Results of surgery for obstructing carcinomatosis of gastrointestinal, pancreatic, or biliary origin. Rectal cancer recurrence after prior resection and radiotherapy: palliation following additional surgery. Management of intestinal obstruction after gastrectomy for carcinoma. Intestinal obstruction in patients with gynaecological malignancies. Survival following intestinal obstruction in ovarian cancer. Ovarian carcinoma complicated by gastric outlet obstruction. Bowel obstruction in patients with ovarian carcinoma: analysis of prognostic factors. Intestinal obstruction in patients with advanced carcinoma of the ovaries treated with combination chemotherapy. Palliative gastrojejunostomy for advanced carcinoma of the stomach. Benefit of palliative surgery for bowel obstruction in advanced ovarian cancer. Results of surgery for malignant bowel obstruction in advanced, unresectable, recurrent colorectal cancer. Management of bowel obstruction in patients with advanced ovarian cancer. Intestinal operations in patients with ovarian carcinoma. Small bowel obstruction after colon resection for benign and malignant diseases. Treatment of bowel obstruction after operation for colorectal carcinoma. Follow-up after primary therapy: management of the symptomatic patient-surgery. Surgical management of bowel obstruction in advanced ovarian carcinoma.
Results of operation for obstructing carcinomatosis of gastrointestinal (GI), pancreatic, or biliary origin were reviewed to assess relief of symptoms, management of re-obstruction, and duration of hospitalization. A retrospective review (1977 to 1986) identified 89 patients, 59 (66%) of whom had tumors originating in the colon, and 19 (21%) in the stomach. Normal bowel function was restored for a median of 102 days in 66 patients (74%) and all but four (94%) were discharged. Forty-one (46%) patients remained unobstructed until death. Twenty-three (26%) were not relieved by operation and died a median of 33 days later (P less than .005). Forty-eight (81.4%) of the 59 colon cancer patients and ten (52.6%) of 19 with gastric cancer (P less than .05) were benefited by the operation, although comparison of duration of function was less striking (P less than .1). In-hospital mortality was 13% and complications occurred in 44%. Obstruction recurred in 38% of those relieved by the initial operation. Normal bowel function was restored in six (46%) of 13 patients undergoing a second laparotomy (median, 158 days) and in six of 13 (46%) treated with nasogastric suction. Obstruction recurred again in four of the latter six patients (median, 39 days). Hospitalization averaged 31 days (median, 25 days) for the first procedure and 41 days (median, 39 days) for patients operated for recurrent obstruction. These results justify laparotomy for intestinal obstruction in known or suspected carcinomatosis, particularly of colonic origin, if performance status is compatible with a reasonable quality of life. Patients with rectal cancer may develop local recurrence despite cancer resection plus treatment with high dose radiation therapy. In this report, symptomatic patients received benefit from repeat resection. The morbidity and mortality can be maintained at an acceptable level with meticulous dissections and consistent use of reconstructive procedures.
                The primary treatment of rectal carcinoma is surgical excision to remove the primary tumor and its draining lymphatic systems. Postoperative radiotherapy may be recommended if tumor has penetrated through the full thickness of the bowel wall, and where there is lymph node involvement. Despite such treatments, tumor may recur locally, producing symptoms relieved by palliative surgery.
                Between 1989 and 1995, twenty patients underwent 21 reoperations for locally recurrent rectal cancer. All patients previously had not only surgical resection but also radiotherapy as treatment. The clinical data available on these patients was critically evaluated.
                Eighty-nine dissections (4.5 per patient) and 39 reconstructive procedures (2.0 per patient) were required on these 20 patients to re-resect rectal cancer in an irradiated site. Major complications occurred in 4 of 21 reoperative procedures (19%). There were no mortalities. Palliative benefits from pain control (8 of 9 patients), resolution of uncontrolled hemorrhage (2 of 2 patients), resolution of pelvic sepsis (2 of 2 patients), and reversal of intestinal obstruction (2 of 2 patients) were clearly demonstrated. The median survival following repeat resection was 24 months.
                Surgical cure following reoperation for recurrent rectal cancer treated initially with resection radiotherapy was uncommon. However, the morbidity and mortality of the procedures were acceptable, the survival was extensive and the palliative effects were substantial. The results of treatment suggest that repeat resection combined with aggressive reconstruction, is an important part of the treatment of symptomatic rectal cancer patients who recur locally, after resection combined with radiation therapy. nan 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. A retrospective survey of 38 ovarian cancer patients who developed radiologically confirmed intestinal obstruction was performed. Twenty-six patients underwent surgery. In the surgical treatment group, obstruction was not due to recurrent disease in six cases. The median survival for the group as a whole was 56 days. Patients in the operative group survived significantly longer than those in the non-operative group. There was an operative mortality of 15% and major postoperative morbidity was seen in 42%. Neither the site of the obstruction nor the type of operation influenced survival. No postoperative chemotherapy responses were seen in previously treated patients. nan A retrospective study was performed in which patients with both bowel obstruction and ovarian carcinoma admitted to the gynecologic oncology service at the Milton S. Hershey Medical Center between July 1, 1980, and June 30, 1987, were examined. Thirty-three patients were identified who fulfilled the inclusion criteria for bowel obstruction that did not occur in the postoperative period. Historical, physical, nutritional, and laboratory variables thought to contribute to patient survival were evaluated by a retrospective chart review. Survival time was not significantly related to presence or absence of tumor at obstruction, type of intervention whether medical or surgical, patient age, or interval from initial diagnosis of ovarian cancer to obstruction. Survival time was found to be significantly related to the prognostic index initially proposed by H. B. Krebs and D. R. Goplerud [Obstet. Gynecol. 61, 327-330 (1983)], P = 0.002. This prognostic index incorporates a multifactorial assessment of patient status including age, nutritional status, tumor spread, ascites, and prior chemotherapy and radiotherapy and can be used to evaluate patients at the time of presentation with intestinal obstruction and to help select optimal treatment for palliation. An analysis of incidence, risk factors and treatment results of intestinal obstruction caused by carcinoma of the ovaries was performed in 310 consecutive patients with carcinoma of the ovaries, The International Federation of Gynecology and Obstetrics stage IIB to IV, treated with combination chemotherapy. With a median observation time of 46 months, the incidence was 14 per cent and the cumulated risk was estimated to be 26 per cent at five years after treatment was begun. Risk factors were stages IIIB and IV, residual primary tumor size greater than 2 centimeters and presence of intestinal carcinomatosis at primary laparotomy. There was no difference in the survival time between 16 conservatively treated patients and 25 surgically treated patients (a median of 30 and 68 days, respectively, p greater than 0.30). The complication risk of surgical treatment was high (64 per cent), and surgical benefit--defined as survival greater than 60 days with total palliation of intestinal symptoms--was achieved in only 32 per cent. The outcome of 51 patients who underwent gastrojejunostomy for unresectable gastric cancer with outlet obstruction was studied to evaluate the palliative benefit. The operative mortality and postoperative complication rates were 22% and 55% respectively. The mean duration of postoperative hospital stay was 13 days and median survival period 14 weeks. Delayed gastric emptying occurred in 21%, mostly in patients with extensive tumour involvement of the stomach and was associated with a poor outcome. Among the survivors, 87.5% were able to take a soft diet by the eighth postoperative day and 60% could cope with the progression of the disease at home. We conclude that gastrojejunostomy offers satisfactory palliation in patients with advanced gastric cancer. To determine the benefit of palliative surgery for patients with advanced ovarian cancer and bowel obstruction and to identify criteria for selecting patients who are most likely to benefit from palliation.
                A retrospective study of patients treated between 1982 and 1992.
                A university-affiliated hospital.
                Fifty-three patients with complete and unresolved bowel obstruction caused by ovarian cancer.
                Surgery for relief of bowel obstruction.
                Postoperative survival longer than 60 days, return home and relief of bowel obstruction for longer than 60 days, factors associated with failure of palliative surgery.
                Successful palliation was achieved in 27 (51%) patients and was associated with the absence of four prognostic factors: palpable abdominal and pelvic masses, ascites exceeding 3 L, multiple obstructive sites and preoperative weight loss greater than 9 kg. Age, time interval between diagnosis of ovarian cancer and bowel obstruction, stage of disease at initial diagnosis, tumour type and grade, site and degree of obstruction, presence of gross residual tumour after initial operation and preoperative use of chemotherapy or radiotherapy did not indicate the success or failure of palliative surgery.
                Palliative surgery for bowel obstruction in advanced ovarian cancer can be worthwhile, and there are four prognostic factors that indicate the likely failure of palliation. 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. 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. Forty-two patients with epithelial ovarian carcinoma underwent intestinal operations at the University of California, Los Angeles, and the City of Hope National Medical Center during the course of the disease. The patients were divided into three groups for purposes of this analysis. The first group had intestinal surgery during their initial laparotomy. Patients in the second group underwent intestinal operation at the time of re-exploration for recurrent disease but had no preoperative signs or symptoms of intestinal tract dysfunction, while those in the third group underwent re-exploration for symptomatic intestinal involvement by tumor. Operative complications, postoperative morbidity, and effect of the resection on disease outcome are analyzed for each group in an attempt to define the indications for intestinal resection or bypass in patients with epithelial ovarian cancer. 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. 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 benefit of secondary surgery in patients (pts) recurring after a negative second look is still a matter of controversy. Twenty-seven patients underwent this procedure: 5 were stage I at primary surgery and 22 stage IIIC. All 5 stage I pts had a pelvic recurrence: 3 were left with no visible tumor and were then treated with cisplatin chemotherapy. Two are alive and with no evidence of disease (NED) at 45 and 62 months. In stage IIIC pts, optimal debulking (< 2 cm) was achieved in 59% (13/22), and 8 of them had no macroscopic residual tumor. All pts were then treated with cisplatin chemotherapy. Only 3 pts are still alive and NED at 56, 61, and 67 months. The most important prognostic parameters regarding secondary surgery seem to be residual tumor volume both at primary and secondary surgery, time interval between negative second-look surgery and recurrence, histology (serous) and degree of differentiation, and response to second-line chemotherapy. Finally, surgery can have a true palliative role in pts who present with bowel obstruction; in our center, most patients who had a definitive procedure did benefit from the quality of life viewpoint. 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.
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.