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Small intestinal obstruction from peritoneal carcinomatosis
Small Intestinal Obstruction from Peritoneal Carcinomatosis
Robert L. Glass, MD, Columbia, Richard J. LeDuc,
BS, Columbia,
Missouri Missouri
Mechanical obstruction of the small intestine is most commonly due to peritoneal adhesions or external hernias. With the possible exception of obstruction in the early postlaparotomy period, the disease presents a surgical emergency [I], delay being advisable only for resuscitation, usually requiring a matter of hours. Small intestinal obstruction from peritoneal carcinomatosis differs from the more common causes because the underlying disease is an advanced stage of a progressive and uncontrollable disease, and strangulation obstruction is uncommon. Material The case records of the Ellis Fischel State Cancer Hospital from 1939 to 1970 were reviewed. There were 111 episodes of small bowel obstruction in eighty-nine patients with tumors of the colon and rectum (forty cases), ovary (fifteen), cervix (thirteen), and miscellaneous areas (twenty-one). There was no difference in the clinical
course of patients with obstruction classified as partial versus complete. The extent of peritoneal involvement by cancer, whether below the umbilicus, above the umbili-
tubation not as planned preparation for surgery. Eleven patients had relief of obstruction for thirty days or more, five died during therapy, and twenty-two required surgery within thirty days. Of the eleven cases with relief of obstruction for thirty days or more, six never had reobstruction, two had reobstruction but did not require surgery, and three had reobstruction and required surgery. The 13 per cent (five of thirty-eight) thirty day mortality compares with a 24 per cent (seventeen of seventy-two) thirty day mortality for surgical treatment. Seventy-two obstructions were treated surgically after adequate preparation. Resection or bypass enteroenterostomy was the procedure employed, occasionally complemented by proximal tube enterostomy. The results were as follows: recurrent obst.ruction (after a thirty day unobstructed interval). six patients; persistent obstruction (within thirty days), seven; no obstruction until death, fort.y-two; death without obstruction within thirty days, seventeen. The thirty day mortality, as just noted, was “4 per cent (seventeen of seventy-two).
cus, or both, did not significantly alter the course. In this retrospective study the use of chemotherapy or radiotherapy was too infrequent to analyze. TABLE
Treatment
Thirty-eight episodes with intravenous fluids -
of obstruction were and nasogastrointestinal _--.
treated in-
-
From the Ellis Flschel State Cancer Hospital, Columbia. Missouri. Reprint requests should be addressed to Dr Glass, Ellis Ffschel Sfate Cancer Hospital. Columbia. Missouri 65201
316
I
Repeated Obstructions in Eighty-Nine Patients
and Results Number of Obstructions 2 3 5 Total
Number 15 1
Per cent 17 1
i
1
17
19
The American Journal of Surgery
Small
veloped recurrent the tube.
obstruction
Intestinal
Obstruction
after early removal
of
Comments
2
4
6
8
10
12
14
16
18
20
hbnth Figure 1. Over-all survival.
Relief of small bowel obstruction from peritoneal carcinomatosis may be obtained in a significant proportion of patients by nasogastric suction and intravenous fluids, and recent work by Schwartz et al [3] suggests that combining intravenous hyperalimentation with systemic chemotherapy may offer benefit. A high incidence of reobstruction follows either operative or nonoperative therapy, but in those operated on the use of a permanent tube jejunostomy proximal to the site oi obstruction seems to prevent the problem of recurrent obstruction. Summary
Nineteen per cent of the patients (seventeen of eighty-nine) had repeated episodes of obstruction. (Table I.) Ketcham et al [2] reported a 33 per cent incidence (twenty-four of seventy-three) of recurrent obstruction in similar patients. The survival curves for the various types of tumor were nearly identical and are shown combined in Figure 1. Only four patients survived more than one year from date of obstruction, two with colon carcinoma and two with ovarian tumors, one of each apparently responding to chemotherapy. Tube jejunostomy was done proximal to the site of obstruction and/or anastomosis nineteen times; the tube was left in from two weeks to more than twelve months. No episodes of obstruction occurred while the tube was in place although three of nineteen de-
Volume 125, March 1973
Small intestinal obstruction from peritoneal carcinomatosis was reviewed at the Ellis Fischel State Cancer Hospital. The outlook is poor for survival and conservative management is warranted as a trial because strangulation obstruction is rare. Reobstruction after either nonoperative or operative management is common, and if surgery is performed, a permanent tube jejunostomy should be considered. References 1. Berne CJ, Payne JH: Diagnosis and management of acute intestinal obstruction. Surg C/in N Amer 34: 1403. 1954. 2. Ketcham AS, Hoye RC, Pilch YH, Morton DL: Delayed intestinal obstruction following treatment for cancer. Cancer 25: 406, 1970. 3. Schwartz GF et al: Combined hyperalimentation and chemotherapy in treatment of disseminated solid tumors. Amer J Sorg 121: 169, 1971.
317
Robert L. Glass, MD, Columbia, Richard J. LeDuc,
BS, Columbia,
Missouri Missouri
Mechanical obstruction of the small intestine is most commonly due to peritoneal adhesions or external hernias. With the possible exception of obstruction in the early postlaparotomy period, the disease presents a surgical emergency [I], delay being advisable only for resuscitation, usually requiring a matter of hours. Small intestinal obstruction from peritoneal carcinomatosis differs from the more common causes because the underlying disease is an advanced stage of a progressive and uncontrollable disease, and strangulation obstruction is uncommon. Material The case records of the Ellis Fischel State Cancer Hospital from 1939 to 1970 were reviewed. There were 111 episodes of small bowel obstruction in eighty-nine patients with tumors of the colon and rectum (forty cases), ovary (fifteen), cervix (thirteen), and miscellaneous areas (twenty-one). There was no difference in the clinical
course of patients with obstruction classified as partial versus complete. The extent of peritoneal involvement by cancer, whether below the umbilicus, above the umbili-
tubation not as planned preparation for surgery. Eleven patients had relief of obstruction for thirty days or more, five died during therapy, and twenty-two required surgery within thirty days. Of the eleven cases with relief of obstruction for thirty days or more, six never had reobstruction, two had reobstruction but did not require surgery, and three had reobstruction and required surgery. The 13 per cent (five of thirty-eight) thirty day mortality compares with a 24 per cent (seventeen of seventy-two) thirty day mortality for surgical treatment. Seventy-two obstructions were treated surgically after adequate preparation. Resection or bypass enteroenterostomy was the procedure employed, occasionally complemented by proximal tube enterostomy. The results were as follows: recurrent obst.ruction (after a thirty day unobstructed interval). six patients; persistent obstruction (within thirty days), seven; no obstruction until death, fort.y-two; death without obstruction within thirty days, seventeen. The thirty day mortality, as just noted, was “4 per cent (seventeen of seventy-two).
cus, or both, did not significantly alter the course. In this retrospective study the use of chemotherapy or radiotherapy was too infrequent to analyze. TABLE
Treatment
Thirty-eight episodes with intravenous fluids -
of obstruction were and nasogastrointestinal _--.
treated in-
-
From the Ellis Flschel State Cancer Hospital, Columbia. Missouri. Reprint requests should be addressed to Dr Glass, Ellis Ffschel Sfate Cancer Hospital. Columbia. Missouri 65201
316
I
Repeated Obstructions in Eighty-Nine Patients
and Results Number of Obstructions 2 3 5 Total
Number 15 1
Per cent 17 1
i
1
17
19
The American Journal of Surgery
Small
veloped recurrent the tube.
obstruction
Intestinal
Obstruction
after early removal
of
Comments
2
4
6
8
10
12
14
16
18
20
hbnth Figure 1. Over-all survival.
Relief of small bowel obstruction from peritoneal carcinomatosis may be obtained in a significant proportion of patients by nasogastric suction and intravenous fluids, and recent work by Schwartz et al [3] suggests that combining intravenous hyperalimentation with systemic chemotherapy may offer benefit. A high incidence of reobstruction follows either operative or nonoperative therapy, but in those operated on the use of a permanent tube jejunostomy proximal to the site oi obstruction seems to prevent the problem of recurrent obstruction. Summary
Nineteen per cent of the patients (seventeen of eighty-nine) had repeated episodes of obstruction. (Table I.) Ketcham et al [2] reported a 33 per cent incidence (twenty-four of seventy-three) of recurrent obstruction in similar patients. The survival curves for the various types of tumor were nearly identical and are shown combined in Figure 1. Only four patients survived more than one year from date of obstruction, two with colon carcinoma and two with ovarian tumors, one of each apparently responding to chemotherapy. Tube jejunostomy was done proximal to the site of obstruction and/or anastomosis nineteen times; the tube was left in from two weeks to more than twelve months. No episodes of obstruction occurred while the tube was in place although three of nineteen de-
Volume 125, March 1973
Small intestinal obstruction from peritoneal carcinomatosis was reviewed at the Ellis Fischel State Cancer Hospital. The outlook is poor for survival and conservative management is warranted as a trial because strangulation obstruction is rare. Reobstruction after either nonoperative or operative management is common, and if surgery is performed, a permanent tube jejunostomy should be considered. References 1. Berne CJ, Payne JH: Diagnosis and management of acute intestinal obstruction. Surg C/in N Amer 34: 1403. 1954. 2. Ketcham AS, Hoye RC, Pilch YH, Morton DL: Delayed intestinal obstruction following treatment for cancer. Cancer 25: 406, 1970. 3. Schwartz GF et al: Combined hyperalimentation and chemotherapy in treatment of disseminated solid tumors. Amer J Sorg 121: 169, 1971.
317