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MEDICAL MANAGEMENT OF INTESTINAL OBSTRUCTION IN PATIENTS WITH ADVANCED MALIGNANT DISEASE
990 TABLE I-SITES OF PRIMARY TUMOURS IN
Hospice
Practice
40
PATIENTS
WITH INTESTINAL OBSTRUCTION
MEDICAL MANAGEMENT OF INTESTINAL OBSTRUCTION IN PATIENTS WITH ADVANCED MALIGNANT DISEASE A Clinical and
Pathological Study
MARY BAINES
D.
J. OLIVER
R. L. CARTER St
Christopher’s Hospice, London;
Wisdom
Royal Marsden Hospital,
Hospice, Rochester; and Sutton
A clinical and pathological study was made of 40 patients with intestinal obstruction due to far-advanced abdominal and/or pelvic malignant disease. Surgical intervention was feasible in only 2 cases. The remaining 38 patients were managed medically without intravenous fluids and nasogastric suction. Obstructive symptoms such as intestinal colic, vomiting, and diarrhoea
Summary
were
effectively controlled by drugs. INTRODUCTION
INTESTINAL obstruction is a common complication in patients with advanced abdominal or pelvic cancer. 1-3 Until recently treatment was either palliative surgery or continuous intravenous fluids and nasogastric suction. The patient’s general condition or extensive (particularly multifocal) disease may preclude operation. Conservative management is rarely acceptable as a long-term procedure, and an alternative approach to treatment is needed. We describe here how intensive medical management can alleviate the severe abdominal pain and vomiting which often dominate the final days and weeks of patients in whom surgical intervention is contraindicated. PATIENTS AND METHODS
The
study was based on 40 consecutive patients (16 men, 24 women) with intestinal obstruction who were treated at St Christopher’s Hospice between October, 1981, and May, 1982, and between March, 1983, and July, 1984. They were aged 26 to 94 years (mean 59). Except for the absence of cancer of the uterine cervix their primary tumours (table I) are representative of those that
cause intestinal obstruction. 37 of the 40 patients had undergone abdominal surgery at least once. 11 of them had had palliative operations to relieve intestinal obstruction-ileocolic anastomosis (5), ileocolic anastomosis and colostomy (1), ileoileal anastomosis and colostomy (1), colostomy (2), and division of malignant adhesions (2). 4 of these patients continued to have obstructive symptoms. The remainder had 10 patients recurrence of obstruction 1-10 months had previously had a laparotomy for intestinal obstruction at which no further procedures were possible. The diagnosis of intestinal obstruction was made clinically and confirmed by plain abdominal X-ray if surgical treatment was
after surgery.
contemplated. Evaluation
of Response
An attempt was made to estimate the severity of each symptom ifit had been left untreated, as a basis for assessing the degree of subsequent symptom control. Three factors were taken into account: (1) severity of symptoms before treatment; (2) dose of medication needed for control-pain requiring morphine 100 mg 4 for example, was judged as severe even if the pain was subsequently abolished; and (3) frequency of medication needed to maintain control.
hourly,
One patient had 2
primary carcinomas,
rectum
and colon.
In evaluating the severity of the treated symptom, account was taken both of the intensity and frequency. Symptoms (scored as severe, moderate, mild, or absent) were assessed by clinical observations (M. B., D. J. 0.) and by detailed study of medical and nursing records. Visual analogue scales were not used. We cite two examples. Vomiting three or four times daily was judged as severe. Colic, felt for one day during 3 weeks, was judged as mild.
Necropsy Procedure Necropsy (by R. L. C.) was confined to the abdominal cavity and its contents. Tissue blocks were taken routinely for histopathology. RESULTS
Surgical treatment of intestinal obstruction was considered for every case. The main indication was the possibility of a single block in a patient whose general medical condition did not preclude surgery. Factors affecting the decision were the previous surgical findings, the opinion of the referring surgeon, the extent of malignant disease, and the patient’s wishes. 2 of the 40 patients were considered suitable for operation. Both of them had’asingle pelvic obstruction despite widespread disease. 1 patient died 24 h after surgery and the second lived for another 3 months. The remaining 38 patients were managed medically for the following reasons: previous laparotomy for obstruction at which no procedure was
possible (10 patients), previous surgical opinion (12),
extensive intra-abdominal disease (9), too old or too ill (5), and surgery refused (2). The results are presented separately for intestinal colic, other forms of abdominal pain, nausea and vomiting, and diarrhoea and constipation (fig 1).
Intestinal Colic
reported by 29 of the 38 patients It was severe in 8 and moderate in 9. Smooth muscle relaxant drugs were used to control colic. Loperamide (’Imodium’) 2 mg four times daily was given for persistent colic in patients who were not vomiting. Hyoscine 0’3-0’66 mg was given sublingually to relieve occasional spasms of colic or prophylactically before meals if food precipitated the symptom. Hyoscine 0.8 mg-2 0 mg was given by continuous subcutaneous infusion with a syringe driver for persistent severe colic. Atropine was substituted if hyoscine caused unacceptable sedation. The syringe driver was used for 20 patients to control not only colic but also other obstructive symptoms. A coeliac axis block with bupivacaine or alcohol, which can be done in the ward with the minimum of delay and disturbance to critically ill patients, was sometimes used to treat severe colic. With medical treatment only 2 patients had moderate colic, 10 had Intestinal colic
was
managed medically.
.
991
recommended dosage were sometimes given orally or by injection, but usually as suppositories, 8 hourly. Although it causes sedation in 56% of patients4 methotrimeprazine (’Nozinan’) 50-150 mg/24 h was given, usually with the syringe driver, to treat otherwise intractable vomiting.
Haloperidol (’Serenace’) 5-10 mg/24 h was given orally or in the syringe driver and occasionally cyclizine (’Valoid’) 150 mg/24 h was added. Metoclopramide and domperidone were found to be effective and may cause the colic to worsen. With medical treatment 4 patients had moderate or severe vomiting, 29 had mild vomiting (not more than one episode per day and little or no nausea). 5 patients stopped vomiting. During the 2112 years of our study the syringe driver became increasingly available and its early use in patients seen in the latter part of the study considerably improved the control of vomiting. Patients were encouraged to eat and drink freely. Most of them chose a mainly fluid diet and, with adequate control of vomiting, dehydration was not a problem. Many patients had previously received conventional conservative treatment for intestinal obstruction. All preferred the use of appropriate antiemetics to the reinsertion of a nasogastric tube. not
Diarrhoea
Fig 1-Diagrammatic representation of symptom control. mild colic, and the other 26 no longer had colic. 1 patient’s severe colic was reduced to mild for a period of 64 days until death. 3 out of 5 given a coeliac block reported considerable relief of pain even though they continued to have hyperperistalsis and borborygmi.
Other Abdominal Pain 35 of the 38 patients had pain other than colic. It was moderate or severe in 15. Pain other than colic could be caused by hepatomegaly, tumour masses, or abdominal distension. This was treated with regular analgesia in doses adjusted to achieve continuous pain control. The commonest regimen was oral morphine mixture in chloroform water every 4 h, or morphine sulphate continus tablets (MST) every 12 h. When nausea and vomiting or extreme weakness precluded oral medication, either oxycodone pectinate (’Proladone’) suppositories 30-60 mg every 8 h or parenteral diamorphine was used. Diamorphine was occasionally given by 4 hourly injection but more often by continuous subcutaneous infusion with the syringe driver. The pain was well controlled. No patient continued to have moderate or severe pain, 4 had mild pain, and the remaining 34 became pain free.
Vomiting All the
Constipation Only 5 patients specifically mentioned this symptom. It was treated only in the few patients in whom a single colonic or rectal obstruction was suspected. This was treated with faecal-softening aperients such as docusate (’Dioctyl’) or ’Milpar’, sometimes with an arachis oil retention enema. Stimulant purgatives and high enemas were avoided since they could worsen the colic. Course of Disease The 38 patients who were not treated surgically continued have their intestinal obstruction until they died 1-12 months later (fig 2). The mean survival was 3’ 7 months. 10 patients who had previously undergone palliative operations survived for a mean of 7 months after surgery. In another 10 patients in whom laparotomy showed no further procedure to be possible the mean survival was 2.99 months. 7 patients lived with intestinal obstruction for 7 months or more. Likely contributory factors were effective chemotherapy (2 patients with ovarian carcinoma who received cis platinum), the development of a faecal fistula (2 patients with ovarian carcinoma who lived for 5 and 10 months), single localised to
patients complained of nausea and vomiting. The
in 12 and moderate in 21. Severity the level of obstruction and could be depended considerable nausea. The vomiting usually accompanied by started by being intermittent but it could become almost continuous and faeculent. The antiemetics most effective in vomiting due to intestinal obstruction were the phenothiazines and butyrophenones. Prochlorperazine (’Stemetil’) and chlorpromazine (’Largactil’) in
vomiting
Diarrhoea was a problem for 13 out of the 38 patients. 4 of them had faecal fistulae (2 enterocutaneous, 2 enterovaginal). The diarrhoea of partial or subacute obstruction sometimes continued until death; sometimes it preceded complete obstruction. This was treated with conventional antidiarrhoeal drugs, loperamide (’Imodium’), and codeine. If the 4 patients with fistulae are excluded, 5 of the remaining 9 were controlled satisfactorily.
was severe on
Fig 2-Survival time (months) of patients admitted with intestinal obstruction.
992
(2 patients with rectal carcinoma), and slowly (3 young patients with disseminated colorectal cancers who survived for 7-9 months). obstructions
growing
tumours
Pathology Findings The principal findings from 18 necropsies are summarised in table II. The clinical diagnosis of malignant obstruction of the small and/or large intestine was confirmed in all cases. Multiple sites of obstruction were common (14/18), especially in patients with an omental mass or malignant adhesions associated with multiple tumour deposits in the peritoneum. Single-level obstruction was found in 4 cases-rectosigmoid and rectal in 2, ileal in 2 (see discussion). Obstruction was more often due to extrinsic compression TABLE II-DISTRIBUTION OF ABDOMINAL AND PELVIC TUMOUR AT NECROPSY IN 18 PATIENTS WITH INTESTINAL OBSTRUCTION
Numbers in parenthesesnumber of patients. SI =small intestine. LI = large intestine.
from extramural masses and adhesions than to intraluminal growth. Lateral spread of tumour along the serosal surface and within the muscle coats of the bowel wall was often seen. Invasion of the mesentery was common, both by nodal metastases and by tumour growing in continuity from the bowel. Intestinal perforation and faecal peritonitis was found in 1 case. 1 patient had a rectovaginal fistula. DISCUSSION
To justify a non-interventional approach to the management of intestinal obstruction in advanced malignant disease it is essential to establish two points: that a representative group of patients has been studied, and that their symptoms have been effectively controlled. The patients described here were referred to St Christopher’s Hospice by both general practitioners and hospital consultants and may be regarded as an otherwise unselected group with intestinal obstruction due to far-advanced malignant disease originating in a variety of common sites. Evaluation of symptoms before and during treatment is difficult in terminally ill patients, given the episodic nature of colic and vomiting and the changing (usually worsening) overall clinical condition; but we attempted to assess the degree of symptom control by studying the medical and nursing records and (usually) by questioning the patients. The drug regimens described here have evolved over several
years.5
The introduction of the syringe driver has allowed analgesics and antiemetics to be given parenterally so that steady blood levels of drugs can be maintained.6 It has been especially valuable in managing patients at home. We have found that adequate control of colic and other forms of visceral pain is reasonably easy. Nausea and vomiting have proved more intractable and most patients continued to have mild vomiting albeit with a little nausea. Surgery must always be considered in the management of every patient with intestinal obstruction. A proportion will have a non-malignant cause for their obstruction, and Walsh and Schofield’ and Osteen et all reported that obstruction in 32% and 38% of cases was due to a benign cause or to an unrelated second primary tumour. Even among patients whose obstruction is due to recurrent cancer there are individuals who will enjoy a long and symptom-free period following palliative surgery. We reviewed the medical records of the 4 patients who were shown at necropsy to have a single, potentially remediable obstruction, but we concluded that their general condition would have precluded surgery. Surgical mortality varies, but it is not insignificant. Ketcham et al8 and Walsh and Schofieldreport 18% and 19%, respectively, but these two studies included few examples of ovarian cancer. Piver et al9 in a survey of 60 patients with ovarian cancer, found a surgical mortality of 32%, and Aranha et allo reported 35%. Surgical morbidity is more difficult to measure. The frequency offaecal fistulae has been recorded as 7-10%. The persistence of obstructive symptoms following palliative surgery has not been reported but 4 out of 11 patients in our series still had an obstruction after laparotomy. Ketcham et al8 described a reobstruction rate of 33%. Impossible to measure is the physical and psychological trauma of a further surgical procedure to patients who have often already had extensive treatment. Duration of survival after palliative surgery for intestinal obstruction due to malignancy has been given as 2.55 months,9 3 months,2 and 11 months.7,8 Our group had a mean survival of 3.7 months from the onset of obstruction, with 7 out of 38 patients (18%) living for more than 7 months. Comparisons between surgical series and the present study cannot, however, be pushed too far since most of the former include few cases of ovarian cancer and many with cancer of the cervix uteri. The decompression of the bowel by nasogastric suction and correction of any fluid and electrolyte imbalance by intravenous infusion before surgery is standard practice, but the value of this regimen as the sole means of treating malignant obstruction is questionable. Aranha et al10 and Glass and LeDuc"report a 1% and 15% sustained response to conservative treatment. Osteen et a12 showed that 23% of patients responded but symptoms recurred in 42% of them. These figures do not take into account the fact that early obstructive symptoms are often intermittent-a regular feature in some of the patients in the present series. A brief comment may be made on the use of limited, symptom-oriented necropsies. This procedure was introduced for selected cases at St Christopher’s Hospice in 1979.12 Limited necropsies have already helped to clarify certain kinds of pain and intractable dysphagia13 and, in the present series, they have provided useful confirmation of clinical diagnoses. Some anomalies have, however, been encountered. In particular, the nature and extent of the pathological findings could not be linked with the severity of colic and abdominal pain experienced during life. During the period that this study was undertaken, the admission records of St Christopher’s Hospice indicate that
993 had intestinal obstruction. Terminal intestinal obstruction occurred in some 10% of hospice patients with primary tumours of the large bowel. It is thus a fairly common terminal event, but the findings reported here indicate that the distressing symptoms of intestinal obstruction due to far-advanced malignant disease can be
3% of all
patients
controlled by drugs.
4.
5. 6. 7.
We thank Mr A. E. Young, consultant surgeon at St Thomas’ Hospital, London, for help with the preparation of this paper; and the Wellcome Foundation for financial support.
Correspondence should be addressed to M. B., St Lawne Park Road, Sydenham, London SE26 6DZ.
Christopher’s Hospice,
8. 9. 10. 11.
Surg 1973; 125: 316. pathological aspects
12. Carter RL. Some
REFERENCES 1 Sise JG, Crichlow RW. Obstruction due to malignant tumours. Sem Oncol 1978; 5: 213-24. 2 Osteen RT, Guyton S, Steele G, Wilson RE Malignant intestinal obstruction Surgery 1980; 67: 611-15.
Child Health PROGNOSIS FOR BABIES WITH MENINGOMYELOCELE AND HIGH LUMBAR PARAPLEGIA AT BIRTH R. G. MENZIES
J.
M. PARKIN
E. N. HEY Princess Mary Maternity
Hospital,
Newcastle upon
Tyne
life
expectation of babies with lumbar meningomyelocele not paralytic offered immediate surgery at birth appears to be influenced by the extent to which parents are involved in the child’s early care. 8 of the 27 children offered family-centred care in one hospital in 1971-80 and not offered immediate surgery survived to school entry and none of these children has since died. All are chairbound and incontinent, but none is intellectually retarded and many are no more handicapped than the children offered immediate surgical treatment at birth. The choice before the family at birth does not have to be presented as an urgent and immediate choice between life and death. Summary
The
JC, Buchler DA, Mack EA, Ruzicka FF, Crowley JJ, Carr WR. The management of ovarian-cancer-caused bowel obstruction. Gynecol Oncol 1981; 12: 186-92. Oliver DJ. The use of methotrimeprazine in terminal care. Br J Clin Pract 1985; 39: 339-40 Baines MJ. Control of other symptoms. In: Saunders CM, ed. The management of terminal malignant disease. London: Edward Arnold, 1984. Regnard C, Newbury A. Pain and the portable syringe pump. Nursing Times 1983; 79: 25-28. Walsh HPJ, Schofield PF. Is laparotomy for small bowel obstruction justified in patients with previously treated malignancy? Br J Surg 1984; 71: 933-35. Ketcham AS, Hoye RC, Pilch YH, Morton DL. Delayed intestinal obstruction following treatment for cancer. Cancer 1970; 25: 406-10. Piver MS, Barlow JJ, Lele SB, Frank A. Survival after ovarian cancer induced intestinal obstruction. Gynecol Oncol 1982; 12: 44-49. Aranha GV, Folk FA, Greenlee HB. Surgical palliation of small bowel obstruction due to metastatic carcinoma. Am Surg 1981; 47: 99-102. Glass RL, LeDuc RJ Small intestinal obstruction for peritoneal carcinomatosis. Am J
3 Tunca
INTRODUCTION
BEFORE the introduction of the Holter valve twenty-five years ago, the prognosis for babies with serious spina bifida was extremely bleak. A policy of immediate back closure with subsequent shunt surgery for the hydrocephalus then developed, but this soon led to the survival of large numbers of very handicapped children. In turn, therefore, a policy of more selective treatment was widely adopted in the United Kingdom after 1971,’ in the belief that children with gross
of advanced malignant disease. In: Saunders CM The management of terminal malignant disease. London: Edward Arnold, 1984. 13. Carter RL, Pittam MR, Tanner NSB. Pain and dysphagia m patients with squamous carcinomas ofthe head and neck-the role of perineural spread. J Roy Soc Med 1982; 75: 598-606.
in several other countries.7-9 A working party for the Northern RHA believed it was possible to reach a consensus on such issues when it reviewed the ethical guidelines involved and published its views in The Lancet ten years ago,1O but this conclusion was based on the assumption that babies not offered surgery would always die within weeks or months if not offered surgery at birth. Evidence, however, from cases selected for referral to a regional surgical centre after delivery"’’shows that this is not always true. Our own experience (based on an unselected group of children) suggests that 30% of all children not offered surgery at birth may survive to enter school 5 years later, and that they enter school with a range of handicap (other than the handicap of wheelchair dependence) little different from that ofa group of children without "adverse criteria"’offered surgery at birth.
SURVEY
Families who are told that their baby is unlikely to survive very long, and that skilled nursing care (with or without medication) may be necessary to keep the baby comfortable, readily accept the idea that their child should remain in hospital. This was not the way the first few babies were managed conservatively in this hospital, however, when a policy of selective treatment for early surgery was introduced in 1971. Three of the first families offered conservative care chose to take their babies home, and nursery staff rapidly came to see from the outset that this could be a valid alternative to continued hospital care. Parents have always, therefore, been encouraged to involve themselves in the child’s care in hospital from birth and have had the alternatives explained to them without pressure to conform to any particular pattern of care, and we soon
hydrocephalus, paralysed legs, or kyphosis at birth would die anyway if not offered immediate surgery; and this is, indeed, what normally happens when such children are cared for in
hospital.2-6 This was not, however, what happened to a group of such children cared for in a family setting in Newcastle between 1971 and 1980. The ethical dilemma facing those responsible for the care of
baby with high paraplegia at birth remains as acute as ever: clinicians in the UK advise against surgical treatment for such children, but this runs counter to the prevailing view a
most
Prognosis for babies with a meningomyelocele not offered surgery at birth between 1971 and 1980 because of adverse factors.!
Hospice
Practice
40
PATIENTS
WITH INTESTINAL OBSTRUCTION
MEDICAL MANAGEMENT OF INTESTINAL OBSTRUCTION IN PATIENTS WITH ADVANCED MALIGNANT DISEASE A Clinical and
Pathological Study
MARY BAINES
D.
J. OLIVER
R. L. CARTER St
Christopher’s Hospice, London;
Wisdom
Royal Marsden Hospital,
Hospice, Rochester; and Sutton
A clinical and pathological study was made of 40 patients with intestinal obstruction due to far-advanced abdominal and/or pelvic malignant disease. Surgical intervention was feasible in only 2 cases. The remaining 38 patients were managed medically without intravenous fluids and nasogastric suction. Obstructive symptoms such as intestinal colic, vomiting, and diarrhoea
Summary
were
effectively controlled by drugs. INTRODUCTION
INTESTINAL obstruction is a common complication in patients with advanced abdominal or pelvic cancer. 1-3 Until recently treatment was either palliative surgery or continuous intravenous fluids and nasogastric suction. The patient’s general condition or extensive (particularly multifocal) disease may preclude operation. Conservative management is rarely acceptable as a long-term procedure, and an alternative approach to treatment is needed. We describe here how intensive medical management can alleviate the severe abdominal pain and vomiting which often dominate the final days and weeks of patients in whom surgical intervention is contraindicated. PATIENTS AND METHODS
The
study was based on 40 consecutive patients (16 men, 24 women) with intestinal obstruction who were treated at St Christopher’s Hospice between October, 1981, and May, 1982, and between March, 1983, and July, 1984. They were aged 26 to 94 years (mean 59). Except for the absence of cancer of the uterine cervix their primary tumours (table I) are representative of those that
cause intestinal obstruction. 37 of the 40 patients had undergone abdominal surgery at least once. 11 of them had had palliative operations to relieve intestinal obstruction-ileocolic anastomosis (5), ileocolic anastomosis and colostomy (1), ileoileal anastomosis and colostomy (1), colostomy (2), and division of malignant adhesions (2). 4 of these patients continued to have obstructive symptoms. The remainder had 10 patients recurrence of obstruction 1-10 months had previously had a laparotomy for intestinal obstruction at which no further procedures were possible. The diagnosis of intestinal obstruction was made clinically and confirmed by plain abdominal X-ray if surgical treatment was
after surgery.
contemplated. Evaluation
of Response
An attempt was made to estimate the severity of each symptom ifit had been left untreated, as a basis for assessing the degree of subsequent symptom control. Three factors were taken into account: (1) severity of symptoms before treatment; (2) dose of medication needed for control-pain requiring morphine 100 mg 4 for example, was judged as severe even if the pain was subsequently abolished; and (3) frequency of medication needed to maintain control.
hourly,
One patient had 2
primary carcinomas,
rectum
and colon.
In evaluating the severity of the treated symptom, account was taken both of the intensity and frequency. Symptoms (scored as severe, moderate, mild, or absent) were assessed by clinical observations (M. B., D. J. 0.) and by detailed study of medical and nursing records. Visual analogue scales were not used. We cite two examples. Vomiting three or four times daily was judged as severe. Colic, felt for one day during 3 weeks, was judged as mild.
Necropsy Procedure Necropsy (by R. L. C.) was confined to the abdominal cavity and its contents. Tissue blocks were taken routinely for histopathology. RESULTS
Surgical treatment of intestinal obstruction was considered for every case. The main indication was the possibility of a single block in a patient whose general medical condition did not preclude surgery. Factors affecting the decision were the previous surgical findings, the opinion of the referring surgeon, the extent of malignant disease, and the patient’s wishes. 2 of the 40 patients were considered suitable for operation. Both of them had’asingle pelvic obstruction despite widespread disease. 1 patient died 24 h after surgery and the second lived for another 3 months. The remaining 38 patients were managed medically for the following reasons: previous laparotomy for obstruction at which no procedure was
possible (10 patients), previous surgical opinion (12),
extensive intra-abdominal disease (9), too old or too ill (5), and surgery refused (2). The results are presented separately for intestinal colic, other forms of abdominal pain, nausea and vomiting, and diarrhoea and constipation (fig 1).
Intestinal Colic
reported by 29 of the 38 patients It was severe in 8 and moderate in 9. Smooth muscle relaxant drugs were used to control colic. Loperamide (’Imodium’) 2 mg four times daily was given for persistent colic in patients who were not vomiting. Hyoscine 0’3-0’66 mg was given sublingually to relieve occasional spasms of colic or prophylactically before meals if food precipitated the symptom. Hyoscine 0.8 mg-2 0 mg was given by continuous subcutaneous infusion with a syringe driver for persistent severe colic. Atropine was substituted if hyoscine caused unacceptable sedation. The syringe driver was used for 20 patients to control not only colic but also other obstructive symptoms. A coeliac axis block with bupivacaine or alcohol, which can be done in the ward with the minimum of delay and disturbance to critically ill patients, was sometimes used to treat severe colic. With medical treatment only 2 patients had moderate colic, 10 had Intestinal colic
was
managed medically.
.
991
recommended dosage were sometimes given orally or by injection, but usually as suppositories, 8 hourly. Although it causes sedation in 56% of patients4 methotrimeprazine (’Nozinan’) 50-150 mg/24 h was given, usually with the syringe driver, to treat otherwise intractable vomiting.
Haloperidol (’Serenace’) 5-10 mg/24 h was given orally or in the syringe driver and occasionally cyclizine (’Valoid’) 150 mg/24 h was added. Metoclopramide and domperidone were found to be effective and may cause the colic to worsen. With medical treatment 4 patients had moderate or severe vomiting, 29 had mild vomiting (not more than one episode per day and little or no nausea). 5 patients stopped vomiting. During the 2112 years of our study the syringe driver became increasingly available and its early use in patients seen in the latter part of the study considerably improved the control of vomiting. Patients were encouraged to eat and drink freely. Most of them chose a mainly fluid diet and, with adequate control of vomiting, dehydration was not a problem. Many patients had previously received conventional conservative treatment for intestinal obstruction. All preferred the use of appropriate antiemetics to the reinsertion of a nasogastric tube. not
Diarrhoea
Fig 1-Diagrammatic representation of symptom control. mild colic, and the other 26 no longer had colic. 1 patient’s severe colic was reduced to mild for a period of 64 days until death. 3 out of 5 given a coeliac block reported considerable relief of pain even though they continued to have hyperperistalsis and borborygmi.
Other Abdominal Pain 35 of the 38 patients had pain other than colic. It was moderate or severe in 15. Pain other than colic could be caused by hepatomegaly, tumour masses, or abdominal distension. This was treated with regular analgesia in doses adjusted to achieve continuous pain control. The commonest regimen was oral morphine mixture in chloroform water every 4 h, or morphine sulphate continus tablets (MST) every 12 h. When nausea and vomiting or extreme weakness precluded oral medication, either oxycodone pectinate (’Proladone’) suppositories 30-60 mg every 8 h or parenteral diamorphine was used. Diamorphine was occasionally given by 4 hourly injection but more often by continuous subcutaneous infusion with the syringe driver. The pain was well controlled. No patient continued to have moderate or severe pain, 4 had mild pain, and the remaining 34 became pain free.
Vomiting All the
Constipation Only 5 patients specifically mentioned this symptom. It was treated only in the few patients in whom a single colonic or rectal obstruction was suspected. This was treated with faecal-softening aperients such as docusate (’Dioctyl’) or ’Milpar’, sometimes with an arachis oil retention enema. Stimulant purgatives and high enemas were avoided since they could worsen the colic. Course of Disease The 38 patients who were not treated surgically continued have their intestinal obstruction until they died 1-12 months later (fig 2). The mean survival was 3’ 7 months. 10 patients who had previously undergone palliative operations survived for a mean of 7 months after surgery. In another 10 patients in whom laparotomy showed no further procedure to be possible the mean survival was 2.99 months. 7 patients lived with intestinal obstruction for 7 months or more. Likely contributory factors were effective chemotherapy (2 patients with ovarian carcinoma who received cis platinum), the development of a faecal fistula (2 patients with ovarian carcinoma who lived for 5 and 10 months), single localised to
patients complained of nausea and vomiting. The
in 12 and moderate in 21. Severity the level of obstruction and could be depended considerable nausea. The vomiting usually accompanied by started by being intermittent but it could become almost continuous and faeculent. The antiemetics most effective in vomiting due to intestinal obstruction were the phenothiazines and butyrophenones. Prochlorperazine (’Stemetil’) and chlorpromazine (’Largactil’) in
vomiting
Diarrhoea was a problem for 13 out of the 38 patients. 4 of them had faecal fistulae (2 enterocutaneous, 2 enterovaginal). The diarrhoea of partial or subacute obstruction sometimes continued until death; sometimes it preceded complete obstruction. This was treated with conventional antidiarrhoeal drugs, loperamide (’Imodium’), and codeine. If the 4 patients with fistulae are excluded, 5 of the remaining 9 were controlled satisfactorily.
was severe on
Fig 2-Survival time (months) of patients admitted with intestinal obstruction.
992
(2 patients with rectal carcinoma), and slowly (3 young patients with disseminated colorectal cancers who survived for 7-9 months). obstructions
growing
tumours
Pathology Findings The principal findings from 18 necropsies are summarised in table II. The clinical diagnosis of malignant obstruction of the small and/or large intestine was confirmed in all cases. Multiple sites of obstruction were common (14/18), especially in patients with an omental mass or malignant adhesions associated with multiple tumour deposits in the peritoneum. Single-level obstruction was found in 4 cases-rectosigmoid and rectal in 2, ileal in 2 (see discussion). Obstruction was more often due to extrinsic compression TABLE II-DISTRIBUTION OF ABDOMINAL AND PELVIC TUMOUR AT NECROPSY IN 18 PATIENTS WITH INTESTINAL OBSTRUCTION
Numbers in parenthesesnumber of patients. SI =small intestine. LI = large intestine.
from extramural masses and adhesions than to intraluminal growth. Lateral spread of tumour along the serosal surface and within the muscle coats of the bowel wall was often seen. Invasion of the mesentery was common, both by nodal metastases and by tumour growing in continuity from the bowel. Intestinal perforation and faecal peritonitis was found in 1 case. 1 patient had a rectovaginal fistula. DISCUSSION
To justify a non-interventional approach to the management of intestinal obstruction in advanced malignant disease it is essential to establish two points: that a representative group of patients has been studied, and that their symptoms have been effectively controlled. The patients described here were referred to St Christopher’s Hospice by both general practitioners and hospital consultants and may be regarded as an otherwise unselected group with intestinal obstruction due to far-advanced malignant disease originating in a variety of common sites. Evaluation of symptoms before and during treatment is difficult in terminally ill patients, given the episodic nature of colic and vomiting and the changing (usually worsening) overall clinical condition; but we attempted to assess the degree of symptom control by studying the medical and nursing records and (usually) by questioning the patients. The drug regimens described here have evolved over several
years.5
The introduction of the syringe driver has allowed analgesics and antiemetics to be given parenterally so that steady blood levels of drugs can be maintained.6 It has been especially valuable in managing patients at home. We have found that adequate control of colic and other forms of visceral pain is reasonably easy. Nausea and vomiting have proved more intractable and most patients continued to have mild vomiting albeit with a little nausea. Surgery must always be considered in the management of every patient with intestinal obstruction. A proportion will have a non-malignant cause for their obstruction, and Walsh and Schofield’ and Osteen et all reported that obstruction in 32% and 38% of cases was due to a benign cause or to an unrelated second primary tumour. Even among patients whose obstruction is due to recurrent cancer there are individuals who will enjoy a long and symptom-free period following palliative surgery. We reviewed the medical records of the 4 patients who were shown at necropsy to have a single, potentially remediable obstruction, but we concluded that their general condition would have precluded surgery. Surgical mortality varies, but it is not insignificant. Ketcham et al8 and Walsh and Schofieldreport 18% and 19%, respectively, but these two studies included few examples of ovarian cancer. Piver et al9 in a survey of 60 patients with ovarian cancer, found a surgical mortality of 32%, and Aranha et allo reported 35%. Surgical morbidity is more difficult to measure. The frequency offaecal fistulae has been recorded as 7-10%. The persistence of obstructive symptoms following palliative surgery has not been reported but 4 out of 11 patients in our series still had an obstruction after laparotomy. Ketcham et al8 described a reobstruction rate of 33%. Impossible to measure is the physical and psychological trauma of a further surgical procedure to patients who have often already had extensive treatment. Duration of survival after palliative surgery for intestinal obstruction due to malignancy has been given as 2.55 months,9 3 months,2 and 11 months.7,8 Our group had a mean survival of 3.7 months from the onset of obstruction, with 7 out of 38 patients (18%) living for more than 7 months. Comparisons between surgical series and the present study cannot, however, be pushed too far since most of the former include few cases of ovarian cancer and many with cancer of the cervix uteri. The decompression of the bowel by nasogastric suction and correction of any fluid and electrolyte imbalance by intravenous infusion before surgery is standard practice, but the value of this regimen as the sole means of treating malignant obstruction is questionable. Aranha et al10 and Glass and LeDuc"report a 1% and 15% sustained response to conservative treatment. Osteen et a12 showed that 23% of patients responded but symptoms recurred in 42% of them. These figures do not take into account the fact that early obstructive symptoms are often intermittent-a regular feature in some of the patients in the present series. A brief comment may be made on the use of limited, symptom-oriented necropsies. This procedure was introduced for selected cases at St Christopher’s Hospice in 1979.12 Limited necropsies have already helped to clarify certain kinds of pain and intractable dysphagia13 and, in the present series, they have provided useful confirmation of clinical diagnoses. Some anomalies have, however, been encountered. In particular, the nature and extent of the pathological findings could not be linked with the severity of colic and abdominal pain experienced during life. During the period that this study was undertaken, the admission records of St Christopher’s Hospice indicate that
993 had intestinal obstruction. Terminal intestinal obstruction occurred in some 10% of hospice patients with primary tumours of the large bowel. It is thus a fairly common terminal event, but the findings reported here indicate that the distressing symptoms of intestinal obstruction due to far-advanced malignant disease can be
3% of all
patients
controlled by drugs.
4.
5. 6. 7.
We thank Mr A. E. Young, consultant surgeon at St Thomas’ Hospital, London, for help with the preparation of this paper; and the Wellcome Foundation for financial support.
Correspondence should be addressed to M. B., St Lawne Park Road, Sydenham, London SE26 6DZ.
Christopher’s Hospice,
8. 9. 10. 11.
Surg 1973; 125: 316. pathological aspects
12. Carter RL. Some
REFERENCES 1 Sise JG, Crichlow RW. Obstruction due to malignant tumours. Sem Oncol 1978; 5: 213-24. 2 Osteen RT, Guyton S, Steele G, Wilson RE Malignant intestinal obstruction Surgery 1980; 67: 611-15.
Child Health PROGNOSIS FOR BABIES WITH MENINGOMYELOCELE AND HIGH LUMBAR PARAPLEGIA AT BIRTH R. G. MENZIES
J.
M. PARKIN
E. N. HEY Princess Mary Maternity
Hospital,
Newcastle upon
Tyne
life
expectation of babies with lumbar meningomyelocele not paralytic offered immediate surgery at birth appears to be influenced by the extent to which parents are involved in the child’s early care. 8 of the 27 children offered family-centred care in one hospital in 1971-80 and not offered immediate surgery survived to school entry and none of these children has since died. All are chairbound and incontinent, but none is intellectually retarded and many are no more handicapped than the children offered immediate surgical treatment at birth. The choice before the family at birth does not have to be presented as an urgent and immediate choice between life and death. Summary
The
JC, Buchler DA, Mack EA, Ruzicka FF, Crowley JJ, Carr WR. The management of ovarian-cancer-caused bowel obstruction. Gynecol Oncol 1981; 12: 186-92. Oliver DJ. The use of methotrimeprazine in terminal care. Br J Clin Pract 1985; 39: 339-40 Baines MJ. Control of other symptoms. In: Saunders CM, ed. The management of terminal malignant disease. London: Edward Arnold, 1984. Regnard C, Newbury A. Pain and the portable syringe pump. Nursing Times 1983; 79: 25-28. Walsh HPJ, Schofield PF. Is laparotomy for small bowel obstruction justified in patients with previously treated malignancy? Br J Surg 1984; 71: 933-35. Ketcham AS, Hoye RC, Pilch YH, Morton DL. Delayed intestinal obstruction following treatment for cancer. Cancer 1970; 25: 406-10. Piver MS, Barlow JJ, Lele SB, Frank A. Survival after ovarian cancer induced intestinal obstruction. Gynecol Oncol 1982; 12: 44-49. Aranha GV, Folk FA, Greenlee HB. Surgical palliation of small bowel obstruction due to metastatic carcinoma. Am Surg 1981; 47: 99-102. Glass RL, LeDuc RJ Small intestinal obstruction for peritoneal carcinomatosis. Am J
3 Tunca
INTRODUCTION
BEFORE the introduction of the Holter valve twenty-five years ago, the prognosis for babies with serious spina bifida was extremely bleak. A policy of immediate back closure with subsequent shunt surgery for the hydrocephalus then developed, but this soon led to the survival of large numbers of very handicapped children. In turn, therefore, a policy of more selective treatment was widely adopted in the United Kingdom after 1971,’ in the belief that children with gross
of advanced malignant disease. In: Saunders CM The management of terminal malignant disease. London: Edward Arnold, 1984. 13. Carter RL, Pittam MR, Tanner NSB. Pain and dysphagia m patients with squamous carcinomas ofthe head and neck-the role of perineural spread. J Roy Soc Med 1982; 75: 598-606.
in several other countries.7-9 A working party for the Northern RHA believed it was possible to reach a consensus on such issues when it reviewed the ethical guidelines involved and published its views in The Lancet ten years ago,1O but this conclusion was based on the assumption that babies not offered surgery would always die within weeks or months if not offered surgery at birth. Evidence, however, from cases selected for referral to a regional surgical centre after delivery"’’shows that this is not always true. Our own experience (based on an unselected group of children) suggests that 30% of all children not offered surgery at birth may survive to enter school 5 years later, and that they enter school with a range of handicap (other than the handicap of wheelchair dependence) little different from that ofa group of children without "adverse criteria"’offered surgery at birth.
SURVEY
Families who are told that their baby is unlikely to survive very long, and that skilled nursing care (with or without medication) may be necessary to keep the baby comfortable, readily accept the idea that their child should remain in hospital. This was not the way the first few babies were managed conservatively in this hospital, however, when a policy of selective treatment for early surgery was introduced in 1971. Three of the first families offered conservative care chose to take their babies home, and nursery staff rapidly came to see from the outset that this could be a valid alternative to continued hospital care. Parents have always, therefore, been encouraged to involve themselves in the child’s care in hospital from birth and have had the alternatives explained to them without pressure to conform to any particular pattern of care, and we soon
hydrocephalus, paralysed legs, or kyphosis at birth would die anyway if not offered immediate surgery; and this is, indeed, what normally happens when such children are cared for in
hospital.2-6 This was not, however, what happened to a group of such children cared for in a family setting in Newcastle between 1971 and 1980. The ethical dilemma facing those responsible for the care of
baby with high paraplegia at birth remains as acute as ever: clinicians in the UK advise against surgical treatment for such children, but this runs counter to the prevailing view a
most
Prognosis for babies with a meningomyelocele not offered surgery at birth between 1971 and 1980 because of adverse factors.!