Interventional palliative strategies for malignant bowel obstruction

Development and validation of a clinical prognosis prediction model for malignant intestinal obstruction: A retrospective cohort study

Malignant bowel obstruction (MBO) is a common and complex condition in clinical practice, which seriously affects the quality of life and prognosis of patients. However, the current lack of effective prognostic models for MBO has greatly limited clinical precision treatment and patient management. Focusing on this issue, this study aims to construct and validate a prognostic model for the overall survival (OS) of MBO patients, providing crucial support for clinical decision - making and improving the prognosis of patients. In this study, 41 items of real - world data from 192 patients in the Affiliated Hospital of Nantong University from January 2022 to January 2024 were collected, including 39 independent variables, survival time, and survival status. Subsequently, the patients were randomly divided into groups at a ratio of 7:3. Predictor variables were screened using the Least Absolute Shrinkage and Selection Operator (LASSO) and multivariate Cox regression, and then a Cox model was constructed. The model was validated using the Concordance index (C - index), time - dependent Receiver Operating Characteristic (ROC) curve, and Decision Curve Analysis (DCA). Finally, a nomogram of the model was created. The study found that significant risk factors affecting patient mortality included chemoradiotherapy (β = - 1.24; HR = 0.29;95%CI, 0.14-0.59), conservative treatment (β = 1.34; HR = 3.81; 95%CI, 1.69-8.55), new cases (β = - 0.96; HR = 0.38; 95%CI, 0.19-0.77), AJCC T stage 4 (β = 2.16; HR = 8.64; 95%CI, 1.47-50.76), red blood cell count (RBC, β = - 0.63; HR = 0.53; ; 95%CI, 0.38-0.80), prothrombin time (PT, β = 0.37; HR = 1.45; ; 95%CI, 1.07-1.97), aspartate aminotransferase (AST, β = 0.01; HR = 1.01; 95%CI, 1.00-1.02), and intestinal necrosis (β = 1.73; HR = 5.62; 95%CI, 1.11-28.27). In the development set, the AUC and C - index values of the prognostic models for 30 - day, 90 - day, and 180 - day are 0.87, 0.94, and 0.92 respectively. In the validation set, the corresponding values are 0.83, 0.96, and 0.89. The results of DCA analysis indicated that the model was reliable and could effectively predict the 30 - day, 90 - day, and 180 - day survival periods of MBO patients. This study successfully constructed and validated a prognostic model for the overall survival of MBO patients. This model identified multiple key prognostic factors and exhibited good predictive performance. It provides important reference for clinicians to predict the survival period of MBO patients and develop personalized treatment plans, and is expected to improve the clinical outcomes of MBO patients.

Surgery in platinum-resistant recurrent epithelial ovarian carcinoma

BACKGROUND

Ovarian cancer is one of the three most common malignant tumors of the female reproductive tract and ranks first in terms of mortality among gynecological tumors. Epithelial ovarian carcinoma (EOC) is the most common ovarian malignancy, accounting for 90% of all primary ovarian tumors. The clinical value of cytoreductive surgery in patients with platinum-resistant recurrent EOC remains largely unclear.

AIM

To evaluate the feasibility of secondary cytoreductive surgery for treating platinum-resistant recurrent EOC.

METHODS

This was a retrospective study of the clinical data of patients with platinum-resistant EOC admitted to the Cancer Hospital of the University of Chinese Academy of Sciences between September 2012 and June 2018. Patient baseline data were obtained from clinical records. Routine follow-up of disease progression was performed as follows. CA125 assessment and physical examination were performed every 3 wk during treatment, including gynecological examination. Imaging assessment was carried out every 12 wk by B-mode ultrasound, computed tomography, or magnetic resonance imaging. The primary outcome was progression-free survival (PFS). Secondary outcomes included overall survival (OS), chemotherapy-free interval (CFI), and complications. Follow-up ended on April 15, 2019.

RESULTS

A total of 38 patients were included. R0 resection was achieved in 25 (65.8%) patients and R1/2 in 13 (34.2%). Twenty-five (65.8%) patients required organ resection. Nine (23.7%) patients had operative complications, 36 (94.7%) received chemotherapy, and five (13.2%) had targeted therapy. Median PFS and OS were 10 (95%CI: 8.27-11.73) months and 28 (95%CI: 12.75-43.25) months, respectively; median CFI was 9 (95%CI: 8.06-9.94) months. R0 resection and postoperative chemotherapy significantly prolonged PFS and OS (all P < 0.05), and R0 resection also significantly prolonged CFI (P < 0.05). Grade ≥ 3 complications were observed, including rectovaginal fistula (n = 1), intestinal and urinary fistulas (n = 1), and renal failure-associated death (n = 1). Except for the patient who died after surgery, all other patients with complications were successfully managed. Two patients developed intestinal obstruction and showed improvement after conservative treatment.

CONCLUSION

Secondary cytoreductive surgery is feasible for treating platinum-resistant recurrent EOC. These findings provide important references for the selection of clinical therapeutic regimens.

Cervical Esophago-Gastric Tubes for Patients with Malignant Ascites

Patients with chronic small bowel obstruction and malignant ascites from diffuse peritoneal carcinomatosis have limited options for gastrointestinal decompression as part of end-of-life palliation. Insertion of a percutaneous gastrostomy tube is relatively contraindicated in patients with ascites. Alternatively, nasogastric tube placement often leads to significant discomfort to patients and necessitates hospitalization during their last days of life. Here, we demonstrate how placing a percutaneous cervical esophago-gastric tube can allow adequate gastrointestinal decompression for terminal patients with malignant small bowel obstruction. This palliative measure allows them to remain in the comfort of their own homes after the procedure.

Percutaneous needle decompression in treatment of malignant small bowel obstruction

AIM: To investigate the efficacy and safety of percutaneous needle decompression in the treatment of malignant small bowel obstruction (MSBO).

METHODS: A prospective analysis of the clinical data of 52 MSBO patients undergoing percutaneous needle decompression was performed.

RESULTS: Percutaneous needle decompression was successful in all 52 patients. Statistically significant differences were observed in symptoms such as vomiting, abdominal distension and abdominal pain before and after treatment (81.6% vs 26.5%, 100% vs 8.2%, and 85.7% vs 46.9%, respectively; all P < 0.05). The overall significantly improved rate was 19.2% (11/52) and the response rate was 94.2% (49/52) using decompression combined with nasal tube placement, local arterial infusion of chemotherapy and nutritional support. During the one-month follow-up period, puncture-related complications were acceptable.

CONCLUSION: Percutaneous needle intestinal decompression is a safe and effective palliative treatment for MSBO.

Enteral stents for the management of malignant colorectal obstruction

Colorectal cancer (CRC) is the 3^rd most common cancer in the United States with more than 10000 new cases diagnosed annually. Approximately 20% of patients with CRC will have distant metastasis at time of diagnosis, making them poor candidates for primary surgical resection. Similarly, 8%-25% of patients with CRC will present with bowel obstruction and will require palliative therapy. Emergent surgical decompression has a high mortality and morbidity, and often leads to a colostomy which impairs the patient’s quality of life. In the last decade, there has been an increasing use of colonic stents for palliative therapy to relieve malignant colonic obstruction. Colonic stents have been shown to be effective and safe to treat obstruction from CRC, and are now the therapy of choice in this scenario. In the setting of an acute bowel obstruction in patients with potentially resectable colon cancer, stents may be used to delay surgery and thus allow for decompression, adequate bowel preparation, and optimization of the patient’s condition for curative surgical intervention. An overall complication rate (major and minor) of up to 25% has been associated with the procedure. Long term failure of stents may result from stent migration and tumor ingrowth. In the majority of cases, repeat stenting or surgical intervention can successfully overcome these adverse effects.

Long-term release of a malignant ileal obstruction by placement of a colorectal self-expandable metal stent

An 84-year-old man underwent the Hartmann procedure with an R1 resection for advanced rectal cancer. One year after surgery, the patient presented with abdominal pain and vomiting. Abdominal radiography and computed tomography revealed an expanding small bowel and ileal obstruction caused by invasion of local, recurrent rectal cancer. In order to release the ileal obstruction, a colorectal self-expandable metal stent was placed via a through-the-scope technique using a colonoscope inserted through a stoma in the transverse colon. After stent placement, the patient's clinical symptoms and signs improved and the symptoms of obstruction did not recur. No major complications associated with the placement of the stent were observed during the 7-month follow-up period. Thus, self-expandable metal stents are a safe and effective palliative treatment for malignant gastroduodenal or colorectal obstructions, and as a bridge to surgery. However, endoscopic placement of these stents in cases of malignant small bowel obstruction is not yet feasible because of the limitations of endoscopic access and the stent delivery system. To our knowledge, this is the first report of malignant ileal obstruction treated with a colorectal self-expandable metal stent using a colonoscope. This case indicates that colorectal self-expandable metal stents can be effectively and safely used to treat malignant ileal obstructions.

Safety and efficacy of radiological percutaneous jejunostomy for decompression of malignant small bowel obstruction

OBJECTIVES

This study aimed to evaluate the safety and efficacy of percutaneous radiological jejunostomy (PRJ) and stent placement in patients with malignant small bowel obstructions (MSBO).

METHODS

A total of 21 patients (mean age 60 years) with single (n = 4) or multiple (n = 17) MSBO underwent PRJ following jejunopexy. The medical records and imaging studies were retrospectively reviewed to evaluate the technical/clinical success and complications. Clinical success was determined by symptomatic relief and radiologic bowel decompression.

RESULTS

PRJ using a 12- or 14-F drainage catheter was technically successful in all patients. Eleven patients required placement of an 18-F nasogastric tube across one (n = 3), two (n = 6) and three (n = 2) obstructions to achieve clinical success. Subsequently, self-expandable stents were placed through the PRJ tracts to recanalise MSBO in four patients. Clinical success was achieved in 18 patients (85.7 %). The median food intake capacity score improved from 4.0 to 2.0 (P = 0.001). There were one major (peritonitis, 4.8 %) and six minor complications (28.6 %)

CONCLUSIONS

PRJ using a nasogastric tube across the obstructions is an effective palliative treatment for MSBO. The PRJ tract can be used as an approach route for stent placement to recanalise MSBO. However, dedicated devices should be developed to reduce frequent procedure-related complications.

KEY POINTS

• Bowel decompression provides palliative treatment in malignant small bowel obstruction • Percutaneous radiological jejunostomy (PRJ) is a safe and effective palliative treatment. • Long tube placement across obstructions facilitates adequate drainage of multiple bowel obstructions. • PRJ tract can be used for stent placement to approach MSBO recanalisation.

Malignant small bowel obstruction: the last frontier for gastrointestinal stenting

See article in J. Gastroenterol. Hepatol. 2012; 27: 1181–1186.

Endoscopic stenting is not as effective for palliation of colorectal obstruction in patients with advanced gastric cancer as emergency surgery

BACKGROUND

Although self-expandable metal stent (SEMS) insertion has been shown to be an effective therapy for palliation of obstruction from colorectal malignancy, the clinical efficacy of SEMS insertion in the palliation of colorectal obstruction from an extracolonic malignancy (ECM) has not been extensively evaluated.

OBJECTIVE

The aim of this study was to evaluate the clinical outcomes and complications of SEMSs compared with those of emergency surgery for relief of colorectal obstruction in patients with advanced gastric cancer (AGC).

DESIGN

Retrospective study.

PATIENTS

From January 2000 to December 2009, patients with AGC who were treated with SEMSs (N = 111) or emergency surgery (N = 69) for palliation of malignant colorectal obstruction were included.

INTERVENTION

SEMS insertion or surgery.

RESULTS

Although acute complications and stoma formations were lower in the SEMS group than in the surgery group, the clinical efficacy of SEMSs was inferior to emergency surgery (technical success, 73.9% vs 94.2%, P = .001; clinical success, 54.1% vs 75.4%, P = .005). SEMS-related complications occurred in 64.5%, including reobstruction (36.8%), stent migration (10.5%), perforation (13.2%), and bleeding (3.9%). The median duration of patency was not statistically different between the patients who underwent SEMS insertion and those who underwent emergency surgery (117 days vs 183 days, P = .105). Patients with fewer than 2 obstructive sites or less than 2 years to obstructive symptom onset after diagnosis of AGC showed better clinical outcomes after endoscopic stenting.

LIMITATIONS

Retrospective and single-center study.

CONCLUSIONS

SEMS insertion seems to be less effective than emergency surgery for the palliation of colorectal obstruction in patients with AGC. Further study is necessary to define those patients with ECM who may benefit from SEMS insertion.

Management of patients with malignant bowel obstruction and stage IV colorectal cancer

BACKGROUND

Malignant bowel obstruction (MBO), a serious problem in stage IV colorectal cancer (CRC) patients, remains poorly understood. Optimal management requires realistic assessment of treatment goals. This study's purpose is to characterize outcomes following palliative intervention for MBO in the setting of metastatic CRC.

STUDY DESIGN

Retrospective review of a prospective palliative database identified 141 patients undergoing surgical (OR; n = 96) or endoscopic (GI; n = 45) procedures for symptoms of MBO.

RESULTS

Median patient age was 58 years, median follow-up 7 months. Most (63%) had multiple sites of metastases. Computed tomography (CT) scan findings of carcinomatosis (p = 0.002), ascites (p = 0.05), and multifocal obstruction with carcinomatosis and ascites (p = 0.03) significantly predicted the need for percutaneous or open gastrostomy tube, or stoma. Procedure-associated morbidity for 81 patients with small bowel obstruction (SBO) was 37%; 7% developed an enterocutaneous fistula/anastomotic leak. Thirty-day mortality was 6%. Most (84%) patients were palliated successfully; some received additional chemotherapy (38%) or surgery (12%). Procedure-associated morbidity for 60 patients with large bowel obstruction (LBO) was 25%; 11 patients (18%) required other procedures for stent failure, with one death at 30 days. Symptom resolution was >97%. Patients with LBO had improved symptom resolution, shorter length of stay (LOS), and longer median survival than patients with SBO.

CONCLUSIONS

Patients with MBO and stage IV CRC were successfully palliated with GI or OR procedures. Patients with CT-identified ascites, carcinomatosis, or multifocal obstruction were least likely to benefit from OR procedures. CT plays an important role in preoperative planning. Sound clinical judgment and improved understanding are required for optimal management of MBO.

Malignant bowel obstruction: a review of current treatment strategies

Malignant bowel obstruction is common in individuals with intra-abdominal and pelvic malignancies and results in considerable suffering. Treatments target both the resolution of obstruction and symptom management. Emerging procedures include stents placement in the bowel to return patency and newer surgical procedures that are evolving to be less invasive. The use of medical interventions like corticosteroids, alone or in concert with additional drugs, can be utilized to achieve resolution of obstruction. Throughout treatment, it is important to also aggressively treat obstructive symptoms like pain and nausea/vomiting. This can mostly be achieved with medications, but use of venting percutaneous endoscopic gastrostomy (PEG) can also relieve symptoms. Parenteral hydration and nutrition use remain controversial with this population. The factor most closely tied to prognosis is performance status.

Current management of small bowel obstruction

SBO is a common disease with multiple causes. The most significant advances over the past several years have involved, first, decision-making techniques to promptly and accurately identify patients who will require exploration, and, second, the increasing use of laparoscopic techniques. "Complete" bowel obstruction is becoming an outdated term, as treatment algorithms use predictive models and oral contrast challenges to select patients for operation without recourse to the notion of "complete obstruction." Laparoscopic techniques are gaining acceptance as a primary modality in the treatment of SBO. Appropriate patient selection is necessary for success, but successful laparoscopic SBO management can reduce postoperative pain, minimize hospital stay, and may lead to fewer adhesions, possibly preventing further adhesive SBO. Strangulation obstruction is the major cause of morbidity and mortality in SBO. Although unrecognized strangulation obstructions remain, their incidence is decreasing with the new protocols in development. Future efforts should focus on incorporating predictive models into management with the goal of eliminating unrecognized strangulation obstructions. Further refinement of the predictive models incorporating outcomes of oral contrast challenges and molecular biomarker data may allow surgeons to reach this goal. In addition, the benefit of the elimination of interpractitioner variability conferred by standardized protocols will in itself improve patient outcomes.

Update on the indications and use of colonic stents

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.

Fluoroscopic management of complications after colorectal stent placement

Colorectal self-expanding metal stents have been widely used as a bridge to surgery in patients with acute malignant colonic obstruction by allowing a single-stage operation, or as a definitive palliative procedure in patients with inoperable tumors. Colonic stents are placed under either fluoroscopic or combined endoscopic and fluoroscopic guidance, with similar technical-success and complication rates. Placement of colonic stents is a very safe procedure with a low procedure-related mortality rate, but serious complications can develop and reinterventions are not uncommon. Most of the complications can be treated by minimally invasive or conservative techniques, while surgical interventions are required for most patients with perforation.