Octreotide in the management of bowel obstruction in terminal ovarian cancer

Clinical Benefits of Octreotide for Managing Persistent Gastrointestinal Fluid Loss in Malignant Small Bowel Obstruction: A Case Report and Literature Review

Malignant small bowel obstruction (mSBO) is a frequent complication in patients with gastrointestinal or gynecologic cancers. For those with inoperable cancers and persistent obstructive symptoms, symptom palliation with a percutaneous gastrostomy tube (PGT) may be required. However, excessive fluid loss from the PGT can lead to significant fluid, electrolyte, and acid-base imbalances. We present a case of a man with metastatic colonic adenocarcinoma who developed mSBO, acute kidney injury, and metabolic alkalosis, all of which were effectively managed with octreotide.

Management of Malignant Bowel Obstruction in Patients with Gynaecological Cancer: A Systematic Review

Objectives: This systematic review aimed to evaluate current surgical and non-surgical management strategies for malignant bowel obstruction (MBO) in patients with gynaecological cancer. Methods: Comprehensive literature searches were conducted across MEDLINE, Embase, CENTRAL, and Scopus, without restrictions on language or publication date. Following the removal of duplicates, 4866 articles were screened, with 34 meeting the inclusion criteria. Results: Surgical intervention remains the definitive treatment for MBO, offering longer symptom-free periods and improved survival, particularly when conservative methods fail. However, the selection of surgical candidates is crucial due to the high risk of morbidity and the potential for significant complications. Non-surgical treatments, such as the use of Gastrografin, Octreotide, and Dexamethasone, along with invasive procedures like nasogastric tubing, percutaneous gastrostomy, and stent placement, offer varying degrees of symptom relief and are often considered when surgery is not feasible. Conclusions: In this article we provide a potential therapeutic algorithm for the management of patients with MBO. This review underscores the urgent need for high-quality research to develop clear, evidence-based guidelines for MBO management in patients with gynaecologic cancer. Establishing standardised protocols will improve patient outcomes by aiding clinicians in making informed, individualised treatment decisions.

The range and suitability of outcome measures used in the assessment of palliative treatment for inoperable malignant bowel obstruction: A systematic review

BACKGROUND

Malignant bowel obstruction, a complication of certain advanced cancers, causes severe symptoms which profoundly affect quality of life. Clinical management remains complex, and outcome assessment is inconsistent.

AIM

To identify outcomes evaluating palliative treatment for inoperable malignant bowel obstruction, as part of a four-phase study developing a core outcome set.

DESIGN

The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA); PROSPERO (ID: CRD42019150648). Eligible studies included at least one subgroup with obstruction below the ligament of Treitz undergoing palliative treatment for inoperable malignant bowel obstruction. Study quality was not assessed because the review does not evaluate efficacy.

DATA SOURCES

Medline, Embase, the Cochrane Database, CINAHL, PSYCinfo Caresearch, Open Grey and BASE were searched for trials and observational studies in October 2021.

RESULTS

A total of 4769 studies were screened, 290 full texts retrieved and 80 (13,898 participants) included in a narrative synthesis; 343 outcomes were extracted verbatim and pooled into 90 unique terms across six domains: physiological, nutrition, life impact, resource use, mortality and survival. Prevalent outcomes included adverse events (78% of studies), survival (54%), symptom control (39%) and mortality (31%). Key individual symptoms assessed were vomiting (41% of studies), nausea (34%) and pain (33%); 19% of studies assessed quality of life.

CONCLUSIONS

Assessment focuses on survival, complications and overall symptom control. There is a need for definitions of treatment 'success' that are meaningful to patients, a more consistent approach to symptom assessment, and greater consideration of how to measure wellbeing in this population.

Non-Surgical Management of Malignant Bowel Obstruction in Advanced Ovarian Cancer patients: A Systematic Review and Meta-Analysis

Background:

Malignant bowel obstruction is a common cause of morbidity and mortality in patients with advanced ovarian cancer. Many patients aren’t suitable for, or decline, surgical decompression. The outcomes for this frail group of patients are not well characterized.

Aim:

To evaluate survival outcomes of ovarian cancer patients who undergo non-surgical management of malignant bowel obstruction.

Design:

Systematic review and meta-analysis.

Data Sources:

Online literature search of Pubmed, Embase and Medline libraries up until December 2020. Searching abstracts of scientific meetings, reference lists of included studies and contacting experts in the field.

Selection Criteria:

Studies that investigated non-surgical management of confirmed bowel obstruction in advanced ovarian cancer patients were included. All levels of evidence including RCTs, cohort studies and case-series if they included greater than 5 patients.

Data Collection and Analysis:

The studies were independently chosen by two reviewers who extracted and analyzed the data separately through OpenMeta Analyst software. Study quality was assessed using the JADAD score and the Newcastle Ottawa Score.

Results:

24 studies met the eligibility criteria for the systematic review and 9 for the meta-analysis. Median survival of patients managed non-surgically for bowel obstruction was 44 days (95% CI 38-49 days, I ² = 0%, P = 0.128).

Conclusion:

The quality of studies was relatively low, however the evidence shows that non-surgical management of bowel obstruction results in a short life expectancy but with controlled symptoms. Where quality of life is the main concern, this may be a feasible and effective strategy.

Medical management of malignant bowel obstruction in patients with advanced cancer: 2021 MASCC guideline update

BACKGROUND

Malignant bowel obstruction (MBO) is a frequent complication in patients with advanced cancer, particularly colon or gynecological malignancies. MASCC previously published a guideline for symptom management of MBO in 2017. This is a 5-year update.

METHOD

A systematic search and review of relevant literature includes a review published in 2010 and 2017. The guideline update used the same literature search process as followed in 2015. The dates of the new search included 2015 up to February 2, 2021. The guidelines involved the pharmacologic management of nausea and vomiting in malignant bowel obstruction (MBO) only. Only randomized trials were included in the updated guideline as evidence. The evidence was reviewed by the panel and the MASCC criteria for establishing a guideline were followed using MASCC level of grading and category of evidence.

RESULTS

There was one systematic review and 3 randomized trials accepted as evidence from 257 abstracts. Octreotide is effective in reducing gastrointestinal secretions and colic and thereby reduces nausea and vomiting caused by MBO. Scopolamine butylbromide is inferior to octreotide in the doses used in the comparison study. Olanzapine or metoclopramide may be effective in reducing nausea and vomiting secondary to partial bowel obstructions. The panel suggests using either drug. Additional studies are needed to clarify benefits. Haloperidol has been used by convention as an antiemetic but has not been subjected to a randomized comparison. Ranitidine plus dexamethasone may be effective in reducing nausea and vomiting from MBO but cannot be recommended until there is a comparison with octreotide.

DISCUSSION

Octreotide remains the drug of choice in managing MBO. Ranitidine was used in one randomized trial in all participants and so its effectiveness as a single drug is not known until there is a randomized comparison with octreotide. Antiemetics such as metoclopramide and olanzapine may be effective, but we have very few randomized trials of antiemetics in MBO.

CONCLUSION

The panel recommends octreotide in non-operable MBO. Randomized trials are needed to clarify ranitidine and antiemetic choices.

Intestinal occlusion by gynecological cancers treated by percutaneous endoscopic gastrostomy and lanreotide: an Aviano National Cancer Institute experience

The Commentary reports on our experience in Centro di Riferimento Oncologico IRCCS Aviano about the integrated and combined treatment with percutaneous endoscopic gastrostomy and lanreotide in patients with bowel obstructions by ovarian cancer and peritoneal carcinomatosis. We treated patients with gynecological cancers and bowel obstruction with percutaneous endoscopic gastrostomy and, when patients were partially responsive, with lanreotide. We registered a constant overall benefit for the quality of life and for the control of symptoms, which is very important especially during the home care follow-up of terminal patients.

A randomized, controlled trial of the efficacy of percutaneous transesophageal gastro-tubing (PTEG) as palliative care for patients with malignant bowel obstruction: the JIVROSG0805 trial

BACKGROUND

A randomized, controlled trial to evaluate the superiority of percutaneous transesophageal gastro-tubing over nasogastric tubing as palliative care for bowel obstruction in patients with terminal malignancy was conducted.

SUBJECTS AND METHODS

The subjects were patients with malignant bowel obstruction with no prospect of improvement, for whom surgery was not indicated and with a Palliative Prognostic Index of < 6. They were randomly allocated in a 1:1 ratio to receive either percutaneous transesophageal gastro-tubing (PTEG group) or nasogastric tubing (NGT group). Their symptom scores (the worst 0 to no symptoms 10) were measured for a 2-week period after enrollment, and the areas under the curves for the two groups were compared. The EQ-5D and SF-8 were also used to assess overall quality of life.

RESULTS

Forty patients were enrolled between October 2009 and January 2015, with 21 allocated to the PTEG group and 19 to the NGT group. The mean areas under the curves (95% confidence intervals) for the PTEG group and the NGT groups were 149.6 (120.3-178.8) and 44.9 (16.4-73.5), respectively, significantly higher for the NGT group (p < 0.0001). The secondary endpoints of quality of life as assessed by the EQ-5D and SF-8 scores were also significantly higher for patients in the PTEG group (p = 0.0036, p = 0.0020). There was no difference in survival between the groups. No serious adverse events were observed.

CONCLUSIONS

In terms of quality of life, percutaneous transesophageal gastro-tubing was superior to nasogastric tubing as palliative care for patients with bowel obstruction due to terminal malignancy.

The Role of Somatostatin and Octreotide in Bowel Obstruction: Pre-Clinic Al and Clinical Results

Malignant bowel obstruction is a common complication in patients with advanced abdominal or pelvic cancer. Whereas surgery should be considered in all cases of malignant bowel obstruction, many advanced and terminal cancer patients are considered unfit for surgery. In such patients with a short life expectancy, gastrointestinal symptoms such as nausea, vomiting, continuous and/or colicky pain, can be controlled by using a pharmacologic approach made up of analgesics, antiemetics and antisecretory drugs, without the use of a venting nasogastric tube. Among the antisecretory drugs, octreotide has been shown to reduce nausea and vomiting in bowel-obstructed patients owing to a reduction of gastrointestinal secretions, thus allowing in most patients removal of the nasogastric tube and the associated distress. Preclinical and clinical studies that demonstrated the role of somatostatin and octreotide in bowel obstruction are reviewed.

Palliative Care in Pancreatic Cancer

BACKGROUND

Pancreatic cancer is a formidable health problem, representing the 10th most common malignancy in the United States and the 4th most common cause of all cancer deaths. The overall 5-year survival rate is 4%, making this disease a model tumor in which to address the specialized care issues of palliative medicine.

METHODS

General considerations in both medical decision-making and symptom management are reviewed. Treatment of patients with locally unresectable, recurrent, or metastatic disease is individualized, based on considerations that include patient age, patient wishes, family influence, insurance constraints, and geographic practice variations.

RESULTS

Success in managing progressive symptoms is needed to palliate patients with advanced pancreatic cancer. Common problems include biliary obstruction, depression, pain, intestinal obstruction, and fatigue.

CONCLUSIONS

Relief of pain and suffering associated with critical illness is required in managing patients with cancer. Pancreatic cancer is a model illness that mandates this need.

Palliative Care in Pancreatic Cancer

Background

Pancreatic cancer is a formidable health problem, representing the 10th most common malignancy in the United States and the 4th most common cause of all cancer deaths. The overall 5-year survival rate is 4%, making this disease a model tumor in which to address the specialized care issues of palliative medicine.

Methods

General considerations in both medical decision-making and symptom management are reviewed. Treatment of patients with locally unresectable, recurrent, or metastatic disease is individualized, based on considerations that include patient age, patient wishes, family influence, insurance constraints, and geographic practice variations.

Results

Success in managing progressive symptoms is needed to palliate patients with advanced pancreatic cancer. Common problems include biliary obstruction, depression, pain, intestinal obstruction, and fatigue.

Conclusions

Relief of pain and suffering associated with critical illness is required in managing patients with cancer. Pancreatic cancer is a model illness that mandates this need.

Somatostatin Analogues Compared With Placebo and Other Pharmacologic Agents in the Management of Symptoms of Inoperable Malignant Bowel Obstruction: A Systematic Review

CONTEXT

Somatostatin analogues are commonly used to relieve symptoms in malignant bowel obstruction (MBO) but are more expensive than other antisecretory agents.

OBJECTIVES

To evaluate the evidence of effectiveness of somatostatin analogues compared with placebo and/or other pharmacologic agents in relieving vomiting in patients with inoperable MBO.

METHODS

MEDLINE, EMBASE, CINAHL, and The Cochrane Controlled Trials Register databases were systematically searched; reference lists of relevant articles were hand searched. Cochrane risk of bias tool was used.

RESULTS

The search identified 420 unique studies. Seven randomized controlled trials (RCTs) met the inclusion criteria (six octreotide studies and one lanreotide); 220 people administered somatostatin analogues and 207 placebo or hyoscine butylbromide. Three RCTs compared a somatostatin analogue with placebo and four with hyoscine butylbromide. Two adequately powered multicenter RCTs with a low Cochrane risk of bias reported no significant difference between somatostatin analogues and placebo in their primary end points. Four RCTs with a high/unclear Cochrane risk of bias reported that somatostatin analogues were more effective than hyoscine butylbromide in reducing vomiting.

CONCLUSION

There is low-level evidence of benefit with somatostatin analogues in the symptomatic treatment of MBO. However, high-level evidence from trials with low risk of bias found no benefit of somatostatin analogues for their primary outcome. There is debate regarding the clinically relevant study end point for symptom control in MBO and when it should be measured. The role of somatostatin analogues in this clinical situation requires further adequately powered, well-designed trials with agreed clinically important end points and measures.

The role of octreotide in symptom management in oncology and palliative care

Objective. To provide an overview of the role of octreotide for managing symptoms in oncology and palliative care.

Data Sources. A search of MEDLINE and IDIS databases from 1985 to 1999 and CANCERLIT from 1993 to 1999 was conducted using the terms octreotide, cancer and palliative care. The reference lists from selected articles were also reviewed. Clinical trial databases on the Internet were searched. Oncology and palliative care textbooks were also used to obtain additional references.

Data Extraction. The retrieved literature was reviewed to discuss the pharmacology, pharmacokinetics, adverse effects, indications and principally, the clinical use of octreotide for controlling a number of symptoms encountered in the oncology and palliative care population.

Data Synthesis. The unique inhibitory activity of octreotide lends itself to many possible indications, including diarrhoea from a number of causes, bowel obstruction, nausea and vomiting, bleeding, death rattle, gastrointestinal fistulae, pain and hypercalcaemia. However, convincing pieces of evidence from large prospective clinical trials are required to realise its full potential in oncology and palliative care. Completed studies and clinical experience suggest that octreotide has a role in the treatment of a number of difficult-to-manage conditions, particularly bowel obstruction and diarrhoea due to disease or treatment-related causes. Proposed benefits of octreotide must be weighed against the possible adverse effects and cost effectiveness of treatment.

Decompressive percutaneous endoscopic gastrostomy in advanced cancer patients with small-bowel obstruction is feasible and effective: a large prospective study

PURPOSE

The purpose of this study was to evaluate patient-centered outcomes of decompressive percutaneous endoscopic gastrostomy (dPEG) in patients with malignant bowel obstruction due to advanced gynecological and gastroenteric malignancies.

METHODS

This is a prospective analysis of 158 consecutive patients with small-bowel obstruction from advanced gynecological and gastroenteric cancer who underwent PEG or percutaneous endoscopic jejunostomy (PEJ) positioning for decompressive purposes from 2002 to 2012. All of them had previous abdominal surgery and were unfit for any other surgical procedures. Symptom relief, procedural complications, and post dPEG palliation were assessed. Global Quality of Life (QoL) was evaluated in the last 2 years (25 consecutive patients) before and 7 days after dPEG placement using the Symptom Distress Scale (SDS).

RESULTS

dPEG was successfully performed in 142 out of 158 patients (89.8 %). Failure of tube placement occurred in 16 patients (10.1 %). In 8/142 (5.6 %) patients, dPEG was guided by abdominal ultrasound. In 3/142 patients, dPEG was CT-guided. In 14 (9.8 %) patients, who had previously undergone total or subtotal gastrectomy, decompressive percutaneous endoscopic jejunostomy (dPEJ) was performed. In 1/14 patients, dPEJ was CT-guided. Out of 142 patients, 110 (77.4 %) experienced relief from nausea and vomiting 2 days after PEG. Out of 142 patients, 116 (81.6 %) were discharged. The median postoperative hospital stay was 9 days (range 3-60). Peristomal infection (14 %) and intermittent obstruction (8.4 %) were the most frequent complications associated with PEG. Median survival time was 57 days (range 4-472) after PEG placement. Twenty-five patients had QoL properly evaluated with SDS score before and 7 days after dPEG. Sixteen patients (64 %) out of 25 exhibited an improvement of QoL (p < 0.05), 7 (28 %) patients exhibited a non-significant worsening of QoL (p = 0.18), and in 2 (8 %) patients, it remained unmodified.

CONCLUSIONS

dPEG is feasible, effective, relieves nausea and vomiting in patients with unremitting small-bowel obstruction from advanced gynecological and gastroenteric cancer, and improves QoL.

Recommendations for bowel obstruction with peritoneal carcinomatosis

This article reports on the clinical practice guidelines developed by a multidisciplinary group working on the indications and uses of the various available treatment options for relieving intestinal obstruction or its symptoms in patients with peritoneal carcinomatosis. These guidelines are based on a literature review and expert opinion. The recommended strategy involves a clinical and radiological evaluation, of which CT of the abdomen is a crucial component. The results, together with an analysis of the prognostic criteria, are used to determine whether surgery or stenting is the best option. In most patients, however, neither option is feasible, and the main emphasis, therefore, is on the role and administration of various symptomatic medications such as glucocorticoids, antiemetic agents, analgesics, and antisecretory agents (anticholinergic drugs, somatostatin analogues, and proton-pump inhibitors). Nasogastric tube feeding is no longer used routinely and should instead be discussed on a case-by-case basis. Recent studies have confirmed the efficacy of somatostatin analogues in relieving obstruction-related symptoms such as nausea, vomiting, and pain. However, the absence of a marketing license and the high cost of these drugs limit their use as the first-line treatment, except in highly selected patients (early recurrence). When these medications fail to alleviate the symptoms of obstruction, venting gastrostomy should be considered promptly. Rehydration is needed for virtually every patient. Parenteral nutrition and pain management should be adjusted according to the patient needs and guidelines.

[Pharmacological treatment of malignant bowel obstruction in severely ill and dying patients : a systematic literature review]

BACKGROUND

Malignant bowel obstruction (MBO) occurs in 3-6% of patients suffering from advanced cancer. The incidence of MBO is highest in patients with gynaecological and colorectal malignancies. Typical symptoms include nausea, vomiting, abdominal pain and constipation. Initially, these symptoms may be isolated and sporadic, becoming more and more intense later on. The suggested treatment includes surgical, interventional and pharmacological strategies depending on the symptom pattern and the performance status of the patient. This study investigates the current evidence of pharmacological treatment for MBO during the last days of life.

MATERIALS AND METHODS

A systematic literature search of the electronic databases PubMed/Medline and Embase from 1966-2011 was conducted. All retrieved publications were screened for relevance with regard to content and methodology on the basis of title and abstract. The full text was obtained for all relevant articles and for those articles where classification was unsure.

RESULTS

The systematic literature search identified 5,431 papers. After screening, 90 publications were analyzed in detail. A total of 69 publications were excluded due to content or methodology. Finally, 21 manuscripts were considered for review. Only a few studies used high quality methodology and they all had rather small sample sizes. In summary, they show weak positive signs of efficacy for the use of somatostatin analogues or anticholinergics in the pharmacological treatment of MBO.

CONCLUSION

These results do not lead to a clear evidence base for the pharmacological treatment of MBO in the last days of life. As adverse events were infrequent and clinical studies suggest efficient symptom relief, the authors recommend the use of octreotide as the first line medication. Butylscopolamine may be an alternative, where octreotide is not available. Higher costs for octreotide compared with butylscopolamine have to be considered. Available data do not allow assessing the effect of corticosteroids on symptoms caused by MBO when given during the last days of life. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").

Management and outcomes of bowel obstruction in patients with stage IV colon cancer: a population-based cohort study

BACKGROUND

Bowel obstruction is a common complication of late-stage abdominal cancer, especially colon cancer, which has been investigated predominantly in small, single-institution studies.

OBJECTIVE

We used a large, population-based data set to explore the surgical treatment of bowel obstruction and its outcomes after hospitalization for obstruction among patients with stage IV colon cancer.

DESIGN

This was a retrospective cohort study.

SETTING AND PATIENTS

We identified 1004 patients aged 65 years or older in the Surveillance, Epidemiology and End Results-Medicare database diagnosed with stage IV colon cancer January 1, 1991 to December 31, 2005, who were later hospitalized for bowel obstruction.

MAIN OUTCOME MEASURES

We describe outcomes after hospitalization and analyzed the associations between surgical treatment of obstruction and outcomes.

RESULTS

Hospitalization for bowel obstruction occurred a median of 7.4 months after colon cancer diagnosis, and median survival after obstruction was approximately 2.5 months. Median hospitalization for obstruction was about 1 week and in-hospital mortality was 12.7%. Between discharge and death, 25% of patients were readmitted to the hospital at least once for obstruction, and, on average, patients lived 5 days out of the hospital for every day in the hospital between obstruction diagnosis and death. Survival was 3 times longer in those whose obstruction claims suggested an adhesive obstruction origin. In multivariable models, surgical compared with nonsurgical management was not associated with prolonged survival (p = 0.134).

LIMITATIONS

Use of an administrative database did not allow determination of quality of life or relief of obstruction as an outcome, nor could nonsurgical interventions, eg, endoscopic stenting or octreotide, be assessed.

CONCLUSIONS

In this population-based study of patients with stage IV colon cancer who had bowel obstruction, overall survival following obstruction was poor irrespective of treatment. Universally poor outcomes suggest that a diagnosis of obstruction in the setting of advanced colon cancer should be considered a preterminal event.

Octreotide prescribing patterns in the palliation of symptomatic inoperable malignant bowel obstruction patients at a single US academic hospital

BACKGROUND

Medical management is the cornerstone of malignant bowel obstruction (MBO) therapy and may include antisecretory agents such as octreotide. Currently, no data exist regarding octreotide prescribing patterns in US academic hospitals in the palliation of inoperable MBO. The aim of this study is to collect octreotide prescribing data to shape future prospective studies.

METHODS

This retrospective chart review evaluated inpatient inoperable MBO admissions at a single academic US hospital between 2008 and 2011. The prescribing primary service (medical vs. surgical), inpatient day initiated, average octreotide daily dose, cumulative octreotide dose, days receiving octreotide, length of stay (LOS), subject age, cancer stage, lines of chemotherapy, cancer type, and overall survival were analyzed utilizing a Wilcoxon rank sum test, Spearman rank correlation test, Kaplan-Meier curves, log rank test, and multiple linear regression analysis when appropriate.

RESULTS

A total of 767 patients received octreotide. A cancer diagnosis was documented in 134 patients and 37 of these (24 females and 13 males; mean age, 56.7 years) had a confirmed inoperable MBO. Statistical significance was not achieved for variables analyzed. However, octreotide prescribing trends were observed for several variables: the mean LOS was equivalent on both services (16.8 vs. 17 days), mean octreotide dose was higher on the medical service (201.2 μg vs. 119 μg surgical), cumulative octreotide dose was higher on the medical service (3,558 vs. 1,884 mcg), mean day of octreotide initiation was roughly equivalent (7.9 days medical vs. 8.8 days surgical), subjects on the medical service had a decreased overall survival, and earlier octreotide initiation (defined as <7 days) was associated with a decreased overall survival.

LIMITATION

The data were collected retrospectively, with a limited population distribution at a specific time.

CONCLUSIONS

These data possibly suggest that the MBO patients on the medical vs. surgical services are distinct patient populations. MBO patients on the medical service trended to receive higher cumulative doses and have a decreased overall survival compared with surgical patients. Consequently, future studies should possibly consider these distinct study groups.

Bowel obstruction in elderly ovarian cancer patients: a population-based study

PURPOSE

Bowel obstruction is a common pre-terminal event in abdominal/pelvic cancer that has mainly been described in small single-institution studies. We used a large, population-based database to investigate the incidence, management, and outcomes of obstruction in ovarian cancer patients.

PATIENTS AND METHODS

We identified patients with stages IC-IV ovarian cancer, aged 65 years or older, in the Surveillance, Epidemiology and End Results (SEER)-Medicare database diagnosed between January 1, 1991 and December 31, 2005. We modeled predictors of inpatient hospitalization for bowel obstruction after cancer diagnosis, categorized management of obstruction, and analyzed the associations between treatment for obstruction and outcomes.

RESULTS

Of 8607 women with ovarian cancer, 1518 (17.6%) were hospitalized for obstruction subsequent to cancer diagnosis. Obstruction at cancer diagnosis (HR=2.17, 95%CI: 1.86-2.52) and mucinous tumor histology (HR=1.45, 95%CI: 1.15-1.83) were associated with increased risk of subsequent obstruction. Surgical management of obstruction was associated with lower 30-day mortality (13.4% in women managed surgically vs. 20.2% in women managed non-surgically), but equivalent survival after 30 days and equivalent rates of post-obstruction chemotherapy. Median post-obstruction survival was 382 days in women with obstructions of adhesive origin and 93 days in others.

CONCLUSION

In this large-scale, population-based assessment of patients with advanced ovarian cancer, nearly 20% of women developed bowel obstruction after cancer diagnosis. While obstruction due to adhesions did not signal the end of life, all other obstructions were pre-terminal events for the majority of patients regardless of treatment.

A prospective study on the efficacy of octreotide in the management of malignant bowel obstruction in gynecologic cancer

OBJECTIVE

Malignant bowel obstruction (MBO), of which symptoms lead to a poor quality of life, is a common and distressing clinical complication in advanced gynecologic cancer. The aim of this study was to prospectively assess the clinical efficacy of octreotide to control vomiting in patients with advanced gynecologic cancer with inoperable gastrointestinal obstruction.

METHODS

Patients with advanced gynecologic cancer, who presented at least one episode of vomiting per day due to MBO, were enrolled in this prospective study from 2006 to 2009. Octreotide was administered when necessary at doses starting with 300 μg up to 600 μg a day by continuous infusion for 2 weeks. Primary end point was vomiting control, which was evaluated by common terminology criteria for adverse events version 3 (CTCAE v3.0). Adverse events were also evaluated by CTCAE v3.0.

RESULTS

Twenty-two cases were enrolled in this study. Octreotide controlled vomiting in 15 cases (68.2%) to grade 0 and 3 cases (13.6%) to grade 1 on CTCAE v3.0. Overall response rate to octreotide treatment was 81.8% in our patients' cohort. Among 14 cases without nasogastric tube, the overall response rate was 93.1% (13/14). Among 8 cases with nasogastric tube, 4 cases were free of tube with decrease of drainage, and overall response rate was 62.5% (5/8). No major adverse events related to octreotide were reported.

CONCLUSIONS

We conclude that 300-μg/d dose of octreotide was effective and safe for Japanese patients with MBO by advanced gynecologic cancer. Octreotide could contribute to better quality of life by avoiding placement of nasogastric tube.

[Treatment of nausea and vomiting with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatinantagonists, benzodiazepines and cannabinoids in palliative care patients : a systematic review]

BACKGROUND

Various recommendations exist for the treatment of nausea and vomiting in palliative care but only few studies and even less systematic reviews look into antiemetic therapy for patients receiving palliative care.

OBJECTIVES

This systematic review aims to analyze the current evidence for antiemetic treatment with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids in palliative care patients with far advanced cancer not receiving chemotherapy or radiotherapy, acquired immune deficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), progressive heart failure, amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). Results regarding evidence of treatment with prokinetic and neuroleptic agents will be published separately.

METHODS

The electronic databases PubMed and EmBase were systematically searched for studies (published 1966-2011) dealing with antiemetic therapy in palliative care and electronic retrieval was completed by manual searching. Studies with patients undergoing chemotherapy or radiotherapy, pediatric studies and studies published in languages other than English or German were excluded. Studies addressing therapy with 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines or cannabinoids were identified and selected for this systematic review.

RESULTS

In the general search 75 relevant studies were found. Of those 36 addressed 5HT3 receptor antagonists, steroids, antihistamines, anticholinergics, somatostatin analogs, benzodiazepines and cannabinoids, 13 considered 5HT3 receptor antagonists, 10 somatostatin antagonists, 9 steroids, 5 cannabinoids, 4 anticholinergics, 1 antihistamines and none benzodiazepines. Furthermore six systematic reviews exist. Evidence for any drug used as an antiemetic is low. Concerning 5HT3 receptor antagonists data are insufficient for recommendations on the treatment of patients with AIDS and MS due to the small size of included patient groups. For patients with cancer contradictory results were published: the larger studies showed a positive effect of 5HT3 receptor antagonists and better efficacy, as compared to metoclopramide, dexamethasone and neuroleptics. Heterogeneous results were found for steroids, with a positive trend for patients with cancer. Data are insufficient for antihistamines. Studies prove effectiveness of butylscopolammonium in the treatment of nausea and vomiting caused by malignant gastrointestinal obstruction, whereas octreotide is superior to butylscopolammonium. Regarding benzodiazepines for symptom control of nausea and vomiting in palliative care patients no studies were detected. Cannabinoids were found to relieve nausea and vomiting in patients with cancer and AIDS but with notable side effects. Furthermore, the studies compared cannabinoids to less recent antiemetic drugs but not, for example to 5HT3 receptor antagonists. Regarding symptom control of nausea and vomiting in patients with COPD, progressive heart failure and ALS no studies were undertaken in patients receiving palliative care.

CONCLUSIONS

In palliative care patients with nausea and vomiting 5HT3 receptor antagonists can be used if treatment with other antiemetics, such as metoclopramide and neuroleptics is not sufficient. There is a trend that steroids in combination with other antiemetics improve symptom relief. Cannabinoids rather have a status as a second line antiemetic. In cases of nausea and vomiting caused by malignant gastrointestinal obstruction octreotide showed the best and butylscopolammonium bromide the second best results. Concerning antihistamines and benzodiazepines insufficient data was found. Recommendations in the literature are mainly based on studies in patients with cancer. The overall strength of evidence is low. More well designed studies in palliative care patients are needed in order to provide evidence-based therapy. The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").

SALTO: a randomized, multicenter study assessing octreotide LAR in inoperable bowel obstruction

This phase II, multicenter, randomized, double-blind, non-comparative study assessed the efficacy and safety of immediate-release octreotide and octreotide LAR, in combination with corticosteroids and standard medical care, on the symptoms of inoperable malignant bowel obstruction (MBO) due to peritoneal carcinomatosis. The primary efficacy endpoint was "success" at day 14 defined as a composite endpoint including the absence of a nasogastric tube, and vomiting less than twice per day and no use of anticholinergic agents. Patients in the octreotide arm received octreotide LAR 30 mg intramuscular (im) on days 1, 29 and 57, as well as daily immediate-release octreotide 600 μg per day plus methylprednisolone on days 1 to 6. Placebo-treated patients received methylprednisolone and matched placebo instead of octreotide. Difficulties associated with enrolling patients at palliative-care stage meant only 64 patients (instead of the planned 102 patients) were randomized, 32 to octreotide and 32 to placebo. Despite randomization, more patients in the octreotide arm (46.4%) than in the placebo arm (21.9%) had a baseline Karnofsky score less than 50. An intention-to-treat analysis showed that in the octreotide and placebo arms, 12 (38%) and nine (28%), respectively, patients were successfully treated at day 14, which increased to 9/15 (60%) and 7/25 (28%), respectively, among patients with a baseline Karnofsky score greater or equal to 50. Octreotide-treated patients reported three drug-related adverse events (AEs), and no drug-related serious AEs or deaths. Octreotide LAR may have a key role in treating patients with a MBO due to peritoneal carcinomatosis, particularly in those with moderately severe disease.

Octreotide for malignant bowel obstruction: twenty years after

Malignant bowel obstruction (MBO) is a challenging complication of advanced cancer. Conservative treatment of inoperable MBO in terminal cancer patients has been found to be effective in controlling the distressing symptoms caused by this complication in inoperable cancer patients. Twenty years ago, octreotide was proposed to treat symptoms related to malignant bowel obstruction. Since then several reports have confirmed the efficacy of octreotide in the management of gastrointestinal symptoms of MBO. Fifteen randomized controlled trials or observational reports with a significant number of patients treated with octreotide have been reviewed; 281 patients were surveyed. Authors reported a therapeutic success ranging between 60% and 90%. Despite the limited number of controlled studies, the large experience acquired through 20 years suggests that octreotide is the first-choice antisecretory agent for MBO. As such, octreotide is the only drug approved by the health-care system in Italy for this treatment.

Efficacy of octreotide in the management of intestinal obstruction: an analysis of 35 cases

AIM: To evaluate the efficacy of octreotide in the management of intestinal obstruction.

METHODS: Sixty-seven patients with intestinal obstruction diagnosed based on clinical grounds and confirmed by plain abdominal radiography were included in the study. These patients were randomly assigned to two groups: octreotide group (n= 35) and control group (n = 32). There are no significant differences between the two groups in terms of age, sex, time from disease onset to hospitalization, and causes of disease (P > 0.05). Patients of the control group underwent routine therapy, including gastroenterol decompression, injection of vegetable oils through a gastric tube, intravenous replacement of fluid and electrolytes, total parenteral nutrition, and antibiotics. Patients of the octreotide group received routine therapy in combination with subcutaneous administration of octreotide 0.1 mg/8 h for 3-14 d.

RESULTS: After treatment, there is no significant difference in the cure rate between the two groups (P > 0.05). The remission rate of symptoms was significantly higher in the octreotide group than in the control group (85.7% vs 62.5%, P = 0.029). The average amount of nasogastric drainage was significantly lower in the octreotide group than in the control group (355.50 mL/d ± 289.89 mL/d vs 595.63 mL/d ± 287.22 mL/d, P = 0.014). Before treatment, 20 patients in the octreotide group and 16 in the control group had a gastric tube placed. After 72 h of treatment, 16 patients in the octreotide group and 4 in the control group had the gastric tube removed (P < 0.05). The average time required to achieve abdominal pain relief, abdominal distention relief and first postoperative passage of gas was significantly lower in the octreotide group than in the control group (3.27 d ± 1.60 d vs 4.55 d ± 1.76 d, 3.00 d ± 1.55 d vs 4.45 d ± 1.96 d, 2.37 d ± 1.47 d vs 3.20 d ± 1.58 d, all P < 0.05). There is no significant difference in the length of average hospital stay between the two groups.

CONCLUSION: Administration of octreotide in combination with traditional pharmacological treatment is effective and safe in the management of bowel obstruction.

Review article: palliative care in gynecologic oncology

Patients with advanced gynecologic malignancies have a multitude of symptoms; pain, nausea, and vomiting, constipation, anorexia, diarrhea, dyspnea, as well as symptoms resulting from intestinal obstruction, hypercalcemia, ascites, and/or ureteral obstruction. Pain is best addressed through a multimodal approach. The optimum palliative management of end-stage malignant intestinal obstruction remains controversial, with no clear guidelines governing the choice of surgical versus medical management. Patient selection for palliative surgery, therefore, should be highly individualized because only carefully selected candidates may derive real benefit from such surgeries. There remains a real need for more emphasis on palliative care education in training programs.

Palliative surgery versus medical management for bowel obstruction in ovarian cancer

BACKGROUND

Ovarian cancer is the sixth most common cancer among women and is usually diagnosed at an advanced stage. Bowel obstruction is a common feature of advanced or recurrent ovarian cancer. Patients with bowel obstruction are generally in poor physical condition with a limited life expectancy. Therefore, maintaining their QoL with effective symptom control is the main purpose of the management of bowel obstruction.

OBJECTIVES

To compare the effectiveness and safety of palliative surgery (surgery performed to control the cancer, reduce symptoms and improve quality of life for those whose cancer is not able to be entirely removed) and medical management for bowel obstruction in women with ovarian cancer.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, The Cochrane Central Register of Controlled trials (CENTRAL), Issue 1 2009, MEDLINE and EMBASE up to February 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Studies that compared palliative surgery and medical interventions, in adult women diagnosed with ovarian cancer who had either full or partial obstruction of the bowel. Randomised controlled trials (RCTs) and non-RCTs that used multivariable statistical adjustment for baseline case mix were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria, abstracted data and assessed risk of bias. One non-randomised study was identified so no meta-analyses were performed.

MAIN RESULTS

The search strategy identified 183 unique references of which 22 were identified as being potentially eligible on the basis of title and abstract. Only one study met our inclusion criteria and was included in the review. It analysed retrospective data for 47 women who received either palliative surgery (n = 27) or medical management with Octreotide (n = 20) and reported overall survival and perioperative mortality and morbidity. Women with poor performance status were excluded from surgery. Although six (22%) women who received surgery had serious complications of the operation and three (11%) died of complications, multivariable analysis found that women who received surgery had significantly (p < 0.001) better survival than women who received Octreotide, after adjustment for important prognostic factors. However, the magnitude of this effect was not reported. Quality of life (QoL) was not reported and adverse events were incompletely documented.

AUTHORS' CONCLUSIONS

We found only low quality evidence comparing palliative surgery and medical management for bowel obstruction in ovarian cancer. Therefore we are unable to reach definite conclusions about the relative benefits and harms of the two forms of treatment, or to identify sub-groups of women who are likely to benefit from one treatment or the other. However, there is weak evidence in support of surgical management to prolong survival.

Multicenter prospective study on efficacy and safety of octreotide for inoperable malignant bowel obstruction

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of octreotide for malignant bowel obstruction in a multicenter study.

METHODS

Terminally ill patients diagnosed with inoperable malignant bowel obstruction were treated with octreotide 300 microg/day. The primary endpoint was the overall improvement rate of subjective abdominal symptoms. The degrees of nausea, vomiting, abdominal pain, distension, anorexia, fatigue, thirst and overall quality of life were evaluated by the self-rating scores selected from the MD Anderson Symptoms Inventory and Kurihara's Face Scale.

RESULTS

Forty-nine patients were enrolled in the study, and 46 patients received study treatment, including 17 gastric, 13 colorectal, 7 ovarian and other cancers. The median survival time was 25 days. The number of vomiting episodes significantly correlated with the MD Anderson Symptoms Inventory nausea and vomiting scores (P< 0.001) before octreotide treatment. Of 43 patients evaluable for efficacy, the scores of all the MD Anderson Symptoms Inventory items except abdominal pain and the number of vomiting episodes improved during the first 4 days of octreotide treatment (P< 0.0062). The MD Anderson Symptoms Inventory scores were decreased in 59-72% of patients, and overall quality-of-life scores improved in 56% of patients. No serious adverse events were observed.

CONCLUSIONS

The high improvement rate in abdominal symptoms suggested the efficacy of octreotide in terminally ill patients with malignant bowel obstruction.

A systematic review of the treatment of nausea and/or vomiting in cancer unrelated to chemotherapy or radiation

CONTEXT

A systematic review of antiemetics for emesis in cancer unrelated to chemotherapy and radiation is an important step in establishing treatment recommendations and guiding future research. Therefore, a systematic review based on the question "What is the evidence that supports antiemetic choices in advanced cancer?" guided this review.

OBJECTIVES

To determine the level of evidence for antiemtrics in the management of nausea and vomiting in advanced cancer unrelated to chemotherapy and radiation, and to discover gaps in the evidence, which would provide important areas for future research.

METHODS

Three databases and independent searches using different MeSH terms were performed. Related links were searched and hand searches of related articles were made. Eligible studies included randomized controlled trials (RCTs), prospective single-drug studies, studies that used guidelines based on the etiology of emesis, cohort studies, retrospective studies, and case series or single-patient reports. Studies that involved treatment of chemotherapy, radiation, or postoperation-related emesis were excluded. Studies that involved the treatment of emesis related to bowel obstruction were included. The strength of evidence was graded as follows: 1) RCTs, A; 2) single-drug prospective studies, B1; 3) studies based on multiple drug choices for etiology of emesis, B2; and 4) cohort, case series, retrospective, and single-patient reports, E. Level of evidence was determined by the Oxford Centre for Evidence-Based Medicine Levels of Evidence (May 2001) (A, B, C, D).

RESULTS

Ninety-three articles were found. Fourteen were RCTs, most of them of low quality, based either on lack of blinding, lack of description of the method of randomization, concealment, and/or attrition. Metoclopramide had modest evidence (B) based on RCTs and prospective cohort studies. Octreotide, dexamethasone, and hyoscine butylbromide are effective in reducing symptoms of bowel obstruction, based on prospective studies and/or one RCT. There was no evidence that either multiple antiemetics or antiemetic choices based on the etiology of emesis were any better than a single antiemetic. There is poor evidence for dose response, intraclass or interclass drug switch, or antiemetic combinations in those individuals failing to respond to the initial antiemetic.

CONCLUSION

There are discrepancies between antiemetic studies and published antiemetic guidelines, which are largely based on expert opinion. Antiemetic recommendations have moderate to weak evidence at best. Prospective randomized trials of single antiemetics are needed to properly establish evidence-based guidelines.

Octreotide acetate successfully treated a bowel obstruction caused by peritoneally disseminated gastric cancer, thereby enabling the subsequent use of oral S-1 chemotherapy

A 68-year-old woman presented with severe bowel obstruction and was subsequently diagnosed with stage IV gastric cancer with peritoneal dissemination. She was immediately stabilized in the hospital with the placement of a nasointestinal tube. Abdominal computed tomography showed multiple intraperitoneal nodules consistent with peritoneal dissemination of the gastric cancer. The patient's inability to tolerate oral intake was a contraindication to using S-1 chemotherapy, currently one of the most effective medications used for gastric cancer in Japan. Therefore, she was initially treated with octreotide acetate (OA). Her bowel obstruction was sufficiently attenuated on the seventh day after the initiation of treatment with OA to permit the initiation of oral S-1, along with low-dose cisplatin (CDDP) and radiation. S-1 was orally administered at a dose of 100 mg/day per body (80 mg/m(2) per day) on days 1-28, and CDDP was infused at a dose of 7.8 mg/day per body (6 mg/m(2) per day) on days 1-5, 8-12, and 15-19. Radiation therapy (2 Gy/day for 5 days/week) was performed with the chemotherapy. Despite no change being shown on her imaging findings with the chemotherapy, the patient's bowel obstruction resolved and she was able to tolerate both liquids and solid food orally. She was discharged 2 months after admission. Seven months after beginning the chemotherapy, she was still doing well on outpatient chemotherapy with S-1 and CDDP, and had no decline in her quality of life or progression of her disease.

Cancer emergencies: the acute abdomen

The most common complaints among patients with cancer who present to the emergency department are related to the gastrointestinal system, and 40% of these patients complain of abdominal pain. These presentations can stem from the underlying malignancy itself, treatment directed toward the disease, or the full range of pathologies present in a healthy population. Immunosuppression may blunt many of the findings one expects in a healthy population of patients, thus rendering the clinical exam less reliable in many patients with cancer. Moreover, the degree of immunosuppression shapes both the types of pathologies the clinician should consider and the rate at which the disease may progress. Understanding the limitations of physical examination, pathophysiology of disease, and the methods by which these diagnoses are established is of critical importance in this population. This article focuses specifically on patients with cancer who present with an acute abdomen, and it discusses how a concurrent malignancy can shape the differential diagnosis in these cases.

Malignant irreversible intestinal obstruction: the powerful association of octreotide to corticosteroids, antiemetics, and analgesics

In the case of malignant intestinal obstruction, surgery often carries important mortality and morbidity risks, and feasibility is neither realistic nor reasonable. A total of 4 clinical cases of intestinal obstruction caused by advanced gastrointestinal cancers in their terminal phase are described. The association of analgesics, corticosteroids, antiemetics, and octreotide was effective to relieve symptoms of intestinal obstruction for the remaining lifetime. The insertion of a nasogastric tube was avoided in 3 of 4 cases. Death occurred 51, 56, and 64 days after clinical and radiological diagnosis of irreversible intestinal obstruction. This combination of drugs appears very powerful and well tolerated. The relatively long survival that was observed should encourage future studies of longer half-life somatostatin analogues with no need of continuous infusion or multiple daily injections.

Mechanical obstruction of the small bowel and colon

Mechanical obstruction of the small bowel and colon is moderately common, accounting for several hundred thousand admissions per year in the United States. Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive obstipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis. Differentiation of total mechanical obstruction from partial mechanical obstruction and pseudo-obstruction is important because total mechanical obstruction is generally treated surgically,whereas the other two entities are usually treated medically. Mechanical obstruction is usually suggested by plain abdominal radiographs, and confirmed by small bowel follow through,abdominal CT, or CT enteroclysis.

Management of malignant bowel obstruction

Malignant bowel obstruction (MBO) is a common and distressing outcome particularly in patients with bowel or gynaecological cancer. Radiological imaging, particularly with CT, is critical in determining the cause of obstruction and possible therapeutic interventions. Although surgery should be the primary treatment for selected patients with MBO, it should not be undertaken routinely in patients known to have poor prognostic criteria for surgical intervention such as intra-abdominal carcinomatosis, poor performance status and massive ascites. A number of treatment options are now available for patients unfit for surgery. Nasogastric drainage should generally only be a temporary measure. Self-expanding metallic stents are an option in malignant obstruction of the gastric outlet, proximal small bowel and colon. Medical measures such as analgesics according to the W.H.O. guidelines provide adequate pain relief. Vomiting may be controlled using anti-secretory drugs or/and anti-emetics. Somatostatin analogues (e.g. octreotide) reduce gastrointestinal secretions very rapidly and have a particularly important role in patients with high obstruction if hyoscine butylbromide fails. A collaborative approach by surgeons and the oncologist and/or palliative care physician as well as an honest discourse between physicians and patients can offer an individualised and appropriate symptom management plan.

Long-acting octreotide for the treatment and symptomatic relief of bowel obstruction in advanced ovarian cancer

Symptoms of malignant bowel obstruction in patients with recurrent ovarian cancer lead to a poor quality of life. Sandostatin LAR Depot (LAR) is an intramuscular, monthly administered, long-acting form of octreotide. LAR's safety and utility were evaluated in a pilot study enrolling 15 advanced ovarian cancer patients with bowel dysfunction. Once safety with subcutaneous (SQ) octreotide was assessed, patients were given 30 mg LAR on Day 1 and octreotide SQ for 2 weeks. Of 13 evaluable patients, three patients had a major response to LAR treatment with reduction in bowel obstruction symptoms, two had a minor response, four had no response, and four had progressive symptoms. Three patients remained on LAR for more than 9 months. No significant toxicities were attributable to octreotide or LAR. Because three patients received nine or more monthly injections of LAR, possible direct antitumor effects of LAR or synergy with chemotherapy needs to be explored.

Palliative care for intestinal obstruction in recurrent ovarian cancer: a multivariate analysis

Bowel obstruction is the most common complication in patients with ovarian cancer. Management of this situation is controversial. The aim of our retrospective study was to determine the best approach for managing bowel obstruction in recurrent ovarian cancer. A retrospective analysis of data on 47 patients with intestinal obstruction by ovarian cancer was performed. Twenty-seven patients were submitted to surgery, with 21 intestinal procedures performed, 2 gastrostomy tubes placed, and 4 patients deemed inoperable. Twenty patients were managed medically with Octreotide (mean dosage of 0.48 mg/day), of which 1 patient required a nasogastric tube. Age, performance status, diagnosis of tumor to occlusion time, obstruction site, previous chemotherapy or radiotherapy, presence of ascites, or palpable masses were the variables analyzed. Student's t-test and Pearson chi-square test were used to compare the two different groups of treatment (surgical vs medical therapy). Disease-free-survival curves were plotted according to the Kaplan-Meier method and analyzed by the log-rank test. Cox's proportional hazards model was used for multivariate analysis. Values less than or equal to 0.05 were considered significant. The mean age of the patients was 58.7 years. Perioperative mortality and morbidity were both 22%. All patients died with minimal distress. Performance status results were significantly different between the patients submitted to surgery and patients treated with Octreotide (P= 0.03). No significant differences were found in the other variables analyzed. In multivariate analysis, only type of treatment emerges as a strong predictor of poor outcome (P < 0.001). Both surgery and Octreotide therapy are able to control distressing symptoms in end-stage ovarian cancer. Survival was significantly longer in the surgical group, and surgical palliation should be considered first in patients with good performance status.

Symptom management in the older adult

Palliative care begins at the time of diagnosis of a life-threatening illness and continues beyond the time of death. Defined in the broadest sense, the goal of palliative care is to provide aggressive symptom management and address the psychological and spiritual needs of the patient and the family. This article reviews the management of some symptoms commonly observed in older patients, highlighting treatment considerations specific to the older population. Ultimately the approach to symptoms must be individualized, and treatment decisions must reflect the patient's goals of care. Although symptom management in older patients may be challenging, it is possible to provide care that significantly enhances quality of life throughout the course of illness.

Surgical management of malignant bowel obstruction

MBO is a common but difficult problem for surgeons caring for cancer patients. Nonsurgical interventions should be considered in all patients with MBO, especially inpatients with limited survival or for whom surgery will have little effect on disease control. Although there is no algorithm for all patients with MBO, decision-making is based on reasonable expectations of survival and treatment-related success. Surgical options can be helpful in the setting of MBO as long as reasonable goals and realistic outcomes are clear.

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What is the best topical anesthetic for nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, and atomized cocaine

INTRODUCTION

Nasogastric intubation has been shown to be a painful procedure for patients. Previous studies have demonstrated the benefit of topical nasal anesthesia in decreasing the pain of this procedure. This study attempts to identify which of 3 topical anesthetic modalities would be preferred by patients.

METHODS

This study had a double-blind, double-dummy randomized triple crossover design with 30 healthy volunteers as participants. Each participant had 3 nasogastric tubes inserted and acted as his or her own control for the 3 study medications: 1.5 mL 4% atomized lidocaine, 1.5 mL 4% atomized cocaine, and 5 mL 2% lidocaine gel. Participants scored pain of tube passage through the nostril as well as global discomfort. They were also asked to identify which agent they preferred.

RESULTS

In our 30 subjects, although no statistically significant difference in nasal pain scores was found, "global discomfort" was less with the lidocaine gel (P =.017). Participants preferred the lidocaine gel over atomized cocaine (P <.00), but not to a statistically significant degree.

DISCUSSION

Two percent lidocaine gel appeared to provide the best option for a topical anesthetic during nasogastric tube insertion.

Two new peptides to improve post-operative gastric ileus in dog

Peptides can influence gastrointestinal motility, and from data obtained earlier in rats, we hypothesized that MTL-RP/Ghrelin, as well as CGRP receptor antagonist 8-37, could improve gastric post-operative ileus in dog. Dogs submitted to laparotomy were perfused with or saline or CGRP 8-37 or MTL-RP/Ghrelin on days 1-4 post-operatively while gastric emptying was estimated by measuring the postprandial increase in plasma acetaminophen ingested with a meal. As expected, in saline-treated animals the gastric emptying function was impaired post-operatively. The total amount of acetaminophen emptied (AUC over 150 min) on post-operative days 1-4 reached respectively 31+/-5%, 65+/-8%, 60+/-8% and 62+/-8% of the normal emptying capacity. CGRP antagonist increased the total emptying of acetaminophen to 52+/-5% on day 1, 95+/-2% on day 2 and 103+/-3% (P<0.05) on day 3. The delayed emptying of acetaminophen seen post-operatively in saline-treated animals could be completely reversed by MTL-RP/Ghrelin (P<0.01) whether it was given at 100 microg/kg on day 2 (102+/-7% of the normal emptying capacity), 4 microg/kg on day 3 (106+/-7%) or 20 microg/kg on day 4 (132+/-8%). As found earlier in rodents, CGRP receptor antagonist 8-37 as well as MTL-RP/Ghrelin are potent prokinetics to improve post-operative gastric ileus in dog.