Japanese Journal of Clinical Oncology 33:357-359 (2003)
© 2003 Foundation for Promotion of Cancer Research
Factors Affecting Successful Palliative Surgery for Malignant Bowel Obstruction due to Peritoneal Dissemination from Colorectal Cancer
Department of Surgery, Tokyo Kosei Nenkin Hospital, Tokyo, Japan
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Background: Nonresectable colorectal cancer often causes malignant intestinal obstruction due to peritoneal dissemination. However, no previous report has specifically investigated which patients, with peritoneal dissemination from colorectal cancer, would actually benefit from palliative surgery. This study defines the selection criteria for patients who are likely to benefit from palliative surgery.
Methods: Twenty-one patients underwent palliative surgery for malignant bowel obstruction due to peritoneal dissemination from colorectal cancer. In all cases, the advanced and nonresectable nature of the tumor was confirmed at laparotomy. Clinical factors such as age, gender, serum level of carcinoembryonic antigen, amount of ascites, location of the primary cancer, surgical procedure, and postoperative chemotherapy were analyzed for prognostic significance in symptom-free and overall survival using the Kaplan–Meier product limit method and the log-rank test.
Results: All the postoperative courses were uneventful. Obstruction recurred after a median symptom-free interval of 61 days in the group with less than 100 ml of ascites, whereas it recurred after 9 days in the group with more than 100 ml of ascites. Symptom-free survival rates in patients who manifested ascites were significantly lower than in those without ascites (P = 0.0321, log-rank method). The symptom-free and overall survival rates in patients who underwent postoperative chemotherapy were significantly higher (P = 0.0225 and 0.0003).
Conclusions: Palliative surgery can be performed effectively for patients without ascites. For patients who do not meet this criterion, a non-surgical procedure may be preferable.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Advanced or recurrent colorectal cancer often causes intestinal obstruction due to peritoneal dissemination, and patients with nonresectable colorectal cancer who develop malignant bowel obstruction present surgeons with a unique challenge. Conservative treatment with nasogastric decompression is often the first choice, but unfortunately, this will be unsuccessful in most patients. Therefore, a clinician is faced with a therapeutic dilemma; on the one hand, it is clear that most of these patients have a limited life expectancy, whereas on the other hand, surgical intervention appears to be unavoidable. Some reports estimated the median survival after palliative surgery to be 1 to 6.5 months (1–4). Moreover, surgical intervention in these patients is associated with substantial perioperative mortality and morbidity rates (1). To our knowledge, no previous report has specifically addressed the question regarding which patients, with peritoneal dissemination from colorectal cancer, would actually benefit from palliative surgery.
Here, we present a retrospective review of 21 patients with nonresectable peritoneal dissemination from colorectal cancer causing malignant bowel obstruction, and define the selection criteria for patients who are likely to benefit from surgery.
|
METHODS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Clinical information was obtained from patient records. In all these patients, the advanced and nonresectable nature of the tumor was confirmed at laparotomy, and palliative surgery was performed. In all cases, the amount of ascites was recorded during surgery. In some cases, intraoperative assessment of disseminated disease was insufficient because of adhesion or because only a small incision was made. In all cases, the amount of oral intake was recorded after surgery.
The clinical factors investigated in this study were: age, gender, serum level of carcinoembryonic antigen (CEA), amount of ascites, location of the primary cancer, surgical procedure, and postoperative chemotherapy. These were analyzed for prognostic significance in symptom-free and overall survival using the Kaplan–Meier product limit method and the log-rank test. Symptom-free survival was defined as the interval from the initiation of oral intake after palliative surgery to its stoppage due to bowel obstruction. The stoppage date for oral intake was defined as the initiation date for intravenous alimentation. Significance was defined as P < 0.05. Statistical analysis was performed with a statistical analysis program package (StatView 5.0, SAS Institute Inc. Cary, NC, USA).
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Between January 1986 and December 2001, 21 patients were treated for malignant bowel obstruction due to peritoneal dissemination from colorectal cancer at the Department of Surgery, Tokyo Kosei Nenkin Hospital, Japan. All cases were identified as recurrent colorectal cancer. There were 12 males and nine females with a mean age of 61.7 (range, 20–88) years.
The median interval between primary and palliative surgery was 14 months (range 3.5–61). In all cases, bowel obstruction occurred due to peritoneal dissemination. The primary procedures included 12 complete resections of the tumor and nine incomplete resections. Colostomy was carried out in six patients. Of these, five patients underwent transversostomy, and one patient underwent sigmoidostomy. An intestinal bypass to relieve malignant bowel obstruction was performed in 11 patients. Of these, three patients underwent double intestinal bypasses, and two patients underwent triple intestinal bypasses. In one patient, bowel resection and not tumor resection was performed. In three patients, a combination of procedures (e.g., bypass with colostomy) was necessary (Table 1).
|
Insufficiency in anastomosis was not observed, and all the postoperative courses were uneventful, with no mortality or morbidity. Postoperative chemotherapy was performed in seven cases (four intravenous administrations, one oral administration, and two intraperitoneal administrations). Obstruction recurred after a median symptom-free interval of 61 days in the group consisting of 14 patients with less than 100 ml of ascites, but in the group of seven patients who manifested ascites (more than 100 ml) it recurred after 9 days. The symptom-free survival rate in patients who manifested ascites was significantly lower than in patients without ascites (P = 0.0321, log-rank method). The symptom-free and overall survival rate in patients who underwent postoperative chemotherapy were significantly higher (P = 0.0225 and 0.0003). Age, gender, serum level of CEA, location of primary cancer, and surgical procedure were not significant prognostic factors (Table 2).
|
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Although in the present study on colorectal cancer the total number of patients was small, two parameters were found to be significant predictors of the outcome in patients with malignant bowel obstruction due to peritoneal dissemination from colorectal cancer.
1. A small amount of ascites (less than 100 ml) was a significant determinant of favorable symptom-free survival after palliative surgery. Ascites may indicate the level of tumor burden, and patients manifesting ascites may have multiple obstruction sites. Apart from obstruction, peritoneal carcinomatosis may cause motility problems because of the intestinal paralysis secondary to extensive tumor involvement of the intestinal mesentery, which cannot be cured by bypass procedures (5). Therefore, this parameter could be a significant determinant of symptom-free survival. Serum CEA level can also reflect the tumor burden. However, in the present study, a low serum CEA level was not found to be a statistically significant prognostic factor. In a study on gastric cancer patients, Mori et al. (6) reported that serum CEA levels of patients with liver metastases were higher than those of patients without them. It is possible that the serum CEA level may not correlate with malignant bowel obstruction, but may correlate with liver metastases.
2. Symptom-free and overall survival rates in patients receiving postoperative chemotherapy were significantly higher. This is considered to be the result of a selection bias due to the retrospective nature of this study and is not a predictor of outcome.
Van Ooijen and colleagues concluded that surgical therapy, for the relief of intestinal obstruction due to carcinoma of the ovary or peritoneal carcinomatosis of other origins, should be reserved for the following three groups of patients: (1) patients who do not manifest ascites; (2) patients who do not have palpable masses; and (3) patients for whom effective chemotherapy may be available (3). Our results are in agreement with theirs, and indicate that palliative surgery can be performed effectively for patients who do not manifest ascites. Peritonectomy procedures and perioperative intraperitoneal chemotherapy have been reported by Averbach and Sugarbaker for palliation of patients suffering from intestinal obstruction due to cancer recurrence (7). Since our study is limited to palliative surgery, our data cannot be used to comment on more aggressive approaches. Legendre et al. (8) reported that postoperative mortality, after palliative surgery, for neoplastic gastrointestinal obstruction was 21%. However, in the present study, all the postoperative courses were uneventful (no morbidity or mortality). These results show that palliative surgery can be safely performed. Fainsinger et al. (9) reported that malignant bowel obstruction can be managed successfully using high doses of corticosteroids, percutaneous gastrostomy, and hydration by hypodermolysis. In our present study, obstruction recurred after the median symptom-free interval of 9 days in the group of patients who manifested ascites. Therefore, these approaches may be favorable for such patients.
In conclusion, palliative surgery can be performed effectively for patients who do not manifest ascites. For patients who manifest ascites, non-surgical procedures such as percutaneous gastrostomy, corticosteroids, and hydration may be preferable.
|
FOOTNOTES |
|---|
+ For reprints and all correspondence: Hisato Higashi, Department of Surgery, Tokyo Kosei Nenkin Hospital, 5-1, Tsukudo-cho, Shinjuku-ku, Tokyo 162-8543, Japan. E-mail: hshigashi{at}tkn-hosp.gr.jp
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
1 Butler JA, Cameron BL, Morrow M, Kahng K, Tom J. Small bowel obstruction in patients with a prior history of cancer. Am J Surg 1991;162:624–8.[CrossRef][Medline]
2 Spears H, Petrelli NJ, Herrera L, Mittelman A. Treatment of bowel obstruction after operation for colorectal carcinoma. Am J Surg 1988;155:383–6.[CrossRef][Medline]
3 Van Ooijen B, Van der Burg MEL, Planting ASTh, Siersema PD, Wiggers T. Surgical treatment or gastric drainage only for intestinal obstruction in patients with carcinoma of the ovary or peritoneal carcinomatosis of other origin. Surg Gynecol Obstet 1993;176:469–74.[Medline]
4 Lau PWK, Lorentz TG. Results of surgery for malignant bowel obstruction in advanced, unresectable, recurrent colorectal cancer. Dis Colon Rectum 1993;36:61–4.[CrossRef][Medline]
5 Krebs HB, Helmkamp BF. Management of intestinal obstruction in ovarian cancer. Oncology 1989;3:25–31.
6 Mori M, Sakaguchi H, Akazawa K, Tsuneyoshi M, Sueishi K, Sugimachi K. Correlation between metastatic site, histological type, and serum tumor markers of gastric carcinoma. Hum Pathol 1995;26:504–8.[Medline]
7 Averbach AM, Sugarbaker PH. Recurrent intraabdominal cancer with intestinal obstruction. Int Surg 1995;80:141–6.[Medline]
8 Legendre H, Vanhuyse F, Caroli-Bosc FX, Pector JC. Survival and quality of life after palliative surgery for neoplastic gastrointestinal obstruction. Eur J Surg Oncol EJSO 2001;27:364–7.
9 Fainsinger RL, Spachynski K, Hanson J, Bruera E. Symptom control in terminally ill patients with malignant bowel obstruction. J Pain Symptom Manage 1994;9:12–8.[CrossRef][Web of Science][Medline]
Received February 7, 2003; accepted June 2, 2003
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  D. J. Casarett and T. E. Quill "I'm Not Ready for Hospice": Strategies for Timely and Effective Hospice Discussions Ann Intern Med, March 20, 2007; 146(6): 443 - 449. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||