy, no late gastrointestinal effects have been reported for this modality alone. Concomitant chemotherapy can modify the gastrointestinal tolerance to radiation. As a late effect, it has also been implicated in the development of bowel obstruction when used after radiation therapy. I 6 , I 9 In our series the SBO in only one patient was attributed to the drug Vinblastine. Most of our patients on chemotherapy received Vincristine, however, which has been implicated in the development of SBO after radiation therapy. ’() The aetiology of SBO in this series is probably multifactorial, being contributed to by a conibination of the laparotomy with the other treatment modalities. To reduce this complication, the place of each must be re-examined. In this early series staging laparotomy was still being evaluated. Today better technologies for staging (e.g. CT and MRI) scans may reduce the need for this procedure. Also, differing treatment approaches, for example more routine use of chemotherapy rather than radiotherapy for earlier stage disease, negates the need for a staging laparotomy which will then not alter the management decision. If both staging laparotomy and its combination with other treatment modalities is responsible for the high incidence of SBO as we suspect, a lower incidence of this distressing late complication will be a desirable consequence of these newer treatment strategies. References MOKKIS D. M . , COI.LMAN J . J . , SLAWSON R. G . ct t i / . ( 1985) Effect 01‘ postoperative radiotherapy on the development 01‘ small bowel obstruction in patients undergoing staging lapitrotomy for Hodgkin’s disease. Air?. J . Cliir. Oirwl. (CCT) 8, 463-73. 2. Di. V U A V. T . JK (19x2) Hodgkin’s disease: Conference summary and future directions. Coi~c.c,rTrrcir. Rep. 66. 1045-55. 3 . Gi,i:i:s J . P. (1982) The changing role of staging laparotoiny in Hodgkiii’s disease: A personal series 01’310 patients. Brit. J. Sur,q. 69. 181-7. 1
OLVER
rr AL.
KIN6tl.l.A T. J . , Fluuss B . A . & GI.A.I.S.I.L.IN E. (1982) Late effects of !radiation therapy i i i the treatiiient o l Hodgkin’s disease. Ctrr~cev 7‘rcwl. R e p . 66, 99 I- 1001. 5 . PiiiLLii’s T. L.. W I ~ A K K AMM. D. & M A K W . I L. S W. ( 1985) Modification of radiation nijury to nornial tissues by chernotherapeutic agents. C(iiiwr 35, 1678-84. 6. MOK V . , LA Liwxrt L . , MOKKIS J . & WII:MANNM . (1984) The Karnolsky Perforinance Status Scale: An exaniination of its reliability antl validity in a research setting. C O I I C53, P ~ 2002-7. 7. BIWGAIXK s.. F ~ L MK. . COI.IxVAN M . (’/ ( I / . ( 197X) Morbidity of staging laparotomy in Hotlgkin’s disease. Aiw. J . Mrd. 64. 429-33. 8. S I A V IR. N & NI..I.SON T. S. (1973) Complication lrom staging laparotomy for Hodgkin’s disease. NCI Monograph 36, 457. 9. GLATSTL-IN E . . G U ~ K N SJL. YM . , ROSI.NI$k.i
Ausr. N . Z . J . Surg. 1990, 60, 585-588
SMALL BOWEL OBSTRUCTION AS A LATE COMPLICATION OF THE TREATMENT OF HODGKIN'S DISEASE IAN
N.
OLVER,' PAULA PEARL,2 PETER
H. W I E R N I K AND ~ JOSEPH AlSNER4
University qf Maryland Cancer Center, University qf Maryland School of Medicine, Baltitnore, Maryland. USA Small bowel obstruction (SBO) as a late complication of the treatment of Hodgkin's disease was found in 32 of 398 ( 8 % ) patients followed over a 20 year period. The vast majority of these patients had an initial staging laparotomy as part of staging protocols. O f 5 I obstructive episodes, 13 were diagnosed clinically, 12 of the 13 had prior radiological or surgical documentation. Thirty-one episodes were shown radiologically; four were demonstrated at laparotomy and three recurrent episodes were identified in an unspecified manner. The mcdian duration of each episode was 3 days and the median time between commencement from treatment for Hodgkin's disease and the development of a SBO was 21 months. Thirty-one of the 32 patients had had a staging laparotomy or prior abdominal surgery. Two patients had SBO because of non-Hodgkin's lymphoma and one had SBO secondary to short bowel syndrome. These are thus not true complications of disease treatment. Twenty-nine of the 32 or 7.2"/0 of patients thus had possible treatment-related SBO. The cause of SBO was recorded as adhesions from previous surgery in 27 of the 51 episodes. This was confirmed at laparotoniy in 16 patients. Twenty-five of the 32 patients had received abdominal irradiation but only three obstructive episodes were attributed to radiation enteritis and fibrosis. In one of 22 patients who received chemotherapy, Vinblastine was implicated as a cause for SBO. Eighteen patients required laparotomy to lyse adhesions while the others were treated conservatively with tube drainage. The aetiologies for these obstructive episodes can be attributed to staging laparotomy and its combination with other treatment modalities, and their incidence is likely to be lower in more recent series where more conservative staging procedures are used.
Key words: Hodgkin's disease, laparotomy, non-Hodgkin's lymphoma, radiation enteritis and fibrosis, short bowel syndrome, small bowel obstruction, Vinblastine. Vincristine.
Introduction Small bowel obstruction (SBO) is a possible late complication associated with the treatment of Hodgkin's disease. I Since a significant proportion of patients with Hodgkin's disease are cured, future treatment strategies should aim to improve survival and reduce the long-term morbidity of therapy.' Treatment related to toxicities should be reviewed so that risks can be identified and balanced against benefit in planning future treatment policy. Staging laparotomy,' abdominal i r r a d i a t i ~ n ,and ~ chemotherapy' could all contribute to the development of
' MB, BS, FRACP. 'NP. 'MD. MD, FACP Present addrcsscs: ' Pctcr MacCallum Canccr
Institutc. Mclbourne. Victoria. Australia. 2.4 Univcrsity of Maryland Canccr Ccntcr, Baltimorc. Maryland, USA. Montcfiore Medical Ccnter. I I I E. 210 Strcct, Bronx. Ncw York, USA.
'
Corrcspondcncc: Ian Olvcr, Pctcr MacCallurn Canccr Institutc. 4x1 Little Lonsdalc Strcct. Melbourne, Vic. 3000. Australia. Acccptcd for publication 28 Fcbruary 1990
small bowel obstruction. We previously reported on the occurrence of SBO in a cohort of 210 patients with Hodgkin's disease. This report extends this analysis to a larger cohort and reviews a group of patients who developed signs or symptoms of partial or complete SBO following a completed treatment for Hodgkin's disease.
Patients and methods The records of patients treated at the University of Maryland Cancer Center (UMCC - formerly the Baltimore Cancer Research Center) between 1966 and 1985 were reviewed to identify those who developed any signs or symptoms of complete or partial SBO. All clinical events were considered including those documented only clinically as well as those documented radiologically or by laparotomy so that an accurate estimate of the incidence of SBO could be obtained. The assessment of the treating physician was used for the evaluation of the cause ot SBO.
OLVER ET A L .
586
Most patients had previously undergone a staging laparotomy which consisted of two needle biopsies of each lobe of the liver and wedge biopsy of the right, removal of the spleen and splenic hilar nodes as well as coeliac, duodenal, para-aortic and bilateral iliac nodes, a right iliac crest marrow biopsy and oophoropexy in the females.
'
Results Fifty-one episodes of SBO were recorded in 32 of the 398 patients treated (8%). If the two patients with second neoplasms are excluded, the incidence is 29 of 398 or 7.2%. Ten patients had multiple obstructive episodes. Three patients had complete and 29 had partial small bowel obstructions. The characteristics of this group of patients who subsequently developed SBO were unremarkable at the time of their presentation with Hodgkin's disease. They were young (median age 26) and their disease had little impact on their ability to carry out normal activities of daily living (often expressed as performance status and scored on a scale such as that devised by Karnofsky of 0-100 where 100 is normal while below 40 indicates inability to care for oneself.6 The predominant histology was nodular sclerosis and most were Stage I1 or 111. Half of the patients had abdominal disease at presentation (Table I ) . Their Hodgkin's disease responded well to treatment with 30 complete responses, one partial response and one patient with progressive disease. At the time of the obstructive episodes the Hodgkin's Table 1. Patient characteristics at initial presentation Number of patients Median age
32 26 (14-61)
Sex: Male Female
Performance status: 80- 100 Histology: Lymphocyte predominant Nodular sclerosis Mixed cellularity Lymphocyte depleted Unknown Stage of diagnosis: IA 11 A 11 B
14 18 32 1
23
5 2 I 3 12
Table 2. Small bowel obstruction
Number of episodes Method of diagnosis: Clinical" Clinical + X-ray Clinical, X-ray and laparotoniy Unknown? Cause: Adhesions Radiation
Other
111 A
Unknown
111 B IV A IV B Unknown Abdominal disease at presentation
Response to Hodgkin's disease to therapy: Complete response Partial response Progressive disease
disease was in remission in 20 patients. Of ten patients who had relapsed, eight relapsed in the abdomen. At the time of the analysis 21 patients were alive and 1 1 dead. The median survival has therefore not been reached at I8 1 months. Thirteen of the 51 episodes were diagnosed on clinical examination only. Twelve of the 13 had documentation of a prior or subsequent episode by radiographic means, or by laprotomy. Thirty-one episodes had radiological confirmation. Four were found at laparotomy and in three with repeated episodes, the method of diagnosis was unspecified (Table 2). The cause of the SBO was recorded by the treating physicians as adhesions from previous surgery in 27 episodes. This diagnosis was confirmed with laparotomy in 16 of the 27 patients including one with a short bowel syndrome after two previous laparotomies. At laparotoniy, the adhesions were lysed and variously described as multiple fibrous adhesions causing obstruction at several levels of the small bowel. In three episodes of obstruction, the cause was thought to be radiation enteritis and fibrosis. This was demonstrated at laparotomy in one of the patients, where deep ulceration of the colon with both acute and chronic inflammation and granulomatous change was described. In two patients the SBO was due to progressive lymphoma. Another patient's first documented obstruction developed while on second-line (salvage) chemotherapy. Vinblastine was implicated as a causal factor. She subsequently had six further episodes of symptomatic partial SBO of uncertain aetiology but refused investigative efforts or laparotomy. Each episode settled with conservative treatment (tube drainage). In 19 cases, the cause of obstruction was not specified by the treating physician. The median duration of each obstructive episode was 3 days (range: 1 day to 3 months intermittent).
Treatment for SBO Laparotomy Conservative (tube drainage) Spontaneous resolution 30 I I
51 13
31 4
3 27 3 3 I8 18 22 II
iMost of these, 12/13, were prior or subsequent events in patients previously documented by other means In thrcc patients tube drainape was needed for relief: diagnosis i \ presumptive. .i-Diagnosis (recurrent) established by the treating physician. or method of assessment otherwise not speciricd.
587
SMALL BOWEL OBSTRUCTION IN HODGKINS DISEASE
The median time between commencement of treatment of Hodgkin's disease and the development of SBO was 21 months with the longest interval being 140 months. Four patients developed SBO after laparotomy but before definitive treatment. Eighteen cases were treated surgically, attempting mainly to treat the obstruction by lysing adhesions. The other episodes were treated conservatively; seven with a Cantor tube and the remainder with nasogastric tubes, fluids and analgesia. Eleven episodes resolved spontaneously (Table 2). The obstructive episodes resolved in all but two cases. In both of these the obstruction was due to malignant disease, as they had developed a diffuse histiocytic lymphoma (DHL). One of these patients died as a complication of gastric outlet obstruction; the other was treated with a Cantor tube, but died of progressive DHL. Thirty-one of the 32 patients had had prior abdominal surgery, the exception being one of the patients whose obstruction was due to DHL. Twenty-nine patients had an initial staging laparotomy. Two of these patients had also had previous abdominal surgery. Of four patients who had a 'restaging' laparotomy, two had had no prior surgery. The treatment of Hodgkin's disease among these 32 patients was radiation therapy plus chemotherapy in 17 patients, radiation therapy alone in 12 patients and chemotherapy alone in three patients. Of the 29 patients who received irradiation, 25 had abdominal fields. Thirteen had a mantle port with extension to the para-aortic nodes, 1 1 received total nodal irradiation and one had fields including pelvis and lumbar spine. In the 20 patients where the irradiation dose was known, it ranged between 40 and 45 Gy using anterior and posterior fields in conventional fractions. Of the 22 patients who received chemotherapy, 15 had nitrogen mustard, Vincristine, Procarbazine and Prednisone (MOPP). The acute gastrointestinal effects of radiation and chemotherapy were no more severe in this group of patients than expected, but one patient receiving irradiation and two receiving chemotherapy developed acute symptoms of partial bowel obstruction.
Discussion The diagnosis of small bowel obstruction as a late complication in the treatment of Hodgkin's disease at 7 . 2 % in our series is higher than in most other series reporting this complication in adults. We have included, however, all patients with clinical or radiological evidence of partial or complete SBO, not only those requiring surgical correction. Most symptomatic episodes resolved with conservative treatment. Given the frequency of this late complication and the long-term survival expected in Hodgkin's disease, we should evaluate our treatment approach and its relationship to the development of bowel obstructions.
It seems that the predominant cause of obstruction was multiple adhesions from the previous laparotomy, but the additive effect of the other treatment modalities must not be overlooked. In the group of patients studied, staging laparotomy was performed on nearly all patients, as part of early staging and investigative protocols. The laparotomy for staging of Hodgkin's disease was used to assess the extent of Hodgkin's disease in the abdomen, particularly splenic and upper abdominal nodal involvement.9 Surgical staging helped to ensure adequate initial treatment fields when involved or involved-plus-adjacent-field irradiation was used. It also allowed a reduction of fields among patients with pathologically staged I and I1 Hodgkin's disease. The staging laparotomy , however, is not uniformly accepted and lesser procedures can be as effective in assessing stage, particularly in earlier stage disease.*.' ' - I 3 In addition, removing the spleen may not offer any advantage. I' Staging laparotomy could still be important if it causes a change in the treatment plan. One of the explanations for the high incidence of SBO, as a late complication in our series might be surgical technique such as incision placement, tissue handling, gauze, talc, etc. The majority of the staging laparotomies in our 398 patients, however, were performed by two surgeons and were thus felt to be generally representative of surgical expertise. The reason that our obstructive episodes occurred late rather than in the first 12 months as reported in most series is unclear? Since most patients treated at the UMCC were on a protocol which included a staging laparotomy, there was no large group treated without laparotomy, for comparison of the incidence of bowel obstruction. At the Peter MacCallum Cancer Institute (Melbourne), however, 74 patients of 197 on a Hodgkin's disease database had not had a laparotomy. All had received chemotherapy and 39 had received abdominal radiotherapy. Only one episode of small bowel obstruction was seen, which pathologically was attributed to radiation, where there was narrowing of the ileum with granuloinatous change and vascular adhesions. Radiation then can also be a contributing factor to SBO. Irradiation damage is usually related to the total dose and volume of small bowel irradiated. Although the para-aortic and pelvic irradiation fields for Hodgkin's disease include considerable portions of small bowel, there is a very low incidence (1-5%) of acute or subacute bowel damage with doses less than 45Gy as is usual in treating Hodgkin's disease.','s The symptoms of late bowel damage may include colicky pain and diarrhoea, or may present as obstruction, often developing within 6-8 months but sometimes occurring 20 years later. The irradiation can cause damage to fine vessels and fibroconnective tissue. Arterial damage with bowel ischaemia is thought to cause strictures. ''.I7
'"
588
Potish analysed risk factors for the development of enteric irradiation damage in 92 women receiving abdominal and pelvic irradiation for ovarian tumours. IXMore than half of the enteric complications could be attributed to the predisposing factors of prior surgery, thin physique and pre-existing vascular damage. The mechanism of the effect of prior surgery is unclear, but certainly more irradiation damage would be anticipated if loops of bowel were fixed by adhesions from the surgery. Of our 33 episodes where aetiology was defined, only three ( 10%) were attributed predominantly to abdominal irradiation; however, this does not reflect the contribution of the combination of surgery plus radiotherapy to this complication. Despite the acute gastrointestinal toxicity of chemotherapy, no late gastrointestinal effects have been reported for this modality alone. Concomitant chemotherapy can modify the gastrointestinal tolerance to radiation. As a late effect, it has also been implicated in the development of bowel obstruction when used after radiation therapy. I 6 , I 9 In our series the SBO in only one patient was attributed to the drug Vinblastine. Most of our patients on chemotherapy received Vincristine, however, which has been implicated in the development of SBO after radiation therapy. ’() The aetiology of SBO in this series is probably multifactorial, being contributed to by a conibination of the laparotomy with the other treatment modalities. To reduce this complication, the place of each must be re-examined. In this early series staging laparotomy was still being evaluated. Today better technologies for staging (e.g. CT and MRI) scans may reduce the need for this procedure. Also, differing treatment approaches, for example more routine use of chemotherapy rather than radiotherapy for earlier stage disease, negates the need for a staging laparotomy which will then not alter the management decision. If both staging laparotomy and its combination with other treatment modalities is responsible for the high incidence of SBO as we suspect, a lower incidence of this distressing late complication will be a desirable consequence of these newer treatment strategies. References MOKKIS D. M . , COI.LMAN J . J . , SLAWSON R. G . ct t i / . ( 1985) Effect 01‘ postoperative radiotherapy on the development 01‘ small bowel obstruction in patients undergoing staging lapitrotomy for Hodgkin’s disease. Air?. J . Cliir. Oirwl. (CCT) 8, 463-73. 2. Di. V U A V. T . JK (19x2) Hodgkin’s disease: Conference summary and future directions. Coi~c.c,rTrrcir. Rep. 66. 1045-55. 3 . Gi,i:i:s J . P. (1982) The changing role of staging laparotoiny in Hodgkiii’s disease: A personal series 01’310 patients. Brit. J. Sur,q. 69. 181-7. 1
OLVER
rr AL.
KIN6tl.l.A T. J . , Fluuss B . A . & GI.A.I.S.I.L.IN E. (1982) Late effects of !radiation therapy i i i the treatiiient o l Hodgkin’s disease. Ctrr~cev 7‘rcwl. R e p . 66, 99 I- 1001. 5 . PiiiLLii’s T. L.. W I ~ A K K AMM. D. & M A K W . I L. S W. ( 1985) Modification of radiation nijury to nornial tissues by chernotherapeutic agents. C(iiiwr 35, 1678-84. 6. MOK V . , LA Liwxrt L . , MOKKIS J . & WII:MANNM . (1984) The Karnolsky Perforinance Status Scale: An exaniination of its reliability antl validity in a research setting. C O I I C53, P ~ 2002-7. 7. BIWGAIXK s.. F ~ L MK. . COI.IxVAN M . (’/ ( I / . ( 197X) Morbidity of staging laparotomy in Hotlgkin’s disease. Aiw. J . Mrd. 64. 429-33. 8. S I A V IR. N & NI..I.SON T. S. (1973) Complication lrom staging laparotomy for Hodgkin’s disease. NCI Monograph 36, 457. 9. GLATSTL-IN E . . G U ~ K N SJL. YM . , ROSI.NI$k.i
